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Home My WebLink AboutMiscellaneous - 45 RUSSETT LANE 4/30/2018 (2) f`7 45 RUSSETT LANE 210/104.A-004&0000.0 oh sewer l � Location � � No. o Date y MORTh L7 TOWN OF NORTH ANDOVER n Certificate of Occupancy $ Building/Frame Permit Fee $ •°' �' <MusFoundation Permit Fee $ �Ss^ tt Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ j 4Qq ✓ Building Inspector `� X31:30 65.00 PAID Div. Public Works 1 1'FIZMIT NO. APPLICATION FOR PERMIT TO I3UIL1)********NORTII A /iOVER, MA . 1 ' Mu'ND. Il)T.NO. Z. RECORBOFOWNERSIIIP DA ' ROOK PAGE LUNE � , SUB UIV. 1.0['No . Q I 1 I0('AI'1(IN I'11RPOSEI)FL)I1111)ING QLpXnO�e V F100 /�, IQ+C e e � n ()WNER'SNAME �. r Ca,t• n yoon NO.OfSTlN21L•S f y"e,(.F ��G� SIZE )1VNER'S ADDRESSc 1E' BASEtiIEFIf OR SLAB �Rl'I117ECI''S NAME SlZE OF PLOOR 1"IMBERS t 2 3 lit III DER'S NAME SPAN DISTANCE TONEARES I'BUILDING DIMENSIONS OF SILLS DIS I'ANCE FROM SPREE I. DIIALNS1(NJS 01:POS IS DISTANCE FROM I..OT LINES-SIDES REAR DIMENSIONS OF GIRDERS ARTA OF LOT FRONTAGE I IEIGI IT OF FOUNDATION TI IICKNL•SS IS BIIILDIN(i NEW SIZE Of"I(X71 ING X IS BUILDING ADDIIION MAI"ERIAL OF CI IIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID(WTIl LED LAND f WILL BUILDING CONFORM TO REC2l11REMEN I S OF CODE IS BUILDING CONNECTED 10 TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO FOWN SEWER i IS BUILDING CONNECTED TO NATURAL GAS LINE INS VIICTIONS I PROPER'fl'INFORMATION LAND COST EST.Bl.lXi.COST" PAGE I FII.1.0(ITSECTI(N4S 1-3 EST.BLDG.COSf PER SQ.FT. EST. BLDG.C,YS PER ROOM EI ECTRIC MIE'fERS Ml1Sf BE ON OtITS1DE OF BUILDING SEPITC PERMI f NO. A I-I ACI IED(iARA(iES Mt)ST C(NdFORM"fO S PAI"E FIRE REGULATIONS 4. -APPRovu)Bl': PLANS MUST BE FILED AND APPROVED BY RIM DING INSPECTOR B1111H)ING INSPEC•I'OR C( / ��8�6��s x-- - � � I� OWNERS'I'ELH" lc i DAII.FILET) �I n 1 � C(NJ'1'R.TEI.b 1 n� X A Cr MAR 4 I + (NJ'fR.I.IC'N �C,aJM.f�(2— A Uf C' i SIGNATURE :OWNER OR r)RFE: (;[: l j€ij_. SSS......... I'F{i;.11TGI2AN'III) I') w FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT KG'1 r"h oPHONE X78 bar/- 6 y7S` LOCATION: Assessors Map Number /0YA PARCEL .SUBDIVISION LOT (S) STREET yS 9"5-5e+t- L� �8� �rZd utr ST. NUMBER y'r '- - -*'**'OFFICIAL USE ONLY*** J` e�hoV� 2,-p1ACW_ RECOMMENDATIONS OF TOWN.AGENTS: - Rear A01CW66N NSER ATION ADMINIZITRA R DATE APPROVED - �I ,,, ! DATE-REJECTED COMMENTS UkL1 U` - \ TOWN PLANNER DATE gPPROVED rl� DATE REJECTED COMMENTS FOOD INSPE, OR-HEALTH DATE APPROVED DATE REJECTED X.,,fSEPTI-C INSPECTOR-ALTH- DATE APPROVED DATE REJECTED COMMENTS 4� PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BUILDING INSPECTOR DATE EIEDBY s TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units...or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. Type of Work: Est. COSAO 0*0 Address of Work yS ups E l - r Owner Name: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Pemit No. Job under $1,000 Date Building not owner-occupied =Owner pulling own permit Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND LINER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date • r' IN CERTIFIED PLOT PLAN Va ° JN PREPARED FOR.' l S Cr `: `'SOiC.'315773 KE/TH YOUNG AT;v 45 RUSSETT LANE NORTH ANDOVER, MA. NORTH ESSEX REGIS TR Y OF DEEDS.'BK. 3849 PG. 306 ASSESSORS MAP 104A, LOT 48 ZONE.' R-1 SCALE.' 1.=50' DATE APRIL 09, 1998 ' 168.38 q� NOTE.' MEASUREMENTS TAKEN r0 S CORNER BOARD LOT /3 ABOVE FOWVD— AT/ON. 44,509 SF# Z�- 7 let 7— WOOD FENCE— 4/.S 1 11 a; \ i \EXISTINGDWELLI GiD i 45.3. \IVO.\45�aa` i i ?./.4' 34.0 //0.00, 150.00, RUSSETT LANE PREPARED BY. JOHN ABAGIS B ASSOCIATES, PROFESSIONAL LAND SURVEYORS 137 CHANDLER ROAD, ANDOVER, MA. (508)- 688-4899 r NO .34 50 A y 7 � /� .i f ,..�.nw .>��;� �i=� '�L�n-�. � •�>°��.'• �yrs-,r.� -- .� i LF r cc �' E tv crc V E i ... �._..,...,...,.«..e_._��wr....yStxrL. =tVn':.«�ewua::nsvnne�em.�•^ ..aw..�+vw_+w.w.a_w-zws+..�.m..um.+.maw'°'a'"".:."'ylY�:.•a.yw.rr.w.w:.�.w+y«a.+�-�� .•____._.�_.__. _s . � Y V �v N,ORT►y E AndoverL Town of � fit,' 0 i1tq% No. f Z _ �o ?, h A C O C E I A dover, Mass., 'p C I-I I CRATED S H � BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......... ...............................y.................. .................... ....... "' Foundation 41"' has ermission to erect... ...".0 .ri.../..... bu'Idin s on ........... . .p + 1 . .. ... � ................. � Rough to be occupied as...13 � � 7X Z �1 , �' a 7 7 �� Chimney ................................................ eY provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough �. 4 f* PERMIT EXPIRES IN 6 MONTHS Final ` 3 *C)6 V UNLESS CONSTRUC N ELECTRICAL INSPECTOR Rough ..... ............V.Vj ........ ...................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR j Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. SEE REVERSE SIDE Smoke Det. FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT � PHONE LOCATION: Assessors Map Number 10Y,41 PARCEL SUBDIVISION LOT (S) Y� �f STREET y::� 9,5.5 e+t- Z-4). -gnbu�r" ST. NUMBER ys "OFFICIAL USE ONLYen.o�� ZpP +�� ejea�,tity jECZ11ENDATIONS OF TOWN AGENTS: _ zeRr A,,AcA NSER ATION ADMINISTRA-tOR DATE APPROVED I�1 `( DATE-REJECTED COMMENTS � It Ki r1o� u v CLC,/t:� ,,_) �, TOWN PLANNER DATE APPROVED r1t DATE REJECTED COMMENTS FOOD INSPE � OR-HEALTH DATE APPROVED 1--� DATE REJECTED SEPTICIINSPEC TOR-HEALTH - DATE APPROVED i79 DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE l� CERTIFIED PLOT PLAN 3cl/3 �,3 0 PREPARED FOR.' res KE/TH YOUNG AT _r 45 RUSSET T LANE NORTH ANDOVER, MA. NORTH ESSEX REGISTRY OF DEEDS.'BK. 3849 PG. 306 ASSESSORS MAP 104A, LOT 48 ZONE.' R-1 SCALE.' 1-=50' DATE APRIL 09, 1998 q2 •• 168.38 NOTE.' 410 s MEASUREMENTS T4s TAKEN TO CORNER BOARD LOT 13 ABOVE FOUND- ATION. 44,509 SF-4 N a � p- WOOD FENCE—� s•\ 4/� -- --- \29 \Ex/s r1NOc Poop ' °'-DWELL/NG 45.3, ANO.\4544 './.4' 34.0' //0.00, 150.00' RUS,SETT LANE PREPARED Sr JOHN ABAGIS 8 ASSOCIATES, PROFESSIONAL LAND SURVEYORS 137 CHANDLER ROAD, ANDOVER, MA. (508)— 688-4899 NC. 34 SC 03-22-99 To: North Andover Board of Health From: Keith E. Young 45 Russett Lane North Andover,MA 01845 Subject: Building Permit Recently I applied for a building permit from the Town of North Andover to conduct improvements on my property. I spoke with a member of the board of health regarding the status of my sewer. This letter is to confirm that I agree to complete the tie in process of my sewer at the above named adress as a requirement to the issuance of a building permit. Sincer y L • Keith E Young Notary Public: /;, -2 My Commission Expires: Xvi // 03 i f7-r CO'v MONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02106 617•292-5560 TRUDY COXE WILLIAM!F WELD Sccrcun Govcmo: ARGEO PAUL CELLLKCI DAVID B.STRUMS IA.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address ��VsS�et/�9j /(Jv 1�OVCP, &,eL Address of Owner: Date of Inspection: /O171,07 (If different) Name of Inspector: BENJAMIN C. OSGOOD JR. 1 am a DEP approved sys(Im inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) I Company Name: NEW ENGLAND ENGINEERING SERVICES, INC. Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 01845 Telephone Number: 508-686-1.768 CERTIFICATION STATEMENT ' I cenify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as of the time of rnspenron. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal sN-stems. The system: /"Passes _ Condrtronalk Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: X�i 1. Date: /O The SN-stem !nspector s submit a copy of this inspection report to the Approving Authoritywithin thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10.000 go or greater, the inspector and the system owner shall submit the repon to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the byyer, if applicable. and the approving authority INSPECTION SUMMARY: Check B, C, of D: s AI SYSTEM PASSES: �_ 1 have not iound any information which indicates that the system violates any of the failure cr-1-:2 zs dtfine�+ in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the -Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes. no. or not determined (Y. N.or ND). Describe basis of determination in all instances. 1f-not determined',explain why not. Theseptic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was instilled within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (rwid 04/75/97) p.9- 1 or 10 --....... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES(continuedi Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health;. Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(sl. The system will pass inspection if(with approval of the Board of Health)- broken pipe(s) are replaces obstruction is removed I t , C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which renuire further evaluation by the Board of Health in order to determine if the system is failing to protect the public health. safeq•and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL FROTECi THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within SO feet of a surface water Cesspool or prn-�• is within SO feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF,APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: , The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. I The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. — The system has a septic tank and soil absorption system and the SAS is within SO feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but SO feet or more from a private water supply well. unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determine distance (approximation not valid). 3) OTHER •w• 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: Dj SYSTEM FAILS: You must indicate either -Yes" or-No-as to each of the following: I have determined that the system violates one or more of the f6llowing failure titers as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface wafers due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution b above outlet invert due to an overloaded or clogged SAS or cesspoI of. Liquid depth'+n cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). t Number of times pumped Any portion of the Soil Absorption System• cesspool or privy is below the high groundwater elevation Am• pon+on of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cess 1 t pool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Anv portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable Nater quality analysis. If the well has been analyzed to be acceptable, attach copv of well water analysis for coliform baagria• volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: I I You must indicate either:Yes- or-No-as to each of the following: The following criteria apply to large systems in addition to the criteria above: + The system serves a facility with a design flow of 10,000 go or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 466 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a napped Zone II of a public water supply well) The owner or operator or any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 . sy SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: y s / 01—Ae- Owner: f'pi fh 16 rJn G— Dale of Inspection: i0 /97 Check if the following have been done: You must indicate either -Yes-or-No" as to each"of the following: Yes,/ No Pumping information was provided by the owner• occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or / as part of this inspections As built plans)have been obtained and examiked. Note if they are not availab'�e w+th N/A. _ The iaciliry or dwelling was inspected for signs of sewage back-up. i _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components" excluding the Soil Absorption System, have been located on the site. ►' _ The septic tank manholets Nereuncovered, opened. and the interior of the septic t.2nk was �n�pected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owners were provided with information on the proper maintenance of / Sub-Surface Disposal System. ✓ _ Existing information. Ex.(Plan at B.O.H. i Determined in the field (if anv_ of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) i S t i (revised 0{/25/17) Page 4 of 10 sy SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C ` / SYSTEM INFORMATION /� Property Address: yJ A60---'se, ��, jVa I�i4'ee, wt* Owner: Xe.A you Date of Inspection: /a/V�y7 FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.dJbedroom for S.A.S Number of bedrooms: Number of current residents: Garbage gr,r.der(yes or no): Al Laundry connected to system (yes or no):* Seasonal use tyes or no):_ // Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): Last date of occupancy: I COMM ERCiAL/I N D USTRIAL: Type of establishment: Design floes•: gallons/dav Grease trap present: (,yes or not , Industrial Waste Holding Tank present: (yes or no)-- Non-sanitary o)_Non-sanitary waste discharged to the Title 5 system (yes or no)_ Water meter readings, if available I Last date of o�cupanc•: OTHER: (Describe! Last date of occupancy. GENERAL JNFORMATION PUMPING RECORDS and source of information ' u�P2d 6 076,v MA $34 l3ye,e System pumped as part of inspection: (yes or no) If yes, volume pumped: galIoAs Reason for pumping t TYPE OF SYSTEM Pf Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, Attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) i (r..K..a 04/25/37) Pa90 5 o1 10 .................... _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYS:TE/M INFORMATION (continued) Property Address: 4f, Owner: , Er 114h ypc� Dale of Inspection: / BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: -'cast iron _40 PVC _other(explain) Distance from private water supply well or suction ILrt Diameter �/•• Comments: (condition of joints, venting, evidence of leakage, etc.) L�yks ,dol ?o/•17's Z64/ Ae SEPTIC TANK:_ I I I (locate on site plana ' Depth below grade:II ' Material of construction: _✓concrete _metal _Fiberglass _Polyethylene _other(explaan) If tank is metal, last age _ Is age confirmed by Cenaficate of Compliance _(Yes/No) ' Dimensions: A�aS-0 G/f G �3I e P`,017 Sludge depth-__ Distance from top of sludge to bottom of outlet tee or b!afflae:�r� Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 8 How dimensions were determined: M64S✓nna4.v�- Comments: (recommendation for pumping, condition of inlet and outltt tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Zio,, ,,/ &1<gva /`'SPS OK ^ 5;-hedo6a f/O 7-9-S �ho�L3 $r3 I I s GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation (or pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (r.vi■.d 04/7s/97) pay. 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �� y/ SYSTEM INFORMATION (continued) Property Address: 51 L e"SP�� /,q, Pd vd,,e4/ m Owner: h e:'/h �40 v-4-. Date of Inspection: /0/7 AF TIGHT OR HOLDING TANK: ,Tank must be pumped prior to,or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons j Design floc` i gallonJda, Alarm level I Alarm in working order _ Yes: _ No � Date of previous pumping: Comments: i (condition of inlet tee. (:ondition of alarm and float switches, etc.) ' i I t DISTRIBUTION BOX:_ (locate on site plan! Depth of liquid level above outlet invert:_ Comments: ' (note ifI vel and distributigqn is equal, evidence of solids carryover, evidence of leakage into or oil of box, etc.) i -l-o a., L-1 4_o /3 R P a-+r L - - 3 0)< h�ys S;. e D�/�•�i a `-v' I I I PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (r.vi..d 04/25/971 P.q. 7 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C V r SYSTEM INrFORMATION (continued) Property Address: 55- pO5 e 0 h Owner: x"'"1 k Vag H cr Date of Inspection: le SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leachingpits• number:_ leaching chambers, number:_ leaching galleries, number: _ ` leaching trenches, number,length: )IN1176 leaching fields. number, dimensions:_ t— overflow cesspool, number: Alternative system: I Name of Technology: ' Comments: ' (note condition of soil, signs of hydraulic (ailure, level of ponding, condition of vegetation• etc.) sc � /�-.��/�►*/� SBO A �o r,(C O l� �0 6��RYt'n�'•t i S Un� �c'rt.n '- Aja I t • t CESSPOOLS: _ (locate on site plan) Number and configuration. Depth-top of liquid to inlet invert: ' Dgpth of solids layer: Depth of scum layer: Dimensions of cesspoo!: Materials of construction: Indication of groundwater: infloLv (cesspool must be pumped as pan of inspection) ' Comments: (note condition of soil, signs of hydraulic failure„level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (riote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r•vieod 04/2S/27) n�q• of 20 -------------- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'SYSTEM INFORMATION (continued) Property Address: Au9se c�v e C, � Owner: K of iq G— Date of Inspection: X91 I q -7 - SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) t-• I lie _V1 ' s IJ II' � I � I } 5 . 0 x tlL o d p S (reviaod 04/25/97) Paq• 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (con(inued) Propertv Address: ZIS eu5s E� rya r�„i rp ems— < «f y Owner: Date of Inspection: / Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abusing property observation hole. basement sump etc.) Determine it irom local conditions Chefk w!th !oca! Board of health I I Che6 FEMA &laps Check pumping records t t i Check local excavators. installers V Use USGS Data Describe in vour own words how vdu established the High Groundwater Elevation.'(Must be completed) t 7tisG� ��ac dr1��Gtt i Cis "-it 'BL1Z la- tA-q ,L- _ A b, f-es A-, sa: L T4 tj k U-4� l*e t_12 y � I I (rwi..d 04/25/97) r.y. 10 0[ 10