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HomeMy WebLinkAboutMiscellaneous - 45 WHITE BIRCH LANE 4/30/2018 (2)OO p 2 o �T 0 CO o c7 o = o o m b (D MAP # LOT PARCEL # STREET („2. ....A� .•UlVk- CONSTRUCTI.ON_APPR ............ HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATEAPP. BY. �... DESIGNER:' PLAN DA-T•E:__�Z _ CONDITIONS WATER SUPPLY: TOWN WELL WELLPERMIT DRILLER._...___._..._---..... __._..__.___._._._._.---_._................. .. WELL TESTS: CHEMICAL DAIS A{'1�fZUVED HA RIA I DA I E (IPPRUVED BACTERIA II DATE COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YE5 NO DATE ISSUED 4 /494 By ______..__.._._...__.._..._...___.._..__ CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID L y =*Q / NO WELL CONSTRUCTION APPROVAL Y NU SEPTIC SYSTEM CONSTRUCTION APPROVAL NO OTHER YES NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE:..._....__..._ ...By: 84-00 . d N N LOT 3 AREA =25579 S. F. rn 4. LOT 4 LOT 2 0 V EXIST 1�•�' i FND. ` w 1 � TOP OF FOUNDA TION ELEV. = 149.8' rn 100.0' WHITE BIRCH LANE FOUNDATION LOCATION PLAN CLIENT. • SCOTT CONSTRUCTION THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION: NORTH ANDOVER A4A. SCALE. -I"=40' DATE.5/2/94 CHRISTIANSEN & SERGI PROLAND! SURVENGI EYORSEERS 160 SUMMER ST. HAVERHILL.MA. 01830 TEL. 508-373-0310 © 1994 BY CHRISTIANSEN & SERGI INC. I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REOUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS, WETLANDS, EASEMENTS, ORDERS OF CONDITIONS,ETC.) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXC£PT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN X SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN k SERGI INC. AND ANY UNAUTHORIZED USE IS PROHIBITED. CHRISTIANSEN i SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- MATION CONTAINED HEREON. BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEMA FLOOD INSURANCE RATE MAP. i COMMUNITY NO.: 250098 0005C DATE.6/2/93 I DWG. NO.: 93067016 1 , � . <•, s�..,1� _t ) t ` it\ ` �•ii •�'` t `� _..'.i { 1 iA 75 t'• i } it . , _'. .i t yid 't7 ,i �,ti r'�,�'�,�'l\41 It �� •;� ,,! S ,� !1 � ;' Z y•• 'Ne Town of North Andover, Massachusetts Form No. 3 t,&ORT1l BOARD OF HEALTH p 19 '°•,o "� DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACMusEt Applicant _ U �- � NAME �'ADggDRESS TELEPHONE Site Location uU k",- - Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH Q� Fee �' D.W.C. No. jq -� -) 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 local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: ` �. —IL-1? C__ - Phone J ✓ �: LOCATION: Assessor's Map Number Subdivision Street ��% ) ' i/l%lLc �� fl", Parcel Lots) St. Number ************************Official Use only************************ RECOMMENDATIONS OF TOWN AGENTS: l � 011; -� Conservation Administrator Comments Town Planner Comments Food Inspector -Health Septic Inspector -Health Consents Public Works - sewer/water connections - driveway permit Fire Department jr Date Approved / Date Rejected Date Approved Date Rejected Date Approve; Date Rejected Date Approved �il /% q - Date Rejected Received by Building Inspector Daze f NORTh ° 1t'*D q F P t » CMUSEt� Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant /M �/�/f=0/1// Test No. Site Location 11)T Reference Plans and Specs.— ENGINEERoFtMIN nwrr Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. IS Fee CHATRMAN, BOARD OF HEALTH Site System Permit No. (!;k¢ m LOT 3 v N W N i AGE 0 o \� LOT 2 5EPTI K ,� TAN �p30 .w 9 EXIST. !� HOUSE 7t7P KNEE►SALL I ,145.88 /0010, - WH/ TE BIRCH L *4NE SLOPE RE01111FEUENT 10ES10N ELEI/QT/ON 4r ........(TOP OF STONE) _ EX/5TIN4 4Z&.4T/ON AT ......... 2E41,1114Fo F/LL _ ............. . ELEWT/ONS DES/lr/V �!S !3U/LT IMI PIPE 041T OF 9041,5E 142.46 142.63 INl/. PIPE INTO T,4NK 141.9G 142.24 I/VI/ PIPE OUT OF T4NX 141. 7o f4 f. 81 /N1/, PIP /NTD 0,50-Y. 1414.7 141.67 INV PIPE OUT OF D. BOX 141.30 141.49 INV END OFPIPE ' # 14 -too f4 f. 12. INV END PIPE TRENCH 14183 Wd TLcle R EYQ TION 135.0 135.0 ,4VE2,40E. STONE, DEPTH QT P�E03E NOTE: T11/5 PZ.4N /5 NOT ,4 lV.41ee41VrY OF 71 -IE 5YSTEM BUT .4 I1EIeIFIURON Of TIVE LOUT/ON OF T11F EX/STING STeUCTI/2ES. .y,� uuiLi SUB-SU�F,4CE O/3POS,4L SYSTEM bV NORTH ANDOVER, MA. FOiP SCOTT CONSTRUCTION SCdGE: 1"=40' 04TE:7/25/94 C14HISTIANSEN SERG1, INC. 1(00 SUMMER SM86- T HAVEAWLL , MASS. 84•�� \ LOT 3 pGE O SEPTIC \ ,� rAN �p30 EX15T. ! HOUSE 717P KNEE►yALL .145-88 100,0, LOT 2 WHI TE BIRCH LANE SOP!' /ZfQU./2'Eil1ElVT C1.50)1,50 a 1,50 — DE.S/0N EL E!/QT/ON 4r ........(TDP OF STONE) _ .. • EX/STING ELEVQrroN Qr. ELEV..4rlONS DES/QN ,4S ;C3L//LT /NV G/PE OUT OF, -/OUSE 142.46 142.63 INV. P/PE INTO T,4NK 14 f. 96 142.24 /NV. P/PE OUT OF T4NX >4 t 70 N f. 81 INV. PIPE INTO D. BOX. 1414.7 141.67 INV. PIPE OUT OF D. BDX 141.30 141.49 CH INV END OFelM ' T#EN , 14 f. 00 f4 f.12 INV END PIPE TRENCH 14183 GV.GTE'R R E14 T/ON 135.0 135.0 ,4VE2,44E. STONE; DEP7-1/ QT Re03E 4 NOTE': T// /S Pl-,4N /S N07,4 111,41 ,,4NTY E OF 7//9 SYSTEM BUT ,4 11E.e/F/UTION OF TV/E LOUTION OF ME EX/ST/NQ STBUCT!/2ES. lz�'ffic �, ms? o"imol f+✓ uuiLi SUB—SU�F,4CE D/SPO ,4L SYSTEM /N NORTH ANDOVER, MA. FDle SCOTT CONSTRUCTION SCdLE� 1"=40' O4TE:7/25/94 C148-15 TIA NSEN SE13 C71, INC. 16,0 SUMMER STREET HAVERHILL , MA55. 8¢.0 LOT 3 IV pGE o00, \ �R SEPTIC \ TANK J �p80 o E1lOT. ! HOUSE ALL -145-88 \ I _w 100, 0, - LOT 2 WH/TE BIRCH L*4NE SLOPE R6oz111ZE"LcNT DES/O/Y R-EVd7ZON 47 ......... (MR OF STONE) _ EX/5TINei EZ&1.dr1oN............. fL��/.�1T/ONS oEs/QN �J,S BU/LT /NV P/PF OUT OF 1-1011,5E 142.46 142.63 INV P/PE INTO T,4NK 141.96 142.24 /NV. PIPE OUT OF TANK f41. 70 141.81 INkI PIPE INTO D. BOX. 141.47 14147 INV PIPE OUT OF D. BOX 141.30 141.49 /NV END OFA/FE, TRENCH 14.1.00 141.12 !NV END PIPE TTEz CH 141.83, GV,GTEie R EIiQ TON 135.0 135.0 ,4VE2,40E- STONE DEPT// 47 f e03E NOTE: T/7//5 PL dN /S N07,4 ,4 11W1e e.4NTY OF TIE SYSTEM BUT Q !/E�2/F/CQT/ON OF TI -IF LOC.4T/ON OF 711E EX/57//116 Mmc!�E Iff wrF D/SPOS,4� SYSTEM /N NORTH ANDOVER, MA. F02 SCOTT CONSTRUCTION 5C.41 -E: J°=40' DATE: 71251-74- C148 / 5 TIA NSEN /25/94 C148/5TIANSEN SERG1, INC, ll00 . SUMMER STREET HAVERH/LL , MASS. DATE�/ O V. � , % 9 9,3 Sheet / of / BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE 0��6 . JPERMIT # RECEIVED /d /•`Ztn %j APPLICANT J t M (,,2/.�U�/� ASSESSOR'S MAP ADDRESS PARCEL # LOT # _ STREET ENGINEER /�1�15T/,9iYSCjI� ADDRESS /l00 �U/�'►/i'JG,� 57 - PLAN T 3 PLAN DATE %AUG /94 REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED 1- A 0619 r io/v o %lT l IV �5 5 /� l'G6 � )/t/cG 6/9,c a F /&I - /q�i927` a , ; k6/VG, �JC.5 MvST MINIM (,v. /9. / 7. 6,33 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTE ONE W'I'NTER STREET. BOSTON. MA 02108 61 i-292-500 WILLIAM F. WELD Governor ARGEO PAUL CELLUCCI Lt. Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �— —�--F CERTIFICATION Property Address: Address of Owner: Date of Inspection'� � �(If different) Name of Inspector: �i 4l D ! Wive a N/z ,b 1 am a DEP pproveiJ system inspector r pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: d r ' / Mailing Address: ke4l C 9' YI�GI-0�r.�� /," Telephone Number: f-7-2 MAR 24 egg I TRUDY LE ��DB. CERTIFICATION STATEMENT I certify 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: .Jeorasses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ FaiI Inspector's Signature: �l/ i'1 Date: The System Inspecto hall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report 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 buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, of D: Aj SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined 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. If "not determined", explain why not. The septic 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 installed 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. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Webhttp:/twww.magnet.state,ma.us/dep 0 Printed on Recyded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:'/9 �ii�� / t C mor ,vi 1A."r Owner: Date of Inspection: BJ SYSTEM CONDITIONALL PASSES (continued) 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 rbstruet+c�"s-seoved am distribution box isllevelled or replaced The system required pumping than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 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. 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 50 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 50 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 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Lho-Property Address: / /�'�`!'t" C C Y'G� F.Ji /�},CJGI,�!►f Owner: /'-14 p Date of Inspection: `J D] 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 following failure criteria 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 _. N� Brackttp of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. N� Discharge or ponding of'effluenf`to "the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. M Static liquid level in:the distribution 'boO,"above;outlet invert due to an overloaded or clogged ° SAS or cesspool. IVP Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _ /A) Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. VO Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. L Any portion of a cesspool 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. Any 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 water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: 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 gpd 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 400 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 mapped Zone II of a public water supply well) The owner or operator of 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 49� /L Owner: Au) Date of Inspection: 3- -y' -4 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: i 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 inspection. 'V _ As built plans have been obtained and examined.'' Note if they are not available with N/A. , olo, 6/ _ The facility or dwelling was inspected for signs of sewage back-up. _ 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 manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. u.,00' 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 owner) were provided with information on the proper maintenance of Sub -Surface Disposal System. Y Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/2S/97) Page 4 of 10 * , a Property Address: Owner:J� D Date of Inspection: S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION r fit rt Ik. L- A) AlD /3y FLOW CONDITIONS RESIDENTIAL: Design flow: e.p.�./bedroom for S.A.S. Number of bedrooms: �� Number of current residents: 3 Garbage grir:der (yes or no):AZ41) Laundry connected to system (yes or no):� Seasonal use (yes or no)"Y-0 Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): i - w Last date of:occupancy;6 Cc{/lpj .e Q'7 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available Last ,date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no))ff5 If yes, volume pumped: Gallons Reason for pumping /&,S Q-eCi '77NM:� TYPE OVYSTEM Septic tank/distribution box/soil absorption system Single cesspool - y Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A 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) (revised 04/25/97) Page 5 of 10 IN f Property Address: Owner: A-419 Date of Inspection: '9 r -91 BUILDING SEWER: (Locate on site plan) r D h bel d �� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) a/ rG k z-10 /Ud Avd ept ow gra e. Material of construction: _11 6st iron _ 40 PVC _ other (explain) Distance from pr. ate water supply well or suction l meter �_�r(- Dia Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:` a ) (locate on site plan) Depth below grade: Material of construction: Ptoncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: Sludge depth: Distance from top ofsludgeto bottom of outlet tee or baffle: ?A Scum thickness:_ a Distance from top of scum to top of outlet tee or baffle:, ,y Distance from bottom of scum to bottaua-of outlet tee or baffle: How dimensions were determined:ld om Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation o outle# invert, structural integrity, evidence of leakage, etc.) ,L/VL SPT �' rh'Le7' G l'y �i Do. y s e� G GREASE TRAP:_ (locate on site plan) Depth below grade: r 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 for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION (continued) Property Address: ,,--> f%/� *.,c 1 r GA, /—/v A -le Owner: Atl-k Q Date of Inspection: 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 Design flow: gallons/day sir Alarm level: Alarm in working order _ Ye9; No e ) Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) j l Depth of liquid level above outlet invertLt Comments: (note if level and di tributipn equal, vidence of solids carryover, evidencec�f leakage into or out of box, etc.) AvA SA1I Wr e s'r !10�tr "a L—e4A-1a S -P PUMP CHAMBERN J7- (locate on site plan) m Pumps in working order: (Yes or No) 41 Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Owner: 94— v Date of Inspection: q SOIL ABSORPTION SYSTEM (SAS):te (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: leaching pits, number:_ leaching chambers, number: leaching galleries, number: leaching trenches, number,length: 2. 6F�/ieMCF-tri leaching fields, number, dimensions: overflow cesspool; number: ' 4 Alternative system: Name of Technology: Comments: CESSPOOLS: _ (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding,�condition of vegetation, etc.) T PRIVY: _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/]S/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C j SYSTEM /INFORMATION (continued) �i,,�. Property Address: 1% lif%/t- !' f.' 9 1 'rc, It /vL� jWv-0 r Owner: k/4 0 Date of Inspection: Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: _Lef�Obtained from Design Plans on record �ervation of Site (Abutting property, observation hole, .basement sump etc.) ,k7e ermine it from local conditions Check -with local Board of heap,(` Chheeck FEMA Maps t., heck pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) r (revised 04/25/97) Page 10 of 10 !