Loading...
HomeMy WebLinkAboutMiscellaneous - 151 Raleigh Tavem 4k 1 d am"On #am% f To) Form No. 1 ,.10RTly 19—L oAPPLK .; A "/ ADRA TEDWpPa`�5 v �SSACHUSE� Applicant AME \ TELEPHONE Site Location I Engineer NAME � TELEPHONE Test/I nspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee < Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. E - Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH ?Qh�s,ED 19�� t� N APPLICATION FOR SITE TESTING/INSPECTION rED ��SSACHUSE��h Applicant AME ADDRESS TELEPHONE Site Location ] Engineer NAME / ADDRESS TELEPHONE Test/Inspection Date and Time Qu, /q CHAIRMAN,BOARD OF HEALTH Fee ` * Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH qA BOARD OF HEALTH �n OL J 19 O A APPLICATION FOR SITE TESTING/INSPECTION ��SSACHUS���� Applicant NAME ADDRESS TELEPHONE Site Location C G Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee--7 ���' �"�'t Test No. = `{ S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. DATE.- LOCATION. ATE:LSCATION. � r=NGINLE, .. BOH WITNE=SS: PERCOLATION TEST >'= L BOTTOM DEPTH OF PERC TEST. TIME OF SGAK: _ V�' (At le s 1 minutes Icnc) TIME AT12" TIME ATc" �_ a � 4� 7 TIME AT OVE ,NIG}-rT SGr,K TIME RTED 6 J NEXT DA" SOAK: ,L / ees; TIME .l"I,T 1 2" ' - f ^ 111/1 E r L CJS T 1NIE A T ., - ��, X43 ►`"��""' ea le x�-a'�t- ..*��i k F c -" t 4 �4 I" i� �}F�r �'ati�"� s} -� s �'+ '•�}A L, -}yt ''J-y -- v � x,�Y x C � L 1.7 h �fW 7 t p to i, �t x IJ i� i tr t4`,x � .} ti ( �1� "� !—r:�rxrg ' r k3 y,�fi�cc+• sp � ��,"` +, i BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS 5 . DATE: - LOCATION OF OIL TESTS: c2q VaA-&- JC-J . Assessor's map & parcel number: OWNER:Ne/G �-ZA / TEL. NO.: ADDRESS: Z 'AWK �� ENGINEER: SSD TEL. NO.:-3S2- /d'7 Z CERTIFIED SOIL EVALUATOR: L� Intended use of land: residential subdivision, single anvil il, com ercial Repair testing Undevel d I t N. A. Conservation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan klL,, 3�1--> 3. Fee of$275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS 5 DATE: LOCATION OF 801L TESTS: 02q 9� Assessor's map & parcel number: OWNER:N)ClG ��-ZA) TEL. NO.: ADDRESS: Z � �'�� ;� ENGINEER: �':�qZ�So TEL. NO.: .���Z CERTIFIED SOIL EVALUATOR: �� Intended use of land: r sidential subdivision, single family home, commercial Repair testing Undeveloped lot testing N. A. Conservation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) _____ 2. Plot planter s�uD 3. Fee of$275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1%100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Town of North Andover t rORTN OFFICE OF 3� . '`•' ��o COMMUNITY DEVELOPMENT AND SERVICES 30 School Street ; North Andover,Massachusetts 01845 WMLIAM J. SCOTT ��SS�cHusE��s Director OUTSIDE CONSULTANT ESCROW AGREEMENT NORTH ANDOVER BOARD OF HEALTH Agreement is made this--111�y - ,1✓ between the r Town of North Andover and of for Soil Tests Plan KNOW ALL men by these present that the Applicant hereby provides the Town of North Andover with a check in the sum of $ , to be deposited in an escrow account for the Town of North Andover and has deposited in an interest— bearing account as designated by the Town Treasurer to be expended by the North Andover Board of Health to insure payment to any outside consultant (s) for Soil Tests, Plan Review for the above referenced project . This agreement shall remain in full force and effect until the specified project has reached completion , o rd of Health Chairman Applicant or Ag nt STEVEN J. D'URSO 5-20/110 1326 22 LILLY POND RD. At 4 BOXFORD, MA 01921 Date Pay to $1 7rr 0 the order of M R 8 Dollars mom. 0 FLEET 56865 SHAWSHEEN OFFICE ANDOVER,MASSACHUSETTS 01810 ° For A / r�eo M, 38-9535 is 0 L 1 0 0 0 2 0 61: 03249 3 5 0 5 5 ii' 3 2 6 i MAIN STREET BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 - APPLICATION FOR SOIL TESTS DATE: LOCA TION OF 801L TESTS: Assessor's map & parcel number: OWNER:N4'/1-' .s�� TEL. NO.: ADDRESS: Z C) ENGINEER: sl$ TEL. NO.: 31Z /617 CERTIFIED SOIL EVALUATOR: S te' X Intended use of land. res.dential subdivision, singlemily oma,�'o ercial Repair testing Undevelo d to esg� N. A. Conservation Commission Approval: IV THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan ktti -S�uD 3. Fee of$275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Town of North Andover NORTH OFFICE OF ���,,��� ,•�tia 3 " o COMMUNITY DEVELOPMENT AND SERVICES )0 . - - 30 School Street WUIJAM J. SCOTT North Andover, Massachusetts 01845 ��5� „o;,�� 5' S�CHUSE Director OUTSIDE CONSULTANT ESCROW AGREEMENT NORTH ANDOVER BOARD OF HEALTH Agreement is made this--I%&y - 15- between the Town of North Andover and J of Q, for �Tests, Plan Review 2q KNOW ALL men by these present that the Applicant hereby provides the Town of North Andover with a check in the sum of $ , to be deposited in an escrow account for the Town of North Andover and has deposited in an interest- bearing account as designated by the Town Treasurer to be expended by the North Andover Board of Health to insure payment to any outside consultant ( s) for Soil Tests, Plan Review for the above referenced project . This agreement shall remain in full force and effect until the specified project has reached completion . o rd of Health Chairman Applicant or Ag nt rti�+� na Lo STEVEN J. D'URSO 5-20/110 1326 22 LILLY POND RD. BOXFORD, MA 01921 Date Pay to the o rder of s oDollars o FLEET 56865 SHAWSHEEN OFFICE ANDOVER, MASSACHUSETTS01810 For x) G ,( / ' e'q JIM 18-95 35 1:0 1 L 0 0 0 20 61: 0 3 2 4 9 3 SOS S" 3 2 6 i NIAIN STREET t � FILE# 107 Forest St Middleton,MA 01949 (508)774-2772 SEPTIC & DRAIN UAVAII SERVICE MTV i;„_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME:' PROPERTY ADDRESS: 2�/�IL�C al N /z� ADDRESS OF OWNER: (if different) DATE OF INSPECTION: NAME OF INSPECTOR: •THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY • 107 Forest St. , FILE# Middleton,MA 01949 (508) 774-2772 SEPTIC & DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /� CERTIFICATION Property Address:2f/"G11/� Address of Owner: Date of Inspection: 6r7_116,00 (If different) Name of Inspector: I am a DEPS provgd system in-ector ursu�annt"to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: / /2? e Mailing Address: 07 Telephone Number: ;9_� �i�-Z77Z 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: _ Passes _ Conditionally Passes Reeds Further Evaluation By the Local Approving Authority Fads Inspector's Signature: �vJjior r$ Date: The Svstem Inspector shall submit a copy this ins 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, Or O AJ SYSTEM PASSES: -AL 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 failfire criteria not evaluated are indicated below. COMMENTS: B) 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 o, 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. (ravisod 04/25/97) Page 1 of 10 i DEP on the World Wide Web: http.uwww.mapnet.state ma.us/der 0 Printed on Recycled Paper FILE# ! l3J` " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: p Date of Inspection:/5,,7-S � . 9� B) SYSTEM CONDITIONALLY 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 Het ). 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(s). The system will pass inspection if ith 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 pri,^' 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 15 FUNCTIONING INA 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 J� 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 supn!v'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 fret 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 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D) SYSTEM FAILS: Y' mus: indicate ether "Yes" or "No" as to each of the following: ) have determined that the system,'violates one or more of the following failure criteria as defined in 310 C.MR 15.303. The Das s for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to torte:- the failure. y s No t/L 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 waters due to an overloaded or clogged SAS o- cesspool. Al Stant liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flov.. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets;. Humber of times pumped_. W ALA portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. ALAAny porton of a cesspool or privy is within 100 feet of a surface water supple or tributary to a surface water supply. _• LSC` Any porton of a cesspool or privy is within a Zone I of a public well. NA 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 rJ acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water' analysis for cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No"as o each of the following: The following criteria apply t arge systems in addition to the criteria above: The system serves a facil' • with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to ublic health and safe and the environment because one or more of the following conditions exist: Yes No th stem is within 400 feet of a surface drinking water supply e systis within 200 feet of a tributary to a surface drinking water supply the system is ted in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone'll of a public water sup well) The ner or operator of any such syste hall bring the system and facility into full compliance with the groundwater treatment program rkVirements of 314 CMR 5.00 and 6.00. P ease consult the local regional office of the Department for further information. (revised 04/25/97) Papa 3 of 20 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ;?q MIX- 1W Owner: p Date of Inspection: /j OGT!� 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 inspection. As built plans have been obtained and examined. Note if they are not available with n;A. J _ 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 N%as 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. / The size and location of the Soil Absorption System on the site has been determined based on: The facility owner Land occupants, if different from owner were provided with information on the proper maintenance of / Sub-Surface Disposal Svstem. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if anv of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) Page 4 of 10 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propem Address: Owner: Date of Inspection FLOW CONDITIONS RESIDENTIAL Design fiovv - p.d./bedroom for S.A.S. Number of bedro ms,3— Number of current residents: Garbage g,. der (yes or no): Laundry co-�ected to syst�rt� ryes or no): d Seasonal use lyes or no):b7- / /� _ Water meter readings, if a able (last two (2i year usage (gpd): V Q (u_�j� Sump Pump Ives or nol: Last date of occupanc}•:_�:YLL��� C MMERCI4UINDUSTRIAL• Typ of establishment: Design 'low:_gallons/da% Grease Ira resent: Ives or _ Industria! �%a Holdine T nk Dresent: (yes or no, 'ion-sanitan Nast disc rged to the Title 5 system: (yes or no)_ Water meter reading if available Last P/ofoancvOTHLast dancv GENERAL INFORMATION PUMPING RECORDS and source of gy' formation /+� ll System pumped as part of inspection: (yes o�no) 0 If yes, volume pumped: -allons Reason for pumping — P OF SYSTEM 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) UA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known)and source of information: __�/� V/ Sewage odors detected when arriving at the site: (yes or no) (revised 04/2S/97) Page 5 of 10 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: /� ,Vr-'d BUILDING SEWER: [�-/ 7/ (Locate on site plan) Depth below grad : / Material of constructs n: ✓cast iron _40 PVC_other(explain) Distance from pnvate water supply well or suction lirt Diameter � ' Comments: onditign,,of joints, venting, evidence of leakage, etc.) SEPTIC TANK: ,��� (locate on site Ian) Depth below grade: co Material of construction: - ncrete _metal Fiberglass _Polyethylene _other(explain) If tank is metal, Inst age = Is age confirmed by Certificate of Compliance =(Yes/Noi Dimensions: D X.S A42:1,o>/>/ltiPd(Sy 2 Sludge depth- 61 Distance from top of sludge to bottom of outlet tee or baffle: ?_g Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: .� Distance from bottom of scum to bono of gutlet tee or affle: How dimensions were determined: Comments: (recommendation for pumping, condition inlet an tie ees or ba s, de of li id I ,el i ela outlet invert, sLru ral in Verity evidence of ge, a .) A�pis, Ito r _e qQ GREASE TW:--A/— (locate RAP:(locate on site plan) Depth below grade+: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top f scum to top of outlet tee or baffle: Distance from, ttom of scum to bottom of outlet tee or baffle: Date of last p ping: Co. . (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural ,integr evidence of Ieakage;.,etc.) (revised 04/]S/97) Pago 6 of to FILE# �XMd 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , J SYSTEM INFORMATION (continued) PropertN Address: ?� /W/}- +�� ONner: .;?Avcor Date of Inspection: 107©Cr TIGHT OR HOLDING TANK: 'Tank must be pumped prior to,or at time, of inspection) (locate on site plan; Depth below grade: aterial of construction: _concret _metal _Fiberglass _Polyethylene _other(expl�in) Dimen'ons: capacity. - Pons Design flo , gal)ons%da% Alarm level.\ Alarm in working order_ Yes; _ No Date of prewo s mping Comments: (condition of let `, condition of alarm and float switches, etc.) i DISTRIBUTION BOX:Yes �Q�jGGj W-d4��(locate on site pian: Depth of liquid level above outlet inert: Comments note if level and dist lbution is equal evid nce of sol s car over, vide `e of leakage into ou of ox, etc.) � r t PUMP CHAMBER: (locate on site plan) Purttps in workinVOL z or Not Alarms,in workin (Yes or No, Comments: (note conditipn 'f pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/87) Page 7 of 10 FILE# ! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /�� k rG/ Owner: 21re, Date of Inspection:/ /2p �3 SOIL ABSORPTION SYSTEM (SAS)J4 (locate on site plan, if possible; ex(;47— not required, but may be approximated by non-intrusive methods) If not determined to be , ep resent explain: P Ca rl.SYl//1lP/' Type: leaching pits, number:_ leaching chambers, number:` leaching galleries, number: leaching trenches, number,length: ��� leaching fields, number, dimensions: P �pf V X�D overflow cesspool, number: Alternative system: Name of Technology: Comments: (note c ndition of soil, sjgns of h dra tic failur , leve of ond'ng, ondition of vegetatio , etc.1 , s rr dt.pr lZOLYW '64?dk 4X IT12L et2d dV1F LA, 110 CESSPOOLS: (locate on site plan) umber and configuration: Depth-top of liquid toin t invert: Dept of solids layer: Depth f scum layer, Dimenst Ts/conruction: ool: Materials oaf Indication owaterinspool must be pumped as part of inspection) Comore ts: (note ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Mateals of constru ion: Dimensions: Depth`ofesolids: Comments (note conditio of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97 • ) Page 8 of 10 FILE# e¢ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C G SYSTEM INFORMATION (continued) Property Address: �� wl Owner. �� Date of Inspection,/,,9 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) tck yarj- House, pow dont a�a� i. �c S 0 Tank I � (=aviaad 0{/2S/97) ?ago 9 of 10 BILE# SUBSURFACE SEWAGE DISPUSAI SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2��u//�'/�/2/ t Owner: �ve/l.Sbyl Date of Inspection%���. Depth to Groundwater /✓*Feet Please indicate all the methods used to determine High Groundwater Elevation: //A Obtained from Design Plans on record ✓ Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how vouu established the High Groundwater Elevation. Must be completed) /- ��IP/P S /1/l� S' rJl S�/ty� cJryl /•� >' .5'�t �� �O J'//, yr GG�4{ �� IvFeae lell 7e- al?"elO Ale ler Aj�,,d alk,��9, Ive 4vl lam r V&Ay et)14,4, IL5a 00;0PU03PFe-,oiw A� (revised 04/25/97) Papa 10 of 10