HomeMy WebLinkAboutPages from Inspection Report .0pern•Address: 015//V,P67///Ye//, /71 GcJi4/ — S• yr3d4vwv'77" R IE CIE II VIE ED
,.ear //,/ MAY i 5 1001
xi.oclaspeaion:
Subsurface Sewage Disposal System Inspection Form HEALTH DEPT.
Part C
System Information(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent landmarks or benchmarks.
Locate all wells within 100•(locate where public water supply comes into house).
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• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r �! SYSTEM INFORMATION
Property Address: 7 ///d/6/9/7/T7 one/- S y/J.fo/!IILXJ77/
Owner: sNheee'v
Date of Inspection: //47-95
FLOW CONDITIONS
RESIDENTIAL:
Design flow:. //t) g.p.d./bedroom.
. . Number of bedrooms(design):___L Number of bedrooms(actual):_fr
Total DESIGN flow 7/g'G•!?�•
Number of current residents:
Garbage grinder(yes or no):_ D
Laundry(separate system) (yes or no):NO: If yes,separata.&nspection.required
Laundry system inspected (yes or no)
Seasonal use(yes or not:Ag
Water meter readings,if available(last two year's usage(gpd):
Sump Pump lyes or no): N4
Last date of occupancy: pl0NC
COMMERCIAL INDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
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:
Pu/4P L /N /993 ?Et' Df,4J/VE7e
System pumped as part of inspection:(yes or no)410
,If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
)( Septic tankldistribution 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.Attach copy of up to date operation and maintenance contract
light Tank Copy of DEP Approval
Other
• APPROXIMATE AGE of all components,date installed-+f known)-and source ofiwformation: - • 4.1:-7, 27) y-•6 Af?AM.< /O
• MP.c 64i) (/ Cur?) /g5J
Sewage odors detected when-arriving at the site:(yes or no)4)O
revised 9/2/98 Page6of11