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HomeMy WebLinkAbout0067 ELLIOTT STREET - Health G7 ELLIOTT ST. , CENTERVILLE A =23J 122 .l f ,r a �y/gllpip///{/J �RE�YC�oc UPC 12534 1Vo. 2� 153LOF{ HASTINGS. UN COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMF'NTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617) 292-5500 TRUDY CORE ARGEO PAUL CELLUCCI Secretary Governor DAVID B. STRUHS SUBSURFACE SEWAGE DISPOSAL SYSTEM IINSpECTM FORM Commissioner PART A CERTIFICATION Property Address: b q Na me of Owner JrZ GWS �q/4dZ�sl Date of Inspection: J^ 7" ! 1 Address of Owner: _T 5'l� e�{SToplus l le- Name of Inspector:(Please Print) Vats Ls / 1 am a DEP approved sy3 urapsetor pumuant t�e- Section 15.340 of Title 5(310 CMR 15.000) Cornparijr Name: o TMailing Address: STD Telephone Number. CERTIR ATION 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-Sitesewage disposal systems. The system: _T Passes Conditionally Passes Needs Further Evalua'on B the Local Approving Authority Fans 3�Z Zgs7. Insprctor's Signa:<aue:ci3 Dace: y�/ - The System Inspector shall submit a copy of this inspection report to the Ap proving Authority(Board of Health or DEP)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`Environmentah protection. The original should be sent to vm system owner and copies sent to the buyer, if applicable,and the approving authority. I Cc �' •C NOTES AND COMMENTS vt j revised 9/2/98 Page I or 11 j Pmted on secycke Pape. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM o PART A CERTIFICATION(continued) Property Address: ��7 t7/ o nr --r,—, 3wner: dl�f� S�� Date of Inspection: 17 INSPECTION SUMMARY: Check A, A C, or D: A. SYS PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure 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 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 120)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 complying septic tank as approved by the Board of Health. 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). 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 wiltpa=inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A // CERTIFICATION(continued) Property Address: rP FLU O t?' S'- Owner: r Date of inspection: 5 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of He"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 IN ACCORDANCE WITH 310 CMR 15.303 0 Hb)THAT THE SYSTEM IS NOT FUNCTIONING1N A-MANNER WHICH yALL PRQTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 ANY)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 of 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 colifo►m 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 vaFid). 3) OTHER revised 9/2/98 Psee3orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(eor*%nd) Property Address: ry 7 �=CL c o :-y ST C'L—, /if g . O wnar: �- Date of Inspection: D. SYSTEM FAILS: /7 qs You must indicate either "Yes" or "No" to each of the following: 41 1 have determined that one or more of the following failure conditions exist as described 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 facilitror system component due to an bvedooded orgylegged SAS or-cesspool. -•� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or -esspool. 'Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. ..iquid depth in 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). Number of times pumped_. 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. 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" 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 surfoce4►4nking•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) i The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: {terr/ Date o �'`f f inspection: r. ,7 — ! -7 jg Check if the following have been done: You must indicate either "Yes" or "No" at to each of the following: Yes No / Pumping information was provided by the owner, occupant,or Board of Health. ]L _ None of the system components haw,been pumped+focatJeaft two weeks and-the system h rates tperiod. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained end examined. Note if they are not available with N/A. V _ The facility or dwelling was inspected for signs of sewage back -up. k-u . 9 P _ The system does not receive non-sanitary or industrial waste flow. Z _ The site was inspected for signs of breakout. ]Z _ 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. A The size and location of the Soil Absorption System orrthe site has been determined based on: fII _ Existing information. For example, 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) 115.302(3)(b)1 The facility owner(and.occupants.if differaut from..owuwl.wwe.provided.with iaforrrtatiomon.tha j rz pw•Rain•ana_ Gf Subsurface Disposal Systems. Yevised 9/2/98 Page 3of11 SURSUnFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property address: (o 't C—"G Lr o r—T - Data of inspection: FLOW CONDITIONSRESIDENTIAL: ` Design flow: 3 o g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow 3 3 o Number of current residents:_- Garbage grinder(yes or no):__&o Laundry(separate system) (yes or no):.AL; If yes,separateinspection.required Laundry system inspected (yes or no) rC� Seasonal use lyes or no):�p Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no):--do Last date of occupancy:_____ =j COMMERCIAL/INDUSTRIAL- Type of establishment:_ N Design flow:_ grid ( 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: System pumped as part of inspection:(yes or no)-LjQ9 If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Q✓r�'X�o C..�"5 pp aS Septic tank/distribution box/soil absorption system _49— Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,If any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other �lle:P ���u..} C- S � APPROXIMATE AGE of all components,date installed4if known)-end source 4f4"ferrnation: Sewage odors detected when arriving at the site:(yes or not revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icorttinued) Property Address: 6,1 gt-4�(_r O r T- ,T e�� Sul, Owner: Date of Inspection: BUILDING SEWER: ' t (Locate on site plan) N I ' Depth below grade: _2Q` Material of construction: ✓cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting,evidence ofJeakage,-etc.) SEPTIC TANK:— ._G0 5 oO L J (locate on site plan) {/ Depth below grade: -'�5i� � Material of construction:L-ctincrete_metal_Fiberglass _Polyethylene other(explain) t?Z—.,l c If tank is metal,list age_ Is.age-confirmed by Certificate of Compliance_(Yes/No) Dimensions: L Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How dimensions were determined: Comments: Done- i(recommendation for pumping, condi ' n of inlet and outlet tees or-baffles, dept squid level in relation to outlet invert, structuraiinte rity, evidence of leakage, a c.) 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 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.) i revised 9/2/98 Page 7of11 SUBSUnrACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C JJ SYSTEM INFORMATION(corrtirwed) Property Address: o rY �T C`= (� /o Dyr oe f Inspection. A. s-/-7 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 Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments.-- (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 page sortl SUBS6nfACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM WFORMATION(continued) Property Address: 6� ��ibT-r T7 S� Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_.. ` (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits,number: leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool,number:-12 �� Alternative system: - Name of Technology: Comments: (note condi' of soil, signs of hydraulic failure,level of ponding, damp soil,cord''on of vegetation, etc.) t it CESSPOOLS:_ (locate on site plan) Number and configuration: -yz [L—^ =�le�.&4, 0-,C Depth-top of liquid to inlet invert: Depth of solids layer: �.7 Depth of scum layer: /K/ &.rr— Dimensions of cesspool: es Materials of construction: (��,� _ Ali Indication of groundwater: 7 �' inflow (cesspool must be pumped as part of inspection) Y', Comments: (note condition of$oil, signs of hydraulic failure,l�ev /1 IF ponding,condition getation,etc.) 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 9/2/98 Page 9of11 SUB, FACE SEWAGE DISPOSAL SYSTEM INSPECTION.—AM PART C SYSTEM INFORMATION(continued) Address: G [ CLL(b rT 5�1— C4glC?74jpcpw 04//Z /jfjf s-/7- .9 Report name Soil Type_ Typical depth to groundwater Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep IM Slope Surface water Check Cellar Shallow wells i Depth to Groundwater Ab Feet ficate all the methods used to determine High Groundwater Elevation: ;lined from Design Plans on record terved.Site(Abutting property,observation hole,basement sump etc.) ermined from local conditions rcked with local Board of health -cked FEMA Maps cked pumping records cked local excavators,installers d USGS Data how you established the High Groundwater Elevation. (Must be completed) -' :d 9/2/98 Page llo[u SUBSU..:ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: i07 ,rl b c-r-►' S'T C8�bT :r-011k-. hti l.- Date of Inspection: si-7 - �� Sg� /07 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) boy 9� I 12 i �7to revised 9/2/96 Page 10of11 i Z (.69,0 d 0 z) D d. 4U� <�cj 1�a N t Lj�y c ~ gLa ,. I iwl I;- 0 99e 9`4 ~ BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTOr4S MILLS, MA 02648 509-771-9399 508429-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Z Z� CERTIFICATION Z Property Address: Date of Inspection: /a,/7/cl'I�' Inspector's Name: Owner's k ess: CER'I'iTICATION STAT .M .NT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of bn-site sewage disposal systems. The System: Passes 'Conditionally Passes Y Needs Further Eval on B Deal Aproving Authority `Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 STIMMARY. A)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"",;Va' i below. ;E B)SYSTEM CONDITIONALLY PASSES; k ;One or more system components need to be replaced or repaired. The system,`upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,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,cracked,structurally unsound,shows substantial infiltration or 'eAltration,'or tank failure is imminenC The system will pass inspection'if ft existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high'atatic 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): - I- } Y u 3a' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)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(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 fiuther 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 WELL 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 r salt marsh. of a bordering elated wetland o a Cesspool or privy is within 50 Feet g vegetated 2)SYSTEM WILL FAIL UNLESS THEBOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE-)"DETERMINES THAT-THE SYSTEM,IS FUNCTION- ING IN A MANNER THAT.PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface 1 or'tribu to a surface water supply. water supply tary PP Y The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less i than 3 ppm. D) STEM FAIIS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CNIR 15.303. The basis for this determination is identified below. The Board of Health, she d be contacted to determine'what will be necessary to correct the failure. ' Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground,or surface waters due to an overloaded or,-clogged SAS,or cesspool. _Static liquid levei in.the'distri6utiori box above outlet`invert Ad`ue to an overloaded or clog- ged SAS.or cesspool. F.. Liquid depth in cesspool is less than 6"below invert of 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). Number of times pumped_ -2 A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (con(inued) 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. 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: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a signifit-nt. threat to public health and safety and the environment because one or more of the following,r ` conditions exist` a , The system-is within 400 Feet of a surface drinking water;supply. ' :The system is mithin.200-Feet of a tnbutary to a surface drinking waters supply r"#:- 4,- The system is located in a nitrogen sensitive area Interim Wellhead'Protection'Vea `'J„ OWPA)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-complianoe*ith'the groundwater treatment program requirements of 314 Chill 5.00 and 6.00. Please consult the'local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if following have been done: ping information was requested of the owner,occupant,and Boaid of Health. -5A+ None of the system components have been pumped for adeast two weeks and the'syWn has ,been receiving normal flow rates during that period. Large volumes-of waterhave�not'lt 6l introduced into the system recently or as part of this inspection. '" s As-built plans have been obtained and examined. Note if they are not available wiW-WA.,.:_, =The facility or dwelling was inspected for signs of sewage back-up: " s The system does not receive non-sanitary or industrial waste flow. site was inspectedtor signs of breakout. {All system components,excluding the Soil Absorption System,have been located onrsite. .k— ]K septic tank manholes were uncovered,opened,and the interior of the septic.",vas in- spocted condition`of baffles or lees,material of construction'dimensrons,y depthi bfrLt d, v � of sludge,depth of scum. r' 3 s.i T 8uwi ,The size and location of the Soil Absorption System on the site has been determined,baserfPci existing information or approximated by non-intrusive methods. -3- �t 4 ,,y i�.i ks- f' -'u:, - t� , i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION / FLOW CONDITIONS Design Flow: Ions Number of Bedrooms: Nu b�er of Current Residents: .�' _ Garbage Grinder: Laundry Connected To System: J(/ Seasonal Use: /fin. Water Meter ,if available: Last Date of Occupancy: COMMFRCLAi/iNDLiSTR1AI Type of Establishment: Design Flow: gallons/day" Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER; Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 7j/Y, �/9 R y System Pumped as part of inspection:C� if yes,volume pumped: Gallons Reason for pumping: F... TYPE OF SYSTEM: Septic TaWdDistribution Box/Soil Absorption System , Single Cesspool Overflow Cesspool ' Shared System(If yes,attachprevious inspection records,if any).. - Other(explain)-7zo , n 0/11,e ac ,amd Ad APPROXIMATE AGE of all-components,date installed(if known)and source of inonnation: ' 02 Sewage „ detected when arriving at the site: w -4- a A,a•, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j: • , :'.—PARTC. GENERAL INFORMATION (continued) SEPTIC TANK: (Depth below grade! Material of Construction: concrete metal. FRP Other: Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from.bottom of scurn to bottom.of outlet tee or baffle:. - Comments (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid�A` level in relation to outlet Invert;structural integrity;evidence of leakage,etc.) GREASE TRAP: NCO Depth Below Grade: Material of Construction: concrete_metal_FRP_Other Dimensions:; Scum Thickness: , Distance from top of scum to top of outlet tee or baffle:" 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.j " ''`} fir ., - r €4 . TIGHT ORI HOLDING TANK:`F Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain)�?.Wf'' Dimensionsa Capacity: gallons Design Flo«•: Rallons/day ' ' ` • v. Alarm Level.: Comments: (condition of inlet.tee,condition of alarm avid float switches.etc.) ;t i%' DISTRIBUTION BOX:_,,�L)D Depth of liquid level above outlet invert: Comments:(note if level and distribution is equal,.evidence of solids carryover.evidence.of leakage into-I.— or out of box,etc.) PUMP CHAMBER: ;.. _.. Rumple in vvotldng order" Commeuts:(note condition of pump chamber,condition of pumps and appurtenances,etc.) F 11 n: a ki ' �r f .�;� G<�.#S ,,,+,.a t t„am 4-.k:':'a t7:" t+�i , � a ��d s f;ir �'i .�.. ?a3c ,�Cm.'.,�r ,Y try,� �-.�.•vm +� �..+� :;Q'�,WR i. „+� � fS. ��;=Y� a �f�'� �F�lm i' � j t ,`� r t .'`e.Y�v�^'' '} d .. ..v.'kl 1 ,C W,.�f rei „��" '`t..:♦ '�. I j i • i, • i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP19CTION FORM PART C i SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): t/ =w (Locate on;site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) :'Knot determined to be present,explain: Type: j Leaching pits,number: Leaching chambers, number: Leaching galleries,number:. Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: / Co :(note condition of soil,si ns of h dra H failure et of ponding,condition o vegetation, etc.) _ CESSPOOLS: Number and configuration: '1' Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of Cesspool: ' S"le Materials of construction; ' " Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comm ts:(note condition of soillc, i of by ulic fail, level of ponding,conditi n ofve n , i - / - i PRIVY:. /vV - .. it Ft .i.,•..?�' Materials of construction: Dimensions: Depth of S�Hds: _----- Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,„.F.. etc.) L,. ° .�x � I i i R. 0 i e I is I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. 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