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Home My WebLink About0130 GUILDFORD ROAD - Health 130 GUILDFORD ROAD, CENTERVILLE A= 172 052 41 1 �llln JJ°�r� UPC 12543 No. 5�R. `Rr c °J� HASTINGS, MN :. l ' 1 V (�/7Z- �% �. BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Of Property Owner's Name . Bate Of Inspection PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and 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 columes 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 avail- able with N/A. __,'The facility or dwelling was inspected for signs of sewage back-up. __The site was inspected for signs of breakout. L,"' All system components, excluding the SAS, 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. _yZ The size and location of the SAS on the site has been determined based on exist- ing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. h • � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLAW C)CNDITIONS If residential number of bedrooms t'/dca/)�L ,D \Y—Y)M hSnumber of current residents YP� garbage grinder, yes or no YL S laundry connected to system, yes or no ,PS_ seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy COAL INFORMATION Pumping records and source of information: > 4LSystem pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type 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, f any) 7 Other (explain) - C Approximate age of all components. Date installed, if known. Source of information: rme Sewage odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / SYSTEM IlNFIORMATION CONTINUED SEPTIC TANK: // (locate on site plan) depth below grade material of construction: !/concrete metal FRP other(explain d' nsions• sludge .depth 3Z-/i 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 Comments: (reccmrendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repair etc. ) &ems re C2e� � DISTRIBUTION BOX:_Q (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, recommendation fro repairs, etc. ) PUMP CHAMBER: —z-/_0 (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of piarrj;m„ and recommendations for maintenance or repairs, etc. ) . t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM nuumATId N oair um SOIL ABSORPTION SYSTEM (SAS) :_L� (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 and number /- /000 leaching chambers and .number leaching galleries and number leaching trenches, number,. length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) sal,/ //a,� CC1V�C • 60 CESSPOOLS (Locate on site plan) : /!I6 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) Ccnments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) PRIVY: (locate on site plan) materials of construction dimensions . depth of solids C c mnents (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INEXI MATION OCNTINUE D SKETCH OF SEWAGE DISPOSAL SYSTEM; include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' o � DEPTH TO GROUNDWATER Z 0 depth to groundwater method of determination or approximation: SUBSURFACE .SEWAGE DISPOSAL.SYSIEM INSPECTION FORM PART C FAILURE C RrrE 2IA Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. Backup of sewage into facility? A/ Discharge or ponding of effluent to the surface of the ground or surface waters? 1v .4 Static liquid level in the districution box above outlet invert? /✓,4 Liquid depth in cesspool, 6" below invert or available volume, 1/2 day flow? N Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial ^ / infiltration? substantial exfiltration? tank failure imminent? /Y Is any portion of the SAS, cesspool or privy, below the high groundwater elevation? Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? . /Y Within a Zone I of a public well? Al Within 50 feet of a private water supply well? IV Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, stet the SAS)? ALess 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, amonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D C�TIFICATION Name of Inspector: ]E�I)Ej4 �O4l Company Name : c !` d�0 f �'U✓�S �tC `c/�� . Company Address Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site .sewage disposal systems. Ch:��Ihave not fo und any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determinimation is provided in the FAILURE CRITERIA section of this form. Inspector's Signature Date Z Original to System Owner Copies to: Buyer (If applicable) Approving authority TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE CCQFbj--Vi 1 � ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) 2 --1 NO. OF BEDROOMS ✓ PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No PF04i e 27� 2�i r y,