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Home My WebLink About0129 HOLLY POINT ROAD - Health 129 HOLLY POINT ROAD,CENTERVILL A= llll �a�.C►�n UPC 12534 �a No.2_ 1_ s' HASTINGS,MN r BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE 1SEWAGE DISPOSALL / SYSTEM INSPECTION FORM Address Of Property Owner's Name L�1�` C1/�� /yU1d/-" - 7,/�j /�: �f'��✓',L�C ��----- Date Of Inspection 'f- -26 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.- ablo. with N/A. The facility or dwelling was inspected for signs of sewage back-up. �- The site was inspected for signs of breakout. d.�'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. _ The size and location of the SAS on the site has been determined based on ecist- ing information or approximated by non-intrusive methods. c� The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 1 / 3 number of bedrooms number of current residents %YD garbage grinder, yes or no S laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: System 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 �i��✓ Single Cesspool 0�✓Overflow cesspool Privy Shared.%system (yes or no) (if yes,. attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: �C ��dPd Sewage odors detected when arriving at the site, yes or no 1�y1 . :° ifs D' r . `ya fi� uf"vfl � 11 �, h , t i SUB3UTtFAC :;SEWAGE DISPOSAL: SYSTEM INSPECTION FORM t 1 SYSPII�I IlQEti�2MATIC[�i ODNTIii[JED (Yocate vn site plan) depth Below grade material of<eonstructon concrete : metal FRP other(explain dimensions `.; sludge depth distance ;from'top of sludge to bottom of outlet tee or baffle scum, thickne.ss dis'tance :.from ;top of scum .to top of outlet tee or baffle distance from_.bottom of scum to bottom of outlet tee or baffle Com tints; . (.recommendation for pump ing, .conditiori of inlet and outlet tees or baffles, depth of liquid:level .in .relation: to outlet invert, structural integrity, g Y. evidence of.aeakage, recommendations for repairs, etc. ) DISTRIBUTION $OX. . (locate on site plan) depth ofliquid level above outlet invert Ca[rrnents (dote if level and distribution is. equal, .evidence of solids carryover, evidence of leakage into :or out 'of box, recommendation fro repairs, etc. ) 77777777777 PUMP C�IAMI3E'ft , (locate: on � te. plan) pumps, in working order,;<yes-or no Coirtm�_nt.S. (note pvdition of pump chamber, `condition of pumps and appurtenances, recarmendatons for maintenance `or repairs, etc: ) } DACE SEWAGE DISPOSAL SYSTEM INSPBcrioN FORM PART. B SYSTEM INFORMATION CONTINUED SOIL ABSORPTION SYSTEM (SAS) :_ (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 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. ) s�i�Oo/e1y Pt CESSPOOLS (Locate on site plan) : number and configuration - 6'0O�n 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, recommendations for maintenance or repairs, etc. ) Ces✓ p,►i�/s AO W'/- ii�� 0 n5 �%7/Q� / ,� D�l�sl�a L !UO e vrcC��tc� PRIVY: f�(� (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, recommendations for maintenance or repairs, etc. ) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION CONTINUED SKETCH OF SEWAGE DISPOSAL SYSTEM; include ties to at least two permanent references landmarks or benchmarks locate all wells within 1.00' r \ 5r7' /0,1ro��o��e III 071 DEPTH TO GROUNDWATER depth to. groundwater method of determination or approximation: II SUBSURFACE .SEWAGE,DISPOSAL.SYSTEM INSPECTION FORM PART C FAILURE CRITERIA 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? Discharge or ponding of effluent to the surface of the ground or surface waters? /rim Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6" below invert or available volume, 112 day flow? 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? A/ Is any portion of the SAS, cesspool or privy, below the high groundwater elevation? Al Within 50 feet of a surface water? I Within 1OO .feet of a surface water supply or tributary to a surface water supply? y Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, net the SAS)? -_-_�__ 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, amonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector: Company Name 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. Check one: V I have not found 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 Original to System Owner Copies to: Buyer (If applicable) Approving authority l -