HomeMy WebLinkAbout0145 KNOTTY PINE LANE - Health 145 Knotty Pine Lane
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP
PARCEL
.� � --
TITLE 5 got
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 145 Knotty Pine 1L4 Nig _
Centerville SEC EIV E
Owner's Name: Austin O'Brien
Owner's Address:
MAR 3 12003
Date of Inspection: 3/21/2003
TOWN OF BARNSTABLE
Name of Inspector: (please print) Kevin J. Sullivan HEALTH DEPT.
Company Name: Ready Rooter
Mailing Address: P.O.Box 371
Sandwich,,MA 02563
Telephone Number: (508)888-6055
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 the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System:
i/ Passes
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails
Inspector's Signature: ,�� /' �.....�.. Date: -3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 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
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 145 Knotty Pine
Centerville
Owner: Austin O'Brien
Date of Inspection: 3/21/2003
Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D
C. S`ystem Passes:
,— have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 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 ap ved by the Board of Health,will pass.
Answer yes,no or not determined (Y,N,ND)in the for the owing statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the eptic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or k failure is imminent.System will pass inspection ifthe
existing tank is replaced with a complying septic tank proved by the Board of Health.
*A metal septic tank will pass inspection if it is struc ly sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is Table.
ND explain:
Observation of sewage backup or br out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, ed or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system req ' ed pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if( approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 145 Knotty Pine
Centerville
Owner: Austin O'Brien
Date of Inspection: 3/21/2003
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require fur/surface
ion by the B d of Health in order to determine if the system
is failing to protect public health,safety onment.
1. System will pass unless Board ote es in accordance with 310 CMR 15.303(lxb)that the
system is not functioning in a mh ill protect public health,safety and the environment:
_Cesspool or privy is within 5rface waterCesspool or privy is within 5ordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,' any)determines that the
system is functioning in a manner that protects the public health,safety and ovironment:
_The system has a septic tank and soil absorption system(SAS)an a SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_The system has a septic tank and SAS and the SAS is with' a Zone 1 of a public water supply.
_The system has a septic tank and SAS and the SAS is 'thin 50 feet of a private water supply well.
_The system has a septic tank and SAS and the S is less than 100 feet but 50 feet or more from a
private water supply well". Method used to dete me distance
"This system passes if the well water analysi ,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compound=indica that the well is free from pollution from that facility and
the presence of ammonia nitrogen and itrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the alysis must be attached to this form.
3. Other:
I
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 145 Knotty Pine
Centerville
Owner: Austin O'Brien
Date of Inspection: 3/21/2003
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ -Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ _jZ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
/Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or
cesspool
iOLiquid depth in cesspool is less than b"below invert or available volume is less than %Z day flow
'`Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Z Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of 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 50 feet of a private water supply well.
y/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. [This system passes if the well water analysis,
performed at a DEP certified laboratory,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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails. I have determined that one or more of the above criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must sere facility with a design flow of 10,000 gpd to 15,000
You must indicate either"yes"or"no"to each of the llowing:
(The following criteria apply to large systems in ad tion to the criteria above)
yes no
the system is within 400 feet of a su ce drinking water supply
the system is within 200 feet of a ibutary to a surface drinking water supply
_the system is located in a nitr en sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water su ly well
If you have answered"yes"to any uestion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the lar system has failed.The owner or operator of any large system considered a
significant threat under Sectio E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner sh uld contact the appropriate regional office of the Department.
r
Page 5 of 11
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 145 Knotty Pine
Centerville
Owner: Austin O'Brien
Date of Inspection: 3/21/2003
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health
,'Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
_ Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
- T
Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different than owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
Existing information.For example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 145 Knotty Pine
Centerville
Owner: Austin O'Brien
Date of Inspection: 3/21/2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): --2�, Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 733cp 6,p,4r
Number of current residents: _
Does residence have a garbage grinder(yes or no): i?�
Is laundry on a separate sewage system(yes or no):h-24if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):A_2,�
Water meter readings,if available(last 2 years usage(gpd)): -Q doh = :5 ?? C 4?a
Sump Pump(yes or no): �
Last date of occupancy:
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203) gpd
Basis of design flow(seats/persons/sqj }:
Grease trap present(yes or no):
Industrial waste holding tank p nt(yes or no):—
Non-sanitary waste dischar to the Title 5 system(yes or no):—
Water meter readings,if 'fable:
Last date of occupan se:
OTHER(desc ' ):
GENERAL INFORMATION
Pumping Records
Sourceofinformation: %t,, � ��
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPF,OF SYSTEM
eptic tank,distzilauticu�.he ,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
�_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,date installed
(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):,620
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 145 Knotty Pine
Centerville
Owner: Austin OBrien
Date of Inspection: 3/21/2003
BUILDING SEWER(locate on site plan) ,
Depth below grade: Q '
Materials of construction:__Stodast iron_40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
"-C-s rev' VC2 Ss=�� c
SEPTIC TANK:_(locate on site plan)
Depth below grade:
Material of construction: concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):`(attach a copy of
certificate)
Dimensions: 4�`
Sludge depth: y "
Distance from the top of sludge to bottom of outlet tee or baffle:
Scum thickness: tjz "
Distance from top of scum to top of outlet tee or bale: 6
Distance from bottom of scum to bottom of outlet tee or baffle: /7
How were dimensions determinedr—,,-,L v
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
r
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 outl tee or baffle:
Distance from bottom of scum to botto of outlet tee or baffle:'
Date of last pumping:
Comments(on pumping recomm f ations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidencb of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 145 Knotty Pine
Centerville
Owner: Austin O'Brien
Date of Inspection: 3/21/2003
TIGHT or HOLDING TANK: (tank must be pumZatt' of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete_metal fiberethylene other(explain):
Dimensions:
Capacity: /switches,
Design Flow:
Alarm present(yes or no):
Alarm level: Alarm ir no):
Date of last pumping:
Comments(condition of alarm ):
DISTRIBUTION BOX: (if present must be o ed)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(not if box is level and distributio 0 outlets equal,any evidence of solids carryover,any 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, ndition of pumps and appurtenances,etc.):
Page 9 of l I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM
INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 145 Knotty Pine
Centerville
Owner: Austin O'Brien
Date of Inspection: 3/21/2003
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
aching pits,number:-1
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): g
CESSPOOLS: (cesspool must be p ped as part of inspection)(locate on site plan)
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 groundwat inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on sit/pl ,
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 145 Knotty Pine
Centerville
Owner: Austin O'Brien
Date of Inspection: 3/21/2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
� S
A ;2 = 3 �
! 3 C
I
• Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM"INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 145 Knotty Pine
Centerville
Owner: Austin O'Brien
Date of Inspection: 3/21/2003
SITE EXAM
Slope
Surface water
Check cellar i/"
Shallow wells
Estimated depth to ground water: l '-feet
Please indicate(check)all methods used to determine the high ground water elevation:
_\,,�btained from system design plans on record—If checked,date of design plan reviewed: �Jc `�� 10y
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with the local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
TOWN OF B ARNSTA.13,LE
LOCATION , 11 VfIN6 et NSC SEWAGE #
VILLAGE GAL t� ,� ASSESSOR'S MAP & LOT Ion
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) �X
NO.OF BEDROOMS
BUILDER OR OWNER CU 6
PERMTTDATE: OMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wcdands exist
within 300 feet of leaching facility) 11 A. Fee;
Furnished by 1,C
1
t- Lit
TOWN OF
B ARNSTAB LE '
LOCATION
1 `i�it(1 � SEWAGE #
VII.LAGE kF , ASSESSOR'S ,%A�
MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING ACHING FACILITY: (type) �� (size) �X i
NO.OF BEDROOMS _
BUILDER OR OWNER �V
PERMITDATE: OMPLIAI`10E DATE:
Separation Distance Between the:
A.�� Fcct
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist iJ Fee:
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) i
Furnished by '��'� -
i
L\
C011S10\��EALTH OF I�L�SSACHI;SETTS
j Expo TI%E OFFICE OF E\vIRO\I�4E\TAL AFFAIR
= - ^ DEPARTMENT OF ENVIRONMENTAL PROTECTION
�F. ONE RI\TER STREET. BOSTO\ 0210r (617) 292-55u
1
TRUDY CORE
Secretary
ARGEO PALL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
�►r I `�
PART A
LotCERTIFICATION 1 CERTIFICATION 1 ( t
Property Address: �l LQ; Name of Owner G�/ �` 4v�,1
/� —OZ-1-kddress of Owner:
Date of Inspection:'67 �if�j ` mil
Name of Inspector: IT ase`Pn )H •�Q e l ��6_D EL1,/C)
I am a DE�P approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)
Cwq)any Name: �!LCst r._> ,? Ek y,,Vrr,1. k.. C ►.' c�
Mailing Address:.�!_&„ 1 �-�g V(O_ b /y /-�r9 r�LC4
Telephone Number: ;-g2 —4` 3-pt. l[F Zo
CERTIFICATION STATEMENT
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
Needs Further Evalu the Local Approving Authority
Fail G
Inspector's Signature: Date:
Z� LC
� f
The System Inspector shall submit a copy of this inspection report to the Approving 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 Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
t
to Ton �v
revised 9/2/98 Page I of 11
-`� Pnnted on Recycled Paper
y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
4operty Address:
Jwnef:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM 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 (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 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 will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to de/iineifsystem 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 (1)(b)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 surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or,�a salt marsh.
21 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 sy�tem 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 coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and t 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 9/2/98 Page 3orll
t
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
property Address:
Owner: l`
Date of Inspection:
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.
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 was 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:
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)
[15.302(3)(b)1
The facility owner (and occupants,if different from owner) were provided with information on the propermaint.enawo-of
Subsurface Disposal Systems.
revised 9/2/98 Page 5of11
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,,
PART C
to SYSTEM INFORMATION
'roperty Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms (design):Q5 Number of bedrooms (actual):
Total DESIGN flow-3!;Q
Number of current residents:
Garbage grinder(yes or no):_m ,` \�
Laundry(separate system) ( es o no N; If yes, separate inspection required
Laundry system inspected yes r no)
Seasonal use (yes or no):
Water meter readings, if available (last two year's usage (gpd):
Sump Pump (yes or no):
Last date of occupancy:--A
COMMERCIALANDUSTRIAL:
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:
System pumped as part of inspection: (yes or o)
If yes, volume pumped: gallons
Reason for pumping:
TYPk 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)
VA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other A
APPROXIMATE AGE of all components, date installed(if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/98 Page 6(if II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: mS 4'4a c
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction:_cast iron_40 PVC_ other (explain)
Distance from privatewater supply well or suction line
Diameter _
Comments: (condition of joints, ventingjeevi ence of leakage,-etc.)
SEPTIC TANK:
TANK: 5
(locate on site plan)
tl
Depth below grade:
Material of construction: lAconcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age Is age confirmed by Certificate of Compliance_ (Yes/No)
Dimensions: C-t
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffler 1
Scum thickness: ( I ��
Distance from top of scum to top of outlet tee or baffle:_ b\
Distance from bottom of scum to bottom of outlet tee or baffle:_
How dimensions were determined: ; N&i A-x ra Q`
comments:
(recommendation for pumping, cond# ition of inlet and outlet tees or baffles, depth of liquid level in relation ti outlet invert, s�j_uctural integrit ,
evidence f I age,etc.) r "t-
V'J
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.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
}yam �
'roperty Address: Y" Y t�z ONLCI
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): S
(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:A(2X(o
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(not condition 5Xf soil, signs of hydraulic failure, level of ponding, damp soil, condition vege ion, etc.) _
r C3 n dv
I
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth 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, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraurrc failure,level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
"operty Address:
lwner: l
Date of Inspection:
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)
Zc:c.,cZr•t
A
G
C-) L
` 1A
revised 9/2/98 Page 10of11
1 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address: ,LS 40 �-oP't.
Owner:
Date of Inspection:
NRCS Report name —_—
Soil Type_ ------- -
Typical depth to groundwater____
USGS Date website visited
Observation Welts checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope r-13
Surface water.."
Check Cellar D"
Shallow wells tj
Estimated Depth to Groundwater 'X Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
\' Checked local excavators,_installers
X Used USGS Data
--DeescCCCribe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11of11