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Home My WebLink About0449 OLD TOWN ROAD - Health 44'' Old Town Load Centerville, A_248 - 140 I ECYCIEp e-llll 1111 UPC 12543 No. 53LOR_ HASTINGS, MN i i L000T.ION 5EWNC-4E PERMIT U0. VILLAGE IWSTQLLER 5 1J&ME ADDRESS BUILDER'S Q &MF- ADDRESS DINTE PER"VT 155UED Is---z-2a2S -D AT-E COMPLI W,.4CE ISSUED : �: A,,r� 1-TOWN OF BARNSTABLE LOCATION 4-15 C451 ` l 6�) QU• SEWAGE # VELLAG Ca-ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO.QWW SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) TW cf-�.51,o (size) NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: a Maximum Adjusted Groundwater Table and 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching faci ' ) Feet Furnished by 01 44 g 61d , Rj CIO fog Ji Q �9p � 1 l i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM e ' Address of property (04q 0 [ ib"� nCi r Lalc Owner' s name �N-e,(k R - 9Uuc(�e`i 1- SJ PQ141 koSeA*Jtf c •Date of Inspection �5t�re po / Agel� )YS '.OIJ PART A w CHECKLIST Chec if the following have been done: Pumping information was requested of the owner, occupant, and Board o± /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 vailable with N/A. The facility or dwelling was inspected for signs of sewage back-up. V T e site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the ite. 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 9pr existing 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. s oo e5,�, , s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS Iff residential 3 number of bedrooms --C_ number of current residents garbage grinder, yes or no laundry connected to s stem, yes or no -LIJDseasonal use, yes or no If nonresidential , calculated flow: Water meter readings, if available: — NdU . Last date of occupancy GENERAL INFORMATION Pumping record a source of information: System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system Septic tank/d ` -- ,,/s�o-�il�, absorption s ste , Single cesspool � �'"f"�'T �ct.- J� Overflow cesspool z 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: Sewage odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B , / SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: / material o co struction: concrete metal FRP other(explain) dimensions: (D I� _,.-2 sludge depth L ' distance from top of sludge to bottom of outlet tee or baffle O scum thickness 0 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 : (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of le kac�e, recommendations for repairs, etc. ) cYt DISTRIBUTION BOX: i , (locate on site plan)' depth of liquid level above outlet invert Comments: (note if level and dist ribution is equal, evidence of solids carryover,� y r, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: �— (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances,. . recommendations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORK PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : V/ (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, atc.. CESSPOOLS (locate on site pal n) : 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) Comments: (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 Comments: (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 INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' �Y9 old �d 0 3 v � [�1 r o,Xr 4v DEPTH TO GROUNDWATER 1�-- depth to groundwater method of determination or approximation: 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? " Static liquid level in the distribution box above outlet invert? P--ko p Liquid depth in cesspool <6" below invert or available volume< 1/2 d flow? tCZ:7,,A zj Required pumping 4 'times or ore in the last year? number of times pumped A , At,&+ c� , ry Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? NIs any portion of the SAS, cesspool or privy: below the hi h groundwater elevation? -_ within 50 feet of a surface water? 4 &OCI- within . 100 feet of a surface water supply or tributary to a surface water supply? N within a Zone I of a public well? 1�1 within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? Oa-.O\ C 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 analysif for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. Iy SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector 1-11, S' NO14A, Company Name �p QL Company Address itz• aZS3 g 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 manitenance of on-site sewage disposal systems. Che one: I have not found any information which indicates that the system fai3 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 determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signatur Date TPI f 9,( 4 Original to system owner Copies to: Buyer (if applicable) Approving authority