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Home My WebLink About0027 OUTPOST LANE - Health 27 OUTPOST LANE, CENTERVILLE A= 172 104 a F f 6 } wI�I' /_ /f 14µECVCLfpcoy UPC 12534 �� 4 d No.2 1 53LOR HASTINGS, MN f f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property �Z 17 �/�-u- jc2� - i • ��n . Owner' s name fo . 01 Date of Inspection Cb PART AC�v� CHECKLIST rp a�L Check if the following have been done: t4` � logo Pumping information was requested of the occupant, and Board c 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. JV 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. _jZ`ihe site was inspected for signs of breakout. All system conponents, 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. he size and location of the SAS on the site has been determined based on 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential �� ?- number of bedrooms _1 number of`'current residents A)0 garbage grinder, yes or no xle laundry connected to system, yes or no -/2 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, or ,no if yes, volume pumped Reason for pumping: C�Type Sepan /distribution box/soil sb orption system spool Y Overflow cesspool Privy All 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: _ ? t�o2— v 0 Sewage odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B / SYSTEM INFORMATION continued SEPTIC TANK: v (locate on site plan) depth below grade: - material of construction: concrete metal FRP �other(explair ..dimensions: !�-•� 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 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, recommendations for repairs, etc. ) y - , 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, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on site plan) U lz 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 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. ) CESSPOOLS (locate on site plan) : number and configuration E�) 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 SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' or- 17D�S/= � 4 DEPTH TO GROUNDWATER 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) by 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? W A-S v�y Liquid depthin cesspool <6" below invert or available volume< 1/2 da,. 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? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? Nwithin 100 feet of a surface water supply or tributary to a surface water supply? W within a Zone I of a public well? W 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? 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 analysi• for coliform bacteria, volatile organic compounds, ammonia nitrogen and. nitrate nitrogen. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company NameG % Company Address `57°� P Y 9 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. Chec - e I have not found any information which indicates that the system fail 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 provi ed in the FAILURE CRITERIA section of this form. Inspector ' s Signature Date _5--- l f— �j,s— Original to system owner Copies to: Buyer ( if applicable) Approving authority TOWN OF BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION ---------- ___.......__._ -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED AA�� STREET ADDRESS ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME PART D - CERTIFICATION NAME OF INSPECTOR " COMPANY NAME nG'2 c COMPANY ADDRESS Z2E - Street Town or City State LIP COMPANY TELEPHONE U4�&_Ly FAX ( - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage di'sposa-i 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 e. System PASSED The inspection which I have conducted has 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. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this ins p ion form. Inspector Signature Date— .. '��1 One copy of this certification must be provided to the OWNER, the BUYER (where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or 'operator shall upgrader! the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc 1 TOWN OF BARNSTABLE LOCATION Le �,.r..12� �4 4°T-39 SEWAGE # /7r)-'I�� VILLAGE ASSESSOR'S MAP &LOT O Z INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / aa,� LEACHING FACILITY: (type) (size) NO. OF BEDROOMS CP- BUILDER O OWNER l i a7J PERMTTDATE: �� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 6 Feet Private Water Supply Well and Leaching Facility (If any wells exist / on site or within 200 feet of leaching facility) /U41 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by k s 5° No...--/ r�---'-=....------ Fs$.. .......................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEA TH ✓Ll OF... ------------------� lop ,� liratinn for 14o nsal Works Tongtrurtinn anvil Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Location-A ss or o. a.. - -e . ' Ow r dres Installer Address U Type of Buildin,,,��g�� e, _ Size Lot.Size feet Dwelling-No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria (. ) Q' Other fixtures _ ___ __ - ----------------------------------------------------------------------------- -------------------- w Design Flow________________________ gallons per person per day. Total daily flow_____._._.____.._...._._gallons. WSeptic Tank Liquid capacity_________gallons Length---------------- Width---------------- Diameter_..____._____.__ Depth__.__________... x Disposal Trench—N/o_____________________ Width_______________�y 33 Lengt --------- Total leaching area_______.__._:.......sq. ft. Seepage Pit No.______F-----_--_-._ Diameter- =�'e$11 rhle€ _ Total leaching area---_ZV�':. t. Z Other Distribution box ( ) Dosing tank '-' Percolation Test Results Performed by...-'- ��L� '� � Date---- a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground 'Water...................... ;3:4 Test Pit No. 2................minutes p inch Depth of Test Pit.................... Depth to ground water__-_-___-__-____-_-_-_-. ---- -•------------------ ODescription of Soil.......................--- •••- ------ ...'---••-•--•------------------------------------------------------- -- ---- ------------------------------------ x w U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------_______________________________________: --------------------------------------•-•••------------------------------------------------------------------------•--------------•------------•---••----------------•---•----------------------------.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has,ftKen issuecoy the b dof h Ith. n Si ned.._ g r -�-- --------- � --------- A Application Approved B Lcsl ate PP PP y---•- -----------• � r� --- V/ Date Application Disapproved for the following reasons--------------------------•------VV--------------..0------------------------------------------------------------- ------------ ----------•----D---ate---------------- Permit No. -....... Issued. --- ate ........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .... .................OF... .. AliptirFa#ioaa for Dispogatl Worko To'niitrurti.vu Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Y . ................................ Location-A ss f or ,Lo o. , ---- O er dress/ Installer Address Type of Building Size Lot____________________ _____Sq. feet Dwelling No. of Bedrooms___________________________________________Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building ._•__ No. of ersons____________________________ Showers G� YP g ----------------------- P ( ) — Cafeteria ( ) P4 Other fixtures ...................................................... W Design Flow_ _....................... `. gallons per person per day. Total daily flow_..__.________________________________-___gallons. WSeptic Tank Liquid capacit _____gallons Length................ Width---------------- Diameter-- ------------- Depth_:.__-_______._. x Disposal Trench—No_____________________ Width............ _ Leng�th.,._____.. ____,_{ Total leaching area.__.._.,. -------- sq. ft. Seepage Pit No.__._._j............ Diameter_/A ,Z_ ep i o mile '_._ Total leaching area___ z Other Distribution box ( ) Dosing tank ( r '-' Percolation Test Results Performed by �"`"'-----------�.44__r ..... �� __- Date__..� �___/✓__�"_._- Test Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water------------------------- 0:4 Test Pit No. 2....._..........minute s p r inch Depth of Test Pit.................... Depth to ground water------------------------ .,_ Description of Soil------------------ "" ✓ - "', : =---------------------•------------------------------•-- U --•--------------------------=---------•--------------•-----•--•-••------------------•-•-------------•-----------•--------•--------•---•------------------ W VNature of Repairs or Alterations—Answer when applicable.----------------------------------------_-----------------------------________________________, --•-------------------------..............................................................---------------------------=-------------------------------=---------------=------__----•------------------ Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en issue y the bo d ofrlth. s4 Signed:- _ . .......................� a = „ .-------- --------- } - ------ ate Application Approved By----- -r `- !°---- - = Date r Application Disapproved for the following reasons:----•-------------------•-•---• -•--------------------•--------••-•--------------•---------•------------------- Date PermitNo.......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................................OF............ ".. ........... Trr1ifirFatr of TAImptl aure ' T 'IS IS TO C�ER IFY, That.the Individual Sewage Disposal System constructed ( �or Repaired ( ) by -td F ----- -- - •--------- ---^-^-------------------------------------------- ---------- t,� Ins I Fr G tallf� at --•---- ------- s.. A '_ °1 r - ........................................... has been installed in accordance with the provisions of Article XI of The State SanV, a ib ry Cle desc be in the application for Disposal Works Construction Permit No-------------------I-_�___ __.._._ dated___., _....... ._: :. ..._..__ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN EE TI�IAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector....................................................................... ------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH :'F �3 ..O F cam` No. - ------- FEE-•-- r=------------ - Permissiop is,hereby granted....... '°_ __: ____ _ _ _ _______ ________ to Constr/ct ) or Repair," ) �t Individua / wage Di oosafl System at ;.� , "_ie � l°%` - -�8-- ' , 1__: _____ Street as shown on the application for Disposal Works Construction Per o:_ ____ ed__�,� -----•-•- DATE_ /13S & -- Board of Health FORM 1255 HOWARREN. INC., PUBLISHERSs