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HomeMy WebLinkAbout0105 BRIARWOOD AVENUE - Health 105':B'riarwood':Averue;. Hyannis_ �I I' i 0 TOWN OF B)ARNSTABLE LOCATION��J� ��f Lc�dQd ,,�� SEWAGE # VILLAGE J04 4245 e pp/ASSES N�R'__S//MA(P�& LpOT�' V—a71/716CrOn"SNAME&PHONE NO2�C%QC1' 7 SEPTIC TANK CAPACITY �� ) ate'W LEACHING FACILITY: (tyre (size (9 )) NO.OF BEDROOMS 3 BUILDER O OWN�,- , u �f PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: 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 facility) Feet Furnished by W �. �� , �1 �. 1 � �, � � � 'I w � COMMONWEALTH OF MASSACHUSETTS x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS C DEPARTMENT OF ENVIRONMENTAL PROTECTION Q / RECEIVED JUL 2 6 2001 TITLE 5 TOWNI OF B DEPT.BLE OFFICIAL INSPECTION FORM—NOT FOR VOLU S SUBSURFACE SEWAGE DISPOSAL'SYSTEM FORM PART A CERTIFICATION Property Address:. %6&01uxo Owner's Name: Owner's Address: Date of Inspection: Name of Inspector: lease print) P�� Company Name: A . 1 ' i Mailing Address: .O= it `✓0C/ jV .� vs Telephone Number: (,2 (fl�C>/ 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 pursuan7passes ection 15.340 of Title 5(310 CMR 15.000). The system: 1 Conditionally Passes Ne F rther Evaluation by the Local Approving Authority esI Inspector's Signature: / Date:, The system inspector shall su mit 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 ofthe 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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—N T FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PA)#T A CERTIFICATION(continued) Property Address: 2:&27 ,7/2&>��� e Owner• Date of Inspecti LZ2?61 1 n Inspection Summary: Check.A,B,C,D or E/ALWA IS complete all of Section D A. stem Passes: I have riot found any information which.indicates' :hat any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria n tevaluate, are indicated below. Comments: B. System Conditionally Passes: One-or more system components as described'in ti e"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. Answer yes,no or not determined(Y,N,ND).in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or he septic tank{whether metal or not)is structurally unsound,•exhibits substantial infiltration or exfiltration or ank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as 1pproved by the Board of.H.ealth. *A metal septic tank-will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or hig static water level in the distribution box due to broken or obstructed%pipe(s)or due to a broken,settled or uneven&tribution boz. System will pass inspection if(with approval of Board of Health): broken pipe(s)are re laced obstruction is remov�d distribution box isle, eled or replaced ND explain: The system.required pumping more than 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 reputed 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: Q Owner: VA iov,41403L// Date of Inspectiot' C. Further Evaluation is Required by the Board of Health: Conditions.exist which.require further.evaluation-by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. . 1."`•System wilFpass unless Board of Heaitti determines in accordance with 310'CMR I5.303(1)(b)that the system is not functioning in a mannerwhich.will protect public health,safety and the environment: Cesspool or,privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. 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,safety and 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 SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is•within 50 feet of a private water supply well. _ The system.has a septic tank and.SAS and the SAS is less than 100,feet but 50 feet or more from a private water supply well". Method used to determine distance "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. 3. Other: 3 Page 4 of]] OFFICIAL.INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) :Property Address: Owner: " Date of Inspectio14._4.".l�La ai/ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the,following for all inspections: Yes N _ Backup of sewage into facility or system component due to overloaded or clogged SAS or°cesspool _ _ 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 an-overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow VRequired pumping more than 4 times in�.he last year NOT due to clogged or obstructed pipe(s).Number of times pumped P! Any portion of the SAS,cesspool or pricy 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. _ Vj Any portion of a cesspool or privy is within Zone l of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. 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 failure criteria exist as described in 310 CMR 15.303,therefore the system fails.Tile 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 serve a facility with a'design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system i.s within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any questibn in Section E the system is considered a significant threat, or answered "yes"in Section D above*the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304..The system owner should contact the appropriate regional office of the Department. 4 f - L Page 5 of 1.1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE 01SPOSAL SYSTEM INSPECTION"FORM PART B. CECKLIST Property Address: ©"'s-Aq'f"�.4/1�0&y a � Owner: Date of Inspectio► : (p/Q.fo.iDl Check if the following have been done.You must indicate"yes"or"tio"as to each of the,following; Yes No Pumping.information.was provided.by the owner,occupant,or:B'ard of FJealtf;. 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? :. ,----,-Iave large..volunies.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? CZ _ 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.conditiott of the baffles or tees, material of construction, dimensions,depth of.liquid,depth.of sludge.and depth of scum? Writhe facility owner(and occupants if.different fi-om owner).provided with.information on the proper maintenance of subsurface sewage disposal systems 7 The size and location of tire,Soil Auso.rption Systeni(SAS)on the site,has been det rmined based an:. Y no ✓_ Existing. nfornration.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 approxiination of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page of 11 OIi'nCIAL-INSPECTION FORMV .NOT FM VOLUNTARY-ASSE SSMENTS SUiIS JRI+ACT SEWAGE DISPOSAL SYSTEM TNSPILCTION FORM PART C SYSTLM INPORN ATION Property Address: 6q,0h9f �,�,7,4 Owner: Date of.Inspectio . p FLOWN CONDITIONS RESIDENTIAL Number of bedrooms(design): . Number of.bedrooms(acntal):' DESIGN flow based'on 310 CM.R 15.203 (for ext.mple:.l 1:0 gpd x#of bedrooms): 3136 -Number of current residents: Does residence'have.a garbage grinder.(yes or no): /, — Is laundry on a separate sewage.`"system-(yes or'tro: if yes separate inspection*reguired] Laundry system inspected es or no Seasonal use:(yes or no)FiClable Water meter readings, if (last 2 years us�jge(gpd)): Sump pump(yes or n �` 'Last date of occupancy: �e�.f! / o . COMMERCIAL,/INDUSTRIAL Type of establishment:.. 'Design flow.(based on 310 CMR.15.203): gpd Basis of design.flow(seats%persons/sgft,etc,): . .. 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/use: OTHER(describe); GENERAL INMYWATION Pumping Records Source of informafion:. ' (' 7� ' Was system.pumped as nart'of the inspection(yes or no):_Z 1_�� If yes,volume pumped: gallons was quantity pumped determined? Reagon Tor.primping: . TYPE OF SYSTEM. _Septic tank,distribution box,sbifabsorption 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 __.,/0tlier`(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors defected when.Arriving at the site(yes-or�)- Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ©'S— /���� �� Owner: Date oflnspectio c4 -Q A BUILDING SEWER(locate on site plan)✓�"" Depth below grade: Materials of construction:=cast iron _40 PVC_other(explain):- Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC.TANKGjlklocate 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: 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: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:/J&�(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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 i Page 8 of 71 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: JV ai&&Vo .� Owner:. Date of Inspecto . ('v jdfo/O I TIGHT or HOLDING TANITtank must be pumped at time of inspection)(locate on site.plan) Depth below grade: Material of construction: concrete metal fiberglass. -olyethylene other(explain): Dimensions- Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): . Alarm level: Alarm in working order(yes or no): Date of Iasrpumping: Comments(condition of alarm and float switches,etc.): i DISTRIBUTION BOX%�if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP CHAMBER: ocate on site plan) Pumps in working order.(yes or no): Alarms in working order(yes or no):. Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION VORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART C SYSTEM INFORMATION(continued) LProperty Address: �' ( /-/,4 Owner: l��e Date of Inspection. (p,/ co 16/ SOIL ABSORPTION SYSTEM(SAS):. (locate on site plan,excavation not required) If SAS not located explain why: Type leaching,pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: :1—Vverflow cesspool,number:_L_ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soili condition of vegetation, tc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: / /000 1911� Depth—top of liquid to inlet invert: L/ Depth of solids layer: Depth of scuin layer: % d1 . Dimensions of cesspool: (® '. Materials of construction: r IQ" Indication of groundwater inflow(yes or no): omments(note conditiot f soil,.Sig s of by -a lic fai e,-level of Pon 'na,condition of vegetation,etc.Ag ): ,c rs Q �3' �� �l 026a � PRIVY/�ocate 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,etc.): 9 Page OFF ICIAL;INSPECTION FORM= OT FOR VOLUNTARY ASSESSMENTS SUBSU RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. P 'RT C SYSTEM INFO ATION(continued) Property Address:. �J Owner: Date of.In'spectio ('��I—)[re©I. SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system includir g ties to at-least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply-enters the building, 10 Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Q (� Owner: 2 C Date of Inspection. %p/�fpl�A SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water ,feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked.with local Board of Health-explain: necked with local excavators, installers-(attach documentation) Accessed USGS database-explain:. You must describe how you established the high ground water elevation: . 11 l/ r BORTO.LOTTI CONSTRUCTION,INC. f ,' 765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A j CERTIFICATION Property Address: Ca(i ' Cc7 Date of Inspection: Ins eckor',sNa))ne: Address: Owner's Name and Add ! p Gr Grp a ry1 �3 w -.04srs _Z 3 CERTIFICATION TATEMENT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my-training and experience in the proper function and maintenance of on-site sewage disposal systems: The System: 1� Passes Conditionally Passes . Needs Further Eval tion By Local Aproving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a opy of this inspection report to the Approving authority within thir- ty(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. INSPECTION SUMMARY,• A)SYST PASSES: . 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes, nor,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,cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)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 C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM 1S FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 an overloaded or clog- ged SAS or cesspool Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM tNSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 1 of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone It of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and.6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART B CHECKLIST Check if the following have been done: (/pumping information was requested of the owner,occupant,and Board of Health. _ one of the system components have been pumped for atleast 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. _I�fAs-built plans have been obtained and examined. Note if they are not available with N/A. r/The facility or dwelling was inspected for signs of sewage back-up. �he 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 site. 1/ The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- cted for condition of baffles or tees, material of construction,dimensions,depth_ of liquid, Tdepth of sludge,depth of scum. The size and location f the it o So Absorption System on the site has been determined based on existing information or approximated by non4trusive methods. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CIIECKLIST(continued) _keThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION / FLOW CONDITIONS RESIDENTIAL: ✓ J Desi n Flow: r� allons Number of Bedrooms: Nu nber of Current Residents: g g _ ( ` nn �ed'fo S stem:f� �.3 Seasonal Use: Garbage tinnier: Laundry G eat .Y `t A _ Water Meter Readings, if vgilable: Last Date of Occupancy: COMMERCIAL/IND USTRIAL:h/ Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V Sys(em: Water Meter Readings, If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATIO PUMPING RECORDS and source of System Pumped as part of inspection: � If y s,voldne pumped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If ye attach pre pus inspection r cords, if any Other(explain)_. �1>7 230 aj 000'010w RO T AGE of all co 0onents,date.instal d if known)and source of information: - r� ,��` Sewage odors detected when arriving at the s►e: -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: concrete metal FRP Other (explain) Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom 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,etc.) GREASE TRAP: Depth Below.Grade: Material of Construction: concrete metal - FRP -Other. (explain) — — — — Dimensions: Scum Thickness: Distance from top of scum to top 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,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material.of Construction:_concrete—metal_FRP Other(explain) Dimensions: Capacity: . . gallons Design Flow: gallons/day Alarm Level: Comments.: (condition of inlet tee,condition of alarm and.float switches,etc.) DISTRIBUTION BOX:ove outl: Depth of liquid level abet invert: Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box,etc.) PUMP CHAMBER:: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 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, number: Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching Gelds, number,dimensions: Overflow cesspool, number: _ P Com ts: (note con ition of 1, Signs of lydraulic failure level of ponding,condition of veg tatio , etc.) �� 6 . !/ �Jfl on CESSPOOLS: Number and configurationJ-J))X eplh-top of liquid to inlet invert: Depth of solids layer: Depth of scwn laver: Dimensions of Cesspool:S��U Jt'S�Cc? Materials of construction " '81(X,6lndication of groundwater: Inflow(cesspool must be pumped as part of inspectian) Comments: (note condition of soilk, sign o hydraulic failure vet of pondi ig,condition of ve�geettation,,/ Il Ji PRIVY: Materials of construction: — Dimensions:_ Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART. . C SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. . Locate all wells within 100 Feet. F U0 U 0 f7p) DEPTH TO GROUNDWATER: ' Depth to groundwater: 7- 7 Feel Meter god of Delermin lion�r Approximation: - 7-