HomeMy WebLinkAbout0261 ROUTE 149 - Health 261 Route 149, Marstons Mills
A= 078 - 029 - 001
e
TOWN OF BARNSTABLE >✓
LOCATIO SEWAGE# _
VILLAGE 11/,!052� ASSESSOR'S MAP & LOT
&PHONE NO. M &Z� Lj a
SEPTIC TANK CAPACITY 4 L
.1"/7
LEACHING FACILITY: (type) C (size)
NO.OF BEDROOMS
BVIL &OR OWNER 415 5 c�/�,C��✓
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility y/r 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 " 2-, � ��
Fl
as
o
,4ibl .
� r
00?T/L I�y
CO',1%40 A EALTH OF NIASSACHUSETTS
®
EXECUTIVE OFF
NVIRONMENTAL AFFAIRS
OFF
ICE
DEPARTMENT OF EN VIROti'MENTAL PROTECTION
-`
7` 01E WINTER STREET. BOSTO'.�• NtA 02108 6I7-292-5`00
7
TRUDY CORE
Secretan
WILLIAM F.WELD -4""'''� I
Govemor •r- " DAVIDVS1 UHS I
f Commissi°oncr
ARGEO PAUL CELLUCCI PECTION FORM �'
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INS '
PART A
CERTIFICATION
o Address of Owner:
Address: "''l.t
Property 3_ —po (If different) r -
Date of Inspection:
Name of Inspector: 21 1
a ved system inspector pursuant to Section 340 of Title 5 (310 CMR 15.000)
I am a DEP p
Company Name: D
Mailing Address:
Telephone Number:
CERTIFICATION STATEMENT proper function and
I certifythat I have personally inspected the sewage disposal ssysteat
rsbaddrsed onand hat theing inf orand atio experience
in l is true' accurate
and complete as of the time of inspection. The inspectionperformed
maintenance of on-site sewage disposal systems. The system:
_ Passes
_ Conditionall-• Passes Approving Authority
_ Needs Further Evaluation By the Local App g
Fail
is —
Date: �—
Inspector's Signature: of completing this
Approving Authority within thirty (30) days
or rester, the inspector and the system owner shall submit
The System Inspector shall submit a copy of this inspection report to the App g
inspection. If the system is a shared system or has a design flow of 10,000 gpd g
the inspection.
to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
t rep on and the approving authority.
and copies sent to the buyer, if applicable,
INSPECTION SUMMARY: Check A, B, C, or D:
Al SYSTEM PASSES:
_ 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.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES: red. The system, upon
nents as described in the "Conditional Pass" section need to be replaced or repaired.
_ One or more system compo roved by the Board of Health, will pass•
completion of the replacement or repair, as approved explainnot.
of a Certificate of
Indicate yes, no, or not determined (Y, t or less Describe bassos of ed the system sinslpector f"not determined",
with 1c�t of the inspect
or
_ The septic tank is metal, unless the ow Pe prior to the
Compliance (attached) indicating that the tank was installed within twenty shows years
septic tank, whether or not metal, is cracked, structurally uii ou p� ttank is replaced placedstantial twith a conforming septic otank
k
the p
failure is imminent. The system will pass inspection if the ex s g
as approved by the Board of Health.
Page 1 of 10
(revised 04/2s/97) rna nel.state.ma.us/dep
DEP on the World Wide Wet: httpjPwww. 9
Printed on Recycled Paper
r,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
e] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or h� static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, se or uneven distribution box. The system will pass inspection if(with approval of the
t Board of Health). Describe servations:
broken ipe(s) are replaced
obstr coon is removed
/requ-- pumping
ibution box is levelled or replaced
_ The system more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection ioval of the Board of Health):
en 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 D ERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH A/Surface
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of water
Cesspool or privy is within 50 feet o(a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOAR OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A NNER 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 to a surface water supply or
tributary to a surface water supply.
The system has a sep c tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a se tic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has aseptic tank and soil absorption system 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 4om pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 pp, Method used to determine distance (approximation.not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPPO ALAYSTEM INSPECTION FORM
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D) SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
5.303. The basis
I have determined that the system violates one or moref f alth should the gbe'co tacted'to determine(what w ll belnecessary to correct
for this determination is identified below. The Board o
the failure.
Yes No
Backup of sewage into facility or system component due o an overloaded or clogged s or cesspool
overloaded or dogged SAS or
ndin of effluent to the surface of t ground or surface waters due to an
_ Discharge or po g
cesspool.
_ Static liquid level in the distribution box ab a outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6" elow invert or available volume is less than 1/2 day flow.
_ Required pumping more than 4 ti es in the last year NOT due to clogged or obstructed pipe(s)•
Number of times pumped _•
Any portion of the Soil Abs o tion System, cesspool or privy is below the high groundwateio aesurface water supply.
Any portion of a cesspoo or privy is within 100 feet of a surface water supply or tributary
' a Zone I of a public well.
Any portion of a cess ool or privy is within
'— private water supply well.
Any portion of a sspoot or privy is within SO feet of a p well with no
'— greater than SO feet from a private water supply
p is less than 100 feet but g able, attach copy of well water analysis for
Any portion of a cesspool or privy
acceptable water quality analysis. If the well has been analyzed to be accept
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or "Noy lato
ees stemsh of hn addition' gto the criteria above:
The following criteria apply g Y
or greater (Large System) and the system is a significant threat to
The system serves a facility d the a desinmfent low °f 1u5e�a odr more of the following conditions exist:
public health and safety
Yes No
_ the system is within 400 feet f a surface drinking water supply
_ the system is within 200 t of a tributary to a surface drinking water supply
the system
is located, n a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone ll of a
public water sup well)
Tonal office of the Department for further information.
o ;' stem shall bring the system and facility into full compliance with the groundwater treatment program
ch
The owner or operator of any su sy
requirements of 314 CMR 5.00 arid.6.00. Please consult the Iota reg
psgo y of 10
(revised 04/25/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addres112-'24( -
Owner:
Date of Inspection: 3 jG—oU
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes /- No =oHea1tV7
Pumping information was provided by the owner, occupant, or B
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:
_ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
/ Sub-Surface Disposal System.
Existing information. Ex. 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)]
(revised 04/25/97) Page 4 of 10
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: f
Date of Inspection: —Ov
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3 V .p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:oO
Garbage grir der (yes or no): &Cl
Laundry cor•reded to system (yes or no):�
Seasonal use ryes or no):-dlG' As,
Water meter readings, if available (last two (2) year usage (gpd): ��
Sump Pump (yes or no):_,&/ /�
Last date of occupancy:
COMMERCI.AUI N DUSTRIAL:
Type of establishment:
Design flow:__gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank pre . (yes or no)_
Non-sanitary waste discharged t e Title 5 system: (yes or no)_
Water meter readings, if avail le:
Last date of o:cupancy
OTHER: (Describe)
Last date of occupancy.
GENERAL INFORMATION
PUMPING RECORDS and source of information 60he
System pumped as part f inspection: (yes or no)—,60
If yes, volume pumped gallons
Reason for pumping
TYPE OF 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)
1/A Technology etc. Copy of up to date contract.
Other .���r� r
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
Page 5 of 10
(revised 04/25/97)
k . �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addresu j
Owner: �c
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC_other (explain)
Distance from private water supply well or suction lint:
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade: /S �
Material of construction: concrete metal Fiberglass Polyethylene other(explain)
if tank is metal,`list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: l'
Sludge depth: y �j
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 dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structura
integrity, evidence of leakage, etc.)
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _,concrete _metal i rglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top f outlet tee or baffle:
Distance from bottom of scum o bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for umping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence leakage, etc.)
-------------
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION, (continued)
Property Address: �-
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethytene _other(explain)
i
Dimensions:
Capacity: gallons
Design flow: gallons/da,.
Alarm level: Alarm in working order T—Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
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, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or NO) /
Comments: /J
(note condition of pump chamber, con ion of pumps and appurtenances, etc.)
page 7 of 10
(revimed 04/25/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 'p iYy
Owner: 4� /-
Date of Inspection: _4, -�p
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 fields, number, dimensions:
overflow cesspool, number: ex-e-
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) .
CESSPOOLS: _
(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 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:L
(locate on site plan)
Materials of construction: A4o z Gam' Dimensions:
Depth of solids:_,2am /;y
Comments: ,/
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page a of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: t
3
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or bomces ants
house)
locate all wells within 100' (Locate where public water supp Y
L�
Paga 9 of 10
(ravisad 04/25/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -2 /"r I Yp'
Owner: 4-4—ii O
Date of Inspection:
3 -Ufa-ori
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
__&.—<eck with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
_LZIU-se USGS Data
Describe in your own words how ,you established the High Groundwater Elevation. Must be completed)
C;2 y �.
(zavimed 04/25/97) Page 10 of 10
- r
f
TOWN OF BARNSTABLE
. LOCATION. of U �I01�l,G' . �y SEWAGE #
f
VILLAGE Akf_ .ems ASSESSOR'S MAP & LOT a78 Pvl
�7�SS i�FAME&PHONE NO. !�/
SEPTIC TANK CAPACITY
LEACHING FACILITY: (typo) (size)
NO.OF BEDROOMS
rBVU:0ER-OR OWNER Sall
PERMTT DATE; . —- COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater.Table and Bottom of Leaching Facility y/r' 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
f
it s g �aa�
i z d
�r In
c .
7-12
,Fl -RECa
"ERTIFIED SEPTIC SYSTEM REPORT APR 3 1997
H _4LTt;�E _-
L
OW ,
_
LOCATION
261 .ROUTE 149
MARSTONS MILLS , MA
MAP 078 PARCEL 029 . 001 LOT 2
PREPARED FOR
SELLER
MS . SUE JOHNSON
261 ROUTE 149
MARSTONS MILLS , 02648
BUYER
MR. HUGH O 'CONNOR
P .O . BOX 106
WATERTOWN , MA 02272
PREPARED BY
HILLIARD HILLER
P .O . BOX 250
CENTERVILLE , MA 02632
508-778-1472
CommonwecM-1 of MessechuseM
•• Executve Office of =nvircnmentol Affcirs
Department of
► Environmental Protection
WHUM F.Weid Trudy Doze
s•=-ary
GOMM
David B. 5trvhs
kq"Paul Cailutxl Commmwn�r
LL Gowsma
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION' FORM
PART A
CERTIFICATION
Addrars a�/ ��� l Address of Owner.
Property /?/'S% % h/G G
Date of Inspeaboe: (If different)
Name of Inspector. N IIIG L
Company Name.Address and Telephone Number! �JO
CERTIFICATION STATEMENT
I oasrfy that'have personally=spec--ed the sewage diapoaal system at this add.^ass and tHat:he i-_crsat:on repored beiow is::se. o,.== to
and complete as of the time of insmcz.on. The iaspe-ion was per onaed based cr. :ny:ra__.g and espenence it :he proper it::.r on sad
*tenaoM of on-ate sewage disposal systems. The water..:
_asses
_ Condi:icnaily Passes
_ Needs Pi rther Evai lotion Bc the Loci Approving Author.:;
_ Fails
Date:
Inspector's Slgtuttuz:
��
'ihe System ILtDeCAr shall submit 8 copy, this iaspecoion reportto the Approvi g Author:v wit=.= thi.y(30) days of gmplaLiag this
inspeeson If the system is a snared system or has a design flow of 10.000 gpd or greater. the inspe•=-or and:he oyster..owner shaL submit the
report to the appropriate regional office of the Department of Environmental Protection.
The orgmal sooeld be sent to the system owner and copies sent to the buyer, if applicable and the approving author.-.
INSPECTION SUMMARY:
CberL'p3,C, or D:
Al �SYSTTEEM PASSES:
(/ l have pat f nmd any infortsation whit indicates that the system violates any o::he aiiuze Criteria as aer ned a 310 Cba 1,3 3.
Any laitura sterna act evaluated are indicated beiow.
B) SYSTEM CONDITIONALLY PASSES:
one or more system components used to be replaced or repaired. 7he system. -,mn gmpietmn of the replacement or repair,passes
Indint•yes,as or act determined(':, N, or ND). Descrbe base of deterinnation :z ail =xt2zces. Lr-not determzaed-, ezplam way not)
_ Tho acetic anh is mr-ai. cracked. str acidly a sound. snows substantai : at:or. or e=fi1trnt:or_ or tank failure is
imminent. The system wlil pass _spec::on :. t,"e exist:g sept:c tars is
es Lace_ w t a�onfor^: g septic :aT.1t at approved
by the Boar)of-ealti:.
(revised 11/03/95) 1
one M"tet Street • Boston, Masaachusetts 02108 • FAX(617) 556-10413 • Teiephone(617) 292-5500
w
CA Pr1n�N OA(t�CYCNO Pipes
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddras: ��� /oTw /U� ��.QST-��
Owner. --c- �JfO//��✓�'
Date of Inspection: 5,//�/76
Bj SYSTEM CONDITIONALLY PASSES (continued)
Sewage ba6mm or breakout or his:.static water level o'oserved the distrbution box. is due to broken or o'bear-acted pipe(s)
or due to a brokm settled or uneven distribution Doz. The system will pass iaspec ion if(with approval of the Board of
Health): I
broken pipe(s) are replaced/
obstruction is removed
distribution box. is levelled,!or replaced
_ The system required puropin€more than four times a-ea:due tc broken or obst:acted pipe(a). The system will pass
inspection if(with approval of the Boar:of health): I
broken pipew are replaced
obst:scion is removed
f
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD,jOF HEALTH:
Conditions east whit:require further evaluation by the Boa.� of health order to dete=jze if the system is failing to protect the
public health safety and the environment.
6'
)
I) SYSTEM WILL PASS UNFLESS BOARD OF HEAL1I3 DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE Eti'VIRONMEN"I'.
r
Caaspooi or privy is within 50 feet of a surface water
Cwsspool or prh+y is within 50 feet of a bordinng vegetated wetand or a salt marsh.
f
S) SYSTEM WILL FAIL UNLFSS THE BOARD OF/HEALTH (AND PUBLIC WATER SUPPLIER IF APPROPRIATE)
DEPERMWFS THAT THE SYSTEM IS FUNCTMONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFE^.'Y AND THE ENVIRONMENT'
j
_ T'se sy has a septic rank and soil absorption sysu= and s •+Pit:::. 100 feet to a surface water su�piy or -butary to a stem
surface water supply. )
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well.
The system has a septic tank and soil ab rption system and is within 50 feet of a private water supply well.
The system has a septic tactic and soil-absorption system and is less than 100 feet but 50 feet or more from a private water
supply weiL un't a well water anaipsis for coldorm bacteria and voiatiie organic compounds indicates that the well is free
from poautiaa from that £scuts and the presence of ammonia n rogen and nit:-are nitrogen is equal to or less than 5;rpm.
3) O'I'SER
f
1
I
1
i
(revised 11/03/95)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEN4 INSPELTION FOPUM
PART A
CERTIFICATION (continued)
Property Address
Owner. /7S
Date of Inspection: �JiSi�r� e-
3/o?oJ77
D) SYSTEM FAILS:
I have dRerninra that the system violates one or mere of the following fail,, cratera as defined in 310 CIL' 15.303. The basis for
this ristsrmination is identiLed below. The Bear'_of t:aalth should be coma red:a deter=e What will be necessar.7 to oor.^ec= the
faiirrre.
_ Bacrzp of sewage into facility or system ccmponent due to an rioaded or clogged SAS or cesspool.
Due'saBe or po ndi g of etlluent to the surface of the ground or rurtace +Pates due to an overloaded or clogged SAS or
_
taaspow.
static liquid level in the distribution box above outlet invert ue to ar.overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or av ble voiu.ne is less than 1;2 day flow.
R&quiRd pumping more than. 4 =nes in the art year NO due to sided or obst:zcted pipers;.
Number of times pumped
Any portion of the Sou Absorption. System. cesspool or p ivy is 'beicµ�the airs groundwater elevation..
Any portion of a cesspool or privy s wit:ir. 100 feet cf a su.• ace water supply or tr butary a Surface Water supply.
Any,portion of a cesspooi or privy is with= a Zone i f a public well.
Any portion of a cesspooi or prvv is within 50 feet f a private water suppiy well.
_ Any portion of a cesspool or priw is less than 100 eet but greater t:an 50 feet atom a private Water suDDIV well with no
accertabie water quality analysis. U the well has n analyzed to be acceptable. attach copy of well water analysis for
coliform bar era, volatile organic compounds. ammonia nitrogen and nit-ate nitrogen.
El LARGE SYSTEM FAILS:
.he follawmg c-%teas apply to Wx— �y�temb Ln aQGtlo to tae crater:a above:
The system ee-v" a fn with a design: flow of 10.0 0 gp .-s system
d or greater(Lae System) and the is a sipifrant threat to public
c..
hs.}!h=Ld saiety and the environment because one o more of the following mnditiors exist:
the sum is with=400 feet of a surface water supply
w
the system is with:=200 feet of a tribu•• /to a surface drink ;water suppiy
_ tha system is located in a nitrogen seas tive area(interim Wellhead?---tecion Area TWO A) or a mapped Zone Z of a pab).L
water suppiy Weil)
^ha awotr or opatatcr of any such system shall brag the system and faciiry Lato fur cmpiiance with the grmmawater treatment prograrn
r VgMr--U of 314 CUR 5.00 and 6.00. Please consult the local regional office of t:a Department for further iafcrmauon.
d(
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTF-M INSPECTION FORM
PART B
CHECKLIST
Property Addre.c ate/ !��✓/ /`�7 � /' T / ,,%
Owner.
Date of Inspection:
Cbeck if the following have been done:
P'ttmping information was requested of the owner. oc`apan:. ar d Boa.�of Health.
4-�oae of the system components have been zu_mDed for at least two weeks and the system has been receiving normal'Sow rates
during that period. 'Large volumes of water nave not been introduced i ntc the system recently or as par. of this inepec:ioa.
LAAs built plans have been obtained and eza^ined. Note :i they are not available with N%A.
The fad it-or dwelling was inspected for sirs of sewage back-up.
LThe system does act receive non-aanitar,.•cr;Mdustrial waste low
-L-the site was inspeced for signs of breakcut.
system components, Mcludi=g the Soil?-bscrptier. Svste^. have been located on the site.
(The septic tank manhoies were uncovered. opened. and the _;-terior of the septic task was inane-zd for condition.of baMes or
tees, material of constr ,czion, dimensions, depth of liquid, depth of siudre, depth of scum.
=Tha size ani location of the Soil Absorption System on the site lass been determined based on eistixLg information or
approrimated by non-intruaive methods.
The faaiity owner(and o=pants, if different from owner, were provided with information on the proper maintenance of Sub-
Surface Disposal Systems.
(revises 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR4f
PART C
SYSTEM INFORMATION
Property Address o7� �' r" le
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Degip flow�pllons
Number of bedrooms:1�
Number of earraat racdents: /
Garbage g:iades(yes or no): t/0
L&mmb7 wed to system(,yeas or no):y
Seasonal we(yes or no):�v
Water meter readings, if available:
Last date of 0errp9 71CT EP I-/,-
COh 4SERCIAL/INDUSTRIAL•
T77 of atabiishmnt: /
Design Aow: - allonsiday
Grease trap present: (yes or no)
Industrial Riarx Holding Tank resent: (yes or no)_
Noa�aaitar9 waste to the Title system: wee or-.no _
Water meter.rudinp if av bie:
Last date of« paacy:Z_
OTHER:(Duc'ioe)
Last date of
GENERAL INFORMATION
PUMPUM RECORDS and source of iniornation:
gysam Pumped as par:of inspeC.ioa: (yes or no
If yea,vohtme pumped: rrallons
Beason for pumping:
TYPE OF SYSTEM
Septic tankidi -fM=n boVsoii absorPtion system
Siam campool
Overaaw orspcol
Shared system(lea or ao) (if yea, ata=Previrnr:inspecion records. any
Otbar(scrplaia)
- ;,ono o '.,+„- T .�� /�iy /l Gl•:�-/�i G �/T /1.`�
19 4
T L-Ltl%�L4
APPSOIDIATE AGE of all c=Pone=. dare nstatlea(if)mown) and source of iafarmatio:.:
Sawsp odors dateced•,ben are vrag at the site: (yes or not �v
(revised 11/03/95) 5
i
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFOP—MATION (oontinucd)
PropertyAddreac �G/ < ir /�/> `Pp:��T.�-r .4-
ow t ere. /.js. S!/,E
Date of Inspection:
SEPTIC TANK: `—
Gocas on sits plan)
Depth baba grade: /-;`J
Ystarial of oosutrvcbn: zwn=vw_metal _FR? _otbenezpiain)
Loc��
Dimmer :
Shrige depth. /4"
Dint from tap of aiudge to bottom of outlet tee or bailie:
Scum thir;mms p
Distance from top of ec= to top of outlet tee or baffle
Distance from bottom of se.=to bars= of outlet tee or ba 1le:
Comments:
(recommendation for pumping, condition of is let and outlet tees or battles. dent:of 11eu:d leves -n reiat:on to outlet inven, st u_tarw integrity,
"xLo a of lsalt ,, etc.) b Ov7G f T
/ZY
GREASE TRAP-_
(bate oa site plan)
Depth bib" grade:
MAMA!of eaaX1L.UCion: _con=ete_meal _rR? _othenezpla::.,
I
Dimensions:
8=thic�aes:
DistR=ftom top of or--=to tap of et tee or baffle:
Distsaa bom bottom of sc= to ' .om of outlet tee or baffle:
Comments:
(reeammendatum for pumping, core ;ti.on of inlet and outlet tees or 'bw!les. depth of',iqund level in relation to outset invert. a:scara1 inter ty,
erideace of Laahage, etc.) 1
(revised 11/03/95) 6
SL'BSLWACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Property Addrew "4:� ,
Owner. �S v� Jv/�,�/> •
Date of Inspeodod
TIGHT OR HOLDING TANK—
(locus on sae pkn)
Depth Wow Redo. mesa)_z RP °the-i I plain)
►Material of o�rucioa: —concrte— — i
I
Daasasionr.
CAp8=7 rtailons
Dwip _�11°nslda�
Alarm
Camme=:
(oondisioa of in1m tee, condition of aia.^m and float switches, i tc.)
i
I
i
I
I
)
DISTRIBUTION Box.— j
Uoete oa site per)
Depth of liquid k9al above outlet invert:
i
Cammo= to or out of'cox. etc.)
(nm if level sad dixr-i tion is equal evidence of solids ca.-cover, evidence of leakage
i
i
PUMP CLIMBER:_
(locus an site plan)
I
pumps m eari=C oruartyw or ao) ( '
i
Cammsms:
(non 000ditiaa of pump ci;-La* er, condition of Puape and appwtemAnces. etc.
i
i
7
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Property Addresc o2G
Owner. �i5. Sv! ✓v/'��o% Y
Date of Iaspsotion:
SOIL ABSORPTION SYSTEM (SAS):-
Goats(a cgs plea, if posable; excavation not required. but may be approxi ated by non-intrusive methods)
If not determined to be present, explain:
Type:
1—hins pits, number:_
le.ehusg chambers, number:_
Incising pllerisc number.
lawhiag treacbm, number,length:
leaching fields, number, dimensions:
over'1ow cesspool, number.
Comments:(note condition of soil. signs of hydraulic falure. level of ponding, candinor.of vegetation.etc.) T/% LB'��'�ii✓ /J//'
/ILL
/Z?"
CESSPOOLS:_
0=te on ate plan)
Number and canfigura=: 1 dy oy
Depth-top of liquid to inlet invert:
Depth of solids
Depth of stem layer- S 41-1
s
Dimmmons of cesspool: !/� ��/.v�/✓� L�ii?%" is /�v %ff/L SC�c%;yTt
Matcial.of camsta9MCtion:
Iadiesdoa of gratmdmuter
irLaw(cesspool must be pumped as par, of inspe--tion.)
C4=m L•(note condition of soil. signs of hydraulic failure, level of pondi::g, condition of vegetation. etc.)
;PRIVY:
(loan an are plan)
Materials of comtruc=n: o� OL'E� �? fi C-��' Dimensions:
Depth of solids:
r1Y1^-- (note edition of soil signs of hydraulic failure, level of n condition of ve pn ding. gerat:on, etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOP-MATION (oontinued)
Address: r,
Owner. �/S
Date of Inspeadon:
SE=CH OF SEWAGE DISPOSAL SYSTEM:
iach tint to at least two permanent references ka or benchmarks
Iowa an wells within 100,
y CG�S��L I
'rb
i
I
I
II
i
U
PR/vY i
I L
❑ I yV ----
w S_
/0»-
DEPTH TO GROUNDWATER
/t
Depth to Finaudwatar. feet i c�,vC Fj�y' 17.E �vii
asthad of dststmm z=or agpsorimation:
.�,/rvivr �%f F Gr/!`�T i? �"%r//" /�'T �'' _"(//�%'•-- ...` :ter ` � 7�/1 � vs Gv�'.F� G Ti- /S
15DGJ a S 3 cwE C 9 3 7, f!�
/�fr.Pv r�«r�F G�5 :f.•- y�" Titer
sa - a� -
(revised 11/03/95) 9