The URL can be used to link to this page

Home My WebLink About0020 DAMIAN WAY - Health 20 DAMIAN WAY, BARNSTABLE A= o t :4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PO Address of propertyOwner ' s name Date of Inspection Ltt I C) PART A d CHECKLIST Check if the following have been done: �' Pumping information was requested of the owner, occupant, and Board of Health. 11,None of the system components have been pupped 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. 4, The facility or dwelling was inspected for signs of sewage back-up. &1 The site was inspected for signs of _breakout. All system components, excluding the SAS, have been located on the s ' te. 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. t/ The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. ` 1/ The facility owner (and occupants, if different from owner) .were provided with information on the proper maintenance of SSDS. .fie SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential LI number of bedrooms number. of current residents (� garbage grinder, yes or no laundryf connected to s stem es or no Y Y .it) seasonal use, yes or. no If nonresidential , calculated flow: Water meter readings, if 'available: Ra V LA-) Last date� of occupancy �. CaQR W`TL CL) GENERAL INFORMATION Pumping records and source-'of information: S stem pumped as a-L� Y P P rt `of inspection, P es P or no Y _ if yes, volume pumped. Reason for pumping: Type of system Septic tank distri buti on box soil absorption system em Single cesspool - Overflow cesspool 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 informat ion: r Sewage odors detected when arriving at the site, yes or no .r 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) r� depth below grade: C/ material of construction: &� concrete metal FRP other(explain) dimensions: G-IP'AZ-L 0CWTVi sludge depth ' Zdistance from top of sludge to bottom of outlet tee or baffle scum thickness Cam" distance from top of scum to top of outlet tee or baffle 15' 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 leaka e, recommendations for repairs, etc. ) LAS—T L11:32y F�T`l-1' &4 rQ 0. , N e: US�k A C-41 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: Y�)� (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 FORM PART B tt SYSTEM INFORMATION continued t 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 'Two 156-0 "L 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 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. ) 11 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 ' r-p Z _ . 2 . . DEPTH TO GROUNDWATER--,' , ,' . 5 depth to groundwater method of determination or approximation: . i 12 r 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? Liquid depth in cesspool <6" below invert or available volume`< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped yj Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: Tbelow the high groundwater elevation? within 50 feet of a surface water? 1� within . l00 feet of a surface water supply or tributary to a surface water supply? rV within a Zone I of a public well? 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 -analysiE for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. l t 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name Company Address 419 —C PT ( A & S ANO `kCH 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 "y training and experience in the proper function and . manitenance of on-site sewage disposal systems. fChZck� - '- `I have not found any information which indicates that the system fails i to adequately protect public health or the environment as defined in 310 CMR 15. 363 . 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 environrent as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature (� Date Original to system—owner - Copies to: H Buyer (if applicable) Approving authority fi