HomeMy WebLinkAbout0036 SALT ROCK ROAD - Health 3� SALT ROCK ROAD, BARNSTABLE
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• SUBSURFACE SEWAGE DISPOSAL S'YSTEH INSPECTION FORX
Address of property S�L7 �"3� �Q ,� I +1 `
Owner' s name ' �aA -Y :501m;l
Date of Inspection 1
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I I PART A
/�� CHECKLIST'
Cher if the following have been done: ,,
Pumping information was requestedjof the' owner, occupant, .and Hoard of
Healthy ' I, 1 I Ii I . ` I , Ij
None of the system; compolnent i have been' pumped for at east,' tw Meeks
and the system has been Ereceiving normal, flow rates during that '�;
periodl.'1, j Large volune,s of water have hot beeh introduced into ;tbe''-'-
set n.1
s m ecentl or as art 'of this in p c io
yste �r� y , �as, ' part � , �I i i
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x d I Note f they, are, not
As built plans haye . bee�; obtained and a amine y,
available l with N/A�, ' ' t �' ; '. a.
The facility or dwe_ling wasi, inspected for signs) of sewage «back-up.
ack up. , jl
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for signs The' site was ins ectea of 'ibreikout. I
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All system fco'mpone'nts fi excluding the ISAS have been locat fled `on the)
Site.
The septic tank lmanho es were runcovered,' opened„ and ,the interior of
the septic 'tank ,was inspected for condition of baffles or tees, !!
materlilal of construction, :dimensions,,' depth of l;iq�uid, depth of
sludge, depth of scum i
The s�i,,ze and ;location of the SAS 'on i the) site ' has been determine «based)
on existing informs:ion +or Approximated' by non intrusive methods.,),� I
V The facility owner Xand occ6p8nts, if; different) from ,owner} Iwera ,
provided with information on the' proper maintenance of SSDS.jj
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �
PART B
SYSTEM INFORliiAATION I I
r ; I FLOW 'CONDITIONS
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If residential
3 number 'of bedrooms A ' '
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number 'of current residents I
YES garbage grinder, yes or no
_ laundry connected to system, yes or no
uo seasonal use, yes or no I�
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If nonresidential , calculated flow: ( ' ' !
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if available:water meter readings„ O ( '
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Last date of occupancy
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GENERAL INFORMATION
Pumping records and sourcelof information:
j�-s System pumped as part� of inspection, yes or no
if yes, volume pumped / nL
Reason for pumping: ,
of
AN® 'To Cock C®NVIrMAI OX Z.
Ty e of sykstem
Septic tank/ /soil absorption system � 'la
Single cesspool
Overflow cesspool
Privy :
Shared system (yes or no) (if yes, attach previous inspection
records, i if any) '
Other (explain)
i Approximate age of all components. Date installed, if known': Source ,'of
information:
l9 7 QO YR5 DL 1) SDfJiPC� ,�•H AS
,CiviLT �®9R0
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�O Sewage odors detected when arriving at the site, yes ori�no �,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
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SEPTIC TANK: '
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(locate on site plan) i
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depth below grade: 1 r{
material of constructionk concrete metal FRP other(explain)
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dimensions: 3'XS2c cjjjL 7`A,(U1K i 4
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sludge depth
"
A' distance from top of sludge to bottom of outlet tee `or baffle
l2' scum thickness i I
i'lH distance from top of �scum to top of outlet tee :or baffle ,
-2h distance from bottom of scum to bottom ,of outlet tee or baffle i
Comments:
(recommendation for pumping, condition of inlet and outlet tees or- baffles,
depth of liquid level in relation to outlet invert, structural integrity, ,
evidence ofileakage, recommendations for repairs, etc. ) �: Ili
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WAS PaMih AS RAPT- 6 t Ms
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DISTRIBUTION BOX:
( locate on site plan)
i' depth �of liquid level above outlet invert
Comments: I ,I I .,. I i I i
note if level and d.istribution 'is equal ; evidence of solids car over
( `� }' ,
evidence of leakage into or out of box, recommendation for repairs, etc. ) ,
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PUMP CHAMBER: + �
( locate on site pP an) "
pumps in working order, yes or no
Comments: i
(note condition of pump ,cham2er, condition of pumps and appurtenances, '
recommendations for maintenance or repairs,etc. )
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION TORm
PART B
SYSTEM IKroRKATION c®ntinu®d.
SOIL ABSORPTION SYSTEM {SAS) : { I
( locate on site, plan, if possible; excavation not required, but may be
approximated by, non-intrusivelmethods)
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. )
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CESSPOOLS (locate on sine plan) :
N/jnumber and configuration'
depth-top lof 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) I
Comments :
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(.note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendationsIfor maintenance or repairs,etc. )
PRhVY : I i
( locate on site plan)
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materials of construction
'
dimensions I '
depth of solids
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Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition, of vegetation, recommendations 'for maintenance or, repairs,etc. )
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r, µ .,.1....unr,•.,.f+W w...'.i.W., ... ,. �,. i ,. .i ., ,. . i, ,... y............... ..I,w.....„.....,,.i, ...».«+..J.:,{.,...-........,..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM IN70Rl4ATION Continuafl �
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least 'two permanent references landmarks] or benchmarks
locate all wells within 100 '
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DEPTH TO GROUNDWATER
depth to groundwater r uj
method of determination or a proximation,: +
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SUBSURFACE SEWAGE, DISPOSAL SYSTEM INSPECTION FORM
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PART C
FAILURE CRITERIA
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Indicate yes , no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
Backup sewage of into facility? !
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Discharge or ponding of effluent to the surface of the ground or
surface waters? '
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Static liquid level in the distribution box above outlet invert?
1 , k
Liquid depth, in cesspool<6" below invert or available volume< 1/2 day
flow?
Required pumping 4 times or more in the 'last year?
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number of times pumped I
Septic tank is metall?I cracked? structurally unsound? substantial
infiltration?' substantial exfiltration? tank failure imminent?
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Is any portion of the SAS , cesspool or privy:
below the high groundwater elevation.
within 50 feet of ? surface water? '
-within f100 , feet of a surface water supply or tributary to a surface
water supply? j I�
within a Zone I of aipublic well?
within 50! feet of abordering vegetated wetland or salt' marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water ;supply well?
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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 nitrogenl.
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- SUBSURFACE SEmAGE ,DISPOSAL SYSTEM INSPECTION FORM
PART D
' CERTIhICATION I
Name of Inspector
Company Name f bp6lriv CoNsfRod,01i I,
Company Address
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Certification Statement f
I certify that I have personally inspected the sewage disposal' system at� _ 4
this address 4nd 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 sewagedisposal systems.
ne/k one : j i � � ,i
I have 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. f '
I have determined that the system fails to protect public health and
the environment- as defined int3101CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector ' s Signature
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Date
Original to system owner �Nlvy
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Copies to: {
Buyer ( if applicable) ,I �
Approving a.uthority TOWN Orr ZMR
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