HomeMy WebLinkAbout0012 VANDUZER ROAD UNIT UNIT 8 - Health 12 Vanduzer Road (Cape Cod Village)
Barnstable ',• ,:A 1 ) �,
A = 352-035-00H
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department ®f 112,
Environmental Protection
�E
William F.Weld .—
Governor .� 2
Trudy Coxe 3 996 w
Secretary,EOEA � p p � .L
David B. Struhs V /� T
Commissioner i /,tea,_
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `
MAP# zD PART A
PAR# 03S-a0H p£ U� �-�" CERTIFICATION �"V£/P F� �.v N�
�v vS
Property Address: Address of Owner:
Date of Inspection: - F4C 4,,1* 44PV1b r/ (If different)
Name of Inspector: -gyp,FS `� S£Ak+$ wAMjNUz�� ,n 1p�� �, , N- �
Company Name, Address and Telephone Number: r`G� �'1
A & B Canco 350 Main Street West Yarmouth, MA 02673 (508) 775-2800
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Y Passes
Conditionally Passes
Needs Further Evaluation By the Local Appro%ing Authority
Fails �/ o
Inspector's Signature: �' Date: O p�"A "!
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Depanmeni of Environmental Protection
The original should be sent to !ire system o„ner anti cops,- ,c:;; Iv till buffer, if aPjj:�Cdl),C :1n(i tlw d(;r!o,,np au'�ori,\.
INSPECTION SUMMARY:
Check A, B, C, or D
A) S7ave
PASSES:
not found an information which •n
Y c 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 completion of the replacement or repair,
passes inspection.
Indicate yes, no, 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 septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95) 1
One Winter Street • Boston, Massachusetts 02106 • FAX(617)556-1049 a Telephone (617)292-5500
A
iet Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B] SYSTEM CONDITIONALLY ASSES (continued)
_ Sewage backu or breakout or high static water level observed in the distri tion box is due to broken or obstructed
pipe(s) or due t a broken, settled or uneven distribution box. The system ill pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required p mping more than four times a year due to oken or obstructed pipe(s). The system will pass
inspection if(with appr al of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY T E BOARD OF HEALTH:
Conditions exist which require further eval ation by the Board of ealth 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 HE LTH DETERMI ES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALT AND SAF AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a rface ater
Cesspool or privy is within 50 feet of a b rderi g vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEAL (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER T A PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The sysiem nas a Septic ldnK anti Sun ubulNuun 5y�,leul and i�, Within 103 frci to a surface water supp!'y or tributary to a
surface water supply.
_ The s\,stem has a septic tank and s it absorption s stem and is within a Zone I of a public water supply well.
The system has a septic tank and oil absorption sy tem and is within 50 feet of a private water supply well.
The system has a septic tank an soil absorption sys m and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well wat r analysis for coliform arteria and volatile organic compounds indicates that the well is
free from pollution from that acility 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 syst m violates one or more of the follo ng failure criteria as defined in 310 CMR 15.303. The basis
for this determination is iden ' ied below. The Board of Health shoul be contacted to determine what will be necessary to correct
the failure.
Backup of sewa a into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or onding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS of
cesspool.
(revised 8/15/95) 2
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D) SYSTEM FAILS (continued):
Static liquid level in he distribution box above outlet invert due to an overloaded or c gged SAS or cesspool.
Liquid depth in cesspo I is less than 6" below invert or available volume is less tha 1/2 day flow.
Required pumping more t an 4 times in the last year NOT due to clogged or o structed pipe(s).
Number of times pumped
Any portion of the Soil Absor tion System, cesspool or privy is below the h' h groundwater elevation.
Any portion of a cesspool or pri y is within 100 feet of a surface water s pply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is ithin 50 feet of a private wat r supply well.
Any portion of a cesspool or privy is les than 100 feet but great than 50 feet from a private water supply well with no
acceptable water quality analysis. If the ell has been analyze to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compou ds, ammonia nitro n and nitrate nitrogen.
E} LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to he cri ria above:
The design flow of system is 10,000 gpd or greater (Large Sy e ) and the system is a significant threat to public health and safety
and the environment because one or more of the following c ditions exist,
the system is within 400 feet of a surface drinking wat supply
_ the system is within 200 feet of a tributary to a urface dr king water supply
_, the system is located in a nitrogen sensitive ea (Interim Ilhead Protection Area (IWPA) or a mapped Zone 11 of a
public water supply well)
The owner or operator of any such system shall bring the sy em and facility into ull compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult t local regional office f the Department for further information.
(revised 8/15/95) 3
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done:
V_ Pu ping information was requested of the owner, occupant, and Board of 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.
Ng 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.
I The system does not receive non-sanitary or industrial waste flow
V The site was inspected for signs of breakout.
ZAll system components,J1PX0W3V81WWM9 have been located on the site.
iThe 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.
WA MONO
JThe iacilri) uccul,.:„�, If d.ffercr,; it r. ;nr; ve c provided v,i;h information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL: wv/rfr
Design flow: �tt* Aall`oons
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):�:Kr
Laundry connected to system'(yes or no):�
Seasonal use (yes or no): T f S
Water meter readings, if available:
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
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:
OTHER: (Describe)
Last date of occupancy:
M
GENERAL INFORMATION
PUMPING RECORDS and source of information:W NCO s:�/�1 � �vinPiN� ,,v s��n�s.� �t�Q C'f�
System pumped as pan of inspection: (yes or no)_O
If yes, volume pumP('d gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Pri
Shared system yes enne) (if ye , attach previous inspection records, if any)
t ere inG/f
APPROXIMATE AGE of all components, date installed (if known) and source of information: ('/NkNO w
Sewage odors detected when arriving at the site: (yes or no) 1►O
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction:\—concreteetal _FRP —other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of o\6baffle:
ffle:
Scum thickness:
Distance from top of scum to top of outlet tDistance from bottom of scum to bottom of baffle:
Comments:
(recommendation for pumping, condition outlet tees or baffles, dep/liquid l in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP:_
(locate on site plan)
Depth below, grade:
Material of construction: _concrete _metal _FRP _other(exp n)
Dimensions:
Scum thickness.
Distance from top of scum to ton of outlet tee or baffle:
Dista-ce from hottom ns <rtirn t^ hottnm of owle, tee o/ettees
Comments:
(recommendation for pumping, condition of inlet and oor baffles, d th of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, et(.)
(revised 8/15/95) 6
, J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:
(locate on site plan)
h
Depth below grade:
Material of construction: ✓concrete _metal _FRP —other(explain)
Dimensions: t I0'8V all L
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)L S S ty/ /•••�
fS 44L /N la/Oit°k/,--A o�Pl7�
eloSo
13oul Coacx5 37rtL 6 oYT0 �owiv iv PlIf Sri o,4 -oAL
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and dis;:ibC;,C e:;_.::'. e.id evade /61 akage into or out of box, etc)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition Aaandenances, etc.
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not re aired, but may be approximated by non-intrusiv 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:
Comments: (note condition of soil, signs of hydraulic failure\vel of pondi 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 in ction)
Comments: (note condition of soil, sign: of hydraul/i (a
ilure, level of pon ing, condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of ydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
O O O
DEPTH TO GROUNDWATER - -Depth to to groundwater: feet _
method of determination or approximation: £�°/!y %o 6-A-0 L'"b l✓y17r;e. 07— Q'Ir 4-) t2
AT /9 tik N o £Ochelly 4.
(revised 8/15/95) 9
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
a
department of
Environmental Protection
William F.Weld ` .'~
Governor 1 � !
T11 Coxe
ec
Sretary,EOEA r 'y
David B. Struhs -~
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
M A P# 3t-a PART A
PAR# 0hs=00,6 CERTIFICATION
��,� e v,E e a2) e0Aj/)os
c
Property Address: H Qulb f�,iv/T a Address of Owner:
Date of Inspection: 7 -S-Y 4' (If different)
Name of Inspector: —V1-,1-A1£S 'Z S£fj*RS
Company Name, Address and Telephone Number:
A & B Canco 350 Main Street West Yarmouth, MA 02673 (508) 775-2800
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on•sittesewage disposal systems. The system:
_V Passes
Conditionally Passes
Needs Further Evaluation Bj the Local Appro�ing Authority
Falls
Inspector's Signature: Date: r/.s q�
The System Inspector shall submit a copy of this inspection repon to the Approving Authority within thirty (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 repon to the appropriate regional office of the Depann,c,nt of Environmental Protectinn
The original should be sent to the system ov.ner and cop,t•r x•:d tv Uk Uu)C;, it app ,cj1 C and.thi' aI;'.rC;,ino aU:�Ori,\'.
INSPECTION SUMMARY:
Check A. B, C, or D
A] 7SYSTE PASSES:
have not found an information which indicates that the system violates an of the failure criteria
Y y y e c to a 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 completion of the replacement or repair,
passes inspection.
Indicate yes, no, 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 septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
.(revised 8/15/95) 1
One Winter Street o Boston, Massachusetts 02108 • FAX(617)556-1049 • Telephone (617)292-55DO
A
iJ Printed on Recycled Paper
H.�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address.
Owner:
Date of Inspection:
B] SYSTEM CONDITI ALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distributio ox is due to broken or obstructed
pipe(s) o due to a broken, settled or uneven distribution box. The system will ass inspection if(with approval of the
Board of ealth):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to br en or obstructed pipe(s). The system will pass
inspection if(wit approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED Y THE BOARD OF HEALTH:
Conditions exist which require further valuation by the Board Health in order to determine if the system is failing to protect the
public health, safety and the environme t.
1) SYSTEM WILL PASS UNLESS BOARD OF EALTH DETER INES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HE A TH AND S ETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet o a surfa a water
Cesspool or privy is within 50 feet of bo ering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF LTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANN T AT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The wstem has a septic ldnh an suii auburpri r bybteni and is within iw fcei to a surface water supple or tr'lbutar)' to a
surface water supply.
_ The system has a septic tank nd soil absorption ystem and is within a Zone I of a public water supply well.
_ The system has a septic to and soil absorption s stem and is within 50 feet of a private water supply well.
_ The system has a septic t nk and soil absorption s tem and is less than 100 feet but 50 feet or more from a private water
supply well, unless a w II water analysis for colifor bacteria and volatile organic compounds indicates that the well is
free from pollution fr m that facility and the presen of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm•
D] SYSTEM FAILS:
I have determined tha the system violates one or more of the follo ing failure criteria as defined in 310 CMR 15.303. The basis
for this determinatio is identified below. The Board of Health sho Id be contacted to determine what will be necessary to correct
the failure.
Back of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
D'scharge or ponding of effluent to the surface of the ground r surface waters due to an overloaded or clogged SAS or
esspool.
(revised 8/1 /95) 2
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Addre
Owner:
Date of Inspection:
D] SYSTEM FAILS (con 'nued):
Static li uid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid dep in cesspool is less than 6" below invert or available volume is les than 1/2 day flow.
Required pum ing more than 4 times in the last year NOT due to clogged r obstructed pipe(s).
Number of time pumped
Any portion of the oil Absorption System, cesspool or privy is below a high groundwater elevation.
Any portion of a cessp of or privy is within 100 feet of a surface ter supply or tributary to a surface water supply.
Any portion of a cesspoo or privy is within a Zone I of a publi well.
Any portion of a cesspool o rivy is within 50 feet of a priv a water supply well.
Any portion of a cesspool or privy is less than 100 feet b greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been alyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic ompounds, ammon' nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in add ion the criteria above:
The design flow of system is 10,000 gpd or greater (L ge System) and the system is a significant threat to public health and safety
and the environment because one or more of the fo o ng conditions exist.
the system is within 400 feet of a surfa drinkin water supply
the system is within 200 feet of a tri utary to a surf a drinking water supply
the system is located in a nitroge sensitive area (Inter Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall ring the system and facility to full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Ple a consult the local regional o ice of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the (following have been done:
Y Pumping information was requested of the owner, occupant, and Board of Health.
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.
/V4 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
V The site was inspected for signs of breakout.
V All system components, have been located on the site.
VThe 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.
JThe iacihiy um.k; kc;,u uccu),.;.1o, ;,r,ne:, acre prodded v.ith information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL: /Al 7'
Design flow: 1 10 eall ns
Number of bedrooms:
Number of current residents: O
Garbage grinder (yes or no): A10
Laundry connected to system (yes or no): IV O
Seasonal use (yes or no): �Ii S
Water meter readings, if available: A/g
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/day
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
L4.J ££kLY 11mj oolvG i�✓ Sinn F/c G�► B 64'1/co
System pumped as pan of inspection: (yes or no) A/O
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)
Other (explain) `7—/1-117-
APPROXIMATE AGE of all components, date installed (if known) and source of information: UN k/VOI,y
Sewage odors detected when arriving at the site: (yes or no) &0
(revised 8/15/95) 5
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add ss:
Owner:
Date of Inspecti n:
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: cncrete _metal _FRP —other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge to \bottm
tlet tee or baffle:
Scum thickness:
Distance from top of scum to toee or baffle:
Distance from bottom of scum toutlet tee or baffle:
Comments:
(recommendation for pumping, inlet and outlet tees or b les, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, e
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to ton of outlet tee r baffle:
Dista^ce from bottom c orn v, hnttnm of o ,ttet tee w baft e
Comments:
(recommendation for pumping. cot) o of inlet and outlet tee or baffles, depth of liquid level in relation to outlet invert, structural
integri�y, evidence of leakage, etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate on site plan)
ri
Depth below grade:
Material of construction: ✓concrete _metal _FRP —other(explain)
Dimensions:
Capacity: gallons _
Design flow: 1/0 gallons/day vNii
Alarm level; 7 00 0 0, J-
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
/ti �- 0✓T -7'£'£ s 11 A L9�P�/ FLa�t 54.E cffts g LL /�v P.��r£
A &Pln L i o Vk ,L S7-Lr- L C o u i',cs 47- 0,V41£
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level abov\invert:
Comments:
(note ii level and dis:rib❑: ce c' cnhd cz �.n.e evidenre o/Iage to or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments;
(note condition of pump chamber, condition of pump and appurt ances, etc.)
-7
(revised 8/15/95) 7
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SY EM (SAS):_
(locate on site plan, if pos ible; excavation not required, but may be approximated by non-intru ' e methods)
If not determined to be pre t, explain:
Type:
leaching pits, number:
leaching chambers, num r:_
leaching galleries, number.
leaching trenches, number, ngth:
leaching fields, number, dim nsions:
overflow cesspool, number:
Comments: (note condition of soil, signs o hydraulic failure, level of pond g, 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 i spe ion)
Comments: (note condition of soil, sign: of hydra u/Ic
failure, le I of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of ydraulic failure, level of po ing, condition of vegetation, etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
o �
DEPTH TO GROUNDWATER
Depth to groundwater: feet /� _
method of determination or approximation: AIaTA/gLa F'b _ A 0 £�Q,0A
(revised 8/15/95) 9