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Home My WebLink AboutTitle V Inspection Report - 1300 SALEM STREET 6/8/1995 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO of property 0wrier ' s name Date of Inspection PART A CHI=LIST Check if the following have been done: Pumping 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 . /V #,-"'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 site was inspected for, signs of breakout . All syster", components , excluding the SAS , 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS . 16 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIOI��S, Tf residential number of bedrooms number of current residents AW garbage grinder, yes or no 77 laundry connected to system, yes or no seasonal use, yes or no If nonresidential , calculated flow: Water meter readings , if available: Last date of occupancy GENERAL INFORMATI014 Pumping records and source of information : ya_ System pumped as part of inspection, yes or no if yes , volume pumped Reason for pumping : Type of system _A-1 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) ,proximate age of all components . Date installed, if known. Source of information : Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPZCTION FORM PART H SYSTEM INFQRMATION continued SEPTIC TANK: __ ( Wcate on site plan) depth below grade :,_.,_.._ material of construction: _. /�� concrete __metal FRP ___,other (explain) dimensions:_ _ /0'-6.. x 3' xit - - �-- _ sludge depth distance from top of sludge to bottom of outlet tee or baffle D_ scum thickness distance frog top of scum to top 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, e7id2nce of leakage , recommendations for repairs , etc. ) (W a:000 ca&L2 L r-1-0,v lUs2 4'✓J P&,v( `:... U r DISTRIBUTION BOX: lw 4 ( locate on site plan) ^--(:; __ depth of liquid level above outlet invent 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 CHKMBER: _. ( 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. ) ).a•- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIQN FORM PART B SYSTEX 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 and number leaching chambers and number leaching galleries and number leaching trenches, number, length _ -- leaching fields, number, dimensions /7-1Ce. 0 dO' overflow cesspool , number ___ 5�� - .� � __- 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 pavt of inspection) Comments : (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs , etc. ) PEI,IVY ; ( locate on site plan) materials of construction di.,,iensions — 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 '. 4 o 14- DEPTH TO GROUNDWATER -_ I0, depth to groundwater method of determination or approximation : 12 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 deter.-mined" , explain why not) l? � Backup of sewage into facility? I/V Discharge or ponding of effluent to the surface of the around or surface waters? 1.L static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? f '. Required pumpingtimes or more in the last year? number of times pumped -/t/,. 't/. Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any pcartion of the SAS , cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? U' within 100 feet of a surface water supply or tributary to a surface water ryupply? within a Zone I of a public well? s^ within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, npt the SAS) ? _ within 50 feet of a private water supply well? less than 1.00 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 . 33 SUBSURFACE SEWAGE D18POSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Namc tifEO iiv c,'-I:v _'j'afev G- .0 tM rlvit tE-s 2,A." ' Company Address 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 zepa;.r are consistent with my training and experience in the proper function and manitenance: of on--site sewage disposal, systems . Check-one : _ �71 have not found any information which indicates that the system fails T to adequately protect public health or the environment as defined in 310 CSR 1.5 . 303 . Any failure criteria not evaluated areas stated in the FAILURE CRITERIA section of this form . I have determined that the system fails to protect public health and the environment as defined in 31.0 C;MR 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: Buyer ( if applicable) Approving authority