669 Part C Septic Inspection 2003 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:; 669 Westhampton Road
Owner: Grossman
Date of Inspection: April 23,2003
TIGHT or HOLDING TANK: NO_(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: _gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level. Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: NO(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc.):
minimal carry over
PUMP CHAMBER: NO_(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: • 669(back)Westhampton Road
Owner: Grossman
Date of Inspection:April 23,2003
SOIL ABSORPTION SYSTEM(SAS): YES (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_1_leaching pits,number: .5 ft.diem 6 ft. deep total 36"lipoid.42-44"eff,lit. (buried 3 ft.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.):No signs of failure. stone ok.and no Groundwater. Too of LT(qJ 36"
CESSPOOLS:N/A (cesspool must be pumped as part of inspection)(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(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
PRIVY: N/A(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,
etc.):
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
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)ale of Inspection: y' 'z3 )o3
;KETCH OF SEWAGE DISPOSAL SYSTEM
'rovide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks OT
ienchtnarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: : 669„(back)Westhampton Ro d
Owner- Grossman
Date of Inspection:April 23,2003
SITE EXAM
Slope
Surface water
Check cellar YES*Dry
Shallow wells
Estimated depth to ground water 9-10'+1-feet
Please indicate(check)all methods used to determine the high ground water elevation:
N/A Obtained from system design plans on record-If checked,date of design plan reviewed:
_Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Warr -v l .a ed on on-site dat
grade apnroa 50-75 feet away._
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