POINT OF SALE INSPECTION SEWAGE TREATMENT SYSTEM (STS) AND/OR PRIVATE WATER SYSTEM (PWS)

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1 Company: Inspector Name: Phone Number: Buyer s Name: Phone Number: Property Address: City: Zip Code: Parcel ID: Date of Inspection: The property has (mark one of each): Bedroom #: HSTS or Municipal Sewer SCPH Records Available?* Yes No PWS or Public Water SCPH Records Available?* Yes No * At the time of the inspection. If available, attach records to the report. The following observations are rendered without knowledge of some of the individual parts of the system(s) being evaluated. This report only applies to the date and time the inspection is conducted and does not guarantee the future performance of the system(s) being evaluated. The boxes below only represent the conclusion of the inspector. For details and comments on the system, please be sure to read the entire report. This report is valid for 2 years from the date of the inspection for the buyer listed above. Based on the information available at the time of the inspection, the HSTS: 1. Appears to be functioning as designed and no nuisance was observed. 2. Was not creating an observable nuisance at the time of the inspection and the house is occupied. 3. Is creating a nuisance and must be brought into compliance. See the comments section for additional details. The gray water for this property appears to be improperly routed. Sewer appears to be available to this property. Please contact the local sewer authority to determine sewer availability. If sewer is available, the structure may be required to tie into sewer and the STS properly abandoned under a permit from SCPH. 4. Due to vacancy, intermittent use, or a lack of available water for testing purposes, the functionality of the STS cannot be determined at this time. A re-inspection is recommended once the structure is occupied for a minimum of 60 days. Please contact the inspector listed above to schedule this re-inspection. 5. This system is a discharging STS. The quality of the discharge could not be observed during the inspection to ensure that the STS is functioning properly. Based on the information available at the time of the inspection, the PWS is: 1. Acceptable for the property. Private Water Contractor ODH Registration #: Registered Service Provider SCPH Registration #: Inspections Performed: STS Inspection PWS Inspection Drinking Water Analyses: Bacteria Lead Nitrate 2. Unacceptable for the property. Once a bacteriological acceptable sample result is received, the PWS will be considered acceptable for the property. Inspector s Signature: Date: / / Registered Contractor s Signature: Date: / / Form provided by: Summit County Public Health 1867 West Market Street Akron, Ohio Phone: (330) Toll-free: 1 (877) Fax: (330) Page 1 of 7 Revised January 2018

2 Property Address: Diagram of the property, including the following: 1. Lot dimensions 2. Location of the house 3. Location of the PWS, STS, city water line and sanitary sewer line, as applicable. 4. Distances in feet between any and all of the above components as well as to the house, all property lines and any other notable features or structures on the property. Note: This is not a survey distances shown are estimated using best available measurements. North Form Provided by: Page 2 of 7

3 STS Inspection: POINT OF SALE INSPECTION Property Address: Year the STS was installed: Information provided by: Health Department Owner Other: A variance was issued for the current septic system: Yes / No / Unknown At the time of the inspection, the house was: occupied intermittent use vacant If vacant, length of time it has been vacant: Number of occupants living in the house in the last 3 months: Septic tank(s): Tank 1 Tank 2 Inlet(s) have risers to grade: Yes No Unknown Yes No Unknown Outlet(s) have risers to grade: Yes No Unknown Yes No Unknown Outlet T is present: Yes No Unknown Yes No Unknown Baffles functioning: Yes No Unknown Yes No Unknown Size: Gallons Unknown Gallons Unknown System has an aerator component: Yes / No If yes: Manufacturer: System is under a current service contract: Yes / No Tanks were last pumped: Month Year Information provided by: Health Department Other (if other, attach copy) Water level in the tank(s) &/or aerobic treatment device before any water use: Tank 1: Tank 2: Water level in the tank(s) &/or aerobic treatment device after hydraulic loading: Tank 1: Tank 2: Volume of water used during hydraulic loading: Gallons System was dye tested: Yes / No If yes, the location(s) the dye was placed: Septic System Type: Tile field Leach well Dry bed / Leach area Evapotranspiration Mound Spray irrigation Drip distribution Low pressure pipe field Discharging Unknown System is designed to alternate: Yes / No If yes, which side is currently in use: If yes, the boxes can be accessed for alternating the fields or lines: Yes / No System has a filter bed: Yes / No / Unknown If yes, the size is: Form Provided by: Page 3 of 7

4 STS Inspection: (cont.) Location of the observed discharge: The discharge was not observable due to: A sample of the discharge was collected: Yes / No If yes, the sample results are attached to this report. Quality / description of the observable discharge: Clear Cloudy Grey Black (property not fully occupied) The wastewater is properly routed: Yes / No If no, see the comments below for details. Inspection comments and additional observations: Septic Musty Odorless None This STS falls under EPA guidelines and requires the submission of an application for Ohio EPA s National Pollutant Discharge Elimination (NPDES) permit. This permit will require annual sampling of the discharge as well as a service contract with a registered service provider. All or some of the STS components are unknown and could not be evaluated during this inspection. This STS is designed to be alternated or diverted. This must be performed every six months. This HSTS was difficult to evaluate due to: Dense overgrowth Snow cover Significant rain fall or snow melt Inaccessibility Lack of records Other: Comments: * On average, a STS or septic system properly treats wastewater for about 20 to 25 years before needing to be replaced. Changes in the number of occupants, water usage or the rerouting of plumbing may affect the future performance of the system. Form Provided by: Page 4 of 7

5 PWS Inspection: Name of contractor who constructed the PWS: Year the PWS was constructed: A variance was issued for the current PWS: Yes / No / Unknown PWS type: Drilled well Driven well Dug well Cistern PWS observed to be: Outside of the foundation Inside the foundation In a well pit Spring Pond Hauled water storage Other (explain): Exposed: inches above final grade Unable to be located Other (explain): Type of casing: Steel Plastic Other (explain): Casing Length: feet Casing Diameter: inches Depth of the well: feet Well cap is: Vermin proof Non-vermin proof Well seal cap Unknown Electrical conduit is seated / sealed in the well cap: Yes / No / Visible signs of a non-sealed well cap observed: Yes / No If yes, explain: Atmospheric water storage or reservoir tank(s) used: Yes / No If yes, Number of tanks: Approximate size: gallons each Location of tanks: Type of pump: Submersible Jet location: Form Provided by: Page 5 of 7

6 PWS Inspection: (cont.) The PWS is accessible for cleaning with a drilling rig: Yes / No / Unknown If no, the reason is: The PWS is accessible for chlorination: Yes / No / Unknown If no, the reason is: Continuous disinfection is used: Yes / No If yes, the type is: Chlorine Ultra violet light Other: The PWS has a filtration component installed: Yes / No / Unknown / If yes, what type: For cisterns only, roof washers are in place: Yes / No / Unknown If yes, how many: For cisterns and hauled water storage tanks, the tank(s) is/(are) water-tight and protected from potential sources of contamination: Yes / No / Unknown If no, the reason is: Flow Rates: (in gallons per minute) Initial flow rate at the beginning of inspection: Flow rate after 35 minutes of flow: Location of flow rate measurement: Pump cavitated (drew in air) or stopped pumping water during measurement: Yes / No Water Sample Screening Results: Prescreening Method: Chlorine: parts per million Nitrate: parts per million Lead: Hours since water was last used: Sample collected: at first draw or after purging system Form Provided by: Page 6 of 7

7 PWS Inspection: (cont.) Water Samples Results: Sample Type: Date: Location of sample tap: Lab Result: Conclusion: Inspection comments and additional observations: This PWS was difficult to evaluate due to: Dense overgrowth Inaccessibility Lack of records Other: Acceptable drinking water sample limits: Total Coliform: 4.0 CFU/100mL E. coli: 0.0 CFU/100mL Lead: 15.0 ug/l Nitrate: 10.0 mg/l Nitrite: 1.0 mg/l Comments: Form Provided by: Page 7 of 7