Fillable Form provided by: Stark County Health Department: Sewage (Stark County Government)

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Form provided by: Stark County Health Department: Sewage (Stark County Government)

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Sewage System Evaluation
Form provided by: Stark County Health Department
7235 Whipple Ave NW Suite B ● North Canton, OH 44720 ● Phone (330) 493-9904 ● Fax (330) 493-9920 ● www.starkhealth.org
Submit completed form to online@starkhealth.org
INSPECTION WAS CONDUCTED BY:_____________________________________ SERVICE PROVIDER #:_____________
PROPERTY ADDRESS:__________________________________________________PARCEL #:________________________
CITY:_________________________________ZIP:____________________TOWNSHIP: _______________________________
OWNER:____________________________________________________OWNER’S PHONE: __________________________
BUYER:____________________________________________________ BUYER’S PHONE: __________________________
PERSON RESPOSIBLE FOR ACCESS & TITLE: ______________________________________________________________
PHONE:_____________________________CELL:___________________________FAX: ______________________________
EMAIL RESULTS TO:_____________________________________________________________________________________
(or) MAIL TO:__________________________________ADDRESS: ________________________________________________
IS HO
ME CONNECTED TO SANITARY SEWER? ( Y / N ) SEWER AVAILABLE? ( Y / N )
PRIVATE HOME SEWAGE TREATMENT SYSTEM RECORDS AVAILABLE? ( Y / N ) (if yes, attach)
AGE OF HOME: _______YRS AGE OF SYSTEM: ________YRS _____UNK NUMBER OF BEDROOMS:________
AGE INFO FROM: ______ OWNER ______ HEALTH DEPT ______ AUDITOR _______ OTHER (see comments)
RECENT WEATHER CONDITIONS: ____________________________________________________________________
AT TIME OF INSPECTION HOUSE WAS: ______ # OCUPPIED ______ INTERMITTENT USE _____ VACANT
IF VACANT, HOW LONG?______________________________________________________________________________
I
N
F
O
PRIMARY TREATMENT:____SEPTIC TANK _____TRASH TRAP _____ OTHER VOLUME(S):_____________________
DATE TANK(S) LAST PUMPED: ____________ INFO SOURCE: _____________ PUMPER:______________________
SECONDARY TREATMENT: ____ N/A ____ AERATOR ____ FILTER BED TYPE/VOLUME:_____________________
IF AERATOR, SERVICE CONTRACT IS REQUIRED, PROVIDER:__________________________________________
DISPERSAL TYPE: ___LEACH LINES ___LEACH WELL ___LEACH BED ___ET ___FRENCH DRAIN ___MOUND
____DIRECT DISCHARGE ____UNKNOWN ____OTHER, see comments SIZE:___________________ ( FT / SQ FT / GAL)
OTHER DEVICES:____ LIFT STATION ____ UPFLOW FILTER ____ PERIMETER/CURTAIN DRAIN ____ ZONE VALVE
UV LIGHT RE-AERATION
ACCESS TO: SEPTIC TANK(S) ( Y / N / N/A ) DIVERSION BOX ( Y / N / N/A )
DISTRIBUTION BOX(S) ( Y / N / N/A ) LEACH WELL(S) ( Y / N / N/A )
C
O
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P
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(or) FAX TO:___________________________________FAX NUMBER:_____________________________________________
Sewage System Evaluation
Form provided by: Stark County Health Department
7235 Whipple Ave NW Suite B ● North Canton, OH 44720 ● Phone (330) 493-9904 ● Fax (330) 493-9920 ● www.starkhealth.org
PROPERTY ADDRESS:_________________________________________ TOWNSHIP:_________________
WAS SYSTEM DYE TESTED?
( Y / N ) COLOR OF DYE USED: ________________________________
DIVERSION BOX— CONDITION: ( SATISFACTORY / DETERIORATING / INHIBITING FLOW / COLLAPSING / NOT OBSERVED / N/A )
DISTRIBUTION BOX— CONDITION: ( SATISFACTORY / DETERIORATING / INHIBITING FLOW / COLLAPSING / NOT OBSERVED / N/A )
CURTAIN DRAIN OR INTERCEPTOR DRAIN OUTLET LOCATED ? ( Y / N ) DRAIN OBSTRUCTED? ( Y / N )
SYSTEM PROBED? ( Y / N ) DEPTH OF COVER OVER TANK _______ LEACH TRENCH/BED DEPTH ________
EFFLUENT LEVEL IN TRENCHES INSPECTED? ( Y / N / N/A / UNABLE TO LOCATE ) - IF NO, STATE WHY IN COMMENTS
CIRCLE ONE: ( DRY / MOIST / SATURATED / SURFACING-BLEEDING ) - NOTE ANY ABNORMALITY IN COMMENTS
WATER LEVEL IN: PRE-HYDRAULIC / POST-HYDRAULIC LOADING)
TANK (#1) ( ________ IN / ________ IN ) - DISTANCE FROM: ( RISER / TANK LID / INLET )
OUTLET TEE / OUTLET BAFFLE: ( SATISFACTORY / DETERIORATING / MISSING / NOT OBSERVED ) - DESCRIBE IN COMMENTS
TANK (#2) ( ________ IN / ________ IN ) - DISTANCE FROM: ( RISER / TANK LID / INLET / N/A )
OUTLET TEE / OUTLET BAFFLE: ( SATISFACTORY / DETERIORATING / MISSING / NOT OBSERVED ) - DESCRIBE IN COMMENTS
*USE CAUTION* AEROBIC TREATMENT DEVICE ( ________ IN / _________IN ) - DISTANCE FROM: ( RISER / TANK LID / INLET / N/A )
LEACH WELL (#1) ( _________ IN / _________ IN ) - DISTANCE FROM: ( RISER / TANK LID / INLET / N/A )
AIR SPACE MEASURED FROM LEACH WELL INLET TO WATER LEVEL ________IN - DESCRIBE IF UNABLE TO DETERMINE
LEACH WELL (#2) ( _________ IN / _________ IN ) - DISTANCE FROM: ( RISER / TANK LID / INLET / N/A)
AIR SPACE MEASURED FROM LEACH WELL INLET TO WATER LEVEL ________IN - DESCRIBE IF UNABLE TO DETERMINE
VOLUME OF WATER USED DURING HYDRAULIC LOADING?
FLOW RATE: ___________ GPM RUN TIME: _____________ MIN ____________ GALLONS
OBSERVABLE EFFLUENT DISCHARGE: ____ CLEAR ____ BLACK ____ CLOUDY ____ ODOR ____ NONE
LOCATION OF DISCHARGE, IF ANY? ___________________________________________________________________________________
BLACK WATER ROUTED INTO SEPTIC? ( Y / N ) GRAY WATER ROUTED INTO SEPTIC? ( Y / N )
WATER SOFTENER PRESENT? ( Y / N ) SOFTENER DISCHARGES TO: ( SEPTIC SYSTEM / EXTERIOR )
FOOTER DISCHARGES TO: ( SEPTIC SYSTEM / EXTERIOR / UNKNOWN )
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N
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T
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O
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SYSTEM DIFFICULT TO EVALUATE DUE TO: (INACCESSIBLE / DENSE OVERGROWTH / RAINFALL / SNOW COVERED / OTHER / N/A)
COMMENTS CONCERNING SYSTEM: ______________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 2 of 4
Sewage System Evaluation
Form provided by: Stark County Health Department
7235 Whipple Ave NW Suite B ● North Canton, OH 44720 ● Phone (330) 493-9904 ● Fax (330) 493-9920 ● www.starkhealth.org
PROPERTY ADDRESS:_________________________________________ TOWNSHIP:_________________
THIS REPORT IS NOT COMPLETE UNTIL A SEWAGE SYSTEM EVALUATION CERTIFICATE OF REVIEW IS ATTACHED.
BASED ON AVAILABLE INFORMATION, THE HOME SEWAGE TREATMENT SYSTEM:
“NOT FUNCTIONING PROPERLY” MEANS: THE SEWAGE TREATMENT SYSTEM IS CAUSING A
PUBLIC HEALTH NUISANCE AS DEFINED BY ORC 3718.011.
_____ APPEARS TO BE FUNCTIONING PROPERLY AT THE DATE AND TIME OF INSPECTION.
_____ IS NOT FUNCTIONING PROPERLY AT THE TIME OF INSPECTION AND MUST BE REPAIRED, REPLACED.
_____ DOES NOT APPEAR TO BE FUNCTIONING PROPERLY AND NEEDS FURTHER EVALUATION.
PLUMBING IS NOT PROPERLY ROUTED IN THE SEWAGE TREATMENT SYSTEM, WHICH IS A PUBLIC
HEALTH NUISANCE.
_____ APPEARS TO BE FUNCTIONING PROPERLY, HOWEVER, SEE COMMENTS BELOW:
_____ AVERAGE LIFE EXPECTANCY OF A SEPTIC SYSTEM IS 20-25 YEARS.
_____ HOME IS VACANT. THEREFORE, THE SEPTIC SYSTEM HAS NOT BEEN IN FULL USE AND
MAY NOT SHOW SIGNS OF DEFECT, IF ANY, UNTIL IN FULL USE.
_____ RECOMMEND TANK (S) TO BE PUMPED, IF NO WRITTEN RECORD IN LAST THREE (3) YEARS
_____ ALL OR SOME OF THE SYSTEM COMPONENTS ARE UNKNOWN
_____ CHANGE IN OCCUPANCY, WATER USAGE, OR THE REQUIRED REROUTING OF PLUMBING
CAN AFFECT FUTURE PERFORMANCE OF THE SYSTEM.
_____ SYSTEM DESIGNED TO BE ALTERNATED/DIVERTED. THIS MUST BE DONE REGULARLY.
_____ ADD RISERS TO SEPTIC TANK (S) TO FACILITATE PUMPING AND SERVICING.
_____ FOOTER WATER DOES NOT APPEAR TO BE ENTERING SYSTEM, HOWEVER, LEAKING SUMP
CROCKS AND/OR BROKEN FOOTER TILES CANNOT BE DETERMINED BY VISUAL INSPECTION.
_____ A SERVICE CONTRACT IS REQUIRED FOR THIS SEWAGE TREATMENT SYSTEM.
OT
HER COMMENTS:_______________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
INS
PECTOR’S SIGNATURE:________________________________ PRINT: ______________________________
INSPECTION DATE(S): ___________________________________________________________________________
T
HIS EVALUATION ONLY APPLIES TO THE DATE AND TIME THE EVALUATION IS MADE, AND IS BASED ON A VISUAL INSPECTION ONLY.
KNOWLEDGE OF THE INDIVIDUAL COMPONENTS MAY BE LIMITED. THIS EVALUATION DOES NOT GUARANTEE THE FUTURE
PERFORMANCE OF THE SEWAGE TREATMENT SYSTEM.
F
URTHER HEALTH DEPARTMENT RECOMMENDATIONS CAN BE FOUND ON THE CERTIFICATE OF REVIEW.
Page 3 of 4
Property Evaluation Diagram
Form provided by: Stark County Health Department
7235 Whipple Ave NW Suite B ● North Canton, OH 44720 ● Phone (330) 493-9904 ● Fax (330) 493-9920 ● www.starkhealth.org
INCLUDE: NORTH ARROW, HOME, SEPTIC SYSTEM, WATER WELL/ WATER LINE, DISTANCES, & HARDSCAPES
Page 4 of 4
DISTANCES:
PRIMARY TREATMENT
TO FOUNDATION
PRIMARY TREATMENT
TO DISPERSAL
PRIMARY TREATMENT
TO WATER SOURCE
PRIMARY TREATMENT
TO PROPERTY LINE
DISPERSAL TO
FOUNDATION
DISPERSAL TO WATER
SOURCE
DISPERSAL TO
PROPERTY LINE
DISTANCES (IF APPLICABLE):
WATER SOURCE TO
FOUNDATION
WATER SOURCE TO
PROPERTY LINE
OTHER DISTANCES (DRIVEWAY,
POND, R/W, ETC.):
DISTANCES (WHEN 100’ OR LESS):
DISPERSAL TO NEIGH-
BORING WELL
PRIMARY TREATMENT TO
NEIGHBORING WELL
MARK N/A IF NOT APPLICABLE
PROPERTY ADDRESS:_________________________________________ TOWNSHIP:_________________
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Form provided by: Stark County Health Department: Sewage (Stark County Government)

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Completed 14 February 2021

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