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270 Septic Inspection 1998 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 220 4.., Boa 2c05b0 Owner: yt1R2McQ Date of Inspection: ^di24t'P BI SYSTEM CONDITIONALLY PASSES (continued. Sewage backup or breakout or high static water level observed in the distribution but is due to broken or obstructed pipets) or due to a broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health,. Describe observations: broken pipers) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(sl inspection if (with approval of the Board of Health, broken pipes) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: The system will pass Conditions exist which require further evaluation by the Board of Health 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 HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER x WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 tees of a bordering vegetated wetland or a salt marsh A SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 3) OTHER The system has a septic tank and soil absorption system (SAS) and the SA5 is within 100 teet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SA5 is within a Zone I of a public water supn'v well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well The system has a septic tank and soil absorption system and the SAS is less than 100 fee:but 50 feet or more from a private water supply well, unless a well water analysis for conform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). (rrviud 04/25/57) Pasta 2 of 10 will]AV F WELD Go.cmu ARGEO PAUL CELLUCCI It 6:wemor i' `ice COMMONWEALTH OF MASSACHUSETTS ' Z5 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAli* ��� DEPARTMENT OF ENVIRONMENTAL PROTECT O DFNr //', ONE N INTER STREET. BOSTON NIA (Cl08 El--29`.?S(L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 220 A) s3r^% Zc A9 j Lee D5 Go 053 Address of Owner: i3o(3 sivkA R ht>Z Date of Inspection: (If different) 27o AvPets,' K D, Name of Inspector: Alan E. Weiss, R.S. , M.S. La-DS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: •ld Haling Address: 3Rf O1A Pnfi PTA Rcl , PP1rhPrtnton MA 01007 Telephone Number: 91e •ell'. • RLDY CORE Score DAVID B STRUHS Commissioner CERTIFICATION STATEMENT cemn that I have personally inspected the sewage disposal system a'. this address and that the information reported below rs true,accurate and complete as of the time of inspection The inspection was penormed based on my training. and experience in the proper function and maintenance of on-site sewage d.sposa' systems. The system / Passes _ Conde-snalh Passes ti eecs `unner Esatuanon B the Local Approving Authon■ Fails Inspector's Signature: Date: The S,ae.m Inspector shall submit a cope of this inspection report to the Approving Authority within thirty G61 F!Q'jpt♦YlGmpleting this inspection It the system is a shred system or has a design Bost) or 10.000 gpd or greater, the inspector and the system owner shall submit the repots to the appropriate regional ohice of the Department of Environmental Protection. The original should be sent to the system owner and come_ sent to the buyer, it applicable. and Inc. approving author-lb INSPECTION SUMMARY: Check A, B, C, or D. A] S'i'STJM PASSES: V I have not found any information which 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 Et,COMMENTS. IN,o& CLACirhs++C BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Iromate 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. unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance :attached. indicating that the tank was installed within twenty (201 years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is immtnent The system snit pass inspection if the existing septic tank is replaced with a conforming septic tank as approved be the Board of Hearth. r..•vad 04/25/97) P.9. 1 of 10 DEP on me Wong Wee Wet n.,,,'we magnet state ma uveee (j Prints'.on Reryoea Pater SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2Z0 nalko szad ?CRt, Owner: Pl ZMoe Date of Inspection: HLI}5e Check if the following have been done- You must indicate either "Yes" or "No" as to each of the following Yes No Leo ✓ Pumping information was provided by the owner, occupant, or 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 pan of this inspection As butt plans have been obtained and examined. Note if they are not available with N/A The facto. or dwelling was inspected for signs of sewage back-up. The sstem does not receive non-sanitary or industrial waste flow The site was inspected tor signs of breakout All system components, excluding the Soil Absorption System, have been located on the site The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected to: condition of baffles or tees. material of construction, dimensions, depth of liquid, depth of sludge, depth of scum The size and location of the Soil Absorption System on the site has been determined based on The lac l htv owner ;and occupants, if different from owner were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.0 Determined in the field of any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable, [15.302(3)(6)] (revised 04/25/9l) ese 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ZZO Z{.+D0oceJ RoAsb Owner: 011‘2M0J2- Date of Inspection: EI Z(1% D] SYSTEM FAILS: You must indicate either "Yes" or No as to each of the following. I have determined that the system violates one or more or the following failure criteria as defined in 310 CMR 13.303 The oasis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distn hubort box above outlet invert due to an overloaded or clogged S4S of cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 12 day dots Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipes. Number of times pumped _ Am portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation Anv (Jordon of a cesspool or pars is within 100 feet of a surface water supply or trlbutarr to a surface water suppls Any ponion of a cesspool or posy is within a Zone I of a public well An portion of a cesspool or prism is within 50 feet of a private water supply well Any ponion of a cesspool or prise is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis lithe well has been analyzed to be acceptable. attach cops or well water analysis for cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: - You must indicate either "Yes' or No as to each of the following:--- The following criteria apply to large systems in addition to the criteria above. The system serves a facille, with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 fee: of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPAI or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facil try into full compliance with the groundwater treatment program requirements co 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information. IrevLW 04/35/571 Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ZZO Cid DO&lei 4040 Owner: lIIwQAOR Date of Inspection: 12,1gg BUILDING SEWER: (Locate on site plan: ft Depth below grade 14 Material of construction _ cast iron 1410 PVC other (explain) Distance from pate water supply well or suction In Diameter Comments. (condition of Joints, venting, evidence of leakage. etc I otL SEPTIC TANK:1 (locate on site plan; Depth below grade. 4 Material ot construction concrete _metal Fiberglass _Polyethylene otheriexplaim If tank is meal, list age Is age confirmed by Certificate of Compliance _(Yesrno, Dimensions 51K 10 X ) r Sludge depth Y', D,s(ance from top ot sludge to bottom 01 outlet tee or baffle 33 Scum thickness 3" Distance from top of scum to top of outlet tee or battle (i f Distance from bottom of scum to bottom of outlet tee or bane If How dimensions were determined. !n«S.r<d Comments (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of Ilqu rd level in relation to outlet invent struclural integrity, evidence of leakage, etc.) '(ntwC{ CGAd1-bc. 5 GREASE TRAP: !( ilocate on site plan) Depth below grade Material of construction _concrete _metal Fiberglass Polyethylene _otherfexplarn) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle. Distance from bonom of scum to bottom of outlet tee or baffle. Date of last pumping. Comments (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc I (r.vi.sd 04/25/9]) P.S. 6 of 10 Property Address: 220 AJ;xs.gtJ Owner: MA2Mo2 Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION V iAp FLOW CONDITIONS RESIDENTIAL: yfs (L (Or7otbs4L) Design flow 3.30 .p.d/bedroom for S A S m Number of bedro s 3 Number of current residents ht Garbage gn der (yes or no) y A' Not iiecccartetiDEil Laundry corrected to system Wes or no) y Seasonal use ryes or no). W Water meter readings, if available (last two (2,year usage (god!. N �A Sump Pump lyes or no). iJ Last date of occupancy Curter-4 COMMERCI AL'I NDUSTRIAL Type ot establishment N14 Design Bow _gal lonsidac Grease trap present. Ives or no'_ Industrial Waste Holding Tank present tees or no. Non-samtary waste discharged to the Title S system Water meter readings, if available Last date of p'cupanc OTHER: !Describe' Last date of occupancy GENERAL INFORMATION PUMPING RECORDS and source or mlormauo^ 2 r3 44d System pumped pan of inspection (yes or na If yes, volume pumped /SD° gallons Reason for pumping Tine/ Rc?„,&S • TYPE OF SYSTEM L-------Septic tank/distribution bodsoil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no} (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract' Other APPROXIMATE AGE of all component( date installed of Hown) and source of information. tiers Sewage odors detected v.hen arriving ar the site eves o- not jsr (revised 04/25/97i v•9• 5 at 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ZLo Aacotjc..) 4c9. Owner: r\rr-re Q. Date of Inspections i\% SOIL ABSORPTION SYSTEM (SAS): y (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. number_ leaching chambers, number.__ leaching galleries, number. leaching trenches, number,length leaching fields, number, dimensions (1) 36 %25. BED, overflow cesspool, number. Alternative system Name of Technology Comments (note condition of sail signs of hydraulic failure, level of pond ing, condition of vegetation, etc.] bcor4 rrnds1-,LAl. CESSPOOLS: Al (locate on site plan) Number and configuration. Depth-top of liquid to inlet invert Depth of solids layer. Depth of scum laver. Dimensions of cesspool. Materials of construction. Indication of groundwater inflow (cesspool must be pumped as part of mspecoon) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /Y (locate on site plan) Materials of construmion Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding. condition of vegetation, etc. Dimensions Ir.v ..d O4/2S/97) Pa94 0 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ZZO AxiDo BCJ R . Ox ner_ FAh21nAo:2 Date of Inspection:8'Z(19e TIGHT OR HOLDING TANK: if Tank must be pumped poor to, or at time, of mspeclionl (locate on site plan. Depth below grade Material of construction concrete metal _Fiberglass_Polyethylene other(explain) Dimensions Capacity- gallons Design flow gallonvdar Alarm level Alarm in v.orkmg order Yes, do Date of previous pumpme Comments Icondmon of inlet tee condition o: alarm and float switches, etc DISTRIBUTION BOX:/ {locate on site plan. oK Depth of liquid level abose outlet coven q} fnvca'e Comments {note if level and distribution is equal, evidence of solids carryover, es,dence of leakage into or out of box, etc l 41 eft s+n h+1(o� k,r•ef Y eyU cl joosQ. PUMP CHAMBER: A/ (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.) Ir.vf..d 04/25/57( Page 7 c. ]0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address, 270 .Ne&CAI Rc4D Owner: n1 QJno2 Date of Inspection:g/L I I q6 Depth to Groundwater 6,5 Feet Se /99Z pert Please indicate all the methods used to determine High Groundwater Elevation: Le/Obtained from Design Plans on record Observation of Site (Abutting properly. observation hole. basement sump etc.) Determrne it from local conditions ar-rheck with local Board of health Cheri. FEMA Maps Check pumping records Cherb local excavators installers Lse CSC': Data Describe in ...Dui' o.,r ords her you established the High Groundwater Elevation. (Must be completed; oc4 Ytzo&J5 ± Pet repel- $91_ P•po If of IC SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) I ) I Propens Address: 110 AuDOgoN l Owner- ( &no 2 s l Date of Inspection: g'Zt14fl SKETCH OF SEWAGE DISPOSAL SYSTEM: ,nclude ties to at least two permanent ref: ences andmarks or be chmarks locate all wells within 100 (Locate whe e pub) ware: supply co s into house) revue O4/25/97) Fag• 9 of 10 KAY S'LS1 �lAt3 N. ,-Lo') 1B h•oexo C>d/WA 5 D Po SAL nil.- Ctrz,v jY .57 no_ if 4' 1Z Pvt Jer 3L-La Por.2 sw� Poc SILL L It iLc .L 0 50/L l o(.2 5 SmL ➢Oq TV-2. B'-1i' IC'-010 +T v,*' S eue fiLry 2/.0 9000 y,m S.e c_..tenet( 711.Lj St/2E 4 n4L 49 (eeel[5. 00,C. 0a ,„..,¢., o 32E5I EA2 /J Die 3 (em.r ro) 1. 334 Y/,D onr tso 0/0 - Y95 p j 2. 30.'1 t6 L.aEO z /CO Sp r 2 V95 p0r 3, 11..a FLL iu T,LE .1L AeTea CLE'Q)J6 ALL Coo,, FN e APta SundA. Rut> D0TLET AT SILL +V 211024.NeyEO • ALL ' Y w4ea /Ss 1 waor4Ft To INC PL,„1ne0 W. 6C. 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