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
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