17 Septic Inspection Form 1999 WILLIAM F MELD
Gone:
MGEO PAL1 CELLUCCI
Lt °pnmm
COMMONWEALTH OF MASSACHUSETTS n -
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Kw 5 pi-
DEPARTME\T OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. eos7oN. MA eIOI el•-'95.530C :IRIJIRORE).
P.
St./SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
� �c^ //'� � PART A
C-5-fe/fir /bt W _// CERTIFICATION
Pro /7 r1'�Tt.,^•-•� -' ttrt
Deis nlpec3kn; Fd 3 98 • Pate._. Address of Owner:
Name of Inspector: (If dtHnen0
yam_
I am•DEP approved system inspector pursuant to Section 15.310 of Title 5 1310 CMR 13.000,
Company Name: Air£nrdapl. Tanana And Pope lr Toa eetion6 Inc.
Mailing Address' 129 N. Elm St . Wo Ref Ipli , Ma 01085
Telephone Number: 411 - RAp_4:•o
UERTIFICATION STATEMENT
I tench That I have personally inspe;iec :rte seas sae disposal system ar IHs address and that the information reported tern,. is true accurate
and complete as of the time of 1-Spent- The im steer.o was performed based on my vanrg anti experience in the props tuncl.on and
mancenance of onA•:e sewage msposal sl stems he stem
re
TRI:DP CORE
Secrtry
DAVID B STRUMS
C on msiener
Passes
Condt.o-ar. Passes
heeds Fanny Ew'!uaaon Bs the tocai Aporamg AuthOnry
FaitH
Inspectors Signature: rrgpya f• ittQQ Dale:
f13/8
The System '-spec°• shag sub...:a copy of this :nsper,o- won to the Approving Authority within thirty (30, days of complenn this
Inspection, If the system u a shared sn'em r has a min Era o' 10000 glad or greater. the inspector an S
the :coon to the appro a the mien owner ehae submit
puytr rest-0nar °flee of a Dep./men! u Environmental Protector. The ongmai should be Mr2 M the iYStem pwner
and Capri nisi to the buyer, 1'iophcad4, anc the aPpr°vmg lit^°qty
4 \ ��!�:d eLQ ,
INSPECTION SUMMARY: Check
A; SYSTEM PASSES:
C, or D
I have net found any information which indicates that the tystern vimaes any of the failure criteria as defined a 310 CMR 15.303.
My failure criteria not•Vitiated are indicated below.
COMMENTS:
EL SYSTEM CONDITIONALLY PASSES:
One Of more system components as described m the 'Conditional Pus" semon need to be replaced or regiret. The sysem, upon
completion of the replacement or repair. as approving by the board M Hoak w,II pass.
Indicate yet, no or not determined (Y, N, Or Describe basis of determination in a1I instances. If not dnarm,ned•, eappM why eta
The septic lank is m unless the own°of operator has pyoyided the system inspector with a copy Of a Oradea*Of
Complunce ed mdtating that the sank was Installed within twenty 1701
the kepi k, yeah substantial prior f, the date 'r the inion o k or
wt The or not meal, is cracked, structurally the ly unsound, shows is inldera co or nw,g I p , or*rile
aailupprovng by the Boad o'Health
pass tmxn'on if the existing seprc w4 is rep;Med inch a conk nnmg aspic bilk
Crevieee 4i21/I71
Bap 1 et se
se•re rim W'ryr Met wet Vic ewes mpti,gate Ta Vane
SUBSLRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
,/ /CERTIFICATION (continued)
Props ty A dress: /7 rymilk.: Il( • `. /dl Lx.t..Z.
Owne : t`tr-a'>r-vnr2
Date of inspection! d d/I3 is
I)SYSTEA CONDITIONALLY PASSES 'continued/
Sewage backup or breakout of h,gh su,,c wirer teal observed in the distribution box n due to broken or obstructed
pipe.,$) or due to a broken. sensed or uneven distribution boa. The system will pail inspection rl Iwith appro4 of the
Board of Health; Describe observations:
broken pipei; are re ad
obstruction rs re ed
d:strsbution bpin levelled or replaced
The system required pum g more than four ernes a year due to broken or obstructed pipets) The syS:em
insoeeon II twee appr at of the Board of Health)-
_ broken pPot!5I are replaced
obwhcl on is removed
II pass
C) FURTGER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ C 0,O t ons et/s/ whet) requ re Luther evacuation by the Board d Health in order to determine if the system a falling tp prole❑ Ile
Fubhc health. safety and the environme9
1) SYSTEM MILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
b HICH WILL PROTECT THE PL'ILIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or on.", a within 50 fee: el arface water
Cesspool or prim, a wnhlc 50 feet, a boroe mg vegeuted wetland or a salt marsh.
it S"STEM WILL FAIL UNLESS THE BO OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAI
Ti! SYSTEM IS FUNCTIONING 1%,A MANNER THAT PROTECTS THE PUIIIC HEALTH AND SAFETY AND THE
F fYtRONMENT:
the system has a spit lc tank arra sod absorption system (SAS) and the SAS is within 100 feet to a surface water supply Of
Irrbutaq to a su'jice water Supply
The system h'alf/i sep:'c tank and Sol abaorpuon system and the SAS is within a Zone I of a public water supply will.
The system )is a septic tank and so I absorption systet and the SAS is within 30 Net of a pnva:e water supply well.
�. The system/has a septic tank and so I absorption System and the SAS is less than lee feet but 5C feet or mote (r011r a
privet wain'wooly well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates dst
the well rs free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
lest than 5 ppm. Merhod used to determine distance (approximation not tend)
3) 0'HER
lraaaN -0d 31/771 Pap 2 St 12
INN
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued;
1 Qe\A.yc.E__
Property A IS: 7 /Y4*asnrfl {/1
Ownet: u,p � �
Date of Imvrction: 10/F�i/9S
0] SYSTEM FAILS:
YOU mutt inditlre either "Yes" or -No' as to each of the foilow'Ins
I have determined that; the system violates One or more of the following fa.lure Intro as elelmeo Tr 310 CY R. 15.303 The oasis
for this oelrminalmn n Idennhed below The Bard of Health anould be contacted to determine what will et necessary to caret,
the bilun
Yes No
- Backup of sewage into facdiry or system component due to an overloaded or clogged SAS or cesspits(
- Discharge d- pending of effluent to the surface of the ground or surface warm due to a+ ewerloade r or clotted SAS or
tesspoo'
- Star; I,ou.d lee' in the dis;r,bo::o- bo
- Loud depart -n cesspoo is Its than 6`
- Recurred pumping mere than 4 tile:
Numper 01 nines Pu-rped
above ouster in due to an overloaded or crossed SAS or cesspool
below we or evadable volume is less than 1:7 day he
If/the last year NQ due to Dogged or oesnuned p pe'.s:
Any poi o-. of the So.; Abhor o- Svster(, cesspool or prin s below the high groundwate• Nevbp:
- An' col io.., PI a cesspo or pro's a with n IOC fel pr a sjr' ce water 1.100'N 0' :r:balary !o a svna e
- A•, ;G-:o- of ace pot: m privy 6 wither. a Zo-e l or a publicc well
sate, SUpph
• AM portion of a cess000 or privy is with a 5C fee; of a p"va'e ware' supply we::
Any Donjon O a cesspool or p•'W is less than 100 Set but greaser run so feet from a ornate water ''•,t'C y well with no
acceotao e water Quality anaiys s if the well has ben analYteo tC be accepuoie attach cops or wet n ate• smiths br
col.•Orm aver a. .o'a•de organ,c coaoo‘nes, ammonia nicregen and nitrate ni(rogen
E) LARGE SYSTEM FAILS:
You mute indicate enhr "Yes' o 'No"as t0 each of the following
The following criteria app', t0 Large systems ■n addition to the otter a above
The system Sent a (acd:ry with a design flow of 1 D,000 god or greater barge System; and the 'mein 3 a sign lice; threat to
public nealth and safety and the environmell because one or more of the lollowing conditions east
Yes No
the system
nn 400 feet of• media drinking wale,Supply
the em rs within 200 feet o4 orbuury to a sudxe drinking water supply
/the system is Ioared in a nitrogen sensitive area (Interim Wellhead Prolet,ion Area , IWPA) or a mapp.d Zee II of
public water supply welt!
The owner Or epemor of any such System shall bring the system end facility into full compliance with the groundwater tre..a:rnent wore
requirements of 314 CMR 5.00 and 6.03. Please consult the loci) repeal (Ate of the Deanme, for further informations.
ae.aea anan+l
Mee 3 et 13
SUISLREACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 1
CHECKLIST
Proper's Addr n. /7 $ L nv.-H1 A
Owner: 1.13
Date of Inyec an /0/1.3 j4
Check if the following have Deer done You must indicate either "Yes'' or •No" as to each of the INlowing
V7 No
2
Pumping information was provlyed by the owner. occupant, or Board of Health.
None or the system components have been pumped for at least two weeks and the system has been re<nvmg no•nat
Co* rates during Th.! prod large volumes of watt, have ma been Introduced mo the system rec,nr y or
as pan of this •CSpect or.
As Duda plans have been OD:a nec a-d eat red
Note I they are not avV'ab'e wen N/A
the fa .;y o'dwe'l,ng was nspened for signs o' sewage back-up.
Tne 5vfte-n d,es not re.e+ve r•Onsa' a rndu s?a' ware flow
The sne was inspe'ed so. sigm of break om
At S.ve.- conpo-enr ern:d^.g the So r AbSDrpocr S‘,cow have been rotated on Me rise
Tne kept c tan( na^.no"JS were cnco,erec. Opened rd tine •n;e'.or of the kept¢ tank was InvOIemd for Condition Di
bares Or tees maet ar 0'Co n strur inn d'ens ons. depth of:rand, depth of slwge depth of s
The size rd roca:,on of the Sol Abs 'peon Systen., on me sire has been de'ermrned based on.
The fat-■ y owre• and OCCCpana. f d.Hereni Iron owner■ rove N0vsded with infOrmaLOn of r V Dr00er mamtena late 0
SubS.Race Dupesa' System
Z.
Euw-g nfo•mar.on Ea Pit. a• 8 0 r+
Dere•r ned n :•.e field bi ar• of the fa'lure crier a reIared :0 an C is at issue, eppnocnaror c drance is
unacceprabe/ It32 2t irba
tra'i. OCAS/HI
aaea 4 of to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
` rrSSTTEM INFORMATION
Proper Adbeel / 7
Owner
Date of Inspection o/L3/9e
RESIDENTIAti [[ 3E0
Design flow ri g t.tl/oeoroa n for S A S
Number of bids
sons Number
Number of curr•nt residents
Corbel,It.•din (yes or no
Laundry terraced to SWtm
Seasonal use ores or no)
Water meter 'sadingi. .1 isfplable nest two (IS Year
Sump Pump lye• or not
ROW CONDITIONS
Last dale or o sc.:pane'
Nr.
Leariej
sOMMflCl a4J cDUSTR1Ali.
lyoe of establpr mint
Design how___ge!ons'das
Cmare IMP p es1rt eyes or no
irsunral Wa!I. Folding Ts •,sent Ives Or no
Non.san,tary i+a.I* do girl Ic t^e Title i sys:e es or no■
Water meter tea it a•adabte
pefrel:,oa,n _
OTHER: !Dealrre
Lan date of orc.canin
GENERAL INFORMATION
PUMPING RECORDS anal 4ycf of int,a+ma
b peo rt sin .
Sp4.- puree[ as pal d mepemon, or no
Il ye o•■nle Dumpec ',lions
Reese. for pumping
TYPE Of5YS1 Er I
✓ Septic I enk/distnbunon box/soli absorption system
Single fNaPCCI
_ Oserfic«cesspool
Privy
Shred iystem (yes or no) tit Yes, enact: previous inspection records, if any)
IM
"f 1.0 etc. Copy of up to date Contract
Other
APPROXIMATE iliiaa of all components, date instilled (if known) and sours of information.
Sewage Son ese emed when arriving at the site
yes or not /(.b
IreverN ea/a e!-`! !ya 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INSOR$tATION 'continued
m( C �7
Propenrn�AAppmess: / [ + 7 ''c"t'''�F'-C3�
Owner: ns ` fn,cyly ne,r.�
Date of Inepechbn:itafgT
BUILDING SEWER:
(Locate on site plan)
Depth below grade /
Materil of construcLor: .E[Up non —40 PVC —other Jeeplain:
Distance from prnue water supply well or swoon ir:. A)ft
n
Daier le
Comments Iconeaton of biota, vent. idercp of leakage,
/In Sd.e raid a-f �.2..Y e (0 .
SEPTIC TANKIDATA_pAx.C,
Moose on Me plan;
Depth bew grade I
below /
Matepa: 04 COnr.Rro'. Zccncrete
me'a _Fibe•gi R SciveP v'ene _otne•ie.c'a ni
If tank n meta'. I.rt age _ is age cr:rfir■ ee b. Cen (icr.e of Compliance ive✓• e
Omens-on; /0 XS
Sludge depth C. rr
Dialect from top of these to bonon of outlet lee or bane 3D •r
Sum thickness- / a n
Distance from top of scum to top o'cutlet tee o• ban'.e f
Distance from bottom o'scum to bcr ogt q(omlt tee brie �_
How gImenslons were determine° L%(wlS `/a SQ
0
Comments
Irecommendation for pumping. COndlton
mtegrM. a/Li') Totalar, erc.
vi
del ides or COMes Cep
of Bout ya el in reiatdl to Duli.F inv n, structural
lie
GREASE TRAP:
(locate on Ire plant
Depth below grade
Meerut of construction concrete meat.Fiberglass _Polyethylene _otherleapltml
Dimensions.
Scum Inrdtnye'._
Distance from top of Kum to top of 0 ee W bade._
Distance from bosom of Kam 1 om of outlet tee of Wavle
Date of wt panning'.
'
Cpmme :.nta
oecom n for pumping, condition of'Het and cutlet tees or baffles, depth of hoInd level in relation to cube 'riven, Svuaura;
Inge$"h, evidence pf leakage. etc.)
tr.W•• e.nIq+)
a.t. 6 et :c
Property A<h4 est
Owner: ` 'a
Cate of Inspect
SUBSURFACE SIWACE DISPDSA(RT C SYSTEM INSPECTION FORM
PA
4 SYSTEM INFORMATION (cont;nded;
ro/ /?I"
TIGHT OR IIC{DING TANK:
(locate on see Ilan)
Depth below RI ade
Material of cone'ruction _concrete ems
'Tank muse be pumped prior Ic. o at t'me, of inspection;
ass Polyethylene o:herlexplalnt
Dimensions _
;Eery f
Oengn 4ow Rallon✓da,
Alarm lave/ Alarm tr
Date of r wO'"'"R order ves No
p eno.s pumomR
Comments
(Conoco` of wie• in condo on or a atm and Opal switches. etc.
DISTRIRL TIOx: I Ok: /92payCC
(locale on sne Da
Oeo'h of Itcald ie e above pave:
Comments
Inge dl
Iron
I a^o Lion s ecka
e
Bence of so het carryover,.R.:Brice o! 'ea age into .r • I of ••y cc_
ie n j.s °L s__ o '!w
PUMP CH4MBIR _
(locate on site p an
Pwmos in Woravg ]roar
Aiannt N working Dreier
Comments.
(rim! Cpnd Rlon car I p
(Yes or No'_
(Yes oe Not_
$iamb!f, condinon of pumps aNd appunena%.w etc I
•
Urvlrra 04g1/t'
Page t •f 10
SUBSURFACE SEWAGE DISPOSAL SYSTE'.' INSPECTION FORM
PART C
,.� � ^
SYSTEM I FORMATION. (continued)
Property s: / 7 /�-c or`' n �,
/ )Q �cA
O --
erltr: v
Date of InpeetiOc? /o/A_a/Q C /^ //
SOIL ARSORPTION SYSTEM (SAS/.l i ij"t
(locate on site plan. If pouibie; excavation not requ,red, but may be apprwimated by non.intruswe methods)
If not determined to be present, ecplam.
Type
leashing pits, number_
leaching chambers, number
leaching salleres, number
Ieachm8 Trenches. numbe4ength /d
Inching helot number, diners,cns
overflow Cesspool, rur,ber_
Alternaitve Sv[Rm.
Name of Techno.ogy.
Comments.
Mote cent:monof Sal sirs of h'S'au'■e failure le
of pondM1 condit on of
�a b
Seat etc.
o eO... IL IP. _ K- _4 a
CESSPOOLS:
(locate on stte plan;
Number and conpµration
Depth-top of Lquid to inlet Inver.
Depth of solids laver.
Depth of scum layef
Dimensions of cnspoo.
Matera!I of Conprucl or
Irtdiat..on of round
inf ow SIDOO; mutt be pumped as pan o'rmpec onl
Comments
(note condition of soil, Ggns of hydra.,
ic faliJle, stye)of ponding, condcon of wgetaeon etc.'
PRIVY:
(locate on silt plan'
Materials of firuction.
Depth of ids
CoM A.
Inge Conditwn of lair, SiffS Of hytlraul failure, levee of pond'..g, cond!non or vegetation, etc.)
Dimensions.___
I •vtaM M/21/077
Rata 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION conGnued>
Properly Addr I i 7 '4M Lu ,„ ()n t-"Q
Owner:
Date of IMpenlore
16713/9 F'
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at leas: two armament 'Hrences land'a•ks or benchmarks
locale all wells within 100 !Locate venue pubhc water mpply comet Jr" hovsel
Invu.a ea/n/n:
F'a 8 '.
�8\
n )
rap . of 10
SLBSLRPACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Owner. Add.esy: r 7 - unwrt
Owner: �•WA.w
yn r
Date of Inspection: .
s3 it
rebut set
Depth. to Groundwater etql Fee
Please md.Ute all the meti'ods used to determine Mtgh Groundwater Elevation-
Oblamed nom Deign Plans on record
O sevat:on c'Sc o (ADUring p'opeey, ob;ersenor hole. basement sump etc.)
De rmme it nom local condcaans
C-en w,tn rocs Board of•eens
_ Cnec. FEMA A'ADS
Check penp.ng teco•ds
Cited; local e'ea•a!J's. rrsta'ett
L;se LSCS Dux
a)e,-A0.-1-
r.
Describe '^ to.' on ..card5 how .o. es:ac'sod the M'gh. Crovndwa'ea Peva;on (Mgt be completed
—no tX1 Lq? d)�%0f fl 6 Z(J 0.± A-sa[u_Si(. ! 4 ./Lt-.l T''P-o' /r I.t.
laawlaaa HM/01
Pap. 00 se It