9 Septic Inspection Form •
LIAM F.WELD
Go cmor
AR3EO PAULCELLUCCI
LL 3ovcmor
Property Address: 9
Da a of Inspection:
Name of Inspector: iO Y1 N
I em a REP appfpred,sys'
Company Name:
• Mailing Address:
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have perso a y inspect
and complete'as of the tim of inspe
maintenance of on-site see ge dispo
- P es'
_
Go dnionalli
_
he-6 Furthe
F s
MMON WEAUTHOF'.MASSACHU,$Efl S
CUTIVE OF4.QF,ENVIRONMENTAL AFFAIRS -PARTMENT OF ENVIRONMENTAL PROTECTION
WINTER STREET. BOSTON. MA 02108 617-292.5800 .r,.
me-ievid eitt 40 ..
RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i;; s:..ce
CERTIFICAT ON +:
P 2.2"( 1--n ti Address of Owner:
- oV s t TTr.i 1 rNlf differenfRnwa blaaupin mauve stir
LU .j ds=! t..anE sett is i .owgs dt.4 N no ;:avni
dor pursuant to Section 15340 of Title:53(310CMRJ5 17(10) -
S4 c, G fs..rre12 Sr L tit) o
S � Z —213 2,
+'.TlF3ri s':.. 'sC /N (.1.31')G3R V VO;TAUJA'N P* rR \ ...-
sewage disposal system at this address and that the information reported below is true, accurate
The inspection leas'performed based on my training and ekperience-.inihe'proper function and
ems. The system: ■ - n '>dr hnc 441st d"am nt44.r
' ;_r:.; till IV.) 2€44 JisN frfl
Tii:O$S AWN N.J:;i:•
ation By the Local Approving Authority
DAVID B.STRUHS L,
Commission
Inspector's Signature:
The System Inspector shag' `ubmlt a c
inspection. If the system P shared
the report to the appropria regional
andlcopies sent to the bu 1e!, if appl
INSPECTION SUMMARY I Chec
A) STEM PASSES:
I have not found any info
Any failure cite is not eva
COMMENTS:
Pl /J e . Date: i l/ o ;/C7 . ..,:.$)
I. t U:•a: p io r1)0.1n -., ./1.12) 3 -I 11IW 1231 .
this Inspection-Teton tdthe Approving Authority withirithirty130)dayi of completing this
or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
of the Department of Environmental Protection. The original should be sent to the system owner
d the approving authority. .
C; or D:
el
. :.rye cs" :: ,
1 1 1: ■■);. . v ecd r r edT
hick'indicates th5tthe system violates any'of the failurecriteria as defined in 3W CMR 15.303:
YSTEM CONDITIONA LY PASS
One or more sys+ compo
completion of tl'$ replace
described in the 'Conditional Pass'section need to be replaced or repaired. The system, upon
epair, as approved by the Board of Health, will pass. -
•
r ND). Describe basis of determination in all instances. If'not determined', explain why not.
unless the owner or operator has provided the system inspector with a copy of a Cenifiote of 1=
dieting that the tank was installed within twenty(20)years prior to the date of the inspection; or
r not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank
ystem wilt pass inspection if the existing septic tank is replaced with a conforming septic tank
of Health.
e yes, no, or not d ! rmined
The se tank is
Comp! de (attac
the se tank,
failure
as app
(r.tse.d 0e/25/97)
• Io 1Pag.:1 of 10.
EP on tie Web Vrkewee: hip:/Ne w.megnelsteteinelWdep
Printed on Recycled Paper
Property Address: '
Owner:
Date of Inspection:
{ B)SYSTEM CONDI
T system
inspection if
Cf FURTHER EVAL
UBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
q '34$ yj,t•9'tt_44. Ark
'r
—F /4.. 2,2,1 S.- '„
I / • Iii
(continued)
reakout or high static water level observed in the distribution box is due to broken or obstructed
roken, settled or uneven distribution box. The system will pass inspection if(with approval of the observations:It?' a),'•:: 3,1AF.12E'J[
Token pipe(s)are replaced.
bstruction is removed;.
istribution box is levelled or replaced
pumping more than four times a year due to broken or obstructed pipe(s)., system willpgass
pproval of the Board of Health): r } es,.ua r r'e;
rokenplpe(s)are Teplaced .ni ms :. >_
bstruction is removed
RED BY THE BOARD OF HEALTH:
Conditions 'isl which
public heal h safety an
1) SYSTEM PASS U
WHICH W
tT
e further evaluation;by the Board of Health in order tgdejermin dAhF system is failing to protect the
-nvironment.
BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOF,FUNCFIONING IN A MANNER
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: • -'-
within 50 feet of a surface water -
within 50 feet of a bordering vegetated wetland or a salt marsh.
THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
C IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY,AND THE
_ C pool or p
_ C pool or p
2) SYSTEM W FAIL
THE SYSTE YY IS FUN
ENVIRON T:
- T ie system h
tary to a
- T e,system h
The system h
- The system h
p ate water
the Nell is
le f than 5 pp
3) OTHER
tic tank and soil absorption system (SA5)and the SAS is within,100 Meet to a surface water supply or
water supply.
tic tank and soil absorption system and thgr SAS i%swithinp Zone I oLtablic water supplywell.
ptic tank and soil absorption system and the 0.5 is within 50 feet of i private water supply well. -
ptic tank and soil absorption system and the SAS is less than 100 feet but @.V9etor more from a
well unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
pollution from that facility and the.presence of ammonia,nitrogen andpitrate nitrogen is equal to or -
ethod used to determine distance (apprpxiI 1ahon not vapid),
(revised 04/05/92)
4?.:t,
Page 2 et 10
107
or 9/10410;
P bperty Address:
ner:
D$te of Inspection:
DJ SYSTEM FAILS:
Y$u must indicate eithe
I have deterrn''
for this deter"
the failure.
Its No
Back
es or
that t
on is
SURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
• », PART A
CERTIFICATION (continued)
I / 1 1 ° fC
to each of the following:
violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
below. The Board of Health should be contacted topteryojnowhat will be necessary to torrea
o a•" vote rtn€;4rrtsoin, ...�.r9 . .
facility or system component due to an overloaded or clogged SA5 or cesspool
effluent as the surface of the ground of surface waters due to anoverlloaded or clogged SAS or.
,.ralen.oat a.a
distribution box above outlet invert due to an overloaded pr clogged SAS or cesspool.
- Discbao-ge or po
cesspool.
i
- Static liquid eve
- Liqui pepth in
- Requ GY¶d pumps
Num of time
Any
Any
An
An
Any
acce
colt
on of th
ion of a
ion of a
ion of a
ion of a
le water
bacteria,
less than 6'below invert or available volurpa is less,[han 14 day,flow.
'. than 4 times in the last year NOT due to-clogged qr obstruaed pipes);
d
Absorption System, cesspool or privy is below the high groundwater elevation.'" ..
P
'of or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
ol or privy is within a Zone lofa public well r. .ss�
• or privy is within,50 feet of a private water supply spell_
:7e e
• or privy is less than 100 feet but greater than 50 feet from a pnypte“Lvater supply well with no
analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
e organic compounds, ammonia nitrogen and nitrate nitrogen..
E7 LARGE SYSTEM FAIL
You muss indicate either es' or
The following c i eria app
The system serve a facility
public health and safety an
Yes No
the
_ the
it
I. _ the sy m isloca' publi4 Later
1
T owner or operator o
r irements of 314 CM
m is wi
Ixr
cad 04/25/97)
such
.00 and
each of the following:
ge systems in addition to the criteria above:
F'
design flow of 10,000 gpd or greater(Large System) and the system isa significant threat to
nvironment because one or more of the following conditions exist:
feet of a surface drinking water supply
feet of a tributary to a surface drinking water supply
a nitrogen sensitive area(Interim Wellhead Protection Area•IWPA)or a popped Zone II of a
I)
shall bring the system and facility into full compliance with the groundwater treatment program
Please consult the local regional office of the Department for further information. -
Pr perty Address:
O4ner:
Da a of Inspection:
Check if the following
Puml}jog info
None Of the syst
flow rates
as part ars
As b It plans h
The acility or d
The
The
All sy tem comp
The pus tank
baff T or tees,
URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ff "'PART B
°C-'CHECKLIST
r-/ /S ,7- K 3 /=u-ti)'
yt (c_12,-02._ Si
/ L / / / 5 ,
u must indicate either'Yes'or'No"as to'each bf the following: -
as provided by the owner,occupant, or Board of Health:
h- sne :: ♦ v[� Sri, mosinrlo et.i:>:@
tponents have been pumped for at least two weeks and the system has been receiving normal
unrig that period'Large volumes'of watethi*eltM beed'4mrdduced'vifo the system recently or
n obtained and examined.•Note if they are not availabliwith WA ;z•.:
was inspected for signs of sewage bads-up ""'n n :4
ceive nomsanitary.or4ndustrial waste Bow. -` Rmva"Uti
for signs of breakout. ,� s nMrx, ,nY
excluding the Soil Absorption System, have been looted on the site.'
les were uncovered, opened, and the interior of the septic tank was inspected for condition of
I of construction,dimensions, depth of liquid;depth of:sludge;depth of scum. ..
Soil-Absorption•System-on the site has been determined based on:°' y._ -.-
d occupants, if different from owner)were provided with information on the proper maintenance of
ystem. _ ..,
x. Plan at B.O.H.-
d (if any of the failure criteria related to Part C is at issue,approximation of distance is
(31(b)l . .. .
L/ Exi `hg inform:
Dell mined in
unac eptable)
Property Address:
Owner:
Da e of Inspection:
RESIDENTIAL:
Design flow. 4'0 proom
Number of bedrooms
ber of current resid
age corder(yes or rl�): (yes dry we (yes to s +j�m"fyes or
asonal use (yes or no) 1i0
er meter readings, ifayaJable (I
ump Pump (yes or no): K'd.
..
. ..-
- -.pp"/
. .:{.p
Last date of occupancy:`IQE5
COMMERCIAL/INDUSTF L.
Type of establishment:
9*
URFACE,s EWAGERISPOSAL;sXSTEM71ySRK,T1(3p1 FORM
tPART C
..RYSTEM INFORMATION ..
32if iK32
FLOW CONDITIONS
now nraw ettiv.N
(2)year usage (gpd):
Design flow:_gallo is/day
Grease trap present: (yes pr not
ndustrial Waste Holding Tank prese
Non-sanitary waste discharged to the
Water meter readings, if available:
ast fate of occupancy:
OTHER: (Describel
_ast date of occupancy
PUMPING RECORDS and source of
System pumped as part of i
If yes, volume pumped:
Reason for pumping.
TYPE OFiSYSTEM
1/ Septic tank/distribution box/
Single cesspool
Overflow ass
Privy
Shared system (lles or no) (i
VA Technology ttc. Copy of
er I
or no)
ystem: (yes or no)_
t u•..1 .r:
GENERAL INFORMATION
anion:
on: (yes or no)�cr
alions
:3. 7 1.,.-1 !
Ho5risty'r r9-.z s
orption system
yasigdnvt:"
ttach previous inspection records, if any)
date contract?
PROXIMATE AGE of all componer
age odors detected when arriving
..es..d 04/25/97)
In::p el
inSir,?sed
ssW'gjyysll(so in 16:1Wh
•
y::uc So n..
installed (if known) and source of information:
0 C.114) £:jr/Z.+tneffier4
rgrf,lya:r ,r ',q4t slk.n.r„sroy4
site_ (yes or no) N0 —'-.� ?:ore r,RPrteistfx ;At q:
en rage 5 of 20
•
Property Address:
Owner:
tl)ate of Inspection:
UILDING SEWER:
ovate on site plan)'
C.lepth below grade:_.__
terial of construction: _cast I
I
bistance from private water suppl
Diameter_
Comments: (condition pf,joints,
BSURFACE SEWAGE'tlSPOSAL'SVSTEMUSPECTIQN jORM
�ro1PART C
SVSTEAAINFORMATION (continued)
// / to /5 7
-'
,,.moo
SEPTIC TANK:_
(locate on site plan)
40 PVC_ather-(explain)
or suaion line -
evidence-of ekage,stcl_.
Depth below grade: L ' /
Material of construction: concr
If tank is metal, list age_ Is
Dimensions:
Q
AvT:
-tF
metal _Fiberglass _Polyethylene _othedexplain) (b: tWcs5
firmed by Certificate of Compliance (Yes/No)m•' a;x>'r
'1511356.4'6 6 a
outlet tee or baffler — r '-'
iyvc
Sludge depth: 'u r
Distance from top of ludge to b
Scum thickness: 9 p'
'.Distance from top of -Cum to top
Distance from bottom pf scum to
'How dimensions wer determin
h ?
let tee or baffle:_e
-
of outlet tee or baffle: t 6 s 974'.94.. _. e:r')1+61
a
n of inlet and outlet tees or baffles depth of liquid level in relation to outlet invert, structural
N7 6 IC x/ N D s_ ({
mm nnn n aenn.0
Comments:
(recommendation for!pumping, c
l integrity evidence of leakage et
L � ✓ E 1r. A IL
GREASE TRAP:_
(locate on site plan) :
Depth below grade:
Material of construct
con
R
banmun
ITV 2 TO 190
:.aYMrb`r . toss4
kpejua w
n offer-0 , , ±
metal_fiberglass _Polyethylene_other(explain)
Dimensions;
Scum thickness:
Distance from top of scum to top
Distance from bottom of scum tc
Date of last pumping:
Comments:
(recommendation fo umping, c
integrity, evidence o leakage, et
.71161141 .
£';%^.92 Mali 97 Ci 1fl
tlet tee or baffle._
m of outlet tee or baffle:_
(rev' d 04/25/54)
;tent° Sark
ri"AJ
D'..tO.
n of inlet and outlet tees or baffles, depth of liquid level in relation to'outlet invert,structural
toff u aws.9ln6 5171.is 549e.114. i w4.ti.*.s.4,a alts iw
Paget of to. 1{rR�ERUe
Property Address:
Owner:
Date of Inspection:
SURFACE'SEWAC��^ ISPOSAL SYSTEM)It35PECTION FORM
s it PART C
°O SYSTitagFORMATION(Continued)
(� fL-ri.,s✓ . 1S
/ ) / . ) q
TIGHT OR HOLDING '
(locate on site plan)
Depth below grade:
"-serial of construction: concrete
ANK:
. �dti A2r WiTZY? AOi.
must be pumped prior to,or at time,dinipedion)'bnPs
oralVN'airway: s: N barn;--.e=e
tah_Fiberglass=Polyethylene—otherlex.piam? . -..
Dimensions: I:
Capacity: '.gallons
Design flow: -01cips/dak,
Alarm level. Alarm in we
Date of previous pumping:
Comments:
(condition of inlet tee, cdridition of a
ISTRIBUTION BOX:_
orate on site plan)
Depth of liquid level abofe outlet in
omments: -
note if level and distribution is equa
UMP CHAMBER:_ -
ocate on site plan) -
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Eomments: • l
'note condition of pump chamber, tor
admszln Jr,
:ad!wn rs::Hist gc-as..
order_Yes; _ No
d float switches, etc.)
sgo!F.dx7 !o (' _-
O N 7L
r!GUgMo-' ' _ Ie
_. _..*ANTI;wG: o: bunk'
nce of solids carryover, evidence of leakage into or out-ofbox-elcf''fcl'° -- — •
yn gy
:t)nan-,mo)
netkbn i won)
revised 04/25/97)
of pumps and appurtenances:etc)-._--
'karma's*lo.thsimala
pbiYyf to
xeb .t^�•^ . ':c r... :s ar'L:si',rl b ergo halo noigbncytoles.
or !v 6 Page ) of 10
Property Address:
Owner:
•Date of Inspection:.) ,
SOIL ABSORPTION(SYSTEM (S
(locate on site plan,•f possible;
If not determined to iF'present,
'Type:
BSURFACE SEWr1OE.DISPOSAL SYSTEM.INSPIFTION FORM
-. ♦g:.1 PART C.. . •
SYSTEMENFORMATION,(continued/
ji�iE' 12215 /2_24
1 l e15 7
— !'1:m"
YbQ
tlan:not required,:but may be approximated by;pon-inpusive methods).rig;
leaching pith pumber•
leaching chambers, nur
leaching galleries, nun
leaching iienchep, num
leaching fields, numbe
overflow cesspool, nur
Alternative system:
Name of Tec)
Comments:
(note condition of soil, signs of
•
lic failure, level ofponding,condition-of vegetation,etc)
•
CESSPOOLS: •
(locate on site plan)!
Number and configuration:
Depth-top of liquid(o inlet in
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:"
Materials of construction:
Indication of groundwater:
inflow (cesspool mus
A.. O 14 V n It tntyS-
Y' oNn ) " z; L. iS' 7H '`1A.. 307s
V 4---le--t-v '7-1
mped as part of inspection)
Comments:
(note condition of s$iI, signs o
PRIVY:
(locate on site plan)
le IC'
•
sow 10 »
lic failure, level of ponding, condition of vegetationyetc);bi,, �.
Materials of construction:
Depth of solids: .
Comments:
(note condition of Soil, signs of
I revive 04/15/f))
:wine V 010 a c.^,mu9
sego y. Nc.: • .cart •
• Dimensions:
lic failure, level of ponding, condition of vegetation, etc.)
01 to (aye a of 10
Property Address:
Owner:
Date of Inspection:
SU
RFACE SEWA jSPOSACSVSTEM kSPEttiOrfFORM
RMAT
��SYSTEeA�'WFORAIATION ieontinued)
q O +3't' 3 /i-/L /
r ra,2 ri Is
, ) 6 ) 7
SKETCH OF SEWAGE DISPOSAL
include ties to at:least
locate all wells Within
Ir..i..a 04/25/S7)
anent referenceilandrnarks or benchmarks
srers
ate where pubinZ'water supply comes inld hoiise��
amix t'-,-4=• : . ...
. by ,ijOaoAt9 nerieD ems:,.
x,25- �...-r:
449^ :o
✓ 6 £ /Z 2Y:
*.
saa.`!ne 10
Property Address:
Owner:
Date of Inspection:
Depth to Groundwater La.Feet
please indicate all the methods u
1/ei obtained from-Design Plan
Observation of Site IAbutti
Determine it from local co
Check with local Boaiil of
Check FEMA Maps
Check pumping records
Check local excavators, int
Use USGS Data 11
It
i
Describe in your own words hoo
(revised 04/25/97)
4
BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
PART C
,,FISTEAUteORMATI ON (cogtinued)
q 6i4Y 6c. .29'1„ 4
I) l 761 c11
P-- 5
Jk' 4 /1.? Rt!leo WA709<.(; FJF.. -
sr T J1111 meis Ir'r*fn etto,A 1 5.14 QI 21
determine.lii r�.
4 �h undwater I anon
__... ..u.; .akn lla�r8 Yltfr w xIL++,: +i
:cord
Derry, observation hole, basement sump etc.)
stablished the High Groundwater Elevation. (Mat be completed)
a- / i / et)
5' • el '.-1 SoU
P.P. 10 of 10