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16 Septic Inspection 2006 COMMONWEALTH OF MASSACHUSETTS. EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICA,. INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA CERTIFICATION ` A°t iA 5) Property Adtl,ress; Owner's Name: t _ Ownee's Address: /( L/u �/ G/,2,(// / ry /' Date of Inspections AX /T 2 407 sU ��w 653, ��� /��p Name of Inspector: (please print Company Name: /` n Mailing Address: 7 Q /�7 C/ /0 Q/ e • .Stmt (T. 5/472,07-7 1-9, Telephone!'<umber: i/6 6 �G /)� .S'.S CERTIFICATION STATEMENT I certify that I hese per inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The'inspection was performed bused on my training and experience in the proper fiurction and maintenance of on she sewage disposal systems.lama DEP approved syste , inspector pursuant to Section 15.340 of Titles(310 CMR 15.000): The system; : .. Inspector's €i;,aature: ' 1 Passes _ Cond' onally P Ne-• urther F. tion by the Local Approving Authority Date: D(o The system inspecor shall submit a copy of this inspection report to the Approving Authority(Board of wealth or DEP)within 30 nays of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner copies sent m the buyer,if applicable,and the approving authority. Notes and Comments •"*This report only describes conditions at the time of Inspection and under the conditions'of use at that time.This Inspection does not address how the system will perform In the future udder the same or different conditions of USE Page 2 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART A CERTIFICATION(oomimmd) Property Address: lb 2/ E • • iI psi Owner. MOAN _PPAl.0 lc!too.o Date of lnspection: -57Q/M/2 Inspection Summary: Cheek A,B,C D or E/ALWAYS complete all of Section D A. System Passes: I hav&not found any infonnmion which indicate;that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Cous mats: B. System Conditionally Panes: 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. Answer yes,no or not determined(Y,N,ND)in the_for the following statements.If'km determined"please explain. • The septic tank Is metal and over 20 years old'or the septic tank(whether metal or not)Is structurally unsound,exhibits substantial infiltration or eaflttmlon or tank Ain Is mmYens.System will pan inspection If the existing tank is replaced with a complying septic tank as approved by the Bond of Health •A metal septic tank will pass Inspection if it is straanally sound,not taking and ifa Certificate ofCompiiance indicating that the tank is less than 20 years old Is available. ND explain: Observation of sewage backup or bleak out or high static water level her the dmrbution box due to broken or obstructed pipe(s)or due to a broken,sealed or uneven distribution box.System will pees inspection if(whh approval of Board of Heal h): brat=pipe(s)seesepbeed obmuct's isiAOwdd _ distribution boot itwled or mptad ND explehc _ The system required pumping more than 4 times ayear due to broken or obstmcted pipe(s).The system will pass inspection if(with approval of the Board oHahk): broken pipe(s)are replaced _obstruction is removed Page 3 of It OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: L� / / li L17.0 Owner: Date of Inspection: /YAM' 'u N F/ ,s O/o 0 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to'protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /''G c4u( ,w,zri 'ng/oal if181../ 5764 Co Owner; Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or X- clogged SAS or cesspool X- Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _QfV�1 Liquid depth in cesspool is less than 6"below invert or available volume is less than''day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped— 3e Any portion of the SAS,cesspool or privy is below high ground water elevation. —/j/-49 Any portion of cesspool or privy is within 100 feel of asurface water supply or tributary to a surface water supply. _d�) Any portion of a cesspool or privy is within a Zone I of a public well. a Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution fromthat facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form] NU (Yes/No)The system fails. I have determined that one or more-of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems:.04/4 To be considered a large system the system must serve-a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200.feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: l6 4W-chi CIA/I .UO/%Y?'fr» OlfdA) M%i Owner: 14144//{ L/ Fie 2FU Date of Inspection: ,1,7#2/(/41 Check if the following have been done. You must indicate'yes"or"no"as to each of the following: Yes No k _ Pumping information was provided by the owner,occupant,or Board of Health XWere any of the system components pumped out in the previous two weeks? yHas the system received normal flows in the previous two week period? X' Have large volumes of water been introduced to the system recently or as part of this inspection? Nat �i f t co f lbek Were s w t p ans of t e system obtained and examined?(If they were not available note as N/A) y Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? XWere all system components,excluding the SAS,located on site? XWere the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no T �ZA�G,4 S/ £ _ Y_ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR I5.302(3)(6)] 5 'Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION IJZ&4' f'SZO 1 & FLOW O ITIONS Property Addres Owner: Dale of Inspection: RESIDENTIAL -y Number of bedrooms(design): 1 Number of bedrooms(actual)._ DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): 3 K SAO - 330 Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(ye or no):42[{ifyes separate inspection required) Laundry system inspected(yes or no): /Q Seasonal use: (yes or no): f IC Water meter readings, if available(last 2 years usage(gpd)): — APO T rQ f /pi ci s%( Sump pump(yes or no):_ A Last date of occupancy: COMMERCIAL/INDUSTRIAL ' Type of establishment tilig Design flow(based on 310 CMR 15.2 ): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of informat ion: 010104 4 - Was system pumped as parlof the inspection(yes or no): If yes,volume pumpedA5Z)Q gallons--How was q amity pum ed determined? puf r ,ZrU 54'9/eA4 ee��ex Reason for pumping: 4oAL-Q0 TYvPE OF SYSTEM ig[y/17 fi-e-GI Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components, date installed(if known)and source of information: 2A—yi'S a1 O ¥ Were sewage odors detected when arriving at the site(yes or no): Ajo 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C p SYSTEM INFORMATION(continued) Property Address: JO !J/•P� r�fff C�'VC A-40 T�q/i417P(Z-c) A104055 Owner /f4?/L-e/ M4c1 L/,E,e,U Date of Inspection: ,,1-7 0/0 BUILDING SEWER(locate on site plan). if Depth below grade: 16° Materials of construction: cast iron 4 PVC other(explain): Distance from private water supply well or suction line: Or I-/C, /a/ sL.O Comments(on condition of joints,venting,evidence of leakage,etc.): • 4�'O P% SEPTIC TANK:_(locate on site plan) • Depth below grade: /8 •Material of construction: t/ ncrete__metal__fiberglass__polyethylene other(explain) If tank is metal list age:= Is age confirmed by a Certificate of Compliance(yes or no)(10 (attach a copy of certificate) • Dimensions: /G I.6a X S k 6 ve ar A/o t>' C/,oe Sludge depth: .eit7 ,a Distance r. Distance from top of sludge to sludge of outlet tee or baffle: < Scum thickness: ,a Distance from top of scum to top of outlet tee or baffle: Pas Distance from bottom of scum to bottom of outlet tee or baffle: • How were dimensions determined: /bt,C 4-1-' --p Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): m*' idi 57vec/ Co wl //a4/ GREASE TRAP: (locate on plan) Depth below grade:_ Material of construction:_concrete metal_fiberglass polyethyle _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or.baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /t[ g/.t-4'£i9 /C v /U/4 Owner: Eiget&C/ A/JA) /C. /4t Date of Inspection: 57e/00 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) plc/n — Depth below grade: Material of construction: concrete metal fiberglass polyethylene_other(explain): Dimensions'. Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no):_ Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) JC%O p /,f T eN� rt eap eon/A/9 19S any /. )Te DST Depth of liquid level box is out et invert: evidence {J� Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence leakage into or out of box,etc.): i PUMP CHAMBER: (locate on site plan) t 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.): 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /t(+ 1f//ZC/7/44,t/t /0,_i /tM' Owner: jyf4 4' //N.c/ /t/Fato 31/4,1B<o Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why:. Z CM XS' % 31) Gv/Txf «;crock %ta"P Type leaching pits,number: Z i°af'/OCUU A_O nee rih'es leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: _overflow cesspool,number: innovative/altemative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc.): ,dny ,100 579-Ai or 06be/rAr !.447 CESSPOOLS: (cesspool muiybe pumped as part of inspection)(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(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) p474 Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /O /glee 0711 OWE 92/01 tsyJ02J //SI /vi41 ,4J41 F/tea Ql Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells w'thin 100 feet.Locate where public water supply enters the building. /t) ,/e fact f 6'v SF_PT/e i%9,v/L s )3oafs, A f 7"/uf 5-11.7 /ID 34/ro se Co / �frz /Fr CLPfll av r ff8,0 B� th2,0 cE — F.t` Sofro r L /3-0O �//c Page I I of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: lb , /2c.Q L4,C/,c_ Owner: /Wig othadti /lkw Ajg Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells A/o 6, Estimated depth to ground water. feet Please indicate(check)all methods used to determine the high ground water elevation: tObtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within ISO feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You most describe how you established the high ground water elevation: