30 Septic Inspection Form 2001 COMMONWEALTH OF MASSACHUSETTS .. r-
VI
EXECUTIVE OFFICE OF ENRONMENTAL AF11 F tis
DEPARTMENT OF ENVIRONMENTAL PROTEEfrION SW 1 0 200,
It
ONE WINTER STREET,BOSTON MA 03108 (617)292-5500
h0_V AMPTpN e0AP0 t)F HEALT✓
"R'.,JY CONE
Srre tary
ARGEO PAT:. (ELLCCCI DAVID B STRUF.S
Governor C:m=_sroner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
3 P .Li.,.. Cat
`V
Property Adbaa: 1141 S PUw fL I VI.- Name of Owner art1A 45
_
Address of Owner: 171dal4.I
Data of Inspect on q/7
Name of Pupae to (Please Print) I�m,kP-Q,Q
I ern a O SP approved snare ins p srsuan to Seaton 15.340 of Tide 51310 CMR 15.0001
Corweny BP": ..Affordable Home and Septic Inspections Inc.
MrIiAQ Adana�at4r. 51 Laurel St.
Telephone NuIIi e:Holyoke, Ma.01040 413-532-8600
CERTIFICATION S rATEMENT
I certify that lb hr personally inspected the sewage dispose: system at this address end that the Info,metion repeated below is true, eccL'ute
and comp'ne a c the time of inspection. The inspection w s performed based on thy training end experience in the proper function and
maintenance of a+site sewage disposal systems. The system:
Poses
_ Cocdnioneny Passes
Needs Further Evaluation By the Local Approving Authority
Fay
CI
Inspector's siy,n one:
re System Insie for shell rutnrl a copy of this inspection report to the Approving Authority (Board of Hee'h Cr DEPINithln M cy 133' days of
mplet,rg this ns eertion. It the system is a shared system o has a des.gn (low of 10,000 god m greeter, the inspector end the system owner
shat submit the rt r n to the epptcpriate n office of the Department of Environmenter Protection The onginel should be sent to the
system owner a c copies sent to the buret. if eppltceble, end the approving authority
NOES AND CC'.t RENTS
. f\5
r;s_d 55 /2/98
Property AE9!ess
Owner: [ )dy
Data of W
tiOtd
)11i//oi
INSPECTION SUMMARY: CheckLA.)B, C, or D.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CEATTFI AT1ON (cored aired)
A. SYSTEM PASSES:
))
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
i criteria not evaluated en indicated below.
COMMENTS:
B. SYSTEM C0NOn1ONALLY PASSES:
ne or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, upon
O
ompletion of the replacement or repair,as approved by the Board of Health. will pass.
Indicate yes, no, or not determined IV. N. or NDI. Describe basis of determination in all instances. If 'not determined explain why C Certificate not of
_ The septic tank is metal, unless the owner or operator has provided the system inspector with copy of the inspection:ate of or
Compliance lanachadl indicating that the tank was installed within twenty (20)years prior to
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or e diltrr tip ,tank as
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic
approved by the Boat llealthh.
/Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipel s)
or due to a broken, settled or uneven distribution box. The system will inspection it (with approval of the Board of
Health).
broken pipelsl tee replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than lour times a year due to broken or obstructed pipets). The system will pass
inspection if with approval of the Board of Health):
broken pipets) are replaced
obstruction is removed
Page2of11
revzseu 9/2/9..p
Property Addy's:
SUBSURFACE SEWAGE DISPOASSAL S STEM INSPECTION FORM
CERTIFICATION (centimes)
•...c_ A-ae`1R.e IN' dry.
Owner: ( yy_LIra W
Data of nspecSM:r(//q(U
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 sfstem is failing to protect the
public health, safely and the environment,
1) IS NOT FUNCTIONING- A MANNER WHICH WILL PROTECT THE PUBLIC RHEALT AND SAFETY AND THE fENVIR ENVIRONMENT:
SYSTDA
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feel of•bordering vegetated wetland or a salt marsh.
ZI FUNCTIONING FAIL UNLESS THE
MANNER THAT
PROTECTS THE PUBLIC HEALTH AND SUPPLIER.
ANDFTHEYENV ENVIRONMENT:
THAT THE SYSTEM IS
_ The system has aseptic tank and soil absorption system ISASI and the 5A5 is within 100 feet of a surface water supply or
tributary to• SYrlils/ce water supply.
The sy ni has a septic tank and soil absorption system and the SAS is within a Zone I of b public water supply well
- In, stern has a septic tank and soil absorption system and the 5A5 is within 50 feet of a'private water supply well.
,- ,The system has a ly well, a wlellabsorption
analysis for coliform bacteria and than
volatileforghnic compounds indicates that the
private water supply w less
well is free from Method pollution from that ine facility and the presence of ammonia
not validl^lt nitrite nitrogen is equal to or e
roan 5 ppm. Method usetl to determine distance
3)
OTHER
revised 9/2/98
Page 3 of II
`1'
Property A4Nas\s: C
Owner: (Jv-yn Yon t `= 4.
Date of Inspection: Y/
D. SYSTEM FAILS-
You must indicate either 'Yes" or No to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis fortis
determination is identified below. The Board of Health should be contacted to determine whet will be necessary to correct the failure.
Yes No SAS or cesspool.
Seckup of sewage into facility or system component due to an overloaded or clogged
SUBSURFACE SEWAGE DLSPO gA ,SYSTEM INSPECTION FORM
CERTIFICATION Hnntirmod)
. Th, ✓w,Y � eye
i
_ Discharge or pending 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 distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6' below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipelsl.
Number of times pumpdc'
Any portion al the Soil Absorption System. cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary toe surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
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 greeter than 50 feet torn a private water suppicr analysis within
acceptable water quality analysis. If the well has been analyzed to be acceptable. attach copy of
coldorm bacteria. volatile organic compounds. ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either -Yes" or 'No" to each of the following:ln to the criteria above:
The following criteria apply to large systems in addition
_ The system serves a facility with a design flow of 10,000 gpd or greeter(Large System) end the systerh is a significant threat to public
heat)and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of• surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in•nitrogen sensitive area(Interim Wellhead Protection Area-IWPAI of a mapped Zone II of a public
water supply well)
Theowner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further infognation.
revised 9/2/98
Pope 4 or I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM BISPECTION FORM B
PART CHECKLIST
"30 YY'..
'Hoperty.A/Qress:
Owner; p NI h a LAm (AA
One at inspection: z,/ I y/a
Check if the following have been done: You must indicate either 'Yes' or 'No" as to each of the following':
yaj
fr
L
L
L
No
_ Pumping information was provided by the owner, occupant, or Board of Health. I flow
Nene of rates during that period. Largeev'o umes of water have not bas introduced into the ssystem l iecently or as inn of tit s
inspection,
As built plans have been obtained and examined. Note if they are not available with WA.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non.sanitary or industrial waste flow.
The site was inspected for 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 for 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:
_ Existing information. For example. Plan at 8.0.11.
_ Determined in the field lit any of the failure criteria related
115.30213Pb/I
I/ The facility owner land occupants. if different from owner
Subsurface Disposal Systems.
revised 9/2/98
M Pen C is at issue, approximation of distance is unacceptable)
I were provided with information on the proper maintenanceal
Pap 5 or U
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
p o
SYSTEM.BiFORMATION
Mid„ IL 1,6=6
PrupemYA _ 30 C1,ux-.... r
Owner: ( 6 e>;or.J z �.L
Dee of Inspection: If
ROW CONDRIONS
RESIDENTIAL:
Design flow: I p tl.lbedroom.
Number of bedrooms(design): 3 Number of bedrooms(actual):_
Total DESIGN flow gap
Number of current residents:
Garbage grinder(yes or nol'_�-o-o
Laundry(separate system) (yes o r nol: La: If yes, separate inspection required
Laundry system inspected Ayes or no)
Seasonal use (yes or nol:..
Water meter readings,if ailable (last two year's usage Igpd) r y 1
Sump Pump(yes or not�n
Lest date of occupancy: "shawl ein
COMMERC
Type of establishment.
Design flow: pod 1 Based on 15.203)
Basis of design flow
Grease trap present:Ht:(yes ��
Industrial Waste Holden o gT6 k present:(yes or no)_
Non-sanitary west schsrged to the Title 5 system: (yes or no)_
Water meter r dings.it available:
Last dateccupancy:��
OTHER:(Describe)
Last date of occupancy:
PUMPING RECORDS and source of information:
System pumped as pan of inspection: (yes
If yes.volume pumped'. gallons
Reason for pumping:
GENERAL INFORMATION
or nol
TYPE)F SYSTEM
✓ Septic tank/distribution boalsoil absorption system
Single cesspool
Overflow cesspool
_ Privy
Shared system Ives or no) Al yes, attach previous inspection records,it any)
_ I:A Technology etc. Attach c DEP copy 1 up to date operation and maintenance contract
Tight Tank Copy o Approval
pprove
Other
APPROXIMATE AGE of all components. date installed 141 knownl and source of information'.
Sewage odors detected when arriving at the site: (ye
revised 9/2/9B
Psee 6 of 11
04 b 5/“ -r.
PropenwAdMtss:
Date of Inspection. /IIY/D
BUILDING SEWER;
(Locate on site plater
SUBSURFACE SEWAGE DISPOSAL C YSTDA INSPECTION FORM
PART SYSTEM INFORMATION learrieaed)
cn�L�^ at)`fQa,✓nfti-cNti
Depth below grade: 1 /a
Material of construction: _cut iron_/90 PVC_other(eaplainl
Distance from private water supply well or suction line A
Diameter `1 ,•
Comments:'condition A joints, venting. evidence oil leakage. etc)
yam..- . e... ti l
SEPTIC TANK:_
(locate on site plan)
Depth below grade Ia
Material of construction:y/ca crete_metal_Fiberglass _Polyethylene_otherleaplainl
It tank is metal,list age Is age confirmed by Certificate of Compliance IYes:NOl
Dimensions: 7>) f. /1C-1-5.
Sludge depth: .38
Distance horn top of sludge to bottom of outlet tee or baffle: f(
:
Scum thickness:_ 1 G rr
Distance from top of scum to top of outlet tee or baffle: it
Distance from bottom of scum to bonorn of outlet tee or battle:
How dimensions were determined: SI `e'iw'ti-
Comments:
(recommendation for pumping. condition 1 inlet and outlet tees or bafes. epth o
eddenc1 y11<akage.etc
GREASE TRAP:_
(locate on site plan)
Depth below grade:__
Material of construction:__CJncret
d level in relation to outlet inveF. structural integrity.
p_QX..
metal Fiberglass Polyethylene Other(explain)
Dimensions:
Scum thicknest< _
Distancyt6m top of sown to top of outlet tee or bafBe:_
()uterine from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
I recommendation for pumping. condition of inlet end outlet tees or ballies,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage. etc.)
revised 9/2/98
Page)of II
SUBSURFACE SEWAGE DISPOSAL C SYSTEM INSPECTION FORM
PART SYSTEM INFORMATION leattrwd)
rti .� 1��'f')'rly.-�1 Y�
PrpertyAy•p���y� a0 0.tsi-s.nxcr�.Ur
Owner is Oro-LLth0 W:Lt
Dee of Inspection: 1� �io I
TIGHT OR HOLDING TANK:
(locate on site plan)
(Tank must be pumped prior to. or at time of, inspectionl
Depth below grade•_
Material of construction: concrete metal Fiberglass Polyethylene otherlexplaln)
Dimensions: '
DeessicitY: /geilons
Dign flow' gallons/day
Alarm present_
Alarm level: Alarm in working order:Yes No
Date of previous pumping:
Comments.
(condition of inlet ter condition of alarm end float switches,etc.)
DISTRIBUTION BOX:isi pAy
(locate on site plan)
Depth of lipoid level above outlet invent±
Comments
(note if l� n
el and distribution is equal, evid} ce o
s f, i
lids carryover, evidence of Ieskage into Or out of boa. arc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order>tY£s or Nol_
Alarms in workigwla
der (Yes or Nol_
Colo a tr
(not; a ndition of pump chamber,condition of pumps and appurtenances. etc.)
revised 9/2/58
Page A o f!'
C? c3 ey lk.vek
SUBSURFACE SEWAGE DISPOSR C AL SYSTEM INSPECTION FORM
PA
\\ �I SYSTEM INFORMATION Icanlirmed)
Properly Add[gae: )C r. Un i I'co'FQ.vv��Y
Owner: (,)e nc L O.vc LL
Date of Impactor:
SOIL ABSORPTION SYSTEM(SAS(:I k ccy, ^k
(locate on site plan, if possible.excavation not required.location may be approximated by non-intrusive methedsI
11 not located,explain:
Type
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number
leaching trenches,number, length:(4 i ■-3
leaching fields, number, dimensions:
overflow cesspool,number._
Alternative system:
Name of Technology:
Comments: bon tl r 4 r
condition of oil, signs of hydraulic failure.Ievtl of ponding dempp mil, cord a f . tc
,.e�.t_. �.� ��n-C aransrain
WL
NJ
•
CESSPOOLS:_
(locate on site plenl
Number and configuration:
Depth.top of liquid to inlet invert:.
Depth of solids layer:
Depth of scum layer.
Dimensions of cc
Materiels of c htucti on'.
Indication groundwater'.
inflow (cesspool must be pumped as part of inspection)
Comments
)note condition of soil, signs of hydraulic failure, level of scantling. condition of vegetation, eto.I
PRIVY:
on sit pini�
Mearials of construction.
'Depth of solids:�_
Comments.
(non condition of soil, signs of hydraulic failure.level of ponding. condition of vegetation, etc.)
Dimensions:
re sea 9/2/96
Page 9 or 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM MSPECTION FORM
PART C
SYSTEM BIFORMATION lconWre+el
C l _;
Popery Attains:
Owner: 1i'Tn V'o lwsIiw
Date of Inspection: �/I1`iIA
SKETCH OF SEWAGE DISPOSAL SYSTEM.
bes to at leas
within t 1OO'plLOOete refeence
landmrks or benchmarks
ere t;supply comes into house)
revised 9/2/98
— 3 Eft lo,efti+„�
Page 10 or 11
fr
nopa°ry!dea:
ow 0,.m(I,�
Det of brspecton:
H IN for
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM C
PART SYSTEM INFORMATION fcarreresadl
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date websim visited
Observation Wells checked Moderate D°eP
Gsoundwamr depth: Shallow
SITE EXAM Slope
Surface water
(pet o W
Shallow wells
Estimated Depth to Gmundwate'7tl Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site )Abutting property. observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators. installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
SIN/9 7
G1� X"` °' ace__ 6 cv
eaised 9/2/98
60,)
Pau a of 11
o.T... (•�.(I