30 Septic Inspection Form 1997 Maim P.Wald
eewr
U hub DOM
ter
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARTA
& flair S ∎c o( CERTIFICATION
3034-■ sso D>. .
Property Addnn
Adder of Omar.
Due a sea entioco Y -Ai 9 1 (If dlfhm0
Noma et leepooter Ca. (3 t s se t(
Carpary Name,Address&ha Telephone Number.
Affordable Home & Septic Inspection Inc.
342 west Rd. Westfield Ma. 01085.
CERTIFICATION STATEMENT 413-568-4289
I entity that I an pneaaily inspected the mop disposal gram at this address and that tits infotmatlon reported Iles Y true setae
std complw a of the time of iapottion. The lapalon who performed baud on my Mains and apaance in the proper function and
oWateaen of en.da sewage diponi systems. The ayrem:
Trudy Con
stet
David B.Stubs
conwanii
Pon
CendtietuBy Paten
Needs pusher Evaluation By the Local Approving Authority
yFaib
maces?.Slfoattua• n _ Dais: err.- : a9. 194 )
Ter Spam Inspector submit a copy of this inspection report to to Approving Authority within thirty(30)an of mmp1tiy this
mspsatbct lithe gstem Y a sand einem or has•&sipn Sow of 10,000 pp4 or rater,the inspector and the system owner shall sack On
tspntt to to antedate regional tela of the Department of Envbmannta)Pnleellen.
Ter'MOW aid b.sent te to system owner ad copies sent to the buyer,U applicable and the appnnag authority.
INSPECTION SUMMARY:
' Mak A B.C.
Al SYSTO[PASSIM
I ban at Rued any bdanatiae which MOW that the system violates any of the failure aaera a Mad in 910 CMS 16303.
Any Oti?as criteria not evaluated an 1pdiated below.
B) SYSTEM CONDmONALLY PASSES:
Oa or on system coapoosate mod a be replaced or naiad. The mtem,upon completion of tie repaerwnt or npW,puler
IsePdmti
Miaa yr,:se,w ea dttnaiad(Y,N,or ND). DM.n4n but.of drarminatlea in a0 tatener. It'but dominant,amain wlp am)
— The septic tank is meta,craned,aneturWy wound.shoo aWtaetiai kdetraaen or Mltntien or tank Callum is
taalaeat The system will pas.tsepenise If to aiming septic tank is upland with a perfuming septic tank a apprend
by the Bead of Health.
(ravel sd 11/07/95) 1
One Winter Siren • Rosary Maaaahuseas 02106 • FAX(617)$561049 • Telephone(617)2024600
0 P,MN an Rowing OW
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIPICATION l.ontinued)
Property Addeo=
O.n•n
Data of In,P..tbs
B)SYSTEM CONDTflONAILY PASSES teentiawd)
_ Imp lookup or breakout or high Mak water Mw)eb.r wed is the distribution bas Y des to broken or oSMtwd pipit.)
or due u a broken.settled or lamp dketributlen boa. T6•sym.m will per lwpetion if(with approni of the Bold of
H'okh):
broken piped an palmed
obrenmtion I.removed
dlr dbotiea hoe is PPS or replaced
The r0omm retested pospiat loan than four times•year dus to broken or obstructed pipets). The epee wIll pan
fap.etion if(with approval of the Board of Health):
_ mien pip(e)an repined
obtnetion Y removed
CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_
Conditions Pet which require hugier eva)tetion by the Baud of Meehh in miler to&ta ndte U the system L failing to protege the
public health, safety and the environment.
1) MANNER WILL PASS WHO WIL UNLESS TECT THHE OF PUBLIC HEALTH AND SAFETY AND THE ENVIROMAENII FUNCTIONING IN A
Csepnol or privy to within 60 feet of•etut'o rater
Compool or privy is within 60 fan of•hindering wputad wetland or a Wt mash.SUPPLIER,IF APPROPRIATE)
dl D�WILL THAT UNLESS H SYSTEM IS FUNCTIONING NtA MANNER THATPRPROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The"Mem haa a peptic tank sad soil akuorption tram sad I.within 100 feet to•suncso water nppi1'or utbiWy Ia a
suns war supply.
9e system has• peptic tank and w0 ahaorptlon syslem and Y within•Zone I of a public water supply well.
The eyelets has•'optic tank and soil abrorption a otem and is within 60 Net of•private.sun supply well.
The spew has a'optie tank and soil akporpaon system and Y W than 100 f st but 60 felt or more from•private water
supply well.plan•well water wiled.for solINem Warts and vobt0•mimic oompmmdp tadis.w that rha wen b B.e
des pollution Sam that fadity and the pns.ecl of ammonia Stropa and nitrate daopn is equal to or Si than 6 ppm
a) MISR
(revised I1/03/96)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Or.nr.
Data of Iaopo0Ooot.
D) SYSTEM FAILS:
f�I ban dmemlped that the Mama violates oat or men of We following Wm criteria as Mined in 310 CIO 16.503.The besu for
stay daaermiaidea Is MntlSed below. The Bond of Neahb should be contacted to determine what will be naceay to correct S.
thm.
Raebup Mango into 6tllity or system eomhooent due to en ewrbded er clogged SAS or arpool.
✓t Discharge or landing of effluent to the nseaee of the/round or surface man due to on overloaded or elodpd SAS or
Merwish
Stark liquid level In rite dertn'eotion'bae dove outlet invert due to an ovuloedd or logged SAS or ewpoot.
_ Liquid depth is cesspool is Ins than d":low invert or available volume is lees than 12 day how.
_ Required pumping more than 4 time in the lam year EQ[du to slogged or e:tNRed pipe(si.
Number of times pumped
My portion of the Soil Absorption System.cesspool or privy is below the high groundwater elevation.
My portion of•awpool or privy is within WO feet of a surface waur supply or tributary to•surface water supply.
Any portion of•cesspool or privy it within a Zone l of•public well.
Any portion of• ouepool or privy is within d0 scot of•private+star supply well
My portion of•cesspool or privy Y Ms Ma 100 Mt but pater than 60 feet from a pnvate ni water r water well anbwi for o
aoaptahI.water quality analysis. If the well ha beta enabsd to:acceptable, attach copy
allkrm bacteria,Mat0e organic compounds,ammonia nitrogen and nitrate Stropn.
RI LARGE SYSTEM FAILS:
The following criteria apply to lerp gnome in addition to the Muria strove.
_
The mum tame a facility with a design flow of 10,000 gpd or realer Gars.Symem)am!6o gr n i••.Clfnaot throat to public
bSS and Mfmy and S.o bdatlent Mae on or more hat:Louawing aadttioae Met.
U•grram is wLLMn 400 east of a mime drinking weer supply
the system Y within 200 feet of a tributary to a meats drinidag water supply
the gatam Is located in•nitrogen senrtiee am(Interim W.Sbssd Promotion Area(1W PA)or•mapped Zest II of•public
water apply"U)
Tha swat at opener of sap such gstem shall bring the arum and facility Into dell complianor with Us poundwatn swam peopwm
ngnbmme of 114 CMS 5.00 and 5.00. Plow mule the heal?Wong efMee of the Department for further idamadon.
(rev Ifed 11/03/95)
S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address
Dormers
Data of la.p••ti•w
Chock If the b➢e.ieg hove been done:
✓Pumping infmmatbn w rnquasted of the ewmr,occupant.and Bold of Health,
;Ohm of the system mmpomate have bum pumped for at Man two week.and the system two been nothing amnia)Gm rata
daring that period. Lapp Mums of water have not been introduced into the t stem recently or as pen of this impmion.
/4.Aa built plans have been obtained end aambd. Note Elba an not.nilabk with N/A.
J ibe tadlity or dwelling w laspectd for alum of eewge bm4.up.
✓'Rye Gram dote not noire sonseaig7 or bduetttal waste flew
✓
The aim w impend for signs of bnskout.
✓AS mean mmpomnte.axhMing the Soil Absorption System,have been located on tit.site.
✓The..pek sty meabols wan mtcennd opened and the interim of the septic tank w Inspected for munition of bailee or
Mac materiel of m etructjaU dimaasbm, depth of liquid depth of shale,depth of meum.
✓Ty aim and location of the SOD Absorption System ea the site Ma bra dmermimd bond es airing Information or
apprcidmatd by nondntnmive methods.
_TTbe bdyq one land mmrpa 4 .If different from owner)were provided with information an the proper malntemme of Sub-
Burnie.Dkpnsal System.
(rwild 11/PINS)
4
I
Property Addnew
Owner
Data.d leep•areor
SUBSURFACE SEWAGE DISPOSAL PART SYSTEM INSPECTION FORM
SYSTEM INFORMATION
FLOW CONDITIONS
Banarnak
Daily low:42 nlC pDaee
Number atSimsc -3
flesh of ants nddmb:
Garter Fader(pm per o). e 5
Wats loasisega w__ Vr or rto):_P5
serest W War Ifswi�DN: /O w r.f t,t_y ci F
Was mater Nadinfp.
Lr Sea ofaauY=J' Cu.W4[-LT t7
pO101UICIAL/INDUSTRIA4 . .
Type of wblletrut:,
Gnwe trap Parent:W s or
Ldweryl Wr Raiding Task o)p_rw
nt:(in or m)_
Nnwiwy veW to discharged
to the Title 5 moron (Tea or nnl_
Water rear nadirs"if available:
Let data of oeaopanq:
*TRIM QNerSw)
Ls data of oroptnq:,
GENERAL INFORMATION
PUMPING RECORDS and source of information:
1-\(> v eC(..o di — C..Lvvq,) + ow mat PV CO y VS.
System pumped as pan of iyyw{on:pr or twtU
Una volume pumped: nllone
Paaaon for ymp1K
Mt 07 IMP=
Irk taekielMOotion box/will abeot$Ion gma
RUN orwfPwl
Overflow eerpwl
"In inspection morels, Y say)
Send afros(sea r real Sr pee.attach prime P,e,e,t
Z Otte( p1.ln) .591-4 ' C A- ah/C Y 4Pa
APPROXIMATE AGE of 411 components,date installed Of kWown)and once of informs: 0 i 4-e v s 9 7 ...� {o .
Sewage radon Stand when arriving at the Wu: Ins or no),P0
lrvlad 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTBat INFORMATION(motioned)
Property Addrt
Orre
• Deb art lm pootioa
SEPTIC TAM�
Oorto a SW PLm)
Dglh below Srods:.da• ,ahnrinFMMI
WSW ofsotnrtia'✓want aed—
SSP/gth.J.±¢��
Diarkmtop of dodge to Oates of outlet to or baEtr ,._-
4a thiamin: _to top Of Miami from top
Mir from Oaasod.wob bottom enOw w m bale.
b�' of lal t and atMr.aw or btdr,depth of liquid Wv.l m relation to outlet Inverts sruetuea)Mavptq,
mdstko Sr pumping,aaditie n P r ,, , 1 �l v is
el Wait raj 1 Ic e Q (I - a
GREASE TRAP_
Onto a So&al
DEEM tan pd:, stab_metal_F1tP_atbMapMMt
WateW efowm.+ebm:
Dtentiaa•
Is EMS-- of outlet b.m OsE7e:,__
DMIr Ss tap of scam o kg
DMlam be tea d seam to bones of man too SEW
(nrmmadmMa Ise)mmP W,eamtMm d1eYt and outlet an or Seta,depth of liquid Mel in relation to outlet invert,nnveaat IabD+b.
OerW'
airs of Wisp,Om)
tnvtsed )1/O3/95)
d
SUBSURFACE SEWAGE DISPOSAL C SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION lonntleued)
Property Addnw:
Owner
Dote d Ins eeRr
TIGHT OR HOLDING TANR:-
Owm w eW plea)
Depth labw
MarW of wefYmhea_Amara_mots)_ppp—aMrtap)ein)
Disoerbn.�
Dalin beer"/day
/yea heb
Comownsrm
Nmdsbs of Set tee,condition of.Lra and Goat ewimbr,a=.)
D/TRIBUI ON ROL— ..
Ora at Site plea)
Depth of Mold Ind Shove oath invert_ -
Oe end distribution Is equal,.Mn *n of solids carryover,avidean of leekye taco or out of hoc,etc.)
(note if leml
PIMP CHA10Hw__
Onto en We Son)
Pomp in working mhrCete or m)
Seat
loom toeditioo of pump chamber,condition of pump end appurtenance.,etc.)
(noised 11/01/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM C
SYSTEM.INFORMATION lma4ausd)
Property Addrna
On=
DM.at Ia•pndbe
SOIL ABSORPTION SYSTEM ISM h not required, b a99�w�h mo•laewin..wadrl morratIon
DmW a dm cola,U posAlr
U not d.nIaa4 tab roast,avian:
I.;
Wain pita,mmbr:.;___
kaoldss e6smbn.number:_
Wells[pilgrim aumban
Lally mnmolm,memb.r,lslLth:
leech.[&1da mambo,&m ow: —
norOos om.pool,author:,
•
Canto Inee.maid=of pt,,Mpg of hydraulic future,level of pending,condition of nptatioaas.)
YBSSIOSIA; Leach— }i
Cowie w S.ylen)
Iamb ea oassuotion: (t/lie
Dptlbp d liquid to inlet ma
rc_y
Dna deeds Won:i T
Depth d moos Nm' S •✓
D4amdS dmoaposl.
Mans doe.atqumpd�.A
i.diedio°d rota mamr� n3 1
C.4o tc
Gammas:f.ae condition of moil,sips of hydraulic how,Nml of pending,condition of vegetation,.m.)
nxvm
Goad.as dmyin)
Maria dmmtrodW:.
Osman:fade m.dsW cleat yips dbrindle fdlun,lent of pending condition of rgnation,dc.)
Depth Mogi&
Dim..da.:
(reeked 11/03/931
e
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6
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*age Dispose v stenba�ptotro \nsPtctionat yon
,P 0\p603p 9e`ssa ob5°�aee Seta e OP P°s aefpo d\0 6ecia\5.305°t
of a,tpoo ,00 PPtd2, he envhOOmen s and node yet
as Ntco\'. s in teceSonha nPt nb\c bea\tb meta\Code,
of the QzOaC be)
on, a
YC ry°ga.,ise of\H ySDe,n f Doe Tttle g e P \5.000 ..he State the subs pitb'W s xty f60y days
Statdispose).s steno o of3\0 CM Sec n � DEs.m.i e, sewage dispose)
sewage E° os ter \P, Sys :r m'wa, n.�.a.a.marz m..m,,
ad
p00,Staco dance°'�Genece\Lae 5ewa6e d�P°sat sy n o ce nt0Y items .'°�,�e eb '`ri'n�
rt In accordance
c cbn5etts nbsncFac £ �me�Ae,arumnarebq ewmrha me;;wece.ww, back it we can rwwn try
cy PC tfds notice.eQ ,t tbde the snbsncftie e4U Ve�nent�faf u 3 gpob caress to, :ie„+w;1 .�,a'0'°.»ee; e r not
ece
,vitb rt & Avis Nico
to cePanlnagcocdance o 30 sr isson i
9e.AmG
Wock abeaiing° Korth Driv°
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tns�\\ec,an Anton, yA
oa d of Dea\tb. on ace eniR\ed op,eQnesdnf 01 06 aMCe r
isedtbaty *onto petition be s � � �Mal
?tease
edtbatyp°{�0pce. ea\tb s.Received ar:(prnrNa,+e� x'nr
PtONdceiPt°f*Os e Boacd°f u •s.signarur
Me to c tact tb - X (Ad �!J!: ..
t - °rive t/ arty
frill CO reo
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Add
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Cons
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I.o essee's Adgresg
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PasppBSYBt for fee.
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Receipt