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50 Septic Inspection 1997 foal/ MMONNEALTH IVIASSACJILLSEITS CUTIVE OFFUICE OF,ENVIRONMENTAL AFFAIRS PARTMENT OF ENVIRONMENTAL PROTECTION'<JnlE' WINTER STREET. BOSTON. MA 02108 617.292-$$00 WILLIAM F.WELD Govemo: GEO PAUL CELLUCCI Lt.Governor J arty Address: �afe of Inspection: a e of Inspector: I am a DEP app Fdsyst or»pang Name: Ma ling Address: Ifelephone Number: FERTIFICATION STATE T RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, F, :.._,A PART A t..:qus 111.1'sr a p L.. CERTIFICATION : .: +:dud' du AA, 5 O U -AS's" C%:rWSwTt,:T.H.S_'srT ow p / 9- Andress of Owner - , • v c P•dn - if differenllun4 4 tss, oiR :.it._ .. Ine)14?Intro 1- rrr ctor pursuant to Section IS.340 of Title;S.(310:CMR_13,000) -- G L. r i#.1.11::0 5 certify that I have perso rIcI complete as of the ti nlainlerance of on-site se inspect of inspe ge dispo es Lb ditionally _ Needs Funhe Fails — 1 1 3 $ 1171/Sri .r,: Yk L13111'.i;,mR el YU;Th.11A`!. sewage disposal system at this address and that the information reported below is true,accurate The inspection was'pedormed based on nsy.'raining and ekperience'-in-the proper_function and ms. The system: _ ..m n ...,inn bee v+wlsr all:.y: x TRUDY CORE_ Stormy DAVID B.STRUBS Commissiorm inspector's Signature: T uation By The.System Inspector sha ubmit a ns Rion If the system �a shared he report to the appropri regional and'cop es sent to the bu , i1 appti N ECTION SUMMARYt YSTEM PASSES: 23N!t0tii?F,0 : . 1; 7.1 01601223111J 22A9 11111 FAIT?-: Ytette U,: (it;lAiH DIl0U9 3147 TD TON, DIN HOIH:Y the Local Approving Authority wic, -naty, t.k test as hither. r. :vhu as it ceders, p x Mt+•e-k-s• Date: I e 19 CIIA: Ill IA`.R ;V .na.4iig fHl ?2i1.1e11 flag ITIW InT?i: this'inspection teportio+the'Approving'Abthor(ry•withinithiny1301idayt of completing this or has a design flow of 10,000 gpd or greater, the inspector and thegystemioWner shall submit of the Department of Environmental Protection The original should be sent to the system owner d the approving authority s vs; o r MS _ _. .. wee.. X"at 6 r L seen) . . have not fount Any failure vice LAMENTS: r t..,s . ... to :Im},,e :v,..;a, 5i6555' hick indicates thanhe system violates any b(the failure aiteru'as defined in 310 CMR 15.303: e indicated belows.3a' .•..' .s'-c.:: bre twnro":! .104.E r.fM+vsl STEM CONDITIO One or more completion of t tar described in the'Conditional Pass'section need to be replaced or repaired. The system,upon epair, as approved by the Board of Health, will pus. - ; ND). Describe basis of determination in all instances. If'not determined',explain why note unless the owner or operator has provided the system inspector with a copy of a Certifiote of ':. dioting that the tank was installed within twenty(20)years prior to the date of the inspection;a!.!. r not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tatlft� , system will pass inspection if the existing septic tank is replaced with a conforming septic. of Health. '!' . Indicate yes, no, or not de rmined _ The sep'c tank is Compl a ce (atta the sept tank, wh failure mminen as app by th re sed 04/2e/911 :: lc 1)ape4 of 10 1Ct\1C1W caw tees EP on tM Wald WMe Web: hap:IMww.maprataaa.ra 0 Prated on Regded Paper dep Property Address: Owner: Date of Inspection; . BI SYSTEM CONDITIONALLY - S age backs Is)or du B d of Flea T BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .. PART A • , . . CERTIFICATION (continued) ,STGY 'Ca 9 lk CS 1) - p ov LI I 10 19 7 (continued) • 4.UAW - eakout or high static water level observed in the distribution box is due to broken or obstructed I.roken, settled or uneven distribution box The system will pass inspection if(with approveLpf the• scribe observations:1/. ."' .•' l'A,ItQr le token pipe(s)are replaced, struction is removed : istribution box is levelled or replaced ! pumping more than four times a year due to broken or obstructed pipe(s). The system willspass .pproval of the Board of Health): oken pose(s) are'replaced ;-4 .t ern 11/1tP'• Ar—. istruction is removed Q FURTHER EVAL Conditions public heal 1) SYSTEM WHICH W RED BY THE BOARD OF HEALTH: ter.talTrI7i Ii• 'InTM e further evaluaticalibYthe adaffl•Rf HealihrIp order toidemmine_if,the system is fading(ci protect the vironment. BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOTAFJOCTIONING IN A MANNER PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:nsbncI3 -- ‘01-06A 8,, "lev, war.' nt. • nu.nula/3 Idoas.0 eS99+.1 within 50 feet of a-surface water within 50 feet of a bordering vegetated wetlanclor a salt marsh. :sea • - ;5"", THE BOARD OF HEALTH (AND PUBLIC WATEIFSUPPLIER71t APPROPRIATE) DETERMINES THAT GIN AMANNER THAT PROTECTS THE PUBLIC HEALTH AND BAFfTY,,AND THE ? Snr L ' . IC tank and soil absorption system ($A5)and the,BAS,4wjltith16,014get,eng surface water supply or water supply. . , ic tank and soil absorption system and thg SAS isawithini Zo9e I pkipAlis rattisupplyinell: is tank and soil absorption system and the SAS is within 50 feet of a private water sUpply"well. tic tank and soil absorption system and the SAS is less than 100 feet but. flit oridoriron a well, unless a well water analysis for coltform bacteria and volatile organic compOundi indicates that pollution frostItat,facility and 0erwinery:gel arreponiApitreigen encl,p)tre nitrogen is equal to or ethod used to determine distance iAppr,fHlyt29,01,),PfIt.Efefr,‘,,i„; ETV1/4:0,0h • .... _ . _-. , . :v.- ,.• .:.'' io bwot .! . .r: ........ ,--L 1^3trI5t-tIqr1 nit 10 .„. . II..) z L“ s„.4 ;1,0 .401 io ./ ,y)D•90,,,,•nstan Iv.on .t.,y etni °T4I.v. w4 ICA WE,I:IC, In 1,-...1.: ;AT illirti: iii>tit F., iltILI Ditnit'orr; _ ,:xIII"..,-',.. • -or- ...sr x tellerrn, ." :: Ai'-:' crI eto,nIb, bast. c '4-k4, ) i PASS U PROTE - Ce pool or p - Ce pool or p 2) SYSTEM W L FAIL U THE SYSTEMIIS FUNGI ENVIRON 3) OTHER T Hsystem I III tr tary to a I T system system e system 'I p te water t II is f le han 5 •• 1111 T T '(eee i aa d 04/25/97) 1 s .." bu4.: V61•IL! 16,0,4* to zrage.2 of 20 tn ass.7.1) Prbperty Address: Owner: Date of Inspection: D SYSTEM FAILS: You must indicate eithe 'Mes"or' I have determi that the for this dete the failure. Yes No I - RackQ.. of sewag 11 Di s a'.e orpo ces - Static '•uid level - (iqui epth in c - Requ • pumpin Num'�!' of times - Any .` ion of t - Any on of a Any po ion of a Any portion of a - Any ion of a acce le water col it bacteria, E)LARGE SYSTEM FAIL$ 11 Yob must indicate either Fes- or' The following t i eria appl The system ser public health a Yes No a facility safety an - the ssl m is wi - the s is wit - the is I publi crier supp The owner or operator o any such requirements of 314 CMR 5.00 and (rkind 04/35/97) SURFACE SEWAGE:D15POSAL SYSTEM INSPECTION FORM c. t;5 PART A CERTIFICATION (continued) �o e— A- P r£ f_ 11 / 10 / 47 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 to.delegnjne,what,will be necessary to correa facility or system component due to an overloaded or clogged SAS or cesspool,' f effluent to the s ^et "s' keen erlo! VfI7ce of the ground or wrface„weien due to an,overoaded of clogged SAS or - distribution box above outlet 'riven due to an overloaded or clogged SAS or cesspool. I is less than 6'below invert or available volume:is less,than 1/2 day flow. - than 4 times inthe last year NOT due to clogged or,obstructed pipets), ;;;Rice , Absorption System, cesspool or privy is below the high groundwater elevation. -- of or privy is within 100 feet of a surface water supply or tributary to a surface water supply. r oI or privy is within alone I of a public well , :son;,m. crass of or privy is within,50 feet of.a private water'VPDly well:uc' cns 5:Y of or privy is less than 100 feet but greater than 50 t et froma prix a water supply well Wath no analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for le organic compounds, ammonia nitrogen and nitrate nitrogen. , ,_ o each of the following: ge systems in addition to the criteria above: design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to nvironment because one or more of the following conditions exist: 3/7 .w C1to)6na 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 mapped Zone)!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. it pe• 3 of 30 'Property Address: Owner: Date of Inspection: Clreck if the following. Yesb No Y 'e been d Pum ing'informa Non of the syst fowl tes A -- as pq of As b t plans h I. The tlity or d The tern doe The i e was ins _ All tern team The pit tank baff es or tees, z The size a([i�d locatior The 4acility ow Sub-Surface Di Ex' ng info, De ermined in unacceptable) (revised 04/2s/a7) . URFACESEWAGE'DISPOSAL SYSTEM INSPECTION FORM t* PART B ". v'tU2HECKLIST o C1-10 irL p L O L' P1_0 I / j 10147 u must indicate'either'Yes'or'No'as to each bf the following: as provided by the owner, occupant, or Board of Health: ponents have been pumped for at least two weeks and the system has been rece ng no mat uring that period:i Large volumes of water have not been`tntrodoced into the system recently or -_ n obtained and examined.'Note if they are notavadablewah WA : '- .. . _ was inspected for signs of sewage back-up. ' - - --- ceive non-sanitarybrindustrial waste flow t a .d:aw I e nu,--tar for signs of breakout s • excluding the Soil Absorption System, have been located on the site 1.. n ,. : u alc„es:$-$'o nota%O .1/. les were uncovered, opened,and the interior of the septic tank was inspected for condition of I of construction, dimensions, depth of liquid;deptff'ohsludgerdepth of scum. __ _. Soil'Absorption'-System`Or,the site has been determined based ono Y^4 — d occupants, if different from owner)were provided with information on the proper maintenance of System r:t u. 17' - &(4 it no .xla x. Plan at B.O.H.:, ....: Id lif any of the failure criteria related to Part C is at issue, approximation of distance is (3)(b)] :2lFAt trf ft 3 Ta. E i:.• _.. �✓ L . '•:Slid' +TJ .^F Mitt! 0 ni tn,lt:IG c ,'s._ tom.i s'L.fv.:OE' sxAaw n atiada-ail _.. trod• .�._ ...^i •< 177,Ar1 vi lhr' :TgRYt A'u. •nc ld tats co so soave* T. 644.19 . f).a isrK v,t AFA- aE(ra aosurlwYls Pere'{ Of 10 (if.:stro.tell Property Address: Owner: Da e of Inspection: RESIDENTIAL: De ign flow. / 6 Og.p ,/bedroom Number of bedrooms Number of current resid is 5 Garbage gnr der(yes or of: .a Laundry connected to system (yes or Seasonal use (yes or no):_D - Water meter readings, if available (I. Sump Pump(yes or no):y1„✓ D UREACE:SfWAG4ANSPOSAL;SXsJEM�.I?* #w q J FORM )nky:PART C tx.:ac:+ .4YSTEN%INFORMATION j- O C / EX r Ff. L ii ) to / v7 FLOW CONDITIONS vtmiI a (2)year usage(god): it/ J A f. r visas: en.w:p rnc•: 1: aca Last date of occupancy:A CSC.- £,QMMERCIAL/INDUST'] U Type of establishment: Design flow:_gallo day. Grepse trap present: (yes •d no) ndustrial Waste Holding ink prese Novi-sanitary waste disch.t ed to the Water meter readings, if ailable: astfate of occupancy:_ OTHER: (Describe) ast date of occupancy, PING RECORDS an system: (yes or no) egbsdaio tpt n- .:. .. .. n. _ mod_ od 0.f mipz iu Irokhol rk 0 t n - source of Lion: System pumped as pan of it If yes, volume pumped: Reason for pumbing. PE 0 YSTEM Septic Iank/distr$ution bo Single cesspool Overflow ass Privy Shard system ( or no) (i I/A Technology c. Copy of PPROXIMATE AGE of ai'componer GENERAL INFORMATION n: (yes or no)S gallons / 3' 00 se , t :r+ rata-mr.,apiow:3QMt nt?c. a , nttst sorption system ?tact pievious inspection records, if any) date contract? - " • tna;a.6i. 1,:r:1 m: mn,y3a icmdbad ii':'-s eA:ralC F y � • e installed (if Sewage odors detected when arriving s..d os/as/all own) and source of information: L/1-4-C, w-' 14;fl 5 .:n;:, .g^ 'oq 4 noas :emn-f»iy:. ite_(yes or no) _ ._. ;.)19 9t aa?:' linsA:.a Mt-ISSN n rag. I of 10 Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) BSURFACE SEWAGE/DISPOSALSYSTEM-'iNSPECTIONFORM 3Tb"PARTC SYSTEAAINFORMATION (continued) p li0 1 / I . ° 197 Depth below grade._4L Material of construction: —cast i Distance from private',water suppl Diameter_ • Comments: (condition,of joints, SEPTIC TANK:_ (locate on site plan) Depth below grade'. Material of construaio If tank is metal, list ag Dimensions' 1 40 PVC_other(explain) or suction hue evidence of leakage,etc.). Is a Sludge depth: /& " Distance from top of udge to bo Scum thickness: cl2 !! Distance from top of cum to top Distance from bottom of scum to How dimensions were determin- Comments: (recommendation for pumping, c integrity, evidence of leakage, et 14 (e)1 L GREASE TRAP: (locate on site plan)' .. ruuu,z, as: • f/ /Llsan rD b metal _Fiberglass _Polyethylene other(explain)�- firmed by Certificate of Compliance _(Yes/No)-".I t;xmr "s ' / syu�st m : 2 ^4T g i 1-1') .a". / _ — V _.. ... so , f outlet tee or baffle:3 lo- .in,IRf4__ -, ;§- tlet tee or baffle (— u - - of outlet tee or baffle: 4/ pRo /38 n of inlet and outlet tees or baffles, depth of liquid level in n i es.% P 0 A. , G lr->yd.'CreO r...o E..f .a.�1 $ Depth below grade: Material of construction: _cone Dimensions: Scum thickness: Distance from top of scum to to Distance from bottom of scum t Date of last pumping: Comments: (recommendation fo pumping, integrity, evidence o leakage, e (rewind 04/25/57) ,,,.,2u,n relation to outlet invert Mu structural .gin w eaev,.»... . ,. i63VYT metal_Fiberglass _Polyethylene _other(explain) tlet tee or baffle: . . . .. .- m of outlet tee or baffle:_ 4.ms1Wt:. ,:SA! '✓e::. s;::.� s;. .TAI ,a- !4&' 3,�. in 11011,0;42:T. t. on of inlet and outlet tees or baffles, depth of liquid level in relation (&outlet invert, structural - /sr nSAIVIW.•k,n nnb,i+aer.? n jape'{ of 10 Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (locate on site plan) -t'' Depth below grade. "I Material of construction:Tioncrete SURFACE SEWAGO4SPOSAL SYSTEM°ItPECTION TDRM vn11.'G T SYSTEI1�iNgORMATION(continued) s6 t /id3P et_ O u /2/9 / I / o /97 most be'pumped'prior to,Dr'at nme;'oT'inspedfoni A t::Y7 Ht.). T. -b: ;LIE Dimensions: tal _Fiberglass--Polyethylene -- other(explain)A Capacity: gpllons. Design flow: IF:09FlSrdas; Alarm level: Alarm in svc Date of previous pumpin : • Comments: (( (condition of inlet tee, condition of a rder_Yes;_ No Boar switches, etc.) „_—;;MdmVm Andreae,robs,' :eckn n Ps;Toffs; �.. sr , ,sw n - _tedr. •O V to wt- p. vM•e.4 yw Kr DISTRIBUTION BOX:_ (locate on site plan) - eepth of liquid level above outlet in omments: note if level and distribut)on is equa UMP CHAMBER: ocate on site plan) umps in working order: (Yes or No) farms in working order(Yes or No)' omments: 10699?) no etgof :nn"wugMto,06.4 se+.min 719w11 s>••w b91•1 k 7;01-'4.0 ce of solids carryover, evidence of leakage-into-or outoObotretc.)1°J zb k C - ote condition of pump tjtamber, co revised 04/25/s7l qnot F;,.'. of pumps and appurtenances, etc.) --. • set be i:51n.:q ..d:turn tnogesxt work. ylvp byrl4o i14 z Ha ltktl J brol Men! . Si floilvasetdah nao re,i krt .-orp .r-r,. ,e_ OunMnnYai e < r,. :tt_s)d pi4sn4,,f in erg: ;aeb•40611.71,•10,0 `w• .._ :r ¢ jN• 7 et 10 Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (locate on site plan, Ifpossible; If not determined to be:present, UBjpRFACE SEWt9eDISPOSAL SYSTEIf4jat4%Pj N FORM Ts,:a PART C SYSTEM)NFORMATION.fpontinued) So cIII APitt p 2_0 La, /2. 0 , / / / fo / y7 Type leaching pits, number leaching chambers, nu leaching galleries, n leaching xsgnclies, nun leaching finds, numb! overflow cesspool, nu Alternative system: name of Tec ion not fequired, but,maybeapproximated byigornjnpusive methpds)4,t _, y .. .. tT glh: sions b"8 I : SILO— f Comments: (note condition of soil, signs of CESSPOOLS: (locate on site plan) Number and configyration: Depth-top of liquid to inlet in Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: indication of groundwater inflow (ce spool must tic failure; level'of-ponding, condition ofvegetation-etc) 9/t-cgiC s.o ped as part of inspection) Comments: (note condition of soil, signs o lic failure, level of condition of vegetation/ C4 Is9:1941(1 e-r rt . <r neu9 PRIVY: (locate on site plan) Materials of construction: Depth of solids:_ Comments: (note condition of soil, signs of / • Di tic failure, level of ponding, condition of vegetation,etc:) (revised 04/25/>7) 1 Property Address: Owner: Date of Inspection • SKETCH OF SEWAGE.DI$POSAL ' include ties to a(least tw locate all wells within 1 13suriiAa SA SPOSAL St'STEM NSPliaTQ FORM "�AIjT C SYSTE/N:lFORAIATION(continued) revised 04/25/)7) c tn�n ✓c L � P oYt 6 / 2747 anent references'andmarks or benchmarks_ le where public'water'supply comes into x 4iR':_„t bmar n Property Address: ■ Owner: Date of Inspection: .1 1: Depth to Groundwater/6 'feet BSURFACE SF)y?AcEpisp940.$ySJE¢) ix[j55 C &FORM ] Tar PARTC SYSTEMINFORMATION (continued) 3v CI1a p� L- p L. oJ24. ) to lq Please indicate all the methods u � V Obtained from Design Pla fip Observation of Bite tIbutti Determine it IrOm local co y Check with local Boatd`of etermine High Groundwater Elevation: cord rty, observation hole, basement sump etc.) Check FEMA Maps Check pumping records Check local excavators, ins Use USGS Data Describe in your own words ho (r.vi..d 04/25/9 7), stablished the High Groundwater Elevation..(Mi be completed) p1t12-c Jo /2� / cg