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