111 Septic Inspection 1995 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property /1/ DONP/9t/ L R)i'E — Ne
Owner' s name ItEL_E J Ke.y�s
Date of Inspection 3-7=/r 9,/
PART A
CHECKLIST
Check if the following have been done:
_✓ Pumping information was requested of the and Board of
Health .
_P/I None of the system components have been pumped for at least two weeks
and the system has been receiving no rnt3l flow 'rates during that
period . Larne volumes of water have not been introduced into the
A system recently or as part of this inspection.
AJAii
As built plans have been obtained and examined. Note if they are not
available with N/A.
/ S The facility or dwelling was inspected for signs of sewage back-up.
/G3 The site was inspected for signs of breakout.
y6...‘ All system components , excluding the SAS, have been located on the
site.
` 63 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 SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
0-- number of bedrooms ad EP,�' S
�_ number of current residents / Otc°Piu" l 4 t y
7Digarbage grinder, es z no
laundry connected o stem, or no
seasonal use, yes o
If nonresidential , calculated
flow: ,43,10 'f^'PA
tU/n
Water meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
Ye-S
PLmnec - /WO- `
1„Fna.mrl o.J 0431-Ps i wU('? 00”- a,.00 Yr? aG PareaCTL
System pumped as part of inspection
if yes, volume pumped
Reason for pumping:
f /Ooo
or Prim EY Ala
Type of system.
_ Septic tank/distribution
_ Single cesspool
Overflow cesspool
Privy
Shared system (yes or no)
records, if any)
✓ Other (explain)
or no
/3y
F
R Vtr Okw &Yr At/ATIAk
box/soil
absorption system
(if yes, attach previous inspection
SAC
Mal( f (No R .
Approximate age of all components. Date installed, if known. Source of
information:
Ala• / S/Wi 5/5775t1 fill74/1AD
r yfl9Rs 460
NO Sewage odors detected when arriving at the site, yes o o
SYSTEM INFORMATION continues
SEPTIC TANK:✓
(locate on site plan)
depth below grade: i2'
material of construction:
metal _FRP _other(explain'.
dimensions: /000 Pict//CNS eo f v 560 x 56 4,0.,,, „der de�
le" sludge depth
distance from top of sludge to bottom of outlet tee or baffle
,VON E- scum thickness
distance from top of scum to top of outlet tee or baffle
distance/jjjyror„ bottor. of scum to bottom of outlet tee or baffle
Comments :
i 20" rFLg
(recommendation for pumping, condition of inlet and outlet tees or baffles
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations fa: repairs, etc. )
54-1.--Tic AIK sapperlOs Z /3L- .n/ &aeh 5ni pE
- 4.. 711 I..P84c.A<rr F( awc Z R6;,nmmeX,f> /iuNUA( pv/npiN&:
—1-0,0. Veri2N6 Reirf'tr Aer p3' stii,oc Tfin4- - AlIrree r a0 OGap
DISTRIBUTION BOX: ICI/n
(locate on site pla 0
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation, for repairs, etc. )
PUMP CHAMBER:
(locate on site Lan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
BUBBURYAOL nLWAUL U4Orwyno. - ••
PART B
8YOTBM I� N/7ORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : Y
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type
--�> leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool , number
Comments:
(note condition of soil ,
condition of vegetation ,
5 _ . rc
OA) Lefe;}-1 JA, PT
signs of hydraulic failure, level of ponding,
re ommendations for maintenance or repairs,etc.
U,v „v
CESSPOOLS ( locate on site plan) :
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth of sour layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
L/%
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments : V
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
PL4 N ViEvO
s)
Le v ni p 4y DRR e Noccrirw ,r5roNl IMR .
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation:
SUBSURFACE SEWAGE DISPOSAL aroma anorrn.aswn sync.
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, II, or IID) . Describe basis of
determination in all instances. If "not determined" • explain why not)
A)O Backup of sewage into facility?
NO_ Discharge or ponding of effluent to the surface of the ground or
surface waters?
lA)IPistatic liquid level in the distribution box above outlet invert?
N8 Liquid depth 'n cesspool <6" below invert or available volume< 1/2 day
flow?
AJ D Required pumping 4 times or more in the last year?
number of tines pumped tore n— [)Vtp P 5°pt IC(° t/
NO Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial enfiltration? tank failure imminent?
Is any portion of the SAS , cesspool or privy:
Sp_ below the high groundwater elevation?
tj O within 50 feet of a surface water?
NO within 100 feet of a surface water supply or tributary to a surface
water supply?
NO within a Zone I of a public well?
NO within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, pot the SAS)?
NO within 50 feet of a private water supply well?
NO less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysis
for coliforn bacteria , volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
FART U
CERTIFICATION
Name of Inspector IIt.kol-tiy C . tAAG..IA)NIS R.S .
Company Name ;idol;
57-r) - 5291
Company Address jJ tnOh1TA(GQC 20 AC
lul l rIAN'.?1DtU AAA , Olo2')
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
- consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Cheri: one:
I/ I have not found any informat
to adequately protect public
310 CMR 15. 303 . Any failure
the FAILURE CRITERIA section
ion which indicates that the system fails
health or the environment as defined in
criteria not evaluated are as stated in
of this form.
stem fails to protect public health and
310 CMR 15. 303. The basis for this
the FAILURE CRITERIA section of this
I have determined that the sy
the environment as defined in
determination is provided in
form.
Inspector' s Signature
Date 5- -
Original to system. owner
Copies to:
Buyer (if - applicable)
Approving authority
Af P 'hARS 12 Be; IN &o e Waf'�^I•'C
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