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757 Septic Inspection 1996 William F. Weld Severna' Trudy Coxe Omit' B.struhs •Commaiwea!!p W.Man Motets ..::, Executive Office of Environmental Affairs Department. of: . Environmental Protection • Western Regional Office ENVIRONMENTAL FIELD SERVICES, INC. P.O. BOX 578 LEEDS, MA 01053 1-413-586-7200 SUBSURFACE SENAGE DISPOSAL SYSTEM INSPECTION FORM PART CERTIFICATION Preperty &arena: 7S7 7/o,riectrjvacs,,Yc�lii ',mH o�aGo Date of Inspection:•. -t /Y. /99G s of t} Name of Inspector: (If different) , epe Coei9n-e. Company Muse, Address and Telephone Rusher: , •Sax S/7. CERTIFICATION STATEMENT Lay's.n. CIOSS I certify that I have personally inspected the sewage disposal system at this address and that the information reported below Is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: L� Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: gate: the System Inspector shell submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. the original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: N STSTBI P/1SSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 peg 15.303. Any failure criteria not evaluated are indicated below. - Si SISTER CONDITIONALLY PASSES: one or more system conponents need to be replaced or repaired. The system, upon cmpletion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, explain why not) The septic tank is metal, tank failure is imminent. conforming septic tank as or ID). Describe basis of determination in all instances. If "not determined", cracked, structurally unsound, shows substantial infiltration or enfiltration, or The system will pass inspection if the existing septic tank is replaced with a approved by the Board of Health. Sewage backup or breakout or or obstructed pipe(s) or due inspection if (with approval (revised 8/15/95) high static water level observed in the distribution box is due to broken to a broken, settled or uneven distribution box. The system will pass of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced 1 436 Dwight Sheet • Springlield, Massachusetts 01103 • FAX • Telephone ENVIRONMENTAL FIELD SERVICES, INC. SEPTIC P.O. BOX 518 LEEDS, MA 01053 SYSTEM 1-413-586-7200 INSPECTION SINSURFACE SE1511E DISPoAL SYSTEM INSPECTION FM LEAYIFICATION (continued) Propertyyp Asa: 73'77/6teneci(d,.v�•nb5omp/c.,,,s4 0/Odd Omer: ,'-(z*Lc,oyol/&,c i)o// Date of Irmprtion: S- iY-96 B1 SYSTEM CONDITIONALLY PASSES (continued) The system required pulping more than four times a year due to broken or obstructed pipe(s). The system will. pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CI FORTNER 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 system is falling to protect the public health, safety and the environment. I) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTBI IS NOT FUNCTIONING IN A MOANER UIICH WILL PROTECT THE PUBLIC HEALTH NO SAFETY AW THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOND OF HEALTH (NW PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A WANNER THAT PROTECT THE PUBLIC IEALTN AND SAFETY AND THE ENVIREBEIIT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil ebsorptioh system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for conform bacteria and volatile organic cm.povds indicates that the well is free from pollution from that facility and the presence of mmionie nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D1 SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system cmryoent due to an overloaded or clogged SAS or cesspool. Discharge or poling 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 pimping more than 4 times in the last year Not due to clogged or obstructed pipe(s). Number of times pumped Any portion of 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 to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. (revised 8/15/95) 2 ENVIRONMENTAL FIELD SERVICES, INC. SEPTIC P.O. 80X 518 LEEDS, MA 01053 SYSTEM 1-413-586-7200 INSPECTION '- Ip�A F11tf SHMSE Bt a Fm MERTIFIGATIION (continued] "Mierty Address: -7S7 7/cvt cc.7fd,yet, 4 ,n o%n,,n9 o/060 Q3a ld.ie Ca// Date of latian: S-%r- 7O Dl SYSTEM FAILS (continued): Any portion of a cesspool or privy Is within 50 feet of a private water supply well. Any porflon of a cesspool or privy le less than 100 feet but greaterlthen 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 collierm bacteria, volatile organic conpouds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (INPA) or a mapped Zone it of a public water supply well) The owner or operator of any such system shall bring the system and facility Into full compliance with the groundwater treatment program requirements of 314 OR 5.00 and 6.00. Please'consult the local regional office of the Department for further information. Check If the following have been done: ing information was requested of the owner, occupant, and Board of Health. None of the system cmpaunts have been pulped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as /part of this inspection. 1s built plans have been obtained and examined. Note if they are not available with N/A.. I,/';he facility or dwelling was inspected for signs of sewage back-to 1/The system does not receive non-sanitary or industrial waste flow 1//The site was Inspected for signs of breakout. ZAil 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 /The size and location of the Soil Absorption System 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 Sub-Surface Disposal System. PMT B CHECKLIST (revised 8/15/95) 3 ENVIRONMENTAL FIELD SERVICES, INC. SEPTIC P.O. BOX 518 LEEDS, MA 01053 SYSTEM 1-413-586-7200 - INSPECTION SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOIE PART C �.o SYSTEM INFORMAYTON Property Address: 767��G/Y-/1cc. >%///2r)admroiro,m9 n/"GO owner: trtr -O-&,,t-,d c°o// Date of fsPection: S/r/-96 FLOW [QBITItxs RESIDENTIAL: Design flow: 1.9Ow4fgallons limber of bedrooms: Number of current residents: • V Garbage grinder (yes or no): es Laundry corrected to system (yes or no): yes Seasonal use (yes or no): nn Water aster readings, if available: Last date of occupancy: erQSIn, COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: last date of occ ancy: OTHER: (Describe) last date of occupancy: GENERAL INFORMATION PUMPING RECORDS end source of information: 7P.,S; .&o,n /Orb/.sew bTP,;17 ,nfre, '. System pepped as part of inspection: (yes or no) .00 if yes, volume pipped: gallons Reason for pumping: TYPE DF STSIDI Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy shared system (yes or no) Of yes, attach previous Inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source ofinnformation: S v� AS' /0 -s-. pc.— DtCP/ .spJ%c/T,: �im•-..EE /4) -ao ,.T. end. Sewage odors detected when arriving at the site: (yes or no) p/, (revised 8/15/95) 4 ENVIRONMENTAL FIELD SERVICES, INC. P.O. BOX 518 LEEDS, MA 01053 1-413-586-7200 St6MFACE %URGE DISPOSAL sY61B1 INSPECTION FDIDI MAY C SYSTBI INFDRMTIDII (continued) Property Address: 7 Jr'% 7/a>encc '�j'oad /VriJ4'-r4•-' "72"9 O/O. d Oar: "fay 0.4a-i/�iic Ca// Date of Inspection: /y-9G SEPTIC TANK: (locate on site plan) Depth below grade: ?.S Materiel of construction: concrete _metal _FRP other(explain) SEPTIC SYSTEM INSPECTION Dimensions: R •c </Y2' x V%v studse depth: N/f1 Distance from top of sludge to bottom of outlet tee or baffle: N/// Scum thickness: /1//9 Distance from top of scum to top of outlet tee or baffle: Nfn Distance from bottom of scum to bottom of outlet tee or baffle: N//i Cements: (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, etc.) nc a - r AIPINfrIWILargrairWIPMIIIMMINIPmflIlt GREASE TRAP:AI A (locate on sit plan) Depth below grade: Materiel of construction: _concrete _metal _FRP other(explain) Dimensions: scum thickness: Distence from top of scum to top of outlet tee or baffle: Distance fret bottom of scum to bottom of outlet tee or baffle: Comments: (recomnendat ion for pumping, condition of inlet and outlet tees or baffles, depth of liquid level In relation to outlet invert, Structural integrity, evidence of leakage, etc.) (revised 8/15/95) 5 ENVIRONMENTAL FIELD SERVICES, INC. SEPTIC P.O. BOX 518 LEEDS, MA 01053 SYSTEM 1413-586-7200 INSPECTION SUBSURFACE SEWAGE DISPOSAL SFST9f INSPECIIDR FORM PART C STSttil INFGUSTIU (continued) Property l4QPCr/ess: 7S 7 7/c>e rc-e->foao!A?>/AC /„a,p>9 ct/Oe D Wert mdtc~C'/ia>/Grt ('o,/ Date of nerktian:s/y/90 TIGHT DR NOISING TAMK.49 (locate on site plan) Depth below.grade:__. . Material of construction: _concrete metal_ FRP __other(explain)' Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOR:jFU-ei✓,- (locate on site plan) Depth of liquid level above outlet invert: N/A Comments: (note if level ani distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) E r _ - .flrlA,w eafl ea frifg4' }7!_.. .. J{: PUP CHAMBER: ✓ (locate on site plan) Purrs in working order:(yes or no) els Cements: (note condition of pulp chamber, condition of purya and appurtenances, etc.) (revised 6/15/95) 6 ENVIRONMENTAL FIELD SERVICES, INC. SEPTIC P.O. BOX 518 LEEDS, MA 01053 SYSTEM 1413-586-7200 - INSPECTION siss tmci WAAGE DISPOSAL STUBS INSPECTION FORK PAST c r . SYSTEM INFORMATION'(titf n04 Property Address: 7S-7 Y/L>f„[L yecg 4/e1.45c20- den //',9 0i9Ge Q1ner: aayy.� Cnee/rn._ ()e// Date of inspection: S/Y-fG SOIL ABSORPTION SYSTEM (SAS):V (locate on site plan, if possible; excavation not required, but may be epproximeted by non-intrusive methods) If not determined to be present, explain: Type. teaching pits, mnber: leaching chambers, mater: teaching galleries, renter:.7 —J. leaching trenches, rember,length: leaching fields, reenter, dimensions: overflow cesspool, number: levet of pording, condition of vegetation etc.) CESSPOOLS. (locate on si a plan) Comments: (note condition of soil, signs of hydraulic failure, Surber and configuration: Depth-top of liquid to Inlet invert: Depth of solids layer: Depth of sous layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pulped as pert of inspection) comments: (note condition of soil, signs of hydraulic failure, level of minding, condition of vegetation, etc.) ( cal b//! (Loloca:e site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.) (revised 8/15/95) ENVIRONMENTAL FIELD SERVICES, INC. SEPTIC P.O. BOX 518 LEEDS MA 01053 SYSTEM 1-413-586-7200 INSPECTION SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART C SYSTEM INFORMATION (continued) PropertyyAAAdddress: 7S7 7/o,r,ec/Qc'oc n724 /./. / eio60 0pater rF I.'fay•-00ct/eu City/ SKETCH Of SEWSE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �o-1 ence ,foorG r C1) N harh'n9/°'� oo�) Ltt DEPTH TO ORENROATER \ Depth to groundwater: /4% feet ) / method of determination or approximation: /T ErZ Lk ® �,7r tq 6 2 /occult)+_ r i.J/ a x#d:a o( i'n cfr (revised D/15/95) 8