82 Septic Inspection 1997 WILLIAM F WELD
Gomm°,
ARGEO PAUL CELLUCCI
U.Governor
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECRTI01,---i.,
ONE WINTER STREET BOSTON. MA p'IOB 61149? 33QI L �Io L
lU
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
Se-F}.7 0N1-vi le�'�(.� CERTIFICATION
Property Addr«s: ?CP-Q n.. T M
Date of lmpectiom lit �9'l
Name of Inspector:
d .eoD
I am a DIP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000)
Company Name: iffoedRhlR Nmm� rind Sm3stlr Tnspectione Inc.
Mallina Address: Sj9 N. Flat St . Wmstfgpl4. Ma 01085
Telephone Number: 411 .. 1AR-49403
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the .nformation 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
Passes
Conditionally Passes
_ Needs Further Evaluation By me Local Approving Authority
Fails
Q.Q Th JLRP
1:7-ltn twee.
Address of Owner:
(If different)
AUG 8
TRUDY CO%E
Secrets()
0AV1D B:STRUMS
Comndsiono
Inspector's Signature:
Date: If//Q'/
The System Inspector shall 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 Cow 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
SUMMARY: Choc A,0, C, or Cr //l a
A) SYSTE ASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
I) SYSTEM CONDITIONALLY PASSES:
_ One or more system components as described in the'Conditional Pas" section need to be replaced or repaired. The symm, upon
completion of the replacement or repair, as approved Isyite board of Health, will pass.
Indicate yes. no, or not determined (Y, N, or ND). scribe basis of determination in all instances. If'not dMemhined", explain why hot.
_ The septic tank is metal as the owner or operator has provided the system inspector with a copy of a Cwninate of
Compliance (attic indicating that the tank was Installed within twenty f201 years prior to the date of the inspection; or
the septic to her or not metal, is cracked, structurally unsound. shows substantial infiltration orakfiltretion, or rank
failure i • minent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as oved by the Board of Health.
(revised *4/23/0i1 Pap 1 se 10
flea an Ira Wnrw NAM Web- nno Iowa.meet Wee ma uYGD
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued/
Property AddRess: 82a-e,{' J' +� 1 to
Owner: i _ C ri k ait.tai cA„
Date of Inspection: '7/in 1'7
B)SYSTEM CONDITIONALLY PASSES {continued:
_ Sewage backup or breakout or high static water level obse he distribution box a due to broken or obstructed
pipets) or due to a broken, settled or uneven distri a The system will pass inspection if with approval of the
Board of Health). Describe observations:
_ broken pipe(s) are rep/
obstruction is remo
distribution bo levelled or replaced
_ The system required pump more than four times a year due to broken or obstructed pipers) The system will pass
inspection if(with appr al of the Board of Health).
_ bro en envoi are replaced
obstruction is removed
CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ Conon:ons exist which require further evaluation by the Board of Health in order to determine if me system is (ailing to protect 1M
public health, safety and the environment
i)
WHICH WILL UNLESS BOAD OF
UBR C HEALTH
SAFETY DETERMINES • THE SYSTEM IS FUNCTIONING IN A MANNER
Cesspool or privy a within 50 feet of a surface -er
Cesspool or privy is within 50 feet of a bor•, ing vegetated wetland or a salt marsh.
THE SYSTEMLIS FUNCTIONING INDARD OF R THAT ROTECESLTHE UBLLIIC SUPPLIER, If HEALTH AND APPROPRIATE) DETERMINES S iHAT FAIL UNLESS THE SAFETY AND THE
ENVIRONMENT:
_ The system has a septic and sal absorption system (SAS) and the SAS ss within 100 feet to a surface water supply or
tributary to a surface •er supply.
_ The system has a - is tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has eptic tank and soil absorption system and the SAS is within 50 feet of a Invite water supply well.
_ The system a septic tank and sal absorption system and the SAS is less than 100 feet ba 50 feet or rrorc Irom a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates the
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
SI OTHER
Irersae% 04/21/17) Pan I of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
.-F CERTIFICATION (continued)
inued)
Properly Address: S & at 12E9; ' e^ccE
Owner: o, u.eivj
cis„
Date of Inspection: ei I In lee 1
DI SYSTEM FAILS:
You must indicate either 'Yes' or No as to each of the following,
_ I have determined that the system violates one or more of the following failure criteria as defined in 310 CY R 15.303. The Oasis
Mr this determination is identrhed below The Board of Health should be contacted to determine what will be necessary to contra
the failure.
Yes No
Backup of sewage into facility or system component due t• overloaded or clogged 5A5 or cesspool.
- Discharge or pending of effluent to the surface o
cesspool
ground or surface waters due to an overloaded or clogged SAS or
▪ Static Loud level .n the distribution box .ove owlet invert due to an overloaded or clogged SAS or cesspool.
- L.gu'd depth 'n cesspool is less th
' below invert or available volume is less than 1/2 day floww
Required pumping more than - times in the last year Ns"due to clogged or obstructed prpe(s:.
Numbs oft mes pumped
Any portion of the So:' Absorption System, cesspool or privy is below the nrgh groundwater elevator.
Any portion ma o spool or p/rys is within 100 feet of a surface water 'app's' or tributary to a surface water supply
Any pomor of a cesspool or privy is within a Zone Iota public well
Any portion of a cesspool or privy is within 50 feet of a private water supply well
Any ponion of a cesspool or privy is 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 lot
cohiorm bacteria, volatile organic compot,nds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate etcher "Yes' or'No" as to each of the following.
The following criteria apply to large systems in addition to the c aria above.
The system serves a facility with a design flow of 10,000 • or greater (Large System) and the system is a significant threat to
public nealth and safety and the environment because e or more of the following conditions exist:
Yes No
the system is within 400 feet of a ace drinking water supply
the system is within 200 feet a tributary to a surface drinking water supply
nitrogen sensitive vu(Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a
_ the system is located in
public water supply
The owner or operator of any such system
requirements of 314 CMR 5.00 and 6 00
lravleae ea/as/ate)
1
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.
Pogo 3 of 30
Property Ad9ress:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
�a 4.,z
r �at:� &-1— ad, e_
Fine
, Iolsri
Check if the following have been done. You must indicate either"Yes'or 'No'as to each of the following-
" No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped 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 teetem recently or
•a part of this inspection
•WWII As built plans have been obta:ne° and examined, Note if they are not available with N/A.
I _ The facility or back-up.
was inspected for signs of sewage bacup.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout
— AB sysien' components excluding the Soil Absorption System, have been located on the site.
IA _ 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
Y —The size and location of the Soli Absorption System on the site has been determined based on.
The facility owner and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System
/
_/ _d Existing information E . Plan at B.O H.
./ _ Determined in the held of any of the failure cetera related to Part C is at issue, approximation of distance is
unacceptable) ft 5.30113i(b1)
(raised O49l/e7) Pary 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property APdrns: g-a- ' ��' �� , /n • -E
Owner: 1 ci ear�t Yr�cl/�
Date of Inspection: :'hl Inn
FLOW CONDITIONS
IggIDENTIALL
Design flow_AWL'pd./bedroom for A5
Number of bedrooms.
Number of current residents
Garbage gr"der was or no:lib
Laundry connected to system )yes or no)4w
Seasonal use (yea or no) '7t-o a
Water meter readings, it�aa$$ailaba (last two (2)year usage tgSd) I e on CL)San
Sump Pump Ives or not yp
Last date of occupano i I.I fl7
SOMMERC I AUI N DU STRIA L
Type of establishment.
Design flow__gallonsrdjs--
Grease trap present (yeg,o'r nm
Industrial Waste Ho >ng Tank present, wes or no:
Non-sanitary wa discharged to the Due 5 system. 'yes or no:_
Water meter r dings, it availabie
Last late oT o-cupanc'
OTHER: (Describe
Lan date of OCWpMc'.
GENEML INFORMATION
PUMPING R RDS'^annd�ISOLjrrrle ofumlorman on
SYste umpl0lfs Oars of inspedton• eyes or noIlD
If yes, volume pumped'. gallons
Reason for pumping.
TYPE CvOYSTEM
Septic tank/distribution box/soil absorption system
Single Cesspool
'— Overflow cesspool
Privy inspection records, if any)
_Shared system (yes or no) (if yes, attach previous inspection
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) source)and source d information: ?474
Sewage odors detected when arriving at the site. (yes or no)Le
(win. 0e/21/0+)
Page It at 10
pa a ..-eCa 4aLt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM Inp.FORMATION (continued)
Ow er:Y Asians:: la a
k-
owner: d a- EN+c
Date of Inspection: 7I li I41
BUILDING SEWER:
(Watt on site plan)
Depth below Stade._
Material of construction'.
iron _40 PVC _other(explain;
Distance from priv watef supply well or suction IIr(
Diameter
Comments: (condition of joints, venting, evidence of leakage, eic.)
SEPTIC TANK:laws-se
(locate on site plan)
II -F-o
DePth below construction 1'a-
Matprh of ConpruOiOn. concrete �mltd. _f:bogks! �POIYethykne �OlhUfeeplmN
If tank is metal, list age -� 1s age confirmed b) Certificate of Compliance —(Yes/No
Dimensions aO X tS x 4
Shrdgt depth. O -d if
Distinct from top of +dge to bottom of outlet we or baffle AI e
Scum thickness: W
Distance from top of scum to top of outlet lee or baffle ba3
u
Distance from bottom of scum to bottom f outlet to or baffle ;Jy
How dimensions were determined.
Comments: h of Iquitl level ;n relation�to outlet wart. structural
(recommendation for pumping, condition f inlet an p t�tees or baffles, pt h i utlet A At mta{rit e+ ce of I kage, etc.) S s is1 !ffa lr eB�.,. smart n -
rrYartrelinmarest
GREASE TIIAP)__
(locate on site plan)
Depth below grade aher(eapta:N
Maserial of Construction concrete —metal _fiberglass _Polyethylene _
DirrtansionS:
Scum thickness
Distance from lop of scum to of outlet tee of baffle.bone
Distinct from m m o bottom of outlet tee or baffle.
�}.KG to
Dade of last pu
Comments.
(worn ion for pumping, condition of inlet and outlet tees or baffles, depth of liouid level in relation to outlet invert. structural
integrity, evidence of leakage, etc.)
!revise. M/ace/a+l
Pell• t of to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
- ��ee SYST�EMnINEOR/A*71ON (continued)
Property Addrgk: �2- mezt: %/deem. F 8 , V-�n.�rvex-
Owner: , O—K i...Ai- e:I- -
Date of Inspection: -(1
TIGHT OR HOLDING TANK:_ lank must be pumped prior to. or at time, of inspection)
(locate on site plan)
Depth below grade'._
Material of construction concrete tal _Fiberglass __Polyethylene other(explain)
Dimensions:
Capacity. gallons
Design Row-. galion✓das
Alarm level - Alarm in working order Yes; No
Date of previous pumping
Comments
(condmon of Met tee. condition of alarm and float switches. etc I
DISTRIIUTION BOX:_
(locate on site plan)
Depth of liquid level
e outlet raven
Comments:
(nde d level and dis ibution is epuat, evidence of solids carryover, evidence of leakage into or out of box etc
PUMP CHAMBER:_
(locate on site plan)
Pumps in werkinr: (Yes or No)
Alarms in work: order(Yes or No
Commam:
(note condition of pump chanter, condition of pumps and appurtenances, etc)
)••,sots •4/25/97)
eau + •s 10
Properly Addles:
Owner:
Date of Inspection:
SOIL ABSORPTION
(locate on site plan,
If not enameled to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
a=a C7aaek2ti-D *e9;
SYSTEM (SAS):_
.n QA4*Jl
if possible, excavation not required, but may be approximated by non-intrusive methods)
be present, explain.
Type
leaching pits, number: cn 8 )O4 X
leaching chambers, number.__
Inching galleries, number_
leaching trenches, number length
leaching fields, number, d,menuons.
overflow cesspool, number.
Alternative system.
Name of Technology:
Comments.
(note o • :ion of soil, signs of h •rauhc failure, level of•onding, condition of v nation, etc.) a
•til!IRrq�.11�11/�f�i�w'a'�7�1IS�:!'t!��-'
CESSPOOLS: _
(locate on site plan)
Number and configura:wn
Depth-top of liquid to mint mven.
Oath of sold.layer
Depth of scum layer.
Dimensions of cesspool.
Materials of construction.
Indication of groundwater.
inflow (Cesspool . be pumped as pan of inspection)
Comment:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.)
PRIVY;
Boots on site Plan)
Mortals of cons t - on:
Depth of solids:
Cornmint:
(net condil• of soil, signs of hydraulic failure, level of pondi:,g, condition of vegetation, etc.)
(revise. e.nann
Dimensions.
sags a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM
INFFORMI ATION continued)
Properly Addrgsf_ t . T C-eS 410‘
a-+t-AZ_
Owner:
Dale of Inspection: -7/I' /on
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
55/25/)7)
raw >1°6's- 'tee
aye I et SO
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,,....yyam. SYSTEM INFORMATION (continued)
Property Adtess: EViFinaxr /GE'G... 123';
Owner: _ n_hisQvtpa.
Date of Inspection: n( 11(q
Depth to Groundwater or t Feet
Please indicate all the methods used to determine High Groundwater Elevation
Obtained horn Design Plans on record
Observation of Site (Abutting property, ohservahon hole. basement sump etc)
Determine it from local conditions
Check wrtn loc., Board of hearth
Check FEMA maps
Check pumping records
Check local excavators, installers
Use USGS Data
t•
Describe in your own words how you establ•shed the High Groundwater Elevation. (hal be completed)
0U 1a kt t
tensor oVLnn
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