168 Title 5 Report, 1996 William F.Weld
—a.
Argo*Paul Cethiod
LL Omen
Cornmonweatth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address Le MS?C k'D6
Date of Impaction: MRy a, t9cioo
Name of Impactor: j'.,n p- iy E. t Pt&t&N S R.S
Company Name,Address and Telephone Number.
'70 Y`AoNTAGUE Rot O
i.'iER+tAMP'foN, Mq. OICa9
CERTIFICATION STATEMENT
I certify that I have persona inspected the sewage disposal system at this address and that the information sported below it true,accurate
and complete as of the time of insp tioa The inspection was performed based on my training and mpvience in the proper function and
maintenance of on-site sewage deposal systems. The
Passes
_ Conditionally
_ Needs Further E Authority
Fails
Address of Owner.
(If di/fennel SR ME
Trudy Cone
acme
DasW B.S9Ws
McM1r or
Inspector's Signatures —Cu,6 yeC _I Data AAA-" 8, 19%
The System Inspector shell submit• f .:'y+`..tab' to the Approving Authority within thirty(30)des of completing this
inspection If the system is a shared system or of 10,000 gpd or greater,the inspector and the system owns 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:
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
My failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSER:
One or more system components need to be replaced or repaired. The system upon completion of the replacement or repair, passe
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instants. If'not determined',apiin wlv not)
The septic tank is metal,cracked structurally unsound,sham substantial infiltration or 6filtretion,or tank failure is
imminent. The system will pass inspection if the misting septic tank is replaced with a conforming septic tank as approved
by the Saud of Health.
(revised 11/03/95) 1
One YAnta Street • Boston,Masa•chuMta 02101 • FAX(611)556-1049 • Telephone(617(292.5500
0 mete on a.nci.d rep.
F.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
•CERTIFICATION(continued)
Property Addeo.. tea NtpvrnCE P43 Cct
Owner. Rcv 2 Prsi GlsknlCoR<GtOR'0
Date of Inspection: (v)Ay 8 tiq
8]SYSTEM CONDMONALLY PASSES(continued)
bi/,a_
Sewage backup or breakout or high static water level Swerved in the distribution box is due to broken or obstructed pips)
or due to•broken,settled or uneven distribution boa. The system will par inspection if(with approval of the Boad of
Health):
_ broken pipe(.)an replaced
_ obstruction is removed
distribution boa is levelled or replaced
The system required pumping more than four times•year dm to broken or obstructed pip.(.). The system w01 pass
inspection if(with approval of the Board of Health):
_ broken pipe(.)are replaced
obstruction is removed
CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Condition.exist which require further evaluation by the Board of Health in order to _ . . if the system le failing to protect the
public health,safety and the environment.
I) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT SYSTEM 18 NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY 1 THE ENVIRONMENT:
- Cesspool or privy is within 50 feet of a surface water
- Cesspool or privy is within 50 feet of•bordering vegetated wetland or•
3) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WA
DETERMINES THAT THE SYSTEMS FUNCTIONING IN A MANNER THAT P
SAFETY AND THE ENVIRONMENT.
3)
- The system has•septic tank and soil absorption system and is within 100 feet
surface water supply.
- The system has•septic tank and soil absorption system and is within•Tons 1
- The system has•septic tank and soil&Sorption system and is within 60 feet
- The system bas•septic tank and soil absorption system and is feu than 100
supply well,unless a well water analysis for coliform bacteria and volatile
from pollution from that facility and the presence of ammon s nitrogen and
OTHER
SUPPLIER,IF APPROPRIATE)
T THE PUBLIC HEALTH AND
•surf we water supply or tributary to•
•public water supply well
•private water supply wall.
but 50 hat or mon from•private water
compounds indicates that the well is tree
nitrogen is qu•1 to or has than 6 ppm.
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Addra.n i‘E=4 map(x RiO6iE- NO{L1tiMvypi Jld F y✓t.6 .
Owner. Roy e Pte. &,F+N6,4?-60R O
Date of Inspection: m y 6., I`j 9(r•
DI SYSTEM FAILS:
VA I have determined that the system violates one or more of the following failure criteria as dead in 910 CUR 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
Lih.re
NO
Backup of sewage into facility or system component due to an overloaded or clogged SAS or carpool.
up Discharge or pending 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 bon above outlet invert due to an overloaded or clogged SAS or cesspool.
tVA Liquid depth in cesspool I.less than S^below invert or available volume is ler than 1/2 day flow.
the Required pumping more than 1 times in the last year NOT due to clogged or obstructed pips(s).
Number of times pumped
f�0 Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
IAA Any portion of•cesspool or privy is within 100 feet of a surface water supply or tributary to•surface water supply.
LA Any portion of•cesspool or privy is within a Zone I of•public well.
1414 Any portion of•cesspool or privy is within 50 feet of•private water supply well.
alp Any portion of•carpool or privy is lea than 100 feet but greater than 50 feet from•private water supply well with no
acceptable water quality analysis. If the well ham been analyzed to be accept able,attach copy of well water midyear for
coliform bacteria,volatile organic compound,ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
ti/A
The following criteria apply to large systems in addition to the criteria above:
The system serves•facility with•design Sow of 10,000 gpd or greater(Large System)and the system is•Madam 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 L within 200 feet of•tributary to•surface drinking water supply
- the system is located in•nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water supply wad)
The owner or operator of any such system shall bring the system and facility into till compliance with the groundwater treatment program
requirement.of 314 ChM 5.00 and 8.00. Please moult the local regional office of the Department for Sather information
(revised 11/03/95) g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
•
Property Addles= LB M^P(-E $2,06E
Owen goy
l ?KT emit N6466ORte
Data of Inspeotlom m A d 8j 19.4 L
Cheek if the following have been done:
yc5 Pump information was requested of the owner,occupant,end Board of Health.
Nom of the system components have been pumped for at Wet two weeks and the ystan has been rereiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently ors put of this inspection.
ya_ N built plan.have been obtained and examined. Note if they an not available with N/A
y The facility or dwelling was inspected for signs of sewage backup.
_The system dote not receive non-sanitary or industrial waste flow C3GS otn.T,f.0 usisscre auLy
The site was inspected for signs of breakout.
yet All system components,excluding the Soil Absorption System,have been located on the site.
yes_The septic tank manholes were uncovered,opened and the interior of the septic tank was inspected for condition of baffles or
tees,material of wotrucewn,dimensions,depth of liquid,depth of sludge, depth of.halm.
Yea_Tha Mee and location of the Soil Absorption System on the site has been determined bald on cutting information or
approtmat.d by non-intrusive methods.
yes_The facility owner(and omrpants,if different from owner)were provided with information on tha proper maintenance of Sub-
Surface Disposal System.
(revi sad 11/03/95)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Addre.c I bed M Pry LE Rif)GE
owner: coy € PRI GIAN6Rt4,<OW
Date of Inspection
M41 8/ 19.9 L
RESIDENTIAL:
Deign flow$' Z.6ZrItnn.
Number of bedrooms:5_
Number at current residents:3
G=t ge Firs=Gee no):` ,
Laundry connected to system(yes or e): '}_t 5
Seasonal are W orfu9):l4Q
Water meter rs.diagr,if available:
FLOW CONDITIONS
Lest data of occupancy: C✓RRF.NTLy OCL Wi cD
COMMERCIAL/INDUSTRIAL:
Tye of establishment: IVA
Design Sow gsOnnatday
Gr....trap present: (yes or no)_
Industrial Ware Holding Tank present:(y=or ro)_
Nonwanitary ware discharged to the Title 5 system:(yes or no)_
Water mate readings,if available
List date of occupancy:_
OTHER:(lesarbe)
Let date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
94./MPk.4 By TR.AK €XGA✓rtTtaU •F LA)iu'WA-4-06446 ¥tk
System pumped as part of inspection)or o), 5 �.... J
I yea volume pumped: 1 SO Q gallons
Reason for pumping KBAI. ESTME 7ak05g172E
TYPRpP SYSTEM
✓ Septic tankMiselbdion baa/aoil absorption system
- Segls orpool
Overflow carpool
- Erie
Shared system(yes or no) (if yr,attach previous section records,if any)
Other(explain) H 'TY c)};TS n1 .7S r!_ X 3'6J kt) E hcH
APPROXIMATE AGE of all components,date installed(if known)and source of information
Sewage odors detected when arriving at the site: (yes __N
(revised 11/03/95)
5
1- 02.5- Ye/tR5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addend (.6e) MMnpc,E ILO GE
Date of Impieties:RA, Pal �i-I n NIfREGVR.1O
Mei t 1440
SEPTIC TANK:
(locate on cite plan)
' QQ t(
Depth below pade:y5 ✓/
listciel of construction:< _metal FRP_other(apInin)
Denounces: ( lo't- X Cue X 5'0)
Sldgedepth:
Distance from top of sludge to bottom of outlet tee or baffle:_
Scum thickness: '! I "
Distance from top of cum to top of outlet tee or baffle:
Distance from bottom of rem to bottom of outlet tee or battle:
Comments:
(commendation for pumping,condition of inlet and outlet tees or baffles,depth of
evidence of leakage,wt.) R - it .1 _ :Si CE OUT $' G ON •L.. iD
Lea Tbi.b1 1Z" dear 1ut•;p !r .o
level in relation to outlet invert,structural integrity,
Depth below grads._
Material of construction:_ =rate metal_FRP_other(aplainl
Dimension.:
Scum thi.Jmsr:_
Distance from top of cum to p of outlet tee or barns:_
Distance from bottom of calm bottom of outlet tee or baffle:_
Comment.:
(recommendation for pumping,
evidence of leakage,etc.)
of inlet and outlet tees or baffles,depth of liquid level in elation to outlet invert,structural integrity,
I revised 11/03/95) e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addreac t&,t MIMI e"")St-
Owner: Roy 4 Pict 6 ANG,R.ECcOR10
Date of Inapeotloo: m ai ®, tQ 9
TIGHT OR HOLDING TAN&_ NA
(brae on sate plan)
Depth blow grade:_
Material of omrt lotion:_concrete
meta) FRP_other(eaplain)
Dimensions:
Capaty: salons
and float switches,etc.)
Design flow: gallons/day
Alarm level:
CommaoY:
(emdition of inlet tee,condition of alarm
V
DISTRIBUTION BOX L"
(beta m site plan) 56 fiTT/tGI `)
Depth of liquid level above outlet invert: i///}'
Comments:
(ate if level and distribution it equal,evidence of solids carryover,evidence of leakage into or out of km,etc.) (3) (20 CCA(�.R
/12 fi:7ZS 413 ThF?'�il //Uinta(Cr ti Pon. 'him" fovFC' T. l ;ttl1lt,n1—
PUMP CHAMBER:_ f�/A
Doane on site plan
Pump in working order.(yas or no)
Comment.:
(note condition of pimp chamber, n of pump and appurtenances etc.)
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address
[�16% MAPO RlD6t
Owwr R°y 4 P!}I CA A N3'A CS ORA0
Date of In. ,Hay g 1494
SOIL ABSORPTION SYSTEM(SAS)✓ — \
G pacific oat. site plan,if pca excavation not required,but may be approximated by non.intn /
u.e method.) I t
If not determined to be present,explain:
leaching pw,number:_
leaching chambers,number:_
; leaching trenches,number,Cugth: ✓ 6 "IR.SNctFE1 0 &SIC
Caching fella,number,dimension.:
overflow cesspool,number_
X 3'w x2,14)EA
Comments:(note condition of soil.sign of hydraulic failure,level of goading, condition of vegetatngNC.)
Ala 6tA e-'S of po..+Di.✓o- oR UiltFi2 St C,NS dF t1ry ORA>u(
rca
CESSPOOLS:
(locate on nee plan)
N/
Number and configuration:
Depth-top of lipid to inlet invert;
Depth of solids layer
Depth of mum layer
Dimensions of cesspool
Materials of monaumiov:
Indication of groundwater:
inflow(carpool BMA be
as part of inspection)
Comment.:(note condition of moil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:
(locate at site plan) N/ii
Materials of constriction. I Dimaoaons:
Depth of solids:
Comments:(note condition of soil,signs
failure,Inal of ponding,condition of vegetation,etc.)
(rwl.ed 11/03/45) g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property 4 Addeo.=x l68 MAKE RIDGE
Owner. Rod/ P/sr Cs.A N6aRE(+WgA6
Date of Inspection:
M Ak/ $ 144b
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include tie.to at beet two permanent roferenc.e landmark.or benchmark.
locate all wells within 100'
Sc c" a,;r c rtlzzz
DEPTH TO GROUNDWATER
Depth to groundwater. > 4 bet
swthsd of deterflation or aMweaimation: I F S I 91 O{}I q
(revised 11/03/95) 9
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