76 Title 5 Reports 1995,1997,1999 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
If residga_j..4l
.3 - number-of bedrooms
2 number of current residents
Na garbage grinder, yes or no
YES laundry connected to system, yes or no
Np fi'y seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available: 9ilociawart CO21 Y ,
I au Ly Last date of occupancy
FLOW CONDITIONS
GENERAL INFORMATION
Pumping records and source of information:
1,-(45-r ?UMPhd6- 19R7
YES System pumped as part of inspection
if yes, volume pumped 140,, G41...
Reason for pumping:
27.NS PEC.Ti n,✓
or no
Type of system
et Septic tank/d '_„_ y soil absorption system ?1"'Y .,
Single cesspool
Overflow cesspool
Privy
n(l Shared system (yes or (if yes, attach previous inspection
records, if any) -
Other (explain)
Approximate age- of all components. Date installed, if known. Source of
information:
a7 YEAlS /T67 - /S68
CONTRA)ern + OwNa2
No Sewage odors detected when arriving at the site, yes or no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 074 /t7A.i,N ST. lvoerHApfro.v,A}Ass,
Owner' s name ucALTC-2-F2oSEftwar claA
Date of Inspection a&&7.3-0iE4i5
PART A
CHECKLIST
MOWHWOMONOOARDOFNEAuH
7
Check if the following have been done:
Pumping information was requested of the owner occupant, and Board of
Health.
V/ 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
system recently or as part of this inspection.
�pA :// As built plans have been obtained and examined. Note if they are not
�Y available with N/A. C.vur2gcioe,&,Loa H9O USV2iL - sNFigh947iO4,
The facility or dwelling was inspected for signs of sewage back-up.
V/The site was inspected for signs of breakout.
✓ All system components, excluding the SAS, 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 scum. -
V/ 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not
approximated by non-intrusive methods)
If not determined to be present, explain:
required, but may be
lC
Type.
leaching
leaching
leaching
leaching
leaching
overflow
DKYwett
pits and number Q
chambers and number
galleries and number
trenches, number, length
fields, number, dimensions
cesspool, number
fQC'av&KBTc' DiVWEct- APP-n&, / zoo GAL
Comments:
(note condition of soil , signs of hydraulic failure, level of pending,.
condition of vegetation, recommendations for maintenance or repairs,etc. )
L.R,.,n} 4tS4 SmnLG. STeSAM AvPRo,t, 53 f Con DZY,.,E[L
CESSPOOLS (locate on site plan) :
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
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:
(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
SEPTIC TANK: /MOGP-•
(locate on site plan)
depth below grade:AA°9osc.tq''//&" 2'S°a ct2. er rank
material of construction: concrete metal
9
FRP other(explain)
Z. v. N.
dimensions: /ot' X 5'$" X 6u'•
/3" sludge depth
4/" distance from top of
—2." scum thickness
3" distance from top of
/'V distance from bottom
sludge to bottom of outlet tee or baffle
scum to top of outlet tee or baffle
of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
TN/S T4N - A/RS ?2EC4ST 7E645 in/ SEPT7c 'Tq,JIC KECCo66 aaS, TR0%K.
Co,v9;non) VaR.Y GC D
DISTRIBUTION BOX: No.wE
(locate on site plan)
0" depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE EISPOSAL SYSTEM: & SITE PLAN
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
(a1 b r�
'
�
{
419-a-&
CoNCeEre-
�3. DES'W Z'
DEPTH TO GROUNDWATER
CATGN 1545,04d
41A2/Ani S T,
6
depth to groundwater
method of determination or approximation:
ra h S TE LEVEL r aye qM 2 N oFF
11
yoMPED 26Svi
C£ivTa;a of S2PT∎
I--NA HAS A IS'-
R1SEC APPROf, �'a
CCVE2 ovCe Top,
/f PPRa$. 2o"covCz
ovEL ConceET£
DRY weCG.
LLL)T S26/ooY34_
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORE
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
A/ Backup of sewage into facility?
A/ Discharge or ponding of effluent to the surface of the ground or
surface waters?
N Static liquid level in the distribution box above outlet invert?
A/D Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
Al Required pumping 4 times or more in the last year?
number of times pumped
Al Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
N below the high groundwater elevation?
N within 50 feet of a surface water?
A! within 100 feet of a surface water supply or tributary to a surface
water supply?
A/ within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only not the SAS) ?
A/ within 50 feet of a private water supply well?
A/ less than 100 feet but greater than 50 feet from a private watrr
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analys>.
for conform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector .50 ba rA 4 Curra r\
Company Name SO n4r
Company Address 1E4-M4, N 'tia. CAIE5m62 FeELP, MASS 0/b,,
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.
Chec one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form. �2 �J p
Inspector' s Signature XJu p ' /" / 6)4N44-n
Date 1 Ei) 45
Original to system owner
Copies to: NoghAw,GrhAl &a4ao of
y&gc.r,f
Buyer (if applicable)
Approving authority
ALt StET<NES AND/VEFSU:Z+ris.✓ri 'ter
ApflO/Mftr /J.vO 4' r ro ScALc
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:U 7& M'9Q'4' ST NoCrWR.•Prora MASS
Owner: AA,Ote M. f- sos4 , Al. reAGE2
Date of Inspection: /7 Tut yq7
B] SYSTEM CONDITIONALLY PASSES (continued) rd/,Q
- Sewage backup or breakout Or high static water level observed in the distribution box is due to broken or obstructed
)(pe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
- The system required pumping more than four times a year due to broken or obstructed pipe(s). The system
inspection if(with approval of the Board of Health).
broken pipes) are replaced
obstruction is removed
ill pass
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /04
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health. saiery and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND 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 BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
—
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone l'of a public water supply well.
—
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
—
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
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).
3) OTHER
Isevf.P4 O.RS/ri)
Page 2 of 10
G C I i s I;
COMMONWEALTH OF MASSACHUSETTS ;I
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS'. a 2 2
DEPARTMENT OF ENVIRONMENTAL PROTECTION,.,_,_.
ONE HINTER STREET. BOSTON. MA 01108 617-292-5500 . .
WILLIAM F HELD TRUD1 COXE
Govemo: Sccreun
DAVID B STRUMS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
ARGEO PAUL CELLUCCI
Li Governor
Property Address:I/76 MA FI AN 5T, No¢TN Api Prom) n Ass Address of Owner:
Date of Inspection: /73 v_Y T7 (If different)
Name of Inspector: lyrt//rpm Cog-rs"
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: $,L/ L.tlLTri
Mailing Address: /A%/a9ArN ,Pd CAA CS TF e 7 rrcO MA A%<a
Telephone Number: a// q- yc, _ 5/Z5.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the iniormation 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 the Local Approving Authority
Fails
Inspector's Signature: WALLA., Cant) Date: I7 91A-Le 7
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (301 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 B, C, or D
A) 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.
Any failure criteria not evaluated are indicated below.
COMMENTS.
BI SYSTEM CONDITIONALLY PASSES: /J/:4,.
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached} indicating that the tank was installed within twenty (201 years prior to the date of the inspection, or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltratiion, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/S ) Page 1 of 10
DEP on The Word Wide Weo hap/wawa magnet Sttate ma uL0c0
Pnnted on Replied Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:*76 MAR. AtJ ST, No re rmAni Pro A.) MArr
Owner: ANDee6-) it + 5v544 M, re AG ER
Date of Inspection: /7 To Ly 57
Check if the following have been done: You must indicate either 'Yes' or 'No' as to each of the following:
3e% 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 system recently or
as pan of this inspection
✓ _ As built plans have been obtained and examined. Note if they are not available with N/A.
Corvr.0 r-ro /aJtcoce RAP uSCFo
The facility or dwelling was inspected for signs of sewage back-up.
Y _ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout
✓ All 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 scum.
The size and location of the Soil 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. Roi f £- occ 4-PARTS y 13u,tgCe
_ Existing information. Ex. Plan at B.O.H. $*n1 CoPY BoH, de- EtveD Sun/c 9S
PR sot SNSPGCr,o A) Sd&IC /S
Determined in the field Cif any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (I5.302(311b))
(:.viva 04/25/97) aago 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM
PART A
CERTIFICATION (continued)
Property Address: 14-74. MA ei AN ST NOLTNannv'r0N MHfJ
Owner: 4)4.p2E4-1 M, ¢ SUSAN M , F7.'• G f2
Date of Inspection: /7 joct 57
DJ SYSTEM FAILS:
You must indicate either "Yes''s" 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 CMR 15.303. The oasis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool
Stale liquid level in the distribution box above outlet inven 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 flon.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets).
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 io a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion 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 br
col norm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS: a//'
You must indicate either "Yes" or "No" as to each of the following.
The following criteria apply to large systems in addition to the criteria above.
The system serves a facility with a design flow of 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.
Yes No
the system is with in 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- IWPA) or a mapped Zone II 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 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised D4/2S/97) P.P. 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:76 f 1#g AN ST. NOETWHMGrON M455.
Owner: QNr,2cw m . -f SUSAN m, PRPGE2
Date of Inspection: 17 Ju Ly 49
BUILDING SEWER:
(Locate on site plan)
Depth below grade,4AA1Y 3'
Material of construction. ✓ cast iron _ 40 PVC_other (explain)
Distance from private water supply well or suction lire-
Diameter y"
Comments (condition of joints, venting, evidence of leakage, etc.)
Nn F✓,t FNCr or I GAKApC
CrTY WAT6E
SEPTIC TANK:_
(locate on site plan)
Depth below grade. c2 4/45 4 Cn,✓c26TE 2r SEC 4-C-4 oag 7%`Nra6r
Material of construction Zconcrete _metal _Fiberglass _Polyethylene _other(explain)
If tank a metal, list age _ Is age confirmed by Cenificate of Compliance _(Yes/Nol
Dimensions /olL- —38'W— 6Y"H
Sludge depth (,r^
Distance from top of sludge to bonom of owlet tee or baffle 38"
Scum thickness 71-"
Distance from top of scum to top of outlet tee or baffle. '31'
Distance from bonom of scum to bonom of outlet tee or barite. /3''
How dimensions were determined. jay MeA$' c,o,
Comments.
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet inven, structural
integrity, evidence of leakage, etc.) t aNK AA, P26Cn ST TEE'S
y R- RG, 1-TEES / vee;man Cc,njD;Tied
T ZaComsav/v7 e?e.MP/NG e e-ty (dAS A G*ROAG6 GE,NOEle)
GREASE TRAP:_
(locate on site plant
Depth below grade
of construction _concrete _metal _Fiberglass _Polyethylene other(explain)
Dimensions:
Scum thickness
from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping
Comments:
(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.)
tr.vf.sd o.ns/an
'.ye 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:74 mma,4m $TFEET NORTNAMP>e.,'
Owner: ANOKEL.o 4/ f SuSANM t FRA&EQ
Date of Inspection: /7 T 97
FLOW CONDITIONS
RESIDENTIAL
Design flow. 3 RI) gpd/bedroom for 5 a5.
Number of bedrooms_3
Number of current residents 2
Garbage g'.'oer Wes or nol ,iZs
Laundry connected to system (yes or no).Yes
Seasonal use ryes or no)p0
Water meter readings. if available (last two (2) year usage (gpd):
Sump Pump Wes or no)W e>
Last dare o' occupant% CVWO!-'NTtt
24'EAg EEA privG.N6w Mp TEK zw Srg4GtD
96.- To TfLY4'7 130(531
I�gcK/
COMMERCIAL/INDUSTRIAL. N/A
Type of eslabLshment
Design flow gallon /day
Grease trap present Ives or no)_
Industrial Waste Holding Tank present Ives or no)_
Non-sanitary waste discharged to the Title S system. Wes or no)_
VA'ater meter readings, it available
Last,date or o cupancs
OTHER: (Describe:
Last date of occupanc\
GENERAL INFORMATION
PUMPING RECORDS and source of information
YES f/Fc Feet 'P,.,
System pumped as pan of inspection: Wes or not s
If yes, volume pumped' /4n gallons
Reason for pumping TRAwSFFC 4/F PROP&K-ry
Lne _ 4PEE✓lovS Ow NE,F
TYPE Of SYSTEM
N/ Septic tanks ; k /soil absorption system LEaC UwU TANt-
Single cesspool
Overflow cesspool
_ Pnry
Aft) Shared system Wes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known/ and source of information: iuS T ALL&I% 1967+ 15 6g
?11yC--A/G5
Sewage odors detected when arriving at the site (yes or no)NO
ta.vs..d 04/25/97) Pope 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:76 MAi'I AN ST. Notn4A ix pro Al,MASS
Owner: 4&O,2Cr✓ nn -f SuSA✓M, F,eAGEQ
Date of Inspection: /7 Stn.y 97
SOIL ABSORPTION SYSTEM (SAS) ✓
llocate on sue plan, if possible: excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits, number:_
leaching chambers. number:n
leaching galleries, number:_
leaching trenches, n mber,length:
leaching fields, number, dimensions.
overflow cesspool, number.
Alternative system
Name of Technology.
Comments
mote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation. etc.)
NON UPRq up.c i4,[y XE n2PNOr2c Le4cM<ri&_CHMnSE.g v (m L,a..:N ✓JG or art, ,a
L4uU C-Ra Ss
CESSPOOLS: N/4
(locate on site plan]
Number and configuration
Depth-top of liquid to inlet mien.
Depth of solids layer.
Depth of scum layer.
Dimensions of cesspool.
Materials of construction.
Indication of groundwater.
inflow (cesspool must be pumped as pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation. etc.)
PRIVY: N A
(locate on site plan)
Materials of construction Dimensions.
Depth of solids.
Comments.
■note condition of sod, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
I rwv.d Q4/]5/9'} Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address3L76 MAYIfiv 5T, /t1O7 ,4MP o,o Mkts,
Owner: A4/0C6pi p t 5✓5aN M. F24GEe
Dale of Inspection'. f7J uuy yl
TIGHT OR HOLDING TANK: N/A Rank must be pumped prior to, or at time, of inspection)
(locale on site plan)
Depth below grade
of construction- concrete _metal _Fiberglass _Polyethylene _otherlexplain)
Dimensions.
Capacity gallons
Design flow gallons/das
Alarm level Alarm in working order _ Yes, _ No
Date of previous pumping
Comments
(rand mon of inlet tee condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_EadE
)locate on site plan.
Depth of liquid level above outlet invert
Comments
mote if level and distribution is equal, evidence of solids carryover, evidence of leakage Into or out of box, etc.)
PUMP CHAMBER."
(locate on site platy
Pumps in working order
in working order
Comments.
(note condition of pump
Wes or Nol_
(Yes or Nol_
chamber, condition of pumps and appurtenances etc.)
Ir.va..d 04/15/07) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address:Ft no MA2,Aru ST. NO2THAM Prore,MACS
Owner: 4nr DreCeell,r.-F Sys4 ,M.
Date of Inspection: /7 TuLY 57 ,r2AGE+2
Depth to Groundwater t, Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site IAbuning property, observation hole, basement sump etc./
✓ Determine it from local conditions
Check with local Board of health
Check FEMA maps
_/Check pumping records
✓ Check local excavators. installers
Use USCS Data
Describe in your own words now you established the High Groundwater Elevation. (Must be completed,
w � �,..P, S a �Dc ,aL�a m G v� 2 w_
?Tate' 93- 6 , 4
us.•d 04/25/97,
Page. 10 oe 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propero, Address:1 7b MAR(P w S-11. /✓a(LI NAM PTOa1 MAST
Owner: 4ND FL 1✓ M + $uSAN M, GRAGG.e
Date of Inspeclon: ) 7 Sot Y 57
SKETCH Of SEWAGE DISPOSAL SYSTEM:
include ties t0 at least two permanent references landmarks or benchmarks
locale all wells within 100' (Locate where public water supply comes into house)
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(reviand 04/25/971
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ARGEO PAUL CELLUCCI
Governor
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON \L1 02108 1617) 29255(0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
AUG 271999
TRJDY COKE
Secr.
DAVI�B STRUHS
Co.Truss: ner
Property Address: 7G47.4e/4N ST, Nog'TN/ln+O','"I• Su55RNry�
Name of OwrKr3u54m $9dAlc {-,2 rc/14i.2D j{A.BMOiv
Address of Owner: 74 "se/4/9 ST. (1/a 2TN4m AT ,i, /yq p/OtO
Date of Inspection: 3 ALI
Name of Inspector: (Please Prirttl G)I Nrkm C U[?T/5
I am a DEP approved system inspector pursuant to Section 15.340 of Tale 51310 CMR 19.0001
Company Name: $ILL ( s)121-l3
Meiling Address: /5 4,4/4f EcL /H4STc CR eLT MA 0(0f2
Telephone Number: (v/3/ ‘0-91.b-g29:3
CERTIFICATION STATEMENT
certify that I have personally inspected the sewage disposal system al this address and that the information reported below s true. a 2Cur a te
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper fdnction and
maintenance of on-site sewage disposal systems. The system:
✓ Passes
_ Conditionally Passes .
_ Needs Further Evaluation By the Local Approving Authority
Fails
inspectors Signature: _ Date: I
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEPlwithin thirty (301 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 me
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98
•
Pose I or ii
0 pr it=cr Recycled Pape
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'ropeety Address: 76, ,%il'le/ot/ ST NO,ermAMpr0/tk
Owner: 5•,rtKAN 048R'E -F ,erc. 4.eD NA,MON
Dale of Inspection: 874 G.5y
INSPECTION SUMMARY: Check 0 B, C, Of D:
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 1 5.303 exist. An fa•u,e
criteria not evaluated are indicated below,
COMMENTS:
SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the •Conditional Pass" eed to be replaced or repaired. Toe system, upon
completion of the replacement or repair, as approved by the Board of Health,section
will pass. •
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate el
Compliance lanachedl indicating that the tank was installed within twenty (201 years prior to the date of the inspeouce or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration. or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health. .
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obsvjctee pipels)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Basic of
Health).
broken pipelsl are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipei
inspection if/with approval of the Board of Health):
broken pipelsl are replaced
obstruction is removed
revised 9/2/98
Page 2 er I I
The system wi. cats
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7(o MAK(AN ST, No ArF/MHOraN
Owner: 54SSAN BA 84 r6 + 2rcH4KO NARA10N
Date of Inspection: 3 A,G• 19
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
IVO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety end the environment.
11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 Itpbl THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT'.
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH AND PUBLIC WATER SUPPLIER, IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: kilt ys
The system has a septic tank and soil absor Ption system (SAS)and the SAS is within 100 feet of a surface wa:e' supply o'
tributary to a surface ware' supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply w
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private watts supply we..
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more 'roc, a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal :o or less
than 5 ppm. Method used to determine distance (approximation not valid).
31 OTHER
revises 9/2/98
Pape 3crII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION /continued)
Property Address: 76 MAKI(1 N ST, NoterNAMpTON
Owner: SSA-Iv 04137AIC ICAAte eta RMOet/
Date of Inspection: 3 A✓G, 1 4
D. SYSTEM FAILS:
You must indicate either "Yes" or No to each of the following:
_ I have determined that one or mole of the following failure conditions exist as described in 310 CMR 15.303. The basis Icr tn�s
determination is identified below. The Board of Health should be contacted to determine whet will be necessary to correct the to lore
Yes No
_✓ Backup of sewage into facility or system component due'to an overloaded or clogged Sr Sim cesspool.
Discharge or ponding of effluent to the surface of the ground or surface)raters due to on overloaded or clogged SAS o
cesspool.
.Z" Static liquid level in the distribution box above outlet invert due to en ovv-oaded.or clogg d SAS or cesspool.
Liquid depth in cesspool is less than 6" below Invert or available volume 4 less than 1/2 day flow.
_✓' Required.pumping more than 4 times in the last year NOT due to clapper :• obstructed pipets).
Number of times pumped •
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater el evat:on.
I/ Any portion of a.cesspool or privy-is within 100 feet of a surface water supply or Winners,to a surlace water supo y
— —
F_ Any portion of a cesspool or privy is within a Zone I ofp public well.
f•V Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_� Any portion of a cesspool or privy is less than 100 feet but greater thar 10 feet from a private water supply well wit
acceptable water quality'analysis. II the well has been analyzed to be iPaptable, attach copy of well water analyse
colilorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes' or "No" oo systems the following:
to the criteria above',
n
The following criteria apply large Y sof in
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) end the system is a significant threat to cjo r.
health and safety and the environment because one or more of the following corflitions exist:
Yes No
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 watensupply
the system Is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA •or a mapped Zone
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 110 CMR 15.30412 . Please consult the local regional
office of the Department for further Information.
revised 9/2/98
Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
hopeny Address: 76 MR21AN ST, NogrRAMp- 25N
Dwner: SuSSAN VASahE 4 R tckareP NA2MON
Date of Inspection: 3Ave, 95
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 Rest 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 cf the
inspection.
�✓/� As built plans have been obtained and examined. Note if they are not available with NIA.
ri _ The facility or dwelling was inspected for signs of sewage backup.
_ The system does not receive non sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All 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 concltion of baNl es
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.0.H.
_ Determined in the field Id any of the failure criteria related to Part C is at issue,approximation of distance is a ceptab:e':
[15.30213/lb)) nac
P/C _ The facility owner and occupants, if different from owner) were provided with information on the propel maintanaocaa'
Subsurface Disposal Systems.
revised 9/2/98
Pegs 5 or II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION
ooperty Address'. 76 MA el Ad ST Noe'rh AM Prom
Owner: SL5AN acceA,i6 i RIGNaes% /-IAKMOtI
Date of Inspecdo : 3 A u 6 99
FLOW CONDITIONS
RESIDENTIAL.
Design flow'. 3 So gp.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual):_a
Total DESIGN flow
Number of current residents;
Garbage grinder (yes or nod_ e5
Laundry (separate system) )yes or no):6; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use )yes or af:NO
Water meter readings.o
if available (last Iwo year's usage (god): 17C2 /JDrrll GS
Sump Pump (yes or no):__Y_E$
Last date of occupancy: C V F{QENTLY
COMMERCIALANDUSTRIAL: /1%/A
Type of establishment'
Design flow' t qpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: )yes m no)_
Non-sanitary waste discharged to the Title 5 system'. (yes or not_
Water meter readings,if available:
Last date of occupancy:
OTHER:IDescribel
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: YES
Po Aka ED TUNE C(S — T u LY /7 — A u&
�/ Q�y
System pumped as part of inspection'. (yes or no) /63
If yes, volume pumped'. / r16 gallons
Reason for pumping'. TPANSF6z of ?PrPeerY
TYPE 9F SYSTEM
t/ Septic tank/dst«kwiewtowlsoil absorption system LEACH/6A G TAN I<
Single cesspool
Overflow cesspool
Privy
A/D Shared system (yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to dale operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components. date installed(if known) and source of information: lflf SY4 BLED x761 "s YES
Sewage odors detected when arriving at the site: (yes or no)OLD
revised 9/2/98
Pepe 6 or II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(confined)
toperty Address: 7(,/),AK/RN ST. NORTH AMPTo4
Owner: 5 55 AA) �j3�'g E } '�t«AMJ ,HAQMOn)
Date of Inspection; 3 Au
SOIL ABSORPTION SYSTEM(SAS): V'
(locate on site plan, ❑ possible; excavation not required, location may be approximated by non intrusive methods)
If not located,explain.
Type
leaching pits, number'.
leaching chamber:, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number. dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
note conditiomof soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
•/p Nyp?AuLIG FA IL i& og po N D(aL&: Lc`ACN RLG CHAgv6FK fs /N r4&r :•-Aw/d
VC- FE Thr al 15 LAw RA55
CESSPOOLS:_AI�A
(locate on site plan)
Number and configuration: '
Depth-top of liquid to inlet invert:
Depth of solids layer:
teeth of scum layer.
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
{note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: Al/o4
(locate on site plan;
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil. signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/99
Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
rroperty Address: 76 MA kJ AN ST, NOETHAMGT d
Owner: Sv55RN gig eAr6 f 21LHR 2D H# RMON
Date of Inspection: 3 A u 6_97
TIGHT OR HOLDING TANK:/4 (Tank must be pumped prior to. or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete metal_Fiberglass_Polyethylene _otherlex plain)
Dimensions
Capacity'. gallons
Design Pow'. gallons/day
Alarm present
Alarm level. Alarm in working order:Yes_ No
Date of previous pumping'.
Comments.
(condition of inlet tee, cond%ion of alarm and float switches. etc.)
DISTRIBUTION BOX: NON6
(locate on site plenl
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. etc.)
PUMP CHAMBER: N/,Q
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)_
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98
Papc 8 of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
`roperty Address. Ea 47AKI AN ST, NORTHAMPL"oni
)wren. Su$SAN 9RBA12 +Rich A-D A/ARmoN
Date of Inspection: 3/}u
BUILDING SEWER:
(Locate on site planl
Depth below grade: 40PRcs_ 3'
Material of construction: ✓cast iron 40 PVC_ other (explain)
Distance from private water supply well or suction line C IT(
Diameter
Comments: (condition of joints, venting, evidence of leakage,etc.)
No Ft DFNGE of LEA K(16-'
WA-rEQ P K554,e Cr va
SEPTIC TANK:_/
(locate an site plant
Depth below grade..- /MS 4 ConrC2frE f.156T+co✓ee Lb FAG'/ ON CLEFNO ur
Material of construction p/ connote_metal_Fiberglass _Polyethylene_otherlexplainl
If tank is metal, list age_ 'Is age confirmed by Certificate of Compliance_ IYes1No
Dimensions: /.(0-0.2(L - 68°W - 64"N
Sludge depth: 4" •
Distance from top of sludge to bosom of outlet tee or baffle: 3(/"
Scum thickness: .3"
Distance from top of scum to top of outlet tee or baffle: 'V
Distance from bottom of scum to bottom of outlet tee or baffle: /37,
How dimensions were dete mined: dY ME4S ,Q. r
nts:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural Integ:ib
evidence of leakage, etc.) 'GCCOrd eND Po IN Pr MC YEAKLY (Ns A G.ABAG£ G ei &DEE)
Tan) k NA S ICc CAST r S 7A£GL65 LA) ILEK:'iiooD Gin/DID/on)
GREASE TRAP: It)/A,
(locate on site plan)
Depth below grade:_
Material of construction: concrete _metal Fiberglass Polyethylene_otherlexplain)
Dim nsions.
Scum thickness'._
Distance from top of scum to top of outlet tee or baffle'._
Distance from bottom of scum to bottom of outlet tee or baffle:_
Date of last pumping.
Comments:
I recommendadon for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural int g'cy
evidence of leakage. etc.)
revised 9/2/98
Pvfe 7 of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontnued)
'rope-my Address:%[ M4E/A4)ST NO2Ty46yQT0.✓
Iwner: Su S SAN 7348 Ara -k ZrcNRRp NARMO.J
Date of Inspection: 3 4,,G.cc
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' ILocate where public water supply comes into house)
H
F-
Lay SIZE MPP°.-oo, longX300'
R LG MEASu.QEM14EAJTS A es APP,20Ar MATE
No SCALE
. i sed
2/98
CATC
MA,2 /f{q/ 5 r
Puge 10 of 11
t
N
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued/
,openey Address: 76 MA2IA0 ST, NogTNAMProe0
Owner. 5v SSAa -gg9ArE 'RiGNACD hlAdMON
Date of Inspection: 3 A oc.Sr
NRCS Repon name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM
1/Slope
es/Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater (. Feet
Please indicate ell the methods used to determine Nigh Groundwater Elevation:
Obtained from Design Plans an record
✓ Observed Site (Abutting property. observation hole, basement sump etc./
✓ Determined from focal conditions
Checked with local Board of health
Checked FEMA Maps
✓ Checked pumping records
Checked local excavators. Installers 4 Bur L0xe
Used USGS Data
Describe how you established the High Groundwater Elevation, (Must be completed/
STKL.Rtn
out W 7C rE2Mr Nen 'FY Fkont SMALLT2iekLe RNL
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eeco_ns F.eoM S0n/E 9$ 5fl-W 4 OEp/N' To C 120 L) D uwe/C egg
REL O.2 JS ( vM -5I-NE 97 514ou (a Dap TN 7aG-Rou ND WA3 C2
sed 9/2/98
Page II of 11