72 Title 5 Inspection Report 1999 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (corrtirued)
Property Address: 72 Du F-r/7 # ) A
Owner:A UD $ f�M 4s DIN
Date et Inspection: J 2 kl q i
INSPECTION SUMMARY: Check A, 8, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or s 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.
t11..
Indicate yes, no, o r not determined IY, 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(W)Yeeretwlalie the date of the inspection;or
the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltretion, 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 obstructed pipelsl
or due to a broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board 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 pipels). The system willows -
inspection if(with approval of the Board of Health):
broken pipelsl are replaced
obstruction is removed
revised 9/2/98
Page 2 of 11
ARGEO PAUL CELLUCCI
Governor
fl
MAR 2 5 per
COMMONWEALTH OF MASSACHUSETTS ---- __
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI 'TNA'fPiO hv!_
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON MA 02108 (617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CEATIFlCAT1DN
Property Address:7 . PUUptny ()a;ve Mn of Owner RYA/ s 77/WO 7Hy Coen(..'
Ue+.W,r If'erprs N tong Address of Owner:7a D✓NOHy D4.
Dete of Inspection:
Name of Inspector(Please Print) DEN r., i - I.RCD✓ayE
I am•DEP approved system inspector pursuers to Section 15.340 of'Ode 5(310 CMR 15.000)
Company Name: DENNIS LACOURSE
Maing Address:
Telephone Number
A.QtESIEFFIELD,MMA 01081
TRUDY COXE
Secretary
DAVID B. STRUHS
Commissioner
CERTIFICATION STATEMENT
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:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Is
Inspector's Siwbse: d '*o Date: S .19-11
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEPlwithin 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, it applicable, and the approving authority.
NOTES AND COMMENTS
4413afr 64.1• t2 5- evj> ,3E RE//Qeu,H
revised 9/2/98
Page 1 of 11
int Primed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Iconeuedl
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either"Yes"or No to each of the following:
I have determined that one or more of the following failure conditions exist as described 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.
Yes No
Backup of sewage into facilitpor system component due an overloaded orclogged SAS or cesspool. '
Discharge or ponding of effluent to the surface of the round or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box aboveputlet 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 pumping more than 4 times in tae last year NOT due to clogged or obstructed pipelsl.
Number of times pumped
Any portion of the Soil Absorption ystem.cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or p y is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or vy is within a Zone I of a public well.
Any portion of a cesspoo
CPT privy is within 50 feel of a private water supply well.
Any portion of a cess of or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water qu ay analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
-coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or No 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¥10.000 gpd or greater(Large System(and the system is a significant threat to public
health and safety and the environment because or more of the following conditions exist:
Yes No
the system is within 400 feet o surface drinking water supply
the system is within 200 fee yofa tributary to a surface drinking water supply
the system is located in atrogen sensitive area(Interim Wellhead Protection Area IWPAI or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(21. Please consult the local regional
office of the Department for further information.
revised 9/2/98
Page 4 of It
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTOR FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER 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 failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETER INES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING N A MANNER WHICH WILL PR CT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT_
Cesspool or privy is within 50 feet of surf a water
Cesspool or privy is within 50 feet of a b rdering vegetated wetland or a salt marsh.
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH IAND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
3) OTHER
The system has a septic tank and soil absorption sy{tem(SAS)and the 5A5 is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorptio system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorp n system end the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absor on system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well w er analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facili and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determinydistance (approximation not vatidl.
revised 9/2/98
Page 3 of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
P roperty Address: 7 7 P U.a Pti 1 y.c.
Owner: qr*r it rim &BDy
D ate of Inspection:
S 1N Y4
FLOW CONDmONS
RESIDENTIAL:
Design flow:4 HD g.p.d./bedroom.
Number of bedrooms(design): + Number of bedrooms(actua0:3__
Total DESIGN flow 41,1'
Number of current residents: O
Garbage grinder)yes or nol:yr.3
Laundry(separate system) (yes or no):ND; If yes, separateinspection required
Laundry system inspected ye or no)
seasonal use(yes or no):Np
Water meter readings,if available(last two year's usage(gpd): t, 3 c7 cuAra r%
Sump Pump(yes or no): WO
Last date of occupancy: 7'kYitt
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: mid 1 ased on 15.203)
Basis of design flow
Grease trap present: (yes or n,
Industrial Waste Holding Ta present:(yes or no)_
Non-sanitary waste disch ged to the Title 5 system: (yes or no)_
Water meter readings,i available:
Last date of occupan
OTHER:(Describe/
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes o r no/44t,P
If yes, volume pumped: /y DD gallons
Reason for pumping: -r w se retie.1
TYPE OF SYSTEM
'4 Septic tank/distribution boxlsoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records.if any)
_
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed Of known)and source of information: - - -- -
(�a5
Swage odors detected when arriving at the site: (yes or no)Lil(J
revised 9/2/98
Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Propwty Address: 72 1P P)-'p+s y 12 t.
Owner: 4NN . Tiers ens P•••
Date of Inspection: 1 •2•14•1/
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health.
_ None of the system components haws been pumped4orat Jeast two weeks and-the system hastaanweceivingvanwal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with NIA.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_X. _ The site was inspected for signs of breakout.
]L _ All system components,excluding the Soil Absorption System, have been located on the site.
i[ _ 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 onthe site has been determined based on:
Existing information. For example, Plan at B.O.H.
- _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.3021311bl]
The facility owner land occupants-if different from owner)were provided with information on tise.propatmaintaflapusf
Subsurface Disposal Systems.
revised 9/2/98
Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTOR FORM
PART C
SYSTEM INFORMATION(cenlinoed)
Prsgarty Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:_(Tank must be pumped prior to. or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction:_concrete_me . _Fiberglass Polyethylene_otherlexplain)
Dimensions:
Capacity: gallons
Design flow: gallons
Alarm present
Alarm level: Mar in working order:Yes No_
Date of previous pumpin
Comments:
(condition of inlet te , condition of alarm and float switches,etc)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above 9s(tlet invert:
Comments:
I note if level and disyi6ution is equal, evident*of solids carryover, evidence of leakage into or out of box, etc.) —
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:IY-s or No)
Alarms in working order es or No)
Comments:
(note condition of pu p chamber,condition of pumps and appurtenances, etc.)
revised 9/2/98
Page 8 or II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7; 'DUNph y. Wiz'
Owner: 4 N a Tins (c eyln7
Data of Inspection:
BUILDING SEWER:
(Locate on site Plan)
Depth below grade: It
Material of construction:_cast iron Y-40 PVC_other(explain)
Distance from private water supply well or suction line .zy'
Diameter Y"
Comments:(condition of joints,venting, evidence of leakage,etc.)
PO( yr' Girth'( Li.46 I " evEey*nia, .9ppFnar TO .rt /ti GOO+ (_a. ,V-t &
SEPTIC TANK..
(locate on site plan)
Depth below o ucL
c
Material of construction: concrete_motel_Fiberglass _Polyethylene_o[herlexpleinl
If tank is metal,list age_ Is egesonfumed by Certificate of Compliance_(Yes/No)
Dimensions: (.$X 124 K 43
Sludge depth: S't
Distance from top of sludge to bottom of outlet tee or baffle:30'
Scum thickness: a " r/
Distance from top of scum to top of outlet tee or baffle: 3
Distance from bottom of scum to bottom of outlet tee or baffle: /4
How dimensions were determined: ay Ru)
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.) TA ry k 7• ) Os OOr? Can a. X71,Al L.;u r A LEVEL 'a 'I .R.Fe✓E OU rtpT
jn1V.PiT— Aypewee r0 ,3c fi'ft.'+ d07,01.4 s Pr-E A L.Tl/.c o✓T BP — ie>; Aft a)IFf
40 5.a. c•—Le10eJ
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete etal_Fiberglass _Polyethylene_otherlexplein)
Dimensions:
Scum thickness:
Distance from top of scum to t of outlet tee or baffle:_
Distance from bottom of scu to bottom of outlet tee or baffle:_
Date of last pumping:
Comments:
/recommendation for umping.condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leaka ,etc.)
revised 9/2/98
Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icarrtirued)
Property Adbess: 72 t) uH Phy
Owner: q.vN r ri r„ (pap
r N
Date of IrssPacbon: ,z •ay,erg
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
1�uFJpHy DGIU&
NoT To Scn(
Fe t,C
641 V W41F<
7a Dutupny
n4iu =
U
E
ti
4
w
0
revised 9/2/98
Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):k
(locate on site plan,if possible:excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type
leaching pits, number:1
leeching chambers.number:_
leaching galleries,number:_
leaching trenches,number,length: a 3D
leaching fields, number, dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding. damp soil,condition of vegetation, etc.)
Yfyc Pit W4D
<r V if to oT3'/ Yd it 11-W. tDivi xer.+aftvr %t✓// CH k Ti cL
!F yOrb ,
4r0ev,_ !3 E/Mr ' > / /at n Li✓c b LOA,. l,7 Y.* /> rotrc5 6. ?C/e4/
)3.77.b-n prr”
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. etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:_
Comments:
(note condition of soil.signs of by raulic failure,level of ponding. condition of vegetation, etc.)
revised 9/2/98
Page 9 of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 72 pump!s y Pet
Owner: 9✓✓ ,- Ti m Gott'to
Date of Inspection: 3 • Z9.SY
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Lt Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Vie Observed Site!Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators.installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Ug Yc> f PIT 711`
f.00S&5 t'WEp fr. Y 7p 'JT �sla+i NO
M'EEpf; Bn- ✓%D iNElr"
revised 9/2/98
Page 11 of U