400 Title 5 Application/Permits 1991, Septic Documents SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address cf property Liao Ario rcarni S 7ea.,4 A o 1% ,, 1/41,1 a'/A _
Owner ' s name �l a.��ue.� Lv. c Se_uss R
Date of Inspection 0 lS a
e/ 2q/9S PART A !! l5
CHECKLIST
Check if the following have been done: NOAH—^^ mbNsN eooano a NEg4irr�
./ Pumping information was requested of the owner, occupant, and -of
Health .
IV 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.
✓ As built plans have been obtained and examined. Note if they are not
available with N/A.
1/ The facility cr dwelling was inspected for signs of sewage back-up.
V The site was inspected for signs of breakout.
• . _ system components , excluding the SAS , have been located on the
eite .
✓ 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.
✓ Tne size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods .
✓ The fa 'fam " -y 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
FLOW CONDITIONS
If residential
3 number of bedrooms
number of current residents
n o garbage grinder, yes or no
/for laundry connected to system.., yes or no
no seasonal use, yes or nc
If nonresidential , calculated flow:
water r..eter readings , if available:
present
Last date of occupancy -
GENERAL INFORMATION
Pumping records and source of information:
2 'eaµ
yes System pumped as part of inspection yes or no
if yes , vclune pumped MOO ya/�,,,,,
Reason for pumping:
Fr Tx S petit �-
Type of system
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection
records , if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
hp Sewage odors detected when arriving at the site, yes or no
SUBSURFACE SEWAGE D SYUCAL a CTLA 1P01,L611wn rvnn
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: /000 adn-is
(locate on site plan)
ci
depth below grade: &Z
material of construction: ✓concrete _metal _FRP _other(explain)
dimensions: 85_ 5H air r
ii
3'S sludge depth
2Y" distance from top of sludge to bottom of outlet tee or baffle
! t " scum thickness
5 distance from top cf scum to top of outlet tee or baffle
if distance from bottom 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 fc: repairs, etc. )
DISTRIBUTION !M. yec
(locate on site plain.) 2 ou //tis
d 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 PORN
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
coe P /a„
DEPTH. TO GROUNDWATER
7 '6 "
depth to groundwater
method of determination Or approximation:
bent e /d in e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : t
(locate on site plan, if possible: excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching
leaching
leaching
leaching
leaching
overflow
pits and number
chambers and number
galleries and number
trenches_ , number, length LSD v. / s•t9esr
fields, number, dimensions
cesspool , number
Comments :
(note ccnditicr of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
CESSPOOLS (locate on site plan) :
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth cf scur layer
dir.ensicns of cesspool
materials of construction
indication of groundwater
inflow (cesspool rust be pumped as
part of inspection)
Comments :
(note condition cf soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate cn 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 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)
nn Backup of sewage into facility?
Na Discharge or ponding of effluent to the surface of the ground or
surface waters?
110 Static liquid level in the distribution box above outlet invert?
Liquid depth 'n cesspool <6" below invert or available volume< 1/2 day
flow?
N4
Po Required pumping 4 times or more in the last year?
number of times pumped
!?n Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS , cesspool or privy:
NU below the high groundwater elevation?
no within 50 feet of a surface water?
no within 100 feet of a surface water supply or tributary to a surface
water supply?
1 ?
no within a Zone I of a public well?
ha within 50 feet of a bordering vegetated
edS)etland or salt marsh
(cesspools and privies only D3I the
110 within 50 feet of a private water supply well?
ILL_ 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
for coliforr bacteria , volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
SUBSURFACE BENAGE DISPOSAL SYSTEM INSPECTION FORM
FART D
CERTIFICATION
Name of Inspector
Fred ri /i O s
Company Name r;/, s En fe `? i's t s n
Company Address
‘ 9 � 7 am /7d. 4r„ hers7 /t/A. 61002
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 .
Check one:
V 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...
Inspector ' s
Date /dc '
Original to
Copies to:
Signature 71
A/2 tips-
system owner
0oa fret 0 //lea t
Buyer ( if applicable)
Approving authority
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•< 'No. 37—cy./
THE COMMONWEALTH OF MASSACHUSETTS
Fa ._Sd....
BOARD F �HEALTH
A
CL • 7 OF /oR A I ptO'J
Appliratinn fur 3ispnsal Marko granuitrurtion tirrmit
Application is hereby made for a Permit to Construct ( ) or Repair X.) an Indic idual Sewage Disposal
System at: 4co AiOR �,p �p-
IN
�bO AUCtrf` e-4n4le0
0A) toear re6e.r
y.�
Own r ` Address
W 1ST✓ R \ L1 Rtw< .�%e!1✓�17i vy ftl✓eR �r ynpley [1A.<
t-1 Installer
Address •dC 3 e4
d• Type of Building h Size Lot. '� Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
(3.ai Other—Type of Building
Other fi res
J7^
W Design Flow S �..$. allons per son per day. Total daily flow_.-, ?O..,YL1S3.-Yl gallons.
W Septic 'bank—Liquid capaajjyy_.{o._`?�altosTy en Ed. Width Diameter Dc
• Disposal Trench—No
• Seepage Pit No Diameter
z Other Distribution box 00 Dosing tankCie O e��(q(j�
Percolation Test Results Performed by ��,%
Test Pit No. 1 Depth of Test Pit 41
dth Total Length i‘...16 Total leaching area
Depth below inlet [Total leaching area._
Q e s Date...0 /
Depth to ground water.____
Test Pit No. ° minutes per inch Depth of Test Pit Depth to ground water
0
U
U
U
a. minutes per inch
s .fr ®TT-
Description of Soil
sYerist iaAAti...a_ ✓Etc- rte C'0.%xI 3
.?.KE. JR. RS
IGISTFATION
#201
y
Nature of Repairs or Alterations—Avswer when applicable-.- {,/;.-,t,,, /�,/tt F k ,7y,�
AA" NA. c.l Ci�Lt ' `J
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by e boar. +f Ih- lth. - C/
�!e
Application Approved By
Application Disapproved for the following reasons'
Permit No
Date
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALfiH
OF
Olrrtifirufr of Otumplitt
THIS I. ERTI�FY, amt theIndiividduu+ Sewage Dispo _System constructed ( ) or Repaired (x)
by at
has been installed in accordance with the provisions of TITLE ,,gyyof The State Sanitary Code a des ibed in the
application for Disposal Works Construction Permit No ' 5 V dated 9/i7/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTE AT THE
SYSTEM WILL FpTIIO�N SATIS/FAC{TORY.
DATE //1
No
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
if
Einpostt1,I flirter
ranted
Permission is hereby g
to Construct ) or Repair ( aodividual Sewar D
at No F� nj ...i
as shown on the application for Disposal Works Construction
DATE
FORM 1255 HOBBS & WARREN. INCPUBLISHERS
'sposal System
Street __
Permit Nojr Ijated._E a
@care of Health