1156 Septic Inspection 1998 a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B( SYSTEM CONDITIONALLY PASSES (continue°,
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstn
pipets; or due to a broken, settled or uneven distr.button box. The system will pass Inspection if(with approval
Board of Health). Describe observations:
broken pipets: 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 pipes). The system will
inspection if(with aooroval of the Board of Health):
broken pipes) are replaced
obstruction is removed
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 p
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MA
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 fee: of a bordering vegetated wetfand or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMIN
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 system (SAS) and the 5A5 is within 100 feet to a surface water s
tributary to a surface water supo!y.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply
The system has a septic tank and soil absorption system and the SAS is within 30 feet of a private water supply
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more frc
private water supply well unless a well water analysis for coliform bacteria and volatile organic compounds indi
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is ec
less than 5 ppm. Method used to determine distance (approximation not valid).
(r.va..a 04/2s/27) Page 2 of 10
WILLIAM F.WELD
Governor
ARGEO PAUL CELLU'CCI
Lt.Governor
COMMONWEALTH OF MASSACHUSETTS
EXECI3RVE OFFICE OF ENVIRONMENTAL AFFAIR
DEPARTMENT OF ENVIRONMENTAL PROTECT ON:
ONE WINTER STREET. BOSTON. MA 02108 BIT-292-5500
OCT 2 61998
')OPTHAMPTON et)::.(:oe«.r
TRUDY COAL
Seven.
DAVID B.STRL'NS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissiova
PART A
'1` CERTIFICATION
Property Address: 1(5 �}�laaM.� Address of Owner:
Date of Inspection: /0 - 2 l `%� (If different)
Name of Inspector: 0.N.(n.lS I am a DLR+m[pwdsxsieRiOg t-tnr pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: r.v.Mailing Address: .
Telephone Numbe Ut
CERTIFICATION STATEMENT
I certifr 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:
4 Passes
C. itlonally Passes
— s Further E4 % the Local Approving Authority
Inspector's Signature/i✓ ir./V`•✓ Date: /B•32"f4
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 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 A, B, C, or D:
AI SYSTEM PASSES:
L/' ' 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 indiated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
_ 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 (20) years prior to the date of the inspection; 0
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or IanF
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.
trevaaed 04/15/971 Page 1 of 10
DEP on the ma%Mini/Yeti cop magnetitate ma uLEep
OP Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: It j(r [✓E'1H4-.pyaa,
Owner: *9,1.0.41 .07 W.tp.T•••
Date of Inspection:
le•xo-.91
It/
Check if the following have been done: You must indicate either "Yes-or "No' as to each of the following:
Yes No
Pumping iniormation was provided by the owner, occupant, or Board of Health.
- None of the system components have been pumped for a least two weeks and the system has been receiving m
Flow rates r.y Q during that period. Large volumes of water have not been introduced into the
as part of this inspection. system rec
1( _ As built plans have been obtained and examined. Note if they are not available with N/A.
][ _ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
— The site was insoeced for signs of breakout
•
X- — 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 conditio
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: -
--X_ — The facility owner and occupants, if different from owner) were provided with information on the proper mainter
Sub-Surface Disposal System.
i _ Existing information. Ex. Plan at B.O.H.
l e.viud 04/25/97)
Determined in the field (if any of the faiiure criteria related to Part C is at issue, approximation of distance is
unacceptable) 115.302;3)1bl]
Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
perty Address:
men
of Inspection:
SYSTEM FAILS:
a must indicate er..er "Yes" or"No- as to each of the following:
I have determined that the system violates one or more of the following faiiure criteria as defined 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.
es No
Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool.
nd or surface waters due to an overloaded or dogged SAS or
_ Discharge or ponding of effluent to the surface of the
cesspool.
Static liquid level in the distribution bo
Liquid depth in cesspool is less than
_ Required pumoing more than 4
Number of times pumped
outlet invert due to an overloaded or clogged SAS or cesspool.
elow invert or available volume Is less than 1/2 day flow.
n the last year NOT due to clogged or obstructed pipe's).
_ Any portion of the Soil •sorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a ce pool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of cesspool or pries is within a Zone I of a public well.
_ my porter of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or pow is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. ;f the well has been analyzed to be acceptable, attach copy of well water analysis for
conform bacteria. volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
LARGE SYSTEM FAILS:
'ou must indicate ether "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 Sys
public health and safety and the environment because one or more of the hallo-
Yes No
the system is within 400 feet of a surface drinking w er supply
I and the system is a significant threat to
g conditions exist:
the system is within 200 feet of a tributary to surface drinking water supply
the system is located in a nitrogen sens e 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 b-ng the system and facilitsanto full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Ple--e consult the local regional office of the Department for further information.
(r.vlxed 04/25/97)
Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: l SL Wen$.rc/7sAr Rp
Owner; pOt Cl'. Uri war"
Date of Inspection: it Ica•xj
BUILDING SEWER;
(Locate on site plan)
II
Depth below grade:,{_
material of construction: _ cast Iron 40 PVC_other(explain)
Distance fro mprivate water supply well or suction line ag
Diameter
Comments: (condition of johns, venting, evidence of leakage, etc.)
ND LERtl i1 ,A r+9 Gras 9j re.r99:7�ta9
SEPTIC TANK:k
locate on site plan)
At
Depth below grade: ID
.Material of construction: itoncrete metal Fiberglass _Polyethylene _othertexplain)
If rank is metal, list age _ Is age confirmed by Certificate of Compliance _Nes/No)
Dimensions. l5 oe 6sOoe9>
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle. St?
Scum thickness. J^
Gu;ance from top of scum to top of outlet tee or badla. Co
Distance from bottom of scum to boron of outlet tee or baffle: /L'�
Mow dimensions were determined: fly Coltfl 7 r• C Et
S e+a pt e.T/ea)
Comments.
(recommendation for pumping, condluon of inlet,and outlet tees or baflles, depth of liquid level in relation to outlet invert, RruCur I
ntegrity, evidence of leakage. etc.) 7gy,f//„ Gait's) PaarY >eter A.v • 7e* w . 11.9 • r/C a- a.k-.
4—r �r2 LEYtL enn gums autitch;g4 Liub
CREASE TRAP:_
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal _Fi. rglass _Polyethylene _ather(exprain)
Dimensions:
Scum thickness:
Distance from top of scum to top of o t tee or baffle:_
Distance from bottom of scum to •• om of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for p Ping, condition of inlet and cutlet tees or bafflesh of liquid level in relation to outlet invert, structural
integrity, evidence o' eakage, etc.)
r.vta.a 09/25/97)
Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 145+4 EVtrrct4nylpA' g.O
Owner: Pls.Ws1//9>zj
Date of Inspection:
TIGHT OR HOLDING TANK:_flank must be pumped prior to. or at time, of inspection)
(locate an site plan)
Depth below grade:
Material of construction: _concrete _metal _Fibe : -ss _Polyethylene other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Ali= level: Alarm in w- ing order _Yes; No
Date of previous pumping.
Comments:
(condition of inlet tee. condi on of aiert, and 5c es, etc)
DISTRIBUTION BOX::
;locate on sire plan)
Depth of liquid level above outlet invert:
D
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box. etc.)
/{pt AhtV LEVEL Mo > SGVUD A7o •al,Y) e44eyete
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes or el_
Alarms in working order(Ye r No)_
Comments:
(note condition of pup 'chamber, condition of pumps and appurtenances etc.)
m...�..a of/]e/an
Page 5 o se
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: di 5/pp hJCri'ft-fq.qrFert
Owner: y74 MyNlr s m->
Date or Inspection: lb (ya
FLOW CONDITIONS
RESIDENTIAL:
Design flow, to 1,0 g p.d/bedroom for S.A.S.
Number of bedrooms.
Number of current residents: A.
Garbage grinder (■es or no): MO
Laundry connected to system (yes or nob yes-
Seasonal use (yes or no): A/0
Water meter readings, if available (last two (2) year usage (gpd): 0 5 g S OO
Sump Pump (yes or no): }tt
Last date of occupancy:
COMMERCIAUIND USTRIAL:
Type or estaollshmenr
Design flow: gallons/day
Grease [ram present: (yes or no)
Industrial waste Holding Tan present: (yes or no)_
Non-sanitary waste disch. :ed to the Tale 5 system: (yes or no)_
Water meter readings. 'available:
last Cate at OCC' .ant1
OTHER: ; escribei
,as: date Cf oc_canc:-
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumpea as part of inspection. (yes or no)41y
If yes, volume pumped: IS Do gallons
Reason for pumping: So/se eat,a 41
TYPE OF SYSTEM
X 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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed Of known) and source of information:
Sewage odors detected when arriving at the site (yes or no1r00
(r.vind 04/25/97(
Pagel Of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: I t b Le We Tfff-S.tptasf
Owner: {Oa Wr[h94/,)
Date of Inspection: )p• P- ice
SOIL ABSORPTION SYSTEM (5A5):1.
(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 pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number,length: (i ^ 90
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
MVP hist. Or- 14 y/24.402 aloe IQ-
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert
Depth of solids laves
Depth of scum laver:
Dimensions of cesspool:
Materials of construction
Indication of groundwa
inflow (ces .ool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(loate on site plan)
Materials of construction. Dimensions:
Depth of solids:
Comments:
(note conditio of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(r.vi..d 04/25/97) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (cc ntinued)
Property Address:../1 51, Lv >TfM✓1^ u
Owner: plc Aid f f:e ej T ) 44"
Date of Inspection:
her.)-1 '11
Depth to Groundwater j_ Feet
Please indicate all the methods used to determine High Groundwater Elevation:
yObtained from Design Plans on record
)( Observation of Sire(Abutting property, observation. hole, basement sump tic.)
%2L. Determine it from local conditions
)( Check with local Board of health
Check F€MA Maps
Check pumping records
Check local excavators. installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevatior. (.NUSt be completed)
TH-f 5 is nohow > 5y sue-'
41711E pit}- 54u.2r - gE
624,ctA /_ :
Get CE 6dts SL 4 A o-M .a
(revised 04/26/57)
Paee 10 of 10
ff N V ( y
per ',V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (con inued)
Property Address: t 1710 10t-STKq.•Sj -c Ali
Owner: m Id4 iwoo•
Date of Inspection:
)6'37.•R5
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)
L
C o-p-vmp eo Qo
(revised 04/25/571
•
Psi* 5 of 30