363 Septic Inspection 1999:GEO PAUL CELLUCCI
✓ernor
AUG 18 1999
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS,r ,;,p orFI
DEPARTMENT OF ENVIRONMENTAL PROTECTION-- —
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500
mQIon1 !
Ro0�vT
Cles �
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SUBSURFACE SEWAGE DISPOSAL SYSTEM MSPECIWN FORM
PART A
CHI7IFICATN)N
3fe3 wes-fhp,rnp-Itn fic,
wry Address: No h-F■ aynp-Ln, rn
i of Inspection: `I 130 199
e of Inspector.(Please Prim) Rob e.t - we Sirov Qt'
I WI•DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15 000)
pony Name: R .5 City; En it In
G Ist raSsiere
Name of Owner Lo15 LL.aie
Address of Owner: 69.1 e
Vero beach pi
' 0
prone Number: f3 (0 -3 -100
TRUDY COXE
Secretary
DAVID B.STRUHS
Commissioner
3z9Go
IIFICATION STATEMENT
tify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
itenance of on-site sewage disposal systems. The system:
/Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
actor's Signature:
Rma," w. 2- r ^-
Date:
-7130 19
System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEPlwhhin thirty/30)days of
eleting this inspection. If the system is a shared system or has a design flow of 10.000 god or greater,the Inspector and the system owner
submit the report to the appropriate regional office of the Department oPEnvbonmental Protection. The original should be sent to the
on owner and copies sent to the buyer,if applicable,and the approving authority.
ES AND COMMENTS JJ ((;; (+ 1
WAS1r•11 inneJt. t w0 4-e 4r4i, J � ce ■ cr' floor- Jk4 ,l ? ro Lo ()I
c_ was Pte,,,,prV 1t' ou-t-slho sov-f ookle . As 0. pa.--I- o-f -fs
15.pcci-iar-1 w (IsLin' vin-ac.k'nc Was PI"AII ec& lyre h,ilie i, Sewef-
,06.4.‘ar1 Sy5-4GV+�1 ,
Se.e,rany `i-o 64, n ¢4 O4- SnnaXX cfi j u_s 1L
Gov e. { lax
11-c;)y`8 wa$i . -t-d 4 e
rised 9/2/98
Page I of 11
154 Primed an Repdae Pape
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
1lCAT10N(continued)
-3Co3 Wes�!lavnp-I-on / n
Address: I'o"#i aIM t$H
Inspection: 7/3o/R9
r10N SUMMARY: Check A B. C, or D:
STEM 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.
NTS: 5 C2 ea 4$-
STEM CONDmONALLY 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.
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;or
the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfihration, 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 pipes)
or due to a broken, settled or uneven distribution box. The system will pass inspection it(w;th approval of the Board of
Health).
broken pipes)are replaced
obstruction is removed
_ distribution box is levelled or replaced
The system required pumping-more than fourtimes a yeardue to broken or obstructed pipets). The intern will-pass-
inspection if(with approval of the Board of Health):
broken pipets)are replaced
obstruction is removed
ised 9/2/98
Page 2 of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART A
3(p3 IweSJ-�.1s�n.v..x'oiosl /?ef,�TNTCA,WN Iwn*aatdl
seems: No hy' cA..n Y�N
Gi,10 S e
°°°`eon. 7I 30 199
THEE 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.
SYSTEM NS 310 OAR 15.30311104 THAT THE
SYSTEM
IS NOT FUNCT N G NA MANNER WHICHILL PROTECT THE PUMJC HEALTH AND SAFETY AND THE ENVIRONMENT:
fJ_D Cesspool or privy is within 50 feettf surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING N A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - -
no
no
OTHER
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of 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 I 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)
iced 9/2/98
Page 3 of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
3(93 we-5+4L /"
Was: No r-4-t,AA ,,.p4-D
L1,0-6G
specto" 713o !aa
MIA FAILS:
inScete 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.
NY Backup eleewage intolacility'orvfafam-eemponentdoee a en overloaded orcMggedSA SOrceaspoal. - -i'"a'�'.k-
Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool. excc)o{ A , : /,‘..... o - WaSti.rHS NIA, k net- wa,A.,
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
A 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 the last year NOT due to clogged or obstructed(Ppels).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
PA Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
litAny portion of a cesspool or privy is-within a Zone I of a public well. - '-
fr!! Any portion of a cesspool or privy is within 50 feet of a private water supply well.
-. I h 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 for
»coliform bacteria,volatile organic compounds.ammonia nitrogen and nitrate nitrogen.
IGE SYSTEM FAILS:
st indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The nd safety and the environment design
because one 10.000
the followingrcondtions exist:and the system is a significant threat to public
No
the system is within 900 feet of a surface drinking water supply
the system-is-within-200 feetof-w-twMwar 4e.aurfaoe4k4nki g'vter4Oplly-'- --
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)
rner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional
d the Department for further information.
ised 9/2/98
Page a or II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CIAECKLIST
3CD3 �r (es� 11�.11vnp 19,4,
tdhass: N o
: GaLase
he 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 systemsompoaents haaabeen pompee Meratlaast two-weeks atariubetystent two-weeks h+abee sceiSs8l 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 obtaiped and examined. Note iij they are not available with N/A.
3oH -Al Its UN.G!<cz{
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 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:-
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 unacceptablel
(15.3021311b)1
_ The facility owner land orrupznt<.if different from.owperLwaraprotdded.with infarznatioo:on tba.prnper-mantenaase f
SubSurface Disposal Systems.
.sed 9/2/98
Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM MPG-CTION FORM
PART C
YSTEM INFORMATION
y Address: AA t^ 1`yy s✓"f. N �
Inspection:
Grosso
713'/x9
FLOW CONDITIONS
NTWL:
flaw: HO g.p.d./bedroom. I
r of bedrooms(design): Number of bedrooms(actuall:1
ESIGN flow //CD
r of current residents:
e grinder(yes or no): no
Y(separate system) (yes or no):,j If yes,separateinspection.requbad - -
y system inspected (yes or no)
Pal use(yes or no):/10 '� �, � 5p� uVG .
meter readings,if available(last two year's usage(gpd):
Pump(yes or no): (h II I
rte of occupancy: r rC5@nTly b4d flea(
iCRCNLINDUSTRIAL: Y
I �TI
,f establishment: 1'� it
flow: mad (B sad on 15.203)
d design flow
trap present:(yes or no)_
rial Waste Holding Tank present:(yes or no)_
Initary waste discharged to the Title 5 system: (yes or no)_
meter readings,if available:
ate of occupancy:
is(Describe)
ate of occupancy:
GENERAL INFORMATION
ING RECORDS and source of information: I I(e bq.jpr e art '� �c�n - cv t'.
?It rnCr4 Jreirr ,r rr .trDi.
System pumped as fartlIou�nspection:(yes or no) - C e o wr f.r�' +nfr P, `o J° '�'1"4-c- b y
If yes,volume pumped:'T"O"ROgallons rcrrFin r�-
Reason for pumping: inspecir d.on and e P C r8 D..(- 6CC U r ,
yr)G0 1-er1G✓nce-
pF 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)
_ I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
iOXIMATE AGE of all components. date in:tagedliffkpow/r)bnpl rce°fei arms/on:3
'D- '/D 4P_ar5 -Far -Fan i a h rid CC(( i.1
lie odors detected when arriving at the site:(yes or no)no
uised 9/2/98
Page 6 of II
c,ert ri
alcl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYS INFORMATION(continued)
3(03 W es p 4-.
Address:
ckaAA-
13° 14‘-1 4
G SEWER: 41 - i ct Fc±
m site plan)
dow grade: 17.. +0 I+LY€yt
of construction'v/Cast iron 40 PVC_other(explain)
from private water supply well or suction line rob I ic.
r
4r,
Rs (condtion of joints,venting,evidence ofloakaedatc)
'4lnin of t Vlo RV t��t_.v�r f
wo Ka
TANK:
m site plan)
�OA.
slow grade:
of construe ' n: Vconcrete_metal_Fiberglass _Polyethylene_otherlexplainl
s[petal.list age IA Js.age confvmed by Certificate of Compliance_(Yes/No)
i
ions: inside , 5 'x 3� x y(o"( Li° ))t t: 'kP'''"_
depth: _-Li" 2 i /Li-
e from top of sludge to bottom of outlet tee or baffle: 7i
sickness: 2-3 s' Il(4 �-t
a from top of scum to top of outlet tee or baffle: 5 q y
e from bottom of scum to bottom of outlqt tee or baffle: I
pensions were determined: akOWTiy
nts:
nendation for pumping. condition of inlet and outlet tees or.baffles,depth of liquid level in relation to outlet invert,structural integn
e of eakage,etaj
driC
� � Rri�r?rr w r"talk
/1Aitn9r
E TRAP:
on site pla I
9n:
fn 3wtstO 5.�o
e
No fetkav_
'slow grade:
d of construction:_concrete_metal_fiberglass _Polyethylene other(explain)
ire
dons:
Ivckness:_
:e from top of scum to top of outlet tee or baffle:
:e from bottom of scum to bottom of outlet tee or baffle:_
f last pumping:
ants: integrity,
emendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural into
ce of leakage.etc.)
ised 9/2/98
Page 7 of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM. RIFORMATION(continued)
21O t we (,
"drew p
npection: G4104-C.
713o/gq
R HOLDNG TANK:FOCI(Tank must be pumped prior to.or at time of,inspection)
1 site plan)
low grade:
of construction:_concrete_metal_Rberglass_Polyethylene_otherlexplain)
Ins:
gallons
ow: gallons/day
e sent
vel: Alarm in working order:Yes_ No_
srevious pumping:
its:
n of inlet tee,condition of alarm and float switches,etc.)
'luncH BOX✓
sn site plan)
OI!
f liquid level above outlet invert:
nts:
level and distri ution is equ. e inairmUr
✓ I y Vi90 u '
enee pf solids carryover,evidence of le
:HAWSER: Nig
on site plan)
in working order:)Yes or No)_
in working order(Yes or No)
ints:
ondition of pump chamber,condition of pumps and appurtenances,etc.)
into or out of
etc
hJa -%GKo✓a
ised 9/2/98
Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM 7FORMATION/continued)
address: of O r / ys-L
tspeeben: '7/3 197
IORPTION SYSTEM(SAS):_
site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
ated,explain:
leeching pits,number:_
leaching chambers.number:_
leaching galleries,number:_ / c
leeching trenches.number.length: I 2i'{1 A ly�(�stS/ ON$ : �S X /
leaching fields, number,dimensions: 4..t
overflow cesspool,number:_
Alternative system:
Name of Technology:
its:
tdition of dl, signs of yd aulic failure,level of pondin•,damp soil,candid of vegetation, etc.)
--
OLS: J4
in site pleb)
and configuration: -
m of(:quid to inlet invert:
I solids layer:
f scum layer:
ohs of cesspool:
s of construction:
in of groundwater:
inflow(cesspool must be pumped as pan of inspection)
nts:
indition of soil,signs of hydraulic failure,level of pending.condition of.vegetation, etc.)
on site plan)
Is of construction:
f solids:_
nts:
ondition of soil,signs of hydraulic failure, level of pending,condition of vegetation;etc.)
Dimensions:
ised 9/2/98
Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Address: �^ 3 ` 'QS 4_4 r _ SY�INFORMATION Icoutirned)
Nor .11' ^� F6."1
Inspection: CAW_
-7/3v/
I 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)
6
5-1- pam en RD ( Q V
� I
i
c'5°" Pon4V
Wnyy uNC1✓rl4<H1N
S6wES
*PPG TANK-
IS.Tk egYr v(3 boy
E51114,1 4-1-ED LEA 0-( BSD
IS `X 2-5 '
ised 9/2/98
T1E5 fb PECillitIVEArf LAND/97,4, ,t5
SWSTQ-rv\
Cnw1 yo A)C-NET
Ti C, a I
Hoosc coRNp
TIE la z
HrxK6 czg&ck
TANK INLET
Zo, o'
3c. of
TAN k CCNTFL
22, 0
31.S'
TANK OUT(-ET
29. 5'
33.0'
CA sT'Q\ I IDN
exx
5 0,
go, o'
Age 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
3(03 YST IIFORMATION(continued)
Address: �jy!C�(
t spection: (j(nG.td%i
1(30/ 99
Report name Solt su.. rao r/A.r../yS�-f� Col M�/455
Soil Type FSo
- c / - ) /1"1-
Typical depth to groundwater /a S — 3.$
Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
AM Slope
Surface water
Check Cellar
Shallow wells
d Depth to Groundwater 3 5Feet
tdicate all the methods used to determine High Groundwater Elevation:
>tained from Design Plans on record
>served.Site(Abutting property. :basement sump etc.)
>termined from local conditions
t acked with local Board of health
t acked FEMA Maps
tacked pumping records
t acked local excavators,installers
sed USGS Data
▪ how you established the High Groundwater Elevation. (Must be completed)
i i is oh5e,r4UAi, 6-t ( n clod K) cv Q• L dt� so, / ceduen ..-,
eCL.-,, ' k4 d, box) 94v? '01,41.(<17'0•15
ap c-/" /5 0 h yc
vaapo, , 2A,e9 %(-41- / ,/ rd re4-1 c. y/ven �"
#41;4' 36" l- faC by /i / 0 t- ? su r J4 y T Po {1Marti
4tu. 190191-0Th of -flak)._ &o ar, u is ccei n txI gn."t
zi ro.a .
sed 9/2/98
Page 11 of 11