411 Septic Inspection 2000 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTIO
One winter Street,Boston Ma 02108(617)292-5500
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NOSTIMainoitioldip of
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI
GOVERNOR DAVID B.STRUMS
COMMISSIONER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 1411 W ESTHAMPTON RD
FLORENCE, MA
Name of Owner: MAZUCH
Address of owner. SAME
Date of Inspection:5130/00
Name of Inspector:(Please Print) JOHN ALVES
I am a DEP approved system inspector pursuant to Section 15.340 of Title 6(310 CMR 15.000)
Company Name: CLEAN SEPTICS
Mailing Address: 540 CENTER ST., LUDLOW,MA
Telephone Number: 413-553-2138
CERTIFICATION STATEMENT
I certify that I have personalty 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 esparlence in
the proper function and maintenance of on-site sewage disposal systems. The system:
ZPasses
_Contfonally Passes
- Needs Further Evaluation By the Local Approving Authority
Fails
Inspectors Signature:
Date 05/302000
The System Inspecto- the a copy of this Inspection report to e Approving Authority(Board of Health or DEP)within thirty
(30)days of compl:: 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.
NOTES AND COMMENTS
DISPOSAL SHOULD BE REMOVED
revised 9/V98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1411 WESTHAMPTON RD
FLORENCE ,MA
Owner. MAZUCH
Date of Inspection: 05/30(2000
INSPECTION SUMMARY: Checl%B,C,or D:
A. SYSTEM PASSES:
YI have not found any information with indicates that any of the failure condi0ons described in 310 CMR 15.303 east. Any
failure aiteria not evaluated are indicated below.
COMMENTS:
SYSTEM CONDITIONALLY PASSES:
One or more system components as deathbed 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 N all instances. If'not determined',explain why not.
The septic tan 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,strucbaalty unsound,shows substantial infiltration or exfiltration. or
tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the dJInbuton box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven dsbbution box. The system wtil pass Inspection If(with approval of the
Board of Health).
_ broken pipe(s)are replaced
obstruction Is removed
dlstilbution box h leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if()Nith approval of the Board of Health):
_ broken pipe(s)are replaced
obstruction Is removed
Revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1411 WESTHAMPTON RD
Owner: MAZUCH
Date of Inspection: 5130/2000
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health ki order to determine if the system is falling to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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:
_ 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 less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for colifom 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
Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL INSPECTOR FORM
PART A
CERTIFICATION(continued)
Property Address: 1411 W ESTHAMPTON RD
Owner: MAZUCH
Date of Inspection: 05/30/2000
D. SYSTEM FAILS:
You must indicate either Nee or'No to each of the following:
I have determined that one or more of the following failure conditions east 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 facility or system component due to an overloaded or dogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS
or cesspool.
Static Liquid level in the distribution box above outlet invert due to an overloaded of dogged SAS or cesspool
Liquid depth in cesspool is less than 6'below Invert or available volume is less than 12 day flow.
Required pumping more than 4 times In the last year NOT due to dogged or obstructed pipe(s).
Number of times pumped
portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is vain 100 feet of a surface water wppty or tributary to a surface water supply.
Any portion of a cesspool or privy is within a zone l of a public well.
My portion of a cesspool or privy is within 50 feet of a private water supply well.
My 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 quatiy analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis
for colform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either'Yee of'No'to each of the following:
The system serves a facility with a design flow of 10,000 gpd or grater(Large System)and the system is a significant threat to public
hea0h and safety and the environment because one or more of the fo0owing conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is wilhin 200 feet of a blbutary to a surface ddnang water supply.
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Are-IWPA)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(2). Please consult the local
regional office of the Department for fuller information.
Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1411 WESTHAMPTON RD
Owner: MAZUCH
Date of Inspection: 05/30/2000
Check if the following have been done: You must indicate either yea"or"No"as to each of the following:
Ye4 No
Ic. 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
Pow 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 m have been obtained and examined. Note If they are not available with WA.
421 _ The facility or dwelling was Inspected for signs of sewage back-up.
The system does not recetre noneanaary or industrial waste flow.
]C _ The site was Inspected for signs of breakout.
All system components,excluding the Soil Absorption System,have been located on the sae
The septic tank manholes were uncovered,opened,and the Interior of the septic tank was inspected for condion 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 N the field(ti any of the failure criteria related to Part C is at issue,approximation of distance is
unacceptable)(15.302(3)(b)I
The facility owner(and occupants,B different from owner)were provided with information on the proper maintenance of
Subsurface Disposal Systems.
Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
PART C
SYSTEM INFORMATION
Property Address: 1411 WESTHAMPTON RD
Owner. MAZUCH
Date of Inspection: 05/30/2000
FLOW CONDITIONS
RESIn flour L:
Design r of bedrooms 110 g.pd(design): om.
Number of bedrooms(design): 4 Number of bedrooms(actuall 4
Total DESIGN flow j4
Number of current residents; 4
Garbage grinder(yes or no): YES
Laundry(separate system) (yes or no): NO : If yes separate Inspection required-
Laundry system inspected(yes or no)
Seasonal use(yes or no): NO
Water meter readings,If available(last two year's usage(gpd): WELL OVER 100'
Sump Pump(yes or no NO
Last date of occupancy PRESENT
COMMERCAL/INDUSTRIAL:
Type of establishment
Design flow gpd (Based on 15203)
Basis of design flow
Grease trap presets:(yes or no)
Industrial Waste Holding Tank present(yes or No)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
Water meter readings if available:
Last date of occupancy:
Other:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
1818 OWNER
System pumped as part of inspection:(yes or no) YES
If yes,volume pumped; 1500 gallons
Reason for pumping REQUESTED
TYPE CIF SYSTEM
Le" Septic tank/distribution bos/soll absortlan system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)
VA 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(a(mown)and source of inormation: 1887 TOWN RECORDS
Sewage odors detected when anbmg at the sae:(yea or No) NO
Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1411 W ESTHAMPTON RD
Ownerer. MAZUCH
Date of Inspectloo: 6/70/2000
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2'4"
Material of construction: cast Iron XX 40 PVC other(explain)
Distance from private water supply well or suction line- TO'
Diameter 4"
Comments:(condition of Joints,venting,evidence of leakage,etc.)
JOINTS OK VFNT OK NO LEAKS
SEPTIC TANK;_
Locate on ale San)
Depth below grade; 2'
Material of construction; XX concrete_metal_Fberglass_Polyeth)lene_Other(explam)
If tank is metal,list age Is age confirmed by Certificate of Compliance
(Yes or No)
Dimenslons D 10' SW St 1500 KELLOGG
Sludge depth: 10"
Distance from top of sludge to bottom of outlet tee or baffle: 2'2"
Scum thickness: 0"
Distance horn top of scum to top of outlet tee or baffle; 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How dimensions were determined: PROBE& MEASURE
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of bquld level in relation to outlet roved,structural
integrity,evidence of leakage etc) PUMP. BAFFLES OK.LEVEL OK.TANK OK.NO LEAKS
GREASE TRAP:
(LOCATE ON SITE PLAN)
Depth below grade:
Material of conetruc0on: concrete_metal Fiberglass_Poyethylene_omer(exptaln)
Dimensions:
Sam thickness:
Distance from tip 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 beet and outlet tees or baffles,depth of liquid level In relation to outlet invert,
structural integrity,evidence of leakage etc.)
Page 7 of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1411 WESTHAMPTON RD
Owner. MAZUCH
Data of Inspection: 513011000
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' conaete_metal_Fiberglass_Polyethylene other(explain)
Dimensions:
Capacity' gallons
Design flow: gallons/day
Alarm Present Alarm lever Alarm in working order:Yes NO
Date of previous pumping:
Commends:
(condition of inlet tee,Cond ion of alarm and float switches,etc.)
DISTRIBUTION BOX;
(locate on site plan)
Depth of liquid level above outlet Invert 0" 105"DOWN
Comments:
(note if level and distribution Is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
LEVEL.DISTRIBUTION EQUAL.NO CARRY OVER.NO LEAKS
PUMP CHAMBER:
(locate on site plan)
Pumps in working order(Yes or No)
Alarms M working order:(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
PAGE of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1411 WESTHAMPTON RD
Owner. MAZUCH
Date of Inspection: 05/30/2000
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,if possible;excavation not required,location may be approedmated by non-intrusive methods)
If not located,explain:
Type
Leaching pile,numbeC_
Leaching chambers,number
Leaching galedes,number:
Leaching benches,number,length: 2 25'
Leaching fields,number,dimensions:
Overflow cesspool,number
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of panting,damp soil,condition of vegetation,etc.)
SOIL GRAVELY.NO HYDRAULIC FAILURE. SOIL DRY. VEGETATION OK
CESSPOOLS:
(locate on s0e plan)
Number and configuration.
Depth-top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer
Dimensions of cesspool:
Materials of consbuction.
Indication of groundwater:
Inflow(cesspool must be pumped as pen 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 hydraulic failure,level of ponding,condition of vegetation,etc.)
Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include tles to at least two permanent reference landmarks or benchmarks
Locate all wells within 100'(locate where public water supply comes Into house)
u (ism (4A-41n0TaN 20 0k
.4-cat
To all penes concerned with this report.
ra on. This Inspection carries no f cas guarantees. The osyfte system
May change dse to maintenance,elements of the weather,number of occupants act,Oc and respect frthe system.Theca s ystems do riot last forever. This is limited Inspection only, tide to provide k normatIon co ncemtht the physical Contlltion observed at the lime of the Nasal ktape dwn. Again this Is not a general warrantee.
Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
STYSTEM INFORMATION(continued)
Property Address: 1011 WESTHAMPTON RD
Owner: MAZUCH
Date of Inspection: 6/30/2000
NRCS Report name
Sou Type
Typical depth to groundwater
USGS Date websde visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 9.5' Feet
Please indicate all the methods used to determine High Groundwater Elevation:
`./ Obtained from Design Plane on record
Observed Site(Abutting property,observation hale,basement sump etc.)
Determined from local candidata
Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Checked local excavators,Netatiers
Used USGS Data
Describe how you established the High Groundwater Elevation.Egg be completed)
PERC 1111/84
O'KEEFE
PAGE 11 OF 11