46 Septic Inspection 1997/1998 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
.Property Address:
Owner:
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES Icontinuedi
/1E)
Sewage backup or breakout or high static water level observed
Opts/ or due to a broken, settled or uneven distribution box.
Board of Health). Describe observations:
broken pipets) are replaced h O
obstruction is removed / 11
distribution box is levelled or replaced
/IQ The system required pumping more than four times a year due
inspection if(with approval of the Board of Health/.
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
No
in the distribution box is due to broken or ob
The system will pass inspection if with appro
d�sfr�lvv�i�� box
n lead., Qr+ +/pc
5y51
to broken or obstructed pipets). The system
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing t
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A.
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
MIPr
Cesspool or privy is within 50 feet of a 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 APPROPRIATE) DETERA
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 SAS Is within 100 feet to a surface war.
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 sup)
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supp
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds i
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen i!
less than 5 ppm. Method used to determine distance (approximation not valid).
(revised 04/15/97)
Page 2 of 10
AM F WELD
for
D PAUL CELLUCCI
rcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
41(41 Wht4tiv St
ty Address: w or -}-6LL....PTov,,t MA- Address of Owner: JokA W , Rig K
1 Inspection: it. SI 1447 (If different) 4C. w6i+}"ier c+,
of Inspector: R b .--{-StT/ a• ) „
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) IJor4I4a..Y'y n"am
^) mA
toy Name: Am Mc/s4 G.vii Eh5ineerc', OfOCoz-
gAddress: P.O • [Sox. 3f;12t 0..- tee r(+ IfYlAu 01004—3312-
one Number: C Litz) 254. -3400
:(CATION STATEMENT
y that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
implete as of the time of Inspection. The inspection was performed based on my training and experience in the proper function and
nance of on-site sewage disposal systems. The system:
COMMONWEALTH OF MASSACHUSETTS I I i J'.
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFATM 2 LJ 1
DEPARTMENT OF ENVIRONMENTAL I
PROTEFITMJlibs-IPTOR BOARD OFHEALTH
ONE WINTER STREET. BOSTON. MA 02108 617-291-5500
TRUDY COXE
Secretary
DAVID B.STRUHS
_asses
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
tor's Signature:
A L)
Date: 42j_18
.stem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
tion. 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
sort to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
:pies sent to the buyer, if applicable, and the approving authority.
CTION SUMMARY: Check A, B, C, or D:
STEM PASSES:
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 indicated below.
BENTS:
STEM 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.
le yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
119 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 exfiltration, or tank
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.
.•a 04/35/91) Page 1 of 10
DEP on the world wide wee hnp/New's magnet state ma uSlOep
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done: You must Indicate either "Yes' or No as to each of the following.
Ves, No
-K/ Pumping information was provided by th owne , occupant, or Board of Health.
— None of the system components have been pumped for at least two weeks and the system has been receiving
Bow rates during that period. Large volumes of water have not been introduced into the system re
as pan of this inspection.
iltsr
V
— e plans have been obtained and examined. Note :i they are not available with N/A
Y _ The facility or dwelling was inspected for signs of sewage back-up.
J[ _ The system does not receive non-sanitary or industrial waste flow.
I/ _ The site was inspected for signs of breakout.
/ IgcfucIi4,
V 2 All system components, wecLd q the Soil Absorption System, have been located on the sit
�/ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condo
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:
✓ The facility owner and occupants, if different from owner) were provided with information on the proper main
/ Sub-Surface Disposal System
V Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is
unacceptable) I)5.302(3)(bll
de/ well a LCCS5 ris//c!!.r ( Zrll,4,1i OA coVereec ±
lnTC'r imc eD WCCC IhSre:-.4 ee
(ravaged 04/25/97) Page 4 of 10
y AdHress:
Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
44, wh,--FFIc' SJ-
N or 44,,u-,f, ) nt h
Toh,n W, Pun
1215 I9-7
TEM FAILS:
tst Indicate e, •er "Yes' or ",No" as to each of the following:
_ I have determined that the system violates one or more of the following failure 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.
o
j Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
y Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool
(NO Q'
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
1 P 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 pipe(s).
Number of times pumped _.
_V Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation
A to•-dingy to -I-cs- pt-f- d.,-1.0. by Hun}kry Assoc. 5110178 — a-�iaol�el.
a_ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
A An. portion of a cesspool or privy is within a Zone I of a public well.
IAAn ponion of a cesspool or privy is within 50 feet of a private water supply well.
1'IT 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 analysts for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
GE SYSTEM FAILS:
Est Indicate either "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 System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
No
the system Is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
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)
vner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
rments of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information,
and 04/25/97) Ps. 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade
of construction. cast iron 40 PVC other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage. etc)
by;I.I; sw,cr g/i rrly b.,lov slab
SEPTIC TANK:_V
(locate on site plan)
Depth below grade: 4-9
Material of construction: ✓concrete _metal _Fiberglass Polyethylene other(explain)
aild no% iasP«fa61c
GV
f Yave✓ye
If tank is metal, list age Iris age confirmed by Certificate of Compliance _(Yes/NO
Dimensions. 1D'S/ X 5, D X- Lit/ II?Oa ATHA (15oa Gate .)
30 "
Sludge depth: _3-4.
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness. vi
Distance from top of scum to top of outlet tee or baffle.�
Distance from bottom of scum to bottom of outlet tee or baffle
How dimensions were determined: Olrobv eta
Comments.
(recommendation for pumping, condition of inlet and o let tees or baffles! depth of liquid level in relation to outlet I vert, struct
Integnry, evidence of leakage, etc) 044 + b e t n Oox/ _ a/ 4i l- Ass G / )1
O(IA Yn'p.L_
GREASE TRAP: N/A
(locate on site plant
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explaln)
Dimensions.
Scum thickness:
Distance from top 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 inlet and outlet tees or baffles, depth of liquid level in relation to outlet Invert, struct
integrity, evidence of leakage. etc)
(revised 04/25/9)) page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Add' F:. H4 W hr14-icr
Nor 41.vr,...e4nii IMA-
thpPCiion: Sod,--: N. PJft.
IZI; �9't
FLOW CONDITIONS
ITIAL:/�
low: aril g.p.d./bedroom for S A S
of bedrooms. 3
of current residents:
grinder (yes or nol:4,
connected to system ( es or nob YCi
use (yes or no):�D T s I 201 9 Pd
Teter readings, if available (last two (21 year usage (gpd): 196 o0 Cu. FT, -co,- 90 + Q!
rmp (yes or nol: AO *L 5 •..'I�d.-S S (•Y^: cl 2, �'--• S�!% . "'3' ''•.•`.
of occupancy: 0CC—t)
'RCIAUI N DUSTRIAL:
establishment:
low: gallons/day
rap present: (yes or na)_
I Waste Holding Tank present: (yes or nol_
nary waste discharged to the Title S system: (yes or not
eter readings, if available.
a -' —1 Nye_
or occupancy.
(Describe)
0? occupancy:
tG RECORDS and source of information.
Ld<+ 1 vneteF Lg ti
s
System pumped part of i95Pection: (yes or no)
If yes. volume pumped. /5 �O ,gallons
Reason for pumping.
GENERAL INFORMATION
ropoffe I-)cn oc oWKc✓
4i' �o pu*,oed; ei /9a7, sllg9Li
INS t(v}Seet + ro0-fit wa Mai 4-94.+rCr
ySYSTEM
Septic rank/distabwse.rbes/soil absorption system e4 s'y Weil /I
Single cesspool
Overflow cesspool
Privy
Shared system (yes or not (if yes, attach previous Inspection records, if any)
I/A Technology etc. Copy of up to date contract?
54-c
(IMATE AGE of all components, date installed (if known) and source of informadoo.
jwsl=IIJ a/ Iggl
ih� ase /iv60_ 5 54-e4.1 .s 15 . 5 yea.--5
odors detected when arriving at the sae. (yes or no) )90
d 04/25/97) P.R• 5 of 10
old
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): s.P
(locate on site plan, if possible; excavation not required, but may be appro
If not determined to be present, explain.
L1100 ton
0.b ovt goof
mated by non-intrusive methods)
Type
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length.
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Dt WEL.L-% 8'} L»N)c, 2 4 /± wlos
b'( 51 " t EFFEc-TtUE V
2 '1 (3£lt"- 62-4pt
AyeR.oX, boo() C14L.
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc) n
SP ( + VPI�1 �-7yi-I Dh norw.SJ- TL- G we(( WAS nr,nrrf a+.wY rh SpecA-cc'
I+ kip , nab- in s-F.+S, roc hye/ e,7ulic -ca ilvre 6°4- �..A, li t/'r( (eve
was bnt4, .ts Sp ect n^' e^cY ala.,ue . S rec...nmerd annt,ol P 5„,PiAS a
c.arr4 / LeLa.r 9v 14A-4)/r1_, /; -Fc of /CA EA p/'t•
EF FLU F.N1T Q, -Asa N AB'_Y CttL
CESSPOOLS: N/A
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert
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: NO
(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.)
(r.vi..d 04/15/97) Page. 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
H�0 W h;r1-F■fr 54.
y Address: No'+ owtprk yA�4}.
Inspection: `?o ht1 w. NVNIC..
IZ/ C i?7
OR HOLDING TANK: Win (Tank must be pumped prior to, or at time, of inspection)
on site plan)
Blow grade:
I of construction: concrete _metal _Fiberglass _Polyethylene other(explain)
ions:
gallons
flow: gallons/day
ever. Alarm in working order_ Yes; _ No
previous pumping.
(1(5
on of inlet tee, condition of alarm and float switches, etc.)
3UTION BOX:liiR
on site plan)
if liquid level above outlet invert
nts.
level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
CHAMBER: NA
on site plan)
in working order: (Yes or No)_
in working order (Yes or Nol_
nts:
mdition of pump chamber, condition of pumps and appurtenances, etc.)
Id 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
46 wh,{}ier 5+,
Property Address: plor+Inann...p%+) 144 14
Owner:
Date of Inspection: .%O Ann IN, Kin lc
J2-/5177
Depth to Groundwater>12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
k7 Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc)
Determine it from local conditions
,Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USCS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
Ies4- p 4- rdsu14-s 012 41i 'ti crown 1%<si Pla.,r on
b`l
44 Ioc&t Boor& o� I4A, r4- pt4-s ) C/lerl
R . braaeau/ H��fl� f�ssoc. ann 3 I I � 7 `j A ". ctihtcl,ad
w :-tti. orty.,k2 12-gitvuji 61fphczdti -s-
F'G c.O■ ,(1
(aaa i aa d 04/99/97) Page ID of 10
y Address:
Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
+1c9 41444-iL✓ Sr
To 1N`n 'N q�7✓n ;C
1 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)
WHtZT)Ee- S{ 6LsE-
w
-T
H oust. 4(0
3 dams + 0 isPOL-1 G aQwc e.
WALe DOT CW,..n
Kea
15000w4L
5E41lIC T4NK
:7 TD GE MANEUT LAA:D YNARcc
'STEM
ao NENT5
R1GNT aepr-
N5E Co 2N E2
(-V- I ')
LEFT zeta P-
C t LoILtdOP.
(4 a)
INLET
31, o '
45.5 '
K cENTee-
35,5'
42,0'
tc. okm.£T
40,5'
3g. 5 '
Yti Well_
103.0 '
Coq. S'
kPPaoxrm 4-TG
LG crf PIT
rd 05/15/9])
Fag* 9 of 10