11 Septic Inspection 2008 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
11 W i�C I Cr" S+,
Property Address: N O ¥Ot^I V1/4
Donuldcks-i-x`onn
Owner:
Date of Inspection:
31(0 98
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of tt
Board of Health). Describe observations: rLP d;j}rinvl-irr Do) rn i(a: rte
broken pipets) are replaced
obstruction is removed 5y`v"""
distribution box is levelled or replaced
1 U The system required pumping more than four times a year due to broken or obstructed pipes) The system will pas!
Inspection If(with approval of the Board of Health):
_ broken pipels) are replaced
obstruction is removed
GI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
NO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to prote
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANN
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
f} 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) DETERMINES
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
No The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water sup;
tributary to a surface water supply.
NO The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply we
Dtp The system has a septic tank and soil absorption system and the 5AS is within 50 feet of a private water supply well
BO The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicat
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) P.g. 2 of 10
WILLIAM F.WELD
Governor
ARCED PAUL CELLUCCI
Lt.Governor
Property Address: N o -lh am p+on in Address of Owner:
Date of Inspection: 31(p I n to (If different)
Name of Inspector: aat,-* -Stover
I am a DEP pproved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15 r�
Company Name: Ayr 1.10•s4 E INerr INqX� �p
Mailing Address: p, O, 130Y 3�IZ et' M^ 0 1004-3 3 12
COMMONWEALTH OF MASSACHUSETTS SEP
RS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF.att(IRS( 2 5
DEPARTMENT OF ENVIRONMENTAL PROTFeeMilinPro .JIt
ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 NBDA:99:�LT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
II Whittler' 5)-•
Telephone Number: (y 1 tea) 2'5 t0 -3 DO
CERTIFICATION STATEMENT
I certify 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:
V. Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails � ll� AA
Inspector's Signature: �,,5� W. %a4/ Date:
TRUDY CORE
Sccretan
DAVID B.STRUHS
Commissioner
Donald gac✓:skosv,
wh■8ter SI-,
.000) Norirk°r_ ,4c^sl Vit4r
Ol O(c2
0413) 584- 9135
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 10000 gpd or greater, the inspector and the system owner shall submit
he 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:
4] SYSTEj1 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.
COMMENTS: 1 e99 cf., fit}- t&45 5howrny Eovh. 3;1 ns skes5 a+ r^c Dec DN
b✓+ it was a s, a -Fa A-fs=r+a/ c..sd, fa.ar-e - Sae: ear to +R.
3] SYSTEM CONDITIONALLY PASSES:
r‘i° 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.
ndicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
AO 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.
Imaged 04/25/97)
DEP on the World
Page 1 of 10
de Web http/Mane magnet state ma usldep
Pnnt • • R -Pa• r
Property Address:
Owner:
Date of Inspection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
I I i f4- er S i .
or-{ 44,,,..<x, �3v�1 141-41-
1205,5,54.12 E/lc -Strowx
Check if the following have been done: You must indicate either "Yes" or No as to each of the following:
Yes No
✓ _ 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 porn
Flow rates during that period. Large volumes of water have not been introduced into the system recent
as pan of this inspection.
_ 14/Pr As built plans have been obtained and examined. Note If they are not available with N/A.
✓ Plan on record 5h o.-15 Sysi-v-s in ba c,)c . SySxrn Wo5 out k i '-t ---rvt. •
The facility or dwelling was inspected for signs of sewage back-up. /21/43-13_r IT F!u
✓ _ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
144.11.14i n&
- All system components, rc'Ld.g 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 <
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 malntenar
Sub-Surface Disposal System.
_/ )./ Existing information. Ex. Plan at B.O.H. �I r,YR, s1 p}- 0.UV PAFT
-` _ Determined in the field if any of the failure criteria related to Pan C is at issue, approximation of distance is
unacceptable/ 1S-302(31(bq �1
Jr y w.Al IMtl.ovtrtv4 + 114jptt.4c.(.
(revi..d 04/25/9,) P.y* 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
i( I.Ahi-ihtr S+.
ierty Address: rAor}h*...f c (i1r
ter: Vonala i'ac't41'
of Inspection: 31 L0 in
SYSTEM FAILS:
must indicate e'.Cr "Yes" or No as to each of the following.
D 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.
No
C1y Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool_
f1 o Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
raj A' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
N IP Liquid depth in cesspool is less than 6" below invert or available volume is less than lit day flow.
110 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets).
Number of times pumped _
no Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
r/l h Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
141Pr_ An. portion of a cesspool or privy is within a Zone I of a public well.
$ Ak_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
giR 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.
LARGE SYSTEM FAILS:
u must 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:
is 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- IWPAI or a mapped Zone It of a
public water supply well)
to owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
iquirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
revised 04/25/97) page 3 et 10
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
wh)1+I<- 5+•
N tkr 'ACT
Dcca,1 DacKS+ram
Depth below grade.
Material of construction: Vast iron _40 PVC_other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, veep rib evidence of leakage, etc.)
voz (a:Ddt 1-I0'+ - in _4.syl ekt et
Lea uC
SEPTIC TANK: ,/
(locate on site plan)
tl
Depth below grade:
Material of construction: %concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
s. rf 1 X
10,E X S,S y,o'
Dimensions. iquid Pe I
Sludge depth: I2" -H" y
Distance from top of jludge to bottom of outlet tee or baffle: 20-2 a
Scum thickness. B
Distance from top of scum to top of outlet tee or baffle: (0 7 a
Distance from bottom of scum to bonom of outlet tee or baffle (ar it
How dimensions were determined. in e 5u rut
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, etc) I fecmnree kid annyfep�i,,c pia �p pro(cni Iii' Icac/x
1-;4 ,id (, Vt( wags- of i kw<..- 1- of % 4- t-hc n- • 144pec-hon• I-{
P[CJnIJ Iq}ION ,lT SCU w. bow owCyyr
0. L I,.7vid 1<v<I ( is.oloo blAiled/ W Sc .urs) oel S.-I- L
OecaJSionol -F loodH�9 r,f' }Aw t, Sep+ice -I-Ank is fSoo
GAksdr' r on, 3A�FI _ Gal. Ailed/ WAS (n 9o-s Sir(
GREASE TRAP: N�A es wrc eAS�- rn-pI } In le-" bn�'I IS Ct-
(locate on site plan) �rFle'♦• bw (, 15 ¢h cloSf.G
-For e-F -{-An k. 1-:9Jid level may nsa �...y -k li[Is o
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _otherlexplain)
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, structural
integrity, evidence of leakage etc.)
(revised 06/05/97)
Page 6 of 10
rty Address:
r:
of Inspection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
W In i;i l es S-i-.
crN w-4-„^I On in
poraIel Backs*own
31ccVTB
FLOW CONDITIONS
iENTIAL:
n flow, ci94 g.p.d./bedroom for SAS.
ter of bedrooms: 3
ter of current residents: 2
rge grinder (yes or no):le,
IN connected to system)(yes or no):Yci
nal use (yes or no):A0
r meter readings, if available (last two (2)year usage (gpd
Pump (yes or no). yes
face of occupancy eicsuRY Occuii
LMERCIAUIN DUSTRIAL:
of establishment.
(n flow: gallons/day
se trap present: (yes or no)_
trial Waste Holding Tank present: (yes or no)_
sanitary waste discharged to the Title S system: (yes or no)_
:r meter readings, if available.
}J e, c4 A1
19 qt. +"7
I,Sezic = y34y414
con3�evt- owl = 52100 co c+•
389708 yg' _53Dp1
32, darn/
date of occupancy:__
IER: (Describe)
date of occupancy:
GENERAL INFORMATION
4PING RECORDS and source of information:
n VC✓' 1a44— IS year 5yak.s. 4e4 purarear
System pumped as part of inyspeection: (yes or no)40
If yes, volume pumped: /500 gallons T
Reason for pumping: z0 - '
'E OF SYSTEM
Septic tank/diet.- 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?
-!t'sk5 ins gec.'6 Tn
ter
oUrve J- en,C berms. 7N,'tiNC
PROXIMATE AGE of all components, date installed s lled lif known) and source of information: Sy S'k"" /5 20 yen, 0 (1
or no) /10
rage odors detected when arr
mg at the site: (
'mind 04/15/57) Pogo 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: f' W%74t N
Owner. Nov- nw,fp kChI ✓✓1A
Date of Inspection: 'DV ctict 6ack54 001
3/(0/ 98
SOIL ABSORPTION SYSTEM (SAS): ✓ ' o
Saxep F a h' "/ brusi methods)
(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.
leaching fields, number, dimensions:
overflow cesspool, number
Alternative system:
Name of Technology:
Y.., of $4.- J1vt L; iv1c :11 dv'( UGLY
L 4-f 1; Me. er 1
4're__ . r. . -t--,,,,,e-t--,,,,,e L
__
£44 , -Prec ,cart; 'CC AAd i A. i_t+ (o'
Comments: Es+i.n,,ieJ 4:Mcn5i po5 Pr c(v'y s+re LI: S,5'L x S$ W X
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc)
5o- f rt v c-hit}t e., Aer nn./. S-
•4oael i.a f
to e
n i.joi it in l•
ens...
y, 0
b.le.
CESSPOOLS: L(I /1")
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth 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:---Fns
(locate on site plan)
Materials of construction:
Depth of solids_
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Dimensions:
(revised 0415/97)
Page a of 10
e Address:
Inspection
SUBSURFACE SEWAGE DISPOSAL AL SYSTEM INSPECTION FORM
SYSTEM INFORMATION (continued)
H Wh;i* er 5+-
/sfor-�-1ir mA
O0n4l4 L )kt ev
31!A93
OR HOLDING TANK: 1'f Ik(Tank must be pumped prior to, or at time, of inspection)
on site plan)
aelow grade:_
I of construction: _concrete _metal _Fiberglass _Polyethylene other(explain)
sions:
ry: gallons
flow: gallons/day
level: Alarm in working order _Yes; _ No
f previous pumping:
ents: l
;ion of inlet tee, condition of alarm and float switches, etc.)
tIBUTION
e on site plan)
of liquid level above outlet invert:
nents:
if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
IP CHAMBER: Plift
se on site plan)
ps in working order: (Yes or Nolte
ms in working order (Yes or No)_
tments:
e condition of pump chamber, condition of pumps and appurtenances, etc.)
Pogo f of 10
wised 01/33/97)
Property Address;
Owner:
Dale of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
WL1 +i-ICv S+,
ND r 1:44
3469 ( 44
7Ponct id 60.Lk5 t"oi....
Depth to Groundwater ��
%3 Feet esfa.Mn'lc et
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
VObservation 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 USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
4.144ev 4a0ble es4-+'4".44--ece 4-o ID.a val 4D 4-Lc. e tit 440 in
o4 „ L SLA Ot .t 3-L..c.: Jasp watt 1K TsSy
we41«0nc toe �J y-C,-� back... y.. TL.LS
Sur Co
ri
wan- -1- 25 rla(aIw jr.cM./. .t.�/' '�'�.t� �c.�
`
71A-sr -60((u w. 0-f 1-l-L C_o r,-c.''t. p t 4- -o L9.3 4 /
\oe-Ie o q/SntYy '' /^�.ZI.L aotO t 'R Otn W-- ,f
W c l( cc 5+^p lC
' t AAs0 // gMAQ 4- s vc Woo Let"'
{ I +V-R4.1 n, J 4J W24G
E 04.40 -rC-4, rif
(revised 04/35/977
9.g. 10 of 10
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
SYSTEM INFORMATION (continued)
I I W t1 :c1r
Address: Nor-Yt^ s^^
Inspection:
DovaIck Sac lcsfro on
.?I4 19S
I OF SEWAGE DISPOSAL SYSTEM: /Lllt.£ 1.. = to
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
ES TD pea.
4STErv\
o Pry fb'ENT
NK I'JL•E.1
srJK ce&STE'L
INK au-MET
_Y
iNTE12 Acc&h$
WtA^IENIT LANDn'TARKS
TIE 1
Imou r0gj
MOUSE C-oRNEe
I n•v '
Zo, 5'
24.o'
revived 04/25/91)
i
T16t 2
LEFT RoNFT
House. CAP IJU-
1-co.S'
Z3.
(1.5'
TIE - 3
Le r 41EA�
1-toOSL CP�FL
19 . 01 I 3co9S
44 KITTIE'P STQE€iI
APPRc'F
vVATEa. ~�
st I JALJ6 NAT[2 LINE
a I__
SEtric TANK
tod GI
Pegs 9 of 10
ROUSE
Tics‘-'%
DR`S WC-
U-we-1 PIT