27 Septic Inspection 1997 Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
]
tilil
IC.-: � , a
B] SYSTEM CONDITIONALLY PASSES (co inued)
Sewage backup or bklaIMIcitilitrliKnkater level observed in the distribution box is due to broken or obstructed
pipe(si or due to a broken,seitleror uneven distribuo• box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
_ obstruction is removed
distribution box is !eve -d or replaced
The system required pumping more an four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of th :oard of Health):
broken pipe 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 falling to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT E SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND E ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering -getated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEA
THE SYSTEM IS FUNCTIONING IN A MANNER
ENVIRONMENT:
(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
AT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
The system has a septic tank and oil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water sup
_ The system has a septic tank nd soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic to and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic :nk and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply w I, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from .ollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. ethod used to determine distance (approximation not valid).
3) OTHER
(revised 09/25/97) Page 2 of 10
WILLIAM F.WELD
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTME • 1^ r. AI PROTECTION
ONE HINTER ST .: F. f n�i�iNV, : " 2- 500
Er I M
NORf HARP1ON.O-cp 1161LJN
I j997 TRUDYCONE
Secret,*
"-'DAVID B.STRLRLS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "ARD OFH'C"dn+missiouer
PART A _. ..___,.. _..
CERTIFICATION
Property Address: -1 CAF{ 1I(64 1'CJr'
Date of Inspection:
Name of Inspector: Da&AIID P. 44 coucse
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: _34 rj4 t
Mailing Address: PQ. t3osS
Telephone Number: `1I3 a one 40a a
Address of Owner:
(If different)
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:
Passes
_ Conditionally Passes
_ N--:. Further Ev
F
Inspector's Signatur
e Local Approving Authority
Date: /2).ZS'S%
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, 8, C, or D:
A] SYSTEM PASSES:
XI 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:
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 lattached) 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.
(ravine 04/25/97) Page 1 of 30
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 7.7 CA LLR%iy.✓ `i'c/UaR�
Owner .TOT.y (oE A bR Si
Date of Inspection: IA,
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 normal
Flow rates ?R 0 during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
`4 As built plans have been obtained and examined. Note if they are not available with N/A.
iC The facility or dwelling was inspected for signs of sewage back-up.
Yj 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
The facility owner and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
) . Existing information. Ex. Plan at B.0 H.
Determined in the field (if any of the failure criteria related to Part C at issue, approximation of distance is
unacceptable) (15.302(3)(b)]
(revised 04/25/50) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FMLS:
You must indicate enr.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.
Yes Na
Backup of sewage into facility or system component • e to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface • the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box .love outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than below invert or available volume is less than 1/2 day flow_
Required pumping more than 4 - es in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Ab arption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a c: spool or privy is within a Zone I of a public well.
Any portion of . cesspool or privy is within 50 feet of a private water supply well.
Any portio 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
conform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You 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 :pd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because . e or more of the following conditions exist:
Yes No
the system is within 400 feet o . surface drinking water supply
the system is within 200 et of a tributary to a surface drinking water supply
the system is locate• in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a
public water supp well)
The owner or operator of any s h system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5..• and 6.00. Please consult the local regional office of the Department for further information.
(r.vis.d 04/15/91) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9.7 CRU nOA'.+ ntn..,.E
Owner: „MDy G E244 S/
Date of Inspection: I l' yy 47
SOIL ABSORPTION SYSTEM (SAS):
(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, numbeglength:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soli, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
OV VD I " Cr Lr.D✓r7 A;. %., /7n1 pF 7,i77- - bu5 /7 re fr'/
3c lOw LEE L Or V;T 9./Y P=et./.1 D Na 6,,ta,..0 P.t A, er4E2ln«T
c I. i
CESSPOOLS:
(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 groundwate
inflow (cesspo•. must be pumped as part 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.)
(revised 04/25/97) Page B of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: A? C4 ill*NA✓ 1-6--rearect
Owner jov 1 GEt845
Date of Inspection:
IN A5. 47
FLOW CONDITIONS
RESIDENTIAL:
Design flow: Air; P.p d/bedroom for S.A.S.
Number of bedrooms: a
Number of current residents:_
Garbage grinder (yes or no) ye* GrCJP-17=m WI// eEE RE /1700 E-0
Laundry connected to system (yes or no):.70E5
Seasonal use (yes or no): ND
Water meter readings, if available (last two (2)year usage (gpd):
Sump Pump (yes or no): ND
Last date of occupancy: 9/17
COMMERCIAUI N DUSTRIAL,
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial N'aste Holding Tank present: s or no)_
Non-sanitary waste discharged to the isle 5 system: (yes or no)_
Water meter readings, if availa
Last date of occupan
OTHER: (Descri.-)
Last date of . cupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information.
System pumped as part of inspection: (yes or no14C5
If yes, volume pumped: //WAD pallons
Reason for pumping: sit SPEGTIex)
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) Of 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: Uu h✓D CON
Sewage odors detected when arriving at the site: (yes or no)4/4
(re vi sod 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
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: concrete_metal _Fiberglass . yethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level. Alarm in workin:; order_ Yes; _ No
Date of previous pumping:
Comments.
(condition of inlet tee, condition .'alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet rcven.
Comments.
(note if level and distribute is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes r No)_
Alarms in working order (Y s or No)
Comments:
(note condition of pu p chamber, condition of pumps and appunenances etc.)
•
.va..d 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 C.9ac4449U
Owner: TODy 6ERB+yI
Date of Inspection: (L.
BUILDING SEWER:
(Locate on site plan)
A
Depth below grade. Ix
Material of construction: tcast iron_40 PVC_other (explain)
Distance from private water supply well or suction line 2 V
Diameter s{"
Comments: (condition of joints, venting, evidence of leakage, etc.)
t?A✓ vom-- S mot 6 — urt cE/P)/
SEPTIC TANK:
(locate on site plan)
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)
Dimensions: /pelt'A IU J-X 64
Sludge depth: /7'1
Distance from top of sludge to bottom of outlet tee or baffle: 13
Scum thickness: / "
Distance from top of scum to top of outlet tee or baffle: w rr
Distance from bottom of scum to bottom of outlet tee or baffle: }6
How dimensions were determined: 10)4;4 Port.,
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to owlet invert, structural
integrity, evidence of leakage, etc.) TA NX 9i�p._�a•e-4 7i '3E /A/ en GSA//7•j(®r0
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal _Fiberglass Polyethylene _other(expfain)
Dimensions:
Scum thickness.
Distance from top of scum to top of o
Distance from bottom of scum to b
Date of last pumping:
Comments:
(recommendation for • mping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evident • leakage, etc.)
tee or baffle:
m of outlet tee or baffle:_
(revived 04/15/97)
Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: a-7 Cq L L 4 H g N
Owner pv GE A. RSgi
Date of Inspection:
Depth to Groundwater )n Fern
7c Rg4[2
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
S. 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 USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
Duo to '
tQ1E-2
DCC`p HetC A? PCP
4i
(rewind 04/25/97) Page 10 of 10
Uo WEEP,0-1_
D2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 6.7 Cq L L4114 r..
Owner:-Topy & R34,4
Date of Inspection:
tl �S -4>
7Eaas/be
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include lies to at least two permanent references landmarks or benchmarks
locate all wells within 100" (Locate where public water supply comes into house)
C.a1-L4k RN rczal co'
(remind 04/25/97) Page 9 of 10