60 Septic Inspection 1997 William F.Weld
coemw
Crum Paul CMluso'
L oc+emor
Commonwealth of Massachusetts
Executive Office of environmental Affairs
Department of
E zvironmental Protection
lli
20 X99
Trudy Cord
Secretary
Davld B. Struhs
Co nms.w,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: ‘00 e,t-S-A'(%E yin, Address of Owner
Date of Inspection: /l-/p-q I I I (If different)
Name of Inspector t_EN ?UGH-
Company Name,Address and Te epitome Number. (f-f t 3) Syq?sZp
�QC(L -UtLDco- /D SHACK �O
Ltit( ILO;
CERTIFICATION STATEMENT r
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, arcuate
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:
a' Passes
_ Conditionally Passes
_ Need.Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature:
t.r Date: ii-/0-4/77 The System Inspector shall 4 cc o section report to the Approving Authority within thirty(3l days e m completing this
inspection. If the system is i shared system the er has a design flow of 10,000 l P or greater, the inspector and the system owner shall submit the
report to the appropriate regional office o[ehe Department of Environmental Protection.
The original should be sent to the system owner and copies lent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B. C, or D:
/Al SYSTEM PA.1:
C 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.
Bl SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes
inspection.
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 teak is metal,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.
(revised 11/03/95)
One Winter Street • Beaton,Massachusetts 02108 • FM(617)556-1049 • Telephone(Cl?)292-5500
0 P,nted on Recycled Pape,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
5, ti MP f -�
�A-6
Property Address: 662 cp4'F•1
Owner. A $�fZ/�
Date of Ins r n
Il—I0-91
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 pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipets)an replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
Cl FU,.THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board or Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 60 feet of a surface water
Cesspool cr priv, is within 50 fear,of a bordering vegetated wetland or a at marsh.
S) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT.
3) OTHER
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system ands within a Zone I of a public water supply well.
The system hes a septic tank end soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and 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
hem pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: C,o compLC_
owner: , "ASAhtc5
Late of Inspection. —l0-4q
DI SYSTEM FAILS:
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
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static Bgwd level in the distribution boz above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1)2 day flow.
Required pumping mom than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_
Any portion of the Soil Absorption 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 cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
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
mliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
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.
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requiremenu of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addraee (0 L[ g 57 M l/'✓$1 "44
Deb '
of lvs ire ' !lam- >
u_o_g17
Check if the following have been done:
/Pumping information was requested of the owner, occupant,and Board of Health.
.MNone of the system component.have been pumped for at least two weeks and the system has been receiving normal flow rates
f, during that period. Large volumes of water have not been introduced into the system recently or as part of the i apecti..n.
ilk As built plans have been obtained and examined Note if they are not available with N/A
J//The facility or dwelling was inspected for signs of sewage back-up.
y The system does not receive non-sa itary or industrial waste flow
/The site was inspected for signs of breakout.
_ All system components,excluding the Soil Absorption ' stem, 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.
L/t!'he size and location of the Soil Absorption System on the site has been determined based on existing information cr
approximated by non-intrusive methods.
/The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
Property Address: (p0 C
Owner.
Date of Inspection: f o_
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
RESIDENTIAL
Design flow: 116 gallons
Number of bedrooms:
Number of current residents±
Garbage grinder(yes or no): WO
laundry connected to system (yes or no):Sx15
Seasonal use (yes or no):S/2
Water meter readings, if available:
si N
FLOW CONDITIONS
Last date of occupancy: QPPCfa'r
COMMERCIAL/INDUSTRIAL:
'type of establishment:
Design flow:_gallons/day
Grease trap present: (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:
Ai z P,)eon
System pumped as part of pectiom(yes or no t+$$
If yes,volume pumped. 12,(a_gallons
Reason for pumping:
f+)n- !(ANIG )NSDw.�UnJ
TYPE OF SYSTEM
- Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yea,attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components,date installed if known)and source of information: 75",*
Sewage odors detected when arriving at the site: (yes or no)_1310
(revised 11103/951
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM IP'3PECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address (QC C( E� ' /U� /�fi>
Owner:
tee of Inspection: 12/71-041-0 9� � /
SEPTIC TANR:4
'loute on site plan)
Depth below grade:
Material of construction:4mncrete metal_FRP_other(explain)
Dimensions: W-uy^ _«�_I - A y„
Sludge depth: ILu1 r
Distance from top of sludge to bottom of outlet Lee or baffle: ?i-y
Scum thickness: 14 f1
Distance from top of scum to op of outlet tee or baffle C)Ir ��s
Distance from bottom of scum to bottom of outlet tee or bugle: -VC
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffle,depth of liquid level in relation to outlet invert,structural integrity,
evidence ofileakage, etc.)
a • fie • • y r• see
GREASE TRAP._
(locate on site plan)
Depth below grade:_
Material of construction: concrete metal_FRP other(explain)
Scum thickness:
Distance from top of mum to top of outlet the or baffle._
Distance from bottom of scum to bottom of outlet tee or baffle:
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 11/03/95) 6
Property Ad.:ream
Owner.
Data of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
II-la-17g
TIGHT OR HOLDING TANK_
(bate on site plan)
Depth below Bade:_
Material of constntction: concrete_metal_FRP _other(explain)
Dimension:
Capacity: gallon
Design flow: gallons/day
Alarm level.
Comments:
(condition of inlet tee condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments.
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
PUMP CHAMBER_
Uaate on site plan)
Pumps in working order:(yes or no)_
CommeaU::
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Ownerty sat CCopp'�/c//E/ha9P E'L_ �� Nf{73-ett z ) r/14
Date of Inspection: - ` l
u -717
SOIL 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 pita,number /- fa as(a'
leaching chamber., number:
leaching galleries number: —
leaching trenches nmher,length:
leaching fields, number,dimensions: / — 12'*v0's I Z r, At
overflow cesspool,number.
Commeav (note eonditiR of soil,signs of hydraulic failure, level
nn/AIPL „ /2132- IA' • 77-/t= 6/
•• a to •.
Y r , la L
t
CESSPOOLS:_
(locate on site plan)
of ponding,condition of vegetation,etc.l
) TFf61U �Xf i - O 12 (
4_ — • _ ,_ "IP q9 I •
ELL)
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:
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions.
Comments: (note comdrtaon of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
(revised 11/07/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addressee ea° 0 770-,0 c7. k -arrl, yl4-
Owmer
Date oflnspeotioo: _IQ—%n 1
FI(EI'CH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater. /V/H feet
method of determination or approximation:
4
\ /
(revised 11/03/95) 11