392 Septic Inspection 2007 COMMONWEALTH OF MASSACHUSETTS.
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A .
CERTIFICATION
Property Address:
Chi F.ST�2F/Ec /?040
Aran ViaaV W/a,9c/r/l9S,t i—TS
Owner's Name: n'-� irilill -. /E-�5k L
Owner's Address, i�ir#'= ,/
err-Fa-a" C u,575:11-4--- ,c/0n&Gc/cir
Name of Inspector:(please print) - LLE_!'7-?7 Se/cCa),%.79 A e
Company Name: /J41ZS seL,0/eL-1∎C /z/Ltie : .
Mailing Address: - F/22 17 O,% -Telephone Number: al'4-1r�fou, _ »-z /&SS
I//3 '7 a Yo 9
CERTIFICATION STATEMENT
I cenify 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 the inspection.The inspection was performed based on my
training and experience In the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system Inspector pursuant to Section 15.340 of Title(310 CMR 15:000)..The system:.
XPasses
Conditionally P
Furth vaIuat$by the Local Approving Authority
Date of Inspection:
/vl%25,5
CIOG* 7_
Inspector's Signature: i c .'L� Date: /a .7g o 7
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.Ifthe system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if appliable,.and the approving
euth 'ty. - -
Notes and Comments 7 //it 1577,{JC SA'',
Trc 0 t�sf-6/Lr .
056- Grp r/JE '/OAy 1uc // ,...rJ'vuu" Jac
"•• his report onlydescribes conditions at the time of Inspection and under the conditions of use at that
time:This inspection does not address how the system will perform In the future under the same or different
conditions of use.
•
Page 2 of 11.
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT&
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM
PART A
CERTIFICATION(..—I 1)
Property Address: 392 C/'k5r/F/L icie_cD EL?
Owner: .4F.I" '3' ,O Z/t$'KL
Dale of inspection:
lG/.,Va 7
Inspection Summary: Cheek A,B,C,D or&(ALWAYS completeal of Section D
A. System Passes:
1 have not found any information which indicates tint any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
L4 4.47/2Ly Cetvv.&e /,fD &4Clc /, 27'
r,.7-7 c oy 5Z.°h
B. System Conditionally Passes:
One or more system componehts as described in the"Condhional 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.
Answer yes,no or not determined(Y,N,ND)in the_for the following stafm•ete If'Mat determined"please
explain.
•
The septic tank Is metal and over 20 yeah old*or the septic tank(whether metal or not)Is structurally
unsound,exhibits substantial Infiltration or exfiltratloa or tank allure k imminent.System will past kspectlon If the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if It is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain: -
Observation of sewage backup or break out or stµio water level in the distribution box due tobroken or
obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)see=placed
_ obstruction is removed
_ distribution box is leaded cc sepiaeed
ND explain:
The system required pumping more than 4 times ayear due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board ofHealth):
_broken pipe(s)are replaced
obstruction is removed
Page 3 of 11
•
OFFICIAL INSPECTION FORM•NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property.Address: J9Z 0-/FS%Z2A./,CC-,0
Anti ti
Owner: AL-Er_,Y c5 AE-.0 a./fL.C,
Date of Inspection: '
to/a 2-/n
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 failing to protect public health,safety or 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 public health„safety and the environment:
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 any)determines that the
system is functioning in,a manner that protects the public health,safety and 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 SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more froth a
private water supply well'. Method used to determine distance
This system passes if the well water analysis,performed at a DEP certified laboratory,for conform
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,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 371 Z C/M S%TCI1.it/Fc 0 ,e/
L.eF,Ds !'e/4 $
Owner: /1L, , cSG.E,p Z/F_�S/GL
Date of Inspection: /(7 ll2 9/d 7
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following for&L inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or cloggett.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 liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
0424 Liquid depth in cesspool is less than 6"below invert or available volume is less than Si day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped .
Z_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
D LW Any portion of a cesspool or privy is within a Zone 1 of a public well.
rt./A Any portion of a cesspool 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.'This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform 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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this forma
IV 0 (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
a
E. Large Systems: 0A.I4
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes 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—I WPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 39 _ CE/ /S T-fi
/;T/J S /11,F 5 3
Owner: 7," cert. P/JZ/T.[.0/,S k L
Date of Inspection:
2/i
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
_v X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received nonnal flows in the previous two week period?
XHave large volumes of water been introduced to the system recently or as part of this inspection?
_ Were as built plans of the system obtained and examined?(If they were not avail▪able note as N/A)
• Was the facility or dwelling inspected for signs of sewage back up?
_ Was the site inspected for signs of break out?
• Were all system components,excluding the SAS,located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
• Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
D/,.5 cC�SS/zd ,014-7,00/416 14 vi�'.r� t- _r
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
ies no 4../e-CGJ/J le?.c.:7
.2L
—
Existing information.For example,a plan at the Board of Health. /9 9' c/
— Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
t
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
392 crf,F57 F/e_ /E c ) fZa
Property Address:
Date of Inspection: /0/00y /o 7
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual). —9
¥ /0is4s,
/c,-Y 1/0
DESIGN flow based on 310 CMR 15.203(for example: 110 god x q of bedrooms): • .3 f JO
Number of current residents: a
Does residence have a garbage grinder(yes or no): /t/O .Xet/71/7-1",/,/B 4
Is laundry on a separate sewage system(yes or no):U.f fif yes separate inspection required) S 0 /i
Laundry system inspected(yes or no): i``"°' L flux—inlay/2.c/ yto /Q g—6 S
Seasonal use:(yes or no): /i/ /
Water meter readings,if available(last 2 years usage(gpd)): %JU4%sc 6€ /Lp C 0,7/1--e G/--ed
red F,rrr///c.y
ieil I/ c
,/on- h/.
Sump pump(yes or no).4CO A/e e,/
Last date of occupancy: 5 Lp ii-9
COMMERCLU/AIDUSTRIAL
Type of establishment: C
Design flow(based on 310 CMR 15.203): eod
Basis of design flow(seats/persons/sgft,etc.):
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/use:
OTHER(describe): (/
GENERAL INFORMATION j' G/9 /o 3)
Pumping Records
Source of information: dtc-i &J'EX_
Was system pumped as part of the inspection(yes or no):_ S
If yes,volume pumped:/OC gallons—How was quantity,pumped determined? /COO 9u
Reason for pumping: f/US/te C f-i o/c1 F /LPG£c#s tc c� d U
PE OF SYSTEM O /Jti 4 2 ep.'rc ha £//Z
Septic tank,distribution box,soil absorption system /'
_Single cesspool
_Overflow cesspool
—Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe); AiC L2 6e nCW sys 6 / 9 9.1
Approximate ageofall com nents,date' stalled(ifknown)and source of information:
G/Z, g° SS/% /y? f g 9 oOv a r�z/u
Were sewage odors detected when arriving at the site(yes or no):_ 0'f/ U/Z/ Cf/ /7 cc
L
A/6 y , 11/1
6
C
Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION4FORM
PART C
SYSTEM INFORMATION(continued)
392 c/ttk-5r i2/c/ado ) D
F/a/J1 /✓) 55
Owner: AZ Fza- c5'C..co a/.Erf%s C_
Property Address:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: 6 C , '
Materials of construction:!East iron = PVC other(explain):
Distance from private water supply well or suction line: " '
Comments(on candid°y of'ointo,venting,evidence of l akage,etc.):
,C/O Afl'/C�C(�,fl S' if'OCec-
C.,tAye -/u ,4vc.-a-- t
SEPTIC TANK:_(locate on site plan)
Depth below grade. <.%,
Material of construction:_Xconcrete_metal fiberglass___polyethylene '4
other(explain) ..%•,
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
Dimensions: 0�O . •tJ . •.6 . % ",c/0 , C/«
Dimansiom: c_
Sludge depth:
/6l ,r
N
Distance from top of sludge to bottom of outlet tee or baffle: I¥
Scum thickness: - -7 i' •
Distance from top of scum to top of outlet tee or baffle: .3
•
Distance from bottom of scum to bottom of outlet tee or baffle: Z.4
How were dimensions determined: "'
Comments(on pumping recommendations,inlet and outlet tee or baffle -as related to oral invert,evidence of leakage,etc.):
J�7 ,lJ�� Ai 3 �/K,/ OF A7.f ey ,pro to�>
lcC4? s9 / c cG/tip/c
GREASE TRAP:_(locate on site plan)
Depth below grade:_ 11-.11=7
Material ofconstruction:_concrete_metal_fiberglass_polyethylene other
(explain):
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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
«/r /%0 GC/KO
7
Page S of II
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
CR r sf/Z-iti Fy p /CO
a ns i-27755
fltlin - 5L C,v
/U/dam//07
TIGHT or HOLDING TANK:_y� (tank must be pumped at time of inspection)(locate on site plan)
n IUe7
Depth below grade:
Material of construction: concrete_metal fiberglass polyethylene other(explain):
Dimensions:
Capacity:
Design Flow:
Alarm present(yes or no):
Alarm level:. Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
gallons
gallons/day
ti
DISTRIBUTION BOX: >< (if present must be openedxlocate on site plan) /�
X.10 St/ /Lig C/— Goer L/E941 ,r1c
Depth of liquid level above outlet invert:. 0 r ICJ /et elr ' rV/ec - (Q-y,�/ti,
Comments(note if box is level and distribution to outlets T,any evidence of solids carryover,any evidence or
leakage into or out of box,etc.):
nOV 45 /4../ 900 C Oe r70 41
A L-L /tit-Le r/S Q' la cja r- pie L
PUMP CHAMBER:_(locate on site pl4 e%/1 .`
Pumps in working order(yes or no):
Alarms in working order(yes or no):_
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
S
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 39z Cl7' e5 ni/2.,C/ /F- CD '
Grr� DJ' /r4f55
Owner: /¢e-4X Jlam a Z/ Fr-41 /co
Date of Inspection: /01.9/07
SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required)
If MS not located explain why:.
Type
_leaching pits,number:
_leaching chambers,number:_
_leaching galleries,number:
leaching trenches,number,length:
XC leaching fields,number,dimensions: /ItiP et.; /KJ / j 5 p
_overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, on of ponding,damp soil,c ndition of vegetation,
etc.): 4 C f .L
o t/7�,
CESSPOOLS:_(cesspool must be pumped as part of inspection)(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(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Qti
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.):
t
9
Page 10 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 39z cfoc5/�/Z_C//FL'+2 /L{?
Lei>�S IV)fl-55 G
Date"
ollnspectioa: � 'LJt I� / �J 5
5 `
/o/8 9/0 7
SKETCH OF.SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including tics to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
10
Past II.of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' -.SYSTEM DaTrIAMAmrriar•---Nnued)
C/fr 57-/F F. cu e O
LC-T /7 7 /77/¢l f
Owner. /din r. r. . _ . LC% G
/o/d 9/07
Property Address:.
Date of Inspection: .
SITE EXAM
Slope
Surface water
Check cellar
_Shallow wells
' Estimated depth to pound was_feet / 7
Please Ind cats(cheek)all methods:used to deters It........a•,a!oono water elevation:
Y
Obtained from system design plans on record•:Ifcheeked,date Orderer plan nviewee
Observed she(abutting property/observation bole within ISO feet of SAS)
�-Chockd with local DOard of Health-expWn:.
----Checked with local excavators.thrillers-(attach documentation)
Accessed USGS database-explain:
Yauunsidescribe bow you blghfround wafer elevation:
el /799