323 Septic Inspection 1999 WILLIAM F.WELD
Governor
ARGEO PAUL CELLUCCI
Lt Governor
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02109 617-292-5500
NOV 1 2
TRL'DY CORE
Secrew,
DAVID B.STRUHS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ Commissioner
PART A
CERTIFICATION
32.3 Cole$ meads( 'd
Property Address: AJ or ha»'r1- )) /y)A
Date of Inspection: ❑15199 F "
Address of Owner
(If different)
Name of Inspector: Rebo- - 54-over- Warts,“rvvl0sfan/ 7194
1 am a DEP,approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Olk('1(A
Company Name: t4m hers tl' Civil PI riCCrf/lq.
Mailing Address: (� C
Sgep fs � , Seat/rPiarN
3z3 Coles MecOow (24.
g Otto'-k-3312
Telephone Number
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:
11/Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: ).iL't• Date: Il LSll r
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty 130) 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:
At SYSTEy 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 /I
COMMENTS: cJIs ( l7J /t
-110.1 be)! ep[4ueI /% 777. Sys feM has tOLU V[:c
a:117 0;62c 4`ta`1 e
B) SYSTEM CONDI NALLY 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.
Ed) 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 120)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.
(revised 04/25/97) can 1 of 10
DEP on the Ware wide Web ntlp'./Mww.magnetstate.ma wasp
/% Pnned m Receded Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
3Z3 Coles FS.) 140•
Property Address: ik o„ + ' P h-', ✓n
Date of n 0
Date of Inspection: R. cn✓"aa�'V�4�
11 IS i 9`I
81 SYSTEM CONDITIONALLY PASSES (continued)
no
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
plpelsl or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
_ broken pipets) are replaced
obstruction is removed
distribution box is levelled or replaced
no 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 pipets) are replaced
obstruction is removed
CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
n� Conditions exist which require further evaluation by the Board of 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:
d R Cesspool or privy is within 50 feet of a surface water
it 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 THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
no
no
QO
4-0
3) OTHER
The system has a septic tank and soil absorption system (SAS)and the SAS 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 and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS 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 tha
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. Method used to determine distance (approximation not valid).
(rwsua 04/2S/97)
Page 2 of 10
Property Address:
Owner:
Date of Inspection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
- _
CERTIFICATION (continued)
323 Coles �r�'L"-btr K.c
nlor+it 3p tLd1l/
T• f2• Buvre,
D1 SYSTEM FAILS: / 1/5 197
Y ust 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.
Yes No /
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or paneling 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.
N/A _ Liquid depth in cesspool is less than 6" below invert or available volume is less than tit day flow.
Required pumping more 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.
1°'/FA• Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
NIAAny portion of a cesspool or privy is within a Zone 1 of a public well.
tgffL Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A 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.
Ef 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:
IN A 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:
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-IWPAI or a mapped Zone II of a
public water supply we'll
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(eevieed 04/05/97) Pogo 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
323 Co In fYLOAte r ,q ,
Property Address: TO De 44, .&,ph *
Owner:
Date of Inspection:
S. /Q . vrei 4� P
rr(s(49
Check if the following have been done: You must indicate either "Yes"or No as to each of the following:
Pumping information was provided by
cupant or Board of Health.
+ k is Sit woek1 c,
None of the system components have been pumped for at least two weeks and the system has been receiving normal
Bow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note :f they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
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.O.H.
Determined in the field if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) It5.302(3)1bn
(revised 04/25/97) epe 4 of 10
313 Colts
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'M ? Y TEM INFORMATION
Property Address: V ss/e a„ „lP` A/KBW44
Owner: / - 1Y% e
Date of Inspection:LT • p
R. aD ear C -R4Anc
/r/s/99 v
FLOW CONDITIONS
RESIDENTIAL:
Design Flow: gg.p.dfbedroom for SAS.
Number of bedrooms: ff Z
Number of current residents:_
Garbage grinder (yes or no): C$
Laundry connected to system &es or no): LG.j
Seasonal use (yes or no): AG Li
e.5
meter readings, if available (last two (2)year usage (god/
Sump Pump(yes or no): ✓/0
Last date of occupancy:
waa
917 +D 9I4q avcray va.cw_gc
1-71 .1 9Pd -
ocwpiea o.E- f'%wt o-f i•+spe�'fie-Li
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 nol_
Water meter readings, if available.
Last date of occupancy.
OTHER: (Describe)
Last date of occupancy.
GENERAL INFORMATION
G RECORDS "source (mio anon:
po ./e a in's , •7dendfon+/ i7 NDvotvaa. ,`198, 5/24 /97
( h, art of ins (yes or ol_ " ��
tgallons
nsr / n -ELn.e. .5“)J Pw ets^. 6a / 776
aa
Lion system T -_'_
PUMPING
em pu ped asp inspection:
If yes, volume pumped: 417."
S0
Reason for pumping: )nSfir e.
TYPE flF SYSTEM
V Septic tank/distribution bodsoil absorp
_ 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?
Other
1PPROXI TE AGE of all components, d to installed (if known) and source of information: /
tre1& Ins FQ 19B7/�LSA*-�bokew, bole 145-140 lied 199' 7.
Sewage odors detected when arriving at the site: (yes or no) no
r E qshiad /97/e
(revised a4/2s/sn Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
323 Coles hleasa oco. I Iht UasA yorv. —
Property Address: formar/n�7�p4tn / m 31 }}���``
Owner: SOS. B4/56 re De Alfa �t
Date of Inspection:
11/5199 b,0 sir
BUILDING SEWER: /SII� �r { ,�K ilerN
(Locate on site plan) 5 t'OJ y 5 8
Depth below grade: 2.41( t
Material of construction. ✓cast iron _40 PVC_other (explain)
Distance from private water supply well or suction line
Diameter H
Comments: (cpppnditwn of joints, venting, evidence of akage, etc.) •
f jrfn aN .
SEPTIC TAANNKj:✓
(locate on site plan)
Depth below grade: 13 n±
Material of construction. coyCrete metal _Fiberglass Polyethylene _otherlexplain)
/hSi-4 Ad ) fir / ZSO ryq/c au+ah&r VL
If tank is metal, list age _ Is age confirmed by Certificate of Confpliance _(Yes/No)
iHO r • eft
Dimensions: I0'Sft_ X tier.0 ± W x "T' 11 5 U 1 c.l it&
Sludge depth: t'• 92 it
Distance from top of sludge to bottom of outlet tee or baffle. J_
Scum thickness: Z.,_3' 4
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or bxffl - 0-2"
How dimensions were determined. ✓nf���/s-l�u
Comments:
(recommendation for pumping. condition of inlet and outle tees or baffles, •epth •f I •uid level in relation to outlet inv-n, structur-
T�'
integrity evidence of leaka e, etc.) I' , U t - • ! � ' "•
'
GREASE TRAP:N14 rctS P a Vww(i k
o✓P
(locate on site pl ) Levi
,Le e-tiq; ,&J
�Ap'I1wM1..t .
••• 44-7 d,,.t. tIo A--
erthay h c.. .V leach cal id,
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 04/35/97) Page 6 of 10
Property Address: WOr+I a.v..p nt ✓h A n
Owner: d
Date of Inspection: SOS• %2,- u rej4r
11/5/ TI
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
323 Coles Meadow kcC
Depth below grade:_
Material of construction: concrete metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order_ Yes;_ No
Date of previous pumping.
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: di wl•i b�lo yrnd�
(locate on site plan) OD
n
Depth of liquid level above outlet invert: D
Comments.
(note if level and distribution is equal, evidence of s ids carryovggr, evidence of leakage into or out of x, etc.) ho SONS
Dis-f*i6 ion bo Nos / 4n.PleaO S/ 1 q o..nd ss ( q co., / •
' n (s t
ellFe rnil a r !l
PUMP CHAMBER: NM
(locate on site plan)
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.)
(:wi..d 04/25/97) Page 1 of 10
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION
(locate on site plan,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
x3�23 Coles_� `m�� tad ow Zf.
N OY-k'ka.vt y ez, �)Q /�
S05. 2 . wr elan!)
1115199
SYSTEM (SAS):
if possible; excavation not required, but may be approximated by non-intrusive methods)
If not, to be press explain:
� M tr141 1,
Type:
1 i a--7 P 4/t wv j"
W ✓ eGOI G'f
T-ut- innta OT
leaching pits, number:_
leaching chambers. number:_
leaching galleries, number:_
leaching trenches, number length: 1, go')
leaching fields, number, dimensions: / ( 2-0 /
overflow cesspool, number:_ LLL
Alternative system:
Name of Technology
Comments:
(note csnnd;b n of so I, sig of hydraulic ailure„1 well of ponding, condition f vegetation, etc.) ,r PLO
vlr- ++,tT ._.._�
CESSPOOLS: 4 A
(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:fi '
(locate on i9rte plan)
Materials of construction: Dimensions:
Depth of solids_
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revived 04/25/97)
Paye I of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM Y'IN�FORM^ATION (continued)
Property Address: 32.3 Coles '� `"C�
tr ..�'
Owner: 1`10r-i4- aI nYh fi'ocl/ M
Date of Inspection: .7pc�r C. Bettor er
n)sta J
SKETCH 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)
(revised 04/25/97)
FENCE
fool-
FErJCE,
B171127.1
i 0
Tal
Seen C.TAN k
12.50 CAL.
10,5
(— — Nit SEPTIC -FMK'
I pan is 1.5
) }IcUSE FKow' NcAN.Q-EST
I DR-INCc c.bwrA- CF F RA"6
\ , kpprrt r1 .
1 I
1 I
G olx s
In EA.Dicsw
RDAD
Pegs 9 at 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
W� SYSTEM INFORMATION (continued)
Property Address: 323 Coles O1 P.ac&ow R
Owner: N oF'4'�..aw.�'tFs'ti /�'4 „I
SOS' R. ad.-c't
Date of Inspection e jkr
IIisl99
Depth to Groundwater IV Feet
Please ii dicate all the methods used to determine High Groundwater Elevation:
7 O ined from Design Plans on record
Observation of Site (Abuning 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)
d104...ewv J . ,tea-T-c0 T 11-45 I/ op f bi
FIWn aSSocio re -� -- oh5/np_O SyS - ( ((n0)
No �c l'/Q'' .ew�7Lo-u.t. /' .d9 a ote'#41
6iroov sV✓'trte ,,� uwc ( ,� , p,/� au_1
affiac
I S aatMv-c. "%G-t- WT dj /'o 0 old way s at) ' -
(revised O4/05/977 69. 10 of 10