50 Septic Inspection 1999 COMMONWEAL;I'II OF MASSACHUSETTS j
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF.MRWHAMProN BOARD OF KALIF
DEPARTMENT OF ENVIRONMENTAL PROTECTION-N�—ONE WINTER STREET. ROSTON MA 112118 Ifilll 2929900
11011
S 26 we
C 46 # /
TRUDY COXE
Seeretaq
ARGEO PAUL CELLUCCI DAVID R.STRUMS
C, rnor Commissioner
`GQQ QO /n lij(J// JYt2/d�GB FACE SEWAGE DISPOSAL SYSTEM MSPECUON FORM
.egr{7i/Z ✓v N47774-cD PARTA
�� Ye r cEnhIncATIGN ,� lT 4 0 !O G C
Property Address: ,7v/e T///9 n-do/dti /%i Name of Own.. %�O BO !r 3-el �%
Adbear of owner L%C o ,Q Alen.
Date ofbapeeti..: 4/1/5/9? -----_..
Name Impeav:(Phone Print) w/L_i //2/IJ IS/%/2 C/T/J /'M C%/�J S�//
1 ern a DEP approved mount Inspect.. em to seethes 1F..'inn 11111011%MI o chin is 0001 LO
conoerry ran: - q//cam//2m wig/7 cirn
MaNrp Addles.: —_ — 4,6 vp/4.,7 e/ Mc' sal a/SO
TelephoneNrmrer_
_---.__ /Y-tic- yal_o 14Q1-7Sf O/05 6'
anoN
girt tTATEaffll ///3 6-32- C6 2 5`
I certify that I here personally Inspected the sewage disposal system at this address and that the Information reported below Is true.sac
mad complete se of the time of Inspection. The Inspection was performed based no my training end experience In the pr• • r function and
maintenance of on-site sewage disposal system.. The system..
✓Conditionally
_ Need.Further Evel
Fells
Impechree Slprbwe:
The System Inspector shall submit a copy of this ion t to the Approving Authority (Board of Health orDEPI a ], 01 days of
completing this inspection. If the system Is a shared system or has a design flaw of 10,000 ppd or greeter.the Inspector end system owner
shall submit the report to the appropriate regional office of the Department of Envuonmentel Protection. The original ehould'be lent loin
• system owner.and copies sent to the buyer.If appllceble. end the approving authority.
NOTES AND COMMENTS
/Cd./ S/// / -C -'y 74C //514/ / /
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revised 9/2/98
Pee. a •d II
Property Address:
Owner:
Dote of Inset don:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
lL/F/Jr so i✓pCERTIFICATION(continued,
/0027/ig"Al"I/ oti - '
LOCO CG 7-11.0 55,..E./ su/.�/fr
INSPECTION SUMMARY: Check A, A C, or U�
_
SYSTEM PASSES:
I have not found any information which indlceles that any of dr. Inure cnndlaone described In 310 CMR 16.303 mist. Any Were
celled.not evaluated are Indicated below.
COMMENTS:
S. SYSTEM CONDITIONALLY PASSES:
One or more myelin component• ne described In tlrn 'Conditional Owes' ennui rind to he replaced or repaired. The system, upon
completion of the npineemnt or repair. n approved by the Rnr.1 nl Ilnllh, will one
Indicate yes. no, or not determined 4Y, N, or ND). Describe besle of determination In all Intones. If not determined".explain why not.
The made honk le mslsl,union the owner or operator hes provided the system inspector with•copy of•Certificate of
Compliman Ieneched)Indicating that the ten% wee Inn.Red whMn twenty 1301 years prier to the date of the kwpeodanl or
the septic tank, whether or not meal.I. necked,nrumonlly unsound, show.substantial infiltration or mMhedon,or last
lsibn I.Imminent. The system will pen Inepectlnn II Our emitting septic tank D repined with•compiyInd e.ada teak as
approved by the Board of Health.
Sewage backup or breakout or high etetic water level observed In the distribution boa le due to broken or attenuated Opals)
or due toe broken, settled or uneven distribution boa the system will pets Inspection 11 Iwlth approval of the Board of
Health).
broken pipets/are replaced
obstruction I.removed
distribution box I. levelled or replaced
The eyetem required pumping-more than four times a year due to broken or obstructed pipets). The irritant w6lpar-
Inspection If(with approval of the Bond of Neelthl:
broken pipets/are replaced
obstruction is removed
et/PC-(J _p/ie `ciL_ 4 e arum/ ,vim-e az)
474-i 57/1(-) 6 7111c/lc /S /c e`;e // /'U
/�/✓c /1 p/`5- /. J Cu0aO
revised 9/2/98
New rd II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
"/7)2 .571 dssrC/J NST .el
Preform Addles.: Nat%/�/i%Z�J O./ D.. ,t1,4
Owner: G_OCOCO /21/9 cr.v -5-C}/2"1
Date at Breweedon:
9 9
FURTHER EVALUATION IS REOUM BY THE BOARD OF HEAllfi:
Conditions mist which require further evaluation by the Board of Health In order lo determine II the system Is felling to protect the
public health,safety end the environment.
11 SYSTEM WILL PASS UNLESS BOARD OF HEAL11I DETERMINES N ACCORDANCE WITH 310 CMR 16.303(1801 THAT THE SYSTEM
IS NOT FUNCTIONING M A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE BRMOIMEIM
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 60 bet of a bordering vegetated wetland or a salt marsh.
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANT DETERMINES THAT THE SYSTEM IS
RNCTIONNO M A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: -
31 OTHER
The system has a septic tank end soil absorption system ISASI 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 soil absorption system and the SAS Is within•tons I of•public water supply wall.
The system has a septic tank and soil absorption system end the SAS Is within 60 feet of•private water supply wall.
The system has a septic tank end toll absorption system and the SAS Is lees than 100 feet but 50 feet or More horn it
private water supply well,unless s well water analysis for conform better,and Wattle organic compounds Indicates tht the
well Is free from pollution from that facility and the pretence of ammonia nitrogen and nitrate nitrogen Is equal to or less
than 6 ppm. Method used to determine distance lapprodmstlon not wadi.
, revised 9/2/98
Pert ii I
2 PC 4„ W
SUBSURFACE SFAGP DISPOSAL SYSTEM INSPECTION FORM
PART A
fU /Ifl 714,,f- 6 ,CFnT TION IcmnroMl
/1-7 0.0-7 97Z74J 141 '
PrePerty Address: LUC CC /t//15 .PJ.t/ L.5 >00,0 4/
Owner:
Dete of InepectIon:
?'/es/7 9
G. SYSTEM MILS: 22/1/A
You must Indicate either "Yes” or No to each of the following.
1 have determined that one or more of the following failure conditions exist as described In 310 CMS 16.303. The bads for this
determination is Identified below. The Board of I lacllb should be ton anted to determine what will be necessary to correct the failure
Yee No
Backup of eewege Into recillron o atem component due nn en overloaded ortlegged SAS ore...poo. s--are-a
Discharge or ponding of effluent to to eurlec•of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level In the disirlburim,hoe /dray. !mean livers dna in an nverinadud or clogged SAS or cesspool.
Liquid depth in cesspool is less than 0'" below Invest or evauehle vat is lees then 1/2 day flow.
Required pumping more than 4 timer In the lean vac. NOT doe to cragged or obstructed please).
Number of times pumped
Any portion of the Soil Absorption System, ceseponl or privy Is below the high groundwater&ovation.
Any portion of a cesspool or privy is within 100 feel of a surface water supply or tributary toe 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 Teel of a private water supply well.
Any portion of a cesspool or privy is less-then 100 lest but greeter Ihen 50 lest from•private wafer supply wee with no
acceptable water quality analysis. If the well has been anelyred to be acceptable.attach copy of well water analysts for
-conform bacteria, volatile organic-compound., ammonia nitrogen and State nitrogen. --
E. LARGE SYSTEM FAILS: div
You must Indicate either"Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to to criteria^bove:
The system saves a facility with a design flow of 10.000 pod or gunner'Large System)and the system Is signl0cent threat to public
health end safety and the environment because one or more of the following conditions eaiat
Yes No
the system is within 400 feet of a eurlece drinking water supply
the system le.within 200 feet of•trilnitery la s eudao.ddNbp-wets..supply
the system is located In a nitrogen sensitive eraa Ilnt• lm Wellhead Protection,Area-IWPA)or a mapped Zone 11 of•pubic
water supply well,
The owner or operator of any such system shall upgrade the system In accordance with 310 CMS 16.304121. Please consult the local regional
office of the Department for further Inforpration.
revised 9/2/98
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•
p ��� SUBSURFACE SEWAGE DIS OSAL SYSTEM INSPECTION FORM
S' //A 7E/f( SYSTEM 17 ARTRMATION
,Co'zt//gl1/pro-(/ i/9
PrelsitRY Alines: 10 C O C O 44/15 U.L1 5 c7p CI/
Owner:
Dem of Inspection: $4//377
FLOW CONRI I IONS
IIEiIDEi1TNL: ,104/1/1
Design flow: c.o.d./bedroom.
d
Number of bedrooms Idesignb_ Number of bedroom+tastlrell:
Total DESIGN flow
Number of current resident.:
Gerb.ge grinder lye.or not:_
Laundry(separate system) lyes or not:
Laundry system inspected (yea or no)
Sosonsl USG(yes or nol:
W.tw meter readings.if avelleble lint two year'•usage lopol:
Sump Pump I .or not:_
Lest date of occupancy:_
: S/Dtct,y/ St
../ a/ L.1<
Type of establishment:
Design flow: 00d 1 Baud 1%.203i
Seals of design flow /f,t.Can /OCJO PT Oren pep present Ins Of rust_ ,(%Q
du
In .tdS present.Holding Tank Preseyes or no/_11-1 U
Nan-ndtary watt*discharged to the Title 6 system:(yes or no1J[/0
Meter meta feedings.If ev,Reble:
Lest deb ofoccupncy: $-7-7e oLCtcy>/ir 0
OTHER:IDascribe)
Last data of occupancy: —
• If ye.. ..prat.Inapecllon requited
PURIM)RECORDS and source of Information:
C O/r/c./ /JAL-o-
9006 .3 l7l, FY 75�
/CO0
096 Gkt/0A/
GENERAL MFORMA UON
,r2an7 on-ix/A-/2 / v97 it„„„np,,,,/
to sr„ooam c/ 4w/oh C/Pfc
/7"c4/ /z /zoO/4ic/d
System pumped as part of Inspection: (yea or not AJO
II yes, volume pumped: 3 00 gallons
Reason for pumping:
/coo�Qee /net)
TYPE Of-SYSTEM
✓ Septic tank/distribution bodsoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) Iii yes. attach previous Inspection records, if any)
I/A Technology etc. Attach copy of up to date operation and rnnintenence tonaecl
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components. date Installed MI known)end source nermadon: .--.• ��g 7—
Sewage odors detected when arriving.1 the site:lye.or Tin)w v
revised 9/2/98
M1ar 6 nd lI
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
4b PART C
.4 %4/e SYSTEM INFORMATION!continued)
Props*Addible: prig/.rc„0 riX
owns: /U0Zr//nrr)p re,.c/
41//s/99
Date of krpodon:
S ULDNO SEWER:
L ocale on site plan)
Depth below grade: 3«�/
Materiel of construction: c.a Iron_40 PVC_ other le apish)
/114 $5
Distance from priln,water supply well or suction line /7N eel
Diameter
Comments:(condition of Joints.s, venting, evidence of l.ekeee,<tcl ._
/7 C/ maser, .7-7 -c/ No 5i7r7 v.= isor;,..eo S
SAttl TANK:_
Robb on she plant
Depth below grade: /
Material of construction: ✓Ee tcrete metal Fiberglass Polyethylene ntlierleepinbd
50
If tank I.plea,net urge_ le.eg.confirmed by Cernnnare of Cmnpllmru IY•slNnl
Dknandone: n X ,3 3o it 3,57) Gate �/I/JC
S iudgedepth: /eS5 /ha", / •••
Dl.tsne•from top of sludge to bottom of outlet tee or belne.__/VO'1-P "451
Scum tNCknn.: do"`P � ."
Distance from top of scum to top of outlet tee or helps:T o
Distance from bottom of scum to bottom of outlet tee or baffle, /P "v
How dimen.lono were determined: fir e eo 5 r>'Le p
Commanld:
(recommendation for pumping.condition of inlet and outlet lees of belnss. depth of liquid level In relation to outlet Invert,ebucturel-M.gdty.
evidence of lea g.,etc.)
CSUSG/lc c)
Iv 1171 X-'e rnsef
GREASE TRAP:
gowns on site plan/ M N
/SOO 0Alt Sey9 c
Depth below grade:_
Materiel of construction: concrete_metal_Fiberglass Polyethylene__otherieepiainl
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:
Dale of sat pumping:
Comments:
Recommendation for pumping.condition of Inlet and outlet tees or baffles. depth of liquid level in relation lo outlet invert, structural Integrity,
evidence of leakage,etc.)
revised 9/2/98
p.I,1 of II
Pmpwl1 Address:
°wont:
Deb of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSIFM INSPECTION FORM
PART C
E4 42 SYSIFM MronMAltoN 'coodmed)
66 //4 /E-6.0 sr
OZ7—,e/ 4niflYZY ft)
rN!/7SS
41/15/ 99
T,BNT OR MOLDING TANK: R nnk mu,I he pumped mint in nr nr tlm. of. less par,lino,
Iloeate on site plenl /t it / .')
Depth below grade:_ Ft/ /Y
Materiel of construction: concf ete metal Fiberglass Polyethylene ell erlekpleInl
D imension:
Cep.clty: gallons
Design flow: gallons/day
Alarm present_
Alarm level: Alarm In working order, Yee No
O ne of previous pumping:
Comments:
loonddon of Inlet tee, condition of alarm end fleet switch-, ete.I
DISTRIBUTION BOX:_ Me"4-"C
(locate on site Alen)
Depth of liquid level above outlet invert:
Comments:
(note II level end distribution is equal. evidence of solids carryover, evidence of leakage Into or out of ben, etc.,
PUMP CHAMBER: 4 N4
(locate on site Olen)
Pumps in working order:(Yes or Not
*Urn In working order(Yes or No)
Commonly:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
, revised 9/2/96
Pqr R of II
alb
Property Address:
On:
Data of Inspection:
SUBSURFACE BEWARE DISPOSAL SYSTEM INSPECTION FORM
PART C
2 L .ter N SYSTEM MFORMAIION (continued'
ye cg 5TA_ e .(JO,Qrhor +-yArem A-I4
LGCOCo 4-7 /9Sox-' S01)?/ �
r//r/€7 9
SOIL ABSORPTION SYSTEM(SAS,:
(locate on elte plan.If possible:mmetvntlmn not required,Inc/radon may ha nnproebnated by non lnhuelv•methods)
If not located. explain: Z ID /IC Y 11 /0/ /5 /,t' . 5fi'/ r'5
Type: ET U//? W a>/777, Z,C_' Sre2A-AP
leaching dta,number:?- ^
leaching chamber.,number: /7/2O C/.0(.//J
leaching gallsb..number:
leaching trenches,number, length:
leaching fields,number,dlmensbnee_
overflow cnepool.number
Alternative system:
Name of Technology:
Comments
(net,condition of colt signs of hydraulic (allure, level of routing dump toil. conditon et vegeutlon, etc.)
4 RC/T.Rit5 /V X00/7 oti J
/UG 5/5 > 4,o /croitb2PnJ f
CESSPOOLS: ,N )4
(locate on ante plan) /°
Number end configuration:
Depth-top of liquid to Inlet Invert:
Depth of solids layer:
Depth of*cum layer:
Dlm.nslo$a of cesspool:
Materials of construction:
Indication of groundwater:
Inflow Icesspod must be pumped as part of Inspection)
Comments:
(note condition of eon. signs of hydraulic failure.level of pending, condition of vegetation, etc.)
PRIVY: . N/!
(locate on alts plan,
Matedele of construction:
Depth of said.:_
Comments:
(note condition of soil signs of hydraulic failure,level of pending, condition of vegelnllon, elc.l
Dimensions:
revised 9/2/98
Foot c nl ti
property Addreee:
Owner
pets of*napeeden:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontwredl
sv r/4177-/� €d sT
/4/0 ' '7/,I tn,,c1JZJ.t/ /1-4%i
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SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include the to et least two permanent talerence landmed•or huminneres
locate NI wells within 100' (Locale where public writer topple cornet Inm imueel
2#27 4-
et A9 4 cr<.�
revised 9/2/9B
Pirko .042-`-/
haywtyAddsea:
owrrw:
Data of Impactors:
NRCS
USGS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
44C/7k SYSTEM INFORMATION(continued)
JZ /Y/4/7-g7471 O Sr
,UO2r1/,,,nj'/o.v /Id/VSI
LOCOCo %n /1 So A-) -5.4
Report name_.. .„
Soil Type_
Typical depth to groundwater
Data website visited
Observation Wails checked
Groundwater depth: Shallow
SITE EXAM
Slope rer—in/—
Surface water b o1cf
Check Cellar ,U4.t./'
Shallow wells A./el
Estimated Depth to Groundwater a Fear
Moderate Ilene
Nee •Indicate ell the methods aced to determine mph thoon lwedr Fleanlinnr
044/ Obtained from Design Plans on record
Observed.Site(Abutting property.observation hole. horseman, some err I
V Determined from local conditions TF ST /'i/ et e n v % 44 r
let Checked with local Board of health
/7 4,41 Checked FEMA Maps
2 AChscked pumping records
II Checked local excavators, installers
/4p II Used USGS Date
Describe how you established the High Groundwater Elevation. (Must be completed/
C—c° 7rce c-ce/ / c- L
8 -NV rog-e-Cc eo
Sr✓(4-7)
NF> z
, o74 /
TC 1
Le SS tilt//7 id• Gm•c/iwct1
revised 9/2/98
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io ye_ 5-z
51/a s f<
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finAm
D
NO M cd--74
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rage II or II