65 Title 5 Report 1995 s WW
BOBBURYACL
Address of property 65 McYRN:N(.7„S:C>E tOR)va - NoS IAdA+i'4N, MPS .
Owner's name NAN:cy IAOORc I l
Date of Inspection VA 1e) tem'
PART A
CEECELIST
Check if the following have been done:
NOanIAWmON NOARDOF HEALTH
$5 Pumping information was requested of the owner, occupant,
Health.
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow 'rates during that
period . Large volumes of water have not been introduced into the
system recently or as part of this inspection.
I/A As built plans have been obtained and examined. Note if they are not
available with N/A.
r inspected for signs of sewage back-up.
�E5 The facility or dwelling was g
ya The site was inspected for signs of breakout.
`%&S All system components , excluding the SAS, have been located on the
site .
yE S 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.
Y.51- L The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
Y f.. The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
.*( hi€T 5AS 'S Ia'Jd ) TU A 1-11 NO
?J LsTR wT'dtki f3OX .
yes
and Board of
FLAW CONDITIONS
If residential
3 number of bedrooms
2- number of current residents
garbage grinder, yes or no
y laundry connected to s stem, yes ora
No seasonal use, yes or so
If nonresidential , calculated flow: Res toOnit
• Water meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
AL
Pumping records and source of information:
NC> welLal Dm RCZCctfS or This Sys'rENt • :5o✓R-GE oP
:Uccle-PAM'l:rM L% <' uR-Wa71 OLQ Al 6(Z o'C' PRoPGYtT�
fES System pumped as part of inspection, es or no
if yes, volune pumped ± )b300 &104L4.01JS
Reason for purping:
PJ=7ar ESTATE TRANSFER
Type of syster.
_ 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)
✓ Other (explain) SGPTtC. TRNV 4 1R/WEU"
Approximate age of all components. Date installed, if known. Source of
information:
Mir DATE OG 't.K AUMTVAn) tS vNKNn�.)N , "it MPS ec=� 'e"kV&c LNG
TH,S vbT fog A� !A-ThST tc yi=A24 4∎R< INpcXZ✓r1 i.) N
C✓ rr al- au Walt
NC) Sewage odors detected when arriving at the site, yes o
SEPTIC TANK: 7L0 •
(locate on site plan)
depth below grade: ± 29
material of construction:
metal _FRP __—other(explsin
dimensions: 601 L :L S w g C6 v fk--fZ ,NLE 1)
sludge depth
distance from top of
&scum thickness
distance from top of
distance from bottom.
sludge to bottom of outlet tee or baffle
scum to top of outlet tee or baffle
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, recommendations for repairs, etc. )
- QCILCV RAFFLE NA.S R= ERICATtA AJA 4,04,10(1) AF Rr'0.4AC J
, , ,1CC P+m'rf C ,s 1 .15"
4 a- I" of LuA ER RP,n:/' ofTicc 1 , JO inietzItT of S 'p 1,C
DISTRIBUTION BOX NUkC
(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, recommendation_ for repairs, etc. )
N/A
PUMP CHAMBER: N/A
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc.)
hkSTEt
if iS QE 4c V W 11.-vi, 1-wt. 5ecntC mN� :S AC—) iP & AS Fi L
disi¢ , L1,,'P gay,. ,e ', owe_ ecq p;pe ,C-itce se,P+4c +ca.. k
dsc,4 =s d,aecil a-e c(ayu,e (I
SYSTEM INYORMAS ve con'suuuu
SOIL ABSORPTION SYSTEM (SAS) : ✓
(locate on non-intrusive l , oible; excavation not required, but .ay be
approximated by
If not determined to be present, explain: ,
�ype
leaching
leaching
leaching
leaching
leaching
overflow
pits and number
chambers and number
galleries and number
h
trenches, number, length
fields, number,
cesspool , number
Comments :
(note condition of soil ,
condition of vegetation,
signs of hydraulic failure, level of ponding,
recommendations for maintenance.or :epairs,etc.)
•
c O-. •O i . — • � '
irsnrial --
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 groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments: signs of hydraulic failure, level of ponding,
(note condition of soil , g
condition of vegetation, recommendations for maintenance or repairs,etc.)
•
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments : level of ponding,
(note condition of soil , signs of hydraulic failure,
condition of vegetation, recommendations for maintenance or repairs,etc.)
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
x0.st.N(a.
fo0O GAl. 6sv T,c
TANG
4" ?VC SewaR pipe
■oRNING,sto& DRivE — Nos r w1/445TO1J, Nye-,
pavvvE LA-
DEPT TO GROUNDWATER
N i)
depth to groundwater
method of determination or approximation:
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (7, ■, or IID) . Describe basis of
determination in all instances. If "not determined", explain why not)
..kg_ Backup of sewage into facility?
NO Discharge or ponding of effluent to the surface of the ground or
surface waters?
N/A Static liquid level in the distribution box above outlet invert?
NIA Liquid depth '_n cesspool <6" below invert or available volume< 1/2 day
flow?
NO Required pumping 4 times or more in the last year?
number of tines pumped
NO Septic tank is metal? cracked? structurally unsound? substantial
in_ iltration' substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
NP below the high groundwater elevation?
No within 50 feet of a surface water?
NO within 100 feet of a surface water supply or tributary to a surface
water supply?
NO within a Zone I of a public well?
NO
(cesspools and vegetated wetland or salt marsh
SAS)?
Na within 50 feet of a private water supply well?
/40 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 coliforn bacteria , volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
Name of Inspector ' "nn.6Tky J'UR4-itJI.JIS
Company Name
Company Address 00 MokrinakL)E Rcec
1).3 Enr{M4 - Mfj 0 10 Z9
QI 527 - 5241
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
. consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check. one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have deterr. ined that the system fails to protect public health and
the environment as defined in 310 CMR 15 . 303. The basis for this
determination is provided in the FAILURE CRITERIA section of this
form. Info
Inspector' s Signature Il�j' Y H.�'n-
Date 5✓
Original to system. owner
Copies to:
Buyer ( if applicable)
Approving authority
Nom.
.0-E- aF -n.kt IwSc)EL1 or, 1"1� a'TL2=1 (3f3Ii.6 I.10ra skit SIGrNS of
DETcxuopn—kw Av-O out& J�o Lo 096 R- („tiC1-"h"6. SoCibS .carrot OBSeCzUdD .(
0;t- or .epTwTflV• , L 1 w' ( Is ± Af3ov ; 'ns
°Ul LbT PIPE. WASEwA 4_4()s ww4 iLowLY. P o SS•16C_• iaz4
SO1.�s
LoGG
F r 5� nom, LL TEwn� - A2E £,Ttiiea A Pc &C&� p 'pz G EC
sc;AL> AT D2 w
ELI Cow; Dee MA--0
a {tt Bafr w N
( _.oR.k-•
A .4- 414-c_ sys' d+u- 1 Re I■eJZ * ' I ige- S
p{S
1.5 wne--(( rc
i- Rz�� M-
F 6c ale„ w, r T«
Oi �2.e_e�c¢_ av��e II 1
UQ