9 Septic Inspection 2000 ARGEO PAUL(ELLUCCI
Governor
COMMONWEALTH OF LL1SMACiju5ETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL At?
DEPARTMENT OF ENVIRONMENTAL PROTEC ON
ONE WINTER STREET.BOSTON MA 02108 (617)2925500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
7 ce tiLUr CERTIFICATION
Property ry Adbas: f i C,TrnA 4f't' 7
Name of Owns.
One of Inspection- O"O f J//� /' �(/(? Address of Owner:
Nan.of Inspector(Please Prim1 all OA(_/' 1f AMYL/
I rata DIP approved system inspector pursuant to Section 15.340 of Title 5 1310 CMR 15.0001
Company Nan*: _.Affordable Home and Septic Inspections Inc.
Mrting Ad&t44 51 Laurel St.
Telephone Nu lye:Holyoke, Ma.01040 413-532-8600
CERTIFICATION S rATEMENT
certify that I Is personally inspected the seweg•dispesa system at this add'.is and that the information ported below is true. a n
end complete a: o the time of inspection. The inspection was performed bend on my training and esperie,c in the proper function and a e
maintenance of on site sewage disposal systems. The system:
JAN I 0 2001 1111il
■
MPTON HOARD OF HE
CONE
Secretary
DAVID B STEUHS
CtnLiss:only
Passes
_ Cocdrnonally Passes -
_ Needs Further Evaluation By the Local Approving Authority
Foils/ 1 n d
Irupecloi•signet re: /-onidd iM..-Wits. Date: 1414 Aro
ate System Impe nor shell submit a copy at this inspector, report to the Approving Authority(Eased of Heart or oEPl within they 1301 de ye of
ompletrg this .r.s)e:tion. If the system is a sharee system or has a des.gn flow of 10.000 god or greater. v e inspector and the system owner
shay submit the re ion to the appropriate regions: office of the Department of Environmental Protection. The rigmel should be sent to the
syssm own,, std copies sent to the buyer, if applicable. end the approving authority
NOTES AND CCs t ENT$
C f��; wQ_.
prised 5/2/98
%
race I at I I
0
espy
open AQSess
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
7�5, ea_hrh.�Jdx
wner: 1'\thtfticA 1
ate of Inspection: 1 i/a /et
SPECTON SUMMARY: CISec(AS, C, or D:
SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310
criteria not evaluated we indicated below.
OMMENTS:
R 15.303 exist. Any failure
SYSTEM CONOMONALLY PASSES:
_ One or more system components as described in the "Conditional Pass' section need to be replaced
completion of the replacement or repair,as approved by the Board of Health.will peas.
idmate yes, no, or not determined(Y. N. or NOT Describe basis of determination in all instances. If 'not del
_ The septic tank is metal.unless the owner or operator has provided the system inspector
Compliance(attach•d)indicating that the tank was installed within twenty(20)years prior
the septic tank, whether or not metal,.is cracked.structurally unsound, shows substantial i
failure is imminent. The system-Will pass inspection If the existing septic tank is replaced
approved by the Boer/ ealth.
Sew backup or breakout or high static water level observed in the distribution box is
or tae to a broken,settled or uneven distribution box. The system will pass inspection if I
eahhl.
broken pipets' are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more then four times a year due to broken or obstructed pip
inspection if(with approval of the Board of Health):
_ broken pipelsl are replaced
obstruction is removed
re ai sett 9/2/98
Pace]of 11
r repaired. The system, upon
rmined", explain why not.
ith a copy or a Certificate of
o the date of the inspection; or
nitration or exfiltratian, or tank
ith a complying septic tank as
to broken or obstructed;opals)
ith approval of the Board of
I. The system will pass
erlY A tas:
9pq
of Inspection: / 4 /:I/o+I
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 s stem is failing to protect the
public health,safety and the environment.
II
SYSTEM NFUNCTIOONIN UNLA MANNER WHICH WILL PROTECT THEJPUBLIC RHEALTH AND SAFETY A D 5.303111(b)THAT THE SYSTEM 310 CMR
_ Cess$e°I or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of•bordering vegetated wetland or a salt marsh.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
.CETIFlCA N Ic°rslinsedl
/1-e)
21 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY IF y
FETY ANDTHEENVt NMENT THAT THE SYSTEM IS
The system has a septic tank a oil-absorption system ISASI and the SAS is within 100 eat of a surface wafer supply or
lributery to a surface supply.
The system has eplic tank and soil absorption system end the SAS is within a Zone I of a public water supply well.water supply
The syste as a septic tank and soil absorption system and the SAS is within 50 feet of private or Tore from a
The tam has a septic wll`aunl unless a wlell water l analysis N•conbem SAS bacteria than
sonic compolunds indicates that the
peal is water supply well, is
well is bee from pollution from that facility and the presence of ammonia not valid'.nit ate nitrogen equal to or less
than 5 ppm. Method used to determine distance
3) OTHER
revised 9/2/98
Page 3 of 11
Add¢FS:- 9 411
kw on.: i/ /old
STEM FAILS•
st indicate either"Yes or"NO- to each of the following:
I have determined that one or more of the following failure conditions exist as described In 310 CMR 1-.303. The basis fort is
determination is identified below. The Board of Health should be contacted to determine what will be scenery to correct the failure.
No into facility or system component due to an overloaded or clogged SAS o cesspool.Backup of
SUBSURFACE SEWAGE DISPOSAL ATb ISM Mitt tend nJru
PART CERTIFICATION(continued)
OD ; 'lr vm„.y,J,‘,1/4„.
sewage
Discharge or ponding of effluent to the surface of the ground or surface waters due to an ov rlosded or clogged SAS or
cesspool.
_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged .AS or cesspool.
Liquid depth in cesspool is less than 6" below invert or ennoble volume is less than 1/2 day flow.
Requited pumping more than 4 - rn the last year (LOT due to clogged or obstructed pipe
Number of times pumped
Any Portion of it Absorption System. cesspool or privy is below the high groundwater elevation.
Any Do• •n of• cesspool or privy is within 100 feet of•surface water supply or tributary t a surface water supply.
Any portion of•cesspool or privy is within•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•cesspool or privy is less-than 100 feet but greater than 50 feet from•priv to water supply well with no
acceptable water quality analysis. If the ell has been analyzed to be acceptable. anach c •y of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen end nitrate nitrogen.
LARGE SYSTEM FAILS:
must indicate either "Yes' or IN to large eachSUms io•sdwiing to the Criteria above'.
The following criteria apply ge
_ The system serves a facility with•design flow of 1 pd or greater(Large System) and the syst-m Is a significant threat to public
health and safety and the environment D one
or more of the following conditions exist:
No syssrfls within 400 feet of a surface drinking water supply
_ thiSYStem is within 200 feet of a tributary to a surface drinking water supply
/ the system is located in a nitrogen sensitive ties(Interim Wellhead Protection Area•IWPAl or a mapped Zone II of a public
water supply well)
,e owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(21. Please consult the local regional
fice of the Department for further infopnetion.
revised 9/2/98
Paged of It
SUBSURFACE SEWAGE DISPOSAL B YSTEM INSPECTION FORM
PART CNECKIYST
vM lN /(_.,e) F.P_rMfiol
y Adde
I krapecdon: fx$A 00 yelS.tM1.kA
•if the following have been done:You must indicate either'Yes' or No es to each of the following'.
No
Pumping information was Pr ovided by the owner,occupant.or Bond of Hu1th.
normal flow
Nona of the system components hove been purnpad for et least two weeks end attw
the system has beenin9
rates during that period. Large volumes of water have not been introduced into the syste recently or as pan of this
inspection.
As built plans have been obtained end examined. Note if they are not available with NIA.
The facility or dwelling was inspected for signs of sewage backup.
The system does not receive non.sanitery or industrial waste Row.
The site was inspected for signs of breakout.
All system components,excluding the Soil Absorption System, have been located on the
The septic tank manholes were uncovered, opened, end the interior of the septic tank was i
or tees, materiel of construction. dimensions, depth of liquid, depth of sludge, depth of sc
The size and location of the Soil Absorption System on the site has been determined base
Existing information. For example,Plan at B.O.H.
Determined in the field(11 any of the failure criteria related to Part C is at issue.approxime'
115.30213)(bll
The facility owner land occupants, it different from owned were provided with informaho
SubSurface Disposal Systems.
nspected for condition of baffles
Page s of 11
evised 9/2/98
on:
on of distance is unacceptable)
on the proper maintenanceAI
Add'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
„SYSTEM NFORtrOi
KC)itee-wq)
1aiMr
nspecd a
on: 1.L , d
IML:
low: l�f: g,p.d.lbedroo
o f bedrooms Idesi9N: v
SIGN flow iz
of current residents:
grinder l yes or no):
'separate system) es
•system inspected pis o
e l use ryes or no/i1L-11
• readings,if a gable
ump yes or no):
to of occupancy:
m.
FLOW CONDITIONS
Number of bedrooms lectuel):2
or nolaL• II yes.sepstne inspection required
r nal
(last two year's usage fgpol: /Utu 60
- 74+-
ERCIAVINDUSTRIAL:
1 establishment: ----
now: vpd I Based on 15.203)
if design flow
!trap present:(yes or )_
vial Waste Holding Tank pre c (yes or no)_
snitery waste disch to the Title 5 system: (yes or stole
meter read available:
ate olocw-GpancY:__
7,
R(Describe)
late of occupancy.
•ING RECORDS and s
roe of infor• ation:
GENERAL INFORMATION
System pumped as part of
II yes, volume pumped:
Reason for pumping:
pection: (yes or no
gallons
P F SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy inspection ncmtls,if any)
Shared system(yes or no (if yes. attach previous up_ ❑A Technology etc. Attach copy Approval
of to date operation and maintenance contract
Tight Tank Copy of
er (C/%�7
PROXIMATE AGE of all components.date Installed lit known))and source of information:
-
wage odors detected when arriving et the site.Ives or nol
•
revised 9/2/98
Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL C SYSTEM INSPECTION FORM
PART SYSTEM NFORMAPON 11
dunnio
y AdySss:, r y
Wpecdon: I A/3pd
NG SEWER:
on site plan)
below gradr ta
al of construction_cast iron //AO PVC other(explain'
ce from// Wale water supply well or suction line
ter yv
(ants'.(condlti•. of joints,venting.*vide a of)eekaga.etc.'
C TANK: .ne
e on site platy
,8
r below grade: II Polyethylene otherleaplainl
rial of construction: concrete_metal_Fiberglass
Lk is metal,list age Is age confirmed by Certificate of Compliance IYes:No)
nsions'. Js h .5-A ')
grice d •from top of sludge to bottom of outlet lee or EaHlc Y
n ehickeess:�
once from top of scum to top of outlet tee or baffle: 1
once from bottom of scum to bottom of ou let e o be le: a
r dimensions were determined: , _
tmems' p pJ inlet and outlet ten or be r1 s.dap do�Elppuld le
ommendetion for pumping. pq me t
lest of leakage. tel
La_ —
EASE TRAP;__,
:ate on Site plan,
pth below grade:, N Mer
Polyethylene_oleaplein)
nerlel of construction: _concrete metal Fiberglass ye Y
Tsion
en thickne of outlet tae or bathe!
stance •m top 01 scum to top 0
isle from bottom of scum to bottom of outlet tee or baffle._
of lest pumping:
'ecommendetion for pumping.condition of inlet and outlet tees or baffles,depth of omments:
[quid level in relation to Outlet invert.Structural integrity,
vidence of leakage,etc.'
n relation to oJtletRnvert,structural integrity.
0
Pagel of U
revised 9/2/96
SUBSURFACE
specton: y 1 a �pOM ((J4[: SEWAGEDISPOSAL SYSTDA INSPECTION FORM
SYSTEMIINFORMATION(eu bwsd)
i-/01 VLs eaWs bet--
t HOLDING TANK: (Tank must be pumped prior to, or et time of. inspection)
site plan)
ow grade:__
sf construcdon:'_concrete_motel Fiberglass_Polyethylene otbateaplain
ins:
germs
ow: gallons/
el: er m in working order:Yes No
e se
previous ping:
m 4s t f inlet tee, condition of dorm end Boat switches,etc.)
BUTTON BOX:S
on site plan)
of liquid level stove outlet invert:_._
ants'.
Slevel - d disv'bmion iseq e6 cvi once pfsd ds c n o� .evi eB leak.-•Into or ou
P CHAMBER:,_
le on site plan)
os in working order:IYe - Nolte
ns In working oFOe es or Nol__.
ments:
conditio pump chamber.condition of pumps end appurtenances,etc.)
eta)
Page 9 of II
revised 9/2/98
A
SUBSURFACE SEWAGE DISPOpA CSYSTEM INSPECTOR FORM
PAT STS I FQRMAnoN(canme,ed)—p g ' s- rip
A J
Bspecton:pon. I'g 1d.fb¶
BSORPFION SYSTEM(SAS): approximated by non-intrusive memo
on site plan.it possible:excavation not requited.location may be appr
mated. explain:
leaching pits. number:,_
leaching chambers,uumeer:_
leaching trenches,number,length.
3 /AWL CX
r,a9 leaching galleries,numbed
leaching fields, number,
dimensions:
overflow cesspool,numbed
Alternative system:
Name of Technology:
Hants: , damp so il.-5P^ditian of vegeui on, ea }
:lN n of soil. spans of hy-reu c failure,level of ponding �Xu y��of eg—q-8189
�N `-
SPOOLS:,_
de on site plan)
ter and configuration:---
th-top of liquid to inlet invert.—�
th of solids layer.
an of scum layer:
nsions of cesspool:.
trials of construction:���----�
cation of groundwater.
inflow'(cesspool must be pumped as part of inspection)
cots'.
ote condition of soil. 'ions,of hydraulic failure,level of ponding, condition of vegetation,etc.1
RIVY:
oc ate gr�sile plan)
Hills of construction'.
pth of solids'__
note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
;omments
Dimensio
Pele 9 of It
revised 9/2/98
SUbSUR/FACEESEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART S now lmtme+dl
/Ul a
se;
tpectim: f 1 .1.�04
)F SEWAGE DISPOSAL SYSTIA;
,nolude ties lwells within 100'locateewhere public water or
benchmarks
boo e comes into house)
(J
revised 9/2/98
Nd12- 6'a'r
page ID of Ii
Added's:. 7 id
,0
on: 2,
nsPectim: is /Aker
SUBSURFACE SEWAGE DISPOSAL CSYSTEM INSPECTION FORM
TS NFOR T10N 1oawlinsi
Clrf
Report name
Soil Type_ groundwater
Typical depth to g1
Data website visited
Observation Wells checked Moderate
Groundwater depth: Shalow
(AM CAP✓
Surface water
Shallow wells
SI
ted Depth to Gmundwete Feet
indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property. observation hole. basement sump etc.)
Determined from local conditions
_Checked with local Board of health
_Checked FEMA Maps
_Checked pumping records
Checked local excavators.Installers
Deep
_Used USGS Data
scribe how you established the High Groundwater Elevation. (Meru be completed)
,O CAI •
tII f1N-^ OAO Pi to 0 Cn
revised 9/2/98
Patc 11 of tt