29 Septic Inspection 2004 tkGEO PAUL CELLUCCI
3uvernor
JANE SWIFT
Lieutenant Governor
COMMONWEALTH OF MASSACHUSETTS /
EXECUTIVE OFFICE OF ENVIRONMENTAL AFT: IRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE TCI: TER STIF E:T, BOSTON, MA 02106 G17-202,5500
,SUBSURFACE SEWAG
Property Address: 3-9 Sq L✓HN L/
,IJd/c?pNr�,b7F7tN , Cy A-
Owner:AC,4 1-0 t e;C
Date of Inspection: s9/ L`
Name of Inspector:(Please Print)
I am a DEP approved syst n_pee`�,
Company Name: le t 'r >s '
Mailing Address: .).9S riTuPtvrfe
Telephone Number: it S'4L 3t2L '
CERTIFICATION STATEMENT
I certify that)have personally inspected uur st
below is true,accurate and complete as el the
and experience in the proper function a,d man, . .
yPasses
_ ConwUonally Past,.:.
_ Needs Further Ev.'.aaho
Fats
Inspectors Signature:
DISPOSAL SYSTEM INSPECTION FORM
PAR1 A
L'CRTIFICATION
Name ofOwneS
ju ____
Address of
cant to Section 15.340 of Title 5(310 CMR 15.00
/rriyuae, s✓ia-
nsposat system at this address and tImt the Imo
maispection. The inspection was performed base
ounce of on-site sewage disposal systems. The syst.
me Local Approving Auttmnty
� P /
The System Inspector shall submit a`fo1.f of the,
DEP)within thirty(30)days of completai a hue ins,
gad or greater,the inspector and the syr,em on...
Department of Environmental Protection. The r..
If applicable,and the approving authority
NOTES MO COMMENTS
Date _.J/T
BOLL DURAND
Secretary
LAUREN A LISS
Commuslonm
i.ss Iron report to the Aparovins Authority(Board.,'"
suei. If the system ism shared system or has Ju.i
a submit the report to the appropriate region:..
d should be sent to the system owner and cops:,
5y6 vt OKC2) GG t;17:
&F ii -c%T7r /1/ :
TIIh udvrm,t,on if”amble m.!
A_ ;n/A9�.-
oh or
uw of 10,000
a of ti
o the ouyer,
SUBSURFACE SEV.ACE DISPOSAL SYSTEM INSPECTION FORM
PART A
C LI<TIFICATION(continued)
Property Address: lS 5y4iffis any
Owner I:$* A' Fin
Date of Inspsobon: 3)z`
o9
INSPECTION SUMMARY: (:heck A, B, C,
A.7CM PASSES:
I have not found any lnformao..n wbiu J.cates that any of the failure conditions described n
exist. Anyfallure criteria not evaluat, d re indicated below.
COMMENTS:
B. STEM CONDITIONALLY PASSE}
or more system compon. its as ruedmthe"Conditional Pass"sect on need to Oy
d. The system,upon r..mple:. .1 the replacement or repair,as approved by b...
rep
pass.
Indicate yes,no or no tennlned(Y,N,or hl
explain why not.
The septic kls mnnl,un.
of a Cerbdcat I C...conch.
years prior to the .te of b4
structurally unsoun.{
system will pass Inspect w
approved by the Bo..,d of H
Sewage backup or Li eako..t
broken or obstrucmd piper
pass inspection if(with app
broke ct p.
o,stribuI
The system r
system wit
revised 9/2/98
dire.,pump..
ass ins,,ection.
broken p.
o,structh
0 CMH 15.303
cod m
if Henan,will
describe basis of determination in a nstances. II" .. deter}aned",
toe owner or operator has pr 'tied the system In:.■.• ._.Jr will a copy
.cached)indicating that r tank was installed with.) ienty(20)
.pection;or the septic k,whether or not metal,.s cr.eked,
..,,stantial infiltration exfltration,or tank failure is e m. Inent. The
um existing septic nk is replaced win a complyin0:epic tank as
static -ter level observed in the distribution L..x s due to
due to a broke ettled or uneven distribution bee I e system will
of the Board of H'. th).
4 are replaced
removed
Lux a levelled or replaced
note than four times a year due to broken or obstruc,e. pipe(.} The
.with approval of the Board of Health)'.
,,l are replaced
removed
SUBSURFACE SEW
DISPOSAL SYSTEM INSPECTION FORM
PART A
C: n•IFICATION(continued)
Property Address: d9 SJrLUAN L" ->?f 44 -10 Ll
Owner. et 017,n,04.
Data of Inspection: 3L o y- -
C. FURTHER EVALUATION IS REQUIhi 0 BY t
BOARD OF HEALTH.
Conditions ex which require!urine r, lion by the Board of Health in order to determin:
fsllins Wprotee •public he.ilth,sat..). and the environment.
1) SYSTEM WILL PAS�NLESS uOARD( r HEALTH DETERMINES IN ACCORDANCE WIT 31C.
(1)(b)THAT THE SYSI•FrM IS NOT FUN( I I ONING IN A MANNER WHICH WILL PROTE THE(
AND SAFETY AND THE NVIR 3NMEN.
Cesspool or privy
Cesspool or privy
thin 5o
Uiin b..
cet of surface water
• t of a bordering vegetated wells or a salt marsh
2) SYSTEM WILL FAIL UNLESS It c BOA.
THAT THE SYSTEM IS FUNCTLJNING
AND THE ENVIRONMENT:
3)
The system has a See:re tai
surface water supply.,r
The system has a set tano
water supply well.
The system has a
water supply w
The system h a set tic tan,
OTHER
or more fro •privav wale(
volatile or nlc come
present of•mmonlr nitro°..
data ne distance.
revised 9/2/98
Or . A
ANNE
it me system is
Cs.R 15.303
UI.LIC HEALTH
H(AND PUBLIC WATER SUPPLIER,IF r.r.Cy DETERMINES
HAT PROTECTS THE PUBLIC HEALTH.•N.1 SAFLTY
.,oil absorption
io a surface ware
soil absorption Syst
tern(SAS)and the SAS is with,, I J feet of
pply.
and the SAS Is within a Zml. • .t a public
soil absorption system -•b the SAS is within 50 (. a private
soil absorption system and •SAS is less than 10(1•et but DO feet
.reply well.unless a well water an sis for collform boom ria and
..ales that the welt is free from poll un from that la<.Lily and the
'd nitrate nitrogen is equal to or less • an 5 ppm. Mete )d used to
proxlmation not valid).
SUBSURFACE SEV. 'Ce DISPOSAL SYSTEM INSPECTION FORM
PART A
, I IFICATION(continued)
Property Address: a4 SYtarri- r7N-r1/41Viary
Owner ✓
Data of inspection: . 3)-2.410
D. SYSTEM FAILS:
You must indicate either'Yes'or"No" to earl
I have determined that one or more c.
The basis for this determination is Id.
what will be necessary to con a ct the
Yes N
Backup of sewage i to facie
*spool.
Da ergo or ponds.,I cleft
or clo••ed SAS or c. sspou.
Static hoot evel in we dist
cesspool.
Liquid depth in cast col is
Required pumping !ore
Number of times pumped
✓✓✓_
My portion of the S ,I y=c
Any portion of•c . .m cool cc
water supply.
Myporti of a cos.cool of
ortion of a ce.-pool
m following:
following failure conditions exist as described In 3':0:,MR 15.303.
ed below. The Board of Health should be contacte c determine
system component due to an over -.ded or clogs d AS or
m,the surface of we gr` . d or surface waters due h. .,n overloaded
.n box above • ❑et invert due to an overloaded m clogged SAS or
My portion of a ces.rool 0,
supply well with no.. cept-
attach copy of well....ter al
nitrogen and nitrate mitroge
E. LARGE SYSTEM FAILS:
you .tldicate either"Yes"or'No' meat
following criteria apply tr large.t
The syste
significant thr
conditions twist:
ryes a facility v. ill a m
to public he tan ark.
Yes NO
the system i
low invert or available volume is less thorn lc day flow.
n the last year NOT due to eloyged or obstruc m .pipe(:).
ystem,cesspool or privy is below the high grnm.d. *ter elevation.
wI •m 100 feet of a surface water supply or trawl ry to a surface
within a Zo I of a public well.
within 50 feet of a wale water supply well,
less than 100 feet but g *ter than 50 feetfro,n a,.rivate water
nur quality analysis. If the w: has been analyzed tc sae acceptable,
for conform bacteria,volatile o chic compounm... nmonia
ne following:
ms in addition to the criteria above:
now of 10 000 gpd or gr rr((Large System)ana mo .ystem is a
-my and theenwr rat because one or more of tin Io lowing
the syste within.00 fei.
th ystem is locals.I In am
apped Zone II of a public
drinking water supply
tr ibutary to a s• ce drinking water supply
sensitive area(Interim head Protection Area PA)or
I oopply well)
The or or operator of any such sys., she ,-y ads the system in accordance with 310
consult the local regional office of the.,cpartm : isr further information.
revised 9/2/9E
Please
SUBSURFACE SEV, DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
property Adores: a syWHr" Ln-
Owner.
Data of Inspection: 3/Lb/r�y.
Check H the following have been done:
Yes/ No
Pumping Information was pr.
None of the system c.ampani
receiving normal floc. rates
the system recently. as pa.
As built plans have b. en obt.
The facility or dwelte ,was.
The system does not cce Iv.
The site was inspect a for s.
All system eomponer..s,eu.
The septic tank man les w,
for condition of bank or It
depth of scum.
The size and locatiol..,f the
Existing information or e._
Determined in the E. .1(if ar.
t
distance is unaccep. .ole)
The facility owner(a...,occ,
proper maintenance al Sub:
revised 9/2/9F
/VU4rwf-ls fe70
. .Late either'Yes'or"No'as to each of the following:
d by the owner,occupant,or Board of Health,
nave been pumped for at least two weeks and the sys •m has been
{I that period. Large volumes of water have not been ntroduced into
ties inspection.
1 and examined. Note if they are not available with NIA
ted for signs of sewage back-up.
.,andary ar industrial waste flow.
he Soil Absorption System,have been located u. U. •site.
acvered,opened,and the interior of the septic tat ia._as Inspected
ateriel of construction,dimensions,depth of liquid.d) .ih of:Judge.
.bsorption System on the site has b en determined Iab ed on
Plan al B.0-H.
he failure criteria related to Part C Is at issue,apnrolh nation of
.. If din erent from owner)were provided with inbn I.al on on the
.,: Disposal Systems.
Su3SURF SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
STEM INFORMATION
Property Address: a4 Sytv/b l.a..
Owner.
Date of Inspection: 3 I a . I o ',
RRE$IDEMILL@H EYI11iL' / l
Design flow:_g.p.d.lbedrood�9 7
Number of bedrooms(design):% N...nberr Rooms tactual). 7
Total DESIGN flow
Number of current residents n=1
Garbage grinder(yes or no):ye-3
Laundry(separate system) (yes or no. NDit .=pars to inspection required
Laundry system Inspected (yes or no)
Seasonal use(yes or no):/ O
Water meter readings,if available(last no ye. s,rge(god): - > "•
, IC=
Sump Pump(yes or no):y0
Last date of occupancy. 571k, C e 'J("
LOW CONDITIONS
Type of as
Design now:
Basis of design
Sow
Grease trap present:(yes or no)_
Industrial Waste Holding Tank present ,es or
Non-sanitary waste discharged to the t
Water meter readings,if available'
Last date of occupancy:
OTHER:(De •e)
Lastd - of occupancy:_
• ■yel,
.: HAL INFORMATION
PUMPING RECORDS and source of inf. matio.
System pumped as part of ins echor, .., no)
If yes,volume pumped:_ gapc.
Reason for pumping:,
pE11p SYSTEM
✓✓_ Septic tank:distribution bosh i abao. ,ystcni
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) lit es,alt. , elous inspection records,if any)
SA Technology etc.Attach co v of up Ate operation and maintenance cony act
Tight Tank Copy of O. P Apt.
Other /y
APPROXIMATE AGE of all components sate in d(if known)and source of IntonnaLan. rr L'n,s
Sewage odors detected when arriving :the s. es or not 1/l)
revised 9/2/9E
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan) ,e
Depth below grade:«
Material of construction:_oast Iron 'i 0 PVC
SUBSURFACE SEW,6[DISPOSAL SYS1 -M INSPECTION FORM
PART C
SYSTC M INFORMATION(C Mimed)
3� Syt-u LA
3h`/o�>
Omer(explain)
Distance frgm private water supply well or acetic t.ue Diameter Y.
Yrt
Comments:(condition of)oin venting.aviden • ot. leakage,etc.)
0 ClieWc-71 em Co-
SEPTIC TANK:_
(locate on site plan)
I
Depth below grader
Material of construction:_concrete_metal—J + glass _POlycth _ogler(explain)
D tank is metal,list age Is age confirmed ft)
Dimensions /20" t x 65.1'' < 5`.°
Sludge depth: /'r
Distance from top�Aludge to bottom of outlet t
Scum thickness:
Distance from top of scum to top of oum■tee or
Distance from bottom of scum to bottom uf�ou�tle'
to
How dimensions were determined:
the ate of Comuh nee (YrsINO)
00 baffle:�_
te7 ,4u
or bathe /
Comments
(recom ndation for pumping.condition of init: .. i outlet tees or 'ties,depth of liquid level In relation to outlet Invert,
structure tegrity,evidence of leakage etc.)
GREASE TRAP:_
(locate on site plan)
Depth below grade:_
Material of construction:_cones _n etal_ F....-glass _POlyey.bo other(explain)
Dimensions: \
Scum thickness:_
Distance from top of scum to top of outlet tee or t::my.
Distance from bottom of scum to bottom of-Maki 0 •off le __
Date of last pumping:
Comments:
(recommendation for pu
structural integrity
og,oonditm of inlet ,nU outlet tees o' b s,depth of liquid level in relation to outlet invert,
nee ofleakagt etc.)
revise,: 9/2/9E
St dSURi SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued;
ProPart Address: g9 . vt-C'r r-d/.
Owner. uf[6 De t- uc tt-
Date at Inapacbon: 3 r `A,/
del.T/.yrv[,r- X)4i
TIGHT OR HOLDING TANK:__(Tank .ust b. yed prior to,or at time ot,inspection)
(locate on site plan)
Depthbcbw grade:_
Material Of Bon:_concrete_ ..ietal_ ,glass__Polyethylene � expla�n)
Dimensions: �>
Capacity: gallons
Design flow: gallons/day
Alarm present_
Alarm level: Alarm In working• ,
Date of previous pumping:
Comments:
(condition of inlet tee,con. •n ofalan and II. to hes.etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid Nivel above outlet inven 0
Comments:
(note B level and distribution Is equal.t de net
PUMP CHAMBER:_
�(�iclU'ona Ian)
Pumps In working FH4),
Manna In working order(Yes or No)_
Comments:
(note condition of pump chambe
revised 9/2/98
carryover,evidence of,eakagt into or out w Lox etc.)
on ot, ,.and ap uurtenances,etc.)
SUUSURF:
Property Address: 02 9 .Sy(tv&. ^A`
Owner 31 / 5/
Dab of Inspection: 2L O
SOIL ABSORPTION SYSTEM(SAS):_
Decals on site plan,If possible;sswveb. n not,
It not located,explain:
Type
leaching pits,number_
leaching chambers,number:_
leaching galleries,number:_
leaching trenches,number.let 07
leaching fields,number,dimen
overflow cesspool,number:_,
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic allure.
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 Pump a as p
Comments:
(note condition of soil,signs of hydraulic ether
PRIVY:_
(locate on site plan)
Materials of construoti
Depth of solids:
Comments:
(nob condition
soil,signs of hydraulic :allure,
revised 9/2/92
seWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
.YSTEM INFORMATION(continued)
Noc nRsZYT%z+�
J,location may be approximated Ly non-intrusive mi (nods)
of pending,damp soil,conution of .ugetation,ate
of pommng,condition of vetelabQn. etc.)
Dxnensia.s.
of ponding,condition of vegetation etc.)
SUSSUR Y.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 02 7 J yL.%r nJ L, �._-. ,kJbt.i%-)An PIZ/V
Owner 434irw sOISF- Id W/' 7/t7.,+rµ '
Data of In•paatian: 3/ /G
SKETCH OF SEWAGE DISPOSAL 5YS i
Irlo Wd tin to at least two per nianen
locate all walla within 100'(Locate
ence landmarks or benchmarks
public water supply comes into house)
SLtSURF. SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: a9 .1 yt u/id-, lent
Owner. 441,4
3/Data of Inspection:
2& U >
NRCS Report
name
Soil Type_
Typical depth to groundwater.
USGS Oats website visited
Observation Wells checked
Groundwater depth: Shallow. _Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater J F ct
Pkase Waste all the methods used to .e term. „n Groundwater Elevation.
Obtained from Design Plana on rt. .,rd
Observed Site(Abutting property :bxer. miss.basemen!sump etc )
_Oefannined from local condition
Checked with local Board of heal(..
Checked FEMA Maps
_Checked pumping records
_Checked local excavators,Install.
Used USGS Data
Describe low you established the Nigh mourn. r Elevation.(MD be complet
St=d /1//ne l) C ./7 U 7]W/
revised 9/2/98