71 Septic Inspection 2003 COMMONWEALTH OF MASSACHUSEI IS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5 ec .771AmprO FheatrH
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 71 SYLVESTER RD
FLORENCE MA
Owner's Name:_JEAN FRANCES_
Owner's Address: SAME
Date of Inspection: 3/27/03
Name of Inspector. (please print) DOM& NATHAN TORRETTt
Company Name: CLEAN SEPTICS
Mailing Address:_P.O.BOX 394
LUDLOW,MA
Telephone Number._583-2138
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 the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the 1.rah Approving Authority
Fails
Inspector's Signature: �`�i%H(ii'�
Date: 3/27/2003
The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)
within 30 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 than submit the report to the appropriate regional office of the DEP.The original
should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority.
Notes and Comments
This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection
does not address how the system will perform in the future under the same or different conditions of use.
•
Page 2 of 11
OFFICAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSEMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 71 SYLVESTER RD
FLORENCE.MA
Owner: FRANCES
Date of Inspection:_3/27/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
/I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in
310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
PUMP SEPTIC TANK EVERY TWO YEARS
B. System Conditionally 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain.
The septic tank is metal and over 20 years olds or the septic tank(whether metal or not)is smtcturally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is
replaced with a complying septic tank as approved by the Board of Health.
*A meal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of
Board of Health):
ND explain:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
•
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_71 SYLVESTER RD
FLORENCE, MA
Owner: FRANCES_
Date of Inspection: 3/27/03
C. 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 system is
failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
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 any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)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 SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank mid SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that 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,provided that no other failure criteria am
triggered.A copy of the analysis must be attached to this form
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 71 SYLVESTER RD
FLORENCE MA
Owner. FRANCES
of Inspection:_3/27/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections.
Yes N
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
/clogged SAS or cesspool
_ t// Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'A day flow
VRequired 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 SAS,cesspool or privy is below high ground water elevation.
>/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
/ supply.
/ Any portion of a cesspool or privy is within a Zone 1 of a public well.
/'Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓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. [This system passes if the well water analysis,pe r
DEP certified laboratory,for conform bacteria and volatile organic compounds indicates that 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,provided that no other failure criteria are triggered.A copy of the analysis
must be attached to this form]
l✓Q (Y 1:0 The system fails.I have determined that one or more of the above failure criteria exist as described in 310
•r 15.303,therefore the system fails.The system owner should contact the Board of Health to determine
what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve 4 facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either`ryes'or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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—IWPA)or a mapped
Zone U of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered"yes"in
Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 OAR 11304.The system
owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 71 SYLVESTER RD_
_ FLORENCE, MA
Owner: FRANCES_
Date of Inspection: 3/27/03
Check if the following have been done.You must indicate'yes"or"no"as to each of the following:
Yes No
t/ _ Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
4 _ Has the system received normal flows in the previous two week period?
_ _
/Werelarge volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
y _ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
/ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Y9 no Existing information.For example,a plan at the Board of Health.
✓✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 MR 15.302(3)(b)1
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_71 SYLVESTER RD_
FLORENCE, MA
Owner._FRANCES_
Date of Inspection: 3/27/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_3_ Number of bedrooms(actual):_3—
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330_
Number of current residents: 2
Does residence have a garbage grinder(yes or no): _NO
Is laundry on a separate sewage system(yes or no): NO lfl yes separate inspection required]
Laundry system inspected(yes or no): _
Seasonal use: (yes or no):_NO_ TOWN WATER
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): _NO_
Last date of occupancy: PRESENT
COMMERCIALIINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):__gpd
Basis of design flow(seats/persons/sq(t,etc.)
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 no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: PUMPED IN 2002
Was system pumped as part of the inspection(yes or no): NO_
If yes,volume pumped:_gallons—How was quantity pumped determined? _
Reason for pumping:
TYPE OF SYSTEM
Septic tank,d(clwbutioubox,soil absorption system
Single cesspool
_Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained
from system owner)
Tight tank _Attach a copy of the DEP approval
VT-Other(describe): LEACH PIT
Approximate age of all components,date installed(if known)and source of information:
1988 HOME OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_71 SYLVESTER RD
FLORENCE MA
Owner. FRANCES_
Date of Inspection:_3/27/03
BUILDING SEWER(locate on site plan)
Depth below grade: 2'8"
Materials of construction: cast iron XX 40 PVC other(explain):_
Distance from private water supply well or suction line:_
Comments(on condition of joints,venting,evidence of leakage,etc.):
JOINTS.VENTS APPEARS OK.NO LEAKS
SEPTC TANK:✓(locate on site plan)
Depth below grade: 22=4^
Material of construction:_XX_concrete_metal fiberglass polyethylene
other(explain)
If tank is metal list age:_ Is age confined by a Certificate of Compliance(yes or no): (attach a copy of certificate)
Dimensions: 10.5'L.5'W.5'D
Sludge depth: NONE
Distance from top of sludge to bottom of outlet tee or baffle:_
Scum thickness: NONE
Distance from top of scum to top of outlet tee or baffle: _
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined. MEASURED integrity,liquid levels as
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural inte�
related to outlet invert,evidence of leakage,Etc.):
BAFFLES OK, STRUCTURAL INTEGRITY. LIQUID LEVELS OK NO LEAKS
CREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass polyethylene_other
(explain):
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(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_71 SYLVESTER RD_
FLORENCE .MA
Owner, FRANCES_
Date of Inspection: 3/27/03
TIGHT or HOLDING TANK:_(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: _other(explain):
Material of construction: concrete_metal_fiberglass polyethylene
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Mann present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: _(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: NONE
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage
into or out of box,etc.):
PUMP CHAMBER:_(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.):
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
71 SYLVESTER RD_
FLORENCE ,MA
3/27/03
Property Address:
Owner: FRANCES
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,excavation not required)
If SAS not located explain why:
Type
V leaching pits,number: 1
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length__
_ leaching fields,number,dimensions: _
_overflow cesspool,number:_
innovative/altemative system Type/name of technology:
Conunents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
SANDY ROCKY LOAM.NO SIGNS OF HYDRAULIC FAILURE, FROM LEACH PIT INVERT TO EFFLUENT
LEVEL IN PIT THERE IS 10"OF SPACE
CESSPOOLS:_(cesspool must be pumped as part of inspection)(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(yes or no):,
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:_(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building.
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Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Propertoy Address: _71 SYLVESTER RD
_ FLORENCE ,MA
Owner. FRANCES
Date of Inspection: 3/27/03
Estimated depth to ground water NONE a 6' feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed: _
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
_Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
SLOPE IN BACKYARD,CHECKED CELLAR