95 Septic Inspecion 2005 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
i /CERTIFICATION
•Property Address: ?`5 fl/et—r9 Y'.x0,1,
Ad4'55
Owner's Name:
- W/L[-/,giy/ .:.,5-7//i/!j
Ownec'sAddress: // it//i •Th' i// S'la
Deft of Inspection:' /Q�/'. Cott s/373 ,. .
Name of Inspector:(pleaseerint) /,/J/Cl-/f7i/'/ s%�jLUj19
Company Name: / 1-77 E.va-
Mailing Address: .filo U /Gp WO/
Telephone Number: •
453Z es.»,SS
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 fie inspection.The inspection was performed baesed on my
fllnif ence in the proper Naetion and maintenance ofon,site sewage disposal systems.lama DEP
or pneumatic*Section 15.340 of Title 5(310 CMR I5.000). The system:
Mitt ,M�,� Passes
Conditionally Passes
RtEHV A Ne mister E b m
4Na a ` e -��. v Fa / / al Y the Local Approving Authority
Inspec F r .
Date:
The system inspector shall submit•copy of this
DEP)within 30 days of completing this inspection.If the system rte is so shared r Approving system or Authority sign fl of of Health 0, 00
gpd or greater,the Inspector and the sbmit to thetaTohase design Sow of the
DEP.The original should be sent to the syste��eraaaind Spies sent the buyer, a appropriate
awn office r the
authority. •
.. - approving
•
Notes and Continents
••••Thb report Sty-describes conditions at the time of inspection and under the conditions of meat that
time:This Inspection does mtit address how the system will perform'Iii the Attire under the sameor different
conditions of use. • .
•
Page 2 ofli.
OFFICLkL.INSPECIION FORM-NOT FOR VOLUNTARY ASSESSNWNT&
SUBSURFACE SEWAGE DISPOSAL SYSEIM INSPECTION FORM
PART A
CERTWIC►TION(oami_I)
Property Address:
S3/Oe s h0- /2,0
Owner: 1411f1 ?l-
Datsoflorpmtba: //41420 5--
Inspection Summary: Cheek A,D,C.D or E/ALWAYS complete all of Section D
A. System Party:
I haves fond any information which I dkakiihat any of the allure criteria described in 310 CAR
13.303 or in 310 CMR 13.304 exist.Any failure eked.not evaluated are indicated below.
Comments:
IL System ConditIonally Panes:
One or more system compounds as described in the"Conditional P ass"section need to be replaced or
repaired.The system,upon'completion of the replacement or repel as approved by the Board of Health,will pass.
Answer yes.no or not determined(Y,N,ND)(n the_for the follwing""•^'•n'• If'not determined"please
explain
The septic tank is mewl and over 20 years old*or the septic tank(whether metal or not)is skuamailY
unsound,
exhibits substantial inanition or
axt l oo t.System will p on if
the
existing tank k with a �ifmt approved by the Bond
A metal tank pass inspection k strucmally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20
Sens old is available.
ND explain:
Obserndop of sewage backup or brak omorhigt stada net lewd in the distribution box thte tote:ken or
obtruded jtipe(s)o due to a broken,settled or mum dlelbadon hoc%mem will pass inspection if(with
,approval offload of Health):
broken p s)sseaRhoed
obstrmthm'hmoved
distribution bat is laded or spliced
ND explain:
The system required pumping more than 4 times ayour em to broken or obrhucted pipe(s).The system will
pus inspection if(with approval of the Board offload*
broken pipe(s)are replaced
obstruction is named
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL PART INSPECTION FORM A
CERTIFICATION(continued)
Property Address:
ogel
Anti .z . i4
Owner: 4 %717/UT
Date of Inspection:
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.
I.
system is notfunction functioning in admanner which will protect public health,safety and the environment the
_ 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 and 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 froth 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
nd
bacteria and volatile organic compounds indicates that the well is free from pollution from tat f ac Inn oandr
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provide
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL DACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ASSESSMENTS
PART A
CERTIFICATION(continued)
Property Address: 5- $tW L r / -U—' �- �id!! .. eii
12 I
V/b/oS
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_( Backup of sewage into facility or system component due to overloaded
waters due m an S or overloaded or
X Discharge or ponding of effluent to the surface of the ground or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
fI,7t Liquid irdepth in cesspool more is times in the last year NOT available volume is
clogged less than'A day flow obstructed pipe(s).Number
of f times p pumped y orpn of h_ wound water elevation.
4a Any portion of the pool cesspool is privy is below high uar
�� Any portion of cesspool or privy is withm 100 far of asurace water supply or tributary to a surface
water supply. is within a Zone L of a public well.
A!fl Any portion of a cesspool.or privy well.
—2 N? Any portion of a cesspool or privy is within 50 feet of a private water supply
04fin My portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
with tt e ora /This te passes organic s
performed ata DEP ifd laboratory,fcoliformbacr a andvolatile water compounds
onia
indicates that the well is free from pollution from that facility and te pres sence
other of moni criteria
nitrogen and nitrate nitrogen is.equal to or less than 5 ppm,provided
are triggered.A copy of the analysis must be attached to this form.)
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 15.303,therefore the system fails.The s m owner �cXt the Board of
05n0 . o failure.
contact
LiAt- /Q�ds
Health w determine what will be necessary to correct the
Owner:
Date of Inspection:
E. Large Systems: to 15,000
To be considered a large system the system must serve-a facility with a design flow of 10,000 gpd
gpd.
You must indicate criteria either a l sto large systems in addition to the criteria above)
(The following critera app Y
yes no water supply
the system is within 400 feet of a surface drinking ppy
_ _ rite 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 II 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])above the large system has failed.The owner or operator of any large system considered a
significant 15.304.Thehsystem owner should contact the under Section
ate reg regional shall
office offiace of the system
stepartme Department.
accordance with 310 CMR under Section E or failed
4
Page 5 of 11 -NOT FOR
OFFICIAL UBSURFACE SEWAGE FORM
DISPOSAL SYSTEM INSPEC ON FORM TS
PART B
CHECKLIST
Property Address: �tiJ
Owner: /' SW/et,.
Date of inspection: 5^
Check if the followin have been done.You must indicate es"or"no"as to each of the followin :
es No
Pumping information was provided by the owner,occupant,or Board of Health
_ 1( Were any of the system components pumped out in the previous two weeks?
s/ _ Has the system received normal flows in the previous two week period? of this inspection?
)( Have large volumes of water been introduced to the system recently or as part
ki Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
,tor
X Was the site inspected for signs of break out? �j� sys
Were all system components,excluding the SAS,
located on site? pOtiN D
Were the septic tank manholes uncovered,opened,and
n the interior for of het a k mane tedtf of scum condition
dition ed for the of the baffles or tees,material of construction,
_x _ 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:
Yes no For example,information. le;aplan 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 CMIR 15.302(3)(b)1.
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOS MNTS
PART C
SYSTEM INFORMATION
lo td.4
Owner: v �1 b S
Date of Inspection: FLOW CO
RESIDENTIAL b of bedrooms J Number of bedrooms(actual) n/t X /5�/
Number ofbedrased (design)._. �LZ-
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): d
Number of current residents'? (yes /U49/U49 Does residence have a garbage grin der(Y or no):
Is laundry on a separate sewage system( es or no):M2[if yes separate inspection required]
Laundry system inspected(yes of no): Na �
Seasonal use;(yes or no): NO d �iC
/1/1.-0 Water meter readings,if available(last 2 years usage(gp )):
Sump pump(yes or no):__Ma
Last date of occupancy:
COMMERCIALINDUSTRIAL D N4
Type of establishment:
Design flow(based on 310 CMR 15.203): xod
Basis of design flow(seats/persons/sgft,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):
Property Address: 9Iff r
GENERAL INF �l
Pumping Records (5-)12/2.1—
Source of information: (-PC 1 `
es or no :_
Was system pumped as part of inspection-How was quantity pumped determined?
If yes,volume pumped:_gallons
Reason for pumping:
TYPE OF SYSTEM
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)
Innovative/Altematsve technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner) of the DEP approval
Tight tank _Attach a copy
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
Page 7 of II
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: w n ij $m) I
Owner: - _GUM 5-4/7.4.T.
`<
Date of Inspection:
tlod:
BUILDING SEWER(locaatelonn site plan)
g
Depth below grade:_�
Materials of grade:t:ton:_ t iron _40 PVC_other(eapl
Distance from private water supply well or suction line: U r
Comments(on condition of joints,venting,evidence of I ge,etc.):
M7
SEPTIC TANK:_(locate on site plan)
Depth below grade: r.~ metal_fiberglass polyethylene
Material of construction:Y-ooncrete
other(explain)
) Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
If tank issW list age: c,p
certificate)
J ,�' C2_—J 8 "'c/o /<�
Dimensions: (O r
Sludge depth: /_ t
Distance fro
Distance from top of sludge to bottom of outlet tee or battle:
Scum thickness:__;_i___
Distance from top•ofscum to top of outlet tee or baffle: ?
Distance from bottom of scum to bottom yf outlet�;v baffle:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.): < ' O'LI
GREASE TRAP: (locate to on site plan)
Depth below grade:_ _other
Material of con __polyethylene traction:_concrete_metal_fiberglass
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottbm of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommends'tons,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outletlinvert,evidence of leakage,etc.):
Page g of I l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL T SYSTEM INSPECTION FORM
SYSTEM INFORMATION(continued)
• �, y
Property Address: r ,t, �/ )
6 �J
Owner: Ui $r/fJtE
Date of Inspection: +1/40/05--
TIGHT or HOI•DWGT
(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:_ _polyethylene other(ezplain):
Material of construction: concrete_metal_fiberglass
Dimensions:
Capacity:Capacity:��-gallonsiday
Design Flow:�-
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comment(condition of alarm and float switches,eta):
NO/VT—
DISTRIBUTION BOX:_(if pre9e1S must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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) 0/V it
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,
Page 9 of 11
OFFICIAL DACE SEWAGE D SPOSAL SYSTEM SPEC ION FORM S ASSESSMENTS
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 / / h ,CO /�N
i. �/4 /w
/!
Owner: /N ni%/—
Date of Inspection:____---- ((/(
SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required)
If SAS not located explain why:.
Type
leaching pits,number:
_
_leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
_leaching fields,number,dimensions:�--
_overflow cesspool,number: nee of technology:
innovative/altemative system Type/name level
Comments(note condition of soil,signs of hydraulic failure,
etc.): , over
of ponding,damp soil,condition of vegetation,
w. <.�• /%C/s
CESSPOOLS:_(cessR l 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): level of ponding,condition of vegetation,etc.):
Comments(note condition of soil,signs of hydraulic failure, P
b41/V
PRIVY:_(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note conditiosigns of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11 '
OFFICIAL INSPECTION FORM VOLUNTARY ASSESSMENTS
SUBSUFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: (J //-A-t /1--g
20-47- 4-,2-9,b
Owner: Ova
Date of Inspection: 9702/0 S
7
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks pr
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
li
10
'age I l of 1I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9s- n� ib AC
�
Owner: P--/A4 �jJtl/ZT
Date Of Inspection:
o s-
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_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:
"arc Zs / A-e f veS ‘e
A/eu_) leac%/1v sys� t-
11