17 Septic Checklists C
7.) ._ i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
/7 d/, Frer Ltd
:dress of property
trier' s namejAme .a�+Th o6./a 5-54 - 220
ite of Inspection
IA3 /9S
PART A
CUECELIBT
ieck if the following have been done:
_pumping information was requested of the owner, occupant, and Board of
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.
/A As built plans have been obtained and examined. Note if they are not
available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up.
:// The site was inspected for signs of breakout.
All system components , excluding the SAS , have been located on the
site .
✓ 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.
v7 The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
✓ The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
ounSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
If residential
—`1 number of bedrooms
_41__ number of current residents
4ja_ garbage grinder, yes or no
J _ laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential , calculated flow:
Water meter readings , if available:
Last date of
occupancy
ackULv lc(
42ry/cice/
FLOW CONDITIONS
GENERAL INFORMATION
Pumping records and source of information:
T— System pumped as part of inspection, yes or no
if yes, volume pumped _ /aoo
Reason for pumping:
Type of system
I� 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)
Approximate age of all components. Date installed, if known. Source of
information:
%fs
Ltz Sewage odors detected when arriving at the site,
yes or no
SUBSURFACE SEWAGE
SYSTEM
TANK:12Q0 Ta/lon s
to on site plan)
below grade:
ial of construction: concrete
DISPOSAL SYSTEM INSPECTION FORM
PART B
INFORMATION continued
metal __FRP
other(explain)
isions
distance from
top of sludge o bottom f outlet t ee or
Isms
sludge depth
scum thickness t 0 let
disc anOe
from top cf scum to top of outlet tee or baffle
distance from bettor of scum to bottom of outlet tee or baffle
!nts: ur.. in condition of inlet and outlet tees or baffles,
1 of liquid for pumping,e• structural integrity,
of liquid level recommendations for repairs, etc. )
c ` e d
dace of leakage, �.Ye
RIBUTION BOY.: V/
:ate on site plan)
depth cf liquid level above. cutlet. invert
n.ents: evidence of solids carryover,
:e if level and distribution is equalzecommendation for repairs, etc. )
9ence of leakage into or out of box,
P CHAMBER:
Cate on site plan)
pumps in working order, yes or no
invents: um chamber, condition of pumps and appurtenances,
:om condition of pump etc.
:or..mendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PORN
SYSTEM INPORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or be.
locate all wells within 100 '
Barn
I App.
I1-ea<ti I
(5011
leo„ s,ri
OLD FERRY ROAD
DEPTH TO GROUNDWATER
3 ±
depth to groundwater
method cf determination pr approximation:
of
e' er
Q
SUBSURFACE SEWAGE DISPOSA BSYSTEM INSPECTION PORN
PART SYSTEM INFORMATION continued
BSORPTION SYSTEM (SAS) : but may be
e on site plan, if possible; excavation not required,
imated by non-intrusive methods)
determined to be present, explain:
ing pits and number
ing chambers and number
ing galleries and number
ing trenches_ , number, length
ing fields, nurber, dimensions
low cesspool , number
of tool , level of p
onding,
nts: signs of hydraulic failure, etc. )
condition f
tion of vegetation, recommendations for maintenance or repairs,etc. )
OOLS (locate on 'site plan) :
=r and confiouration
n-top of liquid tc inlet invert
n of solids layer
t of sour. layer
nsicns of cesspool
rials of construction
cation of groundwater
low (cesspool must be pumped as
t of inspection)
erts: level of ponding,
signs of hydraulic failure, etc. )
:e condition of soil , recommendations for maintenance or repairs,
3ition of vegetation,
ca
cafe on site plan)
.erials of construction
tensions
>th of solids
nmerts '
m signs of hydraulic failure, level of pondin etc. )
e condition of soil , g
nd ition of vegetation, recommendations for maintenance or re airs,
SUBSURFACE SEWAGE DISPOASRATL SYSTEM INSPECTION YORK
FAILURE CRITERIA
N or ND) . Describe basis of
nn, all instances.determined If "not determined" , explain why e yes' instances. If
nation in all
kckup of sewage into facility?
ischarge or ponding of effluent to the surface of the ground or
arface waters?
tatic liquid level in the distribution box above outlet invert?
.iquid depth '-.n cesspool <6" below invert or available volume< 1/2 day
:low?
Required pumping
4 times or more in the last year?
number of of tines pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exf iltration? tank failure imminent?
Is any portion of the SAS , cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone 'I of a public well?
■ within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only D3t
the SAS)?
_ within 50 feet of a private water supply well?
neater than 50 feet from a private water
water quality analysis? If the well
Z less than 100 feet but greater
copy of well water analysis
has been well with no acceptable table, y of well water
ertanaly
for been analbacd to be acceptable, compounds,
for col iforr.. bacteria, volatile organic
nitrate nitrogen.
lad 4e4 / 11/e e: 7,lai 'a
SUBSURFACE SEWAGE DISPOASRAT SYSTEM INSPECTION FORM
CERTIFICATION
Inspector rr'e F/ /O s
Name fir% //05 674r/pr/Ses
SN G .
re red. Aw+ herst
Address 641 /e
Al A . O/OOZ
e .dis osal system at
reported is true, accurate and
dr that hes personally inspected repd ted iswtg performed and
dress and that the information rep inspection was
:o me da the time of ng upgrade, maintenance and repair are
lent with.my rainingnandpexperience in the proper function and
lant with r..- tteisewg
Dance of on-site sewage disposal sy stems.
stem fails
one:
have not found any i which
or thel environment as defined in cates that
o adequately protect public
10 CMR 15. 303 . Any failure criteria not evaluated are as stated in
he FAILURE CRITERIA section of this form• protect public health and
have determined that the system fails to p
he environment as defined nOFAILURE CRITERIA The
section of for
Iet of this
IEterminaticn is p rovided in the
:tor.. �-1 i e eti
a OS' S Signature
8 23/15
nal to oyster. owner Jape
s to: 504 rd o/ flea Ill:
r (if applicable) Ylic77e
loving authority
i Oc 64 /et
/7 047 firr y
.402 /4 ainie /» r/,4
0/OCO
G
4frt//3 rp. WaS k
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist (cont)
2- Construction Inspection
a) Building Sewer(310 CMR 15.222)
All waste pipes tied into building sewer
Schedule 40 PVC 4' or cast iron
Minimum slope of 0 01-0.02
Pipe laid in continuous straight line
Pipe laid on compact,firm base
Cleanouts precede all changes in
alignment/grade
Cleanout provided every 100 ft.
Baill material clean
b) Septic Tank(310 CMR 15.223)
Tank is set level with 6'stone under
(15.226)
Tank is required size/loading per plan
Inlet and outlet are at proper location
(15.227)
Tank is water tight(15.226)
Outlet tees extend 6'above flow line Verify by
Approved filter device placed at outlet DEP list
Gas baffle installed at outlet tee
Visual
Inlet and outlet tees on center line Visual
Tank is backfilled with acceptable material Visual
Approved N/A Problem
Basement check ❑ ❑ ❑
Verify by reading pipe ❑ ❑ ❑
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Visual ❑ ❑
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Visual
Visual
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Visual
Approved/ N/A Problem
Verify by visual/tape
Verify by visuavtape
Check with level
Verify with plan
Verify with plan
Test
Notes:
4 "del
pee System Installation Checklist 11-09.doo•date
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sual/tape ❑ ❑
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Form Name•Page 2 of 6
Commonwealth of Massachusetts
C'Ity/Town of
Septic System Installation Checklist
B. Application Checklist(cont.)
c) Distribution Box(310 CMR 15.232)
All outlet pipes at sameilevabon
L�
Number of outlets plan
Inlet tee min. 1' over outlet
D box set on level base
Top of D box 36" max depth
D box is water-tight
D box has a minimum of 2' thick wall and
17 inside dimension
d) Pump Chamber(310 CMR 15.231)
Tank is set level
Proper volume is provided
Float elevations set per plan
Min.r delivery line to D box
Number of pumps.
Specified pump provided or designers
approval for equal pump
Correct pump sequence
Covers set to grade
Electrical permit provided
6'of stone beneath chamber
Chamber is water-tight
Min. 9" cover provided
Correct loading provided per plan
Notes:
be System Installation Checklist 11-09.doc•date
Check by adding water —
Number of laterals OK par plan
Approved N/A Problem
Visual and wltape
Visual
Visual and w/tape
Add water
Visual and wllevel
Check plan and tank
Measure w/tape
Visual
Visual
Test
Visual
Visual on tank
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[IV' ❑ ❑
Approved N/A Problem
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Fenn Name•Page 3 of 6
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist(cont)
Leaching Facility(310 CMR 15.240)
No frozen material used including back fill Visual
No clay,tailings or stones larger than 6°for
cover material
Soil at bottom/sides of excavation matches
info on deep holes
All impervious layers removed
No remaining NB horizons
Groundwater conditions match plan and
deep holes
Vented if under impervious cover per plan
(15.241)
Vent is protected from precipitation
and animal entry
Cover of a minimum of 9' over leach area
P � w transit
Pipe slope equal to 0.005
Leach area per design(15241)
Excavation is level and at required depth
check plan
Removal of 5 ft material and replacement Vis
(if in fill)
Back fill material is acceptable
Final contours correct per plan
Surface/subsurface drainage away from
leach area
Final grade and side slopes are stable
Distribution lines are capped, vented,or
connected together
Impermeable barrier(15.255[2])
Retaining wall inspected by PE
Retaining wall is waterproofed
Retaining wall barrier is at correct
depth/height
e)
Visual
Visual
to system Installation Checklist 11-09.doc•date
Check with plan Z.
Approved N/A Problem
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Cfr— ❑ ❑
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4.1' ❑ ❑
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Form Name•Page 4 of 6
Commonwealth of Massachusetts
Cityfrown of
Septic System Installation Checklist
B. Application Checklist (cont)
Approved NIA Problem
f) Leaching trenches(310 CMR 15251) ❑ ❑ ❑
Number of trenches: ❑ ❑
Depth of trenches: ❑ ❑ ❑
Wdth of trenches: ❑ ❑ ❑
Trench spacing per plan ❑ i
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Stone is double-washed(314"to 1'/11(15.247)
g) Leaching fields(310 CMR 15.242)
Length of field:
Width of field.
Min.of 2 distribution lines
Separation distance conforms to plan
Stone is double-washed(3/4"to 11/41(15.247)
h) Leaching Pits(310 CMR 15.253)
Number of pits:
Depth of pits:
Stone is double-washed[3/4"to 11/51(15.247)
Each pit has min. 1 20• access cover
Piping network and configuration of
pits/chambers per plan
9 Tight Tank(310 CMR 15.260)
Tank is set level with 6'stone under
Tank is proper size per plan
Pumping contract has been provided
Covers to grade
M/alarm set at 3/5 tank capacity
NV alarm test on separate circuit
is System Installation Checklist 11-09.doc•date
Visual and with level
Visual with plan
Visual
Check floats by raising
Set off alarm
Farm name•Page 5 of 6
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist(cont)
j) Certificate of Compliance(310 CMR 15.021)
As Built Plan Submitted ✓
Signed by Installer
Signed by Designer
Certificate of Compliance Issued
Date
D to
�Dta
430 't0
System Installation Checklist 11-094oc•date
Fpm Name•Page 6 of 6
Checklist for Se c S em Plan Review
d' Application page attached to plan
IS- PE or RS stamp, date,signature
❑ Variances to property line setback distances must have Surveyor stamp
it Le l boundaries noted
,Easements noted proposed noted
e I�/ Dwellings and buildings existing or prop
Location of driveway or parking areas,other impervious areas
e:(LOcation and dimensions of reserve area(new construction only)
System design calculations
❑ Garbage grinder,yes or II
❑ Benchmark not disturbe• • 'nng construction within 75ft of facility
O North arrow
Lt /Contours
It Deep Deep hole location(s)and data
d Perc hole location(s)and data
Li; Elevations
it Names of approving authority-and soil evaluator
(a' location of water supplies, public and private
o Within 400k of system in case of surface water and gravel-packed public water supply
o Within 250ft of system in case of tubular public viater supply
o Within 100ft of system in case of private wells(50ft from
p'Well statement,if applicable- vegetated wetlands
184 of any surface waters,rivers,ve g
5�'/Location of water lines and other subsurface utilities
1Y/Observed and adjusted groundwater elevations in vicinity of system
lFy/Profile of system
4Y/Locus plan to show location of facility,including nearest street
!a Materials of construction and specs for system
ti Gas baffle
/Pipe in center line of tank
--L Double-washed stone
q/Schedule 40 PVC for trafficked areas,house to tank Distances noted from house to tank,etc.
if dosing is proposed,design and specs of dosing system --
_When alternative technology is required,complean and sa3-C5i0cluding hydraulic profile
❑ nches preferred over beds below groundwater level
❑ Buoyancy calculations for tanks or components partly line
3:1 slope outside of mound,toe ending 5ft from property
Local upgrade requests on the plan,all variances
Local upgrade forms attached to the application d 50 or j r[sw!'
d d b -c- 1-`
dots s.{s F)43-3 ate„“X • s ;flcti g>r em-el
to Ck