HomeMy WebLinkAboutTitle V Inspection Report - 45 BRIDGES LANE 10/21/1998 Town of North
OMCE,OF
COMMUNITY DEVELOPMENT AND SERVICES
27 Charles Street 1
o' 1 a
"PS ••"V
North Andover,Massachusetts 0 184 Ar#o
�ssAewus�4�
WILLIAM I SCOTT
Director
(978)688-9531 Fax(978)688.9542
October 21, 1998
Laura Lesch
45 Bridges Lane
North Andover,MA 41845
RE. Title 5 inspection
Dear Ms,Lesch_
The Health Department has received a copy of your recent Title 5 inspection indicating that your
system conditionally passes the inspection with approval of the Board of Health. Once your leaking septic
tank has been replaced,the system should fully pass the Title 5 inspection. Please contract with a North
Andover Licensed Septic installer to apply for a permit and replace your tank. A list is enclosed for your
use.
If you have any questions,please feel free to call the office at the number below.
Sincerely,
Ld 'A-1L.
Sandra Starr,R.S.
Health Administrator
BOARD OF APPEALS 689-9541 BLU DING 688-9545 CONSERVATION 6U-9530 HEALTH 688-9540 PLANNING 698-9535
— --
\ COMMON%VEALTI-I OF MASSACHUSETTS
( EXECL:TIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r I DEPARTNF"T OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. NIA 02108 617-292-$560
TRUDY CO)CE
WILLIA',!F WELD Sccrcun
GOYemo: _(f .
$e(((JJJ DAVID B.S'LRUHS
ARGEO PAUL CELLUCCI Commissioner
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 95 g/-i D UeS �GC19t, �` /� Address of Owner.
Date of Inspection: 11 3fiB 41013010 (if different)
Name of Inspector: BE JAMIN eC. OSGOOD JR. q0 0( Title 5 (310 CMR 15.000)
I am a DEP approved system inspector pursuant to Section tS.3
Company Name: NEW ENGLAND ENGINEERING SERVICES, INC.
Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 0 184 5
Telephone Number: 508-686-1768
CERTIFICATION STATEI LENT
I certify that I have personally inspected the sewage disposal system a th
t is address and that the information reported below is true, accurate
based on my training and experience
and complete as of the time of inspection. The inspection was performed m the proper function and
maintenance of on-site sewage disposal systems. The system:
% asses t
_ &ndtttonalk Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date: v�d
The Svstem !nspector shall submit a copy of this inspection report to the Approving Authority twithin thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 go or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the byyer, if applicable. and the approving authority I
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTE PASSES:
I have not found any information which indicates that the system violates any of the failure criteria zs defined in 310 CMR 15.303.
Any failure criteria not evaluated are indic2ted below.
COMMENTS:
BI 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.
Indicate yes. no, or not determined (Y. N. or ND). Describe basis of determination in LH instances: If'not determined', explain why not.
_ The ieptie tank is metal, unless the owner or operator has provided ttte system inspector with a copy of a Certificate of
Compliance lattachedl indicating that the tank was installed within twenty(20) years Prior to the date of the inspection: or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
I •-r in
. • "•• .. a ��y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /�� �(�I i��ts t aie
Owner: 4u/be esG�
Dale of Inspection:
BI SYSTEM CONDITIONALLY PASSES(continued!
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health;. Describe observations:
broken pipets) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than (our times a year due to broken or obstructed pipe(s1. The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaces
obstruction is removed
Cl FURTHER EVALUATI r ON IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine i(the system i!failing to protect the
public health. safety and the environment:
t) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONOENT:
_ Cesspool or privy is within SO feet of a surface water
Cesspool or pray is within SO feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: i
The system has a septic tank and soil absorption system (&AS) and the SAS is within 100 feet to a surface water supply or
tributary to a surace water supply. I
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water SUP 'Y we
The system has a septic tank and soil absorption system and the SAS is within 50 feet o(a private water supply well.
The system has a septic tank and soil.absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis (or coli(orm bacteria and volatile organic compounds indicates that
the well is free irom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than S ppm. Method used to determine distance (approximation not valid).
3) OTHER
i
(r—i..d 0f/]s/77) P.C. Z or 10
, 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) !
//t�
r p
Property Address: y5 /3e-i�BCS 1-,0 C, AA a40✓C/t•
Owner: �Q✓/Y. 1-G 5GE
Dale of Inspection: 1 i y fU 3�1g9
D) SYSTEM FAILS:
You must indicate either `Yes"or"No"as to each of the following:
( have determined that the system violates one or more of the f6llowing failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct:'.''"'
the failure.
Yes No
Backup of sewage into facility or system component due to an 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
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 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe($).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Anv portion of a 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 I of a public well. )
Any portion of a cesspool or privy is within 50 feet of a private water supply well
Am•portion of a cesspool or privy is less than 100 feet but greater than SO feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coldorm baagria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate either"Yes"or-No'as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design (low of 10,000 go or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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 It of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of tk'Department for further information.
(r•vir.d 04/25/171 rag. 3 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPKYtON FORM
PART 8 `�s
CHECKLIST
Property Address: �,S A3 ri S -c,nt, N• f�.�.iro ue z-
Owner:
Date of Inspection: ��✓�` l�s c k
9L3�5� S to�3o �`i�
Check if the following have been done: You must indicate either `Yes" or"No" as to each•o(the(ollowing-
Yes
�L No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
(low rates during that period. Large volumes of water have not been introduced into the system recently or
nn as pan of this inspection, ,
As built plans have been obtained and cKamined. Note �f they are not available with N/A.
J — The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not recfwe non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components. excluding the Sod Absorption System, have been located on the site.
The septic tank manholets were uncovered, opened, and the interior of the septic tank was in petted(or condition of
banles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum.
/ The size and location of the Soil Absorption System on the site has been determined based on:
_✓ _ The facility owner(and occupants, if different from owner were provided with information on the proper maintenance of
/ Sub-Surface Disposal System.
Existing information. EX.IPIan at B.O.H. t
Determined in the field(if any of the failure criteria related to Pan C is at issue, approximation of distance is
unacceptable) [15.302(31(b)l 1
(r.vl..d 04/23/171 p,p• 4 or 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C -
SYSTEM INFORMATION
z
Property Address: yS �r; y-*s e, N
Owner: �cr
Date of Inspection: / y"
91,3f� a � 1o1,3b `4� •�n��
FLOW CONDITIONS
RESIDENTIAL:
Design flow: Z e.p.dJbedroom for S.A.S her:
Number of bedrooms:l
Number of current residents:•
Garbage gnr.der (yes or no): LA
Laundry corne&ed to system (yes or no):
Seasonal use (yes or no): tV
Water meter readings• i(available (last two (2) year usage (gpd):
.Sump Pump (yes or no): A,�n
Last date of occupancy:
COMMERCIAL/I NDUSTRIAL:
Type of establishment:
Design flow: callons/da%
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or nol_
Non-sanitary waste discharged to the Title.5 system•(yes or nol_
VYater meter readings, ii available•
last date of o•cupancr.
1 I
OTHER: (Describe)
Last date of occupancy.
GENERAL INFORMATION
PUMPING RECORDS and source of(niormat(oan�
System pumped as part of inspection: (yt or nol&O
If yes, volume pumped: >'all s
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)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (i(known) and source of information: a,QS pU- e.2
Sewage odors detected when arriving at the site: (yes or no) /VJ
(r•viv.d 04/25/!71 ►►0• 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '3
PART C '
SYSTEM INFORMATION (continued)
Property Address: !)/� 8/t� e 5 �(/.
� " n
Owner: /.GE✓l C
( Inspection: �'av�txGSG�
Dale o
e,
BUILDING SEWER:
(Locate on site plan)
Depth below grader '
Material of construction: —cast iron 11"40 PVC _other (explain) '
Distance from private water supply well or suction I,rc /V y9
Diameter
Comments: (condition of joints, venting, evident of leakage, etc.) L
eC &.3 ►'J015CY11
SEPTIC TANK:_
(locate on site plans
4
Depth below grade:,
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(expla,n)
If tank is metal, list age _ Is ag`e- confirmed by Cendicate of Compliance _(Yes/Nol
Dimensions:
Sludge depth: D
Distance from top of sludge to bottom of outlet tee or baHlle: 7L 1
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle: JE)'
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined: ryldk3,J'4 ,S>lc%(
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, struou I
integrity, evidence of leakage, etc.) O o
GREASE TRAP: V&
(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:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) –
(r—i..d 04/23/271 Vag- ( or 10
FF
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C a.
SYSTEM INFORMATION (continui:4
n
Property Address: IJv� B/i��cs 6-0.1S N.. 14..cY�Jt2
Owner:
Date of Inspection: 4a"'c` 1,e-ca 11
gl31y8
TIGHT OR HOLDING TANKaj(�T rTank must be pumped prior to,or at time,of inspection) x
(locate on site plan) :^4
Depth below grade:
Material o(constructlon: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacin: gallons
Design floes• gallon/da\
Alarm level Alarm in working order _ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee. condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plant
Depth of liquid level above outlet im•en:-/ _
Comments:
(note if level and distribution is equal, evidence of solids carryo+er, evidence of leakage into or out of box, etc.) q f en— le,el
✓C ems o n /ma c
7L i a of
a
PUMP CHAMBER:.
(locate on site plan)
Pumps in working order: (Yes or Nol
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
tr.�i.•d 04/75/$71 ►.p. 7 of 10
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Vr� .•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
t,
Property Address: yS Bra e�yv �f, N-
Owner. �eLc -
Dale of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required• but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers. number:_
leaching galleries• number: rr
` leaching trenches, number•length: 7.,e z(C S
leaching fields, number• dimensions:_
overflow cesspool, number:
Alternative system:
Name of Technology:
� r
Coimments:
(note condition of soil• signs of hydraulic failure, level of ponding, condition o(vegetation. etc.)
)0b t5 rlo -m^
1
CESSPOOLS:w r r
(locate on site plan)
Number and configuration
Depth-top of liquid to inlet invert:
Drp(h of solids layer•. 1 t
Depth of scum laver:
Dimensions of cesspool:
Materials of construction: I )
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
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:
(riote condition of soil• signs of hydraulic failure. level of ponding, condition of vegetation, etc.)
rr.vl..d Ot/IS/!71 V.V. 4 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ^.
SYSTEM INFORMATION (continued)
nn y,s
Property Address: L�a g�i G Inc fit/. f,,,O.D.j eR
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
� L.I o.J S•c.
J�
1�
(rwi..d 04/2S/971 p•o. 1 0[ 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
j�
Property Address:
i /f/• nc(/J✓UL
Owner. �✓�gr•��se ��.-us.� Via:
Date of Inspection:
`113198 s tD(3� (`t�
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation;
Obtained from Design Plans on record
Observation of Site (Abutting property observation hole• basement sump c(c.)
Determine it from local conditions
i
Check with !oca!•Buard of health
Checi FEMA Maps
Check pumping records
i
Check local excavators, installers
Use USGS Data
Describe in \•our own words ho%v you established the High Groundwater Elevation.!(Must be completed)
�. U•S S.C. S.
/Kit P}
VcC.S �jcen c✓i- c�..--� � Or.�,...�
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(r.vl..d Ot/]3/771 P.9. 10 of 10 ',.
.............._........... ................ L y __...._..� .. ....... ...,. �.
NEW..........w ....W......... _.__.�... .o....� , . .... ... ... ,.....,. —. ,........................ ,. �
September 4, 1998
North Andover Board of Health
Town Hall. Annex
384 Osgood Street
North Andover, MA 01845
RE: TITLE V REPORT 45 Bridges Lane.
Enclosed is a copy of the Title V report for 45 Bridges Lane,North Andover, MA. The system
Conditionally Passed our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely,
m
Benja in C, Osgood r., E.U.
President
33WALKER FROAD SUITE 23-NORTHANDOVER, &O C:)1 45,.(97 )(',86.17U .,(888)359-'7645,-FAX(9-78)685-1099
a-1099
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3
CO!v mO' N\i'EALTH OF MASSACHUSETTS
( EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. NIA 02109 617-292-5500
WILLIAM WELD TRUDY COXE
Sccrcur%
Govcmo:
DAVID B.STRUHS
ARGEO PAUL CELLLICCI
Lt.Govcmor' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: cs t., A/. f}itd)JJC2- Address of Owner.
Date of Inspection: CIV-/AM 9 (If different)
Name of Inspector: B fI N C. OSGOOD JR.
I am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000)
Company Name: NEW ENGLAND ENGINEERING SERVICES, INC.
Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 01845
Telephone Number: 508-686-1768
CERTIFICATION STATEMENT
1 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
5?1asses
ondrtronalh Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: 15, C/ 'Date:47-�' 44-6 —
The Svstem !nspector sha11 submit a copy of the inspection report to the Approving Authoritytwithin thirty (30) days o(eompleting this
inspection. If the system is a shared system or has a design now of 10,000 gpd or greater, the inspector and the system owner shall submit
the repon to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the bt(yer, if applicable, and the approving authority I
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure crae:ia zs defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
eI SYSTEM CONDITIONALLY PASSES:
_zone 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances: If -not determined', explain why not.
_ T(se septic tank is metal unless ht owneror operator t,as provid mhtic-sy stem-m Vcct6r-wi��yro(��nifie�tc-of
Compliance-ottachedl-indicating°that°ihe-unk-was-installed within-twenty-(-20)-Yea(Apr-ior-t'0'4he-dat"f-�nstsect'on% or
the septic tank, whether or not metal, is , shows substantial ift4a"atien or exfilt_ o*-t.*Tk
(ativrt is-imminefit. The system will pass inspection i(the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(r•vi♦-d r 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection: �c'G
9/J19�
Bj SYSTEM CONDITIONALLY PASSES tcontinued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health;. Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than (our 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 replaces
cbstruction is removed
Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which reourre further evaluation by the Board of Health in order to determine if the system.4 failing to protect the
public health. safeq•and the environment:
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or pri"• is within SO feet of a surface water
Cesspool or prr%-�• is within SO feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within too feet to a surface water supply or
tributary to a suriace water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within SO feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but SO feet or more from a
private water supply well, unless a well water analysis for coli(orm bacteria and volatile organic compounds indicates that
the well is free irom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than S ppm. Method used to determine distance (approximation not valid).
3) OTHER
(r.vi•.d Ot/7S/�7) P.g. 2 or 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;
PART A }'
CERTIFICATION (continued)
Property Address: 27'� 13/ i tQ��s i nC, i(f, /�.zYp✓tA
Owner: -c sc f^
Date of Inspection: 3 i
D) SYSTEM FAILS: 6
You must indicate either -Yes"or "No"as to each of the following:
have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to comect
the failure.
Yes No
Backup of sewage into facility or system component due to an 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
a
Static liquid level in the distribution box above outlet raven 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 112 day flow.
Required 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation
Anv ponion of a cesspool or pmj- is within 100 feet of a surface water supply or tributary to a surface water supply.
Any ponion o(a cesspool or privy is within a Zone I of a public well. I
Any portion of a cesspool or privy is within 50 feet of a private water supply well
Anv ponion 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coldorm bactgria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS: I I
You must indicate either "Yes- or 'No- as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 go or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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 II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(r.rviud 04/2s/17) Pay. 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART e
CHECKLIST
Properly Address: / S ��+nl, N• 1q_k' u e./L
Owner:
Dale of Inspection:
9� 3�58
Check if the following have been done: You must indicate either `Yes-or-No" as to each-of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for a( least two weeks and the system has been receiving normal
(low rates during that period. Large volumes of water have not been introduced into the system recently or
as pan of this inspection
nn
`T As built plans have been obtained and examined. Note if they are not available with N/A.
J _ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout
_ All system components, excluding the Soil Absorption System, have been located on the site.
_✓ _ The septic tank manholets were uncovered, opened. and the interior of the septic tank was in1pected (or condition of
baffles or tees, material of construction• dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner tand occupants, if different from owners were provided with information on the proper maintenance of
/ Sub-Surface Disposal System.
Existing information. Ex.tPlan at B.O.H. t
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(6)] I
(r—i—d 04/25/97) P.q. l or 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: l-a✓, �J
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 7 g.p.dA)edroom for S.A.S
Number of bedrooms:,
Number of current residents:,,
Garbage gnr.der (yes or no): LA
Laundry connected to system (yes or no):
Seasonal use (yes or no): N
Water meter readings. if available (last two (1) year usage (gpd):
Sump Pump (yes or no): ,-
Last date of occupancy: Cpl r,2�r�j
COMM ERCIAUINDUSTRIAL:
Type of establishment:
Design flow: Qallons/dav
Grease trap present: (,yes or no)_
Industrial Waste Holding Tank present: Ives or no)_
Non-sanitary waste discharged to the Title 5 system ryes or no)_
Water meter readings, if available-
Last date of o•-cupancy:
a f
OTHER: (Describe)
Last date of occupancy.
GENERAL INFORMATION
PUMPING RECORDS and source of informations ' t
(JhG�
3 y^ -( 1.1eli—S Rot
System pumped as part of inspection: (yes or no)-&O
I( s
Ye , volume Pumped:
ped: Qallo�s
Reason (or 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)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: e--f
Sewage odors detected when arriving at the site: (yes or no) A10
(reviud 04/25/$7) Pay. 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: H- :;
Owner:
Dale of Inspection: `�'zi `x
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _Z40 PVC _other (explain)
Distance from private water supply well or suction liry _jj _
Diameter y•
Comments: (condition of joints, venting, evidence of leakage/, etc.) y
Pi e- hS GJ rX /nS r�tti/
SEPTIC TANK:_
(locate on site plant
Depth below grader
Material of construction: Zconcrete _metal _Fiberglass _Polvethylene _other(explatn)
If tank is metal. list age _ Is age confirmed by Certificate of Compliance —(Yes/No)
Dimensions: /u5-00 6-r4//OKs
Sludge depth: &"
Distance from top of sludge to bottom of outlet tee or baffle: �W'e4-" t
Scum thickness: D ,
Distance from top of scum to top of outlet tee or baffler/[
Distance from bottom of scum to bottom of outlet tee or baffle: I/
How dimensions were determined: ..v(ecu .t ir nc,-
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) 7-a,.6c We-, leoel /" b e•/o.- e 1C ►" r�r'
I I
GREASE TRAP:./V#
(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:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
04/71/)7) P.9. L or 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 41-5- t3ii��cS L-artc it/- f���J✓e2
Owner:
Dale of Inspection: ''`
TIGHT OR HOLDING TANK:Al Y? i7ank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacm: gallons ,
Design flow gallonJda\
Alarm level Alarm In working order _ Yes. _ No
Date of previous pumping:
Comments:
(condition of Inlet tee, condition of alarm and float switches, etc.)
1 % 1
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments
(note if level and distribution Is equal, evidence of solids carryoler, evidence of leakage into or out of box, etc.) GUn��' le-ell
cL 1 yr C L t7/1 /�/0" S !11 d 11 cl� eJ 'k d L w.
Q ��vYtln�s �cV C��rc,�y. �a,^h`�;� �'�Jp9
Vv
PUMP CHAMBER:.
(locate on site plan)
Pumps in working order: (Yes or Not
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(r—i—d 04/75/971 P•y. 7 or 10
...... ........
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 0j B� Cy qcy i,e, N-
Owner: V
Date of Inspection: rG` Se
.q �a1�e
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers. number:_
leaching galleries, number: r
leaching trenches, number•length: ,� 'Tee-t �S
leaching fields, number• dimensions:_
overflow cesspool. number:
Alternative system:
Name of Technology:
�
Cor mments: r
(note condition►of soil, signs o/(f hydraulic failure, level of ponding, condition of vegetation, etc.)
TT/1C�a Ot
• I
CESSPOOLS:4Z&
(locate on site plan)
Number and configuration
Depth-top of liquid to inlet invert:
Dr-pth of solids layer: t
Depth of scum laver:
Dimensions of cesspool:
Materials of construction: I I
Indication of groundwater:
inflow(cesspool must be pumped as pan of inspection)
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 hvdraulic failure, level of ponding, con'�ition of vegetation, etc.)
(r.vi..d o4/25/)7) P.9. a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1�S 8�i cQ� N
Owner: J '
Dale of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
1 t4 S c, I ,
QJ
1 1 1515 1
H �
r—
(r.vi.•d 04/25/971 P.p. 9 of 10 '..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: u
Date of Inspection: ✓�1 `-�
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
-'�_Observanon of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
i .
Check %viih !oca!'Buard of health
Checi. FEMA Maps
Check pumping records
f
Check local excavators, installers
Use USGS Data
Describe in vqur own words how you established the High Ground%•ate( Elevation.!(Must be completed)
P> 0 ?e.-0`.. J-
-h�.1�
( t
2-). �jc0CPHA 4, �oc> na� vice
I ✓t � s�.vim� p i�..
(—i—d 04/75/97) P.q. 10 of 10