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Home My WebLink AboutTitle V Inspection Report - 475 WINTER STREET 6/8/1995 �4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property , Owner's name �� e ,� F "° Date of Inspection o ". „ PART A CHECKLIST Check if the following have been done. .0,1, Pumping information was requested of the owner, occupant, and ward of , Health. 0 ° 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. 0111101" As built plans� have been obtained and examined. Note if they are not j available with N/A. 1 " 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 sate. 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 Nudge, depth of scum. 1 The size and location of the SAS on the site has been determined based ot ,existing information or approximated by non-intrusive methods. Thefacility owner (and occupants, if different from owner) were y provided with information on the proper maintenance of SS®S. I t p t i f f q I 4r I I' i f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION 4 FLOW CONbITIONS If residential number of bedrooms number of current resider � garbage grinder, yes or laundry connected to f ye or no seasonal use, yes or i 6 If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy i. GENERAL INFORMATION Pumping records nd0rcource of information: 41 o System pumped as part of inspection( yes r no if yes, volume pumped Reason for pumping: 1% t Type y f ' stem 900010 Septic tank/distribution box/sail 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: P Sewage odors detected when arriving at the site, yes or no H . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ., SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth belowgrade: �� material of construction: concrete metal F'RP other(explain) „dimensions: sludge depth ""' distance from top of sludge to bottom of outlet tee or baffle scum thickness :i�i distance from top of scum to top of outlet tee or baffle { distance from bottom of scum to bottom of outlet tee or baffle 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 leafage, r commendat mgns for repairspoo tc. ) Vw DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, f' evide a of leafage into or out of box, recommendation for repairs, etc.) a PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) C " Y { m, l SUBSURFACE SEWAGE DISPOSAL SYSTEM XNSPECTICN FORM PART E SYSTEM INFORMATION oontinUed �da 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 and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of getation, recommendations for maintenance or repairs,etc. ) 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 pumped as 1' part of 'inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, l condition of vegetation, recommendations for maintenance or r6pairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION continued �. SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 10,0 ' Lot z w. � , 00N �o �ov � wU N� v000 w� oaN,�a uwN� q wwoomniomwuw im uwwurwwwumomu NI iwm �u c) �mwwm� mimmw �mr j f DEPTH TO GROUNDWATER o � depth to groundwater method of determination or approximation: ,W � � u, wu�ffiw mrwrw �Mx � �uwp SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART iC FAILURE CRITERIA Indicate yes, ago, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? L�iquid , depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structural) unsound? substantial � Y infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: 4 ® 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 wa er supply? within a Zone I of a public well? AL i within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, Dot the SAS) ? V\/ within 50 feet of a private water supply well? i d 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 analys for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. s l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART O CERTIFICATION ,dame of Inspector ICZ Company Fame , n Q Q-. " � { Company Address I � j , ti f;�� on tatement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maiitenance of on-site sewage disposal systems. Chec one 4 I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 383. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. 1' I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature Da te ', original to system owner Copies to., i D �a l �. I Buyer (if applicable) Approving authority f 1' r 1 f p, II f' lyy I!{ 1