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Home My WebLink AboutTitle V Inspection Report - 731 WINTER STREET 7/28/1995 SUBSURFACE SEWAGE DISPOSATj SYSTEM INSPECTION FORM Address of property 1731 w1,vT ✓ s1;� A/. XvPoj AVi Owner 's name AMA ci�9 _ Date of inspection PART A CHECKLIST Check if the following have been done: r/ 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 .recently or as p. Q. this inspection. - system _ 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. ^C7� The site was inspected for signs of breakout. _-Z- ,All system compgn,ents, excluding the SAS , have been located on the sate _.The septic tank manho, es,'were u'naovered, opened, and 'the . interior of the septic tank was. inspected ,for .condition bf baffles or tee's,' -material of co'nstxuct ion, dimenss,oins, depth. of liquid, dept2i of sludge, depth :pf scum'. The size and 1, gcation -pf the SAS o'n ;.the site' hasbeen determined based on ex`isti.ng information or '.approximated: by -,non-intrusive 'methods, ' 'The acil ity' ,ownerV -(and occupants, if different ,krom owner) were provided' with information on the proper' maintenance .of SSDS - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B J SYSTEM INFORMjkTION FLOW CONDITIONS If' residential ?� number; of bedrooms number, of current residents garbage grinder, yes or no laundry connected to system, yes or ,no A/ seasonal use, yes ar no zf nonresia,ential.r, calculated=f1;ow. r � Water meter readings, if available: Last date of occupancy GENERAL INFORKATION Pumping records and source of information ,PVC �C cU.-cSCa ya��L�C Gs System pumped as" part o`f i.nspectio' n, yes or no if yes', volume 'pumped .1S op rr6e� Reason for pumping: , i o N's!' f c T Type 'of system Septic tank/di tribution box%so' h absorpt�an`' system` Si:ngLea cesspool Overflow "cesspool,,. - Privy ;'Shared , system'? (yes or no). (if yes, attach previQu+s i.nspectian . records, if any) Other (explain) Approximate age of all Components'. � Date' installed' if known. Source of information: Sewage odors detected when arxiving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM xI�$PEC'�T®N oR1S SYSTEM INFORMATION Cbntinued (SEPTIC TANK: `{ (Locate on site plan) depth below grade �-� material of construction: concrete metal T,__FRP other(explain) dimensions: U �f sludge , depth ' 2` .distance from top of sludge to bottom of outlet tee or baffle „ scum thickness �" di"stance from top 'of 'scum to top of outlet tee ,or baffle ^(5" ' distance from bottom of scum to bottom of outlet tee or baffle Comments recommendation, ,for pumpJ,ng, ` condition of inlet and 'autl'et tees or baffles, depth of liquid level: in xela - o outlet invert, structural integzity, eyidence;_of ] eakage, recommendations for repairs, etc. ) �,�� -.s ft2 �r v DISTRIBUTION BOX;—i�f (locat'eon. site plan) depth af: liquid -level above outlet invert (riat'e If , level and distribut .on is equal, evidende. Qf solids carryover, evidence of" leakage into or out.'of box:, recommendation tor .r�pairs ,.,etc,) . il� c NS L GG l^tlCl.hws /UO L✓� fJ��t/'C't� C� � C Ce y 011 PUMP CHAMBER (locate `on site plan) pumps in working order, yes or 'no Comments: : . " (ngte' 'condition 'of pulp chamber, condition of pumps -and appurtenances, - recommendations, for maintenance or repairs,etc- ) SUBSURFACE SEWAGE DISPOSAL SYST.EX INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan,... 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 ga leries and number'; leaching trenches, number, length .leaching fields, number, dimensions overflow cesspool , number Comments : (note condition, of soil , signs of��hydrauxic failure," 1Le1` of pondirig, condition of vegetation; " recommendations for maintenance or repairs,etc. ) "5 fsN, o F HVD 2,406 c FA7 i V r'LEL y �6 /1d:j— CESSPOOLS (locate on site plan) number" end configuration depth=top of liquid to inlet invert depth. of solids 1;ayer' depth .of scum layer "dimerision's of cesspool materials of:' construction indication of groundwater inflow (cess.pool , must be pumped as part of inspection) Comments. - (note` `condition of sail, signs of,, hydxaullc` failure, level 'of ponding, condition of vegetation, .:recommendations for,maintenance or repairs,'etc. ) PRIVX: (locate on site plan) mater�aTs of '`consetruction dimensions depth, of: solids Comments note , of soil , signs of ,hydraulic failure, level. of paxidxng, condition of ,vegetation, recommendations 'for maintenance', or "repars,.etc;) 616 s SUBSURFACE SEWAGE, DISPOSAL SYSTEM! INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH .,OF SEWAGE DISPOSAL SYSTEM: include_ ties, to at J.east two .permanent references landmarks or benchmarks locate all wells with J.n 100 '. �Pa , T AP K DEPTH TO GROUNDWATER depth to " groundwater method 'of determination approimatioin; ,.4 12 1..�; y �'• SUBSURFACE SEWAGE --DISPOS�L :BYSTEM INSPECTION FORM .,, ,, PART C der, FAILURE CRITERIA Indicate yes, no, or not 'determined ; (Y, ht, or ND) . Describe basis of determination in all instaric es' . If , "not detexmined"', 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? IV Liquid depth in, cesspool <611 below invert or available volume< .1,/2 day flow? Required pumping 4 times or more in the last year? number of times pumped (7 Septic tank is metal? cracked? structurally .'unsound? `substantial infiltration? substantial, . exfiltration? 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 o a surface water .supply or tributary to a surface water supply? / within a Zone I of a public w ell? r within 50 `feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? G� within 50 feet of a private water supply weld? 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'analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D r1 CERTIFICATION r , Name of Inspector' ge.,jct,km � C.' U ��o�a Company Name NP ,; N�1�, Cry r.,��'rt� Sc,z• ��s �c Company Address' 33 Certification Statement I---certify that I have"personally inspected the sewage disposal: system at this ,address and that the information -reported is true, accurate and co as of the time` of i.nspecti.on. The inspection was performed and any ree.ommenda;tions regarding maintenance and repair are , consistent with my t 'rainig and, experience in the Draper function and manitenance of `.on-site sewage disposal. systems. Che one: : ' , C/ I have not found . . � nfo 7ation which indicates that the system fails to adequately protect public health, or the environment as defined in 310 CMR 15 . 303 Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of thi's `form. 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 determinatio,n :is provided in the FAILURE CtITERIA section of this form Inspector ' s Signature i Date Original to system 'owner Copies to: Buyer ( if applicable) Approving authority "