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HomeMy WebLinkAboutTitle V Inspection Report - 146 OLYMPIC LANE 12/1/1999 107 FOREST STREET FILE # 120199A MIDDLETON,MA 01949 (978)774-2772 SEPTIC & DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: DUBASKA PROPERTY ADDRESS: 146 OLYMPIC LANE,NORTH ANDOVER ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: DECEMBER 1, 1999 NAME OF INSPECTOR: THOMAS CHIGAS * THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 107 FOREST STREET FILE# 120199A MIDDLETON,MA 01949 (978)774-2772 SEPTIC&DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PROPERTY ADDRESS:146 OLYMPIC LANE NAME OF OWNER: DUBASKA NORTH ANDOVER ADDRESS OF OWNER: SAME DATE OF INSPECTION: DECEMBER 1, 1999 NAME OF INSPECTOR: (PLEASE PRINT)THOMAS CHIGAS I AM A DEP APPROVED INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5 (3 10 CMR 15.000) COMPANY NAME: CURRIER SEPTIC &DRA1N MAILING ADDRESS: 107 FOREST STREET; MIDDLETON MA 01949 TELEPHONE NUMBER: (978) 774-2772 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE 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 PREFORMED BASED ON MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEM. THE SYSTEM: PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY YES FAILS f INSPECTOR'S SIGNATURE: % DATE: DECEMBER 1, 1999 THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIS INSPECTEO REPORT TO THE APPROVING AUTHORITY(BOARD OF HEALTH OR DEP) WITHIN THIRTY(30)DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR HAS A DESIGN FLOW OF 10,000 GALLON GPD 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 BUYER,IF APPLICABLE,AND THE APPROVING. NOTES AND COMMENTS: N/A REVISED 9/2/98 PAGE 1 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1, 1999 INSPECTION SUMMARY: CHECK A, B, C, OR A. SYSTEM PASSES: N I HAVE NOT FOUND ANY INFORMATION,WHICH INDICATES THAT ANY OF THE FAILURE CONDITIONS DESCRIBED IN 310 CMR 15.303 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. COMMENTS: B. SYSTEM CONIDTIONALLY PASSES: _NONE 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. N THE SEPTIC TANK IS METAL,UNLESS THE OWNER OR OPERATOR HAS PROVIDED THE SYSTEM INSPECTOR WITH A COPY OF A CERTIFICATE OF COMPLIANCE(ATTACHED)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 COMPLYING SEPTIC TANK AS APPROVED BY THE BOARD OF HEALTH, N 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). N BROKEN PIPE(S)ARE REPLACED N OBSTRUCTION IS REMOVED N DISTRIBUTION BOX IS LEVELLED OR REPLACED N THE SYSTEM REQUIRED PUMPING MORE THAN FOUR TIMES A YEAR DUE TO BROKEN OR OBSTRUCTED PIPE(S). THE SYSTEM WILL PASS INSPECTION IF(WITH APPROVAL OF THE BOARD OF HEALTH): N BROKEN PIPE(S)ARE REPLACED N OBSDTRUCTION IS REMOVED REVISED 9/2/98 PAGE 2 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH, SAFETY AND THE ENVIRONMENT. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(B) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRNONMENT: N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF SURFACE WATER N/A 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 AND SAFETY AND THE ENVIRONMENT: N THE SYTEM 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. N THE SYTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND THE SAS IS WITHIN A ZONE I OF PUBLIC WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS IS LESS THAN 100 FEET BUT 50 FEET MORE FROM A PRIVATE WATER SUPPLY WELL, UNLESS A WELL WATER ANALYSIS FOR COLIFORM BACTERIA AND VOLATILE ORGANIC COMPOUNDS NDICATES THAT THE WELL IS FREE FROM POLLUTION FROM THAT FACILITY AND THE PRESENCE OF AMMONIA NITROGEN AND NITRATE NITROGEN IS EQUAL TO OR LESS THAN 5 PPM. METHOD USED TO DETERMINED DISTANCE (APPROXIMATION NOT VALID). 3) OTHER: N/A REVISED 9/2/98 PAGE 3 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSEPCTION:DECEMBER 1, 1999 D. SYSTEM FAILS: YOU MUST INDICATE EITHER"YES"OR"NO"TO EACH OF THE FOLLOWING: Y I HAVE DETERMINED THAT ONE OR MORE OF THE FOLLOWING FAILURE CONDITIONS EXIST AS DESCRIBED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS IDENTIFIED BELOW. THE BOARD OF HEALTH SHOULD BE CONTRACTED TO DERTERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE. YES NO YES BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR SURFACE WATERS DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE OUTLET INVERT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N/A LIQUID DEPTH IN CESSPOOL IS LESS THAN 6'BELOW INVERT OR AVAILABLE VOLUME IS LESS THAN V2 DAY FLOW. N REQUIRED PUMPING MORE THAN 4 TIMES IN THE LAST YEAR NOT DUE TO CLOGGED OR OBSTRUCTED PIPE(S). NUMBER OF TIMES PUMPED UN ANY PORTION OF THE SOIL ABSORPTION SYSTEM,CESSPOOL OR PRIVY IS BELOW THE HIGH GROUNDWATER ELEVATION. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS LESS THAN 100 FEET BUT GREATER THAN 50 FEET FROM A PRIVATE WATER SUPPLLY WELL WITH NO ACCEPTABLE WATER QUALITY ANALYSIS. IF THE WELL HAS BEEN ANALYZED TO BE ACCEPTABLE,ATTACH COPY OF WELL WATER ANALYSIS FOR COLIFORM BACTERIA,VOLATILE ORGANIC COMPOUNDS,AMMONIA NITROGEN AND NITRATE NITROGEN. E. LARGE SYSTEM FAILS: MUST INDICATES EITHER"YES"OR"NO"TO EACH OF THE FOLLOWING: E FOLLOWING CRITRTIA APPLY TO LARGE SYSTEMS IN ADDIT TO THE CRTERIA ABOVE: N THE SYST RVES A FACILITY WITH A DESIGN FLO 10,000 GPD OR GREATER(LARGE SYSTEM) AND THE SYSTEM IS A S FICANT THREAT TO PUBLIC LTH AND SAFETY AND THE ENVIRONMENT BECAUSE ONE OR MORE OF T LLOWING COND NS EXIST: YES NO THE SYSTEM IS WIT 00 FEET SURFACE DRINKING WATER SUPPLY THE SYSTEM I THIN 200 FEET OF A T TARY TO A SURFACE DRINKING WATER SUPPLY THE SYS S LOCATED IN A NITROGEN SENSI AREA(INTERIM WELLHEAD PROTECTION AREA-IWP A MAPPED ZONE II OF A PUBLIC WATER SUP WELL THE O OR OPERATOR OF ANY SUCH SYSTEM SHALL UPGRADE THE SYSTE ACCORDANCE WITH 310 CM .304(2).PLEASE CONSULT THE LOCAL REGIONAL OFFICE OF THE DEPARTMENT FURTHER FORMATION. REVISED 9/2/98 PAGE 4 OF I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM PART B CHECKLIST PROPERTY ADDRESS: 146 OLYMPIC LN N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1, 1999 CHECK IF THE FOLLOWING HAVE BEEN DONE: YOU MUST INDICATE EITHER"YES" OR"NO" AS TO EACH OF THE FOLLOWING: YES NO Y PUMPING INFORMATION WAS PROVIDED BY THE OWNER, OCCUPANT, OR BOARD OF HEALTH. Y NONE ON 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 SYTEM RECENTLY OR AS PART OF THIS INSPECTION. Y AS BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED.NOTE IF THEY ARE NOT AVAILABLE WITH N/A. Y THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. Y THE SYSTEM DOES NOT RECEIVE NON-SANITARY OR INDUSTRIAL WASTE FLOW. Y THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. Y ALL SYSTEM COMPONENTS, EXCLUDING THE SOIL ABSORPTION SYSTEM HAVE BEEN LOCATED ON THE SITE. Y 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. THE SIZE AND LOCATION OF THE SOIL ABSORPTION SYSTEM ON THE SITE HAS BEEN DETERMINED BASED ON: Y EXISTING INFORMATION. FOR EXAMPLE,PLAN AT B.O.H. Y DETERMINED IN THE FIELD(IF ANY OF THE FAILURE CRITERIA RELATED TO PART C IS AT ISSUE,APPROXIMATION OF DISTANCE IS UNACCEPTABLE) [I 5.302(3)(b)] Y THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SUBSURFACE DISPOSAL SYSTEMS, REVISED 9/2/98 PAGE 5 OF 11 SUBURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1, 1999 FLOW CONDITIONS RESIDENTIAL: DESIGN FLOW: 440G.P.D.BEDROOM. NUMBER OF BEDROOMS(DESIGN): 4 NUMBER OF BEDROOMS(ACTUAL):4 TOTAL DESIGN FLOW:440 NUMBER OF CURRENT RESIDENTS: 3 GARBAGE GRINDER(YES OR NO):YES LAUNDRY(SEPARATE SYSTEM)(YES OR NO):NO;IF YES, SEPARATE INSPECTION REQUIRED LAUNDRY SYSTEM INPECTED(YES OR NO):N/A SEASONAL USE(YES OR NO):NO WATER METER READINGS,IF AVAILABLE(LAST TWO YEAR'S USAGE(GPD): 197,000 GALS USAGE FORM LAST TWO YEARS. SUMP PUMP(YES OR NO):NO LAST DATE OF OCCUPANCY: CURRENT COMMERCIAL/INDUSTRIAL: PE OF ESTABLISHMENT: DES FLOW: GPD(BAESED ON 15.203) BASIS OF IGN FLOW: GREASE TRAP SENT(YES OR NO): INDUSTRAIL WAST LDING T PRESENT(YES OR NO): NON-SANITARY WASTE RGED TO THE TITLE 5 SYSTEM(YES OR NO): WATER METER REDA IF ILABLE: LAST DATE OF O ANCY: OT HE SCRIBE): DATE OF OCCUPANCY: GENERAL INFORMATION PUMPING RECORDS AND SOURCE OF INFORMATION: SYSTEM PUMPED AS PART OF INSPECTION(YES OR NO):NO IF YES, VOLUME PUMPED:N/A GALLONS REASON FOR PUMPING: LAST PUMP WAS FALL 1998 TYPE OF SYSTEM YES SEPTIC TANK/DISTRIBUTION BOX/SOIL ABSORPTION SYSTEM N SINGLE CESSPOOL N OVERFLOW CESSPOOL N PRIVY N SHARED SYSTEM(YES OR NO)(IF YES,ATTACH PREVIOUS INSPECTION RECORDS,IF ANY) N I/A TECHNOLOGY ETC, ATTACH COPY OF UP TO DATE OPERATION AND MAINTENANVE CONTRACT TIGHT TANK COPY OF DEP APPROVAL OTHER:N/A APPROXIMATE AGE OF ALL COMPONENTS,DATE INSTALLED (IF KNOWN)AND SOURCE OF INFORMATION: 19 YEARS OLD.OWNER. SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE(YES OR NO):NO REVISED 9/2/98 PAGE 6 OF I 1 SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1, 1999 BUILDING SEWER: (LOCATE ON THE SITE PLAN) DEPTH BELOW GRADE: 21" MATERIAL OF CONSTRUCTION: YES CAST IRON 40 PVC OTHER(EXPLAIN) DISTANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE:N/A DIAMETER: 4" COMMENTS: (CONDITION OF JOINTS,VENTING,EVIDENCE OF LEAKAGE,ETC.) THE INLET PIPE WAS IN GOOD CONDITION NO SIGNS OF LEAKAGEI IN OR OUT SOILS ARE CLEAN AND DRY. SEPTIC TANK: YES (LOCATE ON SITE PLAN) DEPTH BELOW GARDE: 12" MATERIAL OF CONSTRUCTIOMYESCONCRETE METEL FIBERGLASS POLYETHYLENE OTHER (EXPLAIN):N/A IF TANK IS METAL,LIST AGE N/A IS AGE CONFIRMED BY CERTIFICATE OF COMPLIANCE(YES/NO) DIMENSIONS: 8'L X 4'W X 5'H OUTLET INVERT nn_,4'2" = 1000 GAL TANK. SLUDGE DEPH: 8" DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE:N/A SCUM THICKNESS: <2" DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE:N/A DISTANCE FROM BOTTOM OF SCUM TO BOTTON OF OUTLET TEE OR BAFFLE:N/A HOW DIMENSIONS WERE DETERMINED: SLUDGE JUDGE,ROD,RULER COMMENTS: (RECOMMENDATION FOR PUMPING,CONDITION OF INLET AND OUTLET TEES OR BAFFLES,DEPTH OF LIQUID LEVEL IN REALTION TO OUTLET INVERT,STRUCTURAL INTEGRITY,EVIDENCE OF LEAKAGE,ETC.)THERE'S NO OUTLET TEE BAFFLE ON OUTLET PIPE.THE LIQUID LEVEL n,NORMAL HIGHT,NO SIGNS OF LEAKAGE IN OR OUT SOILS WERE CLEAN AND DRY.THERE WAS NO SIGNS OF DECAY IN OR AROUND COVER AREAS GREASE TRAP: _N LOCATE ON SITE PLAN) DEPT LOW GRADE: MATERIAL ONSTRUCTION: CONCRETE M �ILFIBERGLASS POLYETHLENE OTHER (EXPLAIN) DIMENSIONS: SCUM THICKNESS: DISTANCE FROM TOP OF SCUM T P OF OUTLET TEE OR BAFFLE: DISTANCE FROM BOTTOM O UM TO TTON OF OUTLET TEE OR BAFFLE: DATE OF LAST PUMPIN COMMENTS: (RECD NDATION FOR PUMPING, CONDITION OF INLET A UTLET TEES OR BAFFLES,DEPTH OF LIQUID L IN REALTION TO OUTLET INVERT, STRUCTURAL INTEGRIT IDENCE OF LEAKAGE,ETC.) REVISED 9/2/98 PAGE 7 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1, 1999 TIGHT OR HOLDING TANK: N(TANK MUST BE PUMPED PRIOR TO,OR TIME OF,INSPECTION) CATE ON SITE PLAN) DEPTH B W GRADE: MATERIAL OF STRUCTION: CONCRETE AL FIBERGLASS POLYETHYLENE OTHER (EXPLAIN) DIMENSIONS: CAPACITY: GALLONS DESIGN FLOW: GALL /DAY ALARM PRESENT: ALARM LEVEL: ALARM IN WORKING ORD YES NO DATE OF PRE US PUMPING: COMME (CO TION OF INLET TEE, CONDITION OF ALRM AND FLOAT TCHES, ETC.) DISTRIBUTION BOX: YES (LOCATE ON SITE PLAN) DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 0" DEPTH BELOW GRADE 22" COMMENTS: (NOTE IF LEVEL AND DISTRIBUTION IS EQUAL,EVIDENCE OF SOLIDS CARRYOVER,EVIDENCE OF LEAKAGE INTO OR OUT OF BOX,ETC.) THE D-BOX WAS IN POOR CONDITION SHOWS SIGNS OF DECAY AND LEAKAGE.THERE WAS SIGNS OF SOLID CARRYOVER AND SIGNS OF HYDRAULIC FAILURE THERE WAS LIQUID POOLING IN THE LEACHLINES. PUMP CHAMBER: _N LOCATE ON SITE PLAN) PUMPS IN ING ORDER(YES O): ALARMS IN WO ORD ES OR NO): COMMENTS: (NOTE CONDI S OF PUMP C ER, CONDITION OF PUMPS AND APPURTENANCES,ETC.) REVISED 9/2/98 PAGE 8 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER: DUBASKA DATE OF INSPECTION:DECEMBER 1, 1999 SOIL ABSORPTION SYSYEM(SAS): YES (LOCATE ON SITE PLAN,IF POSSIBLE;EXCAVATION NOT REQUIRED,LOCATION MAY BE APPROXIMATED BY NON-INTRUSIVE METHODS) IF NOT LOCATED,EXPLAIN: TYPE: LEACHING PITS,NUMBER: LEACHING CHAMBERS,NUMBER: LEACHING GALLERIES,NUMBER: LEACHING TRENCHES,NUMBER,LENGTH:FOUR SCH2O PVC 24"W X 80T TRENCHES LEACHING FIELDS,NUMBER,DIMENSIONS: OVERFLOW CESSPOOL,NUMBER: ALTERNATIVE SYSTEM: NAME OF TECHNOLOGY: COMMENTS: (NOTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,DAMP SOIL,CONDITION OF VEGETATION,ETC.) THE LEACH LINES ARE SHOWING SIGNS OF SOLID CARRYOVER AND SIGNS OF FAILURE.HAD DUG OUT IN TRENCH AREA LOCATED STONE AND PIPE FOUND TO BE UNDER HYDRALIC FAILURE. CESSPOOL: N ( CATE ON SITE PLAN) NUMBE ND CONFIGURATION: DEPTH-TOP LIQUID TO INLET INVERT: DEPTH OF SOIL AYER: DEPTH OF SCUM LA R: DIMENSIONS OF CESSP L: MATERIALS OF CONSTRU INDICATION OF GROUND T INFLOW(CESS OL MUST PUMPED AS PART OF INSPECTION) COMME S: (NOT ONDITION OF SOIL,SIGNS OF HYDRAULIC FAILU EVEL OF PONDING,CONDITION OF VEGETATION,ETC.) PRIVY: _N ATE ON SITE PLAN) MATERIALS OF TRUCTION: IMENSIONS: DEPTH SOLIDS: COMMENTS: (NOTE CONDIT 7, SOIL,SIGNS OF HYDRA AILURE,LEVEL OF PONDING,CONDITION OF VEGETATION,ETC.) REVISED 9/2/98 PAGE 9 OF 11 SUBSURFACE SE1� GE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM,INFORMATION(CONTINUED) P OI' �r Ap R.ESS: 196 QLYMPI .��l`l.N•' �` 3:Ii O DAT$ SP$I~7'ION:DECEMBE$ . 1299 SKET OF SEWAGE DISPOSAL SY4/TEm: 'INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCE LANDMARKS OR BENCHMARKS .00ATE ALL WELLS WITHIN 100'(LOCATE WHERE PUBLIC WATER SUPPLY COMES INTO HOUSE) OL k-v� P, C, r • House ^, f �C Sl©Pes SePhc DOD Tank t� Trench kInes is 0 _ .-- �� 4e jve Tl 2-5 2 �� ow4u A ��► � 4 REVIS /9� PAGE 10 OF I I L C tb - 4 16" jY .0,0 / maw �y wb,5,: ♦fit x i j� '. },� i .�J 4 _ f J Jl 7r i Sum W Aw w �Vq �s , Amp lip s go a. j r we a Fm m p � � r � Row �L OT tiL Al Z �>, F f, � / � 3 f t O ,v ev t p � '.' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1 1999 NRCS REPORT NAMEN/A SOIL TYPE N/A TYPICAL DEPTH TO GROUNDWATER N/A USGS DATE WEBSITE VISITED OBSERVATION WELLS CHECKED GROUNDWATER DEPTH: SHALLOW N/A MODERATE DEEP SITE EXAM SLOPE SURFACE WATER CHECK CELLAR SHALLOW WELLS ESTIMATED DEPTH TO GROUNDWATER 4'APPROX FEET PLEASE INDICATE ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION: Y OBTAINED FROM DESIGN PLANS ON RECORD Y OBSERVED SITE(ABUTTING PROPERTY, OBSERVATION HOLE,BASEMENT SUMP,ETC.) Y DETERMINED FROM LOCAL CONDITIONS N CHECKED WITH LOCAL BOARD OF HEALTH N CHECKED FEMA MAPS Y CHECKED PUMPING RECORDS N CHECKED LOCAL EXCAVATORS, INSTALLERS Y USED USGS DATA DESCIBE HOW YOU ESTABLISHED THE HIGH GROUNDWATER ELEVATION. (MUST BE COMPLETED) THE HOUSE HAS 8'FOUNDATION W/NO SUMP PUMP IN BASEMENT AND IT'S DRY.THERE IS A SPOT OF WETLANDS IN BACK YARD LESS THAN 50'AWAY.THERE NO SIGNS OF ABBUTTING PROPERTY'S WELLS WITHIN 100'. REVISED 9/2/98 PAGE 11 OF 11