HomeMy WebLinkAboutTitle V Inspection Report - 35 SHANNON LANE 7/11/1995 " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 3J Aji 19_Ajc�i- 4,c'.(L
Owner ' s name SI�i�Lti /V1c �i.1G
Date of Inspection
PART A
CHECKLIST
Check 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.
As built plans have been obtained and examined. Note if they are riot
available with N/A.
J�
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.
/ 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 .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART S
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
number of current residents
A2 grinder, yes or no
y 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
GENERAL INFORMATION
Pumping records and source of information:
e-
z5 System pumped as part of inspection, yes or no
if yes, volume pumped t 2&c
Reason for pumping :
i. 4'6 A/ t H/144 /Z.
Type of system
_�Septi.c 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:
._ 1 a'!� �
Sewage odors detected when arriving at the site, yes or no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION c'bntinued
,)TIC TANK:_
locate on site plan)
depth below grade:_
material of construction: -/concrete metal FRP other(explain)
dimensions :
wn sludge depth
^? distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from top of scum to top of outlet tee or baffle
17" distance from bottom of scum to bottom of outlet tee or baffle
Comments :
mping , condition of inlet and outlet tees or baffles,
(recommendation for pu
depth of liquid level in relation to outlet invert, struc-tur?�1 integrity,
evidence of leakage, recommendations for repairs, etc. ) IYiscrz TG
A.
47,
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oe
DISTRIBUTION BOX:
( locate on site plan)
0 depth of liquid level above outlet invert
Comments :
(note if level and distribution is equal , evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs , etc. )
PUMP CHAMBER:
(locate on site plan)
pumps in working order,�ga) or 'no
Comments : uxtenances
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs , etc. )
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
JIL 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 .�zc%"
leaching fields , number, dimensions
overflow cesspool , number
Comments :
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for mainte ance 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
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,
condition of vegetation, recommendations for maintenance or repairs , etc. )
! -j )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
:include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
I
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j
DEPTH TO GROUNDWATER
I
S h depth to groundwater j
%'-
method of determination or approximation:
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes , no, 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?
_Zt,, _ Discharge or ponding of effluent to the surface of the ground or
surface waters?
A _ Static liquid level in the distribution box above outlet invert?
Liquid 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 0 _
_e� Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
�/ Is ,any portion of the SAS , cesspool or privy:
_z" 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 'Lone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water supply well?
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 coliform bacteria , volatile organic compounds, ammonia nitrogen
and nitrate nitrogen .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector
Company Name 'oc� vrcj?�
Company Address
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
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
manitenance of on-site sewage disposal systems .
Check one :
v� 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 . 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 C'MR 15 . 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form .
Inspector ' s Signature
Date 2
original to system owner
Copies to:.
Buyer ( if applicable)
Approving authority