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C)1 MON"VV±�A.I..,T.H.. 0 ' ASSACI-USErrPS
EXECUTIVE OFFIC'q OF ENVIRONMENTAL FF'AIMS
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DEPARTMENT T 0 , ENVIRONMENTAL PROTECTION
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TITLE
OF'F'ICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: i"r ;-�.r,P„✓� , ���a.
°r/' `d Cdr' ,mr i „,ye ✓,.�
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Owner's Name: �lC✓�✓,Ffi�"t� ,���
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Owner's Address: �r
Date of Inspection: 4//,7 L L� Nov ,2 t 2 �
0tD 0
�Name of Inspector: (P lease print) ( V1;j`
Company Name c /,✓r,,,. " ✓!if✓ �, {; „�,� t t f
Mailing Address:
Telephone)dumber: � u"�°" l � � ����� °® 6” )
CERTIF'ICA'TION STATEMENT
I 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 the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15,000). The system:
/,,,'Passes
Conditionally Passes
Needs Further Evaluation by,the Local Approving Authority
- — 7.`il's
Itxsptor's Sinafur : Dade:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,0,10
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable„ and the approving
authority.
(Votes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at than
tithe. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/1 5/2000 page 1
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
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SUBSURFACE SEWAGE DISPOSA SYSTEM INSPECTION FORM
_
CERTIFICATION (continued)
Property Addi
Inspection Summary: Check A,B,C,DDnrE/ALWAYS complete all nf Section
A. System Passes:
�
_____ | have not found onybofonnohonw/kiobiudiomea that any ofd`c failure criteria described in3|UCMRl
|5303 or in 3|8CK4R 15.304 exist. Any tai|urc criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: /�//�1,
One mniore system components as described in the"Conditional Pass" section need mbe replaced m |
repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
&nowrrycs. uooromdetcouiocd (Y`NJND) iodbcfordhcGoUnv/ingstatemcnu. l['`umdetcrmiocd''p)ease
explain.
The septic tank is metal and over 20 years old*nr the septic tank(whether metal or not) isstructurally -
unsound, exhibits substantial infiltration cvcxG|tru imn or tank /ai}mr is imminent. System will pass inspection if the
csiodo9 tank is replaced with a complying septic tank as approve(]by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, riot leakin1g,and if a Certificate of Compliance �
indicating that the tank is less than 2O years old isavailable.
`- explain:
Observation of sewage backup or break out or high static water level in the distribution box due u,broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board ofHuolth):
broken pipe(a)are replaced �
obstruction |
�
distribution box b leveled orreplaced |
ND explain:
___ The system required pumping more than 4 times u year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board ufBeu|{h):
6rokco pipe(s)are replaced
obstruction isremoved
ND explain:
�
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OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address;
Owner:A
Date of Inspection;
C. Further Evaluation is Required by the Board of Health; A,"/ m
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CM 15.303(l)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment;
Cesspool or privy is within 50 feet of a surface water
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,safety and environment;
_ The system 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.
'The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates 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, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other;
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTWICA][ION(oou1bmed)
Property Address:
Owner:
Date oyInspection: �
D. System Failure Criteria applicable N all systems:
You must indicate°ycs"nr"no`0n each of the following for all inspections:
Yes No �
— into facility m system component doe to overlomdedmclogged SAS mcesspool
Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS mrcesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
oeoopuml
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Nurnber
of times pumped
___
Aoyportiono[|6eSAS.ccsnpoo|orprivyim6dowbigbgrnundmu<ore>cvudoo.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply. |
Any portion ofu cesspool o,privy is within aZone Lo[u public well.
Any portion ofocesspool or privy bwithin 50 feet ofm private water supply well. �
Any portion ofu cesspool or privy is less than lO0feet but greater than 50feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compotmds
indicates that the well is free from pollution from that facility and the presence ufammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. /k copy of the analysis must bc attached to this form.{
(9e m���oml�K� lhavcdcx�oo�ncd�botoncormoz� n[�6ca6nvcfbU��cri,cria�sis�ma �
� "�-- |
ocs nocdin3|0CMKl5]O3.(herr6orcfhcsys*em5aib, Thcaystemo*nershouNcon/ac\tbcBoardof |
Health to determine what will bc necessary Uncorrect the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either'^yen'`o,'^m/`k»each of the following:
(The following criteria apply m large systems in addition{o the criteria above) �
yes no
the system is within 400 feet ofa 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 m"ped
2000 11 nfupublic water supply well -w�
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered �
"yca"in Section Dabove the large system has failed, The owner or operator of any large system considered a �
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR
}5.3U4�The system owner should contact the appropriate regional office uf the Department,
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OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
—----------
Owner:
Date of Inspection(
Check if the following have been done. You must indicate -'V-es"ar"no°'as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum ?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
'I"he size and location of the Soil Absorption System (SAS)on the site has been determined based oil:
Yes no
Existing information. For example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
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OFFICIAL INSPECTION EO -NOT FOR VOLUNTARY ASSESSMENTS
SUBSUR A E SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION
Property Address: ,���� �1,✓t � ��; �`,d/,
Date of Inspection. ✓e� °''
FLOW CONDITIONS
SIIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): �,,,,�
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no): /
Is laundry on a separate sewage system(ayes or no):��"� [if yes separate inspection required]
Laundry system inspected(yes or no): )"
Seasonal use: (yes or no): /V"
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy: c°
COMMERCIAL/INIDUSTRI AL
Type of establishment:
Design flow(based on 310 CMR 15.203):_ gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system (yes or no): _
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): _
If yes,volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TY OF SYSTEM
,, peptic tank,distribution box, soil absorption system
_Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank —Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
77-77/77 7-7 777t—aT7,
A
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: '1Z
Materials of construction:—cast iron 40 PVC—other(explain):
Distance from private water supply well or suction line: ) '
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK: _(locate on site plan)
Depth below grade:
Material of construction:—concrete—metal_fiberglass___polyethylene
—other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions:
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:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: A,
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
I I r OJ
GREASE TRAP:_(locate on site plan) /rl
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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: A
Date of Inspection:
—LI-1-416�'
TIGHT or HOLDING TANK:'11 1111-/1(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:_
Material of construction: concrete metal fiberglass ....polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:
(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER:4' locate on site plan)
1"
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
8
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSUR ,ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: "I A
Owner: 4"
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): on site plan,excavation not required)
If SAS not located explain why:
Type
—leaching pits,number:
—leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
771 leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation,
etc.):
C c— 'r
CESSPOOLS:/II/111(cesspool must be pumped as part of inspection)(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(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
11
PRIVY:0(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, etc.):
9
Page 10 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION(continued)
Property Address: S/MW V0A) LTV
IUCf
Owner:
Date of Inspection:_ i/
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
CERT/F1ZV OUNDAT/ONPLAN
LOCATED/N Wa -_" o tcv�Q,"ass
SCALE.7"r 4 a DATE: i s ee
S.L.G/L ES R.L.S. v' 412° i4°
LAWRENCEQ NORTH ANDOVER
o
�cg A4 va?4
'/ESrt• `i W
j ISau GA�..ST, (f
Ilk` --
11
L oT Z A wv.
a✓'�F HSE, 74.5! '..
a.r-r-e,e o.g, 78.31
/
CERTIFY THAT TH OFFSETS SHOWN ARE FOR THE USE OF v'
r� �N Gf ii1 4 �s/
OFFSETS SHODYN THE BUILDING INSPECTOR O/VL Y, S SUCH e ''-
CONFORM TO THE USE/S FOR DETERM/NAT/ON OFZON/NG UM
ZONING BY L A OF CONFORM/TY OR NON CONFORM/TY
re
BHAEe rrASS WHEN Gt7NSTRUCTEO
40
Page I I of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: /V '7,4F
SITE EXAM
Slope
Surface water I
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained firom system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked.with local excavators,installers-(attach documentation)
Accessed USGS database-explain: 6/
You must describe how you established the hi h ground water elevation: