HomeMy WebLinkAboutTitle V Inspection Report - 62 STONECLEAVE ROAD 1/23/2018 y. .r;:..
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS
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a DEPARTMENT OF ENVIRONMENTAL PROTECTION
01
I5 2001 ,
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TITLE S
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 61,17 °'° '!
Owner's Name:
Owner's Address:
Date of Inspection: '"
Name of Inspector: (please print) .0
Company Name: brl :ka.,��. �"p °'� '.
Mailing Address: t" ,.°
Telephone Number: E"'°°!72 241 72
CERTIFICATION 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
Nee s F he Ev l6ation by the Local Approving Authority
Fal
Inspector's Signature:
?Date.
The system inspector shall ubruit a copy of this inspection report tWdie Approving Authority(Board of Health or
DEP)within 30 days of 66mpleting this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector acid 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in tate future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
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Page 2 of I I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
VI have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments: .
B. System Conditionally Passes:
One 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
pp pipe(s) ) distribution box. System will pass inspection if(with
obstructed t e s or due to a broken settled or uneven
approval of Board of Health
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
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Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS j
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 6",_2 -,i°leu
Owner: l 42 1 1" i
Date of Inspection. <„
C. Further Evaluation is Required by the Board of Health:
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 deter' ines in accordance with 310 CMR 15.303(1)(b)that the
system isnot functioning in,,a manner which will protect public health;sa `ef�v 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 a 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 ry
the presence of.ammonia nitrogen and nAtraip nitrogen is equal to or'Jess than S ppm,provided that no other ,
failure criteria are triggered.A copy of the analysis must be attached to this form. FF
3. Other.
3
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: i , ,;;
Owner:
1
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
- "'Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
. > logged SAS or ce9spo l ;,:
_ _12 Static liquid level in the distribution box'above outlet invert due town overloaded or clogged SAS or
cesspool.
"tt Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
c/ Any portion of a cesspool or privy is within a Zone 1 of a public well.
„Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet 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 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.]
/ e,,') (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15,303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure,
E. Large Systems: ��
To be considered a large system they-system must serve a facility with a'design flow of 10;000 gpd to 15,000 `
"
gpd.
You must indicate either"yes"or"no"to.each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of 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 mapped
Zone Il of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above 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 310 CMR
15.304,The system owner should contact the appropriate regional office of the Department,
4
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Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECI'LLIST
Property Address:
Owner: L ,
Date of Inspe tion i
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yep No
t Pumping information was provided by the owner,occupant, or Board of Health
✓ere an ofthe system born onents pumped out previous twee"� j
_. y y P � � p wee��;�? ,
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?
m _ Were all system components,excluding the SAS, located on site?
v _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
ofthe 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?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on: �r
AI
Y no Existing information,For example,a plan at, F
,
p p 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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Page 6 of I 1
I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORINT
PART C
SYSTEM INFORMATION `
Property Address:
Owner:
Date of Inspection:
PLOW CONDITIONS
RESIDENTIAL
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( es�r no) 4L5'
Is laundry on a.separate sewage system(yes or no) me.> [if yes separate inspection required]
G' Laundry system inspected(yes or ttq'�:
Seasonal use:,(yes or no):
Water meter`readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): �!�!�j
Last date of occupancy:�c, err:)11
�
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 1.5.203): gpd
Basis of design flow(seats/persons/sgft,etc,):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Nan-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
j Last date of occupancy/use:
l
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: '1 i„ ”"" it" ". � 6o
Was system pumped as part of the inspection(yes or no): ;
If yes,volume pumped: �, gallons--How was quantity pumped determined?
Reason for pumping:
r ,
TY"E OF SYSTEM �" �, R
Septic 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/Altemative 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): /0
6
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Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) �1
1
Property Address: i
Owner: c 6 r) '
Date of Inspection: m �P'
BUILDING SEWER(locate on site plan)
Depth below grader ' ` ,
Materials of construction:��°"cast iron oe 40 PVC_other(explain):
Distance from private water supply well or suction line:
( , g
Comments on canditi�rn of'oints venting,evidence of leakage,etc.):
a ,
SEPTIC TANK: locate on siteplan)
(
Depth below grade:
Material of construction: oncrete 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.: �� r-,
Distance from top of sludge to bottom of outlet tee or baffle 6 r)
Scum thickness: � g'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: d X1.4
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc
GREASE TRAP:_(locate on site plan)
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
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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: 6A 5"161C C)" 41 1111-1,
A) 71
Owner:
Date of Inspection:
TIGHT or HOLDING TANK: (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: "Y —Oons
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:-Z(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:-0
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.):
�-V 0 3o�' "KC"
C"I 6 V
`6
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condi ion of pumps and appurtenances,etc,):
8
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Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART C
SYSTEM INFORMATION(continued)
Property Address:
Date of Inspecti n �' r,w
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not-required)
If SAS not located explain why:
p Y
s ,fype
�e
leachmgpits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
__L 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.):
CESSPOOLS: : (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: j
Materials of construction: '
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetatio'i,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,etc.): J
t
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
a
.Property Address.
ection'
Date of Ins .
Owner:
p
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.
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Page 11 of 11.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
r
Property Address.
Owners s,
Daae of Inspeetio _�
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated de rh to ground waterf ''eet
Please indicate(check)all methods used to determine the highground water elevation:
Obtained from 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:
You must describe how you established the high ground water elevation:
I
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F COMMONViaEALTH OF MASSACHUSETTS
=- >i EXECUTIVE {OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
-- ONE �VI1wTER STREET, BOSTON 14iA 02108 (617) 292-5,500
TRLJDY COXE
Secretarry 5
ARGEO PAUL CELLUCC1 DAV1D B. STRUHS
GovernorCommissionerSUBSURFACE SEWAGE DISPOSAL".SYSTEM INSPECTION FORM
PART A
CERTIFICATION!
"I
Property Address: ) _ w,� a ... Mame of Owner . 4 11`1111 �
Address of Owner: l
Date of inspection: r
Mame of Inspector:(Please Print)
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(31 0CMR 15.000)
Company Name:
Mailing Address: =' 2_
Telephone Number:
CERTIFICATION 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system;
P a s s a s
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date "1. G
The System Inspector shall/'submit a copy of this Inspection 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 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 authority.
NOTES AND COMMENTS
r
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revised 9/2/98 pagcIofII
* Prrmied ox Recycled Paper
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'roperty Address:
Owner:
Dante of Inspection: 5� ��
fNSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
: 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 CONDITIONALLY PASSES:
One or on need to be replaced or repaired, The system, upon
compiet am system
of therepla replacement repts as air, as
as approved b the cribed in the rt6 Boardofof�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.
_ 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.
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).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: f,) '(;1
,i
Date of Inspection:
J C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
i
`
Conditions exist which require further evaluation by the Board of Health In order to determine if the system is failing to protect the
N 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 ENVIRONMENT:
_ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and,the SAS is within a tone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid),
3) OTHER
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revised 92/98 Page 3ofII
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 6 .r
r
Owner: II Io,l�.r ��� f ;r`
Date of Inspection:
D. SYSTEM FAILS: ,
You must indicate either " as" or "No" to each of the following:
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 contacted to determine what will be necessary to correct the failure.
Yes Na
_ Backup of sewage into facility.or system component due to an overloaded orclogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool
q ib ye outlet invgrt due to al overloaded or,clogged SAS or,cesspool.
Al
Static liquid level in the distribution box above
-- — ,,
X
Uqui4 depth in cesspool is less than 5" below invert or available volume is less than 112 day flaw.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
_ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well
Any portion of a cesspool or privy is within 50 feet of a private water supply well
_ Any portion of a cesspool or privy is 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.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes or "No" to each of the following:
The fallowing criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large Systern) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No ;
_ the system is within 400 feet of a surface dr nkin 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 mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15304(2). Please consult the local regional
office of the Department for further information,
revi8ed 9/2/9$ Page 4ofII
"A
s° SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: �.. �t� f ����m p t,,�,� p' r„ r
d
Owner:
Date of Inspection: � "f"J r
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Ye No
Pumping information was provided by the owner, occupant, or 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 not available with N/A,
=facility o�dwpllfng was Inspected for sign iof sewage beck-up.
The system does not receive non-sanitary or industrial waste flow,
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, 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 Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(1 5,302(3)(b)]
The facility owner (and occupants,if different from owner) were provided with information on the proper maintenancs-of
SubSurface Disposal Systems.
revised 9/2/98 pugt-writ
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
y PART C
SYSTEM INFORMATION
.. -
rroperty Address.
n
Owner;
Date of Inspecton: 'f
d
FLOW CONDITIONS
RESIDENTIAL:
Design flaw: g.p.ddbedrpam.
Number of bedrooms (design):L Number of bedrooms (actual):____
Total DESIGN
I Number of current residents;
F:
Garbage grinder(yes or nol: �''�,
Laundry(separate system) (yes or no): .' If yes, separate inspection required
4 Laundry system Inspected (yes or no)
Seasonal use IYes or no): YL
Water meter readings,if available (last two year's usage (gpd): d' °gym
Sump Pump (yes or no}
Last date of occupancy'
' COMMERctALANDU9TR)AL:
Type of establishment: at w
Design flow: 9pd I Based an 15,2031
Basis of design flow_a.___ —__.... _ ..-._........._.__ _.,_...._.._..-_
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non sanitary waste discharged to the Title 5 system: lyes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no) '
If yes, volume pumped: " , u�� gallons
Reason for pumping:
TYPE OF SYSTEM
""Septic tank ldistribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) Ill yes, attach previous inspection records,if any)
I/A Technology etc, Attach copy of up to date operation and maintenance contract
- Tight Tank _Copy of DEP AppWoval . � ,�
Other
APPROXIMATE AGE of all components, date installed(if known) and source of information. Aj
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/98 Page 6efII
o
o�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address. ���>>m un� �a �'� ,�•r��,;� (��� �b;b� . �� w,r,�. �',.�^",��,� :
Owner: m
Date of Inspection:
BUILDING SEWER:
(Locate on site pian)
Depth below grade <
Material of construction: (",east iron 40 PVC_other(explain)
Distance fro private water supply well or suction line
Diameter rr4
Comments: (condition of joints, venting, evidence of leakage,etc.)
SEPTIC TANK: 1, ,
(locate on site n) 1r
Depth below'brade:-4
Material of constructlon,''`concrete—metal Fiberglass ,Polyethylene_other(explain)
If tank is metal, list age_ Wage confirmed by Certificate of Compliance (Yes/No)
� w
Dimensions: °
Sludge depth:
Distance from top of sl dqle to bottom of outlet tee or baffler
Scum thickness: /
Distance from top of scum to top of outlet tee or baffle:' ` �V
Distance from bottom of scum to bottom of outlet tee or batfle:
How dimensions were determined: 0 14
;omments:
frecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc ) r l,.
ua
GREASE TRAP:
—
(locate on site plan)
Depth below grader
Material of construction:,_,,,,,concrete_metal Fiberglass ,,,_,.,.Polyethylene_other(explain)
Dimensions.,
Scum thickness: r ,
6` Distance from tops,of scum too Jop of outlet•tee or,6affle:,
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of/last pumping:
Comments:
frecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7of11
I k9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
property Address:
�..
Owner: ��
Date of Inspection:
C TIGHT OR HOLDING TANK: . (Tank must be pumped prior to, or at time of, inspection)
ilocate on site plan)
y
Depth below grade:
Material of construction:_concrete_metal—Fiberglass_Polyethylene,_other explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present_
Alarm level: Alarm in working order: Yes No Ar•
Date of previclys purtlping: _
Comments:'+ �
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX-
(locate on
OX:(locateon site plan)
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, etc.)
5 r . r,.
PUMP CHAMBER: ,'".
(locate on site plan)
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.)
i
revised 9/2/98 Page 8(if 11
,or
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
property Address: ( r w"" .. ' a & ro „ mk
a.•
aep
Date of Inspection-. l "2.1,111V�
k' SOIL ABSORPTION SYSTEM(SAS): f
(locate on site plan, if possible; excav t'bn�not required,location may be approximated by non-intrusive methods)
if not located, explain:
r
Type'
leaching pits, number:_
$ leaching chambers, number:�
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions: sm. - tit
overflow cesspool, number _'
Alternative system: '' n
i Namara of°,Technolog`y:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
14
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-tap of liquid to inlet Invert:
Depth of solids layer:
)epth of scum layer:
Oimensions 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, etc.)
PRIVY:
pry. (locate on site pian)
Materials of construction: Dimensions:
Depth of'solids;
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
k
revised 9/2/98 Page 9ortt
z
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION! FORM
PART C
SYSTEM INFORMATION(continued}
"roperty Address: ,;' c,
)wner:
Date of Inspection:
u
r.
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
f' locate all wells within 100' (Locate where public water supply comes into house)
V
Xfa ;
revised 9/2/98 Page 10 of 11
f
H
011
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
r°
io
operty Address:
Jwner:
Dante of Inspection: I R; r a 1"'er
S
MRCS Report name_,,,
I Soil Type_
Typical depth to
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow_____.._.._._____ Moderate_—__._,__,,___Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells °I
Estimated Depth to Groundwate :, Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plaits on record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
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revised 9/2/98 Page II of II