HomeMy WebLinkAboutMiscellaneous - 104 BRIDGES LANE 4/30/2018L
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF E
DEPARTMENT OF
NMENTAL AFFAIRS
NMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY
ASSESSMENTS
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM s' �\
PART A
CERTIFICATION
Property Address:
Owner's Name:
Owner's Address:
Date of Inspection: _� Z
Name of Inspector: (please print) P/Z,04 /V /f�"/--/Z
Company Name: "IZ-I A -S Z lzr�(l CV 6.
Mailing Address: S%
I-Ilf-G/yz3
Telephone Number: 6 — SL/4 S �(c
REc-
VED
f . NO V 2 9
TO�'�n, OF 2004
ytAL7'11 DZt ARTMDOTER
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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: ..----' Date: i:Z , z9_
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 10,000
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.
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 the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Pag`2 of 11
OFFICIAL INSPECTION FORM - NOT FOR V UNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYS 'EM INSPECTION FORM
PART A
CERTIFICATION ( ontinued)
Property Address: / AAI) G T $ '4/V\
Owner
Date of Inspection: // z
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D f
A. System Passes:
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:
GG C o rvtl 7—(0 ;j
y
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. r
*A metal septic tank will pass inspection if it is structurally sound, not leakine 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 breakout or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
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:
` Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FORrV` OLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION. FORM
PART A%
CERTIFICATION (continued)
Property Address: 1U.lfi2 �p.G�� S
Owner: IG L Y
Date. of Inspection: 1
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 systemI
is failing to protect public health, safety or the environment.
L. System will passmnless Board of Health determines in. accordance with 310 CMR 15.303(l)(b) that, the
system is not functioning in a manner which will protect public health, safety a'nd 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 environments
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 compoundsindicates 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:
3 .
t
"Page 4 of.1 I
OFFICIAL INSPECTION FORM- NOT FOR (VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATI ON' (continued)
Property Address:
Owner: e- L V
Date of Inspection: Me- V
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
V -Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
— t -'Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
— -1/logged SAS or cesspool
-Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
/�f 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). Number
of times
pumped
`Any portion of the SAS, cesspool or privy is below high groundwater elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
/L-/�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.
:::� FE 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 passesif 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.]
(Yes 4� �0,)le 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. La.rge Systems:
To be considered a large ele�e system must serve a facility with a design flow of 10,000 g . pd 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 a surface drinking water supply
the system is within 200 feet of a tributary to a !ittfface drinking water supply
the system is located in a nitrogen sensitive area (Interim We
11heiia
d Protection Area — IWPA) or a mapped
Zone H of a public water supply well
If youbave 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.
E 0
r °Page 5 of 11
OFFICIAL INSPECTION FORM. -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 32iO6£5
Owner.
Date of Inspection:
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
cI 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 ?
- -- ave large volumes of water been introduced to the system recently or as part of this inspection ?
ere as built plans of the system obtained and examined? (If they were not available note as N/A)
vim_. 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 ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no
existing information. For example, a plan at the Board of Health.
4, — 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)]
5
,.,,, `P%ge 6 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM
PART C
SYSTEM INFORMATION
Property Address:
��/z-7771v�u��
Owner: /C is L
Date of Inspection: h 2-16
` FLOW 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 (yes or no):
'Is laundry on a separate sewage system ( es or no): A" [if yes separate inspection required]
Laundry system inspected (yes
Seasonal use: (yes or no):
Water meter readings, if avail ble .(last 2 years usage (gpd)):
Sump Pump (yes or no): , J"
Last date. of occupancy: C V1, -/Lea -,7''
COMMERCIAL/INDUSTRIAL
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:
TYPE OF SYSTEM
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/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):
6
,
,.,;• Page 7 of I1
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: G 1UJV
Date of Inspection: i 2 OU
BUILDING SEWER (locate onsite plan)
rr.
Depth below grade:
Materials of construction: cast iron t�'6PVC _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: lI`t-" 41
Material of construction: Vroncrete 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: Gx fo x (�
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: 3
How were dimensions determined: %-4g 4- Q x735 e.4 rrl> .
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity; liquid levels
as related to outlet invert, evidence leakage, etc.):
6 60
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.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: my f,e/LYz r Lv
/UOrLily ��U�
Owner: y
Date of Inspection: /
TIGHT or HOLDING TANK: 4Vtank 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: present.must be opened)(locate on site plan)
Depth of liquid level above outlet invert:. ovrl- ET / 3 OL,/ 3�-
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.):
1,o 17 GSIJl j ToXd%
PUMP CHAMBER: ate 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.):
8
" Y . P2tge 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: Mil &y 14?6rg GiV
Owner: G5 e-1, jr
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): locate 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:
_/leaching fields, number, dimensions: 3 /in ps
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.a UG 1' eel A-0
CESSPOOLS:, A) (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.):
PRIVY: _O(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.):
Rage, 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /dy &Z1V6rr
/t/OizT�Y i�Jv�U£a2
Owner: /GGY
Date of Inspection:
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.
L'T,7.
Y �
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Name: Ax? -4-Y
Owner's Address:
Date of Inspection: !/! 6 y
Name of Inspector: (please print) /31ewfll =/fi4v�-
Company Name: .tb.a,riYs;L►�[i�caz�-�f C..
Mailing Address: Ss" 4,14== U ST
LLf�I/l/�,r:S �lfF
Telephone Number:
`Tt
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.,,Lpm a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
1/'Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: '— ,,,...w... Date: /� 3
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 10,000
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.
Notes and Comments
RUMP 1,57110Rr 7-06
****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 the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000
ae�
page 1
-Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM
PART A
CERTIFICATION (continued)
Property Address:
.G 4.� A"
Owner: ��.L y
Date of Insnection•':
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
,� x
I 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:
SYSTEM /il! C O lUA0 177b t/
B. System Conditionally Passes: /U/
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 Lf 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 is 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
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
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:
2
`Page 3 of 11
r
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL_SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /Oy '9Afti6s LN
Owner: r�rCf'
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. t
1. System will pass unless Board of Health determines in accordance with 310 CMR 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 septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tribute to a surface water supply.
PP Y ry' PP Y•
The system has a septic tank and SAS and the SAS. is within a Zone i 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 aseptic 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:
i
3
Page 4 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 14041 /3/L /hCf� t_,t.►
Owner:
Date of Inspection: z
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
clogged SAS or cesspool
V**`Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
MfA cesspool
' Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z dayflow ..
_Required pumping more than 4 times in the last year NOTAue to clogged or obstructed pipe(s). Number
of times pumped
. — V"Any portion of the SAS, cesspool or privy is below high groundwater elevation._
✓Any portion of cesspool or privy is within 100 feet of a surface water. supply or tributary to a surface
water supply.
Y'74ny 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. [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 thatnoother failure criteria ..
are triggered. A copy of the analysis must be attached to this form.]
N (ye, of he system fails. I have determined that one or more of the above failure criteria exist as.
described in 310 CMR 15.303, therefore the sys.tem .fails: The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems: NST
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 "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 a 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 Trapped
Zone II 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 operatorof 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
Page 5 of 11:
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: o /0-Y 1312-1 h 9'£S 4.10
A664 -r" A A,6 WVEL
Owner:
Date of Inspection:
f
Check if the following have been done. You must indicate "yes" or "no" as to each of the followine:
Yes No .,•►j11.�� u� �' �;
;; Pumping information was provided by the owner, occupant, or Board of Health MO—T"S 1
t' Were any of the system componentspumped out in the previous two weeks?
Has the system received normal: flows in the previous two week period ?
V Have large volumes of water been introduced to the system recently or as part of this inspection ?
Were as built plans of system obtained and examined? (If they were not available note as N/A)
V"' 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?
The size and. location of the Soil Absorption System (SAS) on the site has been.determined based on:.
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.0 is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b).]
5
0
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: /d �// fes! 46fS LN
Owner: /NF1' Z L . !
Date of Inspection: 2,.16 41
FLOW CONDITIONS.
RESIDENTIAL
Number of bedrooms. (design): 41 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): Al
Is laundry on a separate sewage system (yes or no): IV [if yes separate inspection required]
Laundry system inspected (yes or no): J�
Seasonal use: (yes or no): //
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): A/
Last date of occupancy: Gy�:rl•'
COMMERCIALANDUST'RIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): _ gpd .
Basis of design flow (seats/peisons/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: SrEu•/40_TS �QwN�lL
Was system pumped as part of the inspection (yes or no):
If yes, volume pumped: /5-409allons -- How was quantity pumped determined?
Reason for pumping:. /.I/fPE c 7- 7-A-�_
TYPE>OF SYSTEM
_�eptic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
—. Privy
_ Shared system (yes or no) (if yes, attach previous inspectionrecords, 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:
s
Were sewage odors detected when arriving at the site (yes or no):
6
Page 7 of 11.
v
t OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: S G
Owner
Date of Inspection- // / 2.% f�S�
BUILDING SEWER (locate on site plan)
Depth below grade: l�
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: Gtr ti
Distance from top of sludge to bottom of outlet tee or baffle:-�f
Scum thickness: ." it 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: C���
` How were dimensions determined: S D /L/J /SDS G/}t LLiAl
Comments (on pumping recommendations, inlet and outlet tee or. baffle condition, structural integrity, liquid levels
as related to outlet invert; evidence of leakage, etc.)
Fid tl2 GOW,9 7 0
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.):
Page 8 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:. /off 4,e -1,o C Gi¢ r-
iU0�715�
Owner• 44 £G.LY
Date of Inspection: 114i G
TIGHT or HOLDING TANK: ...Aftzink 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 resent must be opened)(
( plocate on site plan)
II
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: /" (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.):
8
Page 9 of 11
:w
OFFICIAL INSPECTION FORM —.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �0/SCS GMS
Owner:
Date of Inspection !'2
SOIL ABSORPTION SYSTEM (SAS): "(locate on site plan, excavation not required)
If SAS not located explain why:
j
Type
l
leaching pits, number: _
leaching chambers, number:
leaching galleries, number:
aching trenches, number, length:/i✓5 fi.WM
1/ leaching fields, number, dimensions: j P -x-130
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: 4cesspool 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.):
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.):
9
- r
Page 11 of l'1
r OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS.
E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' SYSTEM INFORMATION (continued)
f Property Address: A0 /3?14A04C.l L Al
t' .tX�K-7i5� i9-rt/f)�ti�lL
`
Owner:•
Date of Inspection: i O
i SITE EXAM.
l: Slope g S
Surface water i Sta p
Check cellar ,pg_ v- .v�
j„ Shallow wells
s - Estimated depth to ground water -,>k— feet .
Please indicate (check) all methods used to determine the high ground 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:
hecked.with local excavators, installers- (attach documentation)
(/AEcessed USGS database -explain:( /Z�x/QA!r77r,_,.c it/ CSS rX
}
You must describe how you established the high ground water elevation: 1 I
INCALY AGTPAt0 5X715-
tAW f STTM, q�� �.pitiF= /
' 1.1
}as Pk �Y6a.Ge.11o J''a 4ti
1Ua St W 0.rd� C ► V �s �i//Sl1�F Rei
a COM MON
`atNK oKt ,! 3 9• S�
r y
1 3 �'�/
!Q V X 0 �,� .�,• �/ 3 4t - gR�gN
" LofS
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTM
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: Zo_// /%I t'S Ag
Owner's Name: (��f
Owner's Address:
Date of Inspection:
Name of Inspector:( lease print) L.•�/ Ur �tl�/1�0
Company Name: 12
Mailing Address:
Telephone Number: q 4F i 9012
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:
Inspector's Signature:
Passes
Conditionally Passes
Nees F er Eva uati
Fai
_
by the Local Approving Authority
The system inspector shall s bmit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of c, pleting 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
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 bf inspection and under the conditions of use at that
time. 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 6/15/2000 page I
4
Page 2 of l l
yf , OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: azl
Owner: D
Date of Inspection: c>7
e Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes: 14
. if I 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. t-
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 is 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
.obstructed ppe(s) or due to a broken, settled or uneven distribution box. System will pass -inspection if (with
approval of Board of Health) °' - f - -
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):
ND explain:
broken pipe(s) are replaced
obstruction is removed 1
2
Page 3 of I 1 .
r
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: GI's
Owner: 6�
Date of Inspection: c a?'1—dd2
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 determines in accordance with 310, CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
W{. --
_ 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
th,e presehce�f-ait ion"ia-nitro en`=and nitrate nitr en is a ualzto or less t aci:5 R
g q . ppm; provided that -no other
failure criteria are triggered. A copy of the analysis must, be attached to this form'.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property. Address:.�D
tea• �c�i���
Owner: &9
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,/►
V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_-k/bischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool )
Sttafic' fq iid level, to the distribution, b x.above outlftavert due to an�overloade3 or ogged SAS or
cesspool
_ je- Liquid depth in cesspool is less than 6" below invert or available volume is less than''/] day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
1 * 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.
_Any portion of a cesspool or privy is within a Zone 1 of a public well.
_t Any portion of a cesspool or.privy is within 50 feet of a private water supply well.
An onion of a cesspool or rt is less than 100 feet but
�✓� Y P P Privy 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 componeds
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.]
I& (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
T 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
o be cohsider d aiarge' ystem the system music 'r4ii fAili -with modes flow of• 0 000 d to -15 0006
h' � � j gP � .,
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 a 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 II 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
x i Page 5 -!of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
:`.. Property Address: /Q 1&/i/l-05 &02-0
}' Owner• 1,3100
Date of Inspection:
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes o
Pumping information was provided by the owner, occupant, or Board of Health
y, of ttte sy le cor¢iponent4p ped out..in-t `e re�+ious two we
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 ?
1/ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
t — —
_ 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 ?
4/01*
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?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
.�:
Yes o, f
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)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Y Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 1.10 gpd x # of bedrooms):
Number of current residents:
Does residence have a garbage grinder (yes or no):A/0
Is laundry on a separate sewage system (yes or no) -.Al [if yes separate inspection required]
Laundry system inspected (ye or no): i
Seasonal -use A-y.e_s#)-h,o)W,
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no) -ND
Last date of occupancy: 6 6u 4t 44
COMMERCIAL/INDUSTRIAL
Type of establishment:
ti
Design flow (based on 310 CMR 15.203): gpd,
Basis of design flow (seats/persons/sqft,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: Pu rpi3e-4. j -L - o
Was system pumped, as part of thl inspection (yes or no). n
If yes, volume pumped-/ -- How was qua ? s te-
_s:jPL&allons Wdi� pumped determined
Reason for pumping:—, 1A.,-3 10 e cr- —741V
W+
TYPE PF SYSTEM,
eptic 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 kn n) and source of information:
Were sewage odors detected when arriving at the site (yes or no):/%V
6
x�,-�rv.ir:. .. �..,.; ..:.:.ti,,,...:.+t�x •..�-��..:p;+a.�s,icy+-�':tir,�a'erwz+K,6''w,-o'*..�.:''.is!✓�i'+i�c�djTi'�'r�:f�aelr'"^. ,..:_..., ... ..: .._ .+�s.T. av+ue:�-vws•.r,;gi.`,a-...w� •-w:...-»..•y; o:� - -, �.,,.s,. ,,., •w,.,-...�_. .-ti. .-.��- `M
Page 7., of 1I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
f
SYSTEM INFORMATION (continued)
Property Address: 1f
Owner:
Date of Inspection:
BUILDING SEWER (locate on site plan)
N; Depth below grade: 100
/ 6 </
Materials of construction: _cast iron PVC _other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.): f
SEPTIC TANK: 4/1ocate on site plan)
p
Depth below grade:
Material of construction: ncrete 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: -57-6" >( 17::- c
Sludge depth:
-Distance from top of sludge to bottom of outlet tee or baffle: 0 5/
Scum thickness; Q r�
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: 77,x[ ot2V&S/�L
Comments (on pumping recommendations, mle�t and outlet tee or baffle condition, structural integrity, liquid levels
h as re ted to outlet invert evidence of leakage, etc.):
Repilie-eW ov-tzer AQA41-4 twAI-X
GREASE TRAP. (locate on site plan)
ja p p
,,,•..44 r--1.,. ,w,Yk.. -♦ - y'.
Depth below grade ' Y
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
t as related to outlet invert, evidence of leakage, etc.):
7
.. _ . : _ .::r... .. �._.1.�YiJ.'.-..n+ r%�i.���i.....: •44L.�Yn`�n+`ro'�ijt4.'�v'Yk 'YY �---.. -. .�.���.. .... :i a ..,�.. ..-.� � .i.r �-. .
n i�-11
. Page 8 of l 1
t OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property.Addressc
K... /
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:
t Capacity G allose ":?'`� ,ti
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:(ifpresent must be o ened)(locate on site plan)
pepih of liquid level above outlet invert: C�
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
Y
PUMP CHAMBER: 010cate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
R: Comments'(note,condition,tfpump�cham.er,condition of sand.a tutenan es,._etc
8
s
F
Page 9,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:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not -required)
If SAS not located explain why:
Tchpit)hg s,��,n in er...
V
117aching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
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,
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:
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.):
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.):
9
Page 10of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION (continued)
Pioperty Address:
Owner:
Date of Inspection:
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.
9.
IN
Estimated depth to ground wateL5' -5 fleet
Please ikAate".(`chii6k)':all methods�u
sed tO deterihin �the high groun44 water Pleyatian:
_ZObtained from system design plans on record -.If checked, date of design plan reviewed: C)
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:
�1
A,
4
ll
�v
LLL
F-
J
Q
W
U-
0 O
o U
a 3
m o
�v
LLL
TO: , NORTH ANDOVER, MASS —.44a --V a-`/ /7 19 �5f
BOARD OF HEALTH ,
FROM:
DESIGN ENGINEER
Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
Z -0 -AJ North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19-
BOARD OF HEALTH
NORTH ANDOVER, MA 01845
978-688-9540
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: -' lj " a -z-- CURRENT INSTALLER'S LICENSE#
LOCATION: !d -(-/ )�r ,- c % ,k j
LICENSED INSTALLER:
SIGNATURE: Vk-'A- /- : 1%/.,/ _
CHECK O
EPHONE# %e 3% -.2 y%l
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
Administrat' a Use Only
D
C
Q
c
C
Z
z
Q
v
l
a
a
2
0
n,
I
z
iv
Q
I.
n
O
(D
6
fl,
0
0
3
3
cn'
0
I
m
n
3.
d
3
_ rD
;:3
Q
(D
O
(D
13
M
h
z v
c rt o
v
0
c
3
rt
D
O
i
fD
n
o 0
o r-
3 3
m
0
rP
o �a
c
q
O
� ` S
lD
'Q
C
-e
'o
0
m
0
0
n
c
3
c�
rr
D
�
1
1
Q
(D
O
(D
13
M
h
I.
M.
qft
at �' - u}- Iw N+ M r+ *,, e+r M M .v_ , ,rt �f .a � r4` .•c
'a
w
ul
CWIQ-
t 7"
44
j
. t
N
Qv
qft
at �' - u}- Iw N+ M r+ *,, e+r M M .v_ , ,rt �f .a � r4` .•c
'a
w
ul
CWIQ-