HomeMy WebLinkAboutMiscellaneous - 107 OLYMPIC LANE 4/30/2018 107 OLYMPIC LANE
210/106.6-0137-0000.0
-C-\ Commonwealth of Massachusetts RECEIVE
City/Town of
System Pumping Record NO 0 2009
Form 4 TOWN OF NORTH A uvER
`"M s••' HEALTH DEPARTME
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health order approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of hou Left front of;housue fight front of house,
Left rear of house, Right rear of house. Left rear of building. ig reailding.
Address C 0 I ` Cy( eLka r
Cityfrown State Zip Code
2. System Owner: �
Name
Address(if different from location)
City/Town State
(0e
Telephone Number d\
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 9-teptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
n P-C AA::�kA C �
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location re contents were disposed:
L.S.D Lowell Waste Water
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
R cE
Commonwealth of Massachuse s ^., . ` ii2
City/Town of S 5 ,�11
f
DOVER
System Pumping Record T HcALOWNO ME NIT
Form 4
.y y
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location
. Left I ont of�Ot
, Left/Right rear of house, Left/right side of house, LeftRight side of buil Ing, Left/ Ig ron wilding, Left/Right rear of building, Under deck
Address
City/Town State V Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip rode
Telephone Number
B. Pumping Record
1. Date of Pumping2. Qu tity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6.
i
6. System Pumped By:
Neil Bateson F5821
Name .Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati contents were disposed:
G.L Lowell Waste Water
Sign a Haule Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(ex le: left front of house)
A/7
DATE OF PUMPING:—6 , QUANTITY PUMPED /00GALLONS
CESSPOOL: N YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: �Ili/i
COMMENTS: 7 /9-
CONTENTS TRANSFERRED TO:
E
TOWN OF
SYSTEM PUMPING RECORDRECEIVED
DATE: �" S NOV - 9 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
(example:left front of house)
C)
DATE OF PUMPING: QUANTITY PUMPED : GALLONS
ANK•
YES SEPTIC
T . NO YES
CESSPOOL: NO
NATURE OF SERVICE.
• ROUTINE
EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIl)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
v
cONTENTs TRANSFERRED To: G.L.S.D Lowell Waste
li
Tom €�F� � ��3VER�, �+�►��`c�+ {�
SYSTEM P RECON
DATE
WSTEM 0 ER ss
SYSTEM LOCATION---.�
107 DLy i�J c spa e
CRATE OF PUIN --�Sr��
_QUANTITY PUMPED ,J oz>
CESSPOOL NOS�P
—.----
'Tic TANK x+10YSR_.____
NA'rORE OF SERVICE, R UTINE CvltelWENCY
OBSERVATIONS: V;
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN LACE
SOOTS _ LEA.CI-IFIEL.D RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVE .__i OlTMR EXPLAIN T
SYSTEM PUMPED BY
o)o
J_.
CONTENTS TRANSFERRED TO
Board of Health
North ,AndoveroMass. SSMC SYSTIM
i INSTALLATIM COCK LISP LOT # y
APPROVED DATE MSUPWOMM MR17 EXCAVATICAOK FAIL
4
t�easo`nst
FAIL OK _
11 i 1. Distance Tot
v a. Wetlands
b. Drains
c. Well
2. Water Line Location
3. No PPC Pipe
4. Septic Tank `
a. Tees - Length & To Clean Out Covers
b. Cement Pipe to Tank - On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal. Amounts
c. No Back Flow
6. ' Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Fids
d. Clean Double Washed Stone
7. Leach Pits
a. Dimensi s
b. Stone epth
c. 9pla Pads
d. Tees
e. C t Pipe to Pit - Both Sides .
/ f. C1 Double Washed Stone
8. No Garbage Disposal
90 Anal Grading Inspection
J . Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with RegarcL to Pere Test
d. Elevations
e: Water Table
SUBSURFACE DISPOSAL SYSTEM CHECK LIST
r _
NORTH ANDOVER BOARD OF HEALTH Y
APPROVED DATE PROVIDED DISAPPROVED DATE TIME REASON
Title 5
Reg. 2. 5 Fail OK The submitted plan must show as a minumum:
the lot to be served (area,dimensions ,lot //,abutters)
(Planning Board files)
b) location and log of deep observation holes-distance
to ties
location and results of percolation tests-distance
to ties '
design calculations & calculations showing required
leaching area
location and dimensions sf system (including reserve
area)
existing and proposed contours
g location- of any wet areas within 100' of the sewage
disposal system or disclaimer (check wetlands mapping)
surface and subsurface drains within 100' of sewage
disposal system or disclaimer
location of any drainage easements within 100' of
setiage disposal system or disclaimer (planning board
files)
known sources of water supply within 200' of sewage
disposal system or disclaimer
location of any proposed well to serve the lot (100'
from leaching facility)
location of water lines on property (10' from. leaching
facilities)
location of benchmark
_ driveways
garbage disposers
no PVC is to be used in construction
a profile of the system (elevations of basement, plumber
pipe septic tank, distribution box inlets and outlets ,
distribution field piping and any other elevations)
maximum ground water elevation in area of sewage disposa
system
plan must be prepared by a Professional Engineer or
other professional authorized by law to prepare such
plans
Septic Tanks
Reg. 6 (a) C acities - 150% of flow, water table , tees, depth
f tees , access, pumping.,
(b Cleanout
c) 10' from cellar wall or inground swimming pool
(d) 25' from subsurface drains
N4th Andover Subsurface disposal system check List - Page 2
Fail OK Distri ution Boxes
Reg.10.2XbSSUMP lope greater than 0.08
Reg.10.4
Leaching Pits
Leaching pits are preferred where the installation is
possible
Reg.11 .2 (a) Calculations of leaching area (minimum 500 S.F. )
Reg.11 .4 (b) Spacing
Reg.11 .1 (c) Surface drainage 2%
aReg.11 .11 d Cover material
_0 re e orae%� SP�aas6. p° A .Yw .�-�, ,, &-. of-� t
Leaching Fields ��� '�
Reg.15.1 (a) ?G ater_than 20 minutes/inch-
Reg-15-1 (b read (minimum 900 S.F. )
Reg.15.4 ( Construction of field
Reg.15.8 d) Surface- drainage 2%
Reg. 3.7 (e) 20' from- cellar wall or inground swimming pool
Leaching Trenches
Reg.14.1 (a) Calculations of leaching area (min. 500 S.F.)
Reg.14. 3 (b Spacing (4 ft. min. 6 ft. with reserve between)
Reg.14.4 (c Dimensions
14.5
Reg.14.6 (d Construction
Reg.14.7 (e Stone
Reg.14.10 (f) Surface drainage 2%
Downhill Slone
Slope y/x = (to be shown)
b) y/x X 150 = (to be shown)
P_ ump a
Reg. 9.1 (a) Approval
Reg. 9.6 (b) Stand-by power
SOIL PROFILE & PERCOLATION TEST DATA
T6'wn/City Ua, A hl Q, ' Po.&Street_6L-YM P t L LA,Q E Lot No.. ?>Z �
Loc./Subdiv.IN G A,LLS C&55) 6 Pl an Owner
Investigator'' A7,,,sA Nt_ .,o Observer Cus�+� f'3r C ttQA� Y
SOIL PROFILES-DATE S-1 8 E-7•� st5 I 1 a
f
' Elev. ' Elev. 3' Elev. 4.Elev.
0 Eb 0 -78 0
0
'TA C3 LE TOP SUB
i
2 0�`� 2 2 2
°GYM P+L
UA,,,,j
3 _ 3 3
d�CtD[ ED _4 4 S 4 4
5 555ot6 6 6 6
f
7 7 S t 7 7
8 8 8 8
'�" T 'EST P�► �
9 9 9 9
10 10 10 10
Benchmark Location
Elevation Datum
Percolation Tests-Date_ cj 41
Pit Number 1 2 3 4 S
Start Saturation
Soak-Mins. �S
Start Test-Time
Drop of 3"-Time
Drop of 6"-Time
Mins. lst 3"Dro
S N
Notes & Sketches on Back rank C. Gelinas & Associates, North And.
x COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a
DEPARTMENT OF ENVIRONMENTAL PROTECTION
n
yt �
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ' TO OFNOF'T"' � 4
BO AD OF H
Property Address: lorl / ne- F
i Mq. v nV 2 8
Owner'sName: P ;
Owner's Address:.
Date of Inspection:
Name of Inspector: (please print) ,`'q/,1m lJS®
Company Name: 1 fS t_
Mailing Address: h Sri Mi/1
m, 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 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: acs Date: 0 �(
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 1
�. age 2 of 11
_ L
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: � -nu/[' L4/)
Owner•�P,Ioh P'NO
.%AI (�V�°/� jj1)Q
n
Date of Inspection:5/
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: �C S
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: x
r
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 pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
t broken piie(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: f
r.
f
2
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Page 3 of l l
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 0 f -�m4/l_
Owner, P 1 r P
Date of Insp'iction: 7;,94J I)d
C. Further Evaluation is Required by the Board of Health:p
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(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 a public water supply.
s _ 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:
t
3
• Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: )Q/1
Owner•(e/
Date of Insptc tion: ?
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 . '. 1 • 4
`Static liquid level in the distribution box*above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
L--Any portion of the SAS,cesspool or privy is below high ground water elevation.
__t,—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.
_ 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 compomads
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/No)The system fails.I have determined that one or more of the above failure criteria exist as
r 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 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 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 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
Page 5of11
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:j o 2 CLI19e—
I yeV.1 rn67 -
Ownerkeiak
Date of Insp ction: _
Check if the following have been done.You must indicate"yes"or"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 previ'bus two weeks?
"Has the system received normal flows in the previous two week period?
LI-1 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?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no n,
_ Existing information.For example,a plan at the Board of Health.~ w
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)]
r '
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Page 6 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 107
N2. 0 A]6 ..I/to I?
Owner: r) ,P 1-<;P I 1-,
Date of InspLvction: a y 0
` 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):/'/0
Is laundry on a separate sewage system(yes or no):/-/u [if yes separate inspection required]
Laundry system inspected(yes or no):�/� , r .
t
Seasonal use:(yes or io)._ :'
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):P-5
Last date of occupancy: f'c_�
COMMERCIALANDUSTRIAL
Type of establishment: l7
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgR,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: l� `i✓
Was system pumped as part of the inspection(yes or no)' �`S
If yes,volume pumped:/ oS � gallons--How was quantity pumped determined? %%2a crZ
Reason for pumping: C In P i c lA n44 L ex
TYPE-OF SYSTEM
_j::j/'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:
ay/r
Were sewage odors detected when arriving at the site(yes or no):�d
6
Page 7 of 11
A
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Q O r Jal)zs,
Owner:5/(:9,z}lDV e7tovq
Date of Inspection: 5/a 4
BUILDING SEWER(locate on site plan)
Depth below grade: + ;
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.):
— Jo -ti rS oa-o r
SEPTIC TANK:/1-55(locate on site plan)
Depth below grade: /q_
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: /0
Sludge depth:
Distance from top of s�dge to bottom of outlet tee or baffle: 3 v
Scum thickness: c `
Distance from top of scum to top of outlet tee or baffle-6
Distance from bottom of scum to bottom of outlet tee or baffle: n
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.):
Mffkr f f 17i4Aii e 6 oo o t'0)--I P t T/o),./ - rGou 159ad/ 7-- VC,��I
GREASE TRAP _(locate on site plan)
Depth below grA*de:
_ 't 9 ^ } t •4 f
Material of construction: r 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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEMS `INFORMATION(continued)
Property Address: log O ;,lel /)L
lyn
�iNt rl
Owner• J_'e,)ah .S/,� ��yl
Date of Inspetlion: 5 0 M
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: %, ga(lons
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 BOXX�(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.):
6v Cox0f TSU N — F/-0WS �-/u (1alyey Due ✓
PUMP CHAMBER) 4T (Iocate 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.):
A �
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:J D r] d IM{)lC 11)l
�� �N''--U QW) veW
Owner:kP.l4Gt) lE1'Sema
Date of Inspe6tion:
SOIL ABSORPTION SYSTEM(SAS): yS (locate on site plan,excavation not required)
If SAS not located explain why:
_ Type
leaching pits,nuthber:
leaching chambers,number: "
leaching galleries,number:
eaching trenches,number,length:
leaching fields,number,dimensions: 4-/Hr`0-
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.):
U
I
CESSPOOLS:N(' (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:#-A (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 11
AO
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEXINFORMATION(continued)
Property Address: It `7 ��1_ �oe—
�/ P
Owner: P j
Date of Inspection-r �?
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.
0 (e ,
�s
10
- _,o; Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /1),0/":
(� 0 )
Owner�e(C��' �P dzw
Date of Inspiction:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground wate4 (=Meet
Please indicate(check)all methods used to determine the high ground water elevation:
btained 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-explaiin; °
You must describe how you established'ithe high.ground,water elevation
/'—/0 kJ,r�7�`U2
,
1
11
ell
• • COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r
DEPARTMENT OF ENVIRONMENTAL PROTE N
TITLE 5F
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES NTS
SUBSURFACE SEWAGE DISPOSAL SYSTM-F'rRM
PART A
CERTIFICATION
Property Address:
Owner's Name: /a/'17b
Owner's Address:
Date of Inspection: 0hoZ
j
Name of Inspector: please print)16hp L
,&eaw
Company Name: P" C Afj(Ce,
Mailing Address. n 30. i
ZMV
L^ /YIGt• 5
Telephone Number: 97jP• -
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 ection 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs F er Evaluation by the Local Approving Authority
Fails
Inspector's Signature: )//z- ate:
The system inspector shall bmit a copy of this inspection report a 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
.. J, ... .. �. ,:._ ¢ _ .. �•.,._� �:..n n. w.awn-.•. ..,.,....,... :.u.,,. .:+, .. �►+rvt ., ,+.r:t. ... , .,.,,.. _ ,_ ,. .-,.n,;.h,.�o -ri.l.,;:: t7,•^w
Page 2 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: �U
Owner:
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
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:
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 pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):" ,1.
broken pipes)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
1'7 Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Q•
Owner:49?2Z
Date of Inspection: -51
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(i)(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 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
the*esence 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
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: O
--
Owner:
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 N_o/'
tl ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
v Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
c ogged SAS or cesspool
Static liquid level in the-distribution box above&tlet-irivert due to an overloaded-or clogged SAS or
sspool
— Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
�equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
f 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.
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.
�y 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 compomads
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/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 the system must serve a facility with a design flow of 10,090 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to 4ach 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 11 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
Page 5 of 11
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"yes"or"no"as to each of the following:
�Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health
J
Were any of the system components pumped out 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?
1/ 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?
Vol"_ 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?
_4`� 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 C is at issue approximation of distance
is unacceptable)[3 10 CMR 15302(3)(b)]
5
;,... _. .,,,.k;u�vti:Y:i° ... - ,.. ti'�Xs4,: ,rif.nveP.•r.�* J':.i.,rte?;}~�.... v,�ra>•�...y,.+-,N..r,,,., �- --•„d
a
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address• M 1 1 M /w/1,0-
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 141 Number of bedrooms(actual):
DESIGN flow based on 310 C1%15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):�r�
Is laundry on a separate sewage system(yes or no)/”U[if yes separate inspection required]
Laundry system inspected(yes or no):._
Seasonal:use-(yes or no):j' o -
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):N U
Last date of occupancy: GG-v�
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: I-jZoc)O
Was system pumped as pgrt of the inspection(yes or no): e
If yes, volume pumped: 40allons--How was umped determined?
s
Reason for pumping: N S Lr A-4
TYP.F SYSTEM
1�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):
App ro to a e of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no)/
6
k Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: st 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: 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
cert
e) gzr
Dimensions: X. , —o `
Sludge depth: y// t
Distance from top tee o
of sludge to bottom of outlet r baffle: 50
Scum thickness: /'rt oy
Distance from top of scum to top of outlet tee or baffle: --- elf
Distance from bottom of scum to bottom outlet tee or baffle:L
How were dimensions determined: -/!q �?'LGC1-,$ U ►�
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relate o outlet invert,evidence f lee,etc.):
249 �
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 .
r Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
NOV' hwl
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: 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 int or out f box etc12,0K
).
2 o K -1Q_0W
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.):
k,
z-
8
Page 9 of 11
h
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
�D
Owner:
Date of Inspection:
f
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:
le Ching trenches,number,length:
ching fields,number,dimensions: �)c 5 'of, pro)(
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.):
a -F O N Gl / 1L)O
CCt
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.):
4
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 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION(continued)
Property Address:� ��f - A ./G 61FE., M
L
Owner:L �
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.
t I
1
1
N
y , s
10
-: Page l l of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: r / 110
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water4w 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: -
Checked.with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must descripe how you establohed t e high ground water elevation:
Li /� .�C 7 eA /v 4 r
7 6
Le,