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HomeMy WebLinkAboutMiscellaneous - 25 WOODBERRY LANE 4/30/2018 (2)0 0 CO 0 0 0 0 0 gm m g � Ll 0 O TO: FROM: NORTH ANDOVER, MASS 0 19 '76 BOARD OF HEALTH / DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at LGy1,bckP-ry /— A'A/"r _ North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated I SOIL PROFILE & PERCOLATION TEST DATA "1�/U• ��over- Town/City No`.&Strreet C', -p' Lot No.� / Loc. /Subdiv.�r'C� G IC Plan Owner j Investigatorb /lU Observer � c SOIL PROFILES-DATE`S Q ~4 1. lev. �' E1 0. 3° Elev.3 4'Elev. 0 0 0 ?' 0 /i icy' 1 1 1 lv� �4 �5 6 1�u 0 2I 2 31 1 3 4 L 4 7 1-- 1 7 B g g 9 9 9 10 r _. 10 I I 10 10 Benchmark Location Elevation Datum Percolation Tests -Date �s Pit Number 1 2 3 4 5 Start Saturation S .2:5, :/3 Soak -Mins —. rn p - U M, „ r„ „ Start Test -Time /0; 00 /./0 cv,3 ) Drop of 3 "-Time U ; / S--9;33 Drop of 6" -Time U:Z 2/ =S v Mins.ist 3"Drop min Mins ° 2nd Notes & Sketches on Back Frank C. Gelinas & Associates, North And. a- 0 IN 0 d' �U n V 0' bl� 5Z74L �� � Gia,'„ K9 ti 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: A 5 UJ 0QA 6a (r V A ne- m, em, A?1ocJv e Owner's Name: Ile r6Gu 14 - Owner's Address: Date of Inspection: Name of Inspector: (please print) '}ohyj 1V I t ce_ 1Zd Company Name: war+ s 5& is Mailing Address: y-7 )?,n I I rogl !31. brad korai,, .moi. Telephone Number: 97 is 37-707 / 1'Crle9l3C�r'a� CT2001 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 Signa Passes Conditionally Passes Local Approving Authority Date: F 5 7-ol The system inspector shall ubmit a copy of this inspection report4d'the Approving Authority (Board of Health or DEP) within 30 days of cdmpleting 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 Page 2 of 1 l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 015 w6cJ be (f V lgne— /VO Ano ' Owner: -1-he rigt, I t Date of Inspection: ? . 195-61 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: w O 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.f4ilure criteria not evaluated -are inoicated below... Y 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. f 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: Obse.1yatim-of-sew.4ge 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): ND explain: broken pipe(s) are replaced obstruction is removed 2 Page 3 of 11 r-�—i OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 95 I QLiK bP (fJ bane No Allo. Owner: Th e r ip u H - Date of Inspection: !7 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. � . -yrs:3�•_ .. �� .n.-; yk _. - �.. . � :, ....�... .. � � , k= . _.,. 1. System will pass unless Board oiHealth 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: _ 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 ata DEP certified laboratory, for coliform bacteria and voatile 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: Page 4 of 11 i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: AS WoaAbE'frJ IQre Owner: �h p r ► 1 '1L ,� Date of Inspection: aT D. System(Failure Criteria 'applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: i Yes,/No y acicup of sewage-pto faeiarsystefi component:due.to.oerloadeor..clogged SSS, or,.cesspool —1 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 idthe distribution box above outlet invert due to an overloaded or clogged SAS or _ A&cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number ttimes pumped Anyportion 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. — Jam/ ny portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water'quality analysis..[This system passes if the well water analysis, performed at a DEP certified, laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] l} (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. Y 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 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. f. 4 i M a , Page 5 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: a5 Woo r.r -1 n e ifs Owner: h er 11 - 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 info&' &i'on was pt6vided bythe-owner,-oc6pant, of Board"otH-e'hl ' _ _V Were any of the system components pumped out in the previous two weeks ? V 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 ? 1/O*O 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 backup? % 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.lo6tioh of.the-Soil-Abgorpti�VSystedt (SAS) -on tl e�sitethas-been determined based on: f ^K Yes i/"n1a 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 4 • j. 1 Page 6 of 1;1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: A5 WayAbf' Ane n o Pno& e( Owner: :VJ 1er IGu 1-t- Date of Inspection: Q—a 5-c 1 FLOW CONDITIONS RESIDENTIAL I/ / Number of bedrooms (design): Number of bedrooms (actual): / DESIGN flow based on 310 CMRJ 5.203 (for example: 110 gpd x # of bedrooms): Number of current residents:p, Does residence hive a.garbage+grinder (yes oar no Jr W. w . Is laundryon a separate swageys'tem (yes or no)�(% [if yes separate i4ispection required] Laundry system inspected ( es or no): Seasonal use: (yes or no)O Water meter readings, if available (last -2 years usage (gpd)): Sump pump (yes or no): &_0 J Last date of occupancy:0'�,�1 e- —/UVJ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): end 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: D I" 3 ra Was system pumped as part of the inspection (Fes or no). If yes, volume pumped; A40 gallons -- How was tt pumped determined.. w ° s.... ty 'a « treason for-0iug6g: enc i�. F s r TYPE l F' SYSTEM eptic tank, distribution box, soil absotptiam system _ Single cesspool Overflow cesspool — ivy _ 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): of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): 60 Page 7 of l l 4 �y 3 `M OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: X25 ix (ty �qn:t Owner: :.&r lay t Date of Inspection: S1 BUILDING SEWER (locate on site plan) Depth below grade: /9 Materials of construction: st iron _40 PVC _other (explain): t Distance from private wteripply will orucnct.linea Comments (on condition ofjoints, venting, evidence of leakage, etc.): SEPTIC TANK: _ ocate on site plan) Depth below grade: Material of constructionie�oncrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: .5' g X Sludge depth: cs " Distance from top ofsludge to bottom of outlet tee or baffle: o 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: �y n• How were dimensions determined: - e 5U Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as re ted to outlet invert, evidence of)eaka eget ): !fl DDG7 %u'"K o0 �. i 'GREASE y, TRAP: _(1$cate on site plan) ` ` °l Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): a 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.): r 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: 5 w0cabe�hy) O oov P Owner: -f-h er 1 Date of Inspection: d ) TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:. _ ��oncrete. etal _fiberglass i . ol, ethyleq othcr(eXplai ): 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: K Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of ' leaka e to or out of box, etc.): I 7f .4 v Y 0-a A0 t S ?'• �dX �cc ► o _CA, I t' PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in waking order -(*6 4 no):... Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ` 8 r v t ._ �t F � � e '. 1 � _ _ r v t ._ �t "Page 9 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) � Property Address: o� S Abp((y 121)c IUn f3� �e r Owner: '�hero u 1 Date of Inspection: _ kT�V4 / SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not -required) If SAS not located explain why:` ` ° a x R a Q u Ty leaching pits, number: leaching 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, et % , Iwo AA AJ C Q/ f -S P -!�D IGS 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)� Ie � Comments (note conditio i+of Broil; signs of �tydraulic ailure, level ofponding, condition of vfgetation, 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 Pa er .._ 10 f: a 0 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM 'INFORMATION (continued) Property Address:r�J` 1N6a f j S _tea 01 Delo e{[ Owner:r m ( i Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM ; Provide a sketch of the sewage disposal system including ties to at least two permannt reference landmarks or, benchmarks. Locate all wells w�iythin 100 feet. ocate wh re public water supply en�rs the building. f y ^ 19 wV ./A_ t � L V F ys . 10 4 % Page 11 of,1 , S t OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:lQ ri1C Owner: fi erka Date of Inspection: SITE EXAM Slope Surface water _ Check cellar Shallow wells Estimated depth to ground water f *tTeet 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: T' You must descri a how you established the high group water elevation: _ } I r E SS 4PPKov(�v 15APPP4v5D REASONS W, nor PP�� �Atii_ 'v SLE ;K, Su M7 W RD D WELL 5t is S'►STS PE'SI6&) DArt' APR�OVPJG AurhoI'�ITY PCA&) DO &A.)clz-\ Fav PATS Cotjvlro�J5 L?Lor— ( to -n-11 S, pr(6 SY5TErtt I i STA u,4T►o�l.J )NSPi�-6To&j IQ5PEcrlon) 4PPI3dVED Pt l5 V--ooc-1 l 94rc D 045 p FOIL PIPE FRO&A bias -ry T/30� Fl 1:7 Flo)L 4,411 -101 -ML ',,"Fbz IoNs QIP "(Yjy) DISAPMOVFID 13C0,50 NS ', FV AL. APPN)VAL DArC D,oTE ��_3 APPRwvJ6 SEPTIC SYSTEM INSPECTION FORM ADDRESS Z 6c� 6&r -r c� DATE INSPECTED PROPERLY FUNCTIONING? �� N WEATHER CONDITIONS COMMENTS: WA i E: P, Cct;AL6 i y '1 ES T- EN. � h�Sui_ i S? DYE TEST PERFORMED? Y N DATE? SKETCH: T -- Please forward us as much of the following information that is possible; 1. Type of system 2. Age 3. Locat ion, � 0 4- Maintenance records and date of last pumping out 1�. Documentation of repairs and reconstruction 6. Site conditions 7. Builder of system 8. Engineer who approved; — Site 7 — System s 9 R Installation Procedure 10, Problems S 2 WATERSHED RESIDENTS QUESTIONNAIRE 1. Name fie= `"r v i i L r -J rI ° 2. Street Address A* �'`� o o -03 R ft`I L JV 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool 19 septic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? snyes ❑ no ❑ do not know- .. ❑ 11-20 years - 6. How old is your sewage disposal system? ❑ 0-5 years ❑ over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes A no ❑ do not know If yes, approximately how long ago? ® 6-10 years years. What was done? i 8. How frequently is your sewage disposal system pumped out? ❑. annually �l ever3 & years ❑ every 5-10 years ❑ over 10 years ❑ never 9. Have you had any problems with your sewage disposal system? ❑ yes no _ If yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine X dishwasher x garbage disposal dehumidifier drain sump pump toilet X roof/pavement drains shower/bathtub X 11. Please state the brand and type (liquid or powder) of detergent you use for: dishwasher C N 5 C,>D 01. clotheswasher Ll m \a - t7 0` vc= 12. Does your property have a lawn? ® yes ❑ no If yes, approximately what size? ED less than 1/4 acre X 1/4 acre ❑ 1/2 acre ` ❑ % acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. -How often do you fertilize your lawn? No. of applications per year 14 Season(s) of the year 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: Li Qv, -o X Check here if your lawn is maintained by a professional landscape contractor. William F. Weld Govemor Trudy Coxe Secretary, EOEA David B. Struhs Commissioner Commonwealth of Massachusetts Executive Office of Environmental Affairs ®apartment of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FI PART A CERTIFICATION Property Address: S- Vj ©o - U VZ \1 L jq Address of Owner: A /4 0 d Ij -rL. Date of Inspection: 7- a. - (If different) Name of Inspector: �sJ Company Name, Address and Telephone Number: AHod v �° ✓ Sn 4 (� �-s�-� ra v 5r �jl V ev �j t CERTIFICATION STATEMENT - &,6Q- Y. I certify that I have personally inspected the sewage disposal system at this address and that the information reported.below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: L.-- asses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature -9 Date: G'. �4 The System Ins e?or submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing bails inspection If the system is a shared system or has a design flo" of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent !c, :!,r' system owner and copies sent to the buyer, if applicable and the approving dutl,oiit�. INSPECTION SUMMARY: Check A; B, C. or D A] SYSTEM PASSES: 11'r S 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. r Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: p A One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston, Massachusetts 02108 a FAX (617) 556-1049 a Telephone (617) 292-5500 A . ii Panted on Recycled Paper Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 4-14 BJ SYSTEM CONDITIONALLY PASSES (continued) � Sewage backup or breakout or high sttaatic water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than'four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of. Health): broken pipe(s) are replaced obstruction is removed CJ 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT HE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ t he system has a septic tank and soil absorption system and is within 100 feel to a surfa_e water supe 'y or tributary to a surface water supply. The system.has.a septic tank and soil absorption system and is within.a,Zone.l of a_public;water supply well. _ _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system hay a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. , D) SYSTEM FAILS: x'+ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an 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. (revised 8/15/95) 2 "I• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: . W 'f C 4 v �- �� A-1. Q 0 Owner: Date of Inspection: D] SYSTEM FAILS (continued): � /�- Static liquid level `n 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pum ed y Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: . The following criteria apply to large systems in addition to the criteria above: The design flog, of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more.of the following conditions exist: 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 's located'in a nitrogen sensitive area' (Int'erim'Wellhead Protect iowArea{(IWPA)'or a mapped Zone 11 of a public water supply welh The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: �j�' Date of Inspection: / i/ -7- 3 ­ Check if the following have been done: v Pumping, information was requested,,of the owner, occupant, aynil Board of Health. � �• K '; �/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates wring that period. Large volumes of water have. not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. t_ The facility or dwelling was inspected for signs of sewage back-up. c% he system does not receive non -sanitary or industrial waste flow _ j�he site was inspected for signs of breakout. _ All system components, excluding the Soil.Absorption System, have been located on the site. `The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or !tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. J_ T e size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. _ The facility o,: ncr (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. t f a , . - •. :� + � ..I -t , pc .- ... s t-•-..-,�r -;iia. .. r . .s , .. �i. '�ti. . � ..r .n,-w....p . �:� �' � :t� . { . +, � a r (revised 8/15/95) 4 ir \ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION .- d 6 �y 4,(' a Property Address: 0w0 V. esl Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: >;allor Number of bedrooms: Number of current residents: Garbage grinder (yes or no):_�/� s Laundry connected to system (yes or no): Seasonal use (yes or no): ---do Water met& readings, if ava'ilable:. L f f" +{ M r • , Last date of occupancy: ---CC" C `0 t e d COMMERCIAUI NDUSTRIAL: Type of establishment: 1l (• fry Design flow:gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION'' PUMPING RECORDS and source of information: Y System pumped as part of.inspection: (yes or no) ,P1 If yes, volume puml)ed• haTU.jallons Rea"son `for pumping. TYPE OSTEM ~ ii' 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: _M - 14-2 Sewage odors detected when arriving at the site: (yes or no) Q (revised 8/15/95) 5 i Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SEPTIC TANK:_ �'P3 (locate on site plan) Depth below grade: Material of construction: VIConcrete _metal _FRP —other(explain) Dimensions *5 xt.�,. ,^ w Sludge depth: r z Distance from top of sludge to bottom of outlet tee or baffler Scum thickness:_ rr Distance from top of scum to top .of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc. tAr C -f Y U f Al G T W;- f GREASE TRAP:_ A (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom nt 5rum if) hottom of outlet tee or battle i Comments , i S ' +-... , 1 i. a, + ' 4 4 rr r e - ro.. a ' r' r �. "'.1 r V •.. ♦.- , ; ''.. Pr i F �. ; . a: .. P' -j. n i f = e (recommendation for pumping, condition ofnlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) i (revised 8/15/95) 6 F � f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: , Owner: Date of. Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: /Y/ Material of construction: concrete metal h r _ _FRP —other(explain) a (explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: yeps (locate on site plan) f Depth of liquid level above outlet invert: '' G + I Comments: (note if le%c! and distnb:a: r eq.,21, e%idccnce of solid cz n-nvPr evidence of leakage into or out of hox, etc.) Cow) Z. f 4&Af a ye c... e G `t�Ur/ PUMP CHAMBER:_ k (locate on site plan) ff Pumps in working order(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_✓.Pi (locate on site plan, if possible; excalation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: ' lelching pifs,. Linbert leaching chambers, number._ I leaching galleries, number: leaching trenches, number,Iength: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. r inflow (cesspool must be pumped as part of inspection) Comments: (ndte condition of soil, `signs of tydraulic failurre;'le'vel of ponding,"condition of vegetation,' etc.) �1 PRIVY: _ # W. (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.) (revised 8/15/95) 8 1 r 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION (continued) / Property Address: ] W Q Q /.�° ✓'i`�.�' /�%�r/ V "�� Owner: ` Date of Inspection: Tt,! SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ( # hy�K�� u ct CI �- C.1'4N4- " - IL y C, t,-4� kc' y DEPTH TO GROUNDWATER r Depth to groundwater: /� 6 feet method of determination or approximation: r /J- 112,- "A10 i A -'P (revised 8/15/95) 9 as.1 /J- 112,- "A10 i A -'P (revised 8/15/95) 9 as.1