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TIGER ENVIRONMENTAL
ENGINEERING
969 WASHINGTON STREET
otwAMTREE, MA 02184 bLH Z b 1997 1
617-849-0088 1 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO�o
PARTA
CERTIFICATION
Address of Property: -Z- (a Z 5 Gz2 +Q c-, -f
Town: " - kt.3�?o ('� N
Owner's Name: P-- I
Date of Inspection: (- el
Name of Inspector: AAAo-w-,
CERTIFICATION STATEMENT
Address of Owner: (if different)
El Voluntary Assessment
(Not Reported)
Name
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:
V, Passes
Conditionally Passes
Needs Further Evaluation By The Local Approving Authority
Fails
Inspector's Signature: ��L
Date: I- L -I - I �
The system inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing
this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system
owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original
should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in
310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
113] SYSTEM CONDITIONALLY PASSES:
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.
TIGER ENVIRONMENTAL
ENGINEERING
969 WASHINGTON STREET
08-14AMTREE, MA 02184
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. . PARTA
CERTIFICATION (continued)
Property Address: '2-(-o?— (50c.-tp.-a St -
I
Owner: his P--I—
Date of Inspection:
014
B] SYSTEM CONDITIONALLY PASSES (continued)
I
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled, or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are placed
obstruction is removed
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 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 PROTECTS THE PUBLIC HEALTH
AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet of a surface water
supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 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 has 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.
1
TIGER ENVIRONMENTAL
ENGINEERING
969 WASHINGTON STREET
kBRAI"WREE, MA 02184
Property Address: S(p �Z_ ilIS05,jD" 6.e -
Owner: /*6 f5L_
Date of Inspection: A— L4 , 11
'Ak
, L
Df SYSTEM:IFAILS:
h a" one or 9
I ve determined that the system vio tes— lreotthetollowinA failure criteria as defined in 310 CIVIR 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 poncling of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
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 1/2 -day flow.,
Required, pumping morethqn 4 times in the last year NOT due.to clogged o p�
rbbstructbd.pi (s)..
Numbe(of times pum 6d:
P.
Any portion of the'soil absorption system, cesspool or privy is below the high roundwater el vation.
91 e
Any portion of a cesspool or privy is within 100 feet of asurface water supply ortri.butary to a surface Water
supply.
Any portion�ot 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. 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 fjow of, system is 10 000 gpd or greater (Jarge,,system),qnd the system, is.asignif icant threat to,public
itAns'exist:
"thea-fth -and safety andih6 Oniiviro'nrr�nt.be_caus�6 onJV more of thegfollowihg cond o
The system is within 400 feet of a surface drinking water supply.
The system is within 200 feet of a tributary to a suface 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).
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 CIVIR 5.00 and 6.00. Please consult the local regional off ice of the Department for further information.
The intent of 310 CM R 15.302 is to provide reasonable guidelines for the inspection of existing systems in as non -intrusive a
manner� as is possible to avoid damage to the system and any unnecessary disturbance of the surrounding soil area which is.
'related to th*e,treatment Process. The inspection, is not designed to provide. information to demonstrate that the system Will
adequately serve the use to,be placed upon it'by the new. owner. The inspection aiteria are intended to allow fortimely inspectio, �i
toavoid undue delay in the transfer of property.
I understand that this report does not constitute a warranty or guarantee of future operation.
Client or Representative Date
3
. I-- I
TIGER ENVIRONMENTAL
ENGINEERING
969 WASHINGTON STREET
tRAt_W.rREE, MA 02184
617-849-0.088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PARTB
CHECKLIST
Property Address: 2 -(PS 504faj 4r
Owner: A, 0�, E L
Date of Inspection: Ci- H- 11
-A 0*
h" 16 ow n dcM6.
Check if t 6 �ii ' i fi�a ee'
--j/' Pumping information was requested of the owner, occupant, and Board of Health.
vl"*' None of the system components have been pumped for at least two weeks and the system has been
receiving normal flow rates during that period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or.dwellingw'as.ins ected for signs of. sewage back-up.
p
The system does not receive non -sanitary or industrial waste flow. 4
The, site was inspected for signs of breakout.
All system components, excluding the soil absorption system, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for
condition of baff les or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth
of scum.
The size and location of the soil absorption system on the site has been determined based on existing
to -ihtrusiv.� meffiods�._ Ix
forrpa i 'h or, appr�ximAt on
9,0 by p,
The facility owner (and occupants, if different from owner) were provided with information on the proper
maintenance of subsurface disposal system.
4
TIGER ENVIRONMENTAL*
ENGINEERING
969 WASHINGTON STREET
<_,8RAATREE, MA 02184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PARTC�
SYSTEM INFORMATION,
Property Address: 2. G 'L- &ol.,tpt-� ep'-r
Owner: Are;, 61 -
Date of Inspection:
FLOW CONDITIONS
AESIDENTIAL:
Design flow: &00 gallons
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no) vjO
Laundry connected to system: (yes or no)
Seasonal use: (yes or no) t,�Q *L
Water meter. readings, if available: 12 a.\\j Aerer to A-A-g::�
Last date, of occupancy:
COMMERCIAL/INDUSTRIAL:.
tl� P,
Type of establishment:
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 sy/emr: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
4
GENERAL INFORMATION
PUMPING RECORDS and source of information: tk-c2'r T?LAwN!qgci?
System pumped as part of inspection: (yes or no) 0
If yes, volume pumped: - gallons
Reason for pumping:
TYPE OF SYSTEM:
Septic tank/distribution box/soil absorption system
Single cesspool
O.ve rf low cesspoo I
Privy
Shared system (yes'or no).(if yes, attach previous records, if any)
'Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: jINS+-Ajj_er)
pe? fRA_ vwpea,
I
TIGER ENVIRONMENTAL' -
ENGINEERING
96.9 WASHINGTON STREET
%RANTREE, MA 02184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARTC
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
Sewage odors detected when arriving at the site: (yes, or no) _4jP7,
SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: concrete metal FRP other (explain)
Dimensions: 11' L 5'W
Sludge depth: - U
Distance from top of sludge to bottom of outlet tee or baff le: 1,
Scum thickness:
Distance from top of scum to top, of outlet tee or baff le: (0
Distance from bottom of scum to bottom of outlet tee or baff le:
I*, p It— I
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.) qL,,,CML4ftj2:RtA VV\9f N!�? -P 01t a" �7— - -16 rz- (3 P, fr— L e--, 1 K3
41&� (:e�0oj-fj'Dh2 - J_fq�Ul]�j I-ZOel_ P5�e OLAA-e14 N cF 0, 6)cm- CAP-
-Pt% -'\V �k -^.AA AA - e-, I -W, I- L. —& -% A- 0 0 ,�- - . , - 2� t-
GREASETRAP:
oocate-on,site plan)+.
Depth below grade:
Material of construction: conc7te metal FRP other (explain)
Dimensions:
Scum thickness:
Distance from top of scum to.
Distance from bottom of tcur
Cornments:.
of outlet tee or baff le:
bottom of outlet tee or baff le:
(recommendation for pum ng, condition of inlet and outlet tees or baff les, depth of. liquid level in relation to outlet invert,
structural integrity,evide7e of leakage, etc.)
A I 1i
04
4- 1
I
TIGER ENVIRONMENtAL;
ENGINEERING
9��9 WA
, �HINGTON STREET
BRAINTREE, MA 02184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARTC
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHTOR-JAOLDING-TANK�,,--
(locate on site plan)
Depth below grade:
Material of construction: concr/te metal FRP _other (explain)
Dimensions:
Capacity: gallons
Design flow: ga s/day
Alarm, level:
Comments: (condition of iVfiet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
4
Comments: (note if level and distribution is equal evidence of solids carry over, evidence of leakage into or out of box, etc.)
126o)( I L - 121 �,w k &L, *co-' NM E� J kVC—'0C 4E- L-5�
PUMP CHAMBER:
(locate on site plan)
Pumps in working order: (y/esr no)
I f pu
Comments: (note condition f pump chamber, condition of pumps and appurtenances, etc.)
I
TIGER ENVIRONMENTAL
ENGINEERING
969 WASHINGTON STREET
'bRARTREE, MA 02184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARTC
S YS TEM INFORMA TION (con tin ued)
Property Address: 'Vo -Z- 6Mlinsj
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): V/
(locate on siteptanjf pos-sib[iE�,,excavation,n.ot��equired, but may I be approximate"d,by, ndnLititrusive methods) -'u
If not determined to be present, explain:
Type:
Leaching pits, number:
Leaching chambers, number:
Leaching galleries, number:
Leaching trenches, number, length: 1-f to, -i k-17 9-101�
Leaching fields, number, dimensions:
Overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 15,n tL POTA4WAt
NC,) TQt,
kkP��O &YOIL41A Aj_
CESSPOOLS:
(locate on site �+Ia)
Number and configur,
Depth -top of liquid to
Depth of solids layer:
Depth of scum layer-
c'y�"
Dimensions of cess
Materials of conj/
str ct
�u
Indication of grou dw
Inflow (ces ol
invert:
ol:
ion:- i -i-
4---, 4
must be pumped as part of inspection)
Comments: (no/Condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY' 0 rA
(locate on she plan)
Materials of construction:
Depth of solids:
Comments: (note conditi(
Dimensions:
of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
I
TIGER ENVIRONMEbitAL'
ENGINEERING
9,69 W��i.HNGTON STREET
B, RAINTREE, MA 02184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARTC
SYSTEM INFORMATION (continued)
I
Property Address: 6054 -yo
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent references, landmarks or benchmarks
'LodarOlall weA4*ithA1-06'�-
4-4
. . . .
A
. . . . .
. .
. . . .
. . .
. . . .
. . . . . . . . .
N C>F +10 Lt�&
. .
. . . .
. . .
A 5e--
. . . . . . . . . . . . . .
. . . . . . .
. . . . .
. . . . . . . . . . .
. . . . . . . . . .
DEPTH TO GROUNDWATER:,;
Depth to.groundwater: << I feet
Method'of determination or approximation: �A—M
-UP910 T-A-fc#')
OAA)Veit—
I