HomeMy WebLinkAboutMiscellaneous - 275 RALEIGH TAVERN LANE 4/30/2018 (2)6:x
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 Addre ZotL RECEIVED
Owner's Namel 1, - 21� Is �OXIF� If JUN 2 3 2005
Owner's Address:
TOWN OF NORTH ANDOVER
Date of inspection: HEALTH DEPARTMENT
Name of Inspector: (please print) 5904 stlsllf
Company Name:
7e j
Mailing Address:
Telephone Number: �Z'�7.c-qS7 279(
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this addre . ss 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
-/ -7— 0 S -
,;>Inspector's Signature: 4:22t-- Date:
z
The system inspector shall submit a copy 6f this inspection report to the Approving Authority (Board of Health or
DEP) within 3 0 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 1)erform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
Inspection Summary: Check A,B,CD or E / ALWAYS complete all of Section D
A. System Passes: —,"'
VK I have not found any information which indicates that any of the failure criteria described in 3 10 CMR
15.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: �-v /A
One or more system components as described in the "Conditional Pase' 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 (YN,ND) in the for the following statements. If "not determined" please
explain.
— The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health): _ broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
— The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
ND explain:
broken pipe(s) are replaced
obstruction is removed -
2
11 Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
1�4411-15FII
Property Address: Q �7 1' 4/
Owner:
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health 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 I of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
— The system has 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:
0 Page 44 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:,
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
— i. --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
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 1/2day flow
— 1,.,,Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
— 'O�.ny portion of the SAS,* cesspool or privy is below high ground water elevation.
— '0�iny 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 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 waterquality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compoumds
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.]
Al., (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 3 10 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 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 Tw*ped
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 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
0 . .#
Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Dlt-K X '1'4
Owner:
Date of Inspection: �-7- 0(
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yvs.,�o
— — Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period ?
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)
41- Was the facility or dwelling inspected for signs of sewage back up?
t,,"— Was the site inspected for signs of breakout?
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
�f&-baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
Was the facilitv owner (and occupants if different from owner) provided with information on the pi�oper
maintenance of subsurface sewage disposal systems 9
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Vrl, no Existing information. For example, a plan at the Board of Health.
Determined in th*e field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
5
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: - P A 4 e e'�7 4 r5v ery
4J"-106V-f—
Owner: r)'ep-
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual): 4
DESIGN flow based on 3 10 CMR 15.203 (for example: I 10 gpd x # of bedrooms):
Number of current residents: -3
Does residence have a garbage grinder (yes or no): �4
Is laundry on a separate sewage system (yes orno):�_7r [if yes separate inspection required)
Laundry system inspected (ye� or no):
Seasonal use: (yes or no): _6/
Water meter readings, if ava lable (last 2 years usage (gpd)):
Sump pump (yes or no): /1
Last date of occupancy: 0 /"& up, e
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: _5 ck
Was system pumped as part of the inspection (yes or no): 4e
If yes, volume pumped: /�_') logallons -- How was quantity pumped determined?
Reason for pumping:
TYItE OF 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
;-b—tained 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:
/ S7 \fl 5
Were sewage odors detected when arriving at the site (yes or no):
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Z�-A- to
-.4 / 0a U -el'
Owner: At t / /),- r � aj-'
Date of Inspection: s- - /7 —o
BUILDING SEWER (locate on site plan)
Depth below grade: '�/ Ll---"
Materials of construction: —cast iron _40 PVC — other (explain):
Distance from private water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
60 0 0 0 C, /- / o / )-/. , ,
SEPTIC TANKYte5(locate on site plan)
Depth below grade: / �F'r
Material of construction- — crete —metal —fiberglass ___polyethylene
If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: 61
Sludge depth: It 11
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: / I � '-
Distance from top of scum to top of outlet tee or baffle- Ll
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: 0/,/ 5 ,' T/E
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
GREASE TRAP: _(Iociie 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 inveM evidence of leakage, etc.):
7
* Paje t of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �2
Owner:
Date of Inspection:
TIGHT or HOLDING TANK:t' / 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: J
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
PUMP CHAMBER: _ (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
8
Page 9 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
'�2 A
Property Address: 2- -2 S' //�' , -/,9 A / -) -, -r " -,*?
Owner:
Date of Inspection: 6- -/ 7- 6 -
SOIL ABSORPTION SYSTEM (SAS): _ (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:'�3
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,
etc.): );'-' r- Z C,- e ef r cle fi 14 /1 )5e 16 tv / /' t 6/ e P"T--
I- / C- /-- .6 / L- (11
CESSPOOLS: L/(tesspool 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.):
W4
PRIVY: '(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, sips of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
0 . ,Page 10 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM 'INFORMATION (continued)
Property Address:
Owner: 4"I)-O�,
Date of Inspection: Z2 7 - Of*
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.
a -7
6 -7,
E
®r
le, W
' ;age I I of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: � j2 /i & /i j—,j (1, k e
/1 " wo U
Owner: /I s, , -/
Date of Inspection: _V7- 01
SITE EXAM
Slope — /0
U47 FA&M s -r.
Surface water
Check cellar
Shallow wells
N
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
L. -/Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked.with local excavators, installers- (attach documentation).
Accessed USGS database -explain:
You must describe bow you established the high ground water elevation:
I I
Commonwealth of Massachusetts
P "City/Town of,NORTH ANDOVER, MANAnTffl�,E�Tjl
.,..System Pum"Ping Recor"d
Form 4
FEB 0
DEP has provided this form for use by local Boards of He 11-11), T4 h e -- 45S 'd f &MI 03\
be submitted to the local Board of Health or other approvi
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
A. Facility Information
1. System Location:
,6
Address
'eev)
11-A9
City/Town State
2. System Own er:
Name
Address (if different from location)
Cityrrown
B. Pumping Record
. 1. Date of Pumping
3. Type of system: El
F-1 Other (describe):
z"In a ,
State
Telephone Number
Quantity Pumped
Zip Code
Zip Code
Record must
1115waz
Gallons U
Cesspool(s) >(Septic Tank Ej Tight Tank
4. Effluent Tee Filter present? [:] Yes. [] No
5. Condition of System:
A
7
If yes, was it cleaned? Ej Yes E] No
r
System Pumped By:
Vehicle License Number
Company
where contents were disposed:
0-20 �D - ?&;/ Aladal�l- // / // I
Signature of Hauler Date
hftp://www.mass.gov/dep/water/approvals/t5forms.htm*inspect
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
TOWN OF NORTH ANDOVER
aj-o(� SYSTEM PUMPINO RECORI)
S/Y STEM 0
SS
7k cto ver—
SYSTEM L(�CATION
JAN 0 6 2005
TOWN OF NORTH ANDOVER
4T
k
DATE OF PUMPINO:
PUMPED:_ 7
� - 5 -
YES
SOPIUC Tank: NU.
NArUREOFSBRVICE: R0u'rINB.,..__...E#, jtit��,y
tt
ObSERVATIONS:
GOOD CONDITION ...._.FULL To CovER
HEAVY ORWE BAMES IN PLACL
ROOTS LWKRP-LD RUNBACK
BXCISSSIVE SOLIDS
SOLID CARRYOVE
R� OTHER EXPLAIN
systompumpodby
O�L
�-'UMMHNTS.
�.:uNrwrs rKANSFtAKBD I*u
BASED UPOAPU5UCRECORE)*,AMVEvrDZ)4CEOtA'TUSGnWt4Ca>
Avomess L�4, K) 0 r6T 4 4M IDO V
L,--_S_oup.c-e Atq L?C)k/ F_ R_
4 -
7441
�4
_Je
013
cl
PRO
a
I
I
4
L
t 12
Z_d
. 11� — Z ?'-,
0�v I
EXisT.
'Zi
! i,5TY,
r DWELLING d
�A ��) v- 1�1
uk)prrz
LOT 19 E3
J, 4
1 e-5)
19
loo,
4r_
7
PARCEL" A"
-1 t2 n4?
REGISTRY: Esse,4 J\L00n4
DE M- t BK. 15 P Z5 -T
PLAN E5
N OTE:
ROBERT G. -GOODWIN. R. L. S. -
82 4EN�RAL`.STREET
ANDOVER, AA
VfAL � I eo 00
LA,,,
CERTIFICATE
I CERTIFY that the Lot shown hereon
that the F_ L L I KA(S sh6wn
i:Z)p_ fv�
__W I T(4 T4 E present.' Zdhi. ng'jLtA.W
of -the
The premisea do
not lie within �A Of
a designated
Flood Hazard Ic- I No
Sv R0316:RT
R. 439 0, %
I
Zone 404fA PAN U xl� CILLETT
Gillett
GaodwsA
14
S L! ,jN4
FORM U - IDT REIZASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: ib�d� -�INLIZ-Siti Phone A 69,-2062
LOCATION: Assessor's Map Number Parcel
Lot (s) 19
Subdivision
S treet F A St. Number X)
Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Town Planner
Comments
Food Insuector-Health
7eDL- Au
Septic Inspector -Health
ccmmne-ts 1191-?Y11'nLM 0./-- -72CLf
Public Wcr"vls - se'vier/wat-er connect-Lons
- drivewav permit
Fire De=art-nie
7W "r,
Received by Building Inspect -or
Date Approved
Date Reected
I --
Date Approved
Date Rejected
Date Ancroved
Daze Re -J -c -ed
Date ADnroved
Date Re7ected
Data
T,
IN A,
o c
Plan
T,oc./,Subdiv.--
invest!-gator Observer
SOIL PROFIL'ES-DATE
4
2 3.
EleV. Elev.
0 0 0
2
3
4
6
7
8,
2
3
2
3 1
4
6
Ties to Test Pits
9 9
9 9
10 10
Loc a t i on
Eleva-tion Datum
Percolation Tests -Date ------
4
Pit Number 2
Start Satj)ration
o ak-Mins.
,
S I J ---T t- - T i m e
Pro f 311 -Time -
Drop
3 3"Dj-
op
i d 3 op
I
13
APF: - -
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
STEINI OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
5-rl 0 &ck—
A//0 pet-)
0 F P U M 1) 1 N G: Q U A N ]'IT Y P U M 1) E D GA L L ON.)
Ct"S S P 0 0 L: N 0 LXE S SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE —6z EMERGENCY
13S 1,'IZ 0 N S:
GOOD CONDITION
1-11-I'AVY GREASE
ROOTS
EACESSIVE SOLIDS
-SOLIDS CARRYOVER
.�YSTENI PUMPED BY:
c o.N 1.,�,l E NT S:
FULLTO COVEI�
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHFIR (EXPLAIN)
Board'of Health
North An4� �qrMaBa.
SEMC STSTEM �
INSTALLATION CH30K LIST
OK
1. Distance To:
a. Wetlands
b. Drains
wen
�2. Water Line Location
3. No PVC Pipe
LOT 02�
fi�'A_VATICWOK FAIL—
4.
Septic' Tank -
a., -Tees -Length & To Clean-iDat Covers
b. Cement Pipe to Tank .- On Both Sides of Tank
Distribution Box
a. Covers &_ Box - No Cracks
b. All Lines Flo-Ang E�ual Amounts
C. No Back Flow
6,-
LeachAeld or Trench
a. Dimensigna—,
b. S Depth
_t
c -,-Capped 'Eads
Clean Double Washed Stone'
Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tees
e. Cement Pipe to Pit Both Sides
f. Clean Double-Was.hed Stone
8.
No Garbage Disposal
9.
Final Grading Inspection
10.
Barricading Covered S�rstem
.11.
As Built Submitted..
a. Lot Location,
b. Dimensions of System
c. Location -4th Regard -to Perc Test
d. 'Elevations
e.* Water Table
I
Bov2r;d of' He th
Nor� Andovar.,Ylass
SUBMPACE DIEM= DMIGN CHFLK LIST
LOT #—d�
APPROVED DATE DISAPPROM DATE
Provided: Reasonst
TitleV �/FAIL
OX
Reg 2.5
e subirLitted plan mwt show as a minimum:
the lot to be served-area.,dimensions lot #.,abatters
b cation and log de-ep observation gles-distance to ties
location and rem,11ts pemolation tersts-distance to ties
design calculations & calculatiens Miowing required leaching area
and dtnersions of ding veserve area
existing and proposed contours
7W.1location.
location any vat areas i4-th-'.n 'AC01 of sowa-ge (Usposal system or
asclaimar-check watloods rapping
(h)Amwface and subsurface drains i4tIY'tn 1001 of sovage disposal
system, or disclaimer
any drainage eaver.ents i4tl-dn 3.001 of aetcga disposal
V(i),/location
L/`/(JY-'IW-ovn
syste-m or disclairier-Plawting Board files
sources of v.-ater supply within 2001 of sewage disposal
wstem or disclaimer
(0-�>ocation of any broposed rell to serve lot -160 I from leaching facility
of vater lines on proparty-101 from leaching facility
vooW
of bw.ichTP--&k
V4Q
(9'r bage d-I-Tosa'.18
V
no PVC to be us-od �n consUsetion
1�� e of Nywoter.-ea-evations of basement.. plumb., pipe.. septic tank,,
- Iyation box !nlots and outlets,, distribution field piping and
cr eley;4MOns
rkiYJwxa gm'und vater elevation in area s"rage div-posal system
plan wast be prepared by a Professional Eaglmeer or other
11--lo(s)
professional authorized by law to pre -pare such plans
Reg 6
S- tic Tanks
a apac t OB- % of flow., -vater table, te.es., dcpth of toes.,
access., purping
leanout
101 from cellar wall or ingromd. mAmAng pool
d) 25, fror. subwarface drains
Reg 10.2
Distribution Doxes
Reg 10.4
7so-pe greater than 0.06
Kb)) mup
L",
i
IDO
Check List
I QK I
2
Leaching Pits
/leaching pits are preferred where the installation is possible
#-�alculations of leaching area-minimm 500 aq ft
OY-sPacing
O'surface drainage 2%
A)'cover material
2, 1 x2 I A" splash pad
tee at elbow
g) no bends in pipe from d -box to pipe
Leaching Flel
g
r
ea
I
a) —no eater t 20 rdnutes/inch
b� area- 900 sq ft
A�
c construe on of field
A.) surfac drainage 2 %
e) 201 -m cellar An or inground s-Andng pool
Leaching TV es
a) calculation o:, eaching area.rdn-500 aq ft
b) spacing -4 6 ft with reserve between,
c) dimmsio
a
d) coust,=
0) stone
surf* drainage 2%
B63--;Mhm Slope
STO—PG—yTx--=-('Eo be shown)
b) ylx X 150 = (to be shown)
s
a) a�W val
'b) s d -by power
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OF CE OF ENVIRONMENTAL AFFAIRS
T 0.
DEPARTMEN OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLU ' SSMENI
SUBSURFACE SEWAGE -,DISPOSAL S�Y�, EM FO
PART A
IN
CERTIFICATION �J9, O�
n 7 7 T KId r
Property Address: 2-7 lco-l-e—j q6 /0 koere) &M
's Name: 141u J/re) /U
's Address: a;z �5' A. I C. Lll�
f Inspection:
of Inspector: (please print) A& 114WW",- rAqfC1A JAN 005
any Name: TC)�,
g Address: 7 -
Owner
Owner
Date o
Name
Comp
Mailin
Telephone Number: W9-- 2 4
CERTIFICATION STA MI
I certify that I have personally insp te
below is true, accurate and compl\ete
training and experience in the proper fi
approved system inspector pursuant
—.5,
Title 5 Inspection Form 6/15/2000 page I
the sejage dispo ystem at this address and that the information reported
of the ti e of the inspection. The inspection was performed based on my
ction a d maintenance of on site sewage disposal systems. I am a DEP
t\o\Secti 15.340 of Title 5 (310 CMR 15.000). The system:
conXiAonally Passes N
Need\kurther Evaluation by
Fails
Inspector's Si ature:
Local Approving AVthority
e: 7 -0
The system ins ct 11 submit a copy of this inspection re to' proving Authority (Board of Health or
ort e
p " to "!e
or repor
DEP) withmi 3 y completing this inspection. If the system is M//are'd system or has a design flow of 10,000
days y
th I su
gpd or greater, e linspe and the system owner shall sub report to the appropriate regional office of the
DEP. The origin should be se n q es s�ent 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.
n
/7)
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OF CE OF ENVIRONMENTAL AFFAIRS
T 0.
DEPARTMEN OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLU ' SSMENI
SUBSURFACE SEWAGE -,DISPOSAL S�Y�, EM FO
PART A
IN
CERTIFICATION �J9, O�
n 7 7 T KId r
Property Address: 2-7 lco-l-e—j q6 /0 koere) &M
's Name: 141u J/re) /U
's Address: a;z �5' A. I C. Lll�
f Inspection:
of Inspector: (please print) A& 114WW",- rAqfC1A JAN 005
any Name: TC)�,
g Address: 7 -
Owner
Owner
Date o
Name
Comp
Mailin
Telephone Number: W9-- 2 4
CERTIFICATION STA MI
I certify that I have personally insp te
below is true, accurate and compl\ete
training and experience in the proper fi
approved system inspector pursuant
—.5,
Title 5 Inspection Form 6/15/2000 page I
the sejage dispo ystem at this address and that the information reported
of the ti e of the inspection. The inspection was performed based on my
ction a d maintenance of on site sewage disposal systems. I am a DEP
t\o\Secti 15.340 of Title 5 (310 CMR 15.000). The system:
conXiAonally Passes N
Need\kurther Evaluation by
Fails
Inspector's Si ature:
Local Approving AVthority
e: 7 -0
The system ins ct 11 submit a copy of this inspection re to' proving Authority (Board of Health or
ort e
p " to "!e
or repor
DEP) withmi 3 y completing this inspection. If the system is M//are'd system or has a design flow of 10,000
days y
th I su
gpd or greater, e linspe and the system owner shall sub report to the appropriate regional office of the
DEP. The origin should be se n q es s�ent 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.
Page 2 of I I
OFFICIAL INSPECTION FORM -
SUBSURFACE SEWAGE DISF
Property Address:
'40T FOP. VOLUNTARY ASSESSMENTS
iSAL SYSTEM INSPECTION FORM
ARTA
ATION (continued)
Owner: Ay
Date of Inspection: 3
Inspection Summary: Check A,B,C,D or E ALWAYS com
,,plete all of �ection
A. System Passes:
have not found any information which indicates t hat any of the failure cri ria i
15.303 or in 3 10 CMR 15.304 exist. Anv failu re criteria not evaluated are indicated belo
Comments:
^ A I
B. System Conditionally Passes: 111,4
One or more system components as desc
repaired: The system, upon completion of the rej
'the'
Answer yes, no or not determined ( �,N,ND) in
explain.
The septic tank is metal and 6ver 2\0ears
unsound, exhibits substantial infiltration or �kltr
existing tank is replaced with a complying sept i
*A metal septic tan"ill pass inspection if it`�js-st,
indicating that the taU Is less than 20 'S fol� is
e
ND explain:
i n 3 1 )OCM
"Conditional IPass" sectjion need to be replacedor
or repair, as approved by the Board of Health, will pass.
e follo)ing
g statements. If "not determined" please
or the septic tank (whether metal or not) is structurally
I or tank failure is imminent. System will pass inspection if the
as approved by the Board of Health.
irally sou—nd,-notleaking and if a �ertificate of Compliance
N
Observation of se age backup or break out or high static water level in t e distribution b6x'due to broken or
water I evel ' n t 'e
obstructed pipe(s) or d2u to. a broken, settled or uneven distribution box. System ill pass inspection if (with
approval of Board of ealth):
�foken pipe(s) are replaced
obstruction is removed
r
ac
distribution box is leveled or -Fe ced
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
- — — —11 .41"
-Page 3 of I I
OFFICIAL INSPECTION FORM - N OT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
bwner: X4
Date of Inspection: le q
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to deterrnin:�f the system
is failing to protect public health, safety or th e e nvirotim ent.
1. System will pass unless Board of Health determines in accordance with 0 CMR 15.303(l)(b) that the
system is not functioning in a manner which will protect pub*10bealt9k,1safe`ty and the envirAnment:
Cesspool or privy is within 50 feet of a ��f�acewater
Cesspool or privy is within 50 feet of a �qrdering vejetated wetl d or a salt marsh
2. System will fail un'tess the Board of I
system is functioning in A�manner that p
The system has a septic tank and!
surface water supply or tributary to a surt- e water �upVly.
SA and the SAS is within a Zone I of a public water supply.
Public Water Supplier, if any) determines that the
public health, safety and environment:
— The system has a septic
(SAS) and the SAS is within 100 feet of a
The system has a septic tank anli SA and -the -SAS is within 50 feet of a private water supply well.
The sys.tem has a septic tank and SASkand the SAS is less than 100 feet but 50 feet or more from a
private water supply Method uselA determine distance
"This system p�s`ses if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and v6latile organic compounds indicates that the well is freelfrom pollution from that facility and
the presence/of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
,Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2-75 2�,- lelg!
Owner:
Date of Inspection: z -,z-1 A SAO
D. System Failure Criteria applicable to allsystems:
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
l,""Static liquid level in the distribution box ab�ove-,outlet invert due4o an overloaded or cloggid SAS or
cesspool
Liquid depth in cesspool is less than 6" below invert or,,available �flume is less than 1/2,cfay flow
i,/Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
11� Any portion of the SAS, cesspool or pri4is below high ground water elevation.
Any portion of cesspool or privy is wi&n 106 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a-c,esspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is ynthin 50 feet of a private water supply well.
Any portion of a cesippol or privy is I I 'ess than 100 feet but greater than 50 feet from a private water
supply well with no acceptable wateriquality .'analysis. IThis system passes if the well water analysis,
performed at a DEPcert4fied laborsto jor coliform bacteria and v olatile organic compounds
ry
indicates that the well is fre ' e from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is eqdal 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.]
(Ye WNO))3he system fails. 11 haved�e_termmed that one or more of the above failure criteria exist as
r b 11
ed in 3 10 CN4R 1-5.303. theref4e the system fails. The system owner should contact the Board f
'k 1 0
Health to determine what will be necessary to correct -the failure.
E. Large Systems:,
To be considered a1arge s�/e ystem must ser ve 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 criieha above)
yes no
the system is� within 400 feet of surface dfi�Jking 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 irrapped
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
44yes" 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 3 10 CMR
15.304. The system owner shobld contact the appropriate regional office of the Department.
I
f , � 4
Page 5 of I I
OFFICIAL INSPECTION FORM — NOTIOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: )-2 S� /24 lei,; 4 7;�tv,-,
thy/ -1— 14,1
Owner: A
Date of Inspection: j /d
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 thepwner, ccupant, or Board of Health
I
&-"'Were any of the system components pumped,out in the previous two weeks?
Has the system received normal flows in the previous two week period ?
Have large volumes.,of water been. introduced to the system re I cently or as part of this inspection ?
&-*`�Were as built plans of the system obtaine'd 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 breaki out ?
Were all system components, excluding the SAS, located on site ?
A.-' Were the septic tank manholes uncovef�ed. opened, and the i . nterio I r of the tank inspected for the condition
of the baffles or tees, material of construction, dim�nsions, 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 p�oper
maintenance of subsurface sewage disposal syst6ms
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.
'�t
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
5
; Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2-7 5- IZr
4f ad
Owner: /_e_5 P�'
Date of Inspection: >70 �'
.1 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: 5
Does residence have a garbage grinder (yes or no): Al
Is laundry on a separate sewage system (yes or no): Al [if yes separate inspection required]
Laundry system inspected (yes or no) -
Seasonal use: (yes, or no): _/_V
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): Al
Last date ofoccupancy: e_-
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gpd
Basis of design flow (seats/per.sons/sqft,etc.):
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: Z )0-,07q
Was system pumped as part of the inspection (y�s or no):
If yes, volume pumped: /500gallons -- How was quantity pumped determined? P,46 -'C'
Reason for pumping:
J?repTY F SYSTEM
t
ic tank, distribution box, soil absorptian 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:
1.5- j112 S_
Were sewage odors detected when arriving at the site (yes or no): IV
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2- 7 57 1�2 14 /' 9:1)6 // �-A
Owner:
Date of Inspection:
BUILDING SEWER (locate on site plan)
-
Depth below grade: 2-,1—
Materials of construction: —cast iron t,**'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: le /I
Material of construction: �4<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: S �-4 WP/f /Z D)
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: / " " A' -
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 9 -
How were dimensions determined: D 0 13 SEe LT- L*1
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
GREASE TRAP: _(locate on site plan)
Depth below grade:
Material of construction: —concrete —metal _fiberglass ___polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _,D4 t -:E& 4 120
"Ww A
Owner: A—WI)SI1541AI)
Date of Inspection: F'!�q
TIGHT or HOLDING TANK: OWnk must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal _fiberglass ___Solyethylen'e _other(explain):
Dimensions:
Capacity: -allons
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.):
D ISTRIBUTION BOX: Z(if present must be opened)(locate on site plan)
Depth of liqu id level above outlet invert: 0
Comments (note if box is level and distri tion to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
e�� adr--,4> ef e-- A1,0 /
PUMP CHAMBER: AV?0cate 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.):
jPage 9 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -:;P -2,7 124 1- F-/ A If
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
:kfeaching chambers, number:
— leaching galleries, number:
— leaching trenches, number, length:
— leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alterriative system Type/name of technology: 1\
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
CESSPOOLS: cesspool must be pumped as part of inspect i on)(1 ocate on site plan)
Number and configuration:
Depth - top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of so 11, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: #0ocate 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
Pqc 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: '7-7 57 ILd
Owner: 19-1("10 Ll-�) ILI
Date of Inspection: 1— // 3165
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,
I
30."
C 6 ?. q 6- C- 2 LI,
F V6,1 i )S- � �3 0
A
- G 21.3
I>-
G /6
A -
n3q
6-
�D zi.,7
A
C -7-
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7_75—
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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)
w -'Accessed USGS database -explain: 6rD.-% AA:5t4P'1Ze"_, e4SC_.�z 4-ff
You mus t describe how you established the high ground water elevation:
A a " Z' 7- 4-1,0