HomeMy WebLinkAboutMiscellaneous - 623 TURNPIKE STREET 4/30/2018 (4)a
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7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPrE__CTION FORM
Address of propertyS�vt�i
owner's name M f'. WC1,t kUh
Date of Inspection �57
_q-5-
PART A
CHECKLIST
Checkifthe following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
`-- 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.
AfIN As built plans have been obtained and examined. Note if they are not
�av&klable with N/A.
The�lacility or dwelling was inspected for signs of sewage.back-up.
!/ The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
}tet e.
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.
wT/he size and location of the SAS on the site has been determined based
on ex'sting information or approximated by non -intrusive methods.
he facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
4 number of bedrooms
number of current residents
D garbage grinder, yes or no
laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow: kc(gq
Water meter readings, if available:
Last date of occupancy
.SrJGY���3x�1�s
�3 65 c�s
L
n!t
s
GENERAL INFORMATION
Pumping records and source of information: V v
System pumped as part of inspection, yes or no
if yes, volume pumped DCt91g. I)
Reason for pumping-
System
umping`
Type system
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information: tct53��'� ig5-S S�S-V V
NO Sewage odors detected when arriving at the site, yes or no
0
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: '
(locate on site plan)
depth below grade:_
material of construction: concrete metal FRP other(explain)
dimensions: �
sludge depth
1a r distance from top of sludge to bottom of outlet tee or baffle
I" scum thickness
-.0 distance from top of scum to top of outlet tee or baffle
L-3 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,
idence of leakage recommendation* for repairq, etc.)
C� CYi uo , . 11-j N
DISTRIBUTION BOX: "
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal,
evidence of leakage into or out of- box. z
evidence of solids carryover,
nnvnrnenrial- i nn. fir. rnr» i rr-- a+ -i. %
PUMP CHAMBER:y�ov\
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc.)
Cpk-+
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION Continued
SKETCH OF SEWAGE DISPOSAL
include ties to at least tw
locate all wells within 100'
A., s r -,
7 rr
(� +0
permane t references landmarks or benchmarks
�)r,u2
w�
3
=1111 6
a eQG
3�
DEPTH TO GROUNDWATER
�r
depth to groundwater
beJot-u h6-66�.3
method of determination or approximation:
GiM- 2UR�`0''1 O
WC) ►k
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indichte yes, no, or not determined (Y, N, or ND). Describe basis of
determination in all instances. If "not determined", explain why not)
N Backup of sewage into facility?,
1�
Discharge or ponding of effluent to the surface of the ground or
surface waters?
'" Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
Required pumping 4 times or more in the last year?
number of times.pumped
Al
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent? •
f�f Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
/v within 50 feet of a surface water?
�V within 100 feet of a surface water supply or tributary to a surface
water supply?
A/. within a Zone I of a public well?
�V within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS)?
it/ within 50 feet of a private water supply well?
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 analyst
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector �j QJ% ` �S. esDn
Company Name QDOA-e-< � 12Vi rl �S�<•
Company Address
l Lj�� oQ
o t �Iv
Certification Statement
I certify that I have personally inspected the sewage disposal system
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
at
and
13
Ct ec one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public
the environment as defined in 310 CMR 15.303. The basis
determination is provi od in the FAILURE CRITERIA section
form.
Inspector's Signature
Date _ 7 _5
original to system owner
Copies to:
Buyer (if applicable)
Approving authority
health and
for this
of this
Commonwealth of Massachusetts
/Y Massachusetts
System Pumping Record
System Owner
System Location
Date of Pumping: Quantity Pumped: e. ; gallons
Cesspool: No Yes Septic Tank: No Yes
System Pumped by: Fetee-doa 5iO&M,6 tid a License #
Contents transferrred to : Greater Lawrence Sanitary District
Date:
Inspector-
('oninion weal th of Massachusetts
Massachusetts
System Pumping Record
System Owner
of C, k
au'd
Date of Pumping:
hy
Cesspool: No Yes L:_l
System Location
Quantity Pumped
Septic Tank: No U
System Pumped by: Fctredda SiteeTATe 4 License #
Contents transferrred to Greater Lawrence Sanitary District
Date:
Inspector -
FA
Yes
gallons
FORM - SV
Commonwealth of Massachusetts
, Massachusetts
System Pumping Record
stem UwneF
Date of Pumping
Cesspool
Fll
Quantity- Pumped: (OCZ)gallons
No a ' Yes : ❑ Septic Tank: No ❑
System Pumped by -
POA �
Contents transferred to:`
Date Inspector
Yes
License #:�