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Home My WebLink AboutMiscellaneous - 1220 SALEM STREET 11/14/2003 COMMONWEALTH OF MASSACHUSETTS w" EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' DEPARTMENT OF ENVIRONMIENTAL PROTECTIO?ti 1 r 1 1 1 L E J _ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION j f Property Address: Owner's Name: ZL11 rte f}_ti` ,N Owner's Address: eFwt Date of Inspection: °Az _6 73 G p � p Name of Inspector: lease print;& @ Company Name: Mailing Address:", Telephone Number: C� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority _ Fails Inspector's Signaturq: ( Date: l.2C The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments LA ii ""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 incner_tinn Fnrm ,cit tnnnn Page 3 of 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART A CERTIFICATION (continued) Property Address: Owner: jar aPt"� Date of Inspection: j/—L4-7 r C. Furt er Evaluation is Required by the Board of Health: ,� Condit �s exist which require further evaluation by the B ard of Health in order to determine if the system is failing to protei public health,safety or the environment. I. System will pas unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not func4ioning in a manner which ill protect public health,safety and the environment: Cesspool orprivy is within 50 feet of surface water _ Cesspool or privy is withut 50 feet a bordering vegetated wetland or a salt marsh Z. System will fail unless the Bo rd of Healt (and Public Water Supplier, if any)determines that the system is functioning in a man r that protects a public health,safety and environment: _ The system'has a sep c tank and soil absorptio system(SAS)and the SAS is within 100 feet of a surface water supply or butary to a surface water sup The system has septic tank and SAS and the SAS is w' in a Zone 1 of a public water supply. _ The system a septic tank and SAS and the SAS is within feet of a private water supply well. _ The syst has a septic tank and SAS and the SAS is less than 10 eet but 50 feet or more from a private wat supply well*•-Method used to determine distance "This ystem passes if the well water analysis,performed at a DEP certified laboratory, for coliform bact to and volatile organic compounds indicates that the well is free from pollution from that facility and th resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other [lure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page S of 1 I ti OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMM PART B CHECKLIST Property Address: ljde . Owner: '1<V ,3 d Date of Inspection: / -! t4 OLS Check if the following have been done. You must indicate `yes"or"no"as to each of the followine: Yes No 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 ? r9�r Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? — Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? — Were the septic tank manholes uncovered. opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System tSAS)on the site has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)) 5 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-2-0 --, - ", �� ALL Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below Bade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction: concrete_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: Sludge depth:_! ,�; �,e\ Distance from top of sludge to bottom of outlet tee or baffle: ivt Scum thickness: ,-:;�"_ Distance from top of scum to top of outlet tee or baffle: �r Distance from bottom of scum to bottom of outlet tee or baffle: 17 How were dimensions determined: Comments(on pumping recommendations inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of le age,etc.): CT GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete metal fiberglass__polvethylene_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.): Page 9 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-U%— Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not 1pcated explain why Type leaching pits, number:_ leaching chambers,number. leaching galleries, number: leaching trenches, number, length: / leaching fields,number, dimensions: overflow cesspool, number: inn ovativeialternative system Type/name of technology: 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 inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: (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.): Page 1 l of 11 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Zj : Owner: ?il 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 propertyiobservation 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 ow you established the high ground water elevati nti �el mss_ 1_,2 I Elzt eva eAL rZ L -- U l�