HomeMy WebLinkAboutTitle V Inspection Report - 40 DUNCAN DRIVE 1/26/1996 I
TIGER ENVIRONMENTAL
ENGINEERING
969 WASHINGTON STREET
BRAINTREE, MA 02184 - w ND�'�f --
HEALTH
617-849-0088 A� l :Al.Ta
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC lO
PART Aa
CERTIFICATION
Address of Property: 140?_ 6o X Gn a Z2!j-r" Address of Owner: (if different)
Town: f.t • kN Tn y ta--rz_- w► A X !a3 l
Owner's Name: Tp,�j)�jt/m V IZ E:D r' Dry Win, 41 .q
Date of Inspection: IN'Vecl° 0-60x' 1-2&—(v El voluntary Assessment
Name of Inspector: 1 z)eu (Not Reported)
Name
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 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:
_asses
Conditionally Passes
Needs Further Evaluation By The Local Approving Authority
Fai
Inspector's Signature: Al Date: 6e—�((„
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] SYSSEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in
310 CM R 15.303.
Any failure criteria not evaluated are indicated below.
B] 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,ortank 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.
1
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1
TIGER ENVIRONMENTAL
ENGINEERING 0 '90
- � q
969 WASHINGTON STREET °P` �� ��
BRAINTREE, MA 02184
617-849-0088 "
SUBSURFACE SEWAGE DISPOSAL`$YRTEM INSPEC 0 FORM
PART A
CERTIFICATION
Address of Property: (f ' r a .. �� Address of Owner: (if different)
Town: .,� , �?r. °rp� �_., ,�
Owner's Name: 24%) .Y Al T)42 cr,:D w 44"1") 0 ("I"'e z
Date of Inspection;: (r lZe d t pe e,,f r 0)e � El Voluntary Assessment
Name of Inspector: f d ) (Not Reported)
CERTIFICATION STATEMENT Name
l
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:
1
Passes
Conditionally Passes
Needs Further Evaluation By The Local Approving Authority
Fail
Inspector's Signature: : Date: ;
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 t
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. j
INSPECTION UMMARY:
Check A, B, C,or D
A S
] YSTEM PASSES:
mow° I have not found any information which indicates that the system violates any of the failure criteria as defined in
310 CM R 15303,
Any failure criteria not evaluated are indicated below,
B] 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,ortank 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.
1
TIGER ENVIRONMENTAL �
ENGINEERING
969 WASHINGTON STREET
BRAINTREE, M/��"02184
61 7-649-06�6
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A'
CERTIFICATION(continued)
Property Address: 1-i(A,' x a.I � �,� f���, f �� � '�� ) 0 r„µ...�
Owner: /-(” /2 .C 0
Date,of Inspection: " I-- le,
B] SYSTEM CONDITIONALLY PASSES(continued)
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
n
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 sr
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. �
2
J
TIGER ENVIRONMENTAL 1
ENGINEERING
969 WASHINGTON STREET
BRAINTREE, MA 02184
617®649®0006 J
4
I
r [
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A'
CERTIFICATION(continued)
Property Address: '" ;> " u!� ..a
Owner:
Date of Inspection: 1.1 f�� ��� I.�,. �.� (. .....
.
D] SYSTEM FAILS:
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
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 ioyert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year N T due to clogged or obstructed pipe(s). k
Number of times pumped
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 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 flow of system is 10,000 gpd or greater(large system) and the system is a significant threat to public
health and saf6ty'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 suface 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).
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.
The intent of 310 CM 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 the treatment process. The inspection is not designed to provide information to demonstrate that the system will J,
adequately serve the use to be placed upon it by the new owner.The inspection criteria are intended to allow for timely inspection
to avoid undue delay in the transfer of property.
IF
understand that this report doe not co su to �arr n y or guarantee of future operation.
�,C C .` f,
Client or Representative P,�,R rt, r � Date ' c �,eF
3
TIGER ENVIRONMENTAL
ENGINEERING
969 WASHINGTON STREET
BRAINTREE MA 02184
617-846-0688
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART
CHECKLIST
Property Address: 'Jaz,.. e�, PJ VQ 'U n V"V
Y, re 1,;?
Owner: 4"'1 R-"E 9
Date of Inspection:
Check if-the following have been done:
L," 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.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs'pf sewage back-up.
The system does not receive non-sanitary or in,dustrial waste flow.
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 baffles 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
information or approximated by non-intrusive methods.
U/ The facility owner(and(
occupants, if different from owner)were provided with information on the proper
maintenance of subsurface disposal system.
ppf
4
TIGER ENVIRONMENTAL
ENGINEERING
969 WASHINGTQN STREET
BRAINTREE, 9A 02184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION
Property Address: (6 e) X P"c)te 9 Ai ) ' tA,-
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: J"°� gallons
Number of be droorns:
Number of current residents:
Garbage grinder: (yes or no) too
Laundry connected to system: (yes or no)
Seasonal use: (yes or no)
Water meter readings, if available: �2 fe oltU.e
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of,establishment: i 14-
Desigrf'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 INFO" I' MATION'
PUMPING RECORDS and source of information: 0/0 k"AJ C-)c,k)
System pumped as part of inspection: (yes or no) y•,e
• If yes, volume pumped: /o cx)
.. gallons
Reason for pumping: A 0 (8, 11 6 L0,11 Cvz.,
TYPE,OF SYSTEM:
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (it yes, attach previous reco' s, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed if known) and source of information:
A <S OtJM&'Ov�
5
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f
A4 TIGER ENVIRONMENTAL
ENGINEERING
969 WASHINGTON STREET
BRAINTREE, MA02184
617-649-0086
i
SUBSURFACE,'SEWAGE DISPOSAL ,SYSTEM INSPECTION FORM
PART C'
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: I e-
g g (y o)
Sewage odors detected when arriving at the site: es or n
SEPTIC TANK: �
t
(locate on site plan)
Depth below grade:
Material of construction: p concrete metal FRP other(explain)
7 �s
Dimensions: r�
Sludge depth: lc� 'A
Distance from top of sludge to bottom of outlet tee or baffle: "
Scum thickness: 6
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baff le: p
Comments: 3
(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) qv,?,A, `tl. r �= w
i
GREASE TRAP:
(locate on site plane
3
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 of scum to bottom of outlet tee or baff le:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baff les,depth of liquid level in relation to outlet invert,
structural integrity, evidence of leakage, etc.)
k
i
a=
6
.n f
TIGER ENVIRONMENTAL
I
ENGINEERING
969 WASHINGTON STREET
BRAINTREE, MA 02184
617-849-0688
SUBSURFACE SEWAGE DISPOSAL",SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ()° „r
Owner:
Date of Inspection: ) " /
TIGHT OR HOLDING TANK:,, 9 , ,
P
(locate on site plan)
i
Depth below grade:
Material of construction: concrete metal FRP other(explain)
Dimensions;
Capacity: gallons
Design flow: gallons/day '
Alarm level:
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)
,
DISTRIBUTION BOX: (4 e .. 6
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: (note if level6 nd ldistribution is equal evidence of solids carry over, evidence of leakage into orbut of box, etc.)
r g
f t"a°"d d°-3 ro 0 @3 l ey m a �"N � k anti 7p `%o 4 f P,5 p
PUMP CHAMBER: �
(locate on site plan)
Pumps in working order: (yes or no)
Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.)
1i
7
I
TIGER ENVIRONMENTAL
ENGINEERING
i
969 WASH INGTO STREET
BRAINTREE, M02184
617-849-0088
S'UBS'URFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address
Owner: �*' '.��,.� . � � �,
..w .o
Date of Inspection: 4 14' ;a q ,
SOIL ABSORPTION SYSTEM(SAS): '
(locate on site plan, if ssible;^excavation not required, but,ma be a roximated b non-intrpsive methods
p p9 q � Y, gip' Y )
If not determined to be present, explain:
Type:
Leaching pits, number: .l.
Leaching chambers, number:
Leaching galleries, number: y
Leaching trenches, number, length: y
Leaching fields, number, dimensions:
Overflow cesspool, number:
H
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS: 0
(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 Indication of ground tote
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: k
(locate on site plan) r
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil;signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
8
TIGER ENVIRONMENTAL
ENGINEERING
969 WASHINGTON STREET
BRAINTREE, MA'�02184 ���
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C �
SYSTEM INFORMATI"N(continued)1
Property Address: C>,)-. &o x(��ovzv 15�-r ,, vN
Owner: ' K f Aj 1)1;7 e. 0
Date of Inspection: .° ' - 1 j � q 6,
SKETCH OF SEWAGE DISPOSAL SYSTEM:
6 Include ties to at least two permanent references, landmarks or benchmarks
` Locate all wells within 16o,
µ
M�
n�
a e a a s • a . Y *W,;�W 9 . ♦ �Mr Y V ♦ �. l�1�"""�p� a ♦ . ♦ a a a f • a
. . . . . . . . . . « �, ,� « „q "� dq . . . . . . . . . .
. . . . . . . . . . . . �, � . . . . . . . . .
. . . . . . . .
( 5 b K
. . . . . . . . i, . . . . . . . . . . . . . . . .
. . . . . . . .- . . . . . . . . . . . . I . . . . . . . .
,.. . . . . . . . . . . . . . . . . .
. . . . . . . `.....� . . . . . .
` DEPTH TO GROUNDWATER:
Depth to groundwater: feet :>
Method of determination or approximation:
Y f') "lye,66 uo 6'FKJT 0 p N j
r �
a�
r
9
TIGER HOME -INSPECTION ,"
r
HIDE THE EYE OF T/ TIGER
rr. 5 969 WASHINGTON STREET 7
BRAINTREE, MA 02184
617-849-0088
�r
t �r
SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION FORX
TITLE 5 INSPECTION FORM
Address of property L ' ,a
Owner' s name ,
Date of inspection
PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Hoard of
Health.
w01/,"' y p pumped for at least two weeks
None of the system components have been
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. "�„w� � �
The facility or dwelling was inspected for signs of sewage back-up. t
L,, '0 The site was inspected for signs of breakout.
All system components, excluding the SAS, 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.
The size and location of the SAS on the site has been determined based :
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
4 , HIRE THE EYE OF THE TIGER
969 WASHINGTON STREET
BRAINTREE, MA 02184
617-849-0088 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM,INFORMATION
FLAW CONDITIONS
If residential
number of bedrooms
number of current residents
- �,�� garbag6 grinder, yds br 'no:laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
Last date of occupancy
` GENERAL INFORMATION
Pumping records and source of information:
�I Lip L a,� but a L-)
if yes, volume pumped yes or no
System pumped as art of inspection
r8.,,...
Reason for umping
4
Y
Typ�'Illof system
M 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:
a e, r "L'-) ' 16 I� „a� L o)LAN <- ,
-LL) Sewage odors detected when arriving at the site, yes or no
V;'" „%�� �,y ,,i ri it�/✓i, ;,/. „, ,rii✓ol�'!!1%%,i/i�%i✓r, , o°,,,
TIGER ,HOME INSPECTION, IN .@ °
HIRE THE EYE OF THE TIGER
r 969 WASHINGTON STREET
r BRAINTREE, MA 02184 9
�. 617-849-0088
r.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART E
SYSTEM INFORMATION continu
SEPTIC TANK:—L", a
(locate on site plan) V
k fl
depth below grade• /
material of construction: concrete metal FRP other(explain)
dimensions: u �
gqd Pa d .
slud de t
1,. 5 � distance from top of sludge to bottom of outlet tee or baffle
617— scum thickness
` t 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, recommendations for repairs, etc. )
� �� �.L. Lp u�t t Ln"2 �.- .._1 L. 4�,�.�• '� .r ����.w..� fto ii,wA J,.e• ¢ i(. 4
DISTRIBUTION BOX:
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
I
PUMP CHAMBER
(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. )
I„( l; / [iC / ;;r r,v
TIGER HOME INSPECTION IN .`�'
HIRE THE EYE OF THE TIGER
r
989 WASHINGTON STREET 10
-, BRAINTREE, MA 02184
817-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : P^',„w,.
(locate on site plan, if possible; excavation not required, but may be
approxim ed by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pi,t p and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
"w � �l�” 1"0 �\% N f p. k w„A J1 ' P,.01 S ��� 8 A
CESSPOOLS (locate on site plan) :
number and configuration
depth-top of liquid to inlet invert Aj
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
r
r
Comments: ,
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. )
j;; r
� aNM
TIGER INSPECTION
E
HIRE THE EYE OF THE TIGER
969 WASHINGTON STREET
BRAINTREE, MA 02184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART E
SYSTEM INFORMATION continued
SKETCH OF BEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
y
.,, ,.. ,. .. ._. a
11
gym'"
f
m
-oe
DEPTH TO GROUNDWATER
16'00 depth to groundwater
.mm r u.�. ..
method of determination or approximation;
NI TIGER, HOME INSPECTION INCoa
HIRE THE EYE OF THE TIGER
969 WASHINGTON STREET 12
BRAINTREE, MA 02184
617-849-0088
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined` (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
_LL2( _ Backup of sewage into facility?
,. Discharge or ponding of effluent to the surface of the ground or
surface waters?
t
twatic liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <611 below invert or available volume< 1/2 day
flow?
r
E
30 Required pumping 4 times or more in the last year?
number of times pumped
1!
-LID Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or, privy.
below the high groundwater elevation?
within 50 feet of a surface water?
�1t within 100 feet of a surface water supply or tributary to a surface
water supply? . ,.
within a Zone I of a public well?
w" within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
l
within 50 feet of a private water supply well?
k,
di
�l
WY less than 100 feet but greater than 50 feet from a private water
t supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysi
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
I
TIGER HOME M INSPECTION I ,.0
.,, HIRE THE EYE OF THE TIGER
969 WASHINGTON STREET
BRAINTREE, MA 02184
617-849-0088
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13
SUBSURFACE SEWAGE DISPOSAL SYSTEX' XNSPECTION FORK
PART D
CERTIFICATION
, 4 J)¢
Name of Insp�eotor
Company Name '.:,
Company Address 1,16a),l (A). !� 4 rW o V,� ( 6 .,r a" A
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
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.
Check one
I have not found any information which indicates that the system fails
to adequately protect public health or the environmen 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 health and
n p p this
the environment as defined i 37.0.. C� 7,�. 303 ., 4 TheF�bag7.h� fore .s
determ nat"ign" is �rovi�ed �i nrn th`e"I FAILURE 'CRITERIA section of this
form.
Inspector's Signature 0� ,::o:« b ' "
Date
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
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HIRE THE EYE OF THE TIGER
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