HomeMy WebLinkAbout0215 BAY LANE - Health w,1 5 Bay Lane
186-013 Centerville
No. 4210 1/3 ORA
Pendaflex
100/.kv
FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTENT INSPECTION FORM
Mark Polselli cell (508)280-7790
Property Address: C�l f sa L/1/ home 255-7709
�, ENVIO-TECH
O��•ncr: �0 i �
Date of Inspection:
SEPTIC INSPECTIONS
D. System Failure Criteria applicable to all systems: MASS-LICENSED
You must indicate"ces" or"no"to each of the following for all inspections:
Yes No
l -D.E.P. CERTIFIED
_ 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
_ —vatic 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 G"below invert or available volume is less than Y day flow
eq�ured pumping more than 4 times in tl►e last ear r OT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS.cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface hater supply or tributary to a surface
eater supply.
y portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 501ect of a private water supph•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 cater quality analysis. [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 trust be attached to this form.]
06e�-4i ', (Yes/No)The system fails.I have detennined that one or tttore of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system.owner should contact the Board of
Health to determine chat will be necessary to correct the failure. /
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