HomeMy WebLinkAbout1378 BUMPS RIVER ROAD - Health 1378 Bumps. River Road, Centerv'
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Commonwealth of Massachusetts
Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1378 Bumps River Road
Property Address
Ann Collins
Owner Owner's Name
information is Centerville MA 02632 08/02/08
required for State Zip Code Date of Inspection
every page. Cityrrown
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key /T ] ¢�
to move your Michael Kellett �Q--'°�Q 0 3
cursor-do not Name of Inspector
use the return
key. Aardvark Environmental Inspections
Company Name
m P.O. Box 896
Company Address
East Dennis MA 02641
revs Cityfrown State Zip Code
508-385-7608 S13742
Telephone Number License Number
B. Certification
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 hjhe 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�-Sectio r.j5.340 of
Title 5(310 CHAR 15.000).The system: GO
-�
® Passes ❑ Conditionally Passes ❑ F�tfl
70
ElNeeds Further Evaluation by the Local Approving Authority = `f'
Ca
N
00 € 7
08/04/08 -
Inspector's Signature Date
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.
""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.
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Commonwealth of Massachusetts
I WTitle 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
� l 1378 Bumps River Road
Property Address
Ann Collins
Owner Owner's Name
information is Centerville MA 02632 08/02/08 _
required for every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cons.)
Inspection Summary: Check A,B,C,D or E/always complete ail of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
S) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" 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 (Y, N, 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
f
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1378 Bumps River Road
Property Address
Ann Collins
Owner Owner's Name
information is Centerville MA 02632 08/02/08
required for —
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ 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):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
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(1)(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 1 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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1378 Bumps River Road
Property Address
Ann Collins
Owner Owner's Name
information is Centerville MA 02632 _08/02/08
required for state Zip Code Date of Inspection
every page. Cityrrown
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 indicates absent 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:
D) System Failure Criteria Applicable to All Systems:
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
❑ ® 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 '/2 day flow
El ® Required pumping more than 4 times in the last year NOT 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.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�y 1378 Bumps River Road
Property Address
Ann Collins —
Owner Owner's Name
information is required for Centerville MA 02632 08/02/08
-
every page. Citylrown State Zip Code Late of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems(cont.):
Yes No
❑ ® 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. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more 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 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.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
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 mapped Zone II 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 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Commonwealth of Massachusetts
Na Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1378 Bumps River Road -
Property Address
Ann Collins
Owner Owner's Name
information is Centerville MA 02632 08/02/08
required for State Zip Code Date of Inspection
every page. Cityrrown
C. Checklist
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 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?
® El available
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(SAS)on the site has
been determined based on:
® ❑ 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) [310 CMR 15.302(5)]
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1378 Bumps River Road
Property Address
Ann Collins
Owner Owner's Name
information is Centerville MA 02632 08/02/08
required for every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual):
4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
440
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump?
❑ Yes ® No
06/08
Last date of occupancy: Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forme Not for Voluntary Assessments
1378 Bumps River Road
Property Address
Ann Collins
Owner Owner's Name
information is Centerville _MA 02632 08/02/08
required for —
every page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of 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)
❑ 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:
12/09/02 per BOH —
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'r 1378 Bumps River Road
Property Address
Ann Collins
Owner Owner's Name
information is Centerville MA 02632 08/02/08
required for City/Town State Zip Code Date of Inspection
every page.
D. System Information (cont.)
Building Sewer(locate on site plan):
2.0
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
1.5
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------
1500 gallons
Dimensions:
4"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
29"
4"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
measured
How were dimensions determined?
CommonweaM of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1378 Bumps River Road
Property Address
Ann Collins
Owner Owner's Name
information is required for Centerville MA 02632 08/02/08
every page. Cityrrown State Zip Code Date of inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.
Grease Trap(locate on site plan):
Depth below grade: feet
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: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal 0 fiberglass ® polyethylene ❑other(explain):
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'Y 1378 Bumps River Road
Property Address
Ann Collins
Owner Owner's dame
information is Centerville MA 02632 08/02/08
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
even
Depth of liquid level above outlet invert
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.):
The box was level and tight with no sign of car over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1378 Bumps River Road
Property Address
Ann Collins
Owner Owner's(Name
information is required for Centerville MA 02632 08/02/08
every page. CitylTown State Zip Code Date of Inspection
D. System Information (coot.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1
❑ leaching chambers number: —
❑ 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.):
This system has two 6'x6' precast pits surrounded by two feet of stone. There was 30"of liquid in the
first pit. the second pit was dry with a stain line at 18".
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 1378 Bumps River Road
Property Address
Ann Collins
Owner Owner's Name
information is Centerville MA 02632 08/02/08
required for every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
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 layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ 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.):
f
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y< 1378 Sumps River Road
Property Address
Ann Collins
Owner Owner's Name
information is Centerville MA 02632 08/02/08
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
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.
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36
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1378 Bumps River Road
Property Address
Ann Collins
Owner Owner's Name
information is Centerville MA 02632 08/02/08
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
20.0
Estimated depth to ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ 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 how you established the high ground water elevation:
USGS maps show an elevation of over 20 feet.
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental 'Protect'ottn
Vml�,F.Weldy.. �`t `� � `��. Trudy Coe f
` S,2:xry
Argeo Paul Celluccl ,,, David B.Sttuhs
u.Governor `s' ComtNrbMr <s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM /�O /' C_
r -3 ¢36C j�S l Ue-�' `� PART A _ y.
C, e i2�el"Ul CERTIFICATION
Property Address: Address of Owner.
Date of Inspection: 1-/J~'0/ (If different)
Name of Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-8 7 7 6
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
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 sew disposal systems. The system:
_ Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
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 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) SYSt1ve
PASSES:
not found any information which indicates that the system,violates any of the failure criteria as defined in 310 CMR 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 ,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,.or tank 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.
(revis 11/03/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556.1049 • Telephone(617)292-SM
Printed on Recycled Paper
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r-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
Property Address: 3 f� GG[h'i/J S J 1!ve 'r' /�C� C'C��'Il'C/!l�-t--
Owner. A O h./`t 's/I e e
Date of Inspection:
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($)
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
obstruction is removed
distribution boa 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 replaced
obstruction is removed
C) THER 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.
SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to 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 I 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.
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 ooliform 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.
S) OTHER
(revised 11/03/95) Z
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM ATION FORM
PART A
CERTIFICATION(continued)
Pro /3 7 � ��.h�� /�rv� � �� C'eal��U</lam.
Owner. Addeess: 9 a � �1 e A.
Date of Inspection: 7
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
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 invert or available volume is less than M day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
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 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 water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
eoliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E]LAR E SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
and safety 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 surface 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 r or operator of any such system shall bring the system and facility into Bill compliance with the groundwater treatment program
meats of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: , ��/'7r-
(c
Owner. /�
Date of Inspection:
Check if the following have been done:
_0 mping 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.
(d 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 of sewage back-up.
"The system does not receive non-sanitary or industrial waste flow
�'The site was inspected for signs of breakout.
�ll m components,excluding the Soil Absorption System, have been located on the site.
�ptic tank manholes were uncovered, opened, and the interior of the
septic tank was Pe p inspected for condition of baffles or
teed,material of construction, dimensions,depth of liquid,depth of sludge, depth of scum.
t_The size and location of the Soil Absorption System on the site has been determined based on existing information or
7 app ted by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper
P p pe maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: I
/3 7 cc�vl,�s RI -L '
Owner. J�
Date of Inspection: ? r7 _ r, jr
FLOW CONDITIONS
RESIDENTIAL
Design flow:L c� / b gallon
Number of bedrooms:-/
Number of current residents: ti/4
Garbage grinder(yes or no):-&IA _
Laundry connected to system(yea or no):Y_
Seasonal use(yes or no):/L-0
Water meter readings,if available: ���� '74
Last date of occupancy: ed
COM ERCIAL INDUSTRIAL
Type of blishment:
Design flo : gallone/day
Graeae tra present: (yes or no)_
Industrial rite Holding Tank present: (yes or no)_
Non-saai waste discharged to the Title 5 system: (yea or no)_
Water mete readings,if available:
Last date occupancy:
OTHER: Describe)
Last date f occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
A
System pumped's of inspection: (yea or no)11i v
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF STEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yea,attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Sewage odors detected when arriving at the site: (yes or no) o
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM IINFORMATION(continued)
Property Address: f 3 � O f �.1 l°�/✓e l' / o ce d?71'/C/I
Owner. A O &"-7'
Date of Inspeotion: `J L
SEPTIC TANK
(locate on site plan)
Depth below grade:/
Material of construction: 14ncrete_metal_FRP_other(explain)
L L �
Dimensions:
Sludge depth:_ ,
Distance from top of sludge to bottom of outlet tee or baffle:_
Scum thickness: l, • C e
Distance from top of scum to top of outlet tee or baffle: O 'I )
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 m' relation to outlet invert,structural integrity,
evidence of leakage,etc.)
G TRAP:_
(locate on ite plan)
Depth below e:
Material of natruction:_concrete_metal_FRP_other(e:plain)
Dimensions:
Scum
Distance top of scum to top of outlet tee or baffle:
Distance m bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommenda ' n for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of ,etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
7 SYSTEM INFORMATION(continued)
Properly Address: �` ' /c�cG .S 1 l l!!C/'
Owner.
Date of Inspection: ? q !9
TIG7 OR HOLDING TANK_
(locate site plan)
Depth grade:
Material construction:
_concrete_metal_FRP_other(explam)
Dimensio
Capacity: ons
Design flow: gallons/day
Alarm/Level:
j//evel:
Co // ts:
(conditio of inlet tee,condition of alarm and float switches,etc.)
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,etc.) LPL R. t
a
PUMP C BER:_
(locate on site plan)
Pumps is wo order:(yes or no) .
Commsats
(note oo Won of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address; :/3 ! ?�
Owner. !�D ket--/- (5� e
Date of Inspection: _/of_C1 js
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
leaching pits,number:
leaching chambers,number:_
leaching galleries,number:
leaching trenches, number,length:
leaching fields,number,dimensions:
over1low cesspool,number:
Comments: (note condition il,e' of hydraulic failure, level of ponding,condition of vegetation,etc.)
/ d 1L L" G Lam. �i Q l` �Jb TO 0e, l=
C LS:_
(locate on ite plan)
Number an configuration:
Depth-top o liquid to inlet invert:
Depth of so' layer.
Depth of layer:
Dimensions f cesspool:
Materials o construction:
Indication •f groundwater:
ow(cesspool must be pumped as part of inspection)
Comments: condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
PRIVY:
(locate on to plan)
Materials f construction: Dimensions:
Depth of lido
Comore (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etcJ
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) /
Property Address:
Owner.
Date of Inspection: `t 1 g..fit (•
SIi3;MH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
06
%i
v`
1 G o-o
A 110 1..dL
to
�v
v
DEPTH TO GROUNDWATER
Depth to groundwater::' feet method of determination or approximation: 6 Z� "jam 1 Ly is 6/
i S
(revised 11/03/95) 9
� )
Fx$.... .. ..
4( / THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Qw� OF. f�.�/ !T.A.4443
...........................................
App iration for Bispniial Works Tnnitrurtiun Prrutit
Application is hereby made for a Permit to C ruct-f' air ( ) an Individual Sewage Disposal
System at: _ ? O !
....... _..... ..... .�. n&w6d.)
`_ - ................•...--
•--.. .. ..... ....... .•.. -- -- --• -'-- -
Lo ti -Addre oL - �No.
w r Address
Installer Address
UType of Building Size Lot....q a 1......Sq. feet
a - Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures --------------------------------------- -
W Design Flow......................5, �_...........-__gallons per person per day. Total daily flow.........................3.3.0......gallons.
WSeptic Tank—Liquid capacity.kCV..gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.......I------------ Diameter.._......__19..... Depth below inlet........ Total leaching area.....&Q..sq. ft.
Z Other Distribution box ( V�' Dosing tank
~' Percolation Test Results Performed by..... ) 0�.......__ '._..n! ..................... Date........................................
aTest Pit No. I......" ....minutes per inch Depth of Test Pit..........! Depth to ground water--------
f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
•-------•----------------------------------------------------------------•------------......---................---•-----...------•-••--.................-----
.0 Description of Soil-------------------------------•-----•------------------•------'-...--•-•--•-------------
-+- /� .-- .................... .a ...........•..........................•..................._......_
w -•--•--•-•-------------------•--•-••-•--•--•-----•-••-•••-----------------------•---•-•-----------••----••-•-----------------------•---••----•-------•-------------•-••-------•----•----•---------------
VNature of Repairs or Alterations—Answer when applicable._..............................................................................................
----------------------------•-------------•-----'---------------------------------------•----------------------------------------------------•-....•-••--••••-••--•-•---••••-•-••-••-•-•'-'-...._..'-•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compli ce ha been issued by the board of health.
Signed -- --- ---- ------------------------------------- ----/ % `
Application Approved By ----------------CJ «..`'.--` ,,,
--------------------------------------------------------
------ - -' ----'-ice- -.....---
Application Disapproved for the following reasons- ------------------------------------------------------------------------
----------------------------------------
Dace
PermitNo. ---- 7..`� ------_---------------- Issued ----------..............................................----------
hhh, � , - IN a,
Dace �.
No.....`? -7Y(e F�s.. ,j
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................�.' �L`u'�`� OF.........x..: -
L._...................... ....................------.............................................
Appliration for Disposal darks Tonstrnrtuan rrntit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at
Lo do Address' y o t No.
•-"`��' Address
........................................ --.............ZM&
� Installer '� Address
Q Type of Building Size Lot......k`,'________......Sq. feet
Dwelling—No. of Bedrooms................_._.___•____._._.._.__.___.Expansion Attic ( ) Garbage Grinder ( )
pa., Other—Type of Building ..................•......... No, of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures:................................. ......W Design Flow..................... ..__..._...____gallons per person per day. Total daily flow............................13f2......gallons.
WSeptic Tank—Liquid capacity. .gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------1------------ iameter-__---__-___�..... Depth below inlet............... Total leaching area...... �?._sq. ft.
Z Other Distribution box ( " Dosing tank ( )
-� -, c -�c1 Y<
'" Percolation Test Results Performed b ' ..............................." .°! ..................... Date.............................'..._..
Test Pit No. I------- '___minutes per inch Depth of .Test Pit.......... ___ Depth to ground water---_--_----_•--____.
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •••••••--••-----------------•••-••••••--......••-•..•••----•••-.....•••--•--•---...-----•---------.....-•••-•------•••-------••-•....•---........•----•....•.
0 Description of Soil.........................................................................................
f
-6
W •-••••••••------------------------------•-----•-•••-•-••••••---------------•-------------••••-••-••----••------•••-'-•---------•--••---•-------•---•••-••••---•-••----••--•-........................•••-
UNature of Repairs or Alterations—Answer when applicable------------------------------------------......................................................
•---------•---------------------------------------------------------•---•--------------...----------------•----••-•-•-••-••-••••----•-•-------••---•••••••---•••-•--•-••--•••••••••--•••--------------•.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance as-been issued by the board of health.
Signed .. ..Signed ....... `... ..._... i " #"+�
Date
Application Approved By .................. *�^--- t -�--� .....-----
Application Disapproved for the following reasons: .......................................... . ....................................... ......................................
...... ................................................... . --. --...-- --- -- -- ... .. ---- --- ........................... ......................------..........
Date
PermitNo. ......(�.. .' 1 �-----------------------_ Issued .-- ---...............--a-.....................................
Da[e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITer#ifioax#e of (fomylianre
THIS IS TO CER IFY hat the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ---------------------- .<-- ... ^
G-� cEe. �(/- Install- 1`
--- -------
Installer
at ----------------- .. -- . --------� � � y�-i --- � .... --------------------
has been installed in accordance with the provisions orTITLE 5 of The Sltate Environmental Code as described in
the application for Disposal Works Construction Permit No. ------------------------------------------------ dated ...-....-..---......----------..----.-----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. �._ :. �..'. 1—........................................... Inspector ...... ...............................................................
/ O THE COMMONWEALTH OF MASSACHUSETTS
4 BOARD OF HEALTH
............t.. ? 4Jt OF............. .......:....: j.:, Sri:.+ G
O.._ .__�._.._. ... FEE.._.. ... '.es........
Bitipooal Works 01. ons#r ion ramit
Permission is hereby granted..........
to Construct ( ) or Re air ( ) an Indivi as Sevc a e Disposal ystem
at No.................. L�.0...I..........
•. ....1.0..............................
Street
as shown on the application for Disposal Works Construction Perptilt N . . __. .___ __ ated..........................................
-••-•----- .---•-• - --------------- --- •• •• ------.....--••-•--.
f� Board of Health
DATE........
rC/
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS -
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LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) -Z— Leovclh (size) F, 000 �g(loins
NO. OF BEDROOMS c' _PRIVATE WELL O :PU:B:Ll.�CWA�TE�
BUILDER OR OWNER kQ d i -77 I `MW
DATE PERMIT ISSUED: Z ! 9
DATE COMPLIANCE ISSUED_ ��-
VARIANCE GRANTED: Yes No
Z.7`
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