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COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS '
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 14 GORHAM LANE CENTERVILLE, MA 02632
Name of Owner JOHN SWEENEY
Address of Owner: n/a
Date of Inspection: 7126/00
Name of Inspector: JOHN GRACE
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636
Telephone Number: 508-664-6813 FAX 508-664-7270
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:
X Passes
_ Conditionally Passes
_ Needs Further Evaluati n By the Local Approving Authority
Fails
Inspector's Signature: Date:7/26100
The System Inspector shall sie
it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If 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.
NOTES AND COMMENTS
"The inspection is based on criteria defined In Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND EVERY ONE TO TWO YEARS.THE LEACH PIT
SHOWS SIGNS OF HAVING 6"OF LEACHING LEFT.AT THE TIME OF THE INSPECTION THE PIT WAS EMPTY.
revised 9/2198 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 14 GORHAM LANE CENTERVILLE, MA 02632
Name of Owner JOHN SWEENEY
Date of Inspection: 7/25100
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
B. 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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nia The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance
attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,
whether or not metal,is 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 complying septic tank as approved by the Board of Health.
n1a 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
_obstruction is removed
_distribution box is levelled or replaced
B& 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
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 14 GORHAM LANE CENTERVILLE, MA 02632
Name of Owner JOHN SWEENEY
Date of Inspection: 7/25/00
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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS 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,Method used to determine distance nla(approximation not valid).
3) OTHER
n/a
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 14 GORHAM LANE CENTERVILLE, MA 02632
Name of Owner JOHN SWEENEY
Date of Inspection: 7/26100
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described 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.
Yes No
- X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
- X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level In the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
- X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
- X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped.Q.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
- X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
- X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
- X 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:
You must indicate either"Yes"or"No"to each of the following:
---- — The following criteria apply to large systems in addition to the criteria above:—
The 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 health and
safety and the environment because one or more of the following conditions exist:
Yes No
- X the system is within 400 feet of a surface drinking water supply
- X the system is within 200 feet of a tributary to a surface drinking water supply
- X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 14 GORHAM LANE CENTERVILLE, MA 02632
Name of Owner: JOHN SWEENEY
Date of Inspection: 7/25/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X _ 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.
X As built plans have been obtained and examined.Note if they are not available with N/A.
X - The facility or dwelling was inspected for signs of sewage back-up.
X - The system does not receive non-sanitary or industrial waste flow.
X - The site was inspected for signs of breakout.
X - All system components,excluding the Soil Absorption System,have been located on the site.
X - 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:
X _ Existing information,For example,Plan at B4O,H,
X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)]
X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
revised 9/2/98 Page 5 of 11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 14 GORHAM LANE CENTERVILLE, MA 02632
Name of Owner JOHN SWEENEY
Date of Inspection: 7/26/00
FLOW CONDITIONS
RESIDENTIAL;
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):
Total DESIGN flow: 330 gpd
Number of current residents:0
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: 6115100
COM MERCIALANDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO -- ---
If yes,volume pumped n/a gallons
Reason for pumping:n/a
TYPE OF SYSTEM
X 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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1975
`-'-- Sewage odors detected when arriving at the site:(yes or no) NO -
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 GORHAM LANE CENTERVILLE, MA 02632
Name of Owner JOHN SWEENEY
Date of Inspection: 7/25100
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 18"
Material of construction: _ cast iron _ 40 Pvc X other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
n/a
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 12"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1000G L 8'6"H 6'7"W 4'10""
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: 4"
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: n/a
How dimensions were determined: MEASURED
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,
etc.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND EVERY ONE YO TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL-LIFE. - ---- -- --_ - - "_--
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
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,
etc.)
n/a
revised 9/2/98 Page 7 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 GORHAM LANE CENTERVILLE, MA 02632
Name of Owner JOHN SWEENEY
Date of Inspection: 7/25/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:N/A Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n/a
- -PUMP CHAMBER:_-
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 GORHAM LANE CENTERVILLE, MA 02632
Name of Owner JOHN SWEENEY
Date of Inspection: 7/25/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nla
Type:
leaching pits,number:(1)1000 GAL 6'X 6
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a,
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE
INSPECTION.THE LIQUID LEVEL IN THE PIT APPEARS TO HAVE BEEN 6"TO PIPE
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nla
revised 912198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 GORHAM LANE CENTERVILLE, MA 02632
Name of Owner JOHN SWEENEY
Date of Inspection: 7/25/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
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Ac '341y
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ec
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 GORHAM LANE CENTERVILLE, MA 02632
Name of Owner JOHN SWEENEY
Date of Inspection: 7126/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a-
Observation Wells checked: NO
Groundwater depth: Shallow_'Moderate_-Deep_
SITE EXAM _ Slope
Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
revised 9l2/98 Page 11 of 11
G 1,P--/A TOWN OF BARNSTABLE
LOCATION m C'�� SEWAGE #
VILLAGE ASSESSOR'S MAP & LO
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS t
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
4
r m •n
O AA
/Ac 3 y
4
LOC T10N ' -_ 5E\ ,E PERMIT MO.
VILLAGE '. - - - - - - 1
71
1 TALL Nl ADDRESS
9
BUILDERS tJ" h ADDRF-S5
DNTE PERKA T 15SUED �
-- D ATE' COMPLI &&ICE ISSUED : r.
1-7
r
f,�,,Y�TOWN OF BARNSTABLE
LOCATION I Ll �r r Nh (-�L SEWAGE #
l VII,LAGE 4^X--bLA U I I (e, ASSESSOR'S MAP & LOT` q-3`10 I
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I o OO
y�LEACHING FACILITY: (type). UP. C-Oul-"6 (size) (tea-Q'.
I NO.OF BEDROOMS 3
BUILDER OR� MQsd l
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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COMMONWEALTH OF MASSACHUSETTS Z S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
a R
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�D '-'ARCEI.,
LOT 1 7 2004
t}F BA;ZNSTABLE
TITLE S 1 �_ i H DEP T.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 14 Gorham Lane
Centerville
Owner's Name: Christine Masotta
Owner's Address:
Date of Inspection:
Name of Inspector.(please print) Wi 1 1 i am _ .Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P 0 Box 1 089
Centerville, MA
Telephone Number: (508) 775-8776
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 Segtion 15.340 of Title 5(310 CMR 15.000). The system:
Passes
�a
Conditionally Passes '
Needs Further Evaluation by the Local Approving Authority =, ¢'
Fails
C c. c n
Inspector's Signature: Date. <) c, =:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Bo d of Hei-Aver
DEP)within 30 days of completing this inspection.If the system is a shared system or has a desi flow of�10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate region 1 office`of the rn
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approxing
authority.
Notes and Comments
""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 tinder the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page i
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 14 Gorham Lane
Centerville
Owner: tine Masotta
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syste asses:
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:
B. System nditionally Passes:
One or ore system components as described in the"Conditional Pass"section need to be replaced or
repaired.The sy tem,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or of determined(Y,N,ND)in the for the following statements.if"not determined"please
explain.
The septic is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits su stantial infiltration or exfiltration or tank failure is imminent_System will pass inspection if the
existing tank is repla d with a complying septic tank as approved by the Board of Health.
•A metal septic tank ill pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the is less than 20 years old is available.
ND explain:
Observation o sewage backup or break out or high static water level in the distribution box due to-broken or _
obstructed pipes)or, ue to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of ealth):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The syst m required pumping more than 4 times a year due to broken or obstrmled pipe(s).The system will
pass inspectio tf(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is ntaovod
�F
ND explain:
Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 14 Gorham Lane
Centerville
Owner: Christine Masotta
Date of Inspection: . —G
G Further valuation is Required by the Board of Health:
Conditio sexist which require further evaluation by the Board of Health in order to determine if the system
is failing to prote t public health,safety or the environment.
1. System will ass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is no functioning in a manner which will protect public health,safety and the environment:
_ Cesspool r privy is within 50 feet of a surface water
— Cesspool o privy is within 50 feet of a bordering vegetated wetland or a salt.marsh
2. System will fail u less the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning n a manner that protects the public health,safety and environment:
The system h aseptic tank and soil absorption system(SAS)and the SAS is within.100 feet of a
surface_ water supp or tributary to a surface water supply.
_ The system h s a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system s a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system as aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more frond a
private water su ply well** Method used to determine distance
"This syste passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and olatile organic compounds indicates that the well is free from pollution from that facility and -
the presen of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure cr' eria are triggered.A copy of the analysis must be attached to this form.
3. Other-
3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 14 Gorham Lane
Centerville
Owner: Christine Masotta
Date of Inspection:D. 'Is
Failure Criteria applicable to all systems:
You must dicate"yes.*or"no"to each of the following for all inspections:
Yes No
ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
D scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
cl gged SAS or cesspool
S tic liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
cc pool
Liq id depth in cesspool is less than 6"below invert or.available volume is less than 14 day flow
Re ired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of t mes pumped
An portion of the SAS,cesspool or privy is below high ground water elevation.
An portion of cesspool or privy is within I00,feet of a surface water supply or tributary to a surface
wa r supply.
An portion of a cesspool or privy is within a Zone I of a.public well.
_ An portion of a cesspool or privy is within 50 feet of a private water supply well.
An portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
su ply well with no acceptable water quality analysis.(This system passes if the well water analysis,
p rformed at a DEP certified laboratory.,(or coliform bacteria and volatile organic compounds
i dicates that the well is free.from pollution from that facility and the presence of ammonia
ttrogeo and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
re triggered.A copy of the analysis must be attached to this form.] _
(Y s/No)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. L rge Systems:To b considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd
Y must indicate either"yes"or"no"to each of the following:
to following criteria apply to large systems in addition to the criteria above)
y 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 11 of a public water supply well
if yo 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 of operator of arry large system considered a
signi cant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.30 .The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 14 Gorham Lane
Centerville
Owner: Christine Masotta
Date of Inspection: Z —G —G
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?
5_ 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?,.
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
, S 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:
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.
rs unacceptable)[310 CMR 15.302(3)(b)j
5
Page 6 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 14 Gorham Lane
en ervi e
Owner: Christ—i—n-e--Ka—sotta
Date of Inspection: &Phg'G
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):4* Number of bedrooms(actual): =�
flow based on 310 C)�5.203 for example: 110 d x#of bedrooms):
1�
DESIGN ( p gpd )
Number of current residents:
Does residence have a garbage ' der(yes or no): i�O
Is laundry on a separate sewage system(yes or no)-.,&�[if yes separate inspection required)
Laundry system inspected Filable
r no): C�
Seasonal use:(yes or no):
Water meter readings,if a (last 2 years usage(gpd)): 2003 - 22,000
Sump pump(yes or no): 2UU2 - , 0 0
Last date of occupancy:
COMMERCIA USTTRIAL
Type of establis ent:
Design flow(bas d on 310 CMR 15.203): gpd
Basis of design ow(seats/persons/sgft,etc.):
Grease trap pre ent(yes or no):_
Industrial was a holding tank present(yes or no):_
Non-sanitary aste discharged to the Title 5 system(yes or no):
Water meter eadings,if available:
Last date of ccupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped:__gallons--How was quantity pumped determined?
Reason for pumping:
TYP F SYSTEM
eptic 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/Altemativc 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:
Were sewage odors detected when arriving at the site(yes or no):�d
6
l'agc 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 14 Gorham Lane
Centerville
Owner: Christine masotta
Dvlc of InIpcctlon:
BUILDING SEWS (locate on site plan)
Depth below grade:
Materials of co/nsiction:_cast iron _40 PVC_other(explau,):
Distance from pr' ate water supply well or suction lone:
Comments(un ondition of juu,ts,venting,evidence of leakage,etc.):
SEPTIC TANK: _(locate on site plan)
g ,►
Depth below grade:
Material of construction:Je!!::c6oncrete metal fiberglass�ol}ethylenc
_othcr(explain) — .
If tank is metal list age:_ Is age confinned•by a Certificate of Compliance(yes or no):—(attach a copy of
certificate) + e ,
Dimensions:1 c-,
Sludge depth: e j—
Distance Gom top of sludge to button of outlet Ice or bafllc:-�—
Scum Ihickness:-�_
+ r
Distance from top of sewn to top of outlet Ice or baffle:
Distance [join bonont of scum to bot�t rypf outlet tee or baflle: /if
Ilow were dimensions determined: U rC- Tia4t, A
Comments(on pumping recommendations, inlet and outlet tee or baflle condition,structural integrity,liquid Icvcls
as related to outlet invert,evidence of Icakage,etc.): Ile 6 ,,
GREASE TRAP:_(locate n site plan) -
Depth below grade:_
Material of construction: concrete metal fiberglass Polyethylene—other
(explain): —
Dimensions:
Scull thickness:
Distance Gom top of s um to top of outlet tee or baffle:
Distance Gom botto of scum to button,of outlet tee or baffle:
Date of last pumpin :
Conuncnts(on pu ,ping recommendations,inlet and outlet ice or ba(llc condition,structural integrity, liquid levels
as related to oull I invert,et•idcnce of leakage,etc.):
7
'age 8 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO101
PART C
SYSTEM INFOR 'IATION(continued)
Property Address: 14 Gorham Lane
Centerville
Owner: Chgistine Masotta
Dale or laspeclloo:_ — —C3
TIGHT_ HOLDING TANK: (tardc must be pumped at time of inspection)(locate on site plan)
Depth below adc
Material of co struction: concrete_metal fiberglass_polyelhyiene other(explaut):
Dimensions:
Capacity: —gallons
Design Flow: gallons/day
Alann present(y s or no):
Alarm level: Alarm in working order(yes or no):—
Date of last 'um
in
Comrncnts(con Ilion of alarm and float switches,ctc.):
DISTRIBUTION BOX: (if present must be opcncd)(locate on site plan)
Depth of liquid level above outlet invert:
Conunents(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.):
PUMP CHAMBER: 7qonlan)Pumps in working order(yeAlarmsinworkingorder(yCommcn►s(note condition r,condition of pumps and appurtenances,etc.):
I
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 Gorham Lane
en ervi e
Owner: Christine Maso a
Date of Inspection:— —8 G
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) ,
If SAS not located explain why:
Ty
peleaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
17
16-4
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: _
Depth—top of liquid to inlet inve
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater i ow(yes or no):
Comments(note condition f soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locat on site plan)
Materials of cons ction:
Dimensions:
Depth of solids:
Comments(no condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 Gorham Lane
Centerville
Owner: Christine Masotta
Date of Inspection:111,E L—c>
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.
p�6
a
1
10
i
Page.)1 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address• 14 Gorham Lane
Centerville
Owner. Christine Masotta
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 property/observation hole within 150 feet of SAS)
Chec .ed with local Board of Health-explain:
ecked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
11