HomeMy WebLinkAbout0026 HENRY F LORING ROAD - Health 26 Henry F. Loring Road, Centerville
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UPC 12543 a
No. 5� 3LOR ��q�ncoNS�a�
HASTINGS, MN
Commonwealth of Massachusetts
Title 5 Official Inspection Form '
r.•7
i:} Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments
/' r�
Property Address
jq t.4 dO/
Owner Owner's Nam
information is ceon�vfef &
VA
required for every /�'J-- �
page. City/Town State Zip Code Date of spec on
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector In ation S'j t3q�y
filling out forms
on the computer,
use only the tab 7 Q Ir� YO
key to move your Name of Inspector _
cursor-do not yv it
use the return Company Name / Q
key.
Company Address lv!4
City/Town State V0�� Zip Code
Tele P hone umber License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the syste
1. Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspector' 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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: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.
Sinsp.doc•rev.71262016 -i;le 5 `ca,inspection=cr.:sutsurace sewage Osposa!system-Page',of to
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Commonwealth of Massachusetts
I
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
a6
�� Property Address C�
QN F ZOr1 N
R
Owner Owner's Name
information is C41giArmi Da c�a /O /3a
required for every •('� in
page. City/Town State Zip Code Date of Apecti6n
C. inspection Summary
Inspection Summary: Complete 1, 21 3, or 5 and all of 4 and 6.
'I) System P es: -
I have not found an information which indicates cates that any or 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:
2) 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.
Check the box for"yes', "no" or"not determined" (Y, N, ND)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.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.Goc-rev.725/2018 ':ve 5 o-r5o'c inspection=o= surosurace sewage Disposai System•Page 2 of 18
Commonwealth of Massachusetts
,I Title 5 Official Inspection
p on Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
.rS o
Owner Owners Name
information is
required for every r
page. City/Town State Zip Cade Date of In echo
C. Inspection Summary (cons.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) 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.
a. 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:
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i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address 16 Ile o eq Zan bi 15
�s
Owner Owner's Name /
information is Q��`! � /tlE�6-v 7 /O Q
required for every �11'' !! �/
page. City/Town State Zip Code Date of}speo on
C. Inspection Summary (cost.)
❑ 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
b. 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.
❑ 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 DCP 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 must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
lip Backup of sewage into facility or system component due to overloaded or
I� logged 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
'itle 6' da"ns�ec?cn For,::SubsuR2ce Swrage Disposal •Page 4 of
Sysrem 18
Sinsp.doc•rev.72620t8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fo - Not for Voluntary Assessments
Property Address,
as o
Owner Owner's Name
information is Ce N / /�
required for every �.,� ✓h !' '< </J 6✓ 2- � /O
page. CityiTown State Zip Code Date of 1 pection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
i Static liquid level in the distribution box above outlet invert due to an overloaded
L or clogged SAS or cesspool
Liquid depth in cesspool is less than 5" below invert or available volume is less
than'/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or
I�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 water supply or
tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
71 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
J 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.]
he system is a cesspool serving a facility with a design flow of 2000 gpd-
^ 10;000 gpd.
l— 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.
5) 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 CA.
Yes No
[� ❑ the system is within 400 feet of a surtace 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
Sinsp.doc• -i;te 5 O`Edaa inspector.=ors Suosu'ace Sewage Disocsal system•Page 5 of 18
2v.7262018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner O G SSD
wner's Name information is Ces4n;iIle
required for every _ 7
41 6 rd
page. City/Town State Zip Code Date of I pec on
C. Inspection Summary (cost.)
If you have answered "yes'to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no" for each of the following for all inspections:
Yes No
[�❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ 000e— 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?
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
r— ❑ 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
u 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)]
5insp tloc.rev.7/26/2018 Tlile 5 cf5dai inspe:ion=crm:suo-: ace sewage Disposal system•Page 6 of?a
Commonwealth of Massachusetts
-. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
eo zil h Q�
Property Address
rOwner Owner's Name �ele"
equir dfore@N /�required for every
page. City/Town State Zip Code Date o In ectio
D. System Information
.1. Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual).-
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#t of bedrooms):
Description: / /O 6-=.
//N`
%_10001
O
Number of current residents.-
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes No
if yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 50
information in this report.)Laundry system inspected? ❑ Yes R o
Seasonal use? ❑ Yes to
Water meter readings; if available (last 2 years usage (gpd)):
Detail:
Sump pump? % Y 9-N0
Last date of occupancy: o
:Sinsp.doc-rev.7�26iZ0�6 'iGe 6cal speCnor.=cr.SuCsu`ace Sewage Djsposai System•?age 7 of 18
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System orm -Not for Voluntary Assessments
Property Address
Owner C' WSJ
Owner's Name
information is
required for every
page. City/Town State = �I
Zip Code Date of ins ctio
D. System Information (cont.)
2. 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
Water treatment unit present?
❑ Yes ❑ No
If yes, discharges to:
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 below):
3. Pumping Records:
Source of information:
Was system pumped as par of the inspection? ❑ Yes L7 No
If yes; volume pumped:
galions
How was quantity pumped determined?
Reason for pumping:
t5insp.00c•rev.7/26/2018 `itle 5 jnaal:nsoett:on Form:Subsurface Sewage Disposai System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
C,4164-SZ'
Owner Owners Name � l
information is v`
required for every
page. City/Town State Zip Code Date/Inspe6tion
D. System Information (cont.)
4. Type of S m:
Septic tank, d 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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if own no source of information:
ORS i01g
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
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.):
t5insp.doc-rev.7/26120�8 -,tie 5-modal inspection Fo,-.Sutsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
fi Title 5 Official Inspection Form
pia Subsurface Sewage Disposal System F rm - Not for Voluntary Assessments
Property Address Z0'-1 94
Owner Owner's Name ass
information is / l' n
required for every H ✓Y /{
page. Cityrrown State Zip Code Date of nspec on
D. System Information (cons.)
6. Septic Tank (locate on site plan).-
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 or certificate) ❑ Yes ❑ No
Dimensions: y� u
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
9-7
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 —
o% -cv/
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert. evidence of leakage, etc.):
law 611111yj#14 #44 C/
00 C/ &It C4 40 or, /0
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A.
Commonwealth of Massachusetts
i Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
\VW. C26 4 0#rl A
04
Property Address
Owner Owner's Name / tiss
information is AX O�G�aI�- 1d 47
required for every TT�� r�
page. City/Town State Zip Code Date of intpection
D. System Information (cont.)
7. 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.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass i❑ polyethylene ❑ other(explain):
Dimensions.-
Capacity: gallons
Design Flow: gallons per day
t5insp.Coc.rev.7126i2018 - -itle 5 Suoscjace Sewage asposai sys[em•?age 1 i of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
-•1, Subsurface Sewage Disposal System FF� - Not for Voluntary Assessments
/I N
Property Address
a &qoo
Owner Owner's Name
information is eN 6 Oc)6 7
required for every •�a4 _
page. City/Town State Zip Code Date of In echo
D. System Information (cons.)
8. Tight or Holding Tank (cant.)
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.):
* Y No
Attach copy of current pumping contract(required). �s copy attached? ❑ es ❑
9. Distribution Box (if present must be opened) (locate on site plan):
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.):
M -
/VV VV_ c9 V7 S u�
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?;Je 5 vifiaa:-nsoecton Four.suosu'ace sewage Disposal system•?age 12 of 18
t6insp.tloc-rev.?26R0'18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form
Not for Voluntary Assessments
Property Address
c� Sso
Owner Owner's Name/ Pil/1` ✓�Ile
� 3�t l0
19
information is (�
required for every
page. City/Town State Zip Code Date off sped n
D. System Information (cons.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
YP
leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovativeiattemative system
Typeiname of technology:
':ue 5 o5oaa =cm,:%uo" ace Sewage Disposal System•Page 13 of 18
t5mspAcc•rev.7262018
c� Commonwealth of Massachusetts
-. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments/
Ae vi jet2
Property Address
r—'a'oq s S
Owner Owners Name/'
information is / QN-k�v` At 00 41,
/v
required for every �/ �/
page. City/Town State Zip Code Date of Insp coon
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
11
-fin Pis or --
12. 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.):
Tiae 5Ica; nspec.10n=or.sucsurtace Sewage Disposal system•?age 14 of 18
Sinsp.tloc•rev.7f2612018
Commonwealth of Massachusetts
Title- 5 Official Inspection Form
Subsurface Sewage Disposal System Fo - Not for Voluntar
y Assessments
Property Address eor
Owner Owners Name SO
information is 4'e',
required for every QH l3�� �p�c r� �•-
page. City/Town State Zip Code Date of I pecti n
D. System Information (cons.)
13. 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.):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�� oZ KO v1Y Lp✓Ivr
Property Address
Owner Owner's Name
information is �iQ�
required for every 4�� VCtt7
page. CitylToum State Zip Code Date of Ins ectio
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmark or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the bu ing. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc-my.712612018 de 5 011,daj irspeCdor.Fe=:Subscrface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments
�2
Property Address
Owner owner's Name
is / � 1 /Orequired for every — yIle-
information (�- /
page. City/Town -h 9
State Zip Code Date of Inspe on
D. System Information (cons.)
15. Site Exam.
El Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water. feet
61
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: pate
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
L� Checked with io ' Board of Health - explain: ! /
FE Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must descr how you e tablishe//d the high ground water elevation:
UoNc�4u l✓1 -Q A
I/r-
Lo C- om-k C/.. /Z1000a 49 0
Lie' h/. "L . p�� t S 10 f
S s O tg q/Q wt !
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Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t8insp.doc-rev.7262018 -1Ge 5 SSca Irspe=or=o-:suos.,raoe sewage oisposai system-Page 17 of 8
Y Commonwealth of Massachusetts
-. � Title 5 Official Inspection Form
14 A Subsurface Sewagge�Disposal System Form -Not for Volunt�ary- Assessments
Property Address
Owner Owners Name
information is
i required for every
page. City/Town State Zip Code Date of I pectin
E. Report Completeness Checklist
Complete all a plicable sections of this form inclusive of:
1
A. Inspector Information: Complete all fields in this section.
B. Certification: Signed & Dated and 1, 2: 3, or 4 checked
C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (F re Criteria) and 6 (Checklist)completed
D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
'ille 5 ot5aai inspection S--rtace Sewage Disposai System-?age is of 18
t5insp.doc-rev.7/26=18
•f
TOWN OF BAFNSTABLE
P
LOCATION _ r" I—O✓=k- !� )ei SEWAGE # � 5 h 1
VILLAGE Ccr• -r`Q v LE ASSESSOR'S MAP&LOT/Zoe /"/G
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /(1 0 °
LEACHING FACILITY: (type) }�i �' (size) tl"'e C -2 fs/`5,
NO.OF BEDROOMS
BUILDER OR OWNER C c II e fF�
PERMI 'DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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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lV
TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection 2 j 19 (508) 385-1300
19 Hummel Drive Qggy 9 j
South Dennis, MA 02660
a t
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
U om F.Weld Trudy Coxe
Argeo Paul Ceiluccl
u Govemor David B.Struhs
Convnwewwr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
f CERTIFICATION
Property Address 6 Gh r •L o✓ /2 e Lr. }c r✓ 11< 1
a
y\ Address of Owner. to e ni�
Date of Inspection: S / 0/9 7 (If different)
Name of Inspector.—r - yy cj, [i rr rt,S (,5 C."� It
Company Name,Address arfd Telephone Number.
Sc� t�6oue , i'
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:
--V— Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: .S' 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) SYSTEM PASSES:
I have 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: IV/4
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,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
,A
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: G Ps-h ✓ V
Owner. Cam, It +f,
Date of Inspection: S /a U /5 7
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
Heahh):
broken pipe(s) are replaced
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 replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /V /A
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 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 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.
3) OTHER
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
' / N /a r
CERTIFICATION(oontinued)
�7
Property Address: C?6 G t� i l0 y lei`
Owner. e6 I/, +-4—<
Date of Inspection S-1.2 0 y 7
DI 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 failure. 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 leas than 6"below invert or available volume is less than I/2 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
ooliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: /A///�
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:
— 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 owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CUR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) z
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECHUST
Property Address: oZ
Owner.
Date of Inspeodon: g
Check if the following have been done:
Pumping information was requested of the owner,occupant, and Board of Health.
one.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.
_I/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
Jz"T'he site was inspected for signs of breakout.
system components, excluding the Soil Absorption System, have been located on the site.
!'he septic tank manholes were uncovered,opened,and the interior of the septic tank W' 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.
_ 1IIe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 6 !7 c �^ r y L o✓
Owner. Co G f�-e-
Date of Inspection:
RESIDENTIALFLOW CONDITIONS
Design flow: a n,
Number of bedrooms: Q
Number of current residents: 1
Garbage grinder(yes or no):-ZO
Laundry connected to system(yes or no):-F S
Seasonal use(yes or no): Nv
Water meter readings, if available: y'e/ol
= 7 00 0
Last date of occupancy: 1Q c v . C CA ,
COMMERCIAL/INDUSTRIAL• 11/9
Type of establishment:
Design flow:------Sallons/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 INFORMATION
PUMPING TORDS and source of information:
1-CPoo--C. sl c CA3�. r s ra a o ✓Jt!� .�.. J� v �.c r� O w K, e- C�w h fir.
System pumped as part of inspection: (yes or no) No
If yes, volume pumped gallons
Reason for pumping:
TYPE F SYSTEM
Sept it 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)and source of information: r' t
Sewage odors detected when arriving at the site: (yes or no) Na
(revised 11/03/95) ,�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�[ SYSTEM INFORMATION(continued)
Property Address: o?6 /7 4 r'r y L o✓; ck y l d
r. C.Owne / /
Date of Inspection:
SEPTIC TANK_V/
(locate on site plan)
Depth below grade: /
Material of construction:Zoondrete_metal_FRP—other(explain)
Dimensions: S X 9 x
Sludge depth.,_,_ r r r
Distance from top of sludge to bottom of outlet tee or baffle: a
Scum this 7
r,
Distance from top of scum to top of outlet tee or baffle: (�
Distance from bottom of scum to bottom of outlet tee or baffle: �r
Comments:
(recommendation for pumping,condition o inlet and outlet tees r baffles,depth of liquid level in relation to outlet ' rt, structural integrity,
evidence of leaks etc.) -i-:I_ ✓ p t G_
j � r ' J t4
c—
G✓ G 4 G Gin
GREASE TRAP: /�
(locate on site plan)
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 baffle:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in Ptrelation to outlet invert, structural in
evidence of leakage, etc.)
(revised 11/03/95) 6
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Q 6 r/'G!n i—y
Owner. C-
Date of Inspection:
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP—other(explain)
Dimensions:
Capacity: ¢allons
Design flow: pllons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
I
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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.) A/c,
/'Gi Lh
PUMP CHAMBER:_.,6/A?
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
n // SYSTEM INFORMATION(Continued)
Property Address: OC � /7`G 4�r Lo k-I vx 3, .
Owner.
to r. Co
l I Inspection:
G���
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:
Tn*:
leaching pits, number:011 L � �� � L�•� �, /��1` W � f� o� � $ f z�'n c .
leaching chambers,number._
leaching galleries, number.
leaching trenches, number,length:
leaching fields, number,dimensions:
overflow cesspool, number:
Commanta: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.)�c1
� i W a—s
G. v fig O N./,y0-t✓
Q v r � S .�y
v►. o S r. c� jG r—K 1 C
{� ✓ .
CESSPOOLS S �, �L, t. c�f f
(locate on site:
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer:
Dimensions of cesspool:
Materials of constriction:
Indication of groundwater:
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: N/4
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments:(note condition of soil, signs of hydraulic(ailure, level of ponding, condition of vegetation,etc.)
(revised 11/03/95) — — 2
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION (continued)
Property Address: 026 //t h I—/y L�J
r:
owne
Date of Inspection:
s /zo /q7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
J�C-. G k
G �
13 , ' 6,2
1600 qullo �,
DEPTH TO GROUNDWATER
Depth to groundwater: S f feet - adjusted high groundwater level _
method of determination or approximation: U C. 3 r a �,,( C,�+ r,,.,�- T 5, 4 a i,,,
s. ui w u o rC' L