HomeMy WebLinkAbout0037 VALLEY BROOK ROAD - Health 37 Valley Brook Road,Centerville,
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�t 05 14 08:30p p.1
Commonwealth of Massachusetts
�., Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owner's Name
informationis fo
required fo revery Centerville MA 02632 10-4-14
page. Cityrrown State Zip Code Date of Inspection
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. General Information
filling out forms � "'Miuunupru"
on the computer, I C' 1 I �\```\` �H OF A4A ,'''/,�
use only the tab .
1 Inspector: ,cy
key to move your per'. G'
cursor-do not James D.Sears ? JAMES ri
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use the return Name of Inspector c>
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CapewideEnterprises,LLC ; �,•. o _o :a*
Company Name ---- — 4e .. If ...•
153 Commercial Street �''iii,,5 INSp�G``\`���
Company Address
Mashpee -- -_- MA 02649
Cityrrown State Zip Code
508-477-8877 _ S1623
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. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems, 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
0 Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
_ 10-4-14
spector'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.
t5ins-1113 Title 5 Official Inspection Fomr.Subsurface Sew2ge Disposal System-Page r of 17
Oct 0514 08:30p p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop _
Owner Owner's Name
Informationis
requiredairedfor every Centerville MA 02632 10-4-14
for
page_ City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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:
Pass system. The system is a 1000 Gal.tank D Box and pit.
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.
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):
i5ins-3H3 Title 5 Official Inspection Form Subsurface Sewage Disposal Splem-Page 2 ar 17
Oct 0514 08:30p p.3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
lug-1
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owner's Name
information is required for every Centerville MA 02632 10-4-14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System wilt pass with Board of Health approval if
pumpstalarms are repaired.
B) System Conditionally Passes(cont.):
❑ 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 obstructedpipe(s). The
❑ Y q P P 9 Y
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):
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
t51ns•3113 Title 5 Official Inspecllor,Fomr Subsurface Sewage Disposar System-Page 3 of 17
Oct 05 14 08:31 p p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owner's Name
information
required for every Centerville MA 02632 10-4-14
page. Cityrrown Sbte Zip Code Date of Inspection
B. Certification (cont.)
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.
❑ 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 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.
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 is less than 6"below invert or available volume is less
than%day flow /'IT
t5ins.3f13 Tine 5 Officiel Inspection Form:Subsurface Sewage Disposal System•Page 4 0`17
Oct 05 14 08:31 p p.5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owner's Name
required Information is Centerville MA 02632 10-4-14
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
Yes No
❑ ® 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.
❑ ® 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 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-
1 d,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.
f51ns•3113 Tille 5 Ofricial Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
l
IOct0514 08:31 p p.6
Commonwealth of Massachusetts
I
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owner's Name
information is required for every Centerville MA 02632 10-4-14
page. Cityrrown State Zip Code (late of Inspection
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?
® ❑ Were 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 CM 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
l
Oct 0514 08:32p p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owner's Name
information is required for every Centerville MA 02632 104-14
page. Cityrrown state Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and Pit.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes [D No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes No
Water meter readings, if available last 2 ears usage d 2012-45,000Gals
g y g (gp ))' 201340,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: PresentDate
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design Flow(seats/personstsq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holdingtank resent?
P El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: .
151ns•3113 Title 5 Official Inspedion Form Subsurface Sewage Disposal System•Page 7 of 17
II
Oct 0514 08:32p p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owner's Name
information is Centerville MA 02632 10-4-14
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
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) 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):
15ins-3113 Title 5Offaal Inspectlon Form:Subsurface Sewage Disposal System.Page 6 of 17
Oct 0514 08:32p p,9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owner's Name
information is Centerville MA 02632 10-4-14
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1984 Permit#84-371.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2'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.):
Pipeing is 4" PVC SCH -40.
Septic Tank (locate on site plan):
"
Depth below grade: 1 155-1
et
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
Dimensions: 1000 Gal.Precast H -10
_._
Sludge depth:
1"
15ins•3/13 Tille 5 Of6cia Inspection Form Subsuriaos Sewage Disposal Syslem•Page 9 e'17
Oct 0514 08:33p p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owner's Name
information is Centerville MA 02632 10-4-14
required for every
page. City/Town state Zip Code Date of Inspection
D. System Information (cons.)
Septic Tank(cost.)
Distance from top of sludge to bottom of outlet tee or baffle 29'
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-Tape
Sludge Judge _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank and cover's at 15" below grade. In and out let baffles. No sign of
leakage or over loading.
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
t5ins.3,113 Tide 5 Official Inspection Formi Subsurface Sewage Disposal System•Page 10 of 17
Oct 0514 08:33p p.11
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owner's Name
information is required for every Centerville MA 02632 10-4-14
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.):
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 ❑ polyethylene ❑other(explain):
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
t5lns•3113 Tile 5 official Inspectlon Form:Subsurface Sewage Disposal System•Page 11 of 17
Oct 05 14 08:33p p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owners Name
inforrnrequired
a Centerville MA 02632 10-4-14
required for every
page. Citylfown State Zip Code Dale of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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.):
D Box is 16"X16"-21" Below grade wl cover at 15". Box is clean and solid w/one line out. No
sign of over loading or solid carry over.
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.
Soil Absorption System(SAS) (locate on site plan,excavation not required):
If SAS not located, explain why:
w`Ins'3113 Tile 5 Official hispectlon Form:Subswfaw Sewage Disposal System•Page 12 W.17
Oct 05 14 08:34p p.13
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owner's Name
information is required for every Centerville MA 02632 10-4-14
page. Cityrrown state Zip Cade Date of Inspection
D. System Information (cant.)
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.):
Leaching is a 1000 Gal. Precast pit w/1'stone. Pit at 43" below grade w/cover at 14" . 1'water
in pit w/stain line 6"above water line. No sign of over loading or solid carry over. No high stain line.
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
t5ins-W13 - TNIe 5 ORiclal"pection Form:Subsurface Severe oispowl System•Page 130117
Oct 0514 08:34p p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owners Name
information is required for every Centerville MA 02632 10-4-14
page. Citylrown State Zip Code Date of Inspection
D. System Information (Cont.)
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.):
t5ins-3113 Title 5 Otidel Inspection Form:SuDsulrace Sewage Disposal Syetem-Page 14 o117
Oct 0514 08:34p p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
kq�t IV,
Owner Owner's Name
required for
is Centerville MA 02632 10-4-14
required for every
page_ Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below.
® hand-sketch in the area below
❑ drawing attached separately
- � = r7 A Edit
z f CK
3
O
i
t5ins•W 3 TiAe 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 ce 17
Oct 05 14 08:35p p.16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
Owner owners Name
information is required for every Centerville MA 02632 10-4-14
page. City(rown Stale Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells "V4
Estimated depth to high ground water: 12' —
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: 10-25-62
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:
T.H. on Design plan 10-25-82 no G_W. at 12'. Bottom of pit at 9' below grade. Bottom of pit at 3'
above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
tsins•.3l13 Title 5 Offldel Inspection Foam:Subsurface Sewage Disposal System•Page 16 of 17
Oct 05 14 08:35p p.17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
? Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Valley Brook Road
Property Address
Melvin Bishop
Owner Owner's Name
information is Centerville MA 02632 10-4-14
required for every
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A. B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
i5ins•3113 Title 5 OfFidd hspedion Farm:Subsurface Sewage Disposal Systen-Page 17 of 17
7/
L O CATION ` S E E PERMIT NO.
VILLAGE
t'l L L
INSTALLER'S NAME A ADDRESS
v ellro
�RUILDER OR w4*1
ITO
N .
DATE PERMIT ISSUED
pDAT E COMPLIANCE ISSUED
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�► � ® nbs£.S .
. �. _ ,, �
�� �.
No��� � .J ; Fus ...............
THE COMMONWEALTH OF MASSACHUSETTS
3 �- BOAR® OF HEALTH
pI ..-----�QW6................OF..........6 r.. .S. . 1�.-----------...---------
�A® lirFa#ion for Bid os al Works (foustrnrtiun ramit
Application is hereby made for a Permit to Construct (vj or Repair ( ) an Individual Sewage Disposal
System at:
.....M.cAA r:o o\6 ....&A .......an .... _.O ----r-L...o.t..--•--
..........•.........•....................
sJ � Location- _ No.� s
................................ .n- �� .........._.....
a v..kar n OS C _ .dd<_
Installer Address 0 1
d Type of Building Size Lot.1.........................Sq. feet
Dwelling—No. of Bedrooms..............�5_.._..........._...._......Expansion Attic (VQ Garbage Grinder (MC)
pa, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures .-----------•--•-•-------••---.... .
W Design Flow.............. d.....................gallons per person per day. Total daily flow..... � �-_.................gallons.
WSeptic Tank—Liquid capacity 9o.gallons Length-----------_--- Width__-............. Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) � t
aPercolation Test Results Performed b ��llLAA...L._...�-..l..... ......................... Date__®.�.a s."._��-'......
-- .
Y
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.._._.._________. _.._. �
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ix .......-....................................................................
O Description of Soil.....0.—,3L --...�5 4Y....-------�r:---•-�V -- -.............................................
x
U ---------•------------------ i.� .�....5..1.1-CAM . V_2�.—.-----------------------------•-------
x ------------------------------------- a--------cr:e.�-------- un a••------------------•------••-•-------•-------------••••-•-••-----•--------•-•-•--•----•-.......
V Nature 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 TL MI i, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed----•• .....)=•• .........................
i fie
Application Approved . -- •-•••-------•-
Date
Application Disapproved or he following reasons:------•--------•-•-----•------------------------------------------------------------------------••••--.....-•---
.................•--••-•-•-•-•-------••-••--•--•---...--•-------•----•--•--•--•---...---._....-•---•-------------------•-••••-•-----------------••-•----------••-•••-••-------••---------•-•-......_....
Date
PermitNo--------------------------------------------------------- Issued_........................................................
Date
t
F:ms. "" .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................OF..........
�^? �.t"..Q.S.T - ✓,
.......... ..............
Appliration for Disposal Works Tonstrurtion Frrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
.........1A.......... F'-'� = ........V J ---•---------------------•-••-•-•--------
�.� Location-Address or Lot No.
.................................... --------- �` = c �o.�.C.......-•---..........----------
Owner Address
Installer Address
Type of Building Size Lot ...k ............Sq. feet
I—I Dwelling—No. of Bedrooms--_--.._---_3-•---•......................Expansion Attic ("Q Garbage Grinder
aOther—Type
of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
� Other fixtures
W Design Flow.............�_U ......................gallons per person per day. Total daily flow_______---.--�•3�- .__.____._......._..gallons.
WSeptic Tank—Liquid capacit)Aw!?..gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-_------------------ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by._ ., _..... ..................... Date. P.". .'.. - ..._...
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ------- ------------ .................................................
---------------------------
•----•--------••-•••-
O Description of Soil.....� -�---....QPP- Vf l..........�:----• ?,+� = ---------------------- .....--.
U •--••------------------•-------•---DL'r ....-:: 1s41L,�� _ �s �-E'.-V-P........................................................
�d - '�,-----....I.. AA.S�------------------------------------------------------------------------------------------------
U Nature 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 Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.-c�okr.l'1'.� 1.------ .... �'�1,,-,Av^ r_- 'C.
Application Approv Date
---------------------•-••----------•----•----•-----...........-•---._._...----- + � ------......--
^' Date
Application Disapprove or he following reasons---------------••--------------------•....-------•-••--•-------------------------------•-- •-----•-•---•......._
.......................................................•-•----------•----••-•--•----••--•------•-----•--------•-•---•---••----------------------------•---------•-•--•--•-•--•-------------------••--••-
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... .......OF............ �.: r'��s ,sue•
..... .. ............................
Tntifiratr of Tomplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by ���^^�� r ? j��- --------------------------`.....------------------....-----.....-----------------------...------------------------......------...•....
at
~'e`'�......--k"a.......'). � -p-_6 .Installer.(.............ao .
has been installed in accordance with the provisions of TITLE. 5 of The State Sanitary C de described in the
application for Disposal Works Construction Permit N�{+ ------------------ date - . ......................
THE ISSUANCE OF THIS CERTIFICATESHALL N SHALL N® BE CONSTRUE® AS A GU'AR�(NTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.�
j
DATE... ""r"' ''_t' �......_._.. Inspector. h.........._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
p�L�� `.. l .t'1..............0 F........� a?k . .f`�..4..�t... 1` .��?......_............_....
0 lhslz�--••--•------ FE •...............
Disposal Works Tonutrnr##ion Trani#
Permission is hereby granted----- C_ '..........� ..._11;1..................................................................................
to Construct ( j,Kor�Repair ( ) an Individual Sewage Di s osal System
at No...... ._
Street
as shown on the application for Disposal Works Construction Per 't o_____________________ eaf df r..
Board of Health
DATE.........
FORM 1255 A. M. SULKIN, INC., BOSTON
`5106,LC- FAM1t_Y -• :6 BEOR0OM
SOW x Itox 3 - 33o6.PP
SEPT►G TANK = 330x15C>% ;A9/G.P. Q p oply ;
�
• uE-"5 t o0o GAL. ZL 1
,
t� P• ;.
ot5Po5At_ PIT- v5E tvo0 GAt_. �P
5%DG.WALL AREA o 150 5,F 1 4.j'
150
BOTTOM AREA= �0 5F• \ a° 1 '
S0 5.F x 1. 01GNQ Zo �3\LL► �, T..•. i } �
'TOTAL- I7E$ 4 5 1
-TdTAL )A►L-Y F\-O� = 330 G,PD, ► gyp' \ =T } f.
�.�. . ,
PE2CO%-ATtoN RATE : 1"1N 2MIN D'P-LE�jS 1 °'e 1 -Tj °` i • ' ' , t ' w
1 N
fyIJ
X-�
Bpi..
jH OF tit q� 1 LOT-DAVID
��\ � � I •r 10
•,) a Y'
hlCHARp (�
A. 7,
C.
TMUUN �^
l i ( PAX-rEN
Na?^,048 No. 29976 y.
9 O A �� ViL�o ! ..
��O stltt`t6y GNAL
'mom,
>rX 144 Pro- 43,p TOP F N u 2 46' o
P- .
Iwv. 41.v
3FT 7f
Loges ¢' 1000 INJ.
E[ 6vK 56PTIC.
1000 iW�, L`D.li -TANK 10�
CowRsE G au. 40.o
• LEAcu
j;
SA►�DY PIT rNY, V.
WITW 46•Z
C17ZAVE(. 1'/3�a, �i 14
ce
IWA',A D ;
ii I MED, �► � � �I,� C1rR.TIFIGD P1.-o�t- PLAID
SAOD PRv F I LG
LoCA-t ►oN CEfQ7E1" % LLB l l
I' EL 30 (.lo SCALE �jGALE 6o'
NO WArM p>--f�N REFERENCE
I
1 CERT1t=Y 'THAT 'THE F•OVw0ATI-wnI SNOW(N ._
i NERs0P1 COMPL` 6 WtTN -CHE S1oE1.1t-� LOT
I (:
A►.It7 S<^T�GK R-6Q�►t2.EM1~N•r� oF -fN� . .. ,
ZoWN ot= BAWJSTAt' E Ah.l'D IS ►Jo`Ir LG 3SS4g D :-`
ILOCINT D WtTN11J T>AC GL°ate Lo.IN
D A-r E 2 6 CJ 1:.� XT E Q a 1�.1 E i N C
—�� BA Y
- REG 1 S'T E26U'i.AN 0,5 u 7-Y E1(oT�S
I' -Tt115 PLA1�1 15 NET E3n5C_D pld AN OSTE2-vILLE Ss.
I� IuSTR-uM6NT 9 v e y -t•t-�E 01=F5E`r5 6W000� �AM�
No T (�E V 5 E To E'T E Ft/A I►mot L oT 1-l I-1>_�j --1 C A N J T K , S H('
A P P\
�.\ CommONWEALTH OF M4SSACHt'SETTS
"] ;: EXECUTIVE OFFICE OF E\VIRON\IF-NTAL RS
DEPARTMENT OF ENVIRONMENTAL �ROT��T10-
ONE WINTER STREET. BOSTON. NIA 02106 FI"-_S_!S:00
�Mn f
W 1LL1A"'F V1 ELD �FO�,qm� �`9> TRUDY COX
Govemc. Se:rca
ARGEO PAUL CELLt'CCI D.4�'ID B ST l
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
Commission-
Lt. sion
PART A
CERTIFICATION
Property Address: 'S1 V411cy 6eeXAC— P-A t a"k�iw�11'�- Address of Owner:
o ?v%-v\VZge,�
Date of Inspection: IO�f,� 'I Of different) t2'1Z UK, Az
Name of Inspector: H, 5-4"' —0"4lv%4 km o.
1 am a DEP ap roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: o 414-1.e En rr're-2 K r•c p r.�/
Mailing Address: in Aox e 3�lf�j C7 245_41-q
Telephone Number: rSe4) !6=2�— /4 ZO
CERTIFICATION STATEMENT
I cem, that I have personalh inspected the se%aee disposal system at this address and tha: the information reported be!o'A is true, accurate
and complete as o-the time of inspect-o-. The inspection Aas performed based on m% training and experience in the proper function, and
maintenance of on-sae sev�age disposa• systems The system:
x Passes
Conc-t-o-.ai:% Passes
1-eec: Furthe• E%a!:,at;on EN the Local Approving Authorin
Inspector's Si gnat ur Date: �6
The Svs:e r InsDecto, sha" submit a cop,, of this inspection report to the Approving Authority within thirr (30) days of completing this
inspec on. It the syste n is a share' system o- has a design floe of 10,000 gpd or greater, the inspector and the system owner shall submit
the repo-i to the a.p-ocr.ate ree,or,al officta of the Department o; Environmentat Prote^.or The ongma! should be sent to the system or,ne,
and copes sent to the buve•, ii applicable. and the approving authonn
INSPECTION SUMMARI: Check A, B, C, or D
AI SYSTEM PASSES:
4— 1 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.
COMMENTS.
BJ SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, upor
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.
_ 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; o
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 conforming septic rank
w approved by the Board of Health.
(rev:.aed 04/25!91) Page 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection.
BJ SYSTEM CONDITIONALLY P ES (continued
_ SeKage backup or b akout or high static water level observed in the distribution box is due to broken or obstructed
pipes) or due to a bro n, settled or uneven distribution box. The system will pass inspection if(with approval of-the
Board of Health'. Descri observations-.
broken (s) are replaced
obstructia is removed
distribution x is levelled or replaced
The system required pumping mo than four times a year due to broken or obstructed pipe(s). The system will pass
insoection if(with approval of the rd of Healthy
broken pipe!si are placed
otstruction is remo
CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD O HEALTH:
Conditions exist which recuire further evaluation by the and of Health in order to determine if the system is failing to proiec the
public hea!zh. saiern-and the environment.
1) SYSTEM KILL PASS UNLES5 BOARD OF HEALTH DETERMI 'ES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH KILL PROTECT THE PUBLIC HEALTH AND SAFETY ND THE ENVIRONMENT:
Cess000l or pri%-� is within 50 fee; of a surface water
Cesspooi or privy is within 50 feet of a bordering vegetat wetland or a sah marsh.
2) SYSTEyt KILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLI WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS TH USL1C HEALTH AND SAFETY AND THE
ENVIRONMENT:
The systern has a septic tank and soil absorption system (SAS' and t e SAS is within 100 feet to a surface water supply or
trioutary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS i within a Zone I of a public water sup.-)Iv well.
The system has a septic tank and soil absorption system and the SAS is ithin 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is le th—'r. 100 feet but 50 feet or more from a
privaie water supply well, uniess a well water analysis for coliform bacteria an+d volatile organic compounds indicates tha
the well is free from pollution from that facility and the presence of Ammon nitrogen and nitrate nitrogen is equal to w
less than 5 ppm. Method used to determine distance (appro ' tion not valid).
3) OTHER
(revisal 04.175/9") Page 2 of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORr.1
PART A
CERTIFICATION (continued)
Propert. Address:
Owner:
Date of Inspection:
D) SYSTEM FAILS:
You must indicate either -N'es" or "No' as to each of the following
have determined that the system violates one or more of the following failure criteria a< fined in 310 CMR 15.303 The bans
for this determination is identified beloN. The Board of Health should be contacted to d termine what will be necessary to correct
the failure.
Yes No
Back4P of se"age.into facility or system component due to an overload or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surf a waters due to an overloaded or clogged SAS or
cesspool.
_ Static hooid level in the distrib,ition boa above outlet invert du to an overloaded'or ciogged SAS or cesspoo;
Lieuid death it cesspoo! is less than 6" below invert or avai ble volume is less than 112 day floe.
Reeu-red pumping more tha- 4 times in the last year N due to clogged or obstructee pipe s
Numoer o,times pumped _.
An, pon,on o�the So!! Aosorption S,.•stern, cesspool r privy is below the high ground ate• eievatior.
An% pon:or of a cesspool or prnv is within, 100 ' t of a surface water suppiv or tribu;an to a surface Kate, supple
And po':ion cf a cesspoo' or pries is Hithir a one I of a public well.
An\. pcnjc- c-*a cesspoo' o- pri%% is withi 50 feet of a private water supph well
Any pon.o-. o:a cesspool or pri\,1• is le s than 100 feet but greater than 50 feet from a private eater suppiv well with no
acceo;abie \&a:e• qualm analy s If a we!I has been analyzed to be acceptable. arach cope of well water analysis for
cohiorm bacteria vo!a:ile organic c mpounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
tiou must indicate a:her "Yes' or "No" as to ea of the following.
The iolio";ng trite .a aop;. to ;arge vstems in addition, to the criteria above:
The system serves a facilm with design floes of 10,000 gpd or greater (large System; and the system is a significant threat to
public health and safety and th environment because one or more of the following conditions exist
Yes No
the system is w thin 400 feet of a surface drinking water supply
the system within 200 feet of a tributary to a surface drinking water supply
the syste is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public ater supply well)
The owner or operator f any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 MR 5.00 and 6.00. Please consult the local regional office of the Department for further information. �
(Tev%aed 04/25/97) Pays 3 of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3'1
Owner: l- u4ck
Date of Inspection: tp 4 fq7
Check if the following have been done: You must indicate either 'Yes" or 'No" as to each of the following.
Yes !No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been rece v:r,g normal
flow rates during that period. large volumes of water have not been introduced into the system recently or
as part of this mspecrion
As built plans have been oo:a:ned and examined. Note if they are not available with N/A
— The fac:!m or d%%elling was rnspecied fo• signs o-*sewage back-up.
The s,.-stem does not receive non-sanitarn or industrial waste flow.
— The site was inspected for signs of breakout
A!I systerr con,ponen.ts. excludir,e the Sod Aosorption System, have been located on the site y
•, — The sep:.c rant: manho;es were uncovered. opened. and the interior of the septic tank was inspected for cond,tior of
baffies or tees, materz o-*cons-ruction. dimensions, deptn of liquid,depth of sludge, depth of scum.
The size and !oca:,on 0 the Sol! Absorption System on the site has been determined based on
in r n; tr m owneri were provided with tniormation on the prop- maintenance of
The iac�I�n o�.ne� nano occupant_. �, d e e o
Sub-Suriace Disposal Svsterr..
N Existing information Ea. Pian at B O.H
— �
— Determined in the meld :c am of the failure criteria related to Part C is at issue, approximation of distance is
unaccep:ab,e 115.302 3;b
(revised 04/25/57, page 4 of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.St
PART C
SYSTEM INFORMATION
Property Address:3'7 \/'k11"jbt WK--
Owner: %p'o
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow 3SO a p.d./bedroom for S.4.S
Number of becrooms dZ
Number o'current residents
Garbage g,, der (yes or no. 1_-k)
Laundry co-•^ected to system (yes or no' nJO
Seasonal use tees or no,.�c)
Water meter readings. if available (last two :2 vear usage Lgpd). #Jn — law Q%o*S r
Sump Pump (ves or not �U
Las; date o-*occupant\ l0 Znfi,p.e.R o,
COMMERCI4L'INDUSTRIAL:
Type of establtshmen:
Design fio%. _ga!ionsda\
Grease trap present tees or no_
Industria! 1%aste Holding Tani; presen, -ves or no_
Non-samtar\ waste d-scna,gec to the Ta,e 5 system ;\es or no
%later meter readings if availabie
Las:Fate o: c,
OTHER: .De:cube
last pate of occucanc.
GENERAL INFORMATION
PUMPING RECORDS and source f information
Systern pumped as par, o inspection. Ives or no.fU
If yes, volume pumped ¢allons
Reason for pumping
TYPE OF SYSTEM
Septic tank/distribution boxrsoil absorption system
Single cesspool
Overflow cesspool
Pnvy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: %'Ah Z "Ipc0 ><
Sewage odors detected when arriving at the site (yes or no) AWN
(revised 04/25/91l Page 5 of 10
SL:BSURFACE SB%AGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propert, Address: 3Z UF�IIe�t�OtIL.
Owner: 1?�MA9
Date of Inspection: �Vl`�r11
BUILDING SEWER:
(Locate on site plan) lic
Depth below grade.
Material of construction. _cast iron _40 PVC _ other (explain'.
Distance from private water supply well or suction h-t
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:�.S
(locate on site plan
Depth below grade
material of construc,o —kconcrete _meta _Fioerglast _Polyethylene _othertexplam
If tank is metal, Iis: age _ I; age con'.rmec b� Ce^:fica:e o; Compiiance _()res No
Dimensiors
Sludge depth
Distance from top c slucee to bonorm of outie: tee o ba�a 32
Scum thickness &-f
�r
Distance from top of scum to top o` outlet tee or ba^,e Icy
Distance from bosom o; scorn to bot c-. o; outlet tee e• bane l ep,
How dimensions were dete•rnmnec
Comments
trecommendat:on fcr pumping condition o� iniet and outlet tees or baffles. depth of liquid leve! in relation to outlet invert, structural
integrity, evidence of leakage. a:c.t MG W -CA t1ru—eSh"Ne r41- ,r�'c4�c tllmur Laou,&los I S%,J—C,. ..
GREASE TRAP:
(locate on site plan:
Depth below grade.
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.
Comments:
(recommendation for pumping, condition of i!ilet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.;
(revised 04!25:9') Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propert% Address: :g1 Vfti(-,%i bwo
O%ner: t•.{�
Date of Inspection: to4457
TIGHT OR HOLDING TANK:-Tank must be pumped prior to, or at time, of inspection:
(locate on site plan,
Depth below grade
Material of construction _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions.
Capacm• galions
Deng^ floes galionscia,
Alarm level karm in �%orking order _ Yes. _ No
Date of precious pumping
Comments
(condition of inlet tee. condrocin o• a'a,m. and float switches. etc.)
DISTRIBUTION BOV%
iioc2:e on site p z-. n
De---.', o' ilcu'd le e` aoo-:e owlet ime^ f�1u�11 e�ulZsa
Corny e-ts
incite leve`' a-: datMb : o^ is eaa' evidence o of as carryover, e%idence of leakage into or out of box, etc.l
Q01.TPQ 4• ��S\l�l�Q-UTulC11�1
PUMP CHAMBER:,
(locate on site plan.
Pumps in working order: (Yes or No,
Alarms in working order (Yes or No
Comments.
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:37 (/M(4t4 6twt_
Owner:
Date of Inspection:!G
f 05?
SOIL ABSORPTION SYSTEM (SAS):
(locate on site.plan, if possible, exca.ation not required. but may be approximated by non intrusive methods,
If not determined to be present, explain:
Type:
leaching pits, number.1l.t(o
leaching chambers, number:_
leaching galleries, number.
leaching trenches. number,length
leaching fteids, numbe•, d--nens.ons
ovet'low cesspool, numbe-
Alternative s.•stem
Name of Tecnroiog.
Comments
mote condition o'soii. s:grs o' hydraulic fatlire, le.•e` of pondtnA. co ttt of vegetation etc
t� _
rC1r�Q.YV1['i �
CESSPOOLS:
(locate on site plar
Number and con-",gjra-.,or.
Depth-top of liquid to inlet tn:er,
Depth of solids lave-
Depth of scum laver
Dimensions of cesspool
Materials of construaior.
Indication of groundwate-
inflow tcesspool must oe pumpeC as par, of inspection;
Comments:
In 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 o' hvdrauhc failure, level of ponding, condition of vegetation, etc.)
(revaeed 04/I5/9^) rage I of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued;
Propert% Address: 37 (/Al(* 'blwo r.-
Owner: 3 `0,A
Date of Inspection:1O(6 l5
7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 (Locate where public water supply comes into house)
yn�
377
3 �
y d
pit-si ,'S�
�36
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM
PART C
SYSTEM INFORMATION (continued)
PropertN Address: 3-7L/0-1 ff b¢cb'C--
Owner:"3p•i7
Date of Inspection:
Depth to GroundHate,-� l Fee:
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained irom Design Plans on record
Observation o'Site (Abutting property. obsenauon hole, basement sump etc.)
Determine it from local conditions
Cnec'K %+rth local Board o• nea::r
Chec'k FE.MA maos
Check p�jmptng records
Check loca! excavato-s irstalle•s
t.se SCs Da'a
r• ,
Describe in voj• o%+- %••o•cs rro••N %o_ es:ac;!s6.ec the Groundwater Elevation. (Must be completed
a-tl�t k f/a k 1�}' h� wa.�.uc.-� � Td�,,.-- P r� r�� �o►
(rev:i•d 04;25Is-. Page 20 of 10