HomeMy WebLinkAbout0183 BUCKWOOD DRIVE - Health 183 Buckwood Drive
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Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal Sy>#em Form Not for Voluntary Assessments
P—? gcf C'�-t'xo 0 C)
Property Address I ---- �- - __...�
_ w+
Owner Cw ner's Name
infomtation is
required for every A✓ Vol: V
�_ / ✓7 Uo�60 // �� .�,,;,
page. Cityrrown State T Zip Code Date f Ins ion ..
_ N
ry
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.
Ynportaor n A General Information fillingthe
out f forrrs ms A.
on the computer,
use ony the tab 1. Inspector
key to move your
cursor-do not
use the return Name of Inspector _
O°npany Name 0 o I
Company Address
Qty/Tow so ? O O ' / State
L740 Zip Code
Telephone mbar L rcense 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. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 C 5.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
rq W/ S
///11,6
hspecto'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 i 0,GGG god or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
"'*This report only cescribes 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.
15ns•3H 3
Tme50fficial InspeotionForm Subsufacesewageoisposal System-Page 1 of17
�� V's
Commonwealth of Massachusetts
Title 5 Official Inspection Foram
Subsurface Sewage; D14"al System Forth -Not for Voluntary Assessments
Property Address
ON ner ON ner's Name
information is
required for every G✓I vl►S dy oc)-tg 0/ 9ft/Ltion
page. City/Town State Zip Code Date
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/a/wayscomplete all of Section D
A) "have
sses:
I not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System 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 ex0ain.
4
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):
x
t5ris•3M3
Title 50ffidal Inspection Form Subsriface Savage Disposal StCtem-Page 2 of 17
Commonwealth of Massachusetts
Tide 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19— �N G�L✓00 �i'l I/�,
Property Address
.�INi ✓l
Ow ner Ow ner's Name
information is //
required for every il G✓4/r �� //,�1 ate'01 6
page. Cityfrown State Zip Code Dati of Inspection
B. Certification (corn.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms 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 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):
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 mannerwhich 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
Lyre•3N 3 Title 5 official Irs pectimFom[SubsurfaceSngeDisposal Systam•Page 3oi17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address L ,
Ow ner ON ner's Name
rreequ'lr�edforev go
,��� �.� 0o-60/
page. Clityfrown c7tState Zip Code Date oflinsp6cWn
B. Certification (colt.)
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 cesspool is less than 6'below invert or available volume is less
than day flow
Ors-3M3 Tide 50flicial Inspection Form:SubsOaceSexrageDisposal System-Page 4of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
VON Vm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V / 9-?
Property Address
Ow nerinfoffnftn is Owner's Name
required for every a NH S
page. City/Town State Zip Code Date of ftpection
B. Certification (cont.)
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 fleet 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.
❑ 1:r3" 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.]
❑ e system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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.
t5ns•3113 Ti9e5Of5aallnspeebanForm sutsuface Somme Disposal System-Fage5of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage
QDisposaI System Form -Not for Voluntary Assessments
Property Address
Owner ���✓I
information is Owner's Name /
required for every G#14/ ���c/
page. Cityf row n State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate`yres°or"no'as to each of the following:
Yes N
2 El Pumping information was rovid e p g provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
❑ the system received normal flows in the previous two week period?
ElHave 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 (f any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 for example: 110( p gpd x#of bedrooms):
t9m-3%3 Title 5Official Inspection F om[Subsurface Sewage Disposal S)SWM•P89e 6 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage O Disposal System Form Not Not for Voluntary Assessments
J
Property Address '
ON ner Owner's Name ,
information is
required for every y1 G✓1 k1
page. Calyrrown 011 State Zip Code Weof In ection
D. System Information
Description:
C� -Fe /C/
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No
information in this report.)
Laundry system inspected? ❑ Yes
Seasonal use? ❑ YeS No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes No
Last date of occupancy: cf,C4
Date
Commercialilndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM R 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Sm•T13 Title 5Official Ire pecficn F amr Subsuface SewVe Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/ 3 9� C,1 —woo 1 �ii r�
Property Address
Ow ner Ow ner's Name / -
requir required for
is f- a ki o t s �i¢ Da b o l ��
required for every
page. CStylrown 01State Zip Code We of Inspection
D. System Information (coat.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of S m: III
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/Altemative 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 VA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(descri be):
t5ns-T13 Yille50MdallmpecdonFomcSubsufaceSewdgeoispoW System-Page Sol f7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
/83 9C., C X-wo� J
Property Address Owl
Owner Owner's Name
information is /77� /�� 0� 60/ 3 <<
required for every G N y(f
page. CRyfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed(if known)and source of infbnnation.ns� ��L
4L41%" aNd 0Isi 00Q151n4 /
Were sewage odors detected when arriving at the site? ❑ Yes
Building Sewer(locate on site plan):
Depth below g feet
Materi of construction:
cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade:
feet
Material 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:
Sludge depth:
15re•3H3
Title5Of ialInspectlan Form SubSWace Sewage Disposal System-PageWW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18.E 41&vvJd
Property Address
ON ner ON ner's Name _
infometion is
requiredforevery ci✓�v1 [I /� �oZ 60/ �/ ��
page. Cityfrown State Zip Code Date Ins action
D. System Information (cost.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness �V SC C,4 V'�
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
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.):
Gw � G;^J -kes / ✓>
o v► �,- I �t'0�7
/ V D 0&
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
tans•3n 3
Title5Official Impaction Fatrt Substrface SevmeDisposal SysDem•Page 10of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
UV 1 ;?3
Property Address �—
�Llt L4
Ow ner ON nets Name I information is r / 1/ 4 of 6�
required for every h✓1 I I
page. C Town State Zip Code Date of hispectlon
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 worldng 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
Mrs-3n3 710050rficial InspecknForm Subsirfaoe SOWMeOisposal System-PVe 11 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not far Voluntary Assessments
�� a��✓c,/o o -Dn o/
� Property Address i
ON ner owners Name ///� (��(� / 31111
(�
ir>forrretion is �"
required for every "/G✓J✓l/t
page. Clly/Town State Zip Code Date at hsp&tbn
D. System Information (cont.)
Distribution Box (f present must be opened)(locate on site plan): _
Depth of liquid level above outlet invert ,�-ye- V�
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.):
�e Sobs
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:
tyre'313 riideSOfficial IrepecfionForm Subsufam Sewage Disposal System•Page 12 of 17
commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage
/Disposal System Forth -Not for Voluntary Assessments
r U✓ �u G h�L✓O c�� ��6 V`>`�+
Property Address
ON ner QN ner's Name
information is
required for every ✓i 1S /9 Oo? 0/ 3 !/ 6
page. CGy/Town r
71 State Zip Code Date of 1 spection
D. System Information (cunt.)
Type:
leaching pits number.
❑ leaching chambers number.
❑ leaching galleries number.
❑ leaching trenches number, length:
leaching fields / / number, dimensions:
❑ overflow cesspool l� number.
❑ innovativelaltemative system
Typetname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
/ CJ ' l4S
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
t5ns-3H 3
Title5Official tMpecfionForm SubstOeCB$eNrageDisposal System-Fte 130f 17
f -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address _
Ow ner
information is CW nei's Name /
required for every �✓r✓I i1 X 0a 60
page. Cylfown State Zip Code Date of Inspection
D. System Information (corn.)
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.):
t.9ns•3M 3
7itle50tficial IrspecticnFarm SubsWace Sewage Dispwal System-Page 14 of 17
Commonweafth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Ow ner Ow ner's Name
infommdon is
required for every Gl N N 13 OP 6 0
page. CRyfrown State Zip Code Date Insp
ection
D. System Information (cost.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where blic water supply enters the building. Check one of the boxes below.
hand-sketch in the area below
❑ drawing attached separately
d+ct✓
C
14G ,020-),
/4 L.,
t5ns-3M3
Tide 50fticial Inspection Famc Subsurface Se"eDisposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
U1WSubsurface Sewage Disposal System form -Not for Voluntary Assessments
&C, 61wood al v-c--
Property Address
Ow ner Oav ner's Name
information is / L1111
-f7requiredforevey q rT y(� /" ��-6 0 3
page. Ctyrrown State Zip Code Date Inspection
D. System Information (cost.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells �f
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from sy
stem design plans on record
If checked, date of design plan reviewed: Date
❑ served 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 hh w yo established the high ground water elevation: /
& 49 — J e
6V I J lam- 7(��f
T(;
�
K
Before filingthis Inspection spec6on Report, please see Report Completeness Checklist on next page.
tsrs-3H3
Title50fficial lnspectionFo=SuburraceSe Me Disposal system-Page le orl7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
/ �J iJu G�✓(,/O�C �/l(i2i
Roperty Address �C✓� vl
Oar nor Ow nees Now
infomedon is
requiredforevery �G vt Nl1
page- CRy/Town State Zip Code Date of pection
E. Report Completeness Checklist
M ft spection Summary:A, B, C, D, or E checked
"Ins�De
Summary D(System Failure Criteria Applicable to All Systems)completed
formation—Estimated depth to high groundwater
S of Sewage Disposal System either drawn on page 15 or attached in separate file
I
i
t5as•sns 70950MW xspeCOMFomi Saeeutaoe sewagaoispwd sPW-Doge 17 d 17
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r Commonwealth of Massachusetts
3:
Executive Office of Environmental Affairs
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Department of
Environmental ` '�
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address; �.� � /7� Address of Owner.
Date of Inspection: -'Z( (If different)
Name of Inspector.
Company Name,Address and Telephone Number.
CERTIFICATION STATEMENT
I oertify 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:
_6-1-passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails'
Inspector's Signature: `✓ Date: l
The System Inspector s mit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner&hall 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 coterie as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate 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 exflltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a yonforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)U&1049 a Telephone(617)292.5500
iJ vnmed on"led v.per
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner.
Date of Inspection:
81 SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the bution box is due to broken or obstructed pipe(#)
or due to a b settled or uneven distribution boz. The system pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or re
The system required ping more than four times a due to broken or obstructed pipe(s). The system will pas#
inspection if(with app al of the Board of Health):
broken pipe(s)are rep ced
obstruction is rem
C) FURTHER EVALUATION IS REQUIRED B TH BOARD OF HEALTH:
Conditions exist which require further ev t n by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the enviroame
1) SYSTEM WILL PASS UNLESS OARD OF H TH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PRO ECT THE PUBLIC EALTH AND SAFETY AND THE ENVIRONMENT:
Ceupool or privy ' within 50 feet of a surface wa
Cesspool or is within 50 feet of a bordering ve ted wetland or a salt,marsh.
2) SYSTEM WILL FAI UNLESS THE BOARD OF HEALTH PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES T THE SYSTEM IS FUNCTIONING IN A THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND T ENVIRONMENT:
The m has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
ce water supply.
e system has a septic tank and soil absorption system and is within a Zone I of a public water supply.well.
_ 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.
S) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner.
Date of I,- tion:
DI SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defuied in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
Backup of sewage ' to facility or system component due to an overloaded or gged SAS or cesspool.
Discharge or ponding of�eMuent to the surface of the ground or surface ten due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution bar above outlet invert du an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or av ble volume is less than 1/2 day flow.
Required pumping more than 4 t es in the last NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption S m, pool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or pri is wit a Zone I of a public well.
Any portion of a cesspool pri%*r is within feet of a private water supply well.
Any portion of a seas 1 cr privy is less than 1 feet but greater than 50 feet from a private water supply well with no
acceptable water ty analysis. If the well has n analyzed to be acceptable,attach copy of well water analysis for
coliform baste ' volatile organic compounds,ammo ' nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAI �.
The following 'teria apply to large systems in addition to the criteria above:
The syste 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 d 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 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
9
Property Address:
Owner.
Date of Inspection:
Check if the following have been done:
`��Pumping information was requested of the owner,occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
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.
L_-T he system does not receive non-sanitary or industrial waste flow
_The site was inspected for signs of breakout.
All system components,excluding the Soil Absorption System,have been located on the site.
The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
v/_The size and location of the Soil Absorption System on the site has been determined based on existing information or
app ted by non-intrusive methods.
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) 4
u
➢) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner. Q �;
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL-
. v
Design flow- sallons
Number of bedrooms: 5
Number of current residents:
Garbage grinder(yes or no): _
Laundry connected to system(yes or no):
Seasonal use(yes or no): ✓� E
Water meter readiW if available: ch� -
Last date of occupancy:
COM M ERC IAL A ND USTRIAL•
Type of establishment:
Design flow:_Ballons/day
Grease trap present: _
Industrial Waste Holdhor no
g--Tank present: r no)_
Non-sanitary waste discharged to the Title 5 syste or nol_
Water meter readings,if available:
Last date of occupancy:
OTHER (Describe)
Lost date of
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no),d,/<:-;P
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF STEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: /��.4n ��/(v_ /0—<�
Sewage odors detected when arriving at the site: (,yes or no).4�
(revised 11/03/95) b
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of Inspection: `3
SEPTIC TANW_
(locate on site plan)
Depth below grade: G
Material of Construction:_concrete_metal_FRP_other(e:plain)
Dimensions: )
Sludge depth: A6-X9�� -q�
Distance from top of sludge to bottom of outlet tee or baffle:
Scum Scum thickness:_ it
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 4d
Comments:
(recommendation for pump' con_ditio-n oytnlet and o tlet tees or baffles, depth of liquid 1 . 1 in relation to e Avert,structural integrity,
eviden f 1 etc.) Ct'✓�'� "f
Alb
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _con metal_FRP_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet or baffle:
Distance from bottom of scum to bo of outlet tee or
Comments:
(recommendation for ping, condition of inlet and outlet tees or baffles,dept d level in relation to outlet invert,structural integrity,
evidence of etc.)
(revised 11/03/95) 6
�i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: , 7n, '3
Owner.
Date of Inspection:
TIGHT.OR HOLDING TANK_
(locate on site plan)
Depth below Bade:
Material of construetion: concrete_metal_M_other(expkin)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee,conditi f alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth.of liquid level above outlet invert:
Comments:
(note if level and ' nbution is dense of solids carryover,evidenge of le into or out o box,etc.
PUMP CHAMBER_
(locate on site plan)
Pumps is wanking order:(yes or no) .
Comments:
(note condition of pump chamber a of pumps and nanoes,etc.)
(revised 11/03/95) 7
s ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t
PART C
SYSTEM INFO�R/MATION(continued)
Property Address:
Owner.
Date of Inspection: 7F-'
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:
lsachinB pits, number:
leaching chambers,number:_
leaching galleries,number:
leaching trenches, number,length: U
leaching fields, number, dimensions: I
overflow cesspool,number:
Comments: (n condition,of soil,signs of dra 'c_f level of pon ndition of ve tatioa etc
X S
CESSPOOLS:_
(locate on site plan)
Number and configure ' n:
Depth-top of liquid to isle vert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as of inspection)
Comments: (note condition of soil, s' of hydraulic failure,leve nding, condition of vegetation,etc.)
i
PRIVY:_
(locate on plan)
of construction: Dimensions:'
Depth of solids:
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
(revised 11/03/95) S
e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: 3 . 2 ( — �-
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
`p
I
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I I
22-
13
13
2-1
DEPTH TO GROUNDWATER
Depth to groundwater._,L-�,_feet z> �S n9
method of dete nation o�ro i on: Ci
(revised 8/1s/9s) 9
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TOWN OF BARNSTABLE
LOCATION SEWAGE#
VILLAGE �S ASSESSOR'S MAP& LOTS 7/"
INSTALLER'S�NAME&PHONE NO. P tA.0 2 ,U
SEPTIC TANK CAPACITY / Oc> d
LEACHING,FACILrTY: (type) 16 Y 2` size)
NO;'OF BEDROOMS 3 {r
BUILDER OR OWNER_ 'Ft..n f"A e
PERMUDATE: `~l�� COMPLIANCE DATE: /a
Separation Distance Between the:.
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (if any wells exist.
on site or within 200 feet-of leaching facility) G Feet
Edge of Wetland and Leaching Facility-(If any wetlands exist �,�
within 300 feet.of'leac 'ng facility) /vQ''�-�' Feet:-':,
Furnished by .� fL�
,
,. Q
°
� f
i
TOWN OF BARNSTABLE
LOCATION I S is lz�v. SEWAGE # 6So
VILLAGE - ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I d
LEACHING FACILITY: (type) size)
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMTTDATE: :9 tL COMPLIANCE DATE: 1:—/Z
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 7 Feet
on site or within 200 feet of leaching facility)
Gc9X�.�
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) S / Feet
Furnished by Q_ �
� � � � � �
f [ t � r �
row � � � �'
(� � � �•G
� � � �
�-
O O
� II
---,
_ _ � �
• t.�
� 4 �
No. i�Q Fee ,!r—o [J
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Dig ozal 6 .5tem Cow5truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Loca tiQnddres�ot � /f Owner's Name,Aciress and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,4nd Tel.No. Designer's Name,Address and Tel.No.
JrMo/2n.,�
2 s S,4 t-4e-
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow i gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature o Repairs or Alterations(Answer when applicable) f�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions .tle 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu d by is Board o ealt q
Signed r �-' Date�1 s l�'l
Application Approved by Date ( -
Application Disapproved for the ollowing reasons
Permit No. - Date Issued
No. �(o S� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC.HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for 30igponl bp$tem Conotruction Permit
t` Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
r Lope' ,Addresis�ot Nq a/r Owner's Name,Address an 1.No.
Assessor's Map/Parcel
Installer's Name,Address,4nd Tel.No. Designer's Name,Address and Tel.No. i
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
I
Design Flow 3 ?> gallons per day.'Calculated daily flow gallons. i
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. '
Description of Soil
Nature o Repairs or Alteration (Answer when applicable) 1;2� 2, S
Date last inspected:
j
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of-Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board qf-tleal � -
Signed %GAL•—�. Date
Application Approved by Date
Application Disapproved for the�following reasons k
i
Permit No. - 49 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System ConstructedA-rRepaired( )Upgraded( )
Abandoned( )bya /
at / has been constructed in accordance l
with the provisions o itle 5 and the for S Disposal stem Construction Permit No. - dated
P Y
Installer •J 117 8 /fllJ Designer
The issuance of his e t shall of constrp as,ajuarantee that the ill function a e!R�e
Date '` Inspe or
N
i
(OFee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migogal *p5tem Construction Permit
Permission is hereby granted to Construct Repair( Upgrade( )Abandon( )
System located at ,•■a a
i
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: Approved by ,
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, (Ile V2r y ,hereby certify that the application for disposal works
construction permit signed by me dated 2 concerning the
property located at eets all of the
following criteria:-
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : DATE: ZZ=l 2-
LICENSED SEPTIC STEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
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