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Executive Office of Er)vironmentai Affairs D.E.P. Tiy� �eptic for
Department of TFto et 10253 CA
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Environmental P�lon
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
PART A to
L N� CERTIFICATION
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Property Address: 18 Christina PathE a Address of Owner:
Date of Inspection:217197 (if different)
Name of Inspector John Gracl Grossman:94 Ardmore Rd.Needham Ma.02194
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes This Inspection Is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.MV findings are of how the system is
performing at the time of the Inspection.My Inspection does
Needs Fu
rthEvaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the
Fails septic system and any of its components useful life.
inspector's Signature: Date: 219f97
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY: 1
Check A. B.C,or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as 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 exfiltration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street 9 Boston,Massachusetts 02108 • FAX(617)5564049 9 Telephone(617)292-5500
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 18 Christina Path Centerville
Owner: Grossman:94 Ardmore Rd.Needham Ma.02194
Date of Inspection:2n197
_ Sewage backup,or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT.THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 teet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D) SYSTEM FAILS:
_ I have determined that the system violates one or more of the,following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 18 Christina Path Centerville
Owner: Grossman:94 Ardmore Rd.Needham Me.02194
Date of Inspection:217197
D] SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information.
(revised 11115195)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 18 Christina Path Centerville
Owner: Grossman:94 Ardmore Rd.Needham Ma.02194
Date of Inspection:217197
Check if the following have been done:
_X_Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the 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.
n1aAs built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
x The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub
Surface Disposal System.
(revised 11115195)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 18 Christina Path Centerville
Owner: Grossman:94 Ardmore Rd.Needham Me.02194
Date of Inspection:2A197
FLOW CONDITIONS
RESIDENTIAL.
Design flow: 339 gallons
Number of bedrooms: 3
Number of current residents: 9
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): Yes
Water meter readings,if available: nla
Last date of occupancy:weekends
COMMERCIAUINDUSTRIAL:
Type of establishment: Ma
Design flow:9 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no)No
Water meter readings,if available: n►a
Last date of occupancy: nN
OTHER:(Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System was last pumped in May 1996
System pumped as part of inspection:(yes or no)No
If yes,volume pumped: 9 gallons
Reason for pumping: n1a
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions 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 information:
1983
Sewage odors detected when arriving at the site:(yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 Christina Path Centerville
Owner: Grossman:94 Ardmore Rd.Needham Ma.02194
Date of Inspection:V7197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 16"
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L8'6-H5'7'W4'IV
Sludge depth:V
Distance from top of sludge to bottom.of outlet tee or baffle: 28'
Scum thickness:6
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle:0
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: nla
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: nla
Scum thickness:n►a
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
nla
(revised 11115195)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 Christina Path Centerville
Owner: Grossman:94 Ardmore Rd.Needham Me.02194
Date of inspection:?A197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:Na
Material of construction,._concrete_metal_FRP_other(explain)
Dimensions: Na
Capacity: n1a gallons
Design flow: Na gallons/day
Alarm level: Na
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Na
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Na
(revised 11115195)
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SUBSURFACE SEWAGE DISPOSALCSYSTEM INSPECTION FORM
SYSTEM INFORMATION(continued)
Property Address: 1s christina Path centerville
Owner: Grossman:94 Ardmore Rd.Needham Me.02194
Date of Inspection:y7197
SOIL ABSORPTION SYSTEM(SAS):X approximated by non-intrusive methods)
(locate on site plan,if possible;excavation not required,but may be
if not determined to be present,explain:
Na
Type: 1,00o gallon leach pit
leaching pits,number:
leaching chambers,number:nla
leaching galleries,number: Na
leaching trenches,number,length: !—a_
leaching fields,number,dimensions:n1a
overflow cesspool,number:n►=
comments:(note
em condty at ition
timeoftheinn of h Risstru turall sound!lic failure,level of ponding,condition of vegetation,etc.)
The lea
CESSPOOLS:
(locate on site plan)
Number and configuration:
nla
Depth-top of liquid to inlet invert: n a
Depth of solids layer: na
Depth of scum layer: n1a
Dimensions of cesspool: Na
Materials of construction: na
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Na
comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,,etc.)
-------------------------
Na
PRIVY:_
(locate on site plan)
Dimensions: n1=_-
Materials of construction: nta
Depth of solids: Na
comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.
Na
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 Christina Path Centerville
Owner: Grossman:94 Ardmore Rd.Needham Ma.02194
Date of Inspection:V7197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
U HC :l
DOG
AA
gq �a Oc
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
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