HomeMy WebLinkAbout0017 KENNEDY TERRACE - Health 17,KENI5 DY TERRACE
Hyannis;
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TOWN OF BARNSTABLE
LOCATION SEWAGE #
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VILLAGE VJ� A IWQXS P-Q& ASSESSOR'S MAP & LOT " 2-
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY X tJ T-N 5"32' 2 4 r% 3l
LEACHING FACILITY: (type) (size) S'b m x
NO.OF BEDROOMS
BUILDER OR OWNER 1FWWtiot \AW C
SATE: i\3�( COMPLIANCE DATE: Z 19
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the a-� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by CLO-�C
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=. C0:�I�iO\- EALTH OF MASSACHUSETTS
-,,.
EhECUTIVE OFFICE OF E\NvIR0NINIENTAL AFFAIRS
-  DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON LA 0210E (617) 292-5500 i +
110 ;
TRU,\DY CORE
/' ) Secretary
ARGEO PAUL CELLUCCI l I ``�A\ID 1�. TRL HS
Governor Co M ' sio;er
6
.7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F 1,g99
PART A \ Qo s
p Q� 0C°1 CERTIFICATION
Property Address: � �Lt�v��`-� \-txt�cl_ Name of Ow '�t� 'Vc' �( \
W. \�{(�NNLSQOIt-Address of Owner:
Date of Inspection:t63� 'l ��+
Name of Inspector:(Please rint)/ [ c1 tt' ='t-DCC.j</U
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 1310 CMR 15.000)
Company Name: 1 k t� 'r�r L.
a... r L.+.- I
Mailing Address::? /L.n a 3gL,- _L4 P4<N JE C-1h 17 Pt U2-C 4-c
Telephone Number: l Sp2_Ct
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:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspectors Signature: Date: 1 al
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to The
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
s b`� C-`cL` t'� 5,,,"s C' -f-
revised 9/2/98 page Iortt
i� Printed on Recycled Paper
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
"roperry Address:
Jwner: r .
Date of Inspection:
z\
INSPECTION SUMMARY: Check A; A C, or D:
A. SYSTEM PASSES: ;
_ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated"below.
COMMENTS: N1zf,.• °Pc',wZwtr��+y r ���y�Z�VZ— O\r Ca 'v"�.
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined(Y. N, or NO). 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; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
ifN
. t .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to de rmine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDAN WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC H AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetl d or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AN PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUB HEALTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorpti n system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absor tion system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil abso ption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil abs rption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well ater analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that fac'ity and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determi distance (approximation not valid).
3) OTHER
revised 9/2/98 Pagc3orn
r 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
have determined that one or more of the following failure conditions exist as descr' ed in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to det rmine what will be necessary to correct the failure.
Yes No
_ Backup of sewage into facility or system component due to an over aded or clogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or rface waters due to an overloaded or clogged SAS or
cesspool
_ Static liquid level in the distribution box above outlet invert d e to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or ava'able volume is less than 1/2 day flow.
_ Required pumping more than 4 times in the last year NO due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool r privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 fee of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zon I of a public well.
Any portion of a cesspool or privy is within 50 eat of a private water supply well.
Any portion of a cesspool or privy is less-tha 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the we has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compoun s, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the foil wing:
The following criteria apply to large systems in dition to the criteria above:
The system serves a facility with a design flo of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment becau a one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet f a tributary to a surface drinking water supply
the system is located in a ni ogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public
water supply well)
in accordance with 310 CMR 15.304(2). Please consult the local regional
The owner or operator of any such system shall upgrade the system
office of the Department for further information.
revised 9/2/98 Pagc'4orII
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST F
Property Address:
Owner: F 1-K
Date of Inspection:
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-receiving rwrmal 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.
x _ The facility or dwelling was inspected for signs of sewage back-up.
The 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.
The size and location of the Soil Absorption System on the site has been determined based on:
�a Existing information. For example, Plan at B.O.H.
)( _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
y 115.302(3)(b)1
The facility owner (and occupants,if different from owner) were provided with information on the proper nwintanaw-fiof
SubSurface Disposal Systems.
revised 9/2/98 Page 5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART C
SYSTEM INFORMATION
'roperty Address:L'l �X wN(AL�
Owner: F�A,
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: _g.p.d./bedroom.
Number of bedrooms(design):— Number of bedrooms (actual): 0"2
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):_k='-'1i
Laundry (separate system) (yes or n2a ; If yes, separate inspection required
Laundry system inspected gS- r no)
Seasonal use (yes or no): 1.
Water meter readings, if available (last two year's usage (gpd): (�
Sump Pump.(yes or no): iJ
Last date of occupancy��.-,--
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd 1 Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank!distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) Of yes, attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed lif known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) .�
revised 9/2/96 Page 6(if II
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(corrtinued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction:_cast iron_40 PVC_other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage,etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:_
Material of construction: concrete_metal_Fiberglass _Polyethylene_ot r(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How dimensions were determined:
'omments:
(recommendation for pumping, condition of inlet and outlet tees r baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal _Fib glass _Polyethylene_other explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outle/teeo affle:Distance from bottom of scum to bottom tee or baffle:
Date of last pumping:Comments:
(recommendation for pumping, condition nd outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/9 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
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:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: -
(note if level and distribution is equal, evidence of solids carryover, eviden of leakage into or out of box, etc.)
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 end purtenances, etc.)
revised 9/2/98. page 8orU
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
4operty Address:
Owner: t - , `
Date of Inspection: ;i 4�
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible: excav tion not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, con ition f vegetation, etc.) t ��
i
CESSPOOLS:_
(locate on site plan)
Number and configuration: L �v
Depth-top of liquid to inlet invert:
Depth of solids layer: ib''
)epth of scum layer: U''
Dimensions of cesspool: 45N Ar X 3
Materials of construction: glac�IC—
Indication of groundwater: (Va
inflow (cesspool must be pumped as part of inspection) tik---)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, conditi of_veg atio etc.)
TgA
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.)
revised 9/2/96 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontinued)
''roperty Address:
Jwner: V-- t r
Date of Inspection: t
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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32)
revised 9/2/98 Page 10ofII
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address:
Owner:V"•
Date of Inspection:k\-OCACI
NRCS Report name
Soil Type_ -
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope P ac
Surface water N0
• Check Cellar 10"
Shallow wells' fU0
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you estakllished the High Groundwater Elevation. (Must be completed) _ Cj
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4
revised 9/2/98 page iiorn
16
(�OR:TOLOTTI CONSTRUCTION INC.
sII88URYACL BEX71C3E• DTBPO.SAL SYSTEK INSPECTION PORN
Data.`•'ofLInapection -- ...
PART A
CHECKLIST
Check if the fol-lowing h`ave .been done:
Pumping...'
umping information was requested of. .the owner, occupant, and Boar-f
Health
S:
_ one 6, rE'a .;s.ystem .components. have been pumped for at least two weC'r:
and take. 4,)',Atem has: heen ;receivinq normal flow rates during that
pe%riod: rqe''.volumes of:. water; have. not been introduced into the
system re-'aantly or:."as':`part 'of this inspection ..
,_j s' bt plans ..have ;been obtained . and examined . Note if they are n, •
avai]F'16 e :With ..N%A.,
dwelling. Was inspected . for signs of sewage back-up .
� :The si4-.(A Was.. inspected for .signs of breakout .
r�All sYst ccomponents, excluding the SAS , have been located, on the
site.
The septic. ..tank manholes were uncovered, opened, and the interior _
the sept'ie• tank. was . inspected : for condition of baffles or tees ,
-mater.ial.:.of.'consti-iction. dimensions, depth of liquid , depth of
sludge-, .,d.epth of scum
The size and:.location of the SAS on the site has been determined ba<;
on ex sting.- inforiiation or approximated by non-intrusive methods .
`hs iaC iity- .owner. (and occupants, if different from owner) were
provided'--with ' information on the proper maintenance of SSDS .
I
X ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
number of current residents
garbage. grinder, e yes_ or no'
laundry connected. to system, yes or no
seasonal Use,._�. eyes Or .no
IT nonresidential, calculated flow:
water meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
Pumping ,records and source of information:
re �z f 6 a�cl 6�o�rs7
oa ---
System .pumped as , part of inspection, yes or no
if yes, volume pumped
Reason for. pumping:
Type of system. ----
Septic. tank/distribution box/soil absorption system
Singly cesspool
Overflow cesspool
Privy
Shared: system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain) _o2
Approximate age of all components. Date installed, if known. Source of
information:
Sewage odors detected when arriving at the site, yes or no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: /Y(l
(locate on site plan)
depth below grade:
material of construction: concrete metal FRP other(explain)
dimensions:
sludge depth
distaa.nce :from. .top of sludge to bottom of outlet tee or baffle
scurd..thickness
distance- from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for .pumping, condition of inlet and outlet tees or baffles ,
depth ,of liquid level in relation to outlet invert, structural integrity ,
evidence of leakage, recommendations for repairs, etc. )
:DISTRIBUTION BOX:
4locate :6n, :site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal , evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
PUMP .CHAMBER: �
(locate On site plan)
pumps in working order, yes.-or no
Comments:
(note condition of pump . chamber, condition of pumps and appurtenances ,
recommendations for maintenance or repairs, etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
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:
Type
leaching -pit and number
leaching chambers and number _
leaching .galleries and number
leaching trenches, number, length
leaching fields, number, _ dimensions
overflow cesspool number z:Q- S?_00 Ot7/. `7 ,
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding ,
condition of vegetation, recommendations for maintenance or repairs , etc . )
4
CESSPOOLS (locate on site plan) : w�
number and configuration
depth-top, of liquid to inlet invert
depth of .solids layer ---
depth . of. scum 'layer 2 - 3 t' S.LU,�6rL
. dimensions of . cesspool sr9 _—
materials . of .construction
indication`.of- groundwater -
inflow (cesspool must be pumped as
part of inspection) u A-
Comments:
(note condition. of soil, signs of hydraulic failure, level of ponding ,
condi.tion`. of vegetation, recommendations for maintenance or repairs , etc . )
- �4-
PRIVY: 1A
(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, recommendations for maintenance or repairs , etc . )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
,:include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
DEPTH TO GROUNDWATER
depth to groundwater
method of' determination or approximation: ® _
Nor e t Offs !I /' vv# —
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, . no, or not,.determined. (Y, N, or ND) . Describe basis of
,..determination -in all instances. If "not determined" , explain why not)
Backup -of sewage into facility?
Discharge or ponding of effluent to the . surface of the ground or
surface waters?
Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool<6" below invert or available volume< 112 da,,
flow?
/A/. Required pumping 4 times or more in the last year?
number of times pumped
/Y Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial enfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within . 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
within 50 feet of a bordering g
ve etated wetland or salt
(cesspools and privies only, the SAS) ? marsh
within 50 feet. of a private water supply well?
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 analys
for, coliform bacteria, volatile organic compounds, ammonia nitrogen
and .-nitrate nitrogen.
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspectors 1
�' P4 I�
- an ComP y Name
Company Address 7�Os
Certification Statement
I certify; U.,at I h.ays person llyr inspected the .3ewage di,s,pQ-5al system at
this .address.,and that the information reported is true, accurate and
complete as` ot. the time of inspection. The inspection was performed and
any recommendations .regarding upgrade, maintenance and repair are
consistent..with ,my training and experience in the proper function and
manitenance. of: on-site sewage disposal systems.
qkec ne:
I. have -not found any information which indicates that the system fails:
to adequately protect public health or the environment as defined in
310 CMR- 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15 . 303 . The basis for this,
determination is provided in the FAILURE CRITERIA section of this.
form.
Inspector's .Signature
Date
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority