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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ]ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
0 CERTIFICATION
Property Address: 85 ���AiA
Owner's Name: .t, � t�G/•!t•�jary p�q,/_�J�
Owner's Address:
Wkk
Date of Inspection: [O/S 06
Name of Inspectotleaprint)Company Name: 4 e4fro�Mailin Address:Telephone Numb
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 the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. Iam a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes C? `=
Needs Further Evaluation by the Local Approving Aut�Tt ty
'Fails
c . w
uo
Inspector's Signature: ;' '
Date: /D
tr.
The system inspector shall submit a copy of this inspecti
DEP)within 30 days of c on report to the Approving Authority(13 and of lth
png this inspection. If the system is a shared system or has a desi n o
omleti flw OTI 0,060
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.
Notes and Comments
****This report only describes conditions at the time of inspection and under
the of
time. This inspection does not address how the system will perform in the future underconditions
same use of that
conditions of use.
or different
Title 5 Inspection Form 6/15/2000
page 1
Page 2ofII
OFFICIAL INSPECTION FORM-=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTIO
N FORM
. PART A
CERTIFICATION(continued)
Property Address: s��i -a
A
Owner: o ci e
Date of Inspection: /D — o6
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I 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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section nee be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the and of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following s ments.If`not determined"please
explain.
The septic tank is metal and over 20 years old*or the septi (whether metal or not)is structurally
unsound,exhibits substantial infiltration or enfiltration or tank ire is imminent System will pass inspection if the
existing tank is replaced with a complying septic tank as ap ved by the Board of Health.
*A metal septic tank will pass inspection if it is sl ctura sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is avai le.
ND explain:
Observation of sewage backup or b ow or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,se d or uneven distribution box. System will pass inspection if(with,
approval of Board of Health):
roken pipe(s)aneieplaced
obstruction'as.removed
distribution box is leveled or replaced
ND explain:
The system re fired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(.w' approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: $-'r h
K
Owner:—IS0r-\1e4A a,
Date of Inspection: to( 00
C. ]Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to ermine if the system is failing to protect public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance with 3 CMR 15.303(i)(b)that the
system is not functioning in a manner which will protect public health afety 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 w and or a salt marsh
2. System will fail unless the Board of Health(and P blic Water Supplier,if any)determines that the
system is functioning in a manner that protects the ublic health,safety and environment:
_ The system has a septic tank and soil abs tion system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surfac water supply.
— The system has a septic tank and S and the SAS is within a Zone I of a public water supply.
_ The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic t and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well** ethod used to determine distance
*This system passes if a well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile ganic compounds indicates that the well is free from pollution from that facility and
the presence of am onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria ar triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of l l
OFFICIAL INSPECTION FORM`—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM
PART.A
CERTIFICATION(continued)
Property Address: $,S:
A i '
Owner: u
Date of Inspection: to 6
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
A� 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''/Z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the 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.
-a Any portion of a cesspool or privy is within a Zone I of a.public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis..[This system passes if the well water..analysis,
performed at a DEP certified laboratory for cothform bacteria and volatile organic_compoands
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,provided that no other-failure criteria
fy, are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)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 acility with a design flow of 1
gpd• 5 0,000 gpd to 15,000
pa
You must indicate either"yes"or"no"to each'of following:
(The following criteria apply to large systems ' .addition to the criteria above)
yes no
the system is within 400 t of a surface drinking water supply
the system is within 0 feet of a tributary to a surface drinking water supply
_ the system is to ted in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a blic water supply well
If you have answer "yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section above the large system has failed.The owner or operator of any large system considered a.significant thre under Section E.or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The stem owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CI-IIECKI:IST
Property Address: .57 i hJ L,
C
Owner' se44C d esv
Date of Inspection: 10 06
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
Qr 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?
Ithe
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
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:
Y no
_ 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 CNM 15.302(3)(b)]
I
5
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Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: cSaet� tsuS _
Date of Inspection: 0(4, 6 —"
RESIDENTIAL
FLOW CONDITIONS
Number of bedrooms(design):_I Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): y�
Number of current residents: 49
Does residence have a garbage grinder(yes or no): /Ib
Is laundry on a separate sewage system(yes or no):!�[if yes separate inspection required]
Laundry system inspected Ves or no): /-V
Seasonal use:(yes or no):. 25
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):/-V
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): -nd
Basis of design flow(seats/persons/sgft c.):
Grease trap present(yes-or no):
Industrial waste holding tank pr nt(yes or no):_
Non-sanitary waste discharg to the Title 5 system(yes or no):
Water meter readings, if ilable:
Last date of occupanc se:
OTHER(desc ' e):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):AD
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
—Septic tank,distribution box,soil absorption system
a 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)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
a�c6
Were sewage odors detected when arriving at the site(yes or no)/v
6
Page 7of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: QS
i ` n .
Owner:
Date of Inspection: p p(5
BUILDING SEWER(locate on site plan)
n
Depth below grade: It
Materials of construction: [cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage,etc.):
SEPTIC TANK:—(locate on site plan)
Depth below grade:
Material of construction:_concrete metal fiberglass pol thylene
—other(explain)
_ -'
If tank is metal list age.— Is age confirmed by a Certific of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of ou t tee or baffle:
Scum thickness:
Distance from top of scum to top of o 11 et tee or baffle:
Distance from bottom of scum to b om of outlet tee or baffle:
How were dimensions determ` d:
Comments(on pumping rec mendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet inve evidence of leakage, etc.):
GREASE TRAP:—(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal . fiberglass--Polyethylene lyethyl other
(explain): — --
Dimensions:
Scum thickness:
Distance from top of scum to top o utlet tee or baffle:
Distance from bottom of scum to ottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping rec endations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, vidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: dS
Date of Inspection: 6 6
TIGFIT or HOLDING TANK: (tank must be pumped time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: 7inorking
Design Flow:
Alarm present(yes or
Alarm level: (yes or no):
Date of last pumping:
Comments(condition es,etc.):
DISTRIBUTION BOX: (if present m e opened)(locate on site plan)
Depth of liquid level above outlet in
Comments(note if box is level distribution to out
equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc. .
PUMP CHAMBER: (locate on site
Pumps in working order(y/oo):
Alarms in working order(Comments(note condition chamber,condition of pumps and appurtenances,etc.):
i
8
Page 9 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 85—
Owner• do i osu�
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
je 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.): `
CESSPOOLS:_1,(_(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: eZ 1 in li A,f
Depth—top of liquid to inlet yivert: , :;A .
Depth of solids layer__
Depth of scum layer: O
Dimensions of cesspool: _V ,
Materials of construction.�lr — —/,1c 'k
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure :level of p ding,condition of vegetation et
6 i h VP O cI' e4 ;„t rr,ril .
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition o oil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
I
9
Page 10 of 11
OFFICIAL INSPECTION FORM•—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM T
. PART C
SYSTEM INFORMATION(continued)
Property Address: rK/4 G��•(
Owner: SDcl a Sus
Date of Inspection: O
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
z V
I
•-Page 11 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
l SYSTEM INFORMATION(continued)
Property Address: M�h
Owner: S ` o
Date of Inspection:
SITE EW Slope
Surface water oJO
Check cellar YlP.S
Shallow wells ad
Estimated depth to ground water Z10 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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 ou established the high ground water a evatio
J� �'`-5 Y - �4-- �E't&1 c3 O (f C31 d C .
11
I •�I�t
- -
COMMONWEALTH OF h1ASSACHi SETTS
__- E�iECL'TI�'E OFFICE OF E\"VIR0N14E\TU AFF.-UP
,
` -=r DEPARTMENT OF ENVIRONMENTAL PROTECTION-'
ONE RT\TER STREET. BOST0N %Lk 02108 (6171 292-55(lo
TRL;DY CORE
Secretary
ARGEO PALL CELLLCCI DAVID B. STRUHS
Governor k. , ... r.. Cornmissirine:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
<.
PART A
`�e 1 CERTIFICATION
Property Address: ?�J N � �IvriS Name of Owner {LO
.- —fress of Owner:
Date of Inspection: `1?j2 �Ct / /
Name of Inspector:(Please Pn )! t C 4[ic' -'�I`�EC ICU ` -_ :� '"J ► �(
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5_(310 CMR 15.000)
Company Name: -�rA.._Y . .
Marring Address: ,o -4 ,4 'Z. 7�?LL. b� NI!�!1-- =17
ephone Td Number: .:�SQ���Lt,�;� s:;;/�,r'='••'P O ,+z; ; , . . ... »�, . .... ... ,
'_CERTIFICATION STATEMENT
I Certify that I have personally inspected the`sewege 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
Conditiorielly Passes"'
Needs Further E u ion BLytheLocal Approving Authority •,,_,, :. .,_: t .
ils
Inspector's Signature: ' Date: 2
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.
�'SI J9
NOTES AND COMMENTS
O
4&C
r
1104 3Igg9
ti
revised 9/2/98 P; .. _
a ? LL Ci'Printed on Recycled Paper
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
'.., PART A ¥
CERTIFICATION (continued)`roperty Address: 9,!�,
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, 8, C, or D:
A. SYSTEM PASSES:
- +a• S( _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist Any failure
T� criteria not evaluated are'indiceted below.'
COMMENTS: (�
B. SYSTEM CONDITIONALLY PASSES:'r'
.-
One or more system components as~described in the "Conditional Pass" section need to be replaced or.repaired The.system,,.upon
d b the Board of Health, will pass._
completion of the replacement or repair, as ap'rave y
Indicate yes, no, or not determined (Y, N, or ND).-Describe basis of determination in all instances. If "not determined", explain why not.z
_ 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. F. tz",
_ 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
-- -.,
Al
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revised 9/2/98 't wa'; <Page2of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A"
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIR BY THE BOARD OF HEALTH:
—Conditions exist which require fu er evaluation by the Board of Heaith in order to determine if the system is failing to protect the
public health, safety and the enviro menL r..r:..
1) SYSTEM WILL PASS UNLESS BOAR OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 surface water
Cesspool or privy is within 50 eet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF H TH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE.SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS E PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil:bsor
bso ption 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 ion system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorp 'on system and the SAS is within 50 feet of a private water supply well..
The system has a septic tank and soil absorpti n system end the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water nalysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and he presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distanc (approximation not valid).
31 OTHER
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,�r # t.+n,.f_.., c,�+ ni`�3:°..,�,.':`.�'0?. ,. sz s-c� ,m'$t"". ?d;t-' .l•..�..,?:,..o«w` ro» ^,b^+:
• . . . !:"s:. _:,F^, n ... .=.r r r tit^?v. -,:^ .
revised 9/2/98 _Page 3of11
r t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A t_
CERTIFICATION`(corrtinuedl
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 described' 310 CMR 15.303. The basis.for this
determination is identified below. The Board of Health should be contacted to'determi a what will be necessary to corre--t the failure.
Yes No
_ Backup of sewage into facility-or system component due to en overload d'or clogged SAS or cesspool. '
Discharge or ponding of effluent to-the surface of the ground or surf ce waters'due'to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due o an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or avail le 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, cesspo or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within,100 eat of~a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within one I of a public well
is with' 50 feet a P I + - -
of M water supply pP Y well.
_* _ Any portion of a cesspool or privy
,,,...,,. ,
_ Any portion of a cesspool or privy is I s•than 100 feet but greater than 50 feet from a private water supply well with.no
acceptable water quality~analysis. If he well'has been analyzed to be acceptable, attach copy of well water analysis for
volatile or anic c mpounds, ammonia nitrogen and nitrate nitrogen.
�coliform bacteria,. 9
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each f the following:
The following criteria apply.to large s tems in addition to the criteria above:
The sY stem serves a facility with a esign flow of 10,000 gpd or greater^(Large System) and the system is a significant threat to public
_
health and safety and the environ ant because one or more of the following conditions exist:
Yes No
the system is wit n 400 feet of a surface drinking water supply
the system is thin 200 feet of a tributary to a surface drinking water supply
the system i located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public
water supp welll .`
The owner or operator of a such system shall upgrade the system to accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department f r further information. t
a
revised 9/2/98 Pagca°rll
1 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
:.CHECKLIST
Property Address: �V I,(/k&
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or."No" as-to each of the following:
s No y
Pumping information was provided by the owner, occupant, or Board of Health.
A _ None of the system components have been pumped for at least two weeks and-the system has been-recehhng r1ormal 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 NIA.
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:
Existing information. For example, Plan at B.O.H. 6
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(15.302(3)(b)]
The facility owner(and occupants,if different from owner) were provided with information on the propernmintanan"-of
SubSurface Disposal Systems.
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revised 9/2/98 � ,40c pagc5of11
SUBSURFACE SEWAGE DISPOSAL,
SYSTEM INSPECTION FORTY
''PART C
( `• (�, SYSTEM INFORMATION
'roper-tyAddress:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:, g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual):
Total DESIGN flow?"*�o
Number of current residents:-L�A19
Garbage grinder(yes or no):_j&(W "` I:, '',
Laundry(separate system) ( es or no): If yes, separate inspection required
Laundry system inspecteiJ e r no) "
Seasonal use (Yes or no):-EJ
Water meter readings, if available (last two year's usage (gpd).
Sump Pump(yes or no):—L3-
Last date of occupancy:, "
COMMERCIALfINDUSTRIAL: "-
Type of establishment:
Design flow: qpd ( 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 not_
Water meter readings,if available:
Last date of occupancy:''
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING.RECORDS and source of information:
tnyos, f a JZ--
System pumped as pan of inspection: (yes or n )_
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) (if 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: 'c2l S
Sewage odors detected when arriving at the site. (Yes or no) r
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-
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction: _cas iron_40 PVC other (explain)
Distance from private water supp well or suction line `
Diameter
Comments: (condition of joints, ven 'ng, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction:_concrete_met Fiberglass _Polyethylene_other(explain)
If tank is metal, list age— Is age confirmed y Certificate of Compliance (Yes/No) -
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet te\outle
:
Scum thickness:
Distance from top of scum to top of outlet tee or
Distance from bottom of scum to bottom of outletfle: „
How dimensions were determined:
'omments:
(recommendation for pumping, condition of inlet aees or 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_Fiberglass _Poly hylene_other(explain)
Dimensions:
Scum thickness: a.
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 inlet and outlet tees or baffles,dep h of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
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revised 9/2/98 Page 7of11 • _ ,..
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
rr a"PART C'
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank ust be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_meta _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 swit es, 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, a deuce 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 and appurtenances,etc.)
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` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
SYSTEM INFORMATION (continued)
'roperty Address: fJS� -
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):-VS
(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, nuimber:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments: `
,(note c ndition of soil, igns of hydraulic failure, level of ponding, damp oiLcon ion o egetation, etc.) p?
t d
CESSPOOLS:
(locate on site pan)
Number and configuration:
Depth-top of liquid to inlet tt inver : a tt
Depth of solids layer: LA
)epth of scum layer.:. A �
Dimensions of cesspool: sell (vim
Materials of construction: ( e�r� yt 4 Sit OC ,
Indication of groundwater:�Jp �+
inflow(cesspool must be pumped as part of inspection) )�CCt S�iPtyw, I v�1G
Ly
Comments:
(n%e condition of soi, signs of hydraulic failure, level of ponding, ondRion of vegetatio e1c.)
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PRIVY:_N=1 r,*
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: -
(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
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revised 9/2/98 pap 9of.lt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
c"PART.0
SYSTEM INFORMATION (continued)
'$roperty Address: v S Li N,4 _
{
)weer:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:"—
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirwed)
:operty Address:g$G u r
Owner:
Date of Inspection:
NRCS Report name ---
Soil Type_ --
Typical depth to groundwater____-_ _ _--
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar 1 ~ 1
Shallow wells '
Estimated Depth to Groundwatertt5 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 established the High Groundwater Elevation. (Must be.completed)
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TOWN OF BARNSTA3LE
LOCATION 2S U SA15, CII-) • SEWAGE #
VILLAGE �4--Mj7g9S ASSESSOR'S NW & LOT
INSTALLER'S NAME&PHONE NO. //��
SE?TIC TANK CAPACITY �)rlOyJ `9t�reaO
LEACHING FACILrIM (type) 6U2t 'r6Q.1 Ci?, 6(size) -6 61A
NO.OF BEDROOMS
BUILDER OR OWNER OLZN iN
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: -
,. x 1S Fcc.
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) F"
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 fee,of leaching facility) N,.JA-' Fce:
Furnished by L`ceD
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