HomeMy WebLinkAbout0023 PAULA LANE - Health 23 P - ,Lt4 Lane - - -
P Ga�
019, 147 - - -- --- -.
1
1
TITLE 5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS,-
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:23 Paula Lane
Cotuit,MA 02635 ®�
Owner's Name: Padgett Builders Inc. ®CT �
Owner's Address:PO Bog 133
2
Cotuit,MA 02635 1 ToyNoF j Date ZQU-
of Inspection 10/10/02
vF TTge<F
Name of Inspector:(please print)David J.Burnie p Gl
Company Name:Wind River Environmental MAP
Mailing Address: 120 Great Western Road PARCEL
South Dennis,MA 02660
Telephone Number:508-760-4827 LOT
CERTIFICATIONT 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.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5
(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Ev * ation by the Local Approving Authority
Fails
Inspector's Signature: Date: Q�
The system inspector shall submit a copy of t s inspection report to the Approving Authority(Board of
Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a
design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the
appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to
the buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at
that time.This inspection does not address how the system will perform in the future under the same
or different conditions of use.
k
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address 23 Paula Lane
Owner:Padgett Builders,Inc.
Date of Inspection: 10/10/02
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 need to be replaced
or repaired. The system,upon completion of the replacement or repair,as approved by the Board of
Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board
of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 23 Paula Lane
Owner: Padgett Builders,Inc.
Date of Inspection: 10/10/02
C. Further Evaluation is Required'by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or-a salt marsh
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
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,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address: 23 Paula Lane
Owner: Padgett Builders,Inc.
Date of Inspection: 10/10/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or
cesspool
____ _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
_X_ 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
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s).Number of times pumped
_X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply.
_X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ 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 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,provided that no other failure criteria are triggered.A copy of the analysis
must be attached to this form.]
_No (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 a facility with a design flow of 10,000 gpd to
159000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 H 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.
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART B
CHECKLIST
Property Address: 23 Paula Lane
Owner:Padgett Builders,Inc.
Date of Inspection: 10/10/02
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_X _ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks?
— _X_ Has the system received normal flows in the previous two week period?
_X_ Has large volume of water been introduced to the system recently or as part of this inspection?
_X _ Were as built plans of the system obtained and examined?(If not available note as N/A)
_X_ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
X_ i Were all system components,excluding the SAS,located on site?
X_ _ 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 ?
_X_ _ 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:
Yes No e
_X_ Existing information.For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation
of distance is unacceptable)[310 CMR 15.302(3)(b)]
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 23 Paula Lane
Owner:Padgett Builders,Inc.
Date of Inspection: 10/10/02
FLOW CONDITIONS `
RESIDENTIAL
Number of bedrooms(design): NA_ Number of bedrooms(actual):_2_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_NA_
Number of current residents:_0_
Does residence have a garbage grinder(yes or no):No_
Is laundry on a separate sewage system(yes or no):No[if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no):Yes
Water meter readings,if available(last 2 years usage(gpd)):2000 25,000 gal 2001 18,000 gal
Sump pump(yes or no):No
Last date of occupancy: Summer 2002
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): end
Basis of design flow(seats/persons/sqft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):'Pumped post inspection
If yes,volume pumped:_1000_gallons--How was quantity pumped determined?Site glass
Reason for pumping:Maintenance
TYPE OF SYSTEM
X_Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract
(to be obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
` Approximate age of all components,date installed(if known)and source of information:Estimated 20 yrs
Were sewage odors detected when arriving at the site(yes or no):No
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Paula Lane
Owner:Padgett Builders,Inc.
Date of Inspection: 10/10/02
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron _X40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
Normal
SEPTIC TANK:_C_(locate on site plan)
Depth below grade:_9"_
Material of construction:_X_concrete-_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a
copy of certificate)
Dimensions: !000
Sludge depth :_3"_
Distance from top of sludge to bottom of outlet tee or baffle:_2+'—
Scum thickness _1"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined:Probed and measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):Tank appeared to be sound with no signs
of leaking,baffles in place,pumped post inspection at request of owner
GREASE TRAP:_(locate on site plan) „
Depth below grade:_
Material of construction:_concrete metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Paula Lane
Owner:Padgett Builders,Inc.
Date of Inspection: 10/10/02
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping: ,
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: NA_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
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.):
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Paula Lane
Owner:Padgett Builders,Inc.
Date of Inspection: 10/10/02
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X leaching pits,number:_I (6 X 6)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.):
Pit contained 6"standing water,normal vegetation with no signs of backup
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 or no):
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.):
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Paula Lane
Owner: Padgett Builders,Inc.
Date of Inspection: 10/10/02
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.
L
Vk
tr
li
I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Paula Lane
Owner: Padgett Builders,Inc.
Date of Inspection: 10/10/02
SITE EXAM
Slope steep slope to front and right side of property
Surface water None
Check cellar None
Shallow wells Abandoned well in front
Estimated depth to ground water 20+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:
_X_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)
X_Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Drop from SAS site to neighbors grade estimated at 15-18 feet with no breakout.. Assuming groundwater
to be at least 2' below surface in neighbor's yard gives 20' from grade to groundwater at SAS site
Bottom of SAS is 8'below grade
Site monitored by USGS well MIW-29 Zone A Adjustment figure for 0/21/02 is 2'
1 � i
d
Vk
TITLE 5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A q
MAP
CERTIFICATION .
PARCEL
Property Address:23 Paula Lane LOT
Cotuit,MA 02635
Owner's Name: Radgett41uHdert4ne-. 1'MAR 1jl--►sSeQ
Owner's Address: PO Box 133
Cotuit,MA 02635 RECDzooZ
Date of Inspection: 10/10/02
OCT Name of Inspector:(please print)David J.BurnieroWN��Company Name: Wind River Environmental HEAL
Mailing Address: 120 Great Western Road
South Dennis,MA 02660
Telephone Number: 508-760-4827
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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5
(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
0
Inspector's Signature: Date:
The system inspector shall submit a coethis inspection report to the Approving Authority(Board of
Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a
design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the
appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to
the buyer,if applicable,and the approving authority.
Notes and Comments
This report only describes conditions at the time of inspection and under the conditions of use at
that time.This inspection does not address how the system will perform in the future under the same
or different conditions of use.
� u
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 23 Paula Lane
Owner: —mARy sic--ss�,�►
Date of Inspection: 10/10/02
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 need to be replaced
or repaired. The system, upon completion of the replacement or repair,as approved by the Board of
Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old' or the septic tank(whether metal or not)is
structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board
of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed.
ND explain:
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 23 Paula Lane
Owner: , . !1Rjz.-Y aT�.►s ►
Date of Inspection: 10/10/02
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. Sypctem will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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
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,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 23 Paula Lane
Owner: .7-nA4'1 ZEase►_
Date of Inspection: 10/10/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or
cesspool
_X_ 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
_X Liquid depth in cesspool is less than 6"below invert or available volume is less than%:day
flow
_ _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s).Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply.
_X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X 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 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,provided that no other failure criteria are triggered.A copy of the analysis
must be attached to this form.]
_No (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 a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 23 Paula Lane
Owner:Padgett-Bvflders�Inc. TnfM
Date of Inspection: 10/10/02
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
►r
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
_X_ Has the system received normal flows in the previous two week period?
— _X_ Has large volume of water been introduced to the system recently or as part of this inspection ?
_X_ _ Were as built plans of the system obtained and examined?(If not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up ?
_X _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS,located on site?
_X_ _ 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 ?
_X_ _ 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:
Yes No
_X_ _ Existing information.For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation
of distance is unacceptable) [310 CMR 15.302(3)(b)]
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 23 Paula Lane
Owner:
Date of Inspection: 10/10/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_NA_ Number of bedrooms(actual):_2_
DESIGN flow based on 31.0 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA_
Number of current residents:_0_
Does residence have a garbage grinder(yes or no):No
Is laundry on a separate sewage system (yes or no):No[if yes separate inspection required]
Laundry system inspected (yes or no):_
Seasonal use: (yes or no): Yes
Water meter readings, if available(last 2 years usage(gpd)): 2000 25,000 gal 2001 18,000 gal
Sump pump(yes or no): No
Last date of occupancy: Sumner 2002
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow (sea ts/persons/sgft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: _
Was system pumped as pert of the inspection(yes or no):Pumped post inspection
If yes,volume pumped: _1000_gallons--How was quantity pumped determined?Site glass
Reason for pumping: Maintenance
TYPE OF SYSTEM
_X_Septic tank, distribution box, soil absorption system
Single cesspool
_Overflow cesspool
_Privy
_Shared system (yes or no) (if yes, attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract
(to be obtained from systern 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:Estimated 20 yrs
Were sewage odors detected when arriving at the site(yes or no):No
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Paula Lane
Owner: .jlkiz-,A wo.ssei-1
Date of Inspection: 10/10/02
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron _X40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
Normal
SEPTIC TANK: C_(locate on site plan)
Depth below grade:_9"_
Material of construction:_X_concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a
copy of certificate)
Dimensions: !000
Sludge depth :_3"_
Distance from top of sludge to bottom of outlet tee or baffle:_2+'—
Scum thickness:_1"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined:Probed and measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):Tank appeared to be sound with no signs
of leaking,baffles in place,pumped post inspection at request of owner
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Paula Lane
Owner: P4dgeu_BuUde_rs4ar-.Tnoti T�
Date of Inspection: 10/10/02
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:_NA_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
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.):
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Paula Lane
Owner: Padrgett-Buil IPrc iac.1F' R;Z�A Zli-or e6l
Date of Inspection: 10/10/02
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number:_1 (6 X 6)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.):
_Pit contained 6"standing water, normal vegetation with no signs of backup
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 or no):
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.):
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Paula Lane
Owner: TrA;21 cTe-,Z;; -S
Date of Inspection: 10/10/02
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.
1/7
I
4
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Paula Lane
Owner: P-aA.eWBrwk1ers;lns. P�hR� rTe�ss� .t
Date of Inspection: 10/10/02
SITE EXAM
Slope steep slope to front and right side of property
Surface water None
Check cellar None
Shallow wells Abandoned well in front
Estimated depth to ground water 20+ 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:
X_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)
X_Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Drop from SAS site to neighbors grade estimated at 15-18 feet with no breakout.. Assuming groundwater
to be at least 2' below surface in neighbor's yard gives 20' from grade to groundwater at SAS site
Bottom of SAS is 8' below grade
Site monitored by USGS well MIW-29 'Lone A Adjustment figure for 0/21/02 is 2'
kLL
1 � l
LOC-Q-T-1-O-N--=- - —5E'-WA-CkE-RER-MIT—U-O.:
TO
-
5-U 1-l.D-E-R-S-t`t-lam
D ATE-CO NLP-l_t-Qa`I-CE-I_SS.U-ER: �
i a t
a
2,
4 ,
C
t
a a
THE COMMONWEALTH OF MASSACHUSETTS
f el�
Application is hereby made for a Permit to;Cons pct or R air an Individual Sewage Disposal
System at: �L
..........W..
ow
Dwelling-r-No. of Bedrooms----------42� Expansion Attic Garbage Grinder (
--------------
D Seepage Pit No......4 ?el ni!
isposal Trench
Z Other Distribution box osing tank
Y-01 lo
U Nature of Repairs or Alterations—Answer when applicable,,...,
| ----'------------------------'-'---------'---'--------'--'---'--------------------------------
� Agcrvuzoor:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code 6 � not m place the system in
operation until a Certificate of Compliance has been iss e, rdt6f h It
Sign --- ---------' -- ----'
Apu1icutixn Approved 0y--, ����� -������������.----'
., _ . »"t e
Application Disapproved for the following reasons:.................................................................................................................
____________________________________________________________________________________________
' om"
PermitNo.......................................................... Issued.....7/--� Date ..................
No......................... Fn$............................_
'. T E.COMMONWEALTH OF MASSACHUSETTS
®®
RD�o t lt�
Appliration for Diopwial WrAa,Tomitrurti n Prrutit
Applica ion is hereby made.10r a'Per it to Co t or air �� aIndividual Sewage Disposal 7-
Syst
I]_ ation_ dres ,
.. �_.. .
- ........Lot o �
f
' ,Ow e ..
W
Installer Address
d Type of uildin Size Lot.............................Sq. feet
U
Dwelling}ZNo": of Bedrooms___._ ._Expansion Attic ( } Garbage Grinder ( )
p, Other—Type of Building ________ __ ________ No. of persons----------------------------- Showers- ( ) — Cafeteria
�� Design Flgw_Other fixty gallons per person per day. Total daily flow______________ ___" _ _____gallons.
--------------------
P Af P g Width Diameter - Depth � 1
W t,
� Se tic Tank�Liquid ca acrt� W adllhns - Len -h ;i -r L'� �et
,Total leachin area__.__._P______..s . f .Disposal Trench='N g q tSeepage Pit �No �_ Diameter epth beldw i otal le n r _sq. ft.
- ---
Z Other Distribution box ( ` ) Dosing tank ( ) . '� �'••' Cr��*y
~' Percolation Test Results Performed by ". ._.._ ___________________________________________ Date........ �
Test Pit' No 1 ._ __:___.__minutes per inch Depth`of Test Pit........... Depth to ground water________________________
fs, Test Pit No. 2................minutes per inch -Depth of Test Pit_______-__:_:______. Depth to ground water........................
P-' = ,f
Description of Soil �
x
U ------•---------- -•-------------••••••••-•-•-------•• -•- ---•- - -----•---•-•---
a _
U Nature of Repairs or Alterations Answer when. applicable____.__: ___•_•_________._ ............................r----- ___4_:__. ....
Agreement
The undersigned agrees to install the aforedescribedAndividual,Sewage Disposal System in accordance with
the provisions of Article'XI of the State Sanitary Code—Th undersig d f the grees not to place the system-in
operation until a Certificate of Compliance has been is ebb r of h
Signe
ate
Application Approved By----•- _ Gtr ---.._ 1�e!>f�1 Date
Application Disapproved for the following reasons:............................. ••---•------•-----•------•--_...----•-•-••-•-•-•-------------=--t 1 r
4
.........................................•-•^------•---•-•••--••--•-^--•-------.........---•^----.._.._._----•------.._...-------______----•-•-------------•-••--------'•---•••••------•............
Date
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
• .... ..... .................
(Irrtif iratr of Toutphaurr
THIS 1 T, C TI a he Individual Sewage Disposal System constructed ( or Repaired ( )
by ...............................................................
- � Installer
at__L. � .... : .�, --- 0--- - ..........................................................
has be f�ialled in accordance with the provisions of Article XI of The State Sanitary Code as scribed.in the
application for Disposal Works Construction Permit No---------- ................. dated___.+2 ___ ._
TUBE;ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT'*,THE
SYSUM WILL FU'NC'TION SATISFACTORY. V
DATE................................................................................. Inspector................-...................................................................
' THE COMMONWEALTH OF MASSA'CHUSETTS
BOARD OF HEAL H
No......... r FEE...................
Permission-is hereby .granted..._•,--•••• -• ..•••• . •` ......
to;Construct or Repai ):a�� Individu ewage Dispos yst`
} Street �� K
-:as shown on the application for.Dis os Works Construction`Per No _ ted_:_.��,
PP p / k/ ...........
t
- - .__ __-••--•DATE......... Board of Health
FORM 1255 HOBB'S & WARREN, INC.; P USHER$ d
rgc.oa
s
SY srE.� Q MAC�lg ►,n
AREA -21�SSq S.F �
,
!
i