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Commonwealth of Massachusetts r
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Executive Office of Environmental Affairs ,p
Department ofT MqR 2
Environmental Protection 9199 =
William F.Weld <'^6j, 6 �.
GovemorLL
Trudy Coxe
Secretory,EOEA
David B. Struhs
Commissioner
O a� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: (�`.E c-t j ►`�t`(1,f F_ ► �'ti� .t Address of Owner: MO5.\2.,. �` �%%�-< 1` Y
Date of Inspection: ".3 t4: (If different) /
Name of inspector.�c -e�� \C�.iY `�
Company Name, Address and Telephone Number:
r 1 4
CERTIFICATION STATEMENT I certif\•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 disposal systems. The system:
` Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails /
Inspector's Signa Date: ��F�4'
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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 Depa�ment of Environmental Protection.
The orig
inal should De sen: t; ^e wsiem owner and copies sem to the buyer, if applicable and the appro',;np au''-or;;).
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
_ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95) 1
One Winter Street Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500
`� Printed on Recycled Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: >Z )e tom. AI-Y Y-- CL)i u%
Owner:
Date of Inspection: /
B] SYSTEM CONDITIONALLY PASSES (continued)
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
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool,or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
l hP w\ ten) has a sermc tank anu soli ausorptiur, System anu Is wilhlll I06 ICCi tU a DUI IGLC woic �iij�j�i) Or triuuiar) to a
surface water supple.
The systen, ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The sysien, has a septic tan, and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm•
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool,
(revised 8/15/95) 2
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
f� Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
t
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
Ni The design flo\% of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is \,\ithin 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area MAIPA) or a mapped Zone II of a
public water supply well'
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 6/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: n `�" ��
Owner:
Date of Inspection: J
Check if the (following have been done:
✓ Pumping information was requested of the owner, occupant, and Board of Health.
4one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
ZAs built plans have been obtained and examined. Note if they are not available with N/A.
//The facility, or dwelling was inspected for signs of sewage back-up.
./The system does not receive non-sanitary or industrial waste flow
/he site was inspected for signs of breakout.
✓ All system components, excluding the Soil Absorption System,have been located on the site.
ZThe 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 or
approximated b\ non-intrusive methods.
-e-- r., �. .p- ,,ere provided \%ith information on the proper maintenance of Sub-
'he o p P P
Surface Disposal System.
(revised 8/15/95, 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: )
Owner. Zh 5• QJ ��-� l�_�
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ;��� gallons
Number of bedrooms: --7>
Number of current residents:
Garbage grinder (yes or no): t-4
Laundry connected to system (ves or no):
Seasonal use (yes or no):-
Water meter readings, if available: t
Last date of occupancy: ` G(
COMMERCIALIINDUSTRIAL:
Type of establishment:
Design flow:__gallons/day
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: ` L
A,2.
System pumped as part of inspection: (yes or no)_
If yes, volume p0rnnvc, 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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 6/15/95) S
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)'
Property Address:
Owner: y Y�� \�Y� Irv. 1alLi�;� ;Z�l
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
Depth below grade:,,
Material of construction: concrete _metal _FRP_other(explain)
Dimensions: A *10
Sludge depth: !j
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: Q �r
Distance from bottom of scum to bottom of outlet tee or baffle: !a
Comments:
(recommendation for pumping, condition of i let d outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) G..c �4c a �. vim_ �;�- �.c� ✓S h 4�'�''��4 S
GREASE TRAP:jy
(locate on site plan)
Depth belov,, grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
D;,ta-ce from hotto— - ran,+, to hn!tnm of outle! tPe o, hartiP
Comments
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 8/!5/95) 6
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �5 �it�rz� �ia► ;.�. �L� �G c%, i
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK&
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal —FRP —other(explain)
Dimensions
Capacity: gallons
Design flow: gallons/day
Alarm level:
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: k�
Comments
(note ii ievei an d struu( ryua:. e ;uence of sc,iid: ca:r,c,et, e,idence of leakage in;o or out of box, 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, etc.)
(revised 6/15/95)
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: I
��� :y
Date of Inspection: `
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 pits, number.,
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
Nc:•f1
CESSPOOLS:
(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 groundv.ae .
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soli, 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.)
(revised 6/15/95) B
. r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ,�S� C �r car. �,� e.�%-A /
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
I
t
DEPTH TO GROUNDWATER
No(,A-in,
Depth to groundwater: feet
L` G
method of determination or approximation: 6711 ►� _! �L_
it
(revised 8/15/95) 9
Loo � %a A' � as -�r
L C A T ION � S E M PERMIT NO.
VILLAGE
INSTA LLER'S AM i ADDRESS ,
GUILDER OR OWNER
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DATE PERMIT ISSUEDlk
d DATE COMPLIANCE ISSUED
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T.13JECT TO APPROVAL M
f, ;R NSTABLE CONSERVATION
COMMISSION
F>; .... . ..............
THE COMMONWEALTH OF MASSACHUSETTS
w BOAR® OF HEALTH
11tyl...................OF...... ................._.........----------•-----------
,� lutt i�an for Disposal Works Tongtrnstiun ttrrmff
Application is hereby made for a Permit to Construct (K or Repair ( ) an Individual Sewage Disposal
System at:
.....�_. 19...... � ...1 t. .......A ..... ........ �,�..1�.E . •------- ------
ocat n-Address
. c.�f ...... :... •----------------•--------- : ,o.l j._� e �° ,_. �(�.......
lot f�'- y ,
wne ^ l
Ad s V
a f .....0 !.—. ....................... ..............................•---....--------............-----...................................
PQ Installer Address
Type of Building Size Lot....j._ . ...1M..Sq. feet
aDwelling—No. of Bedrooms........... ............................Expansion Attic Garbage Grinder
aOther—Type of Building ............................ .No. of persons............................ Showers ( ) — Cafeteria )
� Other fixtu es --- ------------------------------------------------------------------=---------•- - ----------
•..........................
W Design Flow............5-S..._ �..___.•gallons per person per day. Total daily flow.... �1 ..............•.......gallons.
l
W Septic Tank—Liquid capaclty.[_b�gallons Length................ Width................ Diameter................ Depth.-_-�._p_.
xDisposal Trench-11io................:.... Width.................... Total Length...............I.....Total leaching area....................sq. ft.
.. Seepage Pit No........)....._._.... Diameter.....1.2..,........ Depth below inlet.....C.a.......... Total leaching area..��`J...sq. ft.
Z -,Other.-Distribution box Dosing lank ( )
Percg3ation Test Results Performed by...... ........ Date.... .l.,l .�. 1
?• ,Test Pit No. L...._minutes per inch Depth of Test Pi ...I•2.......... Depth to ground wa ter....CM-0-1'LZ
Test Pit No. 2................minutes per inch Depth of Test Pit-__.�_�------... Depth to ground water........!..............
--------•-----------------------------------------•-----------...--------------...:.::..
Descriptionof Soil---:5fr �D--•-------------------------------------------------------•----------------------------------------------------------------------------.....------.
x
v . --------------•-••--•--....-------_----------------------------------.--------- -••
----------------------.----------------------------------------------------_----------------• •------
.. ------
w -----
U Nature of Repairs or Alterations—Answer when applicable..............................................................................................
---- ----------------------------------------•-•-------- ----••------------. ...........-....................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.....................................................=................................ ................................
Dat
Application Approved By.......----. ....................... ....... . ........ . ...--------
D ate
Application Disapproved for the following reasons:..............................................................................................................
--------------------------------------------------•-----------------------••-----------------------------•--•.._..-••••••--••--•-•----••-•-•-•••-------•-----•••-•-•---•-•--••-------•------•-•••-•_--.
Date
PermitNo......................................................... Issued.......................................................
Date
,=
THE COMMONWEALTH OF MASSACHUSETTS
,i BOARD E HEALTH
..................OF...... kZY,/ . . .LC�..........._..._...........
Appliration for Disposal Works Tnnstrnrtion rnmit
Application is hereby made for a Permit to Construct (A or Repair ( ) an Individual Sewage Disposal
System
,,,at:
....6i ._... ?..................................................~t ' J,t _ � ......... ............ ...
......
ocat Ad ress r Lot No.
Gc>jc L•j �?'IG//��,c . t� f1
/��Owner
a Ad s
•.......................... :.OSf :_. ------............._.........._ ..... ...................................•.......
Installer Address
d Type of Building Size Lot....i_. .._�C,_Sq. feet
U Dwelling—No. of Bedrooms............ .....Expansion Attic ( j Garbage Grinder ��s
�,
a4 Other—T e of Building No. of persons-................ Showers —
YP g P ---- (_._.)._..._-Cafeteria-( >
Otherfixtures - • ---------------- ---------------------•------------------------------------
`�
Design Flow............15._._.....4..`ti ,rb...._..gallons per person per day. Total daily flow.......4j=-G4.S-----------------------gallons.
WSeptic Tank—Liquid capacity.`�llons Length................ Width-............... Diameter................ Depth.4_-�(1-._.
x Disposal Trench—Io_____________________ Width.................... Total Length............... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.....!:� ....... Depth below inlet..... ,,......... Total leaching ...sq. ft.
Z Other Distribution box �)�� Dosing pnk ( )
Percolation Test Results Performed b ._.... ? '�' ': '_.�` :.n' --• 1
a Y ;�:-=-- •:� -�( ,•-� .11:.�rc�t,.�.._..--- Date_... � 1-�-�-•�-......------"
Test Pit No. I.......!:�minutes per inch Depth of Test Pi A�-►
p p ._.1.��._____._. Depth to ground water_._.C�.s,;.___
(x, Test Pit No. 2................minutes per inch Depth of Test Pit....I:L........ Depth to ground water--------!...............
---------------------------------------------------•--......------........------•-------•-----------.........................................................
0 Description of Soil... ,1...................................................................................................................................................
x
U -------------------
-----------
•--------------------
---------------
-----------------------
---------------
•----------------------------
•---------_--------------•-------.... -------------
----------------
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
..---•--•-------------------•--------------- ---•...-----•-----------........-----...........---•--------------------------
Agreement: x•.
The undersigned agrees to--install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed..............................................................•-•--•---...------_----
/. ' Date
Application Approved,.By.......
.,.. �� '-•f' = ._ �r _ ,1° ._.._.._.
Application Disapproved for the following reasons:__.a__....________________________________________________________________
•--------••---------•-•-----•--------------'----------------------•-------------.........-----.....-•---..__.....--------------------------------•-•---------------------------------------•----- --•-•-
Date
PermitNo.......................................................... Issued-------------•------------••-•--••-- ..
Date °
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............/.. Via` .. OF. !6. ............................................
Trrtifiratr of Toutpliaurr
THIS IS. TO CERTIFY, That the diddual S wag . > posal S tem constructed ( ) or Repaired.( )
by----------------------------------------------- ...... .;.. ...----.............................-----.........--------•------------
- Installer ✓"�
at-•----------�" '= ---- .!�� %rc = ----�- ------------------------ --------
has been installed in accordance with the provisions of TITLE -g5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___ ------�: .............. dated_-_...____.___.___.......___:___............_...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SA SFACTORY.
DATE.................................................... . ............•--•---- Inspector........&• �...----------•-------•-••--•-•---....._.........----••-•_---.
THE COMMONWEALTH OF MASSACHUSETTS
' BOARD OF HEALTH
No :�....: :.............OF.... .. .................................. FEE. ...............
Disposal n kii. Tans inn nutit
Permission is ereby granted-------- ........-----------------
to Construct o_r Repair ( ),An Individual Sewage Disposal System
at No...- -'�
..................... �a - �..
---------•--------................................
Street pp
as shown on the application for Disposal Works Construction Permit No...__J�^ Dated_.___ ....�1-`. -:
---------------------------------------
DATE -
�� �w % Boar eaZ
-----•-----------•------------ •---(•%---•--•---------------------------•----
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