HomeMy WebLinkAbout0033 RALYN ROAD - Health v
33 Ralyn Road
Cotuit
A =022 065
TOWN OF BARNSTABLE
WAI &A r
y i N _ SEWAGE #
VILLAGE :gfi ASSESSOR'S MAP & LOT
E'1STALLER'S NAME&PHONE NO.
SEPTiC TANK CAPACITY
rEAC;FU G FACIUN: (type) (size)
NO.OF BEDROOMS
waUELDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted.Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
r
BORTOIO►M CONSTRUCPION, INC.
765 Wakeby Road
MARSTONS MILLS, MA 02648
(508) 771-9399
(508) 428-8926
SEWAGE DISPOSAL SYSTEM EUALUATIQ�
Inspected By: /9, Date: /- / 7
y Address: Map & Lot#
COw�yer:
Mailing Address:��.
NOTE: A satisfactory evaluation does not guarantee that the system will continue to'
function. A sketch of the property and sewage disposal 'components must
accompany this fog.
i
RES
ID UI' COMMERCIAL USE
Lot Size: Lot Size:
No. of Bedrooms: Type of Business:
Garbage Grinder:j�'� Water Softner: /J Sq. Ft. .of B1dq..:
Other Water Use: (Appliances)�k)Q.0&4e No. of Employees:
Water Use Activity:
Year RoLnid: Seasonal
Water Source:7(aa2U Water Source: ,
Septic S s T .•t 1 l e Y(Date) � i-l:1
Sys ban _.![!..-�._ Le): Lt' o��'- t
NO. SIZE LENGTH TYPE Fr., TO Fr; TO CONDITION
WELL W ILAND
Building Sewer
Septic Yank
Effluent Pipe
Dist. Box ♦ -
Dist. Pipe
Leach Pit � � -
Flow Difussors
Leach Trench
Stone
Cesspool
Pump/Chamber
Evidence of Ground Stain Yes ( ) No ( Unkriown ( )
Evidence of Breakout/Overload Yes ( ) No Unknown ( )
Evidence of Overflow to Surface Yes ( ) No ( v) Unknown ( )
Evidence of Lush Growth around Pit/Cesspool Yes ( ) No ( v) Unknown ( )
Standing Liquid in Pit 1/2 or More Full Yes ( ) No ( v) Unknown ( )
Evidence of Excessive Pumping Required Yes ( ) No ( V) Unknown ( )
Comnents:,� ,1� 3- Iwo
Lam.
�Cu l
1
c,}is ate
h
TOWN OF BARNSTABLE
LOCATION Am �C') cc� SEWAGE #
VII,LAG 3+`' ASSESSOR' MAP &zX_
&PHONE NO. Q lo�Cn
l�C-t-TC i?S •'V AME
SEPTIC TANK CAPACITY 1
LEACHING FACILITY: (type) �_t I
lls (size)
NO..OF BEDROOMS=
BUILDER OR�WNER, t .� f I00
.�
PERMUDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility _ Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
-� COMMONTV EALTH OF XL4SSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS_
DEPARTMENT OF.ENVIRONMENTAL PROTECTION
a
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES MEND
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A '
CERTIFICATION 3-1
`
w, CO
Property Address: 3 3 "J C
ts3
Owner's Name: N
Owner's Address: T
!�
Date of Inspection:
Name of Inspector: lease pint)
Company Name:
Mailing Address:
Telephone Number:: 8-
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:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Sianature: Date: t�lU
The system inspector shall submit a copy of this 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.
Title-5 Inspection Form 6115r,2000 page I
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete.all of Section D
A. System Passes:
I have not found any information which indicates that anv of the failure criteria descr
ibed in 310 CMR
15.303 or,m 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 t or the septic taru< (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 tan
k is less than 20. ears old is available.
ble.
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:
7
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Paee 3 of 1 1
OFFICIAL, INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
C. Further Evaluation is Required by the Board.of Health:
Conditions exist which require further evaluation by the Board of Health in order..to determine if the sv_stem
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
Z. 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
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 l 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 orzanic 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:
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property.Address:. f
Owner
Date of Inspection- ( 1
D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to each of the-following for air inspections:
Yes N°J
V 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 %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..
. Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a.private water supply well.
11 Any portion of a cesspool or privy is. 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.)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15303,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.
Page 5 of 1.1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection: jC . .�
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
Were any of the system components pumped out in the previous two weeks
_iZ— Has the system received normal flows in the previous two week period?
V Have large volumes of water been introduced to the system recently or as part of this inspection ?
V _ 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
v t
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
of the fr'7es 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:
Yes no
t/ _ Existing information.For example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM INFORMATION
Property Address:
Owner: f
Date,of Inspection: �. j(p
FLOW CONDITIONS
RESIDENTIAL 1/'
Number of bedrooms.(design). Number of bedrooms(actual):
DESIGN flow based on'3I O C R 15.203 (for example: 110 Qpd x'of bedrooms):
Number of current residents:.� /
Does residence have a garbage grinder(yes or no):A/0
Is laundry on a separate sewage system (y s or no):�}.[if yes separate inspection required]
Laundry system inspected(ye,�.or no):
Seasonal use: (yes or no): D
Water meter readings, if avjdilable(last 2 years usage(gpd)): ���@i1�j�hl� ✓ter 1,S�ljdG�
Sump pump(yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL./ /C
Type of establishment:
Design flow(based on 310 CMR 15.203): Qpd
Basis of design flow(seats/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):
i' GENERAL INFORMATION
Pumping Records
Source of information: 674
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: gallons —How was quantity pumped determined?
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)
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
ether(describe): M0,
ZAppro imate age of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no
6
Page 7 of 17
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM.INFORMATION(continued)
Property Address:
1 �
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan) Ak
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance-from private water supply well or suction line:
Comments(on condition ofjoints, venting, evidence of leakage, etc.):
SEPTIC TANK:fl (locate on site plan)
Depth below grade:
Material of construction:_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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle`.
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
GREASE TRAP— locate on site lam
—( 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.):
` 7
Page 8 of I
OFFICIAL INSPECTION FORM-NOT FORYOL;UNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner•
Date of Inspection:
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 Dolyethylene other(explain):.
Dimensions:
Capacity: gallons
Desian 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:W(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.):
3 i
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Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOR'VIATION(continued)
Property Address: r'
Owner
O-gezt
Date of Inspection: 0
1.
SOIL ABSORPTION SYSTEM (SAS):�ocate 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:
ching fields,number. dimensions:
verflow cesspool,numya
utovative/alternative system. Type/name oftechnology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation;
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: k
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool`
Materials of construction: i-�7.a �A- �x PEA;
Indication of.groundwater inflow (yes or no): &1L)
omments (note condition of soil, signs of hydraulic failure,.level of ponding, ondition of vegetation, etc.):
P P/ P. U--C .
oy
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.):
9
Page 10 of 1.1
OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: .
Owner:
Date of Inspection:
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.
�O
a
r
k�.
b uef r1ou)
an
10
Page 11 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: / '16
SITE EXAM
SIope
Surface water
Check cellar
Shallow wells
Estimated depth to around water f feet
Please indicate (check)all methods used to determine the high around 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 you established the high ground water elevation:
11
Permit Number: Date:
Completed by: J
HIGH GROUND-WATER LEVEL COMPUTATION.
� �Site Location: % � 4� Lot No.
Owner: /- L A, Address: - _..
Contractor: Address:--
Notes:
STEP 1 Measure depth to water table -
to nearest 1/10 ft. .........................
...............:.:...............................
Date
month/day/year
STEP 2 Using Water-Level Range Zone:
and Index Well Map locate , . ._
site and determine
OA ,Appropriate index well
OB Water level range zone C
i
STEP 3 Using monthly report Current
Water Resources Conditions'
determine current depth to
water level for._mdex vuelL..._...__....: y'
month/year
STEP 4 Using Table of.Water level-Adjustments
for index well (ST-:E.P 2A),_.cur-rent depth
to water.le.vel:for:index.-well(STEP 3),
and water level zone.(STEP 2B)
determine-water level adjustment ........................................:.................................................
STEP 5 Estimate depth.to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1)
Figure 13.-Reproducible computation form.
15
I
iaw,y��
Via\ COMMT OINTWEAL;TH OF -UASSACHtiSETTS
EXECUTIVE OFFICE OF ENVIROYMENT_AL AFFAIRS
11jEPAR.TME?,;T 'OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM.. -
PART _A
CERTIFICA I IOC,'
Property—ddress- 2
Owner's Name:
Owner's Address: ,��
yG .y f•l.
Date of Inspection:`
(�..�
_ Name of InspeZio�;.� ;ease�p,r,i'nt) )('''�J-�•""�i"B�.J.• -°'�af� `
cci
Company Name: -&Tz
Mailina Address:. r+C 7 n V ( ,
Telephone Number: :
CERTIFICATION STATEMENT
I.certify that 1 have personally inspected the sewage disposal system at this address ana that the inrormation reported
below is tr e,accurate and complete as of.the time of the inspection. The inspection was performed based on y
training and experience.in the proper function andmaintenance of on:site sewage.disposal systems. l am.a DEP ;
approved system inspector pursuant to Suction 15.340 of Title a(3.10 CMR 15:000). iThe system:
i.J Passes
f Condiiionally Passes.
Needs Further Evaluation by the Local Approving-Authority
Tails
I>3spector's Siaat�3re:. �� Date:. (0 �,
The system inspector shall su+b _as copy of this inspection report to the approving Authority(Board of liealtih or
DEP)within'70 days ofcompleting iris inspection. ifthe system is.a shared system or has a design low of 10,000
-C, or V eater,he inspector and the system owner shall submit the report to the:appropriate regional ofrice ofthe
DEP.The oriainal should be sent to the system owner and copies sent to the buy r, if applicable;and the atiprovTlta
aut'P_orliJ.
Notes,and Comments
*"*This report only describes.conditions at the time of inspection.and under:th.e 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.
1
page
5 Title 5 Inspection Form b/.�7._COC
. _ P P �
,
Page 2 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESS�IENI'S
SUBSURFACE SEWAGEDISPOSAE SYSTEM INSPECTION FORM
PART A_
CERTIFICATION (continued)
Property Address.
Owner: lip
Date of Inspection: z e
Inspection Summary: Check A,B,C,D or E.r AL.WAYS complete.all of Section D
A. System Passes:
r I have not found any information which indicates that anv of the failure criteria 'i 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 dot deter_niined(Y,N;ND)in the for the statements. 1-:not determined:'please
explain: -
The septic tank is metaI and over 20 years,olo, or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial.infiltration or eYfltratioii 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, V
ND explain:
Observation of sewage backup or break out or high static water level in.--:e distribution box due to broken or
obstructed pipe(s) or due to a broken, se Lied 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 syste n will
pass inspection if(with.approval.of the Board of Health).:
broken pipe(s),are replaced
obstruction is removed Y
ND explain:
Page of 11
OFFICIAL INSPECTION FORM ' NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'.DISP:OS_AL SYSTEM INSPECTION FORM
PART
CERTIFICATION(continued)
Property Address: s (P �� C= an
Owner , e .
Date of Inspection: /'��.✓�,'� � ,� � tJ
C. Further.Evaluation is Required by the Board.of Health: -'.,'
Conditions exist which requite farther 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-lealth determines in accordance with 3-10 C1YiR 15301(1)(b) that the
System is not functioning in a manner which will protect'public health,,safety and the environment:
_ Cesspool or or-ivy is within 50 feet or a surface water ;
CesspooLor 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,tranner that protects the public health,safety and envIronmena:.
_ The system has,a septic tank'and sot] 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..4 ,
_ The system has a septic tank and SAS and the SAS.is,withm 50 feet of a private water supply well
_ The system.has a septic tank.and SAS and the S'AS.is less than 100 feet but'50 feetbr more from a
private water suppl_-v well-' Method used to determine.'distance
**This system passes i-the weI.1 water'analysis;performed at aDEP certified laboratory,-for coliform
oacteria and volatile orEanic compounds indicates that the well is.free from pollution from that facility and
the presence of a:�menia nitrogen and nitrate nitrogen is equal to or.less than 5 ppm, provided than no other
failure criteria are trianered. A cop;ofthe analysis.riust be attached to this form: '
3. Other:
.. - J. - -
Page 4 of. I 1
OFFICLAL INSPECTION.✓I NOT O.R: ��i�IJI TAR�1 ASSESSIYIENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC.TION.FORM
PARS' A
CERTIFICATION(continued)
Property.Address Y J
Owner: i
Date of Inspection
D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to each.of the following for all inspections:
Yes No
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 around.or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid:levet in the distribution box above.outlet.invert due to an.overloaded or.clogged SAS or
cesspool
Liquid depth in cesspool is less than 5 below invert or available volume is Iess than % 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 potion of the.SAS,.cesspool or privy is-.below high around water elevation.
_ + Any portion of cesspool or privy is within 100.feet of a surface water supply or tributaryto a.surface
water supply.
. Any portion of a cesspool or.privy is within a Zone 1 of.a.public well.
_ Any portion or a cesspool or privy is within d0.fe.etof Lprivate wa er supply well.
Any portion of a cesspool or-privyis.less than 100 felt but areater.ihan.50 reet fom a private water
supply well with no acceptable water qualityanalysis::[This system passes if the welt 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?nitra:te nitrogen.is equai:to or less than pp:z, provided thaf no other failure criteria
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 ofthe 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 largel system the system must serve a. facility with a design flow of 10,000 gpd to 1.3,000
`;pd..
You must indicate either":yes'' or"no" to each of the following:
(The following criteria apply to Iarge 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 drir_kinE wate_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 3'10 CMR
15.304.The system owner.should contact the appropriate regional office of the Department.
',t
Page 5 of I
OFFICIAL INSPECTIO TOR.,7-NOT FOR VOLU-NTAkx ASSESSMENTS ,
SUBSURFACE'SEWAGE;DISPOSAL SYSTEM INSPECTION FOPIINI
PART B.
CHECKLIST
Property Address: J_ C__12?C9ffZcy „
Owner: /,. e_�,:-A—
��d
Date of Inspection: 9 �qlc-,.
Check if the folio xitiz have been done.You.must indicate"yes"or"no as to each of the following:
Yes. No
f Pumping,information was.provided,bythe owner,'occupant; orBoard ofHealth. ,Lr
j�/ Were anv of the system components pumped out in the previous two weeks
Has the system re wed normal flows in the previous two week period ?a
Have larsze volumes of'water been introduced to the system recently or as.part of this inspection
Were as built plans of the system obtai_ned.and examined? (If they were not available note as
_ Was the facility or-dwelling inspected for signs of sewaae back up
` Was the site inspected for signs o'break out?
Were all system components, excluding the SAS, located on site
Were the septic tank.manholes uncovered,'opened, and the interior of the tank inspected for the condition
of the b-affles or tees, material of construction, dimensions;,depth of liquid,.depth.of sludge and.depth of scum ?
Was the cility owner(and occupants if different from,owner)provided with infornaticr on the proper
mair-tenance of subsurface"sewage disposal systems
The size and location of'the Soil Absorption System(SAS) on the site has beendeterminedl based on:
Yes no
Bxistina infernat:on: For e„ ripl.e, a plan at the Board of Health.
Deternlned in the field(if any oI the failure cr?terla.related_to Part C is at issue approximation of d?stance
is unacceptable) [310 C1SR-15.302(3)(b){
z
Page 6 of 11.
OFFICIAL:INSI?ECTION.'FO.RIVI.—NOT FOR VOLUTN AR'Y:.ASSESSMENTS
SUBSURFACE-SEWA'G DISPOSAL SYSTEM'INSPECTION FORM
PART:C
SYSTEM INF.OWYTATI OI
Property Address:
Owner: C la
Date:,ofInspection: , `,/��, ; 4coG
FLOW CONDITIONS
RESIDENTIAL +,"
Number of bedrooms.(design). Number of bedrooms actual
DESIGN flow based on`.310 Ci: of .203 (for ex nple: I I:0 pd x of bedrooms):
Number.of current residents..
.1—� ,
Does residence have a garbage grinder(yes or no):f10
Is laundry on.a:separateaewage system (y s or no):; �.(if yes separate inspection required]
Laundry system ins ectede .or no
y P (. ) /`6I
Seasonal use: (yes or no) ,
Water meter readings; it avaalabie (last 2 years usage (gpd)):
Sump.pump (yes or no) A1.9
Last date of occupancyw
C O M MER CIALIIND USTRIAL,/
Type of.establishment:.
Design flow(based on '5 I0 CMR 15.203): �pd
Basis of-desiznn flow(seats/persons/sq:ft,etc.):
Grease trap present(yes:or-no);—
Industrial waste holding;tar;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)-
GENERA_ L INFORMATION
Pumping Records /J
Source of information: ( Q. ')L
Was sy_stem pumped as Dart of theins ectliion(yes or no).
If yes, volume pumped.: gallons --How was quantity pumped determined?
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, atiach previous inspection records, if any)
_InnovativeiAlternative 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
V.Other(describe):
Appro:imate age of all components, date installed (ifknown) and source of information-
"A /1.� V
Were sewage odors.detected when arrivinQ at the site (yes or no): ry
Page 7 of l 1 .
OFFICIAL INSPECTION FOIL> 1 —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL 1SYSTEM INSPECTION FORM:
PART C
SYSTEM INFORMATION (continued)
Property Address /,
Owner: �JJj�J r Lc
Date of Inspection:
BURDING SEWER(locate on site plan) ��
Depth below grade:
Materials of construction:_cast iron 40 PVC_other(explain)` ..
Distance from private water'supply well or suction line:. r ..•
Comments (on condition;of joints, venting evidence of leakage, etc.):
SEPTIC TANK:/ 2(locate`on site plan) „
Depth below grade:
Material of cons«uctiom._concrete_metal_fberglass__polyethylene
other(explain)
if tank is.metal listaae: is age.confllrmed bv.a Certificate of'Comp.liance(yes or no).:,_(attach.a copy of
certificate) —
Dimensions: ry
SIudae depth_
Distance from top of slud-e to bottom of outlet tee or.baffle:
Scum thickness:
Distance from top of scum_to top.of outlet tee or baffle:.
Distance from bottom of scup-; to bottom of outlet tee'or baffle:
How were dimensions.determined:
Comments g i on nurn n recommendations; inlei and outlet-tee or baffle condition, structural( p- integrity,liquid levels.
as related to outlet invert, evidence of leakage, etc:): ;
GREASE TRA.Pa(locate on site plan)
Depth belowQrade
Material of cons«uction: concrete metal fiberglass polyethylene_other
• (explain):Dimensions:
— —
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.pumpins:
Comments ('on pumping recommendations, inlet.and outlet tee or baffle condition, structural intear ty, liquid levels
as related to outlet invert, evidence Of leakage etc.):
Page 8 of I
OFFICIAL INSPECTION FOR—NOT.FOR:' 'LUNI TARY. ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTIONi FORM
PART C
SYSTEM INFORMATION(con-tinued)
Property Address: ,' �^ �0"0
Owner:'
Date of Inspection:
TIGHT or HOLDING TANK:/ (tank must oe pumped at time of inspection)(loc.ate.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:
Corriments (condition of alarm and float switches, etc.):
DISTRIBIiTiON BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments (note if box isaevel.and distribution to outlets equal,.any evidence of solids carryover any evidence of
leakage into or out of box, etc.):
PUMP CHAM.BER4 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.):
3
Page 9 of 1 1
OFFICIAL INSPECTION FOR:M.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORT
PART C
SYSTEM INFORMATION(continued)
Property Address:- �h cCAG�
Owner- ... ,tit 11,
P 0 /
Date of'Ins ection: r1 _1= e -
�.d
P
SOIL ABSORPTION SYSTEM (SAS): ( cote on site plan, excavation riot required)
If SAS not located explain why:
Type
leaching.pits,number:
leaching chambers;number:
leaching.galleries, number:
leaching trenches; number; length:
aching fields, numb r, dimensions: -
overflow cesspool,number:. r
mnovative!alternati.ve system— Typelnaine of technology:
Comments (note condition of soil. signs ofhydraulic failure, level of ponding, damp soil,;condition of vegetation;
7,V.
CESSPOOLS: / (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: ' _ t ( tl �. i
Depth—top of liquid to inlet invert:
Depth of solids laver —/
Depth of scum layeff '=1 — � /Y � ,• _
Dimensions of cesspool: 64 'e
Materials of construction: 104 i 1'/s3 ^r- % ". � �+2°a✓ .
Indication of groundwater i'n 1ow (yes or no). �li
Comments (note cord/-io- o� soil suns of r_ydraulic failure,level of ponding, ondition of vegetation etc.):
0i/��/
J' :?�eeYL r,-�.1�.'rJ t9 .. .i /' _.��r7 '� .. .//.iia/e ...i� .,r'°✓ i�� p �J /�%"ry�. �.J!r
� ;H4' � 1 '1� �!a� 'i�i, f� f's� -= . %' �L� (`✓1'k,� % � Ly����, 1�',� f �t2- '
PRIVY .�:•i (locate on site plar_)_
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of'-soil -signs of hydraulic failure, level of ponding; condition-of vegetation, etc.)-
tco\+J 6
9
-------------
Page 10 of 1.1
OFFICIAL i iSPECTiO FORM-.SOT FOR VOLTJ-N T'ARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORbrI.
PART C
SYSTEM NFOR-NIATIOo;(continued).
Property Address:,
Owner:
Date of lnspectiom.
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the,sewage disposal system incl_udina ties to at least two permanent reference landmarks or-
benchmarks. Locate all.wells within 100 feet.Locate.where public water supply enters the building.
e
e
r'
r
lv
Page. I of I
OFFICIAL NSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:'.
SITE EXAM
Slope
Surface water
Check.cellar
Shallow wells
Estimated depth to ground water 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 proper y/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with.local excavators;installers- (attach documentation)
g✓Accessed USCS database-explain: k
You must describe how you established the high ground water elevation: }
f
tl
Il •
Permit Number: Date:
Completed by::
HIGH GROUND-WATER LE:VEL'COMPUTATION. ..
Site Location. �� /� Al f-7 Lot No.
Owner: r_ 1/z-e AI:Fn & Address _
Contractor: Address: _ 6_ .1�` .�'%°
r _
Notes--
STEP 1 Measure depth to water table
to nearest 7/1.0 ft ........... ......... ......... .......... ...: ... ....:.... ........ .Date •�'�� :�,�
month/'day/Year
STEP 2 Using Water-Level Range Zone.>
and Index Well Map Locate
site and deterr"Jq
(�A :Appropriate:index well �f
OWate r level range zone :...
STEP 3 ' Using monthly report Current
r'
Water Resources Conditions
.determine current depthao
water..leveI 'br:index.vvell ..... ..
, a
month/year
77
:..-
STEP 4 Using Table of;Water.`le el Adjustments.
for index well`(STEP 2A),.current-depth -
to water--`-level for index-well (STEP 3);
and water level zone (STEP'2B)
determine water.-level adjustment
STEP 5 Estimate depth.to high water '
P 9
by subtracting.the•vvater
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 9) .................
Figure 13.—,Reproducible computation form.
1 ,
T