HomeMy WebLinkAbout0129 SCHOOL STREET - Health 129 SCHOOL STREET, COTUIT
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TOWN OF BARNSTABLE �� �
LOCATION 9S<'hioo1=5 !i SEWAGE #
VILLAGE �O/U% ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. 13rvice .--CG-��
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) j. (size) ®L�
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O. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER %�/27 ,yrelf
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Y _ No
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is Cotuit MA 02635 0520/13
required for every
page. Cityrrown state Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector.
key to move your
cursor-do not Michael Kellett
use the return Name of Inspector
key. -
Aardvark Environmental Inspections
ffi Company Name
d PO Box 896
Company Address ,
East Dennis MA 02641
cdylrown State Zip Code
508-385-7608 S13742
Telephone Number Ucense Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this addles d that the
information reported below is true,accurate and complete as of the time of the inspection.The i►�sp ctio
was performed based on my training and experience in the proper function and maifitbill ante of 6irsite
sewage disposal systems.I am a DEP approved system inspector pursuant to se1t`on 15.3401of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes . ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
0523/13
Inspect is Signature Date
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. T
'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. ( n
t5ins•11J10 Tffie 5 Official In :subslnrace Sewage Deposal system•Page 1 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
n Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is Cotuit MA OZii35 05/20/13
required for every
page. Cityfrown state Zip Code Date of Inspection
B. Certification (cont.)
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 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:
.There is an abandoned line in the front of the house.
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.
Check the box for"yes","no"or"not determined"(Y,N,ND)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 exfittration or tank failure is imminent.System will pass
inspection if the existing tank is replaced with a complying septic tank as approve 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.
❑ Y ❑ N ❑ ND(Explain below):
1
t5ins•11/10 Tide 5Offiicial Inspection Form:Subsurface Sewage Deposal Sysbem•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form:
b Subsurface Sewage Disposal System form-Not for Voluntary Assessments
129 School Street
Property Address x
Carl Perlmutter
Owner Owner's Name
information is Cotuit MA 02635 05/20/13
required for every
page. Cityfrowrn State Zip Code Date of Inspection
B. Certification (font.) r
B) System Conditionally Passes(cone.):
❑ 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 ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ 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 ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): w
•
}
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 prnry is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5OWcW 1nspection Form:Subsurface Sewage Disposal System-Page 3 of 17 -
z -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 129 School Street
Property Address
Carl Perlmutter
Owner Owner's(dame
information is
required for every Cotuit MA 02635 0520f13
page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
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,perforated at a DEP certified laboratory,for fecal
coliform bacteria indicates absent 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
El ® 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
t5ins•11/10 Tdle 50fficlal Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is required for every Cotuit MA 02635 0520/13
page. Cityrrown State Zip Code. Date of Inspection
B. Certification (cunt.)
Yes No
❑ ® 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.
❑ ® 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 fecal conform bacteria indicates absent 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
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria ebst 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.
For large systems,you must indicate either`yes"or"no"to each of the following,in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
El ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection
Area—IWPA)or a mapped Zone li 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 Ness 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
t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is required for every Cotuit MA 02635 0520/13
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
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?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out? ,
® ❑ Were all system components,excluding the SAS,located on site?
® ❑ 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?
® ❑ 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:
® ❑ Existing information. For example,a plan at the Board of Health.
® 0 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(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15203(for example:110 gpd x#of bedrooms): 440
t51ns•11t10 Tdie 5 tffficial Inspecrion Form-Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is required for every Cotuit MA 02635 .05120/13
page. City/rown state Zip Code Date of Inspection
D. System Information
Description:
r
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[If.yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
r
Seasonaluse? ® Yes ❑ No
Water meter readings,if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 10/12Date
CommerciaUlndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
" Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:
t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is Cotuit MA 02636 05I20/13
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
Generale Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? El Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
l
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/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
t I
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Idle 5 Official in Form:Subsurface Sewage Disposal 7 inspection g posal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is required for every Cotuit MA 02635 05/20/13
page. City(rown State Zip Code Date of Inspection
D. System Information (cons)
Approximate age of all components,date installed(if known)and source of information:
25 years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.3
feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage,etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑metal ❑'fiberglass ❑polyethylene ❑other(explain)
If tank is metal,list age:
yeas
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is required for every Cotuit MA 02635 05/20/13
page. City/rown State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cunt.)
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 plan):
Depth below grade: feet
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: Date
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is required for every Cotuit MA 02635 05/20/13
page. C4frown state Zip Code Date of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
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 per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal:System Form-Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is Cotuit MA 02635 0520/13
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(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 ❑ No
Alarms in working order. ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Soil Absorption System(SAS) pocate on site plan,excavation not required):
If SAS not located,explain why:
t5ins•11/10 Tile 5 OfWal inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is Cotuit MA 02635 0520/13
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Type:
❑ leaching pits number
❑ leaching chambers number:
❑ leaching galleries number:
leachingEl trenches number,length:
9
❑ leaching fields number,dimensions:
® overflow cesspool number. 1
❑ 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):
This system has a 3'x5'drywell block pit as an overflow cesspool.There was 2.8 feet between the
inlet invert and the stainline.There was no sign of ponding or past failure.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 2 inline
Depth—top of liquid to inlet invert 'fFJ
Depth of solids layer
Depth of scum layer
2"
Dimensions of cesspool
Materials of construction drywell block
Indication of groundwater inflow ❑ Yes ® No
t5ins•11/10 Tate 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposals System Form Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's(dame
information is required for every Cotuit MA 02635 05f20/13
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
This system has a5'x5'drywell block primary cesspool.The cesspool was sound and had a stainline
at the outlet invert.
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.):
t5ins-11/10 TrUe 5 Oftlal fnspecion Form:Subsurface Sewage Disposal System-Page 14 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
K Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is tuft MA 02635 0520/13
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cunt.)
Sketch Of Sewage Disposal System:Provide a view 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..Check one of the boxes below: .
® hand-sketch in the area below
❑ drawing attached separately,,
porch
24
12
20
26
t5ins-11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 15 of 17
e
Commonwealth of Massachusetts
Title 5 Official Inspectio
n Form
IA
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
\1Wj_
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is required for every Cotuit MA. 02635 0520/13
page. City/Town State Zip code Date of Inspection
D. System Information (cunt.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
20.0
Estimated depth to high ground water feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ 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:
USGS maps show an elevation of over 20.0 feet
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
L
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 School Street
Property Address
Carl Perlmutter
Owner Owner's Name
information is required for every Cotuit MA 02635 05f20/13
page. Citylrown state Zip code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C,D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Idle 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 17 of 17
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0/
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property .l d ci 5c_h00 \ S+ ; C. /�
owner' s name R. M . Turn c c V
Date of Inspection �131q� _,�
PART A
JUN 9 1995
CHECKLIST' HEALTH DEPT.
r70=OF MVMMLE
Check if the following have been done:
✓ Pumping information was requested of the owner, occupant, and Board of
Health.
✓ None 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.
As built plans have been obtained and examined. Note if they are not
available with N/A.
1� The facility or dwelling was inspected for signs of sewage back-up.
c,-' The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
site.
R/ The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
✓ The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
k"' The facility .owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
e
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If esidental
a HTjA3H
oms
f„ -(-purr-ent residents
No garbage grinder, yes or no
_y S laundry connected to system, yes or no
FS seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
Tcrn._ iqq Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
NDNF N RF-C o2a
1-i � System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type of system
Septic tank/distribution box/soil absorption system
✓ Single cesspo.pl
✓ 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. Source of
information:
t ' o Sewage odors detected when arriving at the site, yes or no
4
i
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
S I -S
(locate on site plan)
depth below grade: 1 Fcr_,
material of construction: concrete metal FRP other(explain)
l�cilre_(
dimensions: t7 F{-
ly sludge depth
distance from top of sludge to bottom of outlet tee or baffle
q scum thickness
distance from top of scum to top of outlet tee or baffle
la " distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
Ha-,
rA.na,t yrqb k;eep keinq used 1
(�(i e + �h� C' IoSe Tb Sarn&
l= �N i�3_1'iarl U'i 1 nIC�'
DISTRIBUTION BOX: N Pc
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : ae_5 }fx)bI
(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 and number
leaching chambers and number
leaching galleries and 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, recommendations for maintenance or repairs, etc. )
CESSPOOLS (locate on site plan) :
number and configuration a.c4-,nu CA c. Tonl; I - Uuer Flnc,>
depth-top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool X
materials of constructionrrel
indication of groundwater
inflow (cesspool must be pumped as
part of inspection) a+-e.r t-6Cgun+ercj
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs, etc. )
ti
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
School Street
Porch
A
B
Bulkhead
#2 #1 OO
DEPTH TO GROUNDWATER
A B
3 6 ,9 F--r depth to groundwater— Fn r s►— 12' #1 24'
method of determination or approximation: 26" #2 20'
U, S. bep�. o-�p i n�,p n o C - �� 10� i •C
Log- I � M� k1 -arc - 7 on� f3
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
N Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
Static liquid level in the distribution box above outlet invert?
N Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS , cesspool or privy:
below the high groundwater elevation?
_ within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
— within a Zone I of a public well?
within 50 feet of `a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) .
within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysi
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector BruCe MCti�41� � 5+cr
Company Name 5 h ds
Company Address art Ponce tt-reei-
�S�erv,�le�
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Cheek one:
V I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector' s Signature &,c,-c�-'� � -
Date /7l95
original to system owner
Copies to:
Buyer (if applicable)
Approving authority