HomeMy WebLinkAbout0046 GREAT BAY ROAD - Health 46 GREAT BAY ROAD, OSTERVILLE
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LOCATION ` SEWAGE #
VILLAGE ASSESSOR'S MAP do LOT e�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY \S O O pp!5 Vow- ,
LEACHING FACILITY: (type) F l US So (size)
NO.OF BEDROOMS
E BUILDER OR OWNER
5TE: ZZqbCOMPLIANCE DATE:
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istance Between the: o t
djusted Groundwater Table an � (o Feet
r Supply Well and Leaching Facility (If any wells exist
within 200 feet of leaching facility) I Feet
and and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) lJ Feet
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A
COMMONWEALTH OF MASSACHUSETTS 4b
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION /
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500, A 444 1
� '7VG YFG
4
`91OATRUDY�
� �O/,'�Secretary
ARGEO PAUL CELLUCCI �DAVID B.STRUHS
Governor ` 'Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 46 Great Bay Road,Osterville, MA Name of Owner: David Rowe
Address of Owner: Same
Date of Inspection: July 21, 2000
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: 093
Telephone Number: (508)862-9400 Parcel. 014 .
CERTIFICATION STATEMENT z
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally.Passes
Needs Further Evaluatio the Local Approving Authority
ails AVIInspector's Signature: " Date: July 24, 2000
The System Inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days
of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable,and the approving authority.
NOTES AND COMMENTS
f _
revised 9/2/98 Page Iof11
Printed on Recycled Paper
n
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 46 Great Bay Road, Osterville, MA
Owner: David Rowe
Date of Inspection: July 21, 2000
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is.replaced with a complying septic tank as
approved by the Board of Health.
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
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 46 Great Bay Road, Osterville, MA
David Rowe
Owner: .,
Date of Inspection: July 21, 2000 ,t .1
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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)
THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF ANY)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND
THE ENVIRONMENT:
4_ The system has a_septic tank and soil absorption system(SAS)and the SAS is within,100.feet.to a surface water supply or.
tributary to'a surface water-supply. .:
_ The system has a septic tank and soil absorption system and the SSAS is within a Zone 1 of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid).
3) OTHER
5
revised 9/2/98 Page 3ofll' F
� n
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 46 Great Bay Road, Osterville, MA ..
Owner: David Rowe
Date of Inspection: July 21, 2000
D. SYSTEM FAILS:
You must indicate either"Yes" or"No" as to each of the following:
_ I have determined that one or more of the following failure conditions exist as described 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.
Yes No
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.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than'/z day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the 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 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. 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:
You must indicate either"Yes"or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 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:
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
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 46 Great Bay Road, Osterville, MA a „
Owner: David Rowe Y
Date of Inspection: July 21, 2000
Check if the following have been done: You must indicate either Yes" or No" as to each of the following: .'
Yes No
✓ — Pumping information was provided by the owner,occupant,or 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. "
✓ The facility or dwelling was inspected for signs of sewage back-up.
✓ — The system does not receive non-sanitary or industrial waste flow.
f.
✓ — The site was inspected for signs of breakout.
✓ — All system components,excluding the Soil Absorption System,have been located on the site.
✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles
or tees,material of construction, dimensions,depth of liquid;depth of sludge,depth of scum t
The size and location of the Soil Absorption System on the site has been determined based on
✓ — Existing information. For example,Plan at B.O.H.
✓ Determined in the field(if any of the failure.criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)]
✓ — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
ell
y t
revised 9/2/98 Page 5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 46 Great Bay Road, Osterville, MA '
Owner: David Rowe
Date of Inspection: July 21, 2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 5
Total DESIGN flow n/a
Number of current residents: 2
Garbage grinder(yes or no): nla
Laundry(separate system)(yes or no): No; If yes, separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter_readings, if available(last two year's usage(gpd): 1999-274,000 gals.:1998-153,000gals.
Sump Pump(yes or no): No basement
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: Qpd(Based on 15.203)
Basis of design flow
Grease trap present: (yes or no) _
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Pumped on June 26198-per treatment plant.
System pumped as part of inspection(yes or no): No
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: Unknown . .
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 46 Great Bay Road, Osterwile, MA t !:, 4 , ., •t; ,,: " µ,`r,x, -s:,•„
Owner: David Rowe ;• ,
Date of Inspection: July 21, 2000
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron 40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints,venting,evidence of leakage,etc.) Y
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 16"
Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance—(Yes/No)
Dimensions: 1500 gal. _
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 30" r
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 9" "M 4
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How dimensions were determined: Measuring stick
Comments: w_
(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.) The tees were present. The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None `
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(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 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 46 Great Bay Road, Osterville, MA
Owner: David Rowe
Date of Inspection: July 21, 2000 - �' i .• .
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time,of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No
Date of previous pumping:
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: --
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was not dug up.
PUMP CHAMBER: None
(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.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 46 Great Bay Road, Osterville, MA
Owner: David Rowe
Date of Inspection: July 21, 2000 t ":
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits, number:
leaching chambers, number: 4-flow diffusors (per as built card),
leaching galleries, number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
There were no signs o failure in the flow diffusors. The bottom to grade was approximately 45".
CESSPOOLS: None
(locate on site plan) { ` ,
Number and configuration: ,
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer: F
Dimensions of cesspool: a
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection).
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
PRIVY: None
(locate on site plan)
Materials of construction: f Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
revised 9/.2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 46 Great Bay Road, Osterville, MA
Owner: David Rowe
Date of Inspection: July 21, 2000 <
Map: 093
Parcel: 014
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent,reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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revised 9/2/98 Page 10of11
I _-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 46 Great Bay Road, Osterville, MA _• .
Owner: David Rowe
Date of Inspection: July 21, 2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar "
Shallow wells
Estimated Depth to Groundwater 5 +/- Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
✓ Observed Site(Abutting property,observation hole,basement sump etc.)
✓ Determined from local conditions
✓ Checked with local Board of Health
Checked FEMA Maps
Checked pumping records „
Check local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
The bottom of the flow diffusors to grade was approximately 45". Hand augered down to groundwater, which was 5.0'
below grade. There is no high groundwater adjustment for this area of Little Island per the Health Department.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11ofll
�\ CommON«•EALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF EINVIRONMENTAL AFFAI
DEPART�IE�T OF ENVIRONMENTAL PROT
• ��
ONE WINTER STREET. BOSTON. MA 02105
�UL. 199 .
'CLLIANt F.WELD ep. ) T
�� R 0)
D. STRL•}
ARGEO PALL CELLL•CCI
LLGovemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ ommissior
CH
AP_ 0C:�� . PART A
CERTIFICATION
Property Address; "1 C') ¢ 0S L}w.1 Address of Owner:
Date of Inspection: (.• zj4 :Of different)
Name of Inspector:
am a DEP ap roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name:/f}/ .M4 r,c Cif p•o"c7 h ^-t P M 4----/
Mailing Address: p O /3 ox H II-0 264_51
Telephone Number- irSeV, /4 Zo
CERTIFICATION STATEME\T
I certrfi that I have personally inspected the sewage disposal system at this address and tha: the information reported below is true. accurate
and comole!e as o:the time of rnspec-oo^.. The rnspecion was performed based on my training and experience in the proper:funcion and
maintenance of on-site sewage disposa; systems. The s•stem:
YPasses
_ Concioonaii,, Passes -
tieec: Furthe- Eva!uatlor, Sy the Local Approving Authorm
Fa.:s
1
Inspector's Signature: ADate: -Z Ct
T:,e S%•s:e•- Ins.ecto• sha!! submit a copy of this inspection report to the Approving Authority within than, (30) days of completing this
inspecoon. If(he system is a shared system o, has a design floes• of 10,000 gpd or greater, the inspector and the system, owner shall submit
the report tc the appropriate regional office of the Depa-ment of Envrronmenta� Protection.. The crig:na! should be sent to the system ownf
and copies t-nt to the buyer. if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:-Xv :
I have not found any information which indicates that the system vioiates any of the failure criteria as defined in 310 CMR 15.30
Any failure criteria not evaluated are indicated below. .
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, up(
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes..no, or not determined (Y, N. or NDi. Describe basis of determination in all instances. If'not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection,
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tar
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,
(r..:.•d 01/2S!f7) Pao. 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . f. . •
. PART A
CERTIFICATION (continued)
Tr-
+r`Properq Addrass.>
O Wert . r( j 1. _= ,•,► '
Date of Inspection:
- y1,
BJ SYSTEM CONDITIONALLY PASSES (continj-�d
; C-z-S age backup or'breakout or high static water level observed in the distribution box is due to broken or obstructed
Nt- pipetsl-or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
L - Board of Health). Describe observations: V
s a:, broken pipe(s) are replaced .
obstruction is removed ;�::: ^..._.._., -_ - ,. . •
' 1 C
• r
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if(with approval of the Board of Health): - -
broken pipe:si are replaces -
obstruction is removed
CJ FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require furthe•evaluation by the Board of Health in order to determine if the iystem is failing to protect the
public health. safe and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or pri%-� is within 50 feet of a surface water
Cesspoo! or prn�, 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 THA1 '
THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: `
The system has a septic tank and soil absorption system (SAS) and the 5A5 is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supoiy well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than, 100 fee: but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates tha
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. Method used to determine distance (approximation not valid).
3) _.OTHER
♦. 7. _ - _. .-�._ _•4 ,1. 'ice'. .1•�' .. _
(revimed 04!2S/37) page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Addross:
Owner:
Date of Inspection:
I
Dj SYSTEM FAIL5:
You must indicate either 'Yes- or `No' as to each of the following:
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.
Yes No ,
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.
i
Static !iauid level in the distribition boa above outlet invert due to an.overloaded or clogged SAS or cesspool
Liouid depth in cesspool is less than 6- below invert or available volume is less than 1/2 day fiov.
Recuired pumping more than 4 times in the last year NOT due to clogged or obstructer pipes .
Number o'times pumped _.
An.- portion o'the Soil Aosorption System, cesspool or pri-.)• is below the high groundwate• eievaiio-
Ar.. por::on o'a cesspool or pri.1• is within 100 feet of a surface water supoly or tributar to a surface water supply
Any porion of a cesspoo' or priv%. is withir. a Zone I of a public well.
An,, po-ion o:a cesspool or privy is within 50 feet of a private water supple well
Anv por.,or. o*.a cesspool or prvvy is less than 100 feet but greater than 50 feet from a private eater supply well with no
acceo:able eater qualm\ analvsis. If the well has been analyzed to be acceotabie, anach cop.• of well water analysis for
cohiorm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate either -Yes` or `No- as to each of the following.
The ioho%-•ing criteria aop;% to large systems in addition to the criteria above:
The system serves a iacilir with a design'flow of 10,000 gpd or greater (Large System; and the system is a significant threat to
public hea!th and safer and the environment because one or more of the following conditions exist.
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 11-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 Cr.1R.5.00 and 6.00. Please consult the local regional office of the Department forlurthe.r.inforntatiocv.---
(revised 04/75/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: n Y�
Date of Inspection:
l E.�
Check if the following have been done: You must indicate either 'Yes' or 'No' as to each of the following:
Yes NO
Pumping information was provided by the owner, occupant, or 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 bull' plans have been oo:atned and examined. Note if they are not available with N,A.
_ The facrlm or dwelling was rnspec:ed for signs of sewage back-up.
_ Tne system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All !vsterr: components, excluding the Sod .Aosorpt,on System, have been located on the site. ..
P _ The septic tank manhoies were uncovered. operied. and the interior of the septic tank was inspected for condition of
{y baffies or tees, materta: o' construction. dimensions, deptn of liquid, depth of sludge. depth of scum.
The size and location of the Soil Absorption Svstem on the site has been determined based on.
_ The iacdiv, ovine,F%2no occupants. tf difteren: trom owner were provided with information on the proper maintenance of
Sub-Surface Disposal Svstem.
Existing information. Ex. Plan at 6.0 H.
_ Determined in the field !tf am of the failure criteria related to Part C is at issue, approximation of distance is
unacceotabie (15.302s3):bl!
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.M
PART C
SYSTEM INFORMATION
Property Address: (o
Owner: � -"-
Date of IhspectioA:
FLOW CONDITIONS
RESIDENTIAL:
Design floK 14 U p.d.,bedroom, for S.qS
Number of bedrooms
Number o'current residents-
Garbage g•,:der (yes or no-: Vw y
Laundry cor•^ected to system lees or no!
Seasonal use tees or no!: t--t
Water meter readings. if available (last two d2, year usage tgpd):
Sump Pump lees or nov VJ
La da:e o`occupancv'�fQftii
COMMERC;4L'INDL'STRIAL:
Type of establishment
Design fio%% ¢ahonsida�
Grease trap present tees or no_
Indus:na! %%aste Holding Tani; present. ,ves or no_
':on-sanita,� Mzste discnarged to the T!:je 5 sys;em ;ves or no_
%%ater meter readings 1f availabie
Las pace o: o . ;2--C.
OTHER: .De:crlbe
Lzst date of occuoanc.
GE'vfRAL INFORMATION
PUMPING RECORDS and source of inform tior.
3.�U
System pumped as par, or lnspecuon: tees or nfo.PvC3
If yes, volume pumped ¢allons
Reason for pumping
SYSTEM TY�F
Septic tank/distnbutuon boxfscid absorption system
Single cesspool
Overflow cesspool
Prn%y
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other -. -
APPROXIMATE AGE of all components, date installed (if known) and source of information: C ` ys
Sewage odors detected when arriving at the site. (yes or no) ( :• •• _ =
(revised 04/25/911
Page S of 10
L '
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTE.ki INFORMATION (continued)
Property A�ddres(�s:-
Owner: r �.
Date of inspection: 1.i;�Zt %
BUILDING SEWER:
(Locate on site plan)fro
Depth below grade.
Material of construction. _cast iron _40 PVC _other (explain:
Distance from private water supply well or suction Ire
Diameter
Comments: (condition of joints, venting, evidence of leakage. etc.)
SEPTIC TANK: S
(locate on site p an
Depth below grade-
material of construction- concre:e _me:a _F ioerglass _Polyethylene _othertexplain
If tani Is metal. Ifs: age _ Is age con;irmec o. Ce^.fica:e o: Compitance _(yes.-No
Dimensiors 1Soo V-t-
Sludge depth 34
Disiance from top o: siucee to bor-,om o; ou,;e: tee o• ba';e a
Scum thickness-
Distance from top o:scum to top o;outlet tee or bade
Distance iron, bottom of scum to bo-o--; of outie, tee c- ba,-..e
Now dimensions were determined 0Ju t ,-tAi-
Comments
trecommendatton for pumping. condition o'. Iniet and outlet tees or baffles. depth of liquid level in reiatton to outlet invert, structural
integrity, evidence of leakage. e:c.t
w W\Jfitt 6DZ.Lj C \A Sn U
GREASE TRAP:
(locate on site plan!
Depth below grade:
Material of construction: _concrete _metal Fiberglass _Polyethylene _other(explain)
Dimensions: —
Scum thickness:
Distance from top of scum to top of outlet tee or baffle. — —
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments: _
trecommendatton for pumping.-condition of i,ilet and outlet tees or baffles. depth of liquid level in relation-te-outleNrtvert--structur-al--
mtegrity, evidence of leakage, etc.;
St-'BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-M
PART C
�rr SYSTEM INFORMATION (continued)
Propert% Address:
Owner: k-,
Date of Inspection:` � l
l�
TIGHT OR HOLDING TANK: 'Tank must be pumped prior to, or at time, of inspections
(locate on site plan,
Depth below grade.
Material of construction. _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacrt\• gallons
Design floN galions da.
Alarm level Alarm in %korking orde• _ Yes. _ No
Date of previous pupping
Comments
(condition of role! tee. condition o- a!a-rr. and float switches. etc.)
DISTRIBUTION BOX:
(locate on site pia•:
De:.-:h o;licuid le%el. a00%e ouue: in.e-�
Comments
mote :i leve! and distrib-non it eaua' evidence of solids carn•o3y evidence of leakage into or out of boa, e!c.)
L$'Tv2��c?v'�i�.GYti---� Ja�t L/1'S t!' Oath t0�.1 c+.lRt� b^J0)
.
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.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIt
PART C
SYSTEM INFORMATION (continued)
Property Addr-ss:
Owner:��,a•t
Date of lnspertion:b L2
SOIL ABSORPTION SYSTEM (SAS):*
(locate on site_plan, )i possible: exca.aocin not required, but may be approximated by non-intrusive methodso
If not determined to be present, explain:
Type:
leaching pits. number._ _
leaching chambers, number. pp� �i:'�?"vSSCZ�
leaching galleries, number.
leaching trenches. number.tength:
leaching fields, number,.d.rnensioni
overflow cesspool, number
Alternative system
name of Technoiogv
Comments
mote condition of soil' s!grs of hydraulic failure, leve' of ponding. condition of vege-t)on, etc.)
r �r-j,
i- •—iI�-1t:'t2
CESSPOOLS:
(locate on site plan
Numbe, and configura:,on
Depth-top of liquid to inlet )nver,
Depth of solids laye-
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwate-
inflow• tcesspool must oe pumpeC as pan of inspection
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) -
PRIVY: .�I�
(locate on site plan)
Materials of construction: Dimensions:
Deptho solids: .._ _. ....
Comments _
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
(r.va,ad 04125/97) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION-(continued)
Property Address:
O%ner:
Date of In,pection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
III
y�
z ,
y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propertv Addres..• 4 ' L-1 Q:AV'
Owner:I"-��tfm \
Date of Inspectwn:
Depth to Groundwater- `� Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained irom Design Plans on record
A— Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Cnec'K with Iota! Board o• nea!,,r
Chec%. FENtr. neaps
Check pumping records
Check local eaca%ato-s rnstalle•s
0
Describe in voi, o—. %••oros no- \o_ es:abhshed the tiigh Groundwater Elevation. (Must be completed
y+�V( j'ICvJ �ti�YOSSCK_z, Ar
(rsv.x•d 10 of 10
Permit Number: Date: C
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: �� h .� , y�� �J ��, Lot No.
Owner: Address:
Contractor: PC 1-km_ 3�_1y:kec,"'Wn- 'nA!Address: a-4 4
Notes: U�L 64
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:
OAppropriate index well........................... ........................
OB Water-level range zone ..................................................... 231Nc-�
STEP 3 Using monthly report "Current j
Water Resources Conditions"
determine current depth to
water level for index well .......................
(D, b
month/year
STEP 4 Using Table of Water-level Adjustments
i
for index well (STEP 2A), current depth j
i
to water level for index well (STEP 3), i
and water-level zone (STEP 2B)
determine water-level adjustment .......................................................................................... .l:
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) ................................................ 3
}
Figure 13.--Reproducible computation form.
15
"^
SOLLIVbW
2.5
THE ooMMomvvsxLr* OF MASsAoxusczTs
BOARD OF HEALTH
-_-OF- �$� -���
���
� - -n-v---------- --- -- --p----~ --~-~--~- ~-`-----~-~------ vr~r-----
�� �erebv ��d� �o x �cro�� �o Construct ( ) or ��nu� (��) an Individual Sewage Disposal^^ . ` ' ^��
System at: '
....05
Pq
< Type of Building Size Lot... feet
Other—Type of Building ............................ No. of persons............................ Showers ( ) -- Cafeteria ( )
Septic 4eco
Seepage pit Nu--_--__ Diameter Depth below inlet- Total leaching area. ft.
Z Other Distribution box ( ) Dosing
'- Percolation Tea I`e�orozed Dut�--'Test Pit Pit No. l-.... minutes per inch Depth of Test Pit.................... ncnt to ground wee ./^.^� �'�...
gZf Test Pb No 2................minutes per inch Depth of Test Pit.................... Depth toground water........................ .
.-__'- -'-_-
� 0 of� . -
:V4 ___-'-'_-- -- -----__''---_-_'----_-_--------_'_____.
U Nature of Repairs orAlterud000--Aoswervvbeo applicable--_._.-_--''----_.-_'_--...__-_-__.__-.
.......................................................................................................................................................................................................
, Agreement:
The undersigned agrees to install the uforedescribed Individual Sewage Disposal System in accordance with
| the provisionsof'JI'AIZ- 5 of the State Sanitary [ode—The undersigned further agrees not to place the system in
' �� u C�d�� � �� �� �asoo6bv �� b�����tb
| -`----- ---',---- ' '
� Signed ..... ............-- ........-....
Application Approved Bv---' -���' ` --------------'- -------------------'
_ ~- u*"
Application Disapproved for the following reasons:..............................................................................................................
� -__'-_---_-____'-----__--'-------'--'---'----------'--'_---------------_---_--------_-----------
u"te
No... =
THE COMMONWEALTH OF MASSACHUSETTS /
BOARD OF A HEALT��Hf
..W. ...............OF...6 146.(�,,fL............................
Appliration for Disposal Works Tonotrudion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal
System at
......... . :.. ..... ..........:..... .......... ... .
No. - .......................--
Location ddress or Lot
-----------------------•-----•--Address
W ........... •.. ..... ...-•--------•--•-•••••-•-••-•-••--•--•-----•--
a �!. I taller Address :J'
d Type of Building Size Lot.�t4...��....Sq. feet
U Dwelling—No. of Bedrooms.......... ................................Expansion Attic ( ) Garbage Grinder
Other—T e of Building No. of persons............................ Showers — Cafeteria
P4 Ot er fix ures
--------•-----------------.---••-•....._---•-•----•--••••--•-•--•-•--
Desi n Flow......_ . lions per person per day. Tota daily ow._.. .�'1" l
W g P $ y Y Y '7r
1:4 Septic Tan c�,pacit��L7_gallons Lengt _ ..16 .. Widt � Diameter................ Dept�...............
xDispos� r i�"?-77-'A........---. Width..1.0�........ Total Length.. ....... Total leaching area.��?(P...sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosingto
'-' Percolation Test Results Performed b ' ' iL .::;K.._'_ •.�_ . ___._ Date..... . ... ..............
minutes per inch Depth of Tes" t Pit____________________ Dep to ground water/..
,� Test Pit No. 1.._.�.....
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�j ...... .......... ------------6•----.. .... - - = >�
W -----------•---------•••••-•---------------•-------••--•---•--•----------••••---•-••--•--•----•••------•----••-----------••-----••-••---•------------•------•-•-------•-------------•-•--------•--------
UNature 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 TITLE 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.....T�-----------------r---------------------------------•--------
Date
Application Approved By......... ,x
Date
Application Disapproved for the following reasons:.............................................................................................................._
--••-•--------•.................................•--•-----•-•-•..............-••-•------......------•••----•-•----•..........-•-----•-•--•----•-••----•-----•----------••••---------•-----•-•-----.......
Date
Permit No........ .�.. , f ...... Issued-------•••-----•--•----
Date...............................
y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�.....OF......... ......................................
Trrtif iratr of TI-Impliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by............•••.•...�.-,- -�...... vl `4 - �,� _- ----••.-----•-•----------------•-•-•••--•--....•---••-••---........••-•-...---•-•-•-•-••...................-•--
Installer _:. ........................—......
....at...................... - ...
L.11 ,f
has been installed in accordance with the provisions of'JTITIE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No........ __'?._-._��: s_./.. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r
No.....�r .,.J t - FEE.......�..5 ..^..
Disposal Works 0onstrudiort amit
�l
Permission is hereby granted......---- � ..A1,5�r. r �Lt c.------------------•---.--.-.---.-•--•---.-----.-.-------------.-
to Construct ( ) or Repair ( an ndiv'idual Sewage Disposal System
atNo...................tL r ...try...._... .. t....... �..�_• j- -- Stre
as shown on the applicationfor Disposal Works Construct'on Permit No...., Dated..........................................
I
......................................................................................................
Board of Health
DATE......................................t.........................................
FORM 1255 HOBBS & WARREN.�'�INC.. PUBLISHERS
212 Asa .�..�...
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