HomeMy WebLinkAbout0033 WEST WIND CIRCLE - Health 33 WESINVIND CIRCLE, OSTERV LE
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 33 WESTWIND CIRCLE OSTERVILLE LOT 35
Name of Owner ELROY HILL ��
Address of Owner: 936 LINCOLN PLACE BROOKLYN N.Y.11213
Date of Inspection: 12/7/99
Name of Inspector:(Please Print)JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
r � 0
Company Name: n/aa� O #
Mailing Address: n/a �e�y �9
Telephone Number: n/a oF�a". ,9:9
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 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:
X Passes The Inpection Is based on criteria defined In Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
_ Needs Further Evqlu4tion By the Local Approving Authority performing at the time of the inspection.My inspection does
_ Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: Date:12/16/99
The System Inspector shal submit a 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
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S
USEFULL LIFE.
revised 9/2/98 Page 1 of 11 '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) r
Property Address: 33 WESTWIND CIRCLE OSTERVILLE LOT 35
Owner: ELROY HILL
Date of Inspection:112/7/99
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:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
n1a 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.
Wa 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.
nta 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
n/a 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 2 of 11 F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 33 WESTWIND CIRCLE OSTERVILLE LOT 35
Owner: ELROY HILL
Date of Inspection:12/7/99
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 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:
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 soil absorption system and the SAS is within a Zone I 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 5-0 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 nGa-(approximation not valid).
3) OTHER
n[a
E
revised 9/2198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) '
Property Address: 33 WESTWIND CIRCLE OSTERVILLE LOT 35
Owner: ELROY HILL L
Date of Inspection:1217/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"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
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year:NOT due to clogged or obstructed pipe(s).
Number of times pumped nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following: w
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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 15.30412)..Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST _
Property Address: 33 WESTWIND CIRCLE OSTERVILLE LOT 35
Owner: ELROY HILL
Date of Inspection:12/7/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X 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.
X As built plans have been obtained and examined.Note if they are not available with N/A, -
X The facility or dwelling was inspected for signs of sewage back-up. 9
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding.the Soil Absorption System,have been located on the site:
X 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 Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(1 5.302(3)(b)1
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2198 Page 5 of 11
.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 33 WESTWIND CIRCLE OSTERVILLE LOT 35
Owner: ELROY HILL
Date of Inspection:12/7/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-M g.p.d./bedroom
Number of bedrooms(design): 4 Number of bedrooms(actual):4
Total DESIGN flow: 44Q
Number of current residents:Il
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):JM
Seasonal use(yes or no): YES
Water meter readings,if available(last two year's usage(gpd): n1a
Sump Pump(yes or no): NQ
Last date of occupancy: nLa
COMMERCIAL/INDUSTRIAL
Type of establishment: nLa
Design flow: nLa gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no):DLO
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):No
Water meter readings.if available:nLa
Last date of occupancy: nLa
OTHER: (Describe)
nLa
Last date of occupancy: n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nLa
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped Wit- gallons
Reason for pumping: Wa
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: Wa
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1985 PERMIT 8 =411
Sewage odors detected when arriving at the site:(yes or no): Flo
revised 9/2/98 Page 6 of 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 WESTWIND CIRCLE OSTERVILLE LOT 35
Owner: ELROY HILL "
Date of Inspection:12/7/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: ] '
Material of construction:_ cast iron _40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN ,
Diameter: nta.
Comments: (condition of joints,venting,evidence of leakage,etc.)
n1a
SEPTIC TANK: X
(locate on site plan)
Depth below grade: i
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
Vita ,
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ
Vita
Dimensions: L 8'6"H 5'7"W 4'10"
Sludge depth: L"
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: n!a
How dimensions were determined: MEASURED
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass Polyethylene_other(explain) .
Vita
Dimensions: nta
Scum thickness: Vita
Distance from top of scum to top of outlet tee or baffle:jVa -
Distance from bottom of scum to bottom of outlet tee or baffle Vita ,
Date of last pumping: nta
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.)
Vita
revised 9/2/98 Page 7 of 11
I
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C "
SYSTEM INFORMATION(continued)
Property Address: 33 WESTWIND CIRCLE OSTERVILLE LOT 35
Owner: ELROY HILL
Date of Inspection:12/7/99
TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nta
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nla
Dimensions: nLd
Capacity: nLa gallons
Design flow: nLa gallons/day
Alarm present: NQ
Alarm level:_nLa_ Alarm in working order:Yes_No_ NO
Date of previous pumping: nLa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Wa
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
DISTRIBUTION BOX IS STRUCTURALLY SOUND
PUMP CHAMBER: N12
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NO ,
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,(continued)
Property Address: 33 WESTWIND CIRCLE OSTERVILLE LOT 35
Owner: ELROY HILL
Date of Inspection:12/7199 r.
SOIL ABSORPTION SYSTEM(SAS): X
(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: 1000 GALLON LEACH PIT-EMPTY
leaching chambers,number: 17La
leaching galleries,number: 11La
leaching trenches,number,length: iVa
leaching fields,number,dimensions: nLa
overflow cesspool,number: nLa
Alternative system: Wa
Name of Technology: _nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc:)
THE LEACH PIT IS STRUCTLIRALL SOUND AND FUNTIONING PROPERLY THE PIT HAS NOT HAD MORE THAN Y OF WATER IN IT
CESSPOOLS: _ m
(locate on site plan)
Number and configuration: ida
Depth-top of liquid to inlet invert: nLa
Depth of solids layer: Wa
Depth of scum layer. Wa
Dimensions of cesspool: nLa
Materials of construction: nLa
Indication of groundwater: nLa inflow(cesspool must be pumped as part of inspection)n/.a ,
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc:)
nta
PRIVY: _
(locate on site plan) ~
Materials of construction:nLa Dimensions:n1a -
Depth of solids: Wa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) "
nLa
revised 9/2L98 Page 9 of 11
T.'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 WESTWIND CIRCLE OSTERVILLE LOT 35
Owner: ELROY HILL
Date of Inspection:12/7199
f
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)
s y -
6
t
4A
AC 3),
revised 912198 Page 10 of 11 .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r
PART C
SYSTEM INFORMATION('continued)
Property Address: 33 WESTWIND CIRCLE OSTERVILLE LOT 36, _
Owner: ELROY HILL
Date of Inspection:1217/99
NRCS Report name: nla
Soil Type: n1a r. ,
Typical depth to groundwater: nla
USGS Date website visited: n1a
Observation Wells checked: NO
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope ,,
_ Surface water t
_ Check Cellar `
Shallow wells
Estimated Depth to Groundwater 10 Feet
Please indicate all the methods used to determine High Groundwater Elevation e , 4
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions `a
Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records '
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.('Must be completed)
USGS MAPS AND CHARTS-10+
t 9'
revised 9/2/98 Page 11 of 11
10
RfA �t1!r r^
CONIMON EALTH OF MASSACHt'SETTS
EXECUTIVE OFFICE OF ENVIRONME\TAL AFFAIRS cs f AUlc 1 3
r• 199
DEPARTNIE�T OF E��'IR01NIEITAL PROTECTION '0w" ozAe1E
=� ONE WINTER STREET. BOSTON. NtA 02-106 617-29=-5:00
WILLIAM F.WELD TRL'DY CO)T
Govcmc• Secretarn
ARGEO PAUL CELLL'CCI DAVID B.STRUHS
Lt.Govetnor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 3 �1 �'►�%y't i� �`1 L) )-Zk'V1 k Address of Owner:
Date of Inspection: �y /� (if different)
Name of Inspector: et V ► Cl�a On; Z.rc_V i 1
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 13.000) cz
Company Name:A±/�g ti-4-1'c E17 A-"r�cJ"I a-e P-4,�/.
Mailing Address: PC I;CDA e_3;)P!4 zC4-9
Telephone Number. r-SG2t-J �1=11;— /4c 2-1=
CERTIFICATION STATEMENT
I certin that I have personally inspected the se�aee disposal system at this address and that the information reported belov, is true, accurate
and complete as of the time of inspectoo The inspection was performed based on my training and experience in the proper iuncion and
maintenance of on-site sewage disposa; systems. The system:
Passes '
_ ConoitionaiiI Passes
tieeas Further Evaluat Loca 4pproving Authorir\
F
Inspector's Signature: w Date: 1,
The 5vs;ere Inspector shall' submit a copy of Lhis inspection report to the Approving Authorim, within thirty (30) days of completing this
inspection. If the system is a shared system o, 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; ii applicable, and the approving authority.
INSPECTION.SUMMARY: Check A, B, C, or. D:
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
Bj 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 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; 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 conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continu
Property Address�/
Owner:
-r,Date.ofitnspection:
Bl'SYSTEM CONDITIONALLY PASSES (cont,n -d
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) or due to a broken, settled or uneven distrib tion box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled replaced
The system required pumping more than fo times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of ealth):
broken pipe(s) are repl ed
obstruction is remov "
C) FURTHER EVALUATION 15 REQUIRED BY THE ARD OF HEALTH:
Conditions exist which require further ev uation by the Board of Health in order to determine if the system is failing to protect the
public health, safery and the environme
1) SYSTEM WILL PASS UNLESS BOAR OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUB C HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or pm-, is wit in 50 feet of a surface water
Cesspool or prn- is w hin 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS HE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM 15 FUNCTION NG IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
` ENVIRONMENT:
The system has septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a s dace water supply.
The system h a septic tank and soil absorption system and the SAS is within a Zone I of a public water suprily well.
The system s a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ 1;he system as a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private waj r supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well i 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
(revised 04 r5/97) Psq• 2 of 10 e
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
• FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS:
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 cn ria as defined in 310 CMR 13.303. The basis
for this determination is identified below. The Board of Health should be conta ed to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an ov rloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground surface waters due to an overloaded or clogged SAS or
cesspool.
Static hquid level in the distribution boa above outlet inve due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or vailable volume is less than 1/2 day floe.
Reduired pumping more than 4 times in the last year OT due to clogged or obstructed pipes:.
Number of times pumped _.
Any portion Or the Soil Absorption Svstem, cessp I or privy is below the high groundwater elevation
Arr� por,;on of a cesspool or privy is within, 10 feet of a surface water supply or tributary to a surface water supply..
Any portion or a cesspoo! or priv-v is wrthrr. Zone I of a public well.
Am pe^t;c- o-a cesspool or pri\,ti. is wit n 50 feet of a private water supply well
Any por,.or o-a cesspool or privy is I s than 100 feet but greater than 50 feet from a private water suppiv well with no
acceptable water qualrt\ anak-sis. If a well has been analyzed to be acceptable, attach.copy or well water analysis for
cohiorm bacteria. volatile organic c mpounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "tio" as to each of the following:
.The folio";ng criteria aopiy to large s% ems in addition to the criteria above:
The system Serves a facilin with a d ign flow of 10,000 gpd or greater (Large System; and the system is a significant threat to
public health and safety and the en tronment because one or more of the following conditions exist:
Yes No .
the system is within 4 feet of a surface drinking water supply
the system is within 00 feet of a tributary to a surface drinking water supply
the system is Iota in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public water sup y well)
The owner or operator of any suc system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 a d 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: �-
Owner: Pit MZN i),
Date of Inspection:
Check if-the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes NNo
_ 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 obtained and examined. Note if they are not available with N/A.
The fac;li.. or dwelling %%as inspected for signs of sewage back-up.
The system does not receive non-sanitan• or industrial waste flow.
The site \,+as inspected for signs of breakout.
_ All svFterr. corponents, excluding the Sod .Absorption System, have been located on the site. _.
The septic tank manhoieF were uncovered, opened. and the interior of the septic tank was inspected for condition of
baffies or tees, materiai o' construction, dimensions, deptn of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption 5vstem on the site has been determined based on.
The facilw, owne, ;ano occupants. if difieren: trom owners were provided with information on the proper maintenance of
Sub-Suriace,Disposal 5vstem.
_ Exist!ng information. Ex. Plan at B.O.H.
_ Determined in tree field of an,, of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable (15.302.3t;b!!
(revised 04/25/57) Page 4 of 10
A
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Properh Address: i ;C,1'� uJ jlt�i�� _Clrj ,
Owner: °i IF;
Date of Inspection:
P(�-%��l
FLOW CONDITIONS
RESIDENTIAL:
Design t!—o%ql4 g.o.d./bedroom for S.A.S
Number of bedrooms
NumbeT_o'current residents:jaa
Garbage g•. der (yes or no1:_A20
Laundry co-•^ected to system (yes or no). t4t'17j
Seasonal use (,yes or no::A>
Water meter readings, if available (last two i2; year usage(gpd): dl)d7
Sump Pump lves or nol:_sn
Las: date o'occupanc,
COMMERCI4L1NDLISTRIAL:
Type of establishment.
Design fio�.-_ltalionsida\
Grease trap present. (yes or no
Industria! Taste Holding Tani: present. eves or no
'ion-sanitan Haste discnarged to the T!'ne 5 sysrem: ,ves or no
X%ater meter readings. if available
Las:pate or o c-;:a^c.
OTHER: .Describe
Last care of occicanc.
GENERAL INFORMATION
PUMPING RECORDS and source of information,.
System pumped as par, or i spection: (ves or no,_
If yes, volume pumped gallons
Reason for pumping
TYPE OF SYSTEM
_ Septic tan k/distributton box/soil absorption system
Single cesspool
Ovenlow cesspool
Pn.-)•
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 \"Z:
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) °
Page 5 of 10
' / b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 0!r A,1w,4 �i✓Z�
Owner:
Date of Inspection: i?(�
BUILDING SEWER:
(locate on site plan) �(✓ .
Depth below grader
Material of construction: _cast iron _,40 PVC_other (explain)
Distance from private water supply well or suction li-t
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:-
(locate on site ply
Depth below grade '
Material of construaio.n.: 4concrete _meta' _Fiberglass _Polyethylene _othertexplain!
If tank is metal. Ifs: age _ Is age confirmed b. Ce^:ficate of Compuance _ (Yes'No
Dimensions
Sludge depth tr
Disiance from top o: sludge to botom of outlet tee or ba^le
�r
Scum thickness: �[�•t
Distance from top of scum to top of outlet tee or ba^ie 1
Distance from bottom of scum to bor.o'n of outlet a or bare
How dimensions were determined TT
_ Comments
trecommendation for pumping, rondrtion of�niet a d outlet tees or baffles depth of liquid level in`relation to outlee invert, structural
integri , ev ence of leaks e, etc.t
p, -- r4f I I��OL do'-'e
U ' Ct
GREASE TRAP:
(locate on site plan!
Depth below grade:
Material of construction: -_concrete _metal _Fiberglass _Polyethylene —other(explain)
f
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.;
(revimed 04/25:91) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propertm�ddress: `3
O%ner: Jj 44 f df71_,,,
Date of Inspection:
`+��G
TIGHT OR HOLDING TANK: I/ .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.
Capacity: galions
Design floes galionsda,
Alarm level Alarm in working order _Yes; _ No
Date of previous pumping _
Comments
(condition of inlet tee. condition o-. alarm and float switches. etc.(
DISTRIBUTION BOX:
(locate on site plan
Depth of liquid level above outie: ime^.
Comments:
(note of level a. d die ributior « ea:. evidence of solids carryover, evid rice of leakage into or out of box, etc.)
w i r
PUMP CHAMBER: V)
(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 04/25/97) Page ,7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
-SOIL ABSORPTION SYSTEM (SAS):vEon
(locate on site plan, if possible; excnot required, but may be approximated by non-intrusive methodsi
If not determined to be present, explain:
Type.
leaching pits, number.
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, drmension.s.
overflow cesspool, number
Alternative system
Name of Technolog%•:
Comments.
t to cond 'on of sgii, signs of ydrauhc failure, le el of ponding, onditio �f vegetation, etc.) �1
4
CESSPOOLS: _ �
(locate on sue plan•
Number and configura:,or
Depth-top of liquid to inlet Inver,
Depth of solids layer
Depth of scum layer.
.Dimensions of cesspool
Materials of construction
Indication,of groundwater
inflow (cesspool must De pumper as par, of inspection!
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) pig• a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �S to Ls-1
Owner: *wiv�� � ,
Date of Inspection:
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)
`I Z .
v�
(revised 04125/57) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO!% FORM
PART C
SYSTEM INFORMATION (continued) '
Propertv Address: 3 %kJx5 i I,U►rU
Owner:Aq'f,- '�
Date of Inspection: �3 t y l
en
Depth to Groundwater;�6 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained irom Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Cnec'K with loca! Board o! neaitn
Chec'. FE.N1A maps
Check pumping records
Check local excavators. installers
Use LSCS Da:a
r.
Describe in vox.ov+n %+oro� no%% you established the High CroundN,%ater Elevation. (Must be completed:
1 1
-rt P
lzaysaad 011125.'9 Page 10 of 10
F �� �
LOC-A(iSEWAGE PER IT NO•
VILLAGE
6-sttrui���
INSTA LLER'S NAmmxr a ADDRESS
so
BUILDER OR OWNER
V S a ('{7!-•,ov
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
e
pfJ
O
� o
A^�
Lot 3�--
............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF �HEALTH
......... ..... 14...OF....... ..... - - ........ . . ..........
Appliration for Disposal Works Toustrurtion thrutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
IDR ............................................
............tv V e.k.'ka. ........ ......... ...... ---------------------------
,j,ocation-AVdress of Lo N
_0 ........ ......
.. ... ....... ......................... .....
..... -------
0 ner Address
..........
Installer Address
U Type of Building Size Lot ...Sq. feet
Dwelling—No. of Bedroomj........... --------*------------------
13. Expansion Attic Garbage Grinder
V-
a
Other—Type of Building of persons.......6---------------- Showers Cafeteria
d.
Other fixtur
..
-__ ....._._____gallons gallons per person per day. Total da*1 )jo ......... .. . . gallons.
Design Flow_------------------S w------- \ "*--------------
1:4 Septic Tank4-Liquid*capacity-im-.gallons Length.___,Y.'..... Width.., Diameter................ Depth_.._.........._.
Disposal Trench—No. .................... Width................... Total Length.............._It— Total leaching area . ...........sq. f t.
Seepage Pit No........./---------- Diameter.........e....... Depth below inlet.....'_;�....... Total leaching area.4407---sq. ft.
Other Distribution box ( Dosing tank
4-4
Percolation Test Results Performed by.-
UN.A.0........ Date........4.=
Test Pit No. I................minutes per inch Depth of Test Pit---.-_._............ Depth to ground water.......................
4q Test Pit No. 2................minutesper inch Depth of Test Pit___................. Depth to ground water.-A
P4 ------------------ -------------------------------------
-
0 Description of Soil...............C..e �t��/!_...... ----
e-- ----------------------------------------
-
-----------------------*-------------0--------------------------------*------------------------------------------------------------------------------------------------------------------------------
W.
------------------------------------------------------------------------*-------------------------------------------------------------------------------------------------------*.....*---------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL I Ti IZj 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ed by the board of health.
Certificate of
Compliance has
been i ued by board of heaith�_g ed igned....... .... .. ...... ..... .................
ApplicationAppr ..... . ..................................................................................... ... ..... ....... ..................
Date
Application'Disapprove e following reasons:...............................................................................................................
........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
——---------------------------
Na /•-. .. .: _� FE$.lv................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF�HEATIC-- '( ----OF..... ...
Appliratinn for Disposal Works Tonstrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System
. r > ------------ -------------------------------------- ' .. .. ._........
;> Location Address Or
O ner � Address I
Installer Address
Type of Building Size Lot.!_„ f ....Sq. feet
Dwelling—No, of Bedrooms.......... .............................Expansion Attic ( ) Garbage Grinder ( )
: .v U
`4 Other—Type T e of.Buildin
p, yp g lrSr1�! No. of persons___._.----------------- Showers O — Cafeteria ( )
a' Other fixtur s __.___ '1
,. .� --------------------- ...........................................
:W Design Flow................... _ ............... per person per day. Total dai I flow..._____..__. _ __._._____._____gallons.
Septic Tanl Liquid capacity/ __.gallons. Length___ _.____ Width_ _.___ Diameter................ Depth................
' W Disposal Trench—No.___.____ Width___.._. Total Length Total leaching area s ft.
x P g e-- g -•--- q
Seepage Pit No......../---------- Diameter........ ........ Depth below inlet___ .._..___ Total leaching area.//, Z...sq. ft.
z, Other Distribution box (., ,,.) Dosing tank ( )
Percolation Test Results Performed by- t f.�1!` � 1 : Date___ " �/
as - 'Test.,Pit No. L_______........minutes.per'inch Depth of Test Pit.................... Depth to ground water
Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water_
-------
O -------------
Description of So il______________ _
p t "G` - '------
-__.. .
w
----..........................................
UNature of Repairs or Alterations-'Answer:when applicable...............................................................................................
--------•••-•-------•-------•--------'---•-•-------------•-•••-••-------•-••-----=------------•---••--•-------•---••------•---•-----------•-•--------------•-•---•• ..................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
r,. the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
4 operation until a Certificate of Compliance has been is ued by the board of health. 10,
igned . ..........'. t -•-•----•--
Application Appr�!ed . -------------------- ..........................................i---.._.........------ r -- ---------
4
Date
Application Disapproved a following reasons:-----=-•------------••-----•----=---=-------•------------------•-------------•..............................
-------------------------------------------------••----------------._....------------•------•-...__._..-
j Date
PermitNo--------------------------•.....-------------------_..... Issued_.................................................... -
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. :: :o. ..OF..... G.e :
Trr#if iratr of Tomptianre
THIy/2
TO CERTIFY, Th ,the Indio' ual Sewage , li�sposal System constructed (,�+') or Repaired ( )
by............ "' -•----- ----- __ .. .. -------------------------------------------.....f----------- ----- ----------.
Installer
at
has been installed in accordance with the provisions of TTLE ',of The State Sanitary Code as described.n-the
application for Disposal Works Construction Permit No.__if__G__"._._S_s��......._....... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON iTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................... _:-....... ---••-•-•------------------------ Inspector............ - --•--• -•---------- ..:_......_.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. ....... OF...:.I
Ni ._ FEE.~/d.�.................
- Disposal Works ion #rnr#ion ermii
Permission is hereby granted._...__
...
to Construct '(") or;Repair ( ) an Individual Sewage Disposal System`
atNo.�} : = .—-------og----------- 1 -- - -,-----•---------------••-------- -
J 'B 1✓
as shown;on/th/eapliiion for Disposal Works Construction Per . _____________________ Dated__________.._._..______.________._f/ Board of Health
DATE --•---------
FORM 1255 A. M. SULKIN, INC., BOSTON
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