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Home My WebLink About0011 WATERFORD DRIVE - Health 11 Waterford Drive, Marstons Mills r—A=-056---002-XO1� ` i i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 11 e t I Ord r �+ `I rA ars r01\S W11 i ��Ls��M�® Owner's Name: 1%i Lwu4h rest Owner's Address: 11 V ai rat Dr NOV � 3 2001 Date of Inspection: tjov q, 2,o0 i TOWOF BARNSTABLE HEALTH DEPT. Name of inspector: (please print) �)Rv I l? Company Name: Eto - Tec�l 1=vm yi rt,n m e h try 1 Mailing Address: 43 i rjp3�e Lly, Sw%,kWit-li, MA Telephone Number: SOth Z qq S'7 q 3 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: S RS Date: tJ e J It , The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 0 QOI+e t-�erd Q r l'11arStr�nS rYl�l�t Owner• v Date of Inspection: nv h ?,Poi Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: y/ 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank€eilure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out ar higb static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION(continued) Property Address: I I Wcjte —M IS+t n N Owner: k. -f.Q Date of Inspection: VIoy 1, ?.DU I C. Further Evaluation is Required by the Board of Healtb: Conditions exist which require fiuther 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 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,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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: f Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: it W e f o Owner: T,m ".0 aft tea Date of Inspection: N 04 q, D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for g_Il,inspections:�} Yes No _ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the 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 '/s day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no ether failure criteria are triggered. A copy of the analysis must be attached to this forma V' (Yes/No)The system fails.I have determined that one or mnre of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: It Wa+qQrok O Tiyi t-S`to w) lh`1 Owner: lim Lav Vrpm Date of Inspection: 1 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? v/ Has the system received normal flows in the previous two week period? V Have large volumes of water been introduced to the system recently or as part of this inspection? _ 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: Yes no Existing information. For example,a plan at the Board of Health. _ V 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(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS. , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.. PART C SYSTEM INFORMATION Property Address: It WoIfe �00 Dr Mrs+00.6 wmm — Owner: �f%yh La% rea Date of Inspection: _Wbv 11, ZDO l FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): '5 Number of bedrooms(actual): _ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 5 3 0,-4pA Number of current residents: Z Does residence have a garbage grinder(yes or no): eS Is laundry on a separate sewage system(yes or no): AQ (if yes separate inspection required) Laundry system inspected(yes or no):_�!LA Seasonal use:(yes or no): uv Water meter readings, if available(last 2 years usage(gpd)): IggI - 340 get( Sump pump(yes or no):N q 2 006 - 2 to 3 ipy Last date of occupancy: Cv rr e.w 7-00 e- first 1x11 F - ?-2';ffrof COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgR,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): — Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 0\,j 1iGr - Sy5ffm ( 0+ DVj'jPP4 (►1 rVePtI4 p-fc" 1- Was system pumped as part of the inspection(yes or no): Jc) If yes,volume pumped:_gallons--How-was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM v Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous insptction records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: iZ Yru�S pFrm,4 Myeet 4 jii jg9 - P�UH �Aes Were sewage odors detected when arriving at the site(yes or no):)0 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: \\ WA t e r T r Owner: v! re c Date of Inspection: y ?Qn 1 BUILDING SEWER(locate on site plan) Depth below grade: b_. Materials of construction: _cast iron / 40 PVC_other(explain): Distance from private water supply well or suction line: Z(� �t Comments(on condition of joints,venting,evidence of leakage,etc.): Sewer i5 yewted "rovq t rood VIVO appears S4ryc4,/rA1y <ovwef iv4t, no t�v�c�e�nc Y Q 4 l�rke,� ter pUekt,p i 11�C�l h`�' SEPTIC TANK: (locate on site plan) Depth below grade: 1 .S P6 Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: t /Z t t '> f t Sludge depth: 4 i h Distance from top of sludge to bottom of outlet tee or baffle: 30 r h Scum thickness: ►1 Distance from top of scum to top of outlet tee or baffle: A r 11 Distance from bottom of scum to bottom of outlet tee or baffle: 14 1►1 How were dimensions determined: -p roioQ 1-C fop of. T'q n K Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,.etc.): p rP.d C1t this trh,C • uhl< cswej fee, jpGegr :,try`( tvy'e1((-1 �o4'ri� uI+GI �yticti'r�►�r►�ct cs i►�b nc c�cl• �1r, e�i�Q nr� ref P �►c >r csl . GREASE TRAP:►glocate 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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): I Page 8 of 11 1 OFFICIAL INSPECTION FORM+=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: il W0+e4QY& Ur TA oKS Owner: liw% Lctv& re!Q Date of Inspection: NJ of 0. 2 o p l TIGHT or HOLDING TANK: norx(tank must be pumped at time of inspectioonXbmft on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION.BOX:V(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: jwvf.11� 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.): -box C+pPQgr level t,►ad Sirt;c.to'rqjly 0yg4, Fev rr1Vt1 eltl;Qs ivt �vFt,F 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.): I I I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1\ W r r Mor L, Mia— Owner: 't�M A d� Date of Inspection: rlrw C1 ZVO I SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1 leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: 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.): "-Z.Q p1� le(C4+ed vhd,_t- Vgveo( c1 , ve. v ev`d eqe of ev �ce oiut,A< Oren � lv�'Ix yefe' elliyij or c�gyliL f/M was c�beeiVNcl< CESSPOOLS:A Xcesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY:1Wor,_(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM=JTOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION-(continued) Property Address: %1 W&f e y-krcA Or fll,i t- 0Yt5 N AIS Owner: *iVw 1..4 fth l,eA Date of Inspection: Wg J 11, 2,p()1 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. LOCATIONS A B I 14.5 ft 22.5 ft 2 20 ft 31 ft 3 BEDROOM 3 38 f t 31.5 f t DWELLING # I I -FT w _Z J A 13 w 3 SEPTIC o a TANK 2 O D-BOX LEACH 0 PIT 3 WATERFORD DRIVE Page 11 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: kI Qogr2Yjord Pr YYIu rs tflrlS U�t �� Owner: I' ► Date of Inspection: v CI. W01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water W-t feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting 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: -C,'rn y ri 50.E .f o 0 of of 5 1 s u r fat F wzifer t?Co vet f;0T dttt-y to rr+ Sc4s e7ij fi e gvia ova ' Ft tU (914 Po5y L►��iQj`�tiyfl ►'PPaC� �U -�' -�67 ,v� nwhP►..5 P�'S`>e'f�i 01� �nS C TOWN OF RARNSTABLE I 9 LOCATION SEWAGE # . 6$Zo Cna,•�pl VILLAGE ASSESSOR' MAP &LOTfkSTc -jyS_MU,&:�.S NAME&PHONE SEPTIC TANK CAPACITY D� LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER O OWN®R - PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fee of leac 'ng facility) Feet Furnished by /0 a -�` ;` /I� �,�� ::... . ,�� a o 4 a�it 0 �r � � � ,. IX#,//TOWN,OP EA7-9;NSTABLE LOCATION l�CjT w e �dZc� WJ S SEWAGF. 1 XaI VII:.LAGE C�%)�5� 1 ASSEiSSOR'S MAP & LOT06R., C�C� -�og INSTALLER'S NAME & PHONE NO. �-� Vf�Su\� �� 1`-j(�� SEPTIC TANK CAPACITY IL0,661-A4Vt5 Z� �QtnGh r� (5l.ze) '��v ,w tldV,5 LEACHIi�dG FACILITY:(type) �� \10 NO. OF BEDROOMS _PRIVATE WELL n PU13LIC WATER BUILDER OR OWNER 5 DATE PERMIT ISSUED: 4 - I j $1 DATE C:OLIPLIANCE ISSUED: � VARIANCE. GRANTED: Yes __ __—No _ r -, l r _ � '��'� .,., �' i 1 15��s ,. I -L-I, �' I', V �. � �,� r � .. .,.1` a �J C� p0 . / or Qc,a,Xoa BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION I/A �� MILL' Property Address: (�tJ Date of Inspection: JO Ins o ' Name: OY,Wr's Name and Address: }may ?9 /yCg CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: Passes Conditionally Passes Needs Further Ev ation B t Local Aproving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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. A)SYS rEMASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): - 1 - A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 1 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- .; ged SAS or cesspool: °r 4 Liquid depth in,cesspool.is]ess than 6"below invert or available volume,is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 2- r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is 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 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: _L/'Pumping information was requested of the owner,occupant,and Board of Health. _ None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _,ZAs-built plans have been obtained and examined. Note if they are not available with N/A. __,/-The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _L/The site was inspected for signs of breakout. ✓All system components,excluding the Soil Absorption System, have been located on site. VThe septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART B CHECKLIST(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESLDENTIAL. 1/ Design Flow: Q gallons Number of Bedrooms:—a Number of Current Residents: Garbage Grinder: Laundry Connected.To System: Seasonal Use: Water Meter Reading;if iI ble: Last Date of Occupancy: COMMERCLAIJ NDUSTRIAL:Nd Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION R PUMPING RECORDS and source of information: System Pumped as part of inspection:,X) C) If yes,volume pumped: ons Reason for pumping: TYPE SYSTEM: #✓Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): AP OXIMATE AGE of all components date installed(if known)and source of information: O- Sewage odo s dete d when arriving t the site:�4)a -4- l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: ✓ � � Depth below grader Material of Construction: f/concrete metal FRP_Other (explain) Dimisions:�': S'X &1�5- _Sludge Depth: /� Scum�L�ickness: / Distance from top of sludge to bottom of outlet tee or baffle: 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 1 in r tion t o tlet invert, structural integrity,evidence of leaks e,etc.) U // _ GREASE T : A.)o_ Depth Below Grade: Material of Construction:_concrete_metal_FRP Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top 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,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: ✓ Depth of liquid level above outlet invert: Comments: (note if 1 1 and distribution is equal,evidet a of solids carryover,evidence of le#age into or out o bo ,etc.) PUMP CHAMBEA! r Pump is in working order Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5 l J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: Leaching pits, number: �Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comm (note condition of il, signs of hydrauk failure level of pondin ,condition of yegetation, etc.) Ilk CESSPOOLS: _Aj Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) . -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within IN Feet. V a o AL Do' 31 O DEPTH TO GROUNDWATER: ' Depth to groundwater: -2 Feet Meth of De ermination or Ap roxim lion: Ca' � - 7-