HomeMy WebLinkAbout0078 WHISTLEBERRY DRIVE - Health 78 Whistle-berry Drive
Marsons`Mills.. P `
F A = 063. 082 :
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
IVED
DEPARTMENT-OF ENVIRONMENTAL PROTECTION
DEC 1 7 2002
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM FORM
PART A
CERTIFICATION
Property Address: 'Dgvjitp
it-
Owner's Name:
93
Owner's Address:
kz��,f
Date of Inspection
Name of Inspec, (plea. a print) MAP ��� �T
Company Nam � j
Mailina Address: �. !ff PARCEL s..,LOT
-
Telephone Number:
- --
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is.true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving.Authority
Fails
Inspector's Signature: / Dater
i
L.�
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing,this inspection. If the system is a.shared system or has a design flow of 10,000
gpd.or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2.0.00 page 1
T
T
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT YOR-VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 90
1
Owner• '
Date of Inspec 'on: �,
Ins.pection`Summary: Check A,B;C,D or E/ALWAYS complete all of Section D
'A. ystem Passes:
" I have not'found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
T--,,..,B...System Conditionally Passes:
Orre,or'moree 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 exiciltratiori.or.tank failure is imminent:System will pass inspection if the. '
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if iris structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is avail
able.
-ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than'4_times a year due to broken or obstructed pipe(s).The system.will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page of 11
OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
O
Owner. . 4
Date d Inspe ion: P JIA �Q
,C. Further Evaluation is Required by the Board.of Health:
Conditions exist which require further evaluation by the Board of Health in order,to determine if the system
is failing to protect public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR 13.303(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 1 of a public water supply.
The system has a septic tank and SAS.and the SAS is within 50 feet of a private water supply well-
— The system has a septic tank and SAS and the SAS is less than 100 feet but 30 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 coliforrn
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:
Page 4 of 1 I
OFFICIAL INSPECTION FORM—.NOT FOR YOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12)v ••'"
Owner
Date'o€'Inspecd..lon: 'C 0
0 a
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the:surface of the 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
lcesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow,
t/ 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 la'boratory,.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 thatno other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I.have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303 therefore.the system fails.The s
- � stem owner should contact the Board of Y Y
Health to determine what will be necessary to correct'the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of.10;000 gpd to 15;000
gPd•
You,must indicate either"yes"or"no"to each-of the following:
(The following.criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a.surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is.located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a.mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
'4
Pacre 5 of 1.1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date o Inspec m O a
Check if the following have been done. You must indicate`Yes"or"no"as to each of the following:
Yes No
_ Pumping,information.was provided by the owner, occupant, or Board of Health
Were.any of the system components pumped out in the previous two weeks ?
✓_ Has the system received normal flows in the previous two week period ?
Have large.volumes of water been introduced to the system recently or as part of this inspection?
Were as-built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs.of sewage back up ?
V _ 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?
L _ 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
L/ _ Existing information.For example, a plan.at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CIvIR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2
A •
Owne .
Date-of Inspection:
FLOW CONDITIONS
RESIDENTIAL`
Number.of bedrooms.(design): Number of bedrooms (actual):
DESIGN flow based on 310 CvIR 15.203 (for example: 11,0 gpd x rt of bedrooms):
Number of current residents: Q
Does residence.have a aarbage grinder(yes or n0J%S�T
Is laundry on a separate sewage system(yes or no, [if yes separate inspection required]
Laundry system inspected(yes or no
Seasonal use: (yes or o):
Water meter readings, if available
�a(last 2 years usage(gPd)): 00
Sump pump(yes n
Last date of occupancy: AL
COMMERCIAL/INDUSTRIAL'�,r,
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system (yes or no):—
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records _
Source of information:
W.as system pumped as part of the i pection(yes now)
If yes,volume humped: gallons--How was quantity pumped determined?
Reason for pumping:
TYP OF SYSTEM
—Septic tank, distribution box,soil absorption system
Single cesspool
_Overflow cesspool
Privy .
Shared system(yes or no)(if yes,attach previous inspection records, if any)
_-Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank —Attach a copy of the DEP approval
Other'(describe):
AP x' to age of all components, date installed(if known) and source of information`.
Were sewage odors detected when arriving at the site(yes or n6,-'—" �
6
F'age 7 of l l
OF INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date Inspec on: a
BUILDING SEWER(locate on site plate
Depth below grade:
Materials of construction: cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments (on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK: V(locate on site plan)
Depth below grader
Material of construction: V 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:��• �'�p '�( .�
Sludge depth:
i�
Distance from top of sludge to bottom of outlet tee.or baffle: '
Scum thickness:z_
Distance from top of scum to top of outlet tee or baffle: Z
Distance from bottom of scum to bottom of outlet.tee Qr baffle: 3111
How were dimensions determined: "
utlet tee.or baffle condition,structural integrity, liquid levels
Comments (on pumping recommend tions�iet ndo
related to outlet invert,o idence o akage, etc.):
GREASE TRAR ocate 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:
];ate of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ]FORM
PART C
SYSTEM-INFORMATION(continued)
Property Address:
OwneAInspedion
G�2
Date o :
TIGHT or HOLDING TANK_ (tank:must be pumped at time of inspection)(locate on site plan)
Depth below.grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Desa n 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.):
DISTRIBUTI(.'>N BOX: I/ if present must be opened)(locate on site plan)
(
Depth of liquid level above outlet invert: .. an evidence of
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, y
ea�age into or out of bo te.):
PUMP CHAMBER.:A&locate on site plan)
Pumps in working order Oyes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
8
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owne • —
Date of nspe ion. 00,
SOIL ABSORPTION SYSTEM (SAS):. (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number: '
leaching trenches, number, length:
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,
et ):
Cj
CESSPOOLSAA.—(cesspool must be pumped as part of inspection)(locate on site plan) L �
Number and confiauraticn:
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:f/ 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
t
Paee 10 of 11.
OFFICIAL INSPEECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C-
SYSTEM INFORMATION(continued)
Property Address:
Owner: V�
Date of Inspect. n: s �
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building.
O
-
60
G�
I
2
10
1 I '
Page 11 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
Property Address:
Owner:
Date of Inspec on: ma zyw I,.
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water V 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)
VAccessed USGS database-explain:
You must describe how you established the high ground water elevation:
11
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
n
Site Location: e `l ,1*f// Lot No. _
Owner: ba/^O q/4%/� Address:
Contractor: 161ty, 24/7/0 Address: n
Notes: 2 /l�/IZ5
STEP 1 Measure depth to water table
J
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...................:............ J�....��.....
OWater-level range zone.:...................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ...........................
®z
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B) ,
determine water-level adjustment ......................:....:..............................................................
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) ...............................................................:................................................
Figure 11--Reproducible computation form.
15
i
/00
1 D
tea/ ��`S
COMMONWEALTH OF 1v1MSACHIJSETTS 01
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
11
DEPARTMENT OF ENVIRONMENTAL PROTECTION
�y
/ V
1 yV�
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Pr o.perty Address: 4�J�
A
Owner's Name: c�
RUAVEO
Owner's Addre ��
' NO1� 2 7 �, 0 �h
Date of Inspection: 0 -0 70V1VorftN 4
Name of Inspect r: please rint
Company Name
Railing Address: � � � ►�;�`
IVA CQ 0a
Telephone Number: /3 06
CERTIFICATION STATEMENT
I certify that.I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete'as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes .
eds F h r Evaluation by the Local Approving Authority
ails
Inspector's Signature: Date: -d - C
The system inspector shall submit a cop of this inspection report to the.Approving Authority(Boazd.of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system.or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and.under the conditions of use at that <
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of l 1 \
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: d
Owner. Gtpt,
Date o nspection: _/U/ice /00 ,
Inspection Summary: Check A;B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates.that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
a
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 failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A.metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate.of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to'broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval.of Board of Health):
-broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
;e3of11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY AS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued),
Property Address:
owner: rf- �
Date of spection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation.by the Board of Health in order to determine if the system
is failing to protect public health,-safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303OO 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 ar Supplier,
andif any)
environment:
that the
system is functioning in a in that protects the public health, y
The.system:has a septic tank and soil absorption system(SAS)and.the SAS is within 100 feet of a.
su_rface water supply or tributary to a.surface water supply.
_ The system has a septic tank and SAS and the SAS is within a.Zone 1 of a public water supply.
_ SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and
_ 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 is free froEP m laboratory,
from that c ifor. and
bacteria and volatile organic compounds indicates that rovidea that no other
the presence of:ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,p
failure criteria.are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
GUin1'��Property Address:
Owner: 9&jyji- WE
Date of pection: 66
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following for all inspections'.
Yes Np
J 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
�f Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ .U{ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z.day flow
J Required pumping more than 4 times:in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
V 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 eater than 50 feet from a private water
— greater
.supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a.DEP certified laboratory,for.coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
'"d (Yes/No)The system fails.I have determined that one or mote 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's facility with a design flow of 101000 gpd to 15,000
gPd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
— _ the system is within 200 feet of a tributary to a surface drinking water supply.
— the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in.Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
,
Page 5ofII
OFFICIAL INSPECTION FORM-NOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _
M
Owner: d- v .
Date of .spection:
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
_ Were as built plans of the system obtained and.examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out.?
_ Were all system components,excluding the SAS,located on site?
f_ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
othe�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)providedwith 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.
1/ 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)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-;NOT FOR:VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL°SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 10
Ownknjs
v�
Datepection: 6 0A, DO
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: I10 gpd x#`of bedrooms)'
Number of current residents:
Does residence have a garbage grinder(yes or no)/. -Z'
Is laundry on a separate sewage system(yes or no)?3Lr-[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):, f, ..,
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no) ti
Last date of occupancy: cw - G �2 %LCnZC�P /L =fC'P. O
COMMERCIAL/INDUSTRIAL
Type of establishment:.
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):,.
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):. .
GENERAL INFORMATION
Pumping Records e
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:,
T7. eptic
F SYSTEM
tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool .
Pri vy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a co of the current operation and maintenance contract to be
PY P
_obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Ap roximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
I
Page 7 ON 1
OFFICIAL.INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ge
Owner:
Date of spection: 70 0
BUILDING SEWER(locate on site.plan).
Depth below grade:
Materials of construction:_cast iron 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc:):
SEPTIC TANK: (locate on site plan)
Depth below grade: 1
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: /0•s"k(o x S
Sludge depth:
Distance from-'top of sludge to bottom of outlet tee or baffle:.
Scum thickness:-6?; '
Distance,-from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: //f
How were dimensions determined:
Comments(on pumping recommend tions,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as,related to outlet invert, evidence o leakage,etc.):
GREASE TRAP/(I"llocate 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:T
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):.
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
--I M,' C)t�-49
Owner: Lt Q t;Zrtte&17-'
Date of spection: O pU
TIGHT or HOLDING TANK. 6"'(tank must be pumped at time of inspection)(locate on-site plan)
Depth below grade:
Material of construction: concrete metal - fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/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: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: w l
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
1 akage into or out of box,etc. :
i
PUMP CHAMBE jRTlocate 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.):-
.g
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
,
Property Address:
Owner: , ;
Date of spection: U
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number: c9
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.)
JF
Ater ape G�
CESSPOOLA�cesspool 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:/ ocate 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=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: -
Date of pection: 4..
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.
/�b
o
t
C? '
0
10
rage i i. or i i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: cl
Date of spection: O
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water Z 1 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:
Aom
�'�14P5
t
11
COMMONWEALTH OF MASSACHUSETTS 4 #
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
PROTECTION
DEPARTMENT OF ENVIRONMENTAL ,G,
Noll 6 2000
-41 TORWO
€Q a
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS `
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM.
PART A
CERTIFICATION
Property Address:
A
Owner's Name:
Owner's Addre
AZZ
Date of Inspection!
Name of Inspec r: pleas.e rint
Company Name
Mailing Address: - IVA CQ! e
Telephone Number: /3 0 Q r
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete'as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Wails
Passes .
r Evaluation by the Local Approving Authority
tl
Inspector's Signature: Dire:
The system inspector shall submit a cop of this inspection report to the\Approving Authority(Board-of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
RJ '.
Page 2 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: '
MOM
Owner. c(�Qj�,
Date o nspection: _Z0/ice /U G
Inspection Summary: Check A;B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not.found any information which indicates.that any of the failure criteria described in 31.0 CMR
I5.30S or in 310 C MR 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 failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurallysound,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*or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval.of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
j
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address: GLJ ®
Owner J , .
Date of spection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation.by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a.manner.which will protect pubfie 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._-ias a septic tank and soil absorption system(SAS)and.the SAS is within 100 feet of a
su_rface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has,a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well`*. Method used to determine distance
"This system passes if the well water analysis,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:
3
Page 4 of 11 t ,
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Wor
Owner:
Date of pection:
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following for all inspections:
Yes Np
_ ✓ Backup of sewage into facility or system component due to overloadedor 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
_ tJ 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
tl 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 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. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
.indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 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 II of a public water supply well "
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
I
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
�19
Owner: cf
Date of spection: Ji3�eC)
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
_j'Z'— Were any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period?
_ Have large volumes of water been introduced to the system recently or as part of this.inspection?
_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or.dwelling inspected for signs of sewage back up?
_ Was the site inspected for signs of break out?
Were all system components,excluding the SAS, located on site ?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the.Soil Absorption System (SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
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)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 0-
Owner:
Date of spection: 43 00
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):C? Number of bedrooms(actual): .�
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): k-?30
Number of current residents: _.
Does residence have a garbage grinder(yes or no):/'&"
Is laundry on a separate sewage system(yes or no)?2-[if yes separate inspection required]`
Laundry system inspected(yes or no):/2Uj--
Seasonal use:(yes or no): j --
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy:M" - O/Zo441 ozW 1kdzW~
COMMERCIAL/INDUSTRIAL/,A,r&
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):—
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the ' section(yes or no
P (Y ) —
If yes, volume pumped: gallons-=How was quantity pumped determined?
Reason for pumping:
TYP&OF SYSTEM
eptic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
—Other(describe):
Ap roximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):7—
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of spection: 3 Zoo
BUILDING SEWER(locate
to ate on siteplan)
Depth below grade:
Materials of construction:_cast iron 40 PVC_other(explain):
Distance from private water,supply well or suction line:
Comments(on condition of joints,venting,'evidence of leakage, etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade:l
Material of construction:_c%ncrete_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: /O•S"k 6 , k 6—
Sludge depth: 9--
Distance from top of sludge to bottom of outlet tee or baffle: )6
Scum thickness:_ p ,.
Distance.from top of scum to top of outlet tee or baffle: q
Distance from bottom of scum to bottom of outlet tee.or baffle:
How were dimensions determined: �,�,i��
Comments(on pumping recommendd ti�let and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence o leakage, etc.): ,
i�
GREASE TRAPAflZTocate 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.):.
7
E�
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: k �
Owner:
Date of spection: Pbo
TIGHT or HOLDING TANK tank must be pumped at time of inspection)(iocate 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: r/ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:L��� n'g �
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
1 akage into or out of box,etc. : •,
PUMP CHAMBEY Tlocate on site plan)
Pumps.in working order(yes or no):
Alarms in workingorder(yes or no):
Comments(note condition of pump chamber;condition of pumps and appurtenances,etc.):
8
Page 9 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
AM
Owner:
Date of spection:_-,Z(j-41-TZorj
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Trope
leaching pits,number o
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,
et.:.)-
0 124
��..
C, pejdj,p
CESSPOOL1A�cesspool 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/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-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
lop
Property Address: A /L)
Owner:
Date of spection:A;%a!&
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all.wells within 100 feet.Locate where public water supply enters the building.
o 56
0
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17M
A-
Owner: r�k
Date of spection: O
SITE EXAM
Slope
Surface water
Check cellar
Sha_low wells
Estimated depth to ground water Z 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:
✓1?4P5
i
11
LOCATION - t7 f SEWAGE PERMI:T, _ NO.
�-
VILLAGE '
1 t ;. IVW g 0 /S
I N S T A LLER'S NAME j ADDRESS
p !L F l
BUILDER' OR OWNER
t
DATE PERMIT ISS Ut D
v
DATE COMPLIANCE ISSUED
3 57
z� 37
�y.
� t
4 � n
T \ 1
V
No...?.S}.. Fka.. `�`.
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD� OF HEALTH
......`...w..N•..................oF Lr; ..........................
Applirafiau for Miami al Works Tonstrnrtinn Famit
Application is hereby made for a Permit to Construct (K) or Repair ( ) an,Individual Sewage Disposal
System at:
-Alf.S����4�-:S.......................o:.r..-.......................................................
Location-Address or Lot No.
....-----C ......_(.-. .. ..................................................... ........... ..................................................
Owner ----•...........................•Address•
Installer Address
Type of Building Size Lot.4'A_-QQ��-_..Sq. feet
U Dwelling—No. of Bedrooms....A----------------------------------Expansion Attic ( ) Garbage Grinder
PL, Other-T e of Building No. of persons-----------------••.•_-.--._ Showers — Cafeteria
a' Other fixture
-----------------------
W Design Flow................ ...................gallons per person per day. Total daily flow........`4 ................._......gallons.
WSeptic Tank-Liquid capacity_.O. allons. Length..V>-A9.... Width.b.'.`?�.-- Diameter---------------- DepthS-- ....
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................Sq. ft.
Seepage Pit No._-__.Z--------- Diameter--_---e?----_._-- Depth below inlet....-62........... Total leaching area-
Seepage ft.
Z Other Distribution box Yeis Dosino, tank
`-' Percolation Test Results Performed by. ............. Date....
---------------
aTest Pit No. 1....CZ.minutes per inch Depth of Test Pit---- ------- Depth to ground water... ................. cou(b.m
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
04 ....:... ......... ..�__ --.�_.. _---__-...
O Description of Soil zJ t- �� ................... 1.,� •---
x
W .-------------------------------------------------------------------------------------------------------•---------------------------------------------------•------•--------------------------------•••.
UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------
---------------------------------••------------------------------•--------------------------•----••-----•-••-•---------------------------------.....__....--------------------------•••................
Agreement: n
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iii s, y g g p y
5 of the State Sanitar Code—The undersigned further agrees not to lace the system in
operat' unt Ce ficate of Comp fiance has ris ayt�tard of health.
Signed --------------•-•• •.... Date
Appliion Approved By-•-•-•......-•--••--• --•--••--•-- ........................
Date
Application Disapproved for the following yeas s:-••••---•••••-••-•--•••-••••--•--••----•-----•--•-----••---•------------•••-•--••-•-------••---••--•.........._.
--••-----•-•-----------------••---...-------•----------...--..------------------------•---••-•--------•--I-•••---•---•--•-••--•--•-•••-----•••---------------•----•-------•-----------•-•-•--•-----------
Date
PermitNo......................................................... Issued.......................................................
Date
No......................... Fns..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�01 OF a`'i\ i ` _J_._�.+.� ♦-.f ".
, ppliration for Dispasal Works Tontitruction Vamit
Application is hereby made for a Permit to Construct (t'y) or Repair ( ) an Individual Sewage Disposal
System at: -•-�. ...... ...... Z
�_. �� * . ,
—^_ - -Location-Address or Lot No.
....................... = ...................... ..........--.....................................................................................
Owner Address
..................................... --•-----•----•----------------•------•----•----........._... ---•-
Installer Address
U Type of Building Size Lot___... f '.___Sq. feet
�-, Dwelling—No. of Bedrooms.___..eil�____________________________•._..__Expansion Attic ( ) Garbage Grinder (,Lo)-
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' ! Other fixtures __________________________
Design Flow................ .....................gallons per person per day. Total daily flow_______:`-�r-:-.-__________ ___..___gal
W Ions.
WSeptic Tank—Liquid capacity__'_�5X-gallons Length_il c:_Le__._ Width__, ___� _.. Diameter------- ..... Depth_S_-_`_t_..
x Disposal Trench—No.____________________ Width.................... Total Length........ Total leaching area-------------------- ft.
Seepage Pit No...... �--------- Diameter........-,+-------- Depth below inlet____ ___________ Total leaching area.......�_: ...sq. ft.
Z Other Distribution box '(`e_,,� Dosing tank (, a j +
Percolation Test Results Performed by __ .. -- _ _._} "Y + i '+ z _?
............. Date-- --1•----
Test Pit No. 1----- ___-.minutes per inch Depth of Test Pit....A............... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_____-_________________-
Qe , .
O Description of Soil....O_'_ c:,' s:- ! >
....................................
1 .-------- ---
�
...........-..................................................................................................
W ;.
U Nature of Repairs or Alterations—Answer when applicable_____________________________ ....................Y '._________..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of"U4 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operat• unt• Ce -ficate of Compli nce has b , is ed ,y t board of health.
�,. i
igned----- -_••--•- •---•=-•--•-•------------------•------••-•••--••-•-•• --••• ........... /9--
Date
APPIiion Approved..BY = ---•-----•- ----------------------•-- ........................................
Date
Application Disapproved:f or the..f ollowing real s:-----••--------•---------------•-------•---------------•----------------------•----------------••--......-----
t
z♦ Date
PermitNo................ Issued.......................................................
:.. ----;t^- Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. ........................OF.,..................................................................................
THIS IS TO CEA TIFY, Th t the,Individual Sewage Disposal System constructed ( or Repaired ( )
W-0 --------------------•----------------•----------_____-----_______. ...._..--•----•-------•-•--...--•---•--.....-•-•----......_........._
tom'=------------••---------- -..._ --------------------------------------------------------------------
--
has been instaiied in":accordance tvith'YIZe provisions of r1 r 5 of The State Sanitary Code as described in the.
application forDis osai Works Construction Permit No.___.___ __ __ _"-" dated---------- "`
THE ISSUANCE OF THIS CERTIEICA E-SHALL NOT BE CONSTRUED ASA GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................ _..`.` .....-----.... .hV,
.. Inspector4mtma�•••••••-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r
........................................OF......................................................................................
NO..:...-�5. _3 0) FEE........................
Permission is hereby granted x ��u> ..•/ O-RI-�-------------•---------__...---•--------•.......--------.....____---•-----•---
fi
" 1 to Construct ` ) or Rep •r ( ) an Individ al Sewa e Disposal Syst
� t� �• p Mtn
__D ._. . 'Uwe 7 ( hl sj/r beaay IJ?ire
r..' Street tom?
as shown on the application for Disposal Works Construction Permit No_ ________________ Dated______ _ry_ g ..............
S5" Boa e
DATE............... __-•-i-5------4-----------------•------------.._..._.
r k.,
FORM 1255 HOBBS & WA REN, INC., PUBLISH.ERSS
• ` � lit `?
P,r E,li? L�AG•a
o
//o
✓ ��� //a 7
Q sac •�
/vAf
l �
A03 u
_ \lY
1N OFs�F�11.OF
ti
t PETER `.' 4 ' RICHARD ``
^:''s B A.
' AXTER
No. 29733 " No.24043
A p e LL
Fc/ST
` 11
OA7,4
-USE /J"oo G J� . �• "
ap r�,s .,
\ "
TER >;. RICHA c�
SULLIVAN ! A. f^r
G.Rl� No. 2�733 f ``'j,9 �B�XT r
to • �d����GiG7�ti�Cj .��, 4 �� �Y40CL
Fi
ToTDL 1�E.s✓cat,/ - Bs® G.r'�.C� �5�.� -- �� '. ;�- ' �--
od
T
4/�a 1�0) /lea Pric.� f .r�i�
Z � Z'/DOO /N✓. - GAL, /N� :i
BoX //D. //�•,� , '•°
c� F
.pia- Tlq.v.� k
I ,. •� //v✓. //VIA
G ''. � �-•� ,, �/�`�° //a'Y G•E.2T/F/EO PG OT ,�!Q,,/
,$GGLC' 7A7;-- Lz
I/z •t/o Ove 9.
/ GE,eri�Y Tf/.4T
f/E�Eo v COMPLY.S W/Tf/T,yE 5���1,/NE B,4x 7-,.2 IT Ao!Y
.4tiO oS 7r,5/1Ge �2EQv/eENI�NrS d.� Th'� .eEGisr���.[�tr✓o sve�Eyo,P�
Tox�Iv oF,��,y_�,�•� t1Nll /S NOT G�s�.21i/,Glc a- �1�.�
LOG.4TE.O W/TH/iV T,�/E .CL�,ppG.4/it/,
14.�.L/ca ter- , �7-avl7 c/
` ��8-S� '��l C �� . '\ T//lt P�-•eiv /s it/o o Div,a/V/iY.ST,e-
_l� -G• tea. ` F c.�G� ,�,....�..--- T 13.4SE
-�/.�1E�Yr-..fvE�/C-•Y.4�V0 T.�,�E o.��S�r.�
oa4 2 iG/aT!dE USEp
T�EST�G/S/,i Lar G/NE,S