HomeMy WebLinkAbout0055 AUGUSTA NATIONAL DR - Health (2) 56 Augusta National Drive,
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COMM ONWEAI_:C[1 OF MASSACI-RJSE'17S A_A__
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EXECUTIVI�. OFFICE (w ENVIRONMENTAL. AFFAILZS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Map:_355— Lot:_149_
Par:_ 15
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION r
Property Address:_56 Augusta National Dr. C'tJ/''1l�lAQvltJ
_Barnstable_ ,
Owner's Name: F.W.McAbee t
Owner's Address: same
c C_
Date of Inspection:_6/27/05
Name of Inspector: Dion C. Dugan LD
Company Name:_ 1543 Main St.
Mailing Address: Brewster,MA 02631 ^� ?9
Telephone Number: 508-896-9390
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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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 6/27/05
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 inspectionAf 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: *Recommend: Maintenance pumping 3—5 yrs.
***
***May have running toilet. Running
toilets can cause early leach pit failure.
Recommend Septic Tank be pumped now.
t
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
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OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_56 Augusta National Dr.
_Barnstable_
Owner's Name:_F. W. McAbee_
Date of Inspection:_6/27/05
Inspection Summary: Check' A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X_ 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:
N/A 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:
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SVSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 56 Augusta National Dr.
_Barnstable_
Owner's Name: F. W. McAbee_
Date of Inspection:_6/27/05_
C. Further Evaluation is Required by the Board of Health:
o I
N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or 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:
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_56 Augusta National Dr.
_Barnstable_
Owner's Name:_F. W. McAbee_
Date of Inspection:_6/27/05
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
—X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a.Zone I of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (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 forma
_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 system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
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
_N/A the system is within 400 feet of a surface drinking water supply
_N/A _ the system is within 200 feet of a tributary to a surface drinking water supply
N/A_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— I WPA)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
Page 5 of' I
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 13
CHECKLIST
Property Address:_56 Augusta National Dr.
_Barnstable_
Owner's Name: F. W. McAbee_
Date of Inspection:_6/27/05
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner,occupant, or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks
_X_ Has the system received normal flows in the previous two week period'?
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection ?
_X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components, excluding the SAS, located on site`'
_X _ 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 "
_X_ _ 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
_X_ _ Existing information. For example, a plan at the Board of Health.
X 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 G of'I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_56 Augusta National Dr. r
_Barnstable_
Owner's Name: F. W. McAbee_
Date of Inspection:__6/27/05
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_3_ Number of bedrooms(actual):_3_
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms):_330
Number of current residents:
Does residence have a garbage grinder(yes or no):_no_
Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required)
Laundry system inspected(yes or no):_no
Seasonal use: (yes or no):_yes_
Water meter readings, if available(last 2 years usage(gpd)): 2003:_161,000 gal. ; 2004: 192,000 gal.
Sump pump(yes or no):_no_ (w/sprinkler system)
Last date of occupancy:_March 2005
COMMERCIAL/INDUSTRIAL: N/A
Type of establishment: N/A
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:_Pumping: unknown owner
Was system pumped as part of the inspection(yes or no): NO_
If yes, volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X_Septic tank, distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
NO_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):
Approximate age of all components,date installed(if known)and source of information:
_Installed_not on record B.O.H.
Were sewage odors detected when arriving at the site(yes or no): NO_
Page 7 of I I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_56 Augusta National Dr.
_Barnstable_
Owner's Name:_F. W. McAbee_
Date of Inspection:_6/27/05
BUILDING SEWER(locate on site plan)
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Depth below grade:_32"_
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:_N/A
Comments(on condition of joints, venting,evidence of leakage, etc.):
_Joints are tight,venting is through the roof,no signs of leakage.
SEPTIC TANK:—YES—locate on site plan)
Depth below grade:_20"_outlet cover built up to grade w/cast iron cover_
Material of construction:_X_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:_1000 Gallon_
Sludge depth._16"
Distance from top of sludge to bottom of outlet tee or baffle: 14"
Scum thickness:_2"
Distance from top of scum to top of outlet tee or baffle:_6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined:_by tape and rod
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Recommend septic tank be pumped now.Tank and tees in good condition, no sign of leakage.
*Recommend: Maintenance pumping every 3—5 yrs.
GREASE TRAP:_N/A_locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural Integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
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OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,(continued)
Property Address:_56 Augusta National Dr.
_Barnstable_
Owner's Name: F. W. McAbee
Date of Inspection:_6/27/05_
TIGHT or HOLDING TANK:_N/A_(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:_YES_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_0"_
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.):
D-Box is level with some signs of carry over and no signs of leakage
_w/C.I.cover built up to grade.
PUMP CHAMBER:_N/A_(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.):
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_56 Augusta National Dr.
—Barnstable_
Owner's Name: F. W. McAbee_
Date of Inspection:_6/27/05_
SOIL ABSORPTION SYSTEM (SAS): _YES_(locate on site plan,excavation not required).
If SAS not located explain why:
Type
_X_leaching pits,number:_one 6' x 6'pit w/1'stone_
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.): Pit found w/37"of liquid in it,no staining,no sign of failure.
CESSPOOLS: N/A_(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.):
*Recommend: Maintenance pumping every 3-5 yrs.
PRIVY:—N/A(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.):
Page 10 of
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:_56 Augusta National Dr.
_Barnstable_
Owner's Name:_F. W. McAbee_
Date of Inspection:_6/27/0.5_
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.
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Page I I of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 56 Augusta National Dr.
'_Barnstable_
Owner's Name: F. W. McAbee_
Date of Inspection:_6/27/05_
SITE EXAM
Slope
Surface water ,
Check cellar
Shallow wells
Estimated depth to ground water_22_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)
_X_Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
By U.S.G.S.Atlas HA—692. >5'of separation.
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commonwealth of Massachusetts
Exec
utive Office of Environmental AffalrsBUG ��i
Department of '. �� i -
gnvironmental Protection
William F.Weld 10
Oov�rnor �• � '
Trudy Coxe
8ecrelary,EoFJ1 "
David B. Struhs
Commletloner
SUBSURTACE SEWAGE WSPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION '
Property Address-
Address
�.o/iI 't��+f � Address of Owner:
(If different)
Date of Inspection: �Gd
Name of.lnspector: %on.-VIY 't• 64.r4
Company Name, Address andlGlephons�Number:
54-,Aigj,+ F&wl,
T.o.Da.x
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes Authority
_ Needs Further Evaluation By the Local Approving .
_ Fails �• q. /.
pater
Inspector's Signature 7`,� J
this
hin
) days of
ing
The System Inspector shall submit a copy or this inspection) flow of 10,000rt to the Pgpd onggreta eori11iew��spectortand Oche systenCownee1 shall submit
i inspection. If the system is a shared system of has a design
the report to the appropriate regional office of the Department of Environmental protection.
The original should be sent to the sysiern owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
At SYSTEM PASSES:
I have not found any infotmation 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.
01 SYSTEM CONDITIONALLY PASSES:
I placed nr tepaited.. The System, Upon tbniple(foh of the replacement or repair,
One or more 'system components heed to be re
passes_Inspection.
t
Indicate yes, no, or not determined (Y, N, or Nu). Describe basis of determination In all lhstancts. If"riot determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltraiion, or tank failure is
imminent. The system will pass inspection If the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(Yevised 9/15/95) 1
One Winter Street . .a Boston,Massachusetts WOO ♦ FAX(617)SW 049 a Telephone(617)292-5500
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�il�Pdnied on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERtIFICAtION (continued)
Property Address:
Owner: E.•IL/ ��QG
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued) .
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ 1lie 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 t
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 TH
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The syslem has a septic lank and soil absorption system and is within 100 feel to a surface water supply ur tributary lu
surface water supply.
_ l lie system has a septic lank and soil absorption systern and is within a Zone I of a public water supply weft.
_ The system has a septic tank and soil absorption system and is within 50 feel 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 w
supply well, unless a well water analysis for coliform bacteria and.volatile organic compounds indicates that the well i
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less tha
ppm.
r.
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 bas
for this determination Is identified below, The Board of Health should be,contacted to determine.what will.be necessary to cor
the failure.
Backup of sewage Into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged.SAS c
cesspool.
(revised 8/15/95) Z
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A
CERTIFICATION (continued)
Property Address:
Owner: EAxl-
Date of Inspection: WAL194 ,
D) SYSTEM FAILS (continued):
_ 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 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
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 large systems in addition to the criteria above:
The design flow of 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 11 of a
public water supply well)
The owner or operator of any such
ea
system6500. Please consult the local regionaling the em office of the Department for furthernfomiat o
into full
with
h itreatment program
requirements of 314 CMR 5.00
(revised 8/15/95) 3
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Properly Address: S6
Owner: For(.
Date of Inspection: 71A6116
Check if the following have been done:
ZPumping information was requested of the owner, occupant, and Board of Health.
_✓None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volunies of water have not been introduced into the system recently or as part of this inspection.
✓As built plans have been obtained and examined. Note If they are not available with N/A.
_ihe facility or dwelling was inspected for signs of sewage back-up.
✓1'he system does not receive non-sanitary or industrial waste now
ZThe site was inspected for signs of breakout.
✓AII system componetts, excluding the Soil Absorption System, have been located on the site.
ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
✓The size andt location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility o%�ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:,$6 A,-7,j.+- Dr
Owner: t;Ar l
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: W_gallons
Number of bedrooms: 3
Number of current residents:
Garbage grinder(yes or no): K
Laundry connected to system (yes or no):Y
Seasonal use (yes or no): N
Water meter readings, if available: /au�6 6,ty 9S-9L
Last date of occupancy:
COMMERCIAUIND USTRIAI:
Type of establishment:
Design flow: allons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no),
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, If available: .
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
u PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping: -
TYPE OF SYSTEM
Septic lank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous Inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: 7&u. All
Sewage odors detected when arriving at the site: (yes or no)
(revised S/iS/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C. •
SYSTEM INFORMATION (continued)
Property Address: 36 Avtva;6 90"Low'.) T)c.
Owner: GArl
Date of Inspection: -g1jZA/ >e
SEPTIC TANK:
(locate on site plan)
Depth below grader
Material of construction: Zconcrete _metal _FRP —other(explain)
Dimensions: V X Wle S
Sludge depth: q"
Distance from top of sludge to bottom of outlet tee or baffle: 3'
r
Scum thickness: O
Distance from top of scum to lop of outlet lee or baffle: O'v 0 r
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural.
integrity, evidence of leakage, etc.) 7"- k anad Sl+w� i+re siT. erLee&g�rA or di► aar
GREASE TRAP:—
(locate on site plan)
Depth below grade:
Material of construction: _concrete _meta) FRO ,_other(explain) -
Dimensions:
Scum thickness:
r Distance from lop of scum to top of outlet lee or ba(fle:
Distance frorn bottom of From M bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
Integrity, evidence of leakage, etc.)
ri
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: SG Aque}*
Owner: e4d
Date.of Inspection:
TIGHT OR HOLDING TANK:
(locate on site plan)
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:_
(locale on site plan) -
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids cirrynver, evidence of leakage Into or out of box, etc.)
Ill& xui ar Lt kma or- 30),A Carn.e, -b 8eN Le ace) .
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
trevieed 8/is/9s) 7
,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: Sr
Owner: IrArl
Date of Inspection: ,'t�/9b
SOIL ABSORPTION SYSTEM (SAS):_
e methods)
(locate on site plan, If possible; excavation not required, but may be approximated by non-intrusiv
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length: 1 ,?T,Lx
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
Fetid r;,.. �»acl 51,n� wor Vngp=I�.
CESSPOOLS: —
(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 (cesspool must be pumped as part of Inspection) .
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:,
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 114S/95) B
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:SG Q'I's+r. U+►}►a�.n� D�
Owner: F,41
Dale of Inspection: WA411 .
SKETCH OF SEWAGE
DISP
OSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
j
• .
►
DEPTH TO GROUNDWATER
Depth to groundwater: -4.`4 S feet
method of determination or approximation: Mo..�a•nw. L-0¢.11 awe►„ of fir*'
(revised 8115195) 9
t '
i