HomeMy WebLinkAboutInspection Report 2002 Jul 06 \
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�� .. ,. o TO '�TN � F' YARM (� UTH
� � '� 1146 ROliTE 28 SOUTH YARMOUTH MASSACHUSETTS 026(4-44�1
� MATTACHEES� �
���+oOR�TfO�b�'� Telephone(70R) 398-2231, Ex[. 241 — Fax(508) 39�-?365
BOARD OF HEALTH
August 21, 2002
Robert Romano
26 Drake Street
Yarmouth Port MA 02675
RE: Subsurface Sewage Disposal System Inspection Report, 22 Driftwood Lane, South
Yarmouth
Dear Mr. Romano:
I This department is in receipt of a subsurface sewage disposa.l system inspection report
regarding the above referenced property conducted by Dan A. Speakrnan on July 6, 2002.
II� The report identifies the septic system has havin failed the ins ection for the followin
g P g
� reason:
1. Leach pit shows evidence of overflowing.
You have sizty (60) days from the date of this letter to obtain engineered plans and
upgrade your septic system to state Title 5 requirements. We are aware that you have
retained an engineer who has scheduled a perc test with this office.
If you should have any questions or comments relative to the above, please contact me at
the Health Department. I can be reached by telephoning the number printed above on
Monday through Friday from 9:00 to 11:00 AM during regularly scheduled office hours.
Since ly,
, _
Bruce G. Murphy, MPH .
Health Director
BGM/mar
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�• � � COMMONWE.ALTH OF MASSACHUSETTS
:.;����� EXECI����,O�FIGE,OF E,�ROI�IVIENTAL.AF�A.IRS :;�-
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��'3'� �<,`a��tDEPA�R.TMENT�OF{ENVIRONMENT�iL�PR`OTECTI4N
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TITLE 5... _._ ._ _ .�.... � . ... ,4 _..rt,,: ;:i
OFFICIAL INSPECTION.�FQ, ,R�VI ,�NO,T,FOR,VOIa,UNTARY^AS,SESSMENTS . ;
SU$SUR�A�E SEWAGE DISPOSAL SYSTEIVI FO12M � '
PARTA �fi .,� r ^.,.�._
CERTIFICATION
� �.�, � • .�..,ti. ..:0 1'+'�_h^r� 1' n. ' r i.• {, tryE � r �-� i .
� 'T I ,.I�.fii ti���`r� ••f.I'';I�� r••lp;•�.;j. ,:' r,�.•it ^il t!t�i�.tE;!f��r:) 'J*t.,� ., >;!., ��ii� .,,. : i
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Property Address: 2 Z �Tc/ic'_T(�i�i�'C�i'G�..:c_7.' ' . �� ,,. . , , ., . , r �,,,,. ..
y.q��o�r-r��� .c��r 1'YI�j-�:"�°� /o? �`/
Owner's Name:�� �o�Y,9v.�o � d T. �S '
..,:. _..._... .._....
_..._ .. _ ..._ �.. _ ..._ _�..._.__.
Owner's Address:-2��FX''�#�–�,r .- — ,
_. __ . _ vT�/F� 2.�<•�, 0 2�,�.�_. , .. . .._
Date of Inspectfon: � O�-
Name of Inspector•(ptease print) �"�k'� "+�`1i3`�`"�.`` '� ' `��� ��
Company Name S �j����
�r�T i t 7 i.. �� 1 �a �� f iv � {q t !'
Mailmg`Adi�ress tj� � � ,�, n tfF ri ��rl s�� ' �'"' o"r`�^ __.
. ;�:r, .,,r..�.�: �, ,� �{. ,;���r �, �_,:,��n�, ����on.a�eSEng �iv . �
� ` land�unreying •
Telepbone Number: ��5�(�yPH.S,(�•��•�,�
.. , : . . . ,, . ,:���<,�;��; ; �, , :�r�,NoRhHanxt�h;M.e,►��a.
CERTIFICATION�STATEMEI�7T -�
_.F : ;,; ;;� � �,-.
I certify that I have personally inspected the sewage disposal,system at this'address and that the information reported
below is true,accurate and��omplete as,o�'„the�t;�e,o�#the��spe�t�ion?�'he�uisp��ctio��yyasaperformed bas,�d on;my
',�r .� � ,,,.��� � � � , �.i,
training and expenence iri the prope�� ,�c,�1o���(tnainten�ar�ce,q�on,s��,�sewage�:disposal,s'ystems 1 am�apEP, .,
approved system inspector pursuant�tp�Sect�on 1�340 of Tit�e35(�10,C�1VIRi15 00¢)�s�Thersystem, � � , � ,,,
�i,,,.�'+;' .��� ?, ,ycrrij�'r �( tr>,ry ` A�i;f� �i•)i`� fJ7fi,t fl� , t� '� . �„ `,f .. .
Passes � _; , ,{�
Conditionally Passes . � � � � � � , - '
Needs Further Evaluation by the Local Approying Authoriry
��.
. .. . , : , s.. ..r� .��V�.:r! j i (,y, >t4`'`a! I'1 � � � 11 '�.! �9�i � 0`il�� t ry7, �;, �f.�la ,'d•i � . .
Inspector.'s,Signature. � ��-►�. . ,7,, ,,,Date:., ��1-. �, �, ;n t;,j;,;, ,_.
. , . � �
.¢sftl��filp s�'r,�;? t: �r..:
The system inspectoi shall submit a copy of this inspectioh�report�t�thc�Appro�iing.Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the systemtis a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit�the report•Co�the appropriate regional office ofthe
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,;; -�tU�t!�.�:�!"s, ,M�'�'�oi :�:D l'� <; ���t'!�+it,�s�,r�tt*��;��;(-r`r�r�.����r'u�;�T
(;P�fi:3'{�l.t ii7, . �1 9f7i r+� �i;'✓:511'(XP i�;i !! , ,
, . .
::?F i ' '.J''?' '?i2f�[C]I:`::{UTt� :
4�( \fF�r i 'Jl�f�nll�ll��:`(A,�. ..._ .
****This report only describes conditions at the time of inspect�on 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/IS/2000 page 1
f
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Page 2 of 11 ' � • . '_,
. . . . , . . . . .. . _ ' . � . _ ... J�� .. . , . .. � , � � ,
, ., � .
OFFICIAIr INSPECTION FORM�—NOT FOR VOLUNTARY ASSESSMENTS � �
�:, SUBSURFACE SEWAGE DISPOSAL� SYSTEM�INSPECTION FORM - '
;
PART A , � '
CERTIFICATION (continued) �C
I
Property Address: 22 �/2/,c7'Cc:Jo c�C �
i
Owner: O A.,vo
Date of Inspection: 7 c� ,v-�.
Inspection�Summary Check A;B;C,D$or E%ALWAY� complete all of Section D" `
g�.y � !? ;�. �. i .. ..... ., . r. �. ; . .... , . f., , _. .
A. System Passes: a.� � X ' �
I have not found any information which indicates that any of the failure criteria described in 310 CMR �
I 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. ;
Commeats:
B. System Conditionally Passes: � � I
�.T� �����^�f tµ14 t:y�11 �.'4 �j,�k p�.:� .. _ . . : '.
One or more`syste� 2n Qneti��s'��scribed in the"Conditional Pass"section need to be replaced or ;
tr'e a+�a.s.�;r• h
repaired.The�ysts�,u � p etio�r'tif the„replacement or repair,as approved by the Board of Health,wiil pass.
.t.....�;�'t���?:� i'�f��(E�Y3����7it�;.;
,,
'1.����S��t3�.��'•�,��'�'U��3�q��r
Answer yes,no or fio`C�`eie��n�d�>Yl,�'f��i�lthe 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 strvcturally
unsound,'exhibits substantial inf ltration or exfiltration or tank failure`is imminent. System will pass inspection if the
existing tank is replaced`with`a complyirig'septic tank'as approved by'the Board of Health. � �""
*A meta] 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 4
obstrvcted 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
� ,. . .. . . . . . .iry. .. ... .. .. � t� i., . � . - . . � � .
, . . i. : . .. ' .�.. , . �. . . '.:. .. : .:. .: . . . . .. . .. . � .. . ...�- I
ND explain: �
�
�
2
. . .J . � . . � . � . � . . . � � _ .. .
�. • �age 3 of 11
, � OFFICIAL INSPECT�IC,Ol����0 aR1VI;NN,OT�FOR,��4LUN�'�RY,ASSESSMENTS .
3UBSURFACE•SEWAGE�DISPOS�L�SXSTEIVI INSPECTI�N,FORM_;�
_ � . . .. ., ,. ... ..a, s. 1..a4 1 ca�i� �-�tr r« 'S.� ,� �.�\s I�...t. ...t. .1. .. ti ......., . . .. ..
PART�A �� ,
.�.,...R x.�. . .. . .. . � � ' .
CE TIFICATION�(continued) �:,
,,.r�u ,�„�{.:, . . . .
Property Address: 22 c,�2��Twc7.o�o
_ . ._.�. . . . .. __.._._. _ '
. .:�
Owner: �a�
Date of Inspection: - �.�.. _...:..: .__, . _.__.....
. � . . . . .;.�. 7,;. �� �::. ;.�,. .
C. Further Evaluation is Required by the Board of Health: ,.c1 � � � "� ` `
..,...ee��, tfr rt4 .Gn<. �„.,�, p , .z.^� „.. r ,
Conditions exist which require furtlier eyaluation�by the Board of Health in order to determine if the systein
is failing to protect public health,safety or ttie env�onment, � �
„ .
.:; �. .,; . ,. . .. �; .
. . . -:: .�:.' . �.. . .� .. ... ..,. .:�-. •�-.. , n'r .,�
i. Sy,stem will pass unless.Board,of Health determines,la accqrdance,�;ith 31QCMR 15.303,(1)(b)that the
system is not functloning in_a manner which;will�protect,public health,safety�and the,environmeat:
: t; .;,� � �:: ,�.;,��;�:.
Cesspool or privy is within SO,feetof a surface water :, ,., ,.,, ; ... � , .,;, j , ;
_ Cesspool�or privy is within 50 feet`of a bordcring vegetated wetland or a salt marsh ,r,,�,;,.
;,r, ,�.:;,; „� . ,,,�,�t�,a'v� ;+•ti,r,un^r,7 ;T^,..;, �� �:..�j ,��,,.,.5� „n� rr .f��.y:5 �1. tt'{ri� r (tr,i ]
, � ; , . . .�.. ,. , ,.. � , �-i; h )t�F(" .,>... . , +j r I ;t;;�iil{l(�Y �.'� ,n...{;:
,, . .. . ,
..... .
� ...� .. ..; � .. .�. _ � � �.. .. �. . . . .: � � ��)'���'fitl!': �:91'fi'i�}l•.
� ' ., .. .. i�'�' .�t{i,`•� ��,{1"��r�f�',t�;{ �,C:',j � � ,�:yi'1y*^!n�;1'�f�'3;'^k's �� "�(?a��.�t"!}f'{fy�{''�r�r'', ._.. . .. .
.. . ('i �;�.' �.1 7,.'� :,� .... , qPi,'.t�. y� } ;':.�, �.1 r��..,,: t � i � ' �/ ,"� � ,,. �n .'�.:.. �<v I�:�i�l !`(5 I."a..
2. System will fail unless the Board of Healfh(and Publjc�Water Supplier,if any)determines that the
system is functioning in a mander that,protects the�public,health,.sa�ety,and�epviron,ment i�,��,+,ti;^
� __.
� � � t•.ti�r {r,i��;,yaiq•fi`tii.qc�l�r��?r, �n•,)� r12 .ri��lr�,. 3t;��ift��v���{n:n�� m�� n'���r�,ai•sr�� r;i�,,
The system has a septic.,tank and sQil;apsorption sysfem(SA$)and the SAS,i�s,with�;n;�00 feet:of a �
surface water su�ply,or tributary to a surface water:supply,�,, „,, :; ,, ,r,,,, , f,;, ,�, f, ��,�. ��f,.,�„
.. . � . � .
.
. :��r p';�+ ���v�ii t = t% p i�!3 r ri rY"-'x FJ .�'. � �n�.}� a Yr.�{ F'1 a�ui f� y '`F' i.3'�r �yiix�,=-. .
_ The system has a septic.tank and S�AS and the,$AS is,vyi m a..Zone� l.;of a public water supply.
. .... .�� , . � , .�� , „l3 ., ;. �: b.. 7s,t �S � .. :{i ,. � . .a7 .. . .��.:t :�::t! t.�.,.:f..;..
. � . ^.'71 � r? ..;.�y y ��i�r. �r ii� S'h���lt�Yef :�'r7r+ ,�fl�cr4'��+�n�h ;#�f etrh+�-�i��r'�3rt'���: 4a.:���:�ff'! f17rFr,.�'r.,fryn�•i''111 �
..
_ The system has a septic tank,and S}$,and the,SAS ts,withua 50 feet pf a pr}vate water supply.well.
The system,has a septic tank and:.SAS.and the,SA$,�s,_#ess than 100 feet but.50 feet,or more fro�a .
, , „ �;. :,.., ; � :, , .
private wafer.supply well**. Metho,d used�to determine distance
� '. . .�Y�ttt�r,. :,fi ,,-`r.,j ..�,;.i�,.. .,.�. :, � i.;,�. ��. r . . .'�,� i���r..�, 3 .. , ,
**This system passes if the well water analys�s,performed at a DEP certified laboratory;�for colifoim
bacteria and volatile organic eompounds 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 S ppm,provided thay no other .
-failure criteria are triggered::A,copy ofthe analysis must,be attached to this�formt7,p jt,,�;, �, ; ;�,,,� , � , ,, ;_
;,, ,
a �ii rj�r y n: �riil 't(� .,. �:��: ;.i `(_.'� . -
' . � •i�.�F, +,"i'. ;i. .. . .. . , (�., . . ,. ... . , { ' .. .. . ., � ... � . �.
3. Other.
. . . , ., ..
. ..... ���r,��ii r �'.i"•.f, t„' '':!; f)C'w'1���U� f�f. : `'.; , i ,..!�:'�? fi �'f,1�1t1! r tl( {�Y�F,:Y{7�'rf t�1itT✓i.?�:ii
� � � . . - ..�a /�j{'Yld ..'f.'� 'i �� i�)i}' ;(% }i ..i i j . .
_ . . . ���.,-,..`f;, __ , {. .."1�11 r�,`7 ;t`��',1?l � �i'��f'i' r1E1.1:t.•`Llr ,Tj: e����i��?7�..`dl:'(i �
. . '��ft�' ;n^:t" '! ��i:ti� �"f:fl T , ��: f i l ..11' :f ��r�1 Yi, �L ` � 1 il��
._ . . . . . .. . . . . �(:1 . �. , `:i �r j. .}��'i)'_ ..1 '�Sl�)�. . . . .. ..
.. � . ., . .�:7 .r!, ':r.r���s4 �i7�r•Cir .� ..�ii'.if� ..�.�.i. � tr.ilL.i ',i}�-r� i)_. ... r. .:t�ytiii���9� c,F) �1.�:f�.�7 �: ., .., . . �
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3 .
Page 4 of 1 I � ` � .
�. „ON FORM-NOT FOR VOLUNTA:RY ASSESSMENTS � !
OFFICIAL INSPECTI
SUBSURFACE SEWAGE'DISPOS A I:'S Y S T E M'I N S P E C T I O N F O R M` -
PART A.��, I
,. . �
CERTIFICATION(continuedj '
Property Address: 2 Z 1.�'�?/f"i�'-vc�� - �
Owner• .�'c� ,,
Date of Inspection:_ v'L
D. System Failure Criteria applicable to all systems:
You musf indicate"yes"or"no"to each of the following for all inspect'ions:` � �
Yes No , �
�-�ackup of sewage into faciliry 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 disti-ibution 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%day flow
_ vRequired 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.
�ny portion of cesspool or priry is within 100 feet of a surface water supply or tributary to a surface
water supply.'_ ., :�.: .. , ; . : , .,
� Any portion of a cesspoo]orprivy is within a Zone 1 of a public well.
�Any portion of a cesspool or privy is within SO feet of a private water supply well.
�Any poition 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 systeui passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria,and volatile organic compounds
ipdicates that the well is free from pollution from thaYfacility and the presence of ammonia
nitrogen and nitrate nitrogea 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.] .
� r�(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 targe system the system must serve a fac�l�ty with a design ilow of 10,000 gpd to 15,Q00
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 I
15.304.The system owner should contact the appropriate regional office of the Department. �
�
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. • . �Page 5 of 11 ,
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� � OFF'ICL�L INSPE(�'I'I�N�<F'OP�r�NOTrFO��V���AR1��A�SESSIVIEI�TS
S�TBSIJR�ACE��EWAG'�'DYSP`OS�ALr�SI'STEIVI•I1+�SPECTYON-�dRM �
. .,. P�'AR'P�B` `
�f��i"�",C�i�`CI�TST� ' i ;..�,
PropertyAddress: 2� �62//�7woc.o4 '''': `
...,
. . . ......._.._........'�...........,r_...t..:_.�._..:..'.:._.�._:�..„._._ � �
Owner: Y�.D�+-N9..�—c� - ;:< ,•: �
_ � / _ �, . .. ._.. ..
Date of Inspection: 7 / 44 l�'ti- .. - . -- .- -.--. "�� � ' '`'
� . . �7��. A 3:.�`i� 'f,•a� i F,� . . .. �
,•
'. . ,j�;r'� ;(':; `':r.`•' '
Check if the following have been done.You.mnst indicafe'`�es"'o�"`ilo"'�'sTto`each of'tfie'folto�"ving:�"��'"'3� �'�'"•''
' „ . ,.. , , , a :�: . , , . .. „� __. . .�. , ,.. .. . .,
_. . . ,.
� ' . . . � � .. . � i?j �Si:i�:; r.''�`lil�`� , i . ' . �
YP.$ 1`I� ) �t}j1r �r ..,�! � !; t � '1':
� ... . ... � ' , ., I� ' -.��. . �
✓ Pumping infonriation was`pio'v'ided tiy the owrier, occupant,or Boar'd of Health "'F�
— — __._ ,c ; ^vj ,�.:;:a.. ,� �� ,'
�—�Vere any of the system components pumped out ui the previous two weeks 7- t"'' �U '�� " ' ' r'
- - . . �. _._._........._. ...._._.._..... .._.. ,, t;;� ��;t �'�' �.1�;�� � f J2F.i) ., .._.."YP.tt�.it' i,.,.. 't _....•i :°`� .
�—'Ifas the system received normal flows in the previous two week period? . ��'' ��' ?''' '�' ''�`' "`•'
�_ . . . .. . ,^ . ;`�.j:5.� ... . I! .�I'. .
c��ave lazge volumes of water been introduced to the system recently or as part,of this inspection?,
— _ zAai!..., G.i..� ,� .).�S s� ;'
«�. ;tr ,, ��•� •.
c�-- Were as built plans of the syste�n obtained and examined?(If they,were not available note as N/A)
, ;,�::t r�.�M.�! `!r�'�.)li(F �)�7, :;., �,,,. n•; �
, __ _ .. .......
✓� Vdas the facility or dwelling inspected for signs of sewage back'u�fl1�2'�° -''�� ` �'g�� '""r= '`` ` ;�, `
- - .i,,it�(� En,l, ;.p7�:��'! , .
ti� Was the site inspected for signs of break out? "'" `� "'� '���°a""`?.'i, fiJ° `;"`r'+ � '' � �` 11,
- - � _._ 'l<�r„ 1_�; r: 5, , _ .;:�I 5t� rt i'tGc��r>r{�.itt!17F,°- ,,�t , rr .
✓ Were all system components,excluding the SAS;located an site?��• -- ��'�'r-1�svs�i ,<��rs�,r 3z >> rr •;. � :` :
— — . . . _ . _ , . . � . � � � .� _. _... ,���;"._/�.a!�, � �a:J�;_i.� :�:c:r; ....
_�� 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 ofJiquid,depth of sludge_and depth of scum?'
,r�. ..r� ,,,,,:..�.,....� , rq.,..�;.,...�� � .
✓Was the facility owner(and occupariis if different`from owner)piovided with information on the proper
maintenance of subsurface sewage disposal systems? '� `''^'j �` ` ' `
-�r�rt;:.�*�tr:tir•.; !�, , . ,
�_____. _.:.. _ _..._ �...._.._...�.._ ,,. _.._
. lr�r•yft !9!)ffCk{1"13t'�2fL{".'P�?��: iG-'t 2.C.V^.f1ft'fi!(� II3yS7`�: 'r: ,�i
...
i �• •
. ._ _......_..... ....
.;i�i1i�'rT'i+.-.;}..�';'.;{�. ��.,:� % ..:�'j:d ; .< <.�.�.i:.'t."_ �ITG�� i�i �.z)'li�'ICiU•:j..,f'.` .;:1�! , , . .
T'he size and location of the Soil Absorption System(SAS)on the site has been determ'ined based on:
. � � . . . . �},r i r�y;,..rt >i � . . �
Yes no �
�^ Existing information.For example,a plan at the Boaid'of Hea'Ith''` '"' ��'j� "���s���r�� r�c �
!�:�-� •31 �'�
� Determined in the field(if any of the failure criteria related to Part C is at issue approzimation of distance
is unacceptable)(310 CMR 15.302(3)(b)J . , ��i' ;
f�r(5!? �� p�')".f,'7�11 !!{)S '`17�',+,+? ,'EF;� ����I jQ?3`.f.tl�w25'� �1�((1tI 1��'�'S'�� ff':.t.Y; 1):r.�,.. .--
�� T �"1. . , fi;j�. ;r� ^ 11C?r;;'lltf .'?'�(t ' .ri,l:Y�sf ��!ii �ai:��-, �: �i�il;lf�'� .'1�C7��1:?f�:l'.k��lVl7t+(?'i°,171r1';i'vi�E,'r,�n,
� . . . . . . , . . . f�� r(..V+'� f` .,?G�%4�f� .1 ..., :. .
� . . . St . -. tf ���r��� 'afS�7i•, �r � .I..,.
, n ;i,4>lt. ;i; ;
' .'���:i�. .. . . .. .
.. . +,i,� �it},,�,iC .:�....,. �1.,t. �:, !).., '� � �Ii1 ':alz`i>� � �.. :f'".:0,. �j:�.) '�r; ,� ,. .. ,
. . . )�.. tF. �'IiV�?.� . �I. I'r. ��.1^� a.. � r. :i S.� . .... .�
S
/ Page 6 of 11
� . •
OFFICIAL INSPECTION FORM—NOT.FOR:VOLUNTARY:ASSESSMENTS . �
SUBSURFACE SE}?VAGE DISPOSAL SYSTEJVI,�NSPECTION;FORM s E
PAR�'r C i
SYSTEM INFORMATYON �
�
Property Address: z Z �/z//r'i�C�Uc7� ,
Owner:� _ _ _. _ _
Date of Inspection:---w2£��, v�.. – _
_.. .
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):� Number of bedrooms(actual): �
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3-3�
Number of current residents: "—
Uoes residence have a garbage grinder(yes or no):�a �
Is laundry on a separate sewage system(yes or no):Lv�[if yes separate inspection required] �
Laundry system inspected(yes or no):_
Seasonal use: (yes or no): U�. , ,
. �..,
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):��
Last date of occupancy: ` C�J t
COMMERCIAL/INDUSTRIAL ` �
Type of establishment: '� ��
Design flow(based on 310 CMR 15.203): �pd
Basis of design flow(seats/persons/sqft,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 � i
Pumping Records � , � ;
Source of information:�U ^�/,�O `�� , 4 � '' •' o `� � '
Was system pumped as part of the inspection(yes or no):_
If yes, volume pumped:_gallons--How was quantiry pumped determined? '
Reason for pumping: . �
TYPE O�SYSTEM ,
Lgeptic tank,distribution box,soil absorption system ,
Single cesspool .
OverElow cesspool ,:, �
Privy
Shazed system(yes or no)(if yes,attach previous inspection records, if any)
Innovative/Altemative 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 aee of all components,date installed(if known)and source of information:
/�i ��/�,�
Were sewage odors detected when arriving at the site(yes or no):�Uv
6 '
� ' Page 7 of 11 I , .. , .
i ,, .;, . ,. ,, . ,, : ,
f '.. ' f',S 'h .
'?'Y`I,�"r� .7� 'n��tM',��'�/ �.#.. �� � 1 A' + ' v'"`"YI` `r rI!Yr4.
� � "OFFI�I'�i`L`INSFE�CT�� "� ,.�, I��FO�Ft�f���I'�A.��'� ,����S,�S�i�NTS
�SiTBSURFACE�S�EW�G��1�I5''P���AL�SI'ST��1V�'INSPE�C�TI0�1�FbRM
s,,, „ �z;�'� " � L� , ,,
'?;
,:,SYS�'�E����d �� �'IC'�N(co�f�ai�i�d)
. . ., ,
�,-�: :��.�-���,r, _�
Property Address: Z2 ,�/E�/«4�:� � .�_.._....-.�.....---��--
. .
_ ._.._.---.__�__.__......._......_,�...... .
Owner� i�'' Jd ' -• _...--.�.-. • --- ----.... ,�r�.:`:`
:nr 1� �,,� • �,;
Date of Inspection: 7 G �U�- �. ��:. ��. -- _ . ,
� �cl.,�, „t ; � 3s..:,0(lfit!'I{1^,.,n2 t�O QfiTt? t;' �';`�CjtYi�tt� �i�'� ]�+.iiSfi �+nhf) .�..... �'t.'St°,'� ili�.�4r"`.i.I6 ;;. ;n "S�t1>�; i
BUILDING�§EWER(�ocate on site plan�
II�� ni ., w�t� U tr;-:'�.i
Depthbelowgrade 30 ,' �,, r�.-t ,a�,�,,;�,-+�i + , ,.. �,, - " '
f � '�' .;�),'. i .n�, .:
, ..:.:,.. �`�-�VC "' other p ,� .r; � �.. .._ � �, ,�r :
Materials of construction:�_cast iron (ex lam :-~--• --
Distancei from private water supply we11-or sucrion�line:�-- ��-.-_._..�„___._.. __ � _ ._ _. •
Commenu(on condition of joinu,venting;evidence of leakage,etc.): ° - � ���r� . � .;
l�C.� C�c�OA CO+.�ol77D-J ��a�(�,� __ . .._w. __ t r.- ..
, . .. ,� _.__. �,._. ......... . : ,,1 �, �.:.�:
� y(G1Q i�i.?q i !;;"�e•�lt� ,iTiS�t`.
(�>r r; :.•:.� ri•;r, �tn;��ic�„r �i ri��i! z f :}i <.mn��:
SEPTIC TANK:�-�{�ate on site plan) �� �- � -•� ��
� � � � ... . ��,t: itti3'.ii� 1c. i�i�� : ;,1�:
Depth below grade: . ���' . . ;�r, s-� h� ,,"i< <a .:��c ` . . :; ,. .
Materialofconstnictiori:"��e6ficrete=-metal��fiberglass_--'Aolyethylene•�-- °-.•----.---.--....-_._ �___.__
.__ . _other(explain)-.._�:.__.. _._�._�..�_...�.__,�___...._..�
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):T(attach a copy of
certificate) : " '`. ; . v : . .. .
� fq A rt ii7'JSfi^rl(ti;'fr9fT�"C!7'+r�i>t!n'! SR9P.ry'i��t) ... �,(1`�T��7'�T��:�rs:SS•Fa•,-.
Dimensions: ,DD�G�-�.
Sludge depth _ j" � , ; , ;
� rr�vna r9l.t,a � J' i��»; ! ��,��{ i< „ ,� ,i
Distance,from,top of�ludge to bottom,of outlet,�ee or�ba,ffie�,3�1 ;;�r»G;f, r:.�r�'rv♦:!�a �r�;y�1� ,c�:�,i��,,,:�,.r.�,;'
Scum thickne�s: � �r
Distance from top of scum to top of outlet tee or baffle: e�3� `'�'yt�: ,�c•i"���,u,: ;.^ � . .
Distance from bottom�of scum to�bottom-of�outlertee��orbaffle:��•r� - - ��- + - �--- ----- -
How were dimensions determined:_.........____../'�►.�1.__4�f�•2(,�^_s t_._.__.... _.._...__.._ _ _ . _._....---.. . .. . _
Comments(on pumping recommendations,inlet and outlet tee or baf�le condition,structural integrity,liquid levels
as related to outlet invert evidence of.leakage,etc.): ,t��, t.�'�a,a�,� �,�, ` .'ti�.�,�?,� ,.'�� ;{�;,.,.,
%/9,� '►Zt �S �'.'9 O �� r'.J �.!.O� 7�'�' .
_._. ��, ,, ..✓t ..c• � , . ';U`.
� . . � . � � . . - �. , . . .. , �S'��f'3;?�'e�j,j Y �i�a�_ ;7''�',v'.`J 'j ,.i`i�!? . . .
GREASE TRAP;I�'a�{tocafe`ori s'ite plari)'� -r` -�r,r , . G,r�}�� 'rrn:��.r, �}r:�,� � . :,�� _t, ;�; , ,; ,.,
Depthtielow grade: .,.._..:._ .__..._,. _...�m ..,..;._.._.._... . _. �..,. .. , ......._..�..__:....w._._... _,.
Material of construction: concrete_metal_fiberglass_�olyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baf�le:
Distance from bottom of scum to bottom of outlettee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): ,
, , � i
7
f
Page 8 of 11 `. '
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OFFI��� INSPECT�ON FO�tM-:NOT FOR.VOLUNTARY ASSESSMENTS , '
,3UB.SURFAGE-SE, AGE DISPQS�AI.SY$TEM IN$PECTION;FORM = �
., , . � ; . : , ,
. . _ . . , PART,C� k
•, �
SYS.�'�M INFORMATION:(continued) (
:, , ,. � . . ., , w .. _ _ �
Property Address: �'7 ��//rT�UCx'�-J �
4
Owner: �A�-� .
Date of Inspection: ;� �'� �
TIGHT or HOLDING TANK:�(tank must be pumped at time of inspection)(locate on site plan)
Depth below gade:
Material of construction: concrete metal fiberglass_polyethylene other(explain): ;
_ i
_ _.._ . _ , . :. ,
Dimensions:
_ ,... , ; . . : ,, _
Capacity: gallons
Design Flow: gallons/day
Alazm 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:
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.):
PUMP CHAMBER: �(locate on site plan) � �
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Commenu(note condition of pump chamber,condition of pumps and appurtenances,etc.):
�: : '
�
8
r ,
� . - . Page9ofil . . .
� _ . ,' �
. � OFFICIAL`iINSPECTiION,�F�.ORM:��TO�'FOR�}�,OI�IUII�T�A�2Y'�iSSESSMENTS
SUBSURFACE��SEWAC�EDISP,OS` "A��S�S.TENif'INSPECTION?FORM
, . . P. �AR�C ,
SliYSTEM�IN..FOR;MATION�(co�►"t'inl�ea)
Property Address: T2 D/Z/�cg�� ,
, .... . . � 37 r...���:, �`�. . '
Owner: �'O .J O __....._..�...__.�..� __. �--
.,.__.__ ._._____ ..�...
Date of Inspection: � �e �v� :-,<,� ���!?
_.._...._ . :,., �,,;
SOIL ABSORPTION SYSTEM(SAS): '�r�ocate on site plan,ezcavation not requ�redj
!�>:�'�'�;'!�.lA�t:)=f��� ;d�r�Vs:��.�iti fi..�►._.�t.
If SAS not located'explain why. ":��rrzc��{c::��; ±�,::}! ts c+t�:s;; �rii:�;f,���i ri::;�yY�f��cr,�-,:a e;i�r�'�; �.^`'�n .t:�':,t�. s ^b;,...�`�
,;„ , •
..a ,y,..� ��t 7 >" � i'1 ;'? ,� '�� � �"i� �11� ;�'li"ld Y.i.,�� {Irr i i(r.
Typ�ching pits,number:�
leaching chambers,number: �
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovaHve/alternative system Type/name of technology: '
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): . O'N i � ( �
P� T f-G4S cav�t �"co�4--T Sc�N � "
�:J�r" "•.� ,�'C � a� �/
CESSPOOLS:�(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):
Comrnents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRM':�(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids: _
Comments(note condition of soil,signs of hydraulic failure,level ofponding,condition of vegetation,etc.):
,.9
r
i 4. �
Page 10 of 11 + � .
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OFFICIAi:INSPECTION'FORM-NOT FOR V:OLUNTARY ASSESSMENTS , t
;
SUBSURFACE SEWAGE'DISPOSAL-�SYSTEM INSPECTION F.ORM °
PART C
SYSTEM:INFORMATION(continued) �
f
4
Property Address: ��. �/2/,��wd d� __ . _
Owner: �n '�'r9..� O ' .
Date of Inspection: U�
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposa] 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. �
�2�
P
W
0
. �
i
�
�: _
.�� /� %C v� c� � G-,�`1�.,1E
�o '
� , `',� �-� ,
.t
, , � Page 11 of 11 � �
. �.
i � ' OFFICIAL INSPECTION FORM:-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM
�;� ' .:PART 1C' ,�y.
SYSTEM INFORMATION(continued) '
Property Address: 2Z �/2/.�7G�?
Owner:_�c�c� �.1
Date of Inspection:_ v't
SITE EXAM .
Slope
� Surface water
Check cellar
Shallow wells
Estimated depth to ground water�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:
Che�ked with local excavators,installers-(attach documentation)
{
��ccessed USGS database-explain:
You must describe how you established the high ground water elevation:
(� S G S �v� S NE�"/'— _
- �i ;