HomeMy WebLinkAboutInspection Report 1995 May 08 ` BORTOLOTTI CONSTRUCTION, INC. MAY 1 5 S95 I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
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PART A — CHECKLIST
CHECK IF THE FOLLOWING HAVE BEEN DONE:
PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH.
I//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 COLUMES 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.
I/ THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP.
/THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT.
IZALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE.
j/ THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED
FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE,
DEPTH OF SCUM.
THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR
APPROXIMATED BY NON-INTRUSIVE METHODS.
/THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER
MAINTENANCE OF SSDS.
PART B — SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL
No of Bedrooms o.Z No of Current Residents - /1/ef Garbage Grinder
Laundry Connected to System /�'p _ Seasonal Use
NON RESIDENTIAL:
Calculated flow)
WATER METER READINGS,IF AVAILABLE:
-- — --- -- - — _ - GALLONS
Pumping Records and Source/of Information:
4,7-v Pd in !/ Gi /9 1 4 T)v - 013'14 • /
SYSTEM PUMPED AS PART OF INSPECTION? 4/0 IF YES,VOLUME PUMPED= GALS
Reason for Pumping:
TYPE OF SYSTEM:
Septic tank/distribution box/soil absorption system
Single Cesspool Overflow Cesspool Privy
Shared system (if yes,attach previous inspection records, if any)
Other(explain) T`c»e ay �e� 7�,�.�- 7>-.80,1!7>-.80,1! ✓a
, �
J, 4(CeSSOZ/e -
_ .4-each R -, ,, �cc ra6/e.,
Approximate age of all components. Date installed,if known. Source of information.
A412e / /171 a/Z—c_42
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE?
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SEPTIC TANK:
grade:below
DepthI Dimensions: i
p �I
�' Sys w X � G _X 6_i/e/
Material of construction: -Concrete Metal FRP Other}
Sludge Depth One Distance from top of sludge to bottom of outlet tee or baffle
Scum Thickness /ne, Distance from Top of Scum to top of outlet tee or baffle
Distance from bottom of Scum to bottom of outlet tee or baffle
C°11-1±-11:21,-58:
omma ts:
� :s ct /000c3�DY2, -CGS/�i' 6-7244'77-a-',24 tc,i"�j /7o S/GC�e O� scee,97
ail e ins e i`z4 o cd--/e/%/
a t}e:i- 7" 5/0 yradc. 0--,4 gems we,tie- /ee'C/
DISTRIBUTION BOX: ✓ DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT
Comments:
&Oe/ / YLl D`- Cf rc --s,sQ.CJ/e
PUMP CHAMBER: I Pumps in working order?
Comments:
SOIL ABSORPTION SYSTEM (SAS):
IF NOT PRESENT, PLAIN:
TYPE: 0 ,CCPS.S'Q w P
Commen -C�
CESSPOOLS: A4 Number and configuration
Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer
Dimension of cesspool Materials of construction
Indication of groundwater inflow(cesspool must be pumped)
Comments:
PRIVY:
Materials of construction
Dimensions Depth of solids
Comments:
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• • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS.
LOCATE ALL WELLS WITHIN 100'
kl/()%1-' C)41/1 066
w
O
{
DEPTH TO GROUNDWATER: Z7 DEPTH TO GROUNDWATER
METHOD OF DETERMINATION OR APPROXIMATION:
ifierth4'i kI 4:M7 U13. ge?)`m{ t'eri4/' Ge%yeo/s1.//1/ey OS'
r l,S, G•5. 6/evion /vier m4./es
•
' - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C FAILURE CRITERIA
/ (Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.)
/Y Backup of Sewage into Facility?
'./ Discharge or ponding of effluent to the surface of the ground or surface waters?
Static liquid level in the districution box above outlet invert? ioa weep
HA- Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow?
Required pumping 4 times or more in the last year? Number of times pumped
A Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration?
tank failure imminent?
A/ Is any portion of the SAS,cesspool or privy, below the high groundwater elevation?
Within 50 feet of a surface water?
/Y Within 100 feet of a surface water supply or tributary to a surface water supply?
Within a Zone I of a public well?
A Within 50 feet of a private water supply well?
/y Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)?
_ /1 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,amonia nitrogen and nitrate nitrogen.
PART D — CERTIFICATION
INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS
COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399
CERTIFICATION STATEMENT
I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION
REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY
RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE
IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS.
CHECK ONE:
1//°I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC
HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS
STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM.
I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN
310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS
FORM.
INSPECTOR'S SIGNATURE: "79-1.
DATE: 5-kil95
ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY