Inspection results must be submitted on this form. Inspection forms may not be altered in any way.

Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key.

A. General Information

1.   Inspector:

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B. Certification

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:

       FORMCHECKBOX   Passes

       FORMCHECKBOX   Conditionally Passes

       FORMCHECKBOX   Fails

       FORMCHECKBOX   Needs Further Evaluation by the Local Approving Authority

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      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.

****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.

Inspection Summary: Check  A,B,C,D or E / always complete all of Section D

B. Certification (cont.)

A)   System Passes:

       FORMCHECKBOX   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:

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B)   System Conditionally Passes:

       FORMCHECKBOX   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  FORMCHECKBOX  for the following statements. If “not determined,” please explain.

       FORMCHECKBOX   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:

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       FORMCHECKBOX   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):

             FORMCHECKBOX         broken pipe(s) are replaced

             FORMCHECKBOX         obstruction is removed

B. Certification (cont.)

      B)   System Conditionally Passes (cont.):

             FORMCHECKBOX         distribution box is leveled or replaced

      ND Explain:

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       FORMCHECKBOX   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):

             FORMCHECKBOX         broken pipe(s) are replaced

             FORMCHECKBOX         obstruction is removed

      ND Explain:

      C)   Further Evaluation is Required by the Board of Health:

       FORMCHECKBOX   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:

             FORMCHECKBOX         Cesspool or privy is within 50 feet of a surface water

             FORMCHECKBOX         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:

             FORMCHECKBOX         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.

             FORMCHECKBOX         The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water                   supply.

             FORMCHECKBOX         The system has a septic tank and SAS and the SAS is within 50 feet of a private water                   supply well.

B. Certification (cont.)

C)   Further Evaluation is Required by the Board of Health (cont.):

       FORMCHECKBOX   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:

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      ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent 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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D)   System Failure Criteria Applicable to All Systems:

      You must indicate “Yes” or “No” to each of the following for all inspections:

Yes

No

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      Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool

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      Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool

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      Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool

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      Liquid depth in cesspool is less than 6” below invert or available volume is less than ½ day flow

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      Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped:  FORMTEXT      .

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      Any portion of the SAS, cesspool or privy is below high ground water elevation.

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      Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.

B. Certification (cont.)

D)   System Failure Criteria Applicable to All Systems (cont.):

Yes

No

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      Any portion of a cesspool or privy is within a Zone 1 of a public well.

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      Any portion of a cesspool or privy is within 50 feet of a private water supply well.

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      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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.]

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      The system is a cesspool serving a facility with a design flow of 2000gpd-10,000gpd.

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      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.

      For large systems, you must indicate either “yes” or “no” to each of the following, in addition to the questions in Section D.

Yes

No

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      the system is within 400 feet of a surface drinking water supply

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      the system is within 200 feet of a tributary to a surface drinking water supply

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      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.

C. Checklist

      Check if the following have been done. You must indicate “yes” or “no” as to each of the following:

Yes

No

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      Pumping information was provided by the owner, occupant, or Board of Health

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      Were any of the system components pumped out in the previous two weeks?

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      Has the system received normal flows in the previous two week period?

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      Have large volumes of water been introduced to the system recently or as part of this inspection?

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      Were as built plans of the system obtained and examined? (If they were not available note as N/A)

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      Was the facility or dwelling inspected for signs of sewage back up?

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      Was the site inspected for signs of break out?

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      Were all system components, excluding the SAS, located on site?

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      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?

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      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:

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      Existing information. For example, a plan at the Board of Health.

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      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(5)]

D. System Information

      Residential Flow Conditions:

      Number of bedrooms (design):

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      Number of bedrooms (actual):

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      DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):

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      Number of current residents:

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      Does residence have a garbage grinder?

       FORMCHECKBOX   Yes   FORMCHECKBOX    No

      Is laundry on a separate sewage system? [if yes separate inspection required]

       FORMCHECKBOX   Yes   FORMCHECKBOX    No

      Laundry system inspected?

       FORMCHECKBOX   Yes   FORMCHECKBOX    No

      Seasonal use?

       FORMCHECKBOX   Yes   FORMCHECKBOX    No

      Water meter readings, if available (last 2 years usage (gpd)):

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      Sump pump?

       FORMCHECKBOX   Yes   FORMCHECKBOX    No

      Last date of occupancy:

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      Commercial/Industrial Flow Conditions:

      Type of Establishment:

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      Design flow (based on 310 CMR 15.203):

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      Basis of design flow (seats/persons/sq.ft., etc.):

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      Grease trap present?

       FORMCHECKBOX   Yes   FORMCHECKBOX    No

      Industrial waste holding tank present?

       FORMCHECKBOX   Yes   FORMCHECKBOX    No

      Non-sanitary waste discharged to the Title 5 system?

       FORMCHECKBOX   Yes   FORMCHECKBOX    No

      Water meter readings, if available:

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      Last date of occupancy/use:

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      Other (describe):

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D. System Information (cont.)

General Information

      Pumping Records:

      Source of information:

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      Was system pumped as part of the inspection?

       FORMCHECKBOX   Yes   FORMCHECKBOX    No

      If yes, volume pumped:

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      How was quantity pumped determined?

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      Reason for pumping:

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      Type of System:

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      Septic tank, distribution box, soil absorption system

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      Single cesspool

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      Overflow cesspool

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      Privy

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      Shared system (yes or no) (if yes, attach previous inspection records, if any)

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      Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner)

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      Tight tank. Attach a copy of the DEP approval.

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      Other (describe):

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      Approximate age of all components, date installed (if known) and source of information:

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      Were sewage odors detected when arriving at the site?

       FORMCHECKBOX   Yes   FORMCHECKBOX    No

D. System Information (cont.)

      Building Sewer (locate on site plan):

      Depth below grade:

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      Material of construction:

       FORMCHECKBOX  cast iron

       FORMCHECKBOX  40 PVC

       FORMCHECKBOX  other (explain):

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      Distance from private water supply well or suction line:

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      Comments (on condition of joints, venting, evidence of leakage, etc.):

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      Septic Tank (locate on site plan):

      Depth below grade:

      Material of construction:

       FORMCHECKBOX  concrete

       FORMCHECKBOX  metal

       FORMCHECKBOX  fiberglass

       FORMCHECKBOX  polyethylene

       FORMCHECKBOX  other (explain)

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      If tank is metal, list age:

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      Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)

       FORMCHECKBOX   Yes   FORMCHECKBOX    No

      Dimensions:

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      Sludge depth:

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      Distance from top of sludge to bottom of outlet tee or baffle

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      Scum thickness

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      Distance from top of scum to top of outlet tee or baffle

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      Distance from bottom of scum to bottom of outlet tee or baffle

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      How were dimensions determined?

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D. System Information (cont.)

      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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      Grease Trap (locate on site plan):

      Depth below grade:

      Material of construction:

       FORMCHECKBOX  concrete

       FORMCHECKBOX  metal

       FORMCHECKBOX  fiberglass

       FORMCHECKBOX  polyethylene

       FORMCHECKBOX  other (explain):

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      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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      Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):

      Depth below grade:

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      Material of construction:

       FORMCHECKBOX  concrete

       FORMCHECKBOX  metal

       FORMCHECKBOX  fiberglass

       FORMCHECKBOX  polyethylene

       FORMCHECKBOX  other (explain):

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D. System Information (cont.)

      Tight or Holding Tank (cont.)

      Dimensions:

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      Capacity:

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      Design Flow:

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      Alarm present:

       FORMCHECKBOX   Yes      FORMCHECKBOX   No

      Alarm level:

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      Alarm in working order:

       FORMCHECKBOX   Yes      FORMCHECKBOX   No

      Date of last pumping:

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      Comments (condition of alarm and float switches, etc.):

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      * Attach copy of current pumping contract (required). Is copy attached?

       FORMCHECKBOX   Yes      FORMCHECKBOX   No

      Distribution Box (if present must be opened) (locate on site plan):

      Depth of liquid level above outlet invert

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      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.):

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      Pump Chamber (locate on site plan):

      Pumps in working order:

       FORMCHECKBOX   Yes      FORMCHECKBOX   No

      Alarms in working order:

       FORMCHECKBOX   Yes      FORMCHECKBOX   No

D. System Information (cont.)

      Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):

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      Soil Absorption System (SAS) (locate on site plan, excavation not required):

      If SAS not located, explain why:

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      Type:

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      leaching pits

      number:

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      leaching chambers

      number:

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      leaching galleries

      number:

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      leaching trenches

      number, length:

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      leaching fields

      number, dimensions:

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      overflow cesspool

      number:

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      innovative/alternative system

      Type/name of technology:

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      Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.):

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D. System Information (cont.)

      Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):

      Number and configuration

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      Depth – top of liquid to inlet invert

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      Depth of solids layer

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      Depth of scum layer

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      Dimensions of cesspool

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      Materials of construction

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      Indication of groundwater inflow

       FORMCHECKBOX   Yes       FORMCHECKBOX   No

      Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):

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      Privy (locate on site plan):

      Materials of construction:

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      Dimensions

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      Depth of solids

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      Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):

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D. System Information (cont.)

      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.

      Site Exam:

      Slope

      Surface water

      Check cellar

      Shallow wells

      Estimated depth to ground water:

      Please indicate all methods used to determine the high ground water elevation:

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      Obtained from system design plans on record

      If checked, date of design plan reviewed:

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      Observed site (abutting property/observation hole within 150 feet of SAS)

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      Checked with local Board of Health - explain:

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      Checked with local excavators, installers - (attach documentation)

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      Accessed USGS database - explain:

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      You must describe how you established the high ground water elevation:

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