HomeMy WebLinkAboutTitle V Inspection Report - 1 SCOTT CIRCLE 12/13/1997 COMMONW'EAL.'TH OF MASSACHUSETTS
XECU 1"IVF OFFICE OF ENvI RONMFN'TAL AFFAIRS
c TTATt ME " 'I' OF ENVIRONMENTAL PROTECTION
ION
ONE WINTER STREET. BOSTON. MA 02108 617a292.5$00
TRUDY CORE
WILLIAM F.WELD Secretary
Govemo:
DAVID B.STRL)FIS
A1RGEO PAUL CELLUCCI Commissioner
Lt.Governor SUBSURFACE SEWAGE 171SPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: C � C` � of Owner:
(.late of Inspection: _, 1�—�� (If different)
Name of In ctor: \ . Iles -
I am a DEP approved system mspe tar pursuant to Section 15.390 of Title 5 (310 CMR,15.000)
Company Name:
Mailing Address: ° 12A
f U
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete'as of the time of inspection, The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage .isposal systems, The system,
?,.,Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving authority within thirty (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 Department of Environmental Protection, The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, 8, C, or
A) SYSTEM PASS
I have not found any information 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.
COMMENTS:
01 SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section heed to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Wealth, will past.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances, If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
® Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, 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.
(revised 04/25/17) Page 1 69 10
t7EP on the Wodd Wde web: http:/ ,megnet.Otate,ma.ua/dep
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: V
Owner: io 0 �J6� C]V
Date of Inspection: tom_ ,
BJ SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The 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
Cj FURTHER EVALUATION 15 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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF EA AND SAFETY AND THE ENVIRONMENT;
SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH
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 WILLIFAIL UNCTIONING IN A MANNER ETHAT PROTECTS THE PUBLIC SUPPLIER, OF HEALTH AND PSAFFETY ANDDETERMINES THAT
THE
THE SYSTEM
ENVIRONMENT:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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 pp
m. Method used to determine distance (approximation.not valid).
3) OTHER
(revised 04/75/97) Pago 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: S ot,s 00(_V'K �21�
Owner: %C
Date of Inspection:
Dj SYSTEM FAILS;
You must indicate either "Yes" or"No" as to each of the following:
1 have determined that the system violates one or more of the following failure criteria as defined in 310 CM
R 15.303. The basis
for this determination is identified below, The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes ,No
_ Backup of sewage into facility or system component due town overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or avagable volume is less than 1/2 day flow.
_ I
_ 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 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 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:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
Y
(rovisod 01/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISP OSRALBYSTEM INSPECTION FORM
P
CHECKLIST
&J. dk�.
Property Address:
Owner.
Date of Inspection:
ust indicate either"Yes" or"No" as to each of the following:
Check if the following h ave been done: You m
Yes o rovided by the owner,occupant, or Board of Health.
Pumping information was p • n receiving normal
onents have been pumped for at least two weeks and the system has bee
None of the system comp of water have not been introduced into the system recently or
flow rates during that period. Large volumes
as part of this inspection.
/ As built plans have been obtained and examined. Note if they are not available with N/A.
_v
The facility or dwelling was inspected for signs of sewage back-up.
G
ive non-sanitary or industrial,waste flow,
The system does not rece
The site was inspected for signs of breakout.
stem components, excluding the Soil Absorption System, have been located on the site. for condition of
All system tic tank was
o ions and the interior of the of depth of scum.
,. The septic tank manholes were uncovered, Pe
depth of liquid,depth of sludge,
baffles or tees, material of construction, dimensions, on:
m owner) were provided with information on the proper maintenance of
The size and location of the Soil Absorption d ffereM from site has been determined based
The facility ownenSy�temPants,
Sub-Surface Disposal
Existing information. Ex. Plan at B.O.H• approximation of distance is
Determined in the field (if any of the failure criteria related to Part C is at issue,
unacceptable) [I 5.302(3)(b)]
page 4 of 10
(=eviaod 04/25/87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: C C_ •�, �`1�`�� �'
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: /bedroom for S.A.S.
Number of bedrooms:
Number of current residents
Garbage gander (yes or no):
Laundry connected to syge(n (yes or no): S
Seasonal use (yes or no):1 ►c)
Water meter readings, if available (last two(2)year usage (gpd):
Sump Pump (yes or no): �
Last date of occupancy. w�C
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_gallons/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
PUMPING RECORDS and source of information:
System pumped as part of inaction: (yes or no)—V0'!:;'
If yes, volume pum cam) Ilon
Reason for pumping S7
TYPE OE,5yWM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
1/A Technology etc. Copy of up to date contracts"
Other
E
!'Z -
(MATE A of II components, date installed (if known) and source of information: ®
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/2S/97) page 5 of 20
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Ad dress:
Owner;
Date of Inspection;
BUILDING SEWER:
(locate on site plan)
Depth below grade: '3C (expla' ) q
Material of construction: t iron a � other ' l V11
Distance frgm Private water supply well or suction lire
Diameter "�
Comments; (co dition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK;;
(locate on site plan)
l Depth b elow grade:Material of construction: metal Fiberglass Polyethylene rother(explain)
If tank is metal, list age Is age confirmed by Certificate of Compliance ®(Yes/No)
Dimensions: I,to t Y's t U( tic?,5.— = cros
Sludge depth; ) ry
1
Distance from top ftsludge to bottom of outlet tee or baffle:,_.
Scum thickness: r(
Distance from,top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: uk)7 C
Now dimensions were determined: O&A—s)U<-e.. S Ze_ `
�
Comments:
Condit
(recommendation far pumping, ' f inlet d out t tee or baffl s, depth of liquid level ip relatipn ` out t invert, structural ,
integrity, evid nce f leak e, a .) �► , t `
GREASE TRAP:W—W1
(locate on site plan)
Depth below grade:
Material of construction: —concrete rmetal __Fiberglass __polyethylene rother(explain)
Dimensions:
Scum thickness:._ .__
Distance from top of scum u top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
(recommendation for
integrity, evidence of leakage, etc.)
Psg® 6 of 30
(rrvioed 04/2S/97)
e '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ' (f-t 4k�
Owner:
Date of Inspection;
TIGHT OR HOLDING TANK: (Tank must be pumped prior to,or 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 level; Alarm in working order_Yes; _ No
Date of previous pumping.
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX.
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: ��
(note if level and istribu'on�is equal, evidence of solids carryov r, evidence,,of I akage into or out o x, etc.)
PUMP CHAMBER;-tA0v,4)-
(locate o n site p lan)
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.)
(revised 0{/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
= SYSTEM INFORMATION (continued)
Property Address:
Owner: �t�?
Date of Inspection;
t3-
SOIL ABSORPTION SYSTEM (SAS): ---''
(locate on site plan, if possible; excavation bot required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:___
leaching galleries, number.
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system: a
Name of Technology:
Comments:
In co dip'o of s il, signs a h draulic ilure, evell of p ndi
nding, cot' n of vegetation etc.)
t c1
s..)
CESSPOOLS:kLD(pe
(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) .
Dimensions:
Materials of construction:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(zevinea 04/35/97) se9* ® of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: t Sf
CA [,a
Owner: �J1 C✓T�QJ�
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at leas rmanent references landmarks or benchmarks
locate all wells withi 100' (Locate here public water supply comes into house)
Q �y
p,
It
(revised 0{/24/87) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ( E J r —
P Y \-
Owner: �C?+ � )v�
Date of Inspection: of tj
Depth to Groundwater Feet
Please indica all the methods used to determine High Groundwater Elevation:
�Obtain m Design Plans on record
Obsery lon of Site (Abutting property, observation hole, basement sump etc.)
D etermin ,it from local conditions
Ct/ heck with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
(zsvinod 04/25/97) Page 10 of 10
TEL: (5013) 475-1474
FAX: (5013) 475-5451
BATES ON ENTERPRISES, INC.
Excavating-Water & Sewer Lines-Septic Systems & Pumping Service
1 1 I Argilla Road M Andover, Mass. 011310
Title 5 Inspection Report
Property Address : ------------------
Owner : -----------------------
Date Of Inspection :
--------
My report contained herein does not constitute a guarantee
of future usage and the functionality of the existing septic
system. such report issued herewith is merely based upon my
observations, and I hereby disclaim any further operation
of your current septic system.
Neil J Bateson
Bateson Enterprises Ind.
11 of 1 L