HomeMy WebLinkAboutTitle V Inspection Report - 878 WINTER STREET 3/22/1996 ;
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Commonwealth calfh of Massachusetts
Executive,Office of ENronme nfcal Affairs ` 54;
Department of
Environmental Protection
VV IIIIe t F.Weld
Governor
Trudy X
Secret.y,EtJEA
David S.Struha
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
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Property Address: � Address of Owner:
Gate of Inspection: ;� (if different)
Name of Inspectors
Company Name, Address and 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 disposal systems. The system:
Passes
Conditionally Passes
® Needs Further Evaluation By the Local Approving Authority
Fails
inspector's Signature: " Date:
, m
The System inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completingw
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 tolhe 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, B, C, or D:
A] SY TEM PASSES:
1" I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.301
Any failure criteria not evaluated are indicated below,
I3] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
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, 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 9/15/95) 1
One Winter Street a Boston,Massachusetts 021064 0 F (617)556-1049 a Telephone(617)
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
44/1'1v r vox. f, /"V'o"'/4100,
Property Address: ef
Owner:
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 obstruct
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval ofit e
Board of Health):
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
Cl 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 the
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 THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The SvStern has a septic tank and soil absorption system and is within 100 feet to a surface water supply or trlbutary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet 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 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
ppm,
D) SYSTEM FAILS: 1 141411
1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 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.
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 or
cesspool.
(revised 8/15/95) 2,
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 6
CHECKLIST
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Property Address: VS
Owner: r/'I, ,
Gate of Inspection: ,
�c
Check if the following have been done:
4urrtping 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 volumes of water have not been introduced into the system recently or as part of this inspection.
/ built plans have been obtained and examined. Note if they are not available with NX
The facility or dwelling was inspected for signs of sewage back-up.
'0' T"he system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout
ZlAl system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
�ees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
®The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
ll
The facility okw ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 9/15/95)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: (,f", 3
Owner: e 0 J
0V,re
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ---�gallo s
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):�Tll/
Laundry connected to system��rs or no): s/yo
Seasonal use (yes or no).__�_
Water meter readings, if available:
Last date of occupancy:A� it e I'd
COMMERCIALANDUSTRIAL:
Type of establishment: J,
Design flaw: 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 in rmation:
System pumped as part of inspection: (yes or n
If yes, volume pumped irtr gallons
Reason for pumping:
TYPE 'EM
O 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)
Other(explain)_-
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION I FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Cate of Inspection:
SEPTIC TANK:
(locate on site plan)
r�
Depth below grade: ,
Material of construction. concrete ,metal _FRP—other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 111
Scum thickness . L° �
Distance from top of scum to top of outlet tee or baffle;
Distance from bottom of scum to bottom of outlet tee or baffle: IV; r
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' 's ;�e' '1 a„d
m_ 737T77-TI- . . � .
GREASE TRAP_„
(locate on site plan)
Depth below grade:
Material of construction: —concrete metal _FRP—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 battle:
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, et(.)
(revised 6/15/95)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: f
Owner:
Date of InspectionN ,a. ms�
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: concrete—metal TFRP„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:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distributicr is eaua!, evidence of solids carryover, evidence of leakage into or out of box, etc.)
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,)
(revised 8/15/95) 7
9s F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection;
SOIL ABSORPTION SYSTEM
(locate on site plan, if possible; excavation not required, but maybe 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:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS: /,41 A.
(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 8/15/95) 8
s;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C n
SYSTEM INFORMATION (continued)
Property Address:: "
Owner:
Date of Inspection;.
SKETCH OF SEWAGE DISPOSAL SYSTEM;
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100"
r
0
00,001" 100o
IUOII ,0
i"
Dm
W 0
io
i
00
DEPTH TO GROUNDWATER
method of determination ur
Depth to groundwater. feat
approximation �� � ' �� r .W� 7"
(revised 8/15/95) 9