HomeMy WebLinkAboutTitle V Inspection Report - 136 ROCKY BROOK ROAD 2/24/2000 Q'
COMMONIATALTH OF MASSACHUSETTS
_ ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
I = ' DEPARTmr,,NT OF ENwRONMENTAL PRO'T'ECTION
'.a ONE WINTER ITREET, BOSTON 1AA 02106 (617) 292-5500
TRTJDY COXE
Secretat-y
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Comnvssioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC71ON FORM
X;;' PART
CERTIFICATION
Property Address: °E.. Add ess oN m of Owner s o
Date of Inspection: . °`
Name of Inspector:(Please Print)
I am a DEP approved system Inspector pursuant to Section 1 5.340 of Tide 5(310 CMR 15.000)
Company NameMails n g Address:
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
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Inspector's Signature: , Date. "
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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.
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
V .'roperty Address:
Jwrr+ew:
Date of Inspection: m 'ye 7 C� a`� �.°° '' �✓
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
a- 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,
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 complying septic tank as
approved by the Board of Health.
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).
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 systern will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
y CERTIFICATION (continued)
Property Address:
Owner:'
pate of inspeclfon: `
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Z6,
Conditions exist which require further evaluation by the Board of Health in order to determine It the system is failing to protect the
public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of 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 ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
— 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.
_ 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 coliforrn 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, Method used to determine distance (approximation not valid).
3) OTHER
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
^
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following;
I have determined that one or more of the following failure conditions exist as described 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.
Yes No
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,
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 available volume is less than 1/2 day flow.
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 I 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
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen,
E, LARGE SYSTEM FAILS:
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:
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 It of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2)• Please consult the local regional
office of the Department for further information,
revised 9/2/98 Page 4of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PANT B
CHECKLIST
Prop"Address:
Owner:
Date of'Inspection: Y
C)
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or 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.
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As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All 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 tees, 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. For example, Plan at B.O.H.
� Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[15.302(3)(b))
_ The facility owner (and occupants,if different from owner) were provided Witt,information on the proper maintenance-of
Subsurface Disposal Systems.
revised 9/2/98 Pagcsof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
� . j0v m
'roperty Address:
Owner: �
m
Date of,lnspection: pu b �� Gk
�.
FLOW CONDITIONS
RESIDENTIAL;
Design flow; g.p,d./bedroon y.,'
Number of bedrooms (design): ., Number of bedrooms (actual):_
Total DESIGN flow
Number of currant residents:
Garbage grinder(yes or no): ����
Laundry(separate systems (y s/sir no),-2/,j; If yes, separate inspection required
Laundry system inspected (ye or no)
Seasonal use (yes or no): 1, r.,,
Water meter readings, if available (last two year's usage
Sump Pump(yes or no► d
Last date of occupancy , ' r
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd ( ase rin 15.203)
Basis of design —___—
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 inspection: (yes or no)
If yes, volume pumped d`," ) gallons .
Reason for pumping: f �' d Ord�
TYPE OF SYSTEM
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
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 9/2/98 Page 6ofI1
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address:
Owner:
Date of Inspection:
"'q i.........
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: cast iron 6-46 PVC— other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (co'r;d)tion of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:—Y,I A')'
(locate on site plan)'
j c
Depth below grade:7.,
Material of construction:c,'concrete—metal_Fiberglass _Polyethylene_other(explaln)
If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
Now dimensions were determined:
'ornments:
(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.)
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:—concrete_metal_Fiberglass _Polyethylene_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 baffle:
Date of last pumping:
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.)
revised 9/2/98 Page 7 of 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Iroperty Address:
Owner.
Date of Ins on:
....... .....
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan) ,44
Depth below grade:
Material of construction:—concrete—metal—Fiberglass_Polyethylene_other(explain)
Dimensions:
Capacity:_gallons
Design flow: gallons/day
Alarm present_
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:L'
(locate on site plan)
'wl
Depth of liquid level above outlet inveqr""
Comments:
(note if level and distribution is equal, 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)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc,)
revised 9/2/98 Page 8 of 11
W
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
c)
Iroperty Address:
9
Jwner: k"
), % ........
"2
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_ el
leaching trenches, number, length: of
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth 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 9/2/98 Rage 9 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
''roperty Address;
)caner; �.
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
n %
operty Address: 0
Jwner:
Date of Inspection:
� " ,
MRCS Report name
Soil Type -----
Typical depth to groundwater - ___ _
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow____ Moderate_ -Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
_ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
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revised 9/2/98 Page ttof11