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HomeMy WebLinkAboutTitle V Inspection Report - 890 JOHNSON STREET 6/18/1999 COMMONWEALTI-1. OF MASSACHUSETTS Em.Cu"'.r'IVE OF FIQH OF ENVIRONMENrm,AFFAm DEPARTMENT OF EINMIONMBNTAL PROTEMON ONE WTNTER STREET, BOSTON MA 02108 (617)292-6500 TRUDY CORE". Secretary ARGFO PAUL CEI,LtJC('l DAVID B,STRUITS Governor SUBSURIF-ACE SEWAGE DISPOSAL SYSTEIMA INSPECTION FORM Commissioner PART A CERTIFICATION ILI, Nan"of Owner U Propeq-ty Ackire": Cr) )v "X, of Adtlress OWrM r 0- " , * Date of InsPectierr: —C"k! .- Name of lospectm:A�- o 1;nfn) I am a CEP_01 -)WOV systeeminspoct Pursuant to Section 16.340 of"ride 5(310 CMR 15.000) Company Name: MrAnq Address: +1 o(a to Telephone Number: C '"r4 S[A AR0 jgMENT_R_ I certify that I have personally Inspected the sewage dispoird system at this address and that the Information reported below Is true, 4wourato and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and innintenenco of on-site sewage disposal systems. The system: '0 asses Conditionally Posses the Local Approving Authority C) kisPector's Signature: Date: 6--- ( 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 shelf submit the report to the appropriate regional office of the Department of Environmental P.rotection. The original should be sent to the system owner and copies sent to the buyer,If applicable, and the approving authority. NOTES AND COMMENTS .............. T, 4 revised 9/2/98 Page I of 11 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION( ) Prot"Ad�essz (_.) )�1V�� _)!\ � . 1° Cf1`��. ��t LS2 Owner: Date of Inspection: INSPECTION SUMMARY: Check A, 8, C, of 0: A. SYSTEM PA§SES: 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: 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(201 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 pipets) 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 system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed P revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Address:` fS-[ ( i �`A p , • / 1'ro�rtY �?�')J f�-� JC.1r\V\�-F.Jtf\,.`�� Owner: C 4-1FJ_ Date of Inspecti(m: C. 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 AEI 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 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. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: C-� 'SO�1� 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of tines pumped_,. Any portion of the Soil Absorption System, cesspool at 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 analysts 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 11 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 infognation. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART B CHECKLIST Property Address-. Date of Inspection: 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. L% None of the system components have been pumped for at least two weeks and the system has been•recelving•ttorrnal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. L 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 system does not receive non-sanitary or Industrial waste flow. The site was inspected for signs of breakout. L- All system components, excluding the Soil Absorption System,have been located on the alto. A__ 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: % 1 - Existing information. For example, Plan at B.O.H. f 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)) 1..'. _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. d revised 9/2/98 Pages or ii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: `3C--( c o", ,?.0 Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: I(U g.p.d./bed o m. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow L L 1 1 _ Number of current residents Garbage grinder(yes or no): � Laundry(separate system) (yes or no):t'�k-A, If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no): fit' ` Water meter readings,if available (last two year's usage(gpd): / Sump Pump(yes or no►: �> 1 Last date of occupancy: LuS ,VA COMMERCIALIINDUSTRIAL: Type of establishment: Design flow: gpdd ( Based on 15.203) Basis of design flow 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: t CXV ga Ions Reason for pumping: (y1 S` 6 �t�`tiA ' P TYPE OF SYSTEM t "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 TR MATE AGE ot all compo ents, date installed(if known)and jource of information: T CPWS, '3��--vr, OICA Callo- PICZAAA, Sewage odors detected when arriving at the site: (yes or no) �lC� revised 9/,2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM S N FORM PART C SYSTEM INFORMATION( ) Property Address:° ��f Owner: Date of Inspection: <_r ( `C 1 ,-- tz��_�f P BUILDING SEVWER:L ✓ (Locate on site plan) 11 Depth below grade: I D Material of construction: v st 4ron 40 PVC other(explai ) \ u74 Jv t.`— �(t l,A Distance fro p'ivate water supply well or suction line Diameter Comments: conditign of j rots,venting, evidence of leakage,etc.) v` IE�CI.tt.< SEPTIC TANK: (locate on site plan) n If Depth below grade: �? Material of construction: v'i`oncrete_metal Fiberglass Polyethylene_other(expiain) If tank is metal,list age Is age confirmed by Certificate of Compliance v(Yes/No) Dimensions: �—j I K , L_r �r S- 1 Sludge depth: I `i t/ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: I It Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to boi pm _f qutlet tep or baffle: How dimensions were determined: ._�,) Y -t'r'od- - -"z." �S�v , C__e Comments: (recommendation for pumpin ditio of IN t a outie tees or affles, a th of li d lev 1 in►ela�ionrt,,tpp ou et ve $ rof i Irity,,c ] evi ence of leak ge,etc '� C � b U\ e WN1P a CIL GR SE P: (locate on site plan) Depth below grade:. Material of construction:_concrete_metal_Fiberglass Polyethylene,_other(expiain) 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 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM SPEC FORM PART C SYSTEM INFORMATION( ) Property Address )C'/ cam•j(� _j�( ��'Cti " �� Owner: 1 Date of Inspection: ' TIGHT OR HOLDING TANK02 (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_otherfexplain) 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 BOXL,-- (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: � � (note Jif llev 1 and{i'strib do is eq al, evidence of solid arryo er,evidenc f leakage into or out of kox, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) p Alarms in working order(Yes or No)-- � Comments: (no a ondition of ump chamb t.�conditio of pum s and p rtenanc e �'� -''� pc",(V Xk - ti. revised 9/2/98 Page 8of11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SAYS FORMATION(continued) Property Address°. ��recC � _� Y Owner: 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: ++ leaching trenches,number,length:4��u`C= Ljc IC.. leaching fields,number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note conditio of soil signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) IL -- , - r� F > M,i e-! - CESSPOOLS: (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:V\001'(-�_ (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 Page 9orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART G SYSTEM INFORMATION(continued) Property Adckess: Owner: Date of Inspection: SKETCH OF SEWAGE ISPOSAL SYSTEM: include ties t at least two permane t reference landmarks or benchmarks locate all we s within 100' (Locate here public water supply comes into house) -- ---- �,l )Gt A I IC ri ` II revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM ), INFORMATION( ) Property AddressC�U �� Owner: Date of Ins - NRCS 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-t Feet Please indicate all the methods used to determine High Groundwater Elevation: L Obtained from-Design Plans on record bse►ved Site(Abutting property, observation hole,basement sump etc.) etermined 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) a revised 9/2/98 Page It of 11 Tel: (978)475-4786 Fax: (978)475-5451 ATEON ENTERPRISES, INC. Excavating-Water.& sewer Lines-Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: ��� Owner: Lee 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. /r/x Neil J. Bateson Bateson Enterprises, Inc.