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HomeMy WebLinkAboutTitle V Inspection Report - 24 PATTON LANE 4/16/1998 C191 COMMONWEALTH OF MASSACHUSETTS y EXECUTIVE OFFICE OF ENVIRONMENTAL E�vTAI�.AFFAIRS i DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, NIA 02108 617.393.500 i WILLIAM F.WELD TItUDY COXE Secretar1' Governo: ARGEO PAUL CELLUCCI DAVID B.STRU"S Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A � 1 CERTIFICATION Property Address: a Plry c ,1 (-v\, " `J' QQ-(' Address of Owners Date of Inspection: — -) (if different) Name of Inspector: I am a DEP...approved system ins eetar to Section 15.340 of Title 5 (310 CMR,95,1100) Company Name: _SC:; __. y -• c Mailing . _ t ( _ C"c f t't.cmel 0 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: l"sses Conditionally Passes oNe�edsurther luation By the Local App roving Authority ins ectars Signature: Date:The System Inspector sof 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, B, C, or D: AI SYSTE SES: 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: e1 SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The systern, 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 NO), Describe basis of determination in all instances. If"not determined", eaplain why hot, The septic tank is metal, unless the owner or operator has provided the system Inspector with a copy of a Cettificaite of a� Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the Inspedion; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiitration, 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. ' (ravi.ead 04/25/97) tags 1 69 10 DLP on the Worid Wide Web http://vtivar, nst btate.ma.us/dep 0 Printed on Recycled raper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t t CERTIFICATION (continued) 4 Property Address: y V�� L-V) Owner: cZ Date of Inspection: Y B] 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 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 prowdt 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 ENVVIRONMENT: . _ 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND'FHE ENVIRONMENT: _ The system has a septic tank and soil absorption system (SASS and the SAS is Within 100 feet to a strritt water sufsply or, tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS it Within a Zone 1 of a'public water supply welt. The system has a septic tank and soil absorption system and the SAS is within 50 foet of a private*Ater supply Well: The system has a septic tank and soil absorption system and the SAS is less than 1100 feet but S0 feet or!titore from a private water supply well, unless a well water analysis for coliform bacteria And volatile organic cdrnpt)und3 indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and niCrate nitrogen'113 equal to or less than 5 ppm. Method used to determine distance _ (apprbxirttation,t�ot valid). 3) OTHER (revised 04/25/97) Yay ,.1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: L4 fix) Owner: N� Date of Inspection: `i� D) SYSTEM FAILS: You must indicate either "Yes" or I have determined that the system violates one o following: : '"No" as to each of the f y r 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. 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" as to each of the foflowing: 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 mote 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•(WPA)or a mapped Zone'll'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 informatlbrt. (revised 04/25/97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CRECKLISt . rr� Property Address: cat q �'t -- Owner: ale Date of Inspection: U- I(D-9:Ej Check if the following have been done: You must indicate either "Yes"or"No"as to each of the following: Yes o Pumping information was provided by the owner, occupant, or Board of Health. Lam'_ 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. �__—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. L Th'e 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. on the site has been determined based on: The size and location of the Soil Absorption System t _ The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of . / Sub-Surface Disposal System. c Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C it at issue, approximation of distan'tan,is unacceptable) [15.302(3)(b)) Y". (revisod 04/25/47) pagi di 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM,INFORMATION Property Address, p y �y Owner: � JJ Date of Inspection: "' Q 't FLOW CONDITIONS RESIDENTIAL: Design flow: 1S0 p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage gander(yes or no):_AtO Laundry connected to sysiierp� (yes or no): s X45 3 Seasonal use (yes or no): NO rj �'� =a 3 y«a /7 DA Water meter readings, if v ilable (last two (2) year usage (gpd): Sump Pump (yes or no): O 3a© Last date of occupancy: 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: ' CxAA Q• System pumped as part of inspection: (yes or ho)- q..q. If yes, volume pum gallons , Reason for pumping °v�`Y� -�C�-Wtt--'k 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) VA Technology etc. Copy of up to date contract? Other APPRO (MATE AGE of all components, date installed (if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) � (zeviud 04/25/97) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C e SYSTEM INFORMATION (continues!) Property Address: `4 Pk o, 41 Owner: 0(2 Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: 3 Material of construction: _cast iron 4�0 PVC othher,(e1xp`lai� Distance from private water supply well or suction lire Diameter Comments-(c-(onSlitiioon�of joints, venting, evidence of leakage, etc.) SEPTIC TANK:.. ✓ t ct ,Q-O- locate o n site Ian) P r✓ � Depth below grade: � Material of construction: _ oncrete metal Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance (Yes/No) i Dimensions: to�<s �x y Sludge depth: 3 I p Distance from top of sludge to bottom of outlet tee or baffle: C� Scum thickness: �` t Distance from top of scum to top of outlet tee or baffle: I it Distance from bottom of scum to bottorrt of u let tee or baffle: How dimensions were determined: S4 J Comments: (recommendation for pumping, conditi of inlet and utlet e r baffles, depth of hould le e) i relation t outlet ert, str ural ^ l�� Xfo integ ity, evide ce of le kageC etc.) �` t(`'�y G O GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explaln) 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 ih relation to outlet invert, Structural integrity, evidence of leakage, etc.) (revir•d 04/25/97) Page 6 of it1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK:t""" 4 (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/dav 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: C-"l Comments: (note if I el an distr'bLition is a ual, evidence of solids car,tryover gvidence of leakage into or ut of b x� et .) PU MP 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 04/25/97) ?age 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: -,�L% t�-.�:�r n Owner. �;(' Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation 'not 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: rr le leaching trenches, number, ngth: 3 't u '� r leaching fields, number, dimensions:_ overflow cesspool, number: Alternative system: Name of Technology: Comments: (notf co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) f 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: (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.) (ravixed 04/25/97) Page of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOWATION (continued) Property Address: t '" Owner: .'e V�� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) xf7e r�Q_ A 1 ' /0 0 Do" (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: IV Depth to Groundwater -'Feet Please indicate all the methods used to determine High Groundwater Elevation: L O6tained.fro6 Design Plans on record t (Observation bf Site (Abutting property, observation hole, basement sump etc.) �- Determine it from local conditions t Check 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) ` (revised 04/25/97) Page 10 of 20 TEL: (508) 475-1474 rAX: (508) 475-5451 B��I_ESON ENTERPRISES, INC. Fxcavating-\Nater & Sewer Lines- Septic Systems & Pumping;Service I 1 I nrgilla Road Andover, Mass. 0 18 10 Title 5 Inspection Report L-1 Pct-16k:)V-'� 1t1,A'w_0—(r 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 Inc . Page 11 of 11