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Home My WebLink AboutTitle V Inspection Report - 41 CEDAR LANE 9/9/1996 PILE# 107 Forest St. e� Middi®ton,ANA 01949 ( 0W) 774®2772 Al SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME; PROPERTY ADDRESS: ceclar C2/7 /7 CJl '/" Ala, ADDRESS OF OWNER Sak (if different) DATE OF INSPECTION: NAME OF INSPECTOR: ,,°7 Zysco n��j THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY� FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /W, CERTIFICATION Property Address: �� C' cz/ lane /U 10106 "Adress of Owner: 6V-k� Date of Inspection:. �.f, q; /��G (If different) Name of Inspector: Company Name, Address and Telephone Number: Currier Septic& Drain Service, Inc. 107 Forest Street, Middleton, MA 01949 (508) 774-2772 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 p/ 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: Chec6 B, C, or D: A) -SYSTEM PASSES: y 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. B) 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 dtermination 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 8115/95) FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (conriNvid) 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): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced A) 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 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 system has a septic tank and soil absorption system and 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 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: I 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 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) D) SYSTEM FAILS(continued) Static liquid level in the distribution box above oulet invert due to an overloaded or clogged SAS or I cesspool. N 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 AAny 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 tt II water supply. /V 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: The fo lowing criteria apply to large systems in addition to the criteria above: The design flo system is 10,000 gpd or greater(Large System) and the system is a significant threat�utslic health and safety an a environment because one or more of the following conditions exist: the system is within 400 fe of a surface drinking water supply `" the system �� !— y tem is within 200 feet of a tnbutary to a sV fac drinking water supply the system is located in a nitro en'Sensitive area(Int rim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water.-supply well) The owner or operator o much system shall bring the system and facility into ful Hance with the groundwater treatment progra quirements of 314 CMR 5.00 and 6.00. Please consult the local regio office of the or for further infformation. (revised 8/15/95) 3 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: pumping information was requested of the owner, occupant, and Board of Health _ZNone 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. Z'The facility or dwelling was inspected for signs of sewage back-up. _L/The system does not receive non-sanitary or industrial waste flow. he 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. t:/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. l/The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal System. (revised 8/15/95) 4 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 4 FLOW CONDITIONS RESIDENTIAL: Design flow: RESIDENTIAL: gallons Number of bedrooms: Number of current residents: ;21-6.3 Garbage grinder(yes or<o:_AdQ Laundry connected to s ste ye or no):/e! Seasonal use(yes oz. !�0 Water meter readings, if available:�Bz',u a- Last date of occupancy: burr ,-N CQMMER .IAI/INt111CTR1A1. Type-of-establishment: Design flow:�— Ilons/day Grease trap present: (yes Industrial Waste Holding Tank pre sen . no) Non-sanitary waste discharged to the Title 5 s ste Water meter readings, if avialble: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING R C07DS and source of information: System pumped part of inspection: r no),A If yes, volume pumped:! gallons Reason for pumping: Am; TYPE BF 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) Other(explain) AP,PROXIMATE AGE of all components, date installed (if known) and source of information: v22 Sewage odors detected when arriving at the site: (yes no (revised 8/15/95) 5 LFILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SEPTIC TAM:An S (locate on site eA Depth below grader Material of construction: ncrete_Metal_FRP_other(explain) Dimensions.__ 6gil Baffle Depth Below Outlet Invert: Sludge depth: e:� V r Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: '' Distance from top of scum to top of outlet tee or baffle: 4L�._ Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to I iv r�� f��T'�/ ,"f�f,:a a': P" �`• C.+ .";,r out t in v structural integrity, evidence of lea a e,etc.) /�� U_6 r s C Q 7A' c -D r N Cz GREASE TRAP:/�U (locatee on site p a) Depth below gra Material of construction:_ ete metal_FRP_other(explain) Dimensions: Baffle Depth Below Outlet Invert: 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 baf h----a--T Comments: (recommendation for pi g, condition of inlet and outlet tees or baffles, depth of liquid le relation to outlet invert, structural integrity, vidence of leakage, etc.) (revised 8/15/95) 6 FILE# ! 7"96 r`C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) TIGHT OR HOLDING TANK:-LJv (lo ate on site plan) Depth below e: Material of construc i : concrete_metal_FRP—other(explain) Dimensions: --- --` Capacity: gallons Design flow: gallons/day Alarm level: Comments (condition-ofinlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:, ACS (locate on site plan) Depth below grade:gOOu Depth of liquid level above outlet invert: e,-o Dimensions of D-Box:- e 'Depth of Sump: x Zo Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — ;-s- �e r e i' PZX v 71i2 D B )c- ;S. / <)x 4/i I - - 7re, �&.d n ena PUMP CHAMBER:IUD (locate on site plan Depth below grade: Pumps in working order:(yes or no) Comments: _ (note conditions of pump chamber, condition of ps-an appurtenances, etc.) (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM (SAS): S (locate on site plan, if possible excava io not required, but may be approximately by non-intrusive methods) Depth to bottom of SASS 6"(Stone o Pi If not determined to be present, explain:dca b// Type: leaching pits, number: c5Z_ _67`D ee-j X 7 �«• (ter . �� rtG' �z` leaching chambers, number: / j �ow �a � w/cF 0 leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) o i h / r cL _ <?net a rcc Ve �� td Z7 V C)_SSPOOLS: (locatq on site plan) Depth bbl grade: Number and c i uration: Depth-top of liquid et invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool a pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetatio , PRIVY:'LU (locate on site plan) Materials of construction---- `__-- _:Dimensions': Depth of solids: Comments: (note condition of soil, signs of h liG-failure, level of ponding;oondt ion of vegetation, etc.) (revised 8/15/95) 8 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' CGaIQr one A�� 7- = 30 i At6D � G i� �� Eel La.►t R�. An�avt'/' 91" D Se Pz ptrc- fa = � � D z 12��, c� F4 7P I /3C� D DEPTH OF GROUNDWATER / Depth to groundwater:f" feet method of determination or approximation: �;s- r 'fi1Qt� (revised 8/15/95) 9