HomeMy WebLinkAboutTitle V Inspection Report - 10 CHERISE CIRCLE 12/1/1998 0
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR m ° °
DEPARTMENT OF ENVIRONMENTAL PROTECT N
e
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUI CEL,LUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Properly Address: � A: r„ ��r;. � � s, (� Name of Owner �:'a � c r A :� ,
At,, 6', A^AOI, Address of Owner: ,) a A e i,,)a
Date of Inspection: :�a a F iM , A
Name of Inspector:(Please Print) 'AA n�ee:r Al 08 U f,L,"aA A
am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: "AF .. j) �wA "A 0:A ed
Mailing Address: ;7% w t 1,1�, /'V, L?l AAA° r� "': A J!,I
Telephone Number: Ai'I ,' , t A 4 1 2 ",
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. a" ".A AAA "AAAA :•�: , Date: _/j,
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"to
system owner-and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
S®6 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: (�" ,,At ' ,� , 'r, I e PQ f^),'U b,:w e,
Owner: 'g, Q V"4 a 7"�I
Date of Inspection:
INSPECTION SUMMARY: Ctwk A, 61 C or ®:
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:
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.
V10 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-e year-due to broken or obstructed pipes►. The-system wi1Fsu—
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
CERTIFICATION(continued)
Property Address c e c
Owner: `�, ���.., a v"o I `01��
Date of Inspection: >.
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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MARINER WHICH,WILL.PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVJRONMENTd.
/1/1 1,` Cesspool or privy is within 50 feet of surface water
(j 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: -
L 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.
n: 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
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (confirmed)
Property Address; l '" 6"" :.e &
Owner: c, .)..o-�! '�`" i r "1,",
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
d r; 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 4ecili or-system component,due go an overloaded orpclogged 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
_ L/'o 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.
LZ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
r Number of times pumped
Imo" Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. -
W fl,. 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
4 " 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 organia 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 gr ter(Large System) and the system is a significant threat to public
health and safety and the environm t because on or more of the ollowing conditions exist:
Yes No
® _ the system is within 40 feet f a so ace drinking ater suppl
the system is-witMain 20 feet-of t ' utary-to a rfaco drink waters pfdY..
the system is located 1 a nitrogen ensitive are (Interim head Pro action Area-IWPA) or a mapped Zone II of a public
water supply well)
The owner or operator of any such syste 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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: �.? (,, ("'p�� a. �. i"1 :�.. pd /)A,m 1")I fL : g,-
Owner:
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
oL'.'........� Pumping information was provided by the owner, occupant, or Board of Health. f w -�� ", A t
-None of the system-components kauebeen pumped4or-at,least two weeks and-the mystem hasbeeafmcei ng 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.
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.N.
Determined in the field (if an of the failure criteria related to Part C is at issue,_ y approximation of distance is unacceptable)
.- [15.302(3)(b))
_ The facility owner(and_occupants,if different from.owner)..were,provided.with informatiomDri lba.pmpar_maintenaacaof
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: c e r s ` �:°r �' � �, 4 �� e �..,
Owner:
Date of Inspection: d �r
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms(design):_ Number of bedrooms(actual): "
Total DESIGN flow_
Number of current residents: ..,
Garbage grinder(yes orb : LLL
Laundry(separate system) (yes or n ):� 'L�►►; If yes, separateAnspection,required --
Laundry system inspect d (yes or, o�)
Seasonal use(yes or
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or,,q ,
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no) 7
Non-sanitary waste discharged to the Title 5 syste : (y s no)_
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
pumped System
If yes vm
olepumped: inspection: " or no)
gallons _
Reason for pumping: C,krer,. 1"kr era a&I M err
s r P
TYPE OF-SYSTEM
' Septic tank/distribution ox so 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 dif known)-and source of,information: r.. :.. 1.
y m
5.7)4 �� ,
Sewage odors detected when arriving at the site: (yes or o►r ,
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: e °p I°: I
Owner:
Date of Inspection: �"
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction:_cast iron 40 PVC_i�r( plain) P" .
Distance from private water supply well or suction lie
Diameter
Comments: (condition of joints,venting,evidence Jea t
SEPTIC TANK: e.1'
(locate on site pan)
Depth below grade:
Material of construction:_,"c ncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is►petal,list age Is.age-confirmed by Certificate of Compliance_(Yes/No)
Dimensions: S " �� X
Sludge depth: L " ,��
Distance from top of sludge to bottom of outlet tee or baffle: .. " —`
Scum thickness: ".it f
Distance from top of scum to top of outlet tee or baffle: U
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined:1
Comments:
c g pumping,am Condition Hof inlet and outlet tee��or-baff s depth of liquid level n relation on to outlet invert,aa cturaHntegrity,
(recommendation stru
e idence of leakage,etc.)
ammen a ion or c
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_ her(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet te/tand a fie:
Distance from bottom of scum to bottom of ot or ba le:
Date of last pumping: V
Comments; /affles, ,,,,,,,. w„
(recommendation for pumping, condition of in o t t tees or pt h of iquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address' f
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (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_ ther(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working orde :Yes 0-
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm an float s itches, etc.)
DISTRIBUTION BOX: e.
(locate on site plan)
Depth of liquid level above outlet invert: IN I�n
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
Wjdq a d r m�' � 41
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,conditi f p�ps and /urten�7kesl tc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: I ki C e i r.) a I'C/
Owner: Sc �, i'"„ r r° ,,..
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):'
(locate on site plan, if possible; exca a ion 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:
leaching fields, number, dimensions: .,` A •t"�r, `
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,)
m &a ��'Vaa a�� 'Nrc;;m �o-01,.,rc 'j��,e, �v�"zwa"pm) a�.a
re
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-tap 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 par, of nspecti n)
Comments:
(note condition of sail, signs of hydraulic failur , level of nding,co dition of.vegetation, etc.)
PRIVY:
(locate on site plan)
Materjals of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level po ng, cond' ion v getationr etc.)
4 14 ,11
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Pro Address: hD 0 �..r :", ;'a �'�" I R
Owner:
Date of Inspectimc �''lo�` A
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)
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(corMnued)
Property Address: c, e
Owner:
Date of Ins on
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)
. "
r t.k�' C n c V� Ao
. N
revised 9/2/98 Page 11 of 11