HomeMy WebLinkAboutTitle V Inspection Report - 20 ENGLISH CIRCLE 4/23/1998 aa�:� �,
CO\4MON\VEALTH OF MASSAC14USETTS
( EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
Ic a
�.t DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. f,tA 0210E 617-292-5560
th1LLLa,!f WELD TRUDY COXE
5ecrctan
Govcrno:
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
I,,- Address of Owner:
Property Address: M«�(� �f�"�i� Zu ��f3�/t C{� G (If different)
of Inspection: y�23 4i �l/ arf
Name of Inspector: BENJAMIN C. OSGOOD JR.
I ?m z DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: NEW ENGLAND ENGINEERING SERVICES, INC.
Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 01845
Telephone Number: 508-686-1768
CERTIFICATION STATEIAENT
I cenify 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:
V se Passes
&ndtUonalh Passes I
_ Needs Funher [%-aluation By the Local Approving Authority
_ Fails
s
Inspector's Signature: Date:
OW
The Svstem !nspector shall submit a copy of this inspection report to the Approving Authority iwithin thirty (30) days of completing this
inspection. if the system is a shared system or hac a design flow of 10,000 gpd or greater, (he 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, i(applicable, and the approving authority
INSPECTION SUMMARY: Check A, B, C, or D:
AJ ,SYSTEM PASSES:
tl I have not found any information which indicates that the system violates any of the failure :rite:ia as defir~ed in 310 MR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
81 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(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 conforming septic tank
as approved by the Board of Health.
(rovxa d 04/75/97) part. 1 or 10
w ....:
y
a° Y
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2,(>
Owner: J�Ce/L)4 S�11 a 0.5 G
Date of Inspection:
41 Z,3)C1&
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 (our 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 replace&
obstruction is removed
C) FURTHER EVALUATI i ON IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which reouire further evaluation by the Board of Health in order to determine if the system js (ailing 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 FROTECT 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: I
® The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributalry 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 coli(orm 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
(r®vf®od aai�sy�7) page a or io
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 r����s�k � rc IC JU AuJef. /�
Owner: s -
Date of Inspection: tern e.
412,3 lei b
D) SYSTEM FAILS:
You must indicate either "Yes" or "No"as to each of the following:
1 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.
Yes No
Y 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 to 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 times pumped
Any port on of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Anv portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
® Any ponion of a cesspool or privy is within a Zone I o(a public well.
® Am ponion of a cesspool or pricy is within 50 feet of a private water supply well
Amy ponion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable eater quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
cohiorm baagria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: I I
You must indicate either -Yes- or "No" as to each of the following:
The following crnena apply to large systems in addition to the criteria above:
The system serves a (a6lity with a design (low 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 If 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 information.
(reviaad 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 0,CD /U- 4},n0o,)t/L AA/4
Owner: fJtu/L1af ron�c i
Date of Inspection:
N z3�q-
Check if the following have been done: You must indicate either `Yes"or 'No" as to each-of the following:
Yes Na
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
As built plans have been obtained and examined. Note d they are not available with N/A.
✓ _ The facility or dwelling was inspected (or signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout
f All system components. excluding the Soil Absorption System, have been located on the site.
The septic tank manholets 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:
_ The facility owner tand occupants, if different from owners were provided with information on the proper maintenance of
Sub-Surface Disposal System.
V� Existing information. Ex.iPlan at B.O.H.
Determined in the field (if anv of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (13.302(3)(b)J I
(rmvised 04/2$/971 pings 4 of 10 ',.
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORMATION
Property Address: ;2C7 �v �;s C�rr(,C , AJ.
Owner: M'-el,V,
Date of Inspection:
41 a31�o
FLOW CONDITIONS
RESIDENTIAL:
Design flow: b p.dJbedroom for S.A.S
Number of bedrooms: dV-
Number of current residents:
Garbage gr,r.der(yes or no?:-6/—
Laundry connected to system (yes or no)
Seasonal use (yes or no):fV
Water meter readings" if available (last two (2) year usage (gpd):
Sump Pump (yes or no): IV
Last date of occupancy°_Cu rv `�
COMM ERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)�
Industrial Waste Holding Tank present: (ves 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)_
1(yes,Ye , pumped:
Ped: _ ;Zallo s
Reason for pumping
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
APPROXIMATE AGE of all components, date installed (if known) and source of information: 6-iS k.-I
Sewage odors detected when arriving at the site: (yes or no)
(s®vlaod 44/25/97) Papa 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -,a �; L C,`,Y� i11. p c2, Mme,.
Owner: ► r lG�t�1. S�'r"+�,. e
Dale of Inspection:
BUILDING SEWER:
(Locate on site plan)
,r
Depth below grade: 1 Z
Material of construction: ®cast iron ✓40 PVC_other (explain)
Distance from private water supply well or suction Iirs'
Diameter `<
Comments: (condition of joints, venting, evidence of leakage, etc.)
f2C
SEPTIC TANK:_
(locate on site plane
Depth below grader
Material of construction: }concrete _metal _Fiberglass _Polvethylene _other(explarn)
If tank is metal, list age — Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: 1,5-00 '&
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baiflie: 46
Scum thickness:" ,
_
Distance from top of scum to top of outlet tee or baffle: C",
� �
Distance from bottom of scum to bonom of outlet tee or baffle: _
How dimensions were determined: tyt ccRsu�� 5 7')C k
Comments:
(recommendation for pumping, condition of inlet and outlet tees or b!Affles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) nor t.✓ 6,6e,Cy C.0---0-��'t. ob .-"p� �e
11 //y (/C.
✓� KSC c?v. e F r.. i G ry -�� G"
Te–e.y I
GREASE TRAP:AZA–
(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.)
(rmvis®d 04/25/97) Pqq® 4 of 10 ',.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
II SYSTEM INFORMATION (continued)
Property Address: 2 0 I vVw 6 r^c rr 4L /11, IA'd.,u0✓-L , items.
Owner: 1'Y1Rt' �� rvecrt
Date of Inspection:
TIGHT OR HOLDING TANK: -rank 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:
Capacm: gallons i
Design floe . gallonJda�
Alarm level Alarm in working order _ Yes. _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
? ' a
t
DISTRIBUTION BOX:
(locate on site plan)
rr
Depth of liquid level above outlet invert: 0
Comments:
(note if level and distribution is equal, evidence of solids carryoier, evidence of leakage into or out of box, etc.)
Inc X iK 6 {"t.)✓r /I/..- c ." 4e^,c zj- cc-y, &,/3a 1/ 1 Cyr tc ccy e c7X
i S S`�.r71' �.�, � ��'�C`r r`y rcx Cs��er w-�.5 �F=k«�•,� ch f-- i'v.s�e�>`7ar-
I I
PUMP CHAMBER: '
(locate on site plan)
Pumps in working order: (Yes or Not
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/1 5/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: QO F-jjy1,51n L'< -c G { h-). A40
Owner: nAA(LK Si u26"&1IT
Date of Inspection:
cl'22. )C5 a -
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: , r
leaching trenches, number,length: . y� CawJr wi, > `
leaching fields, number, dimensions:_
overflow cesspool, number:
Alternative system:
Name of Technology:
r r r
Comments:
(note pcondition of soil, signs of hydraulic failure, level of ponding, condition-of vegetation, etc.)
11 c �a L t-+ s fifmn, Lo��S ✓►a/`a7'i r+
• t
CESSPOOLS:AM
(locate on site plan)
Number and configuration
Depth4op of liquid to inlet rnven:
Dgpth,of solids layer:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction: I I
Indication of groundwater
inflow (cesspool must be pumped as pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:&V,/`/
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Coments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(r•vieed 04/25/97) vsga 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12C7 vlr�li S V� Gt rc C /Aj, ouec M�$
Owner: A4,,a v, 5� Itiec
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)
Rte
V� r
(�,IV�'
f
(r®vi®®d 04/25/97) Pe.g® 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: 2c� �.�w�is [ �irc(e AJ- ,M 4
Owner; mug to V
Date of Inspection: � 'c
q
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
' Obtained from Design Plans on record
---_X_ Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with !o--a! Board of health
Cheri. FEMA heaps
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)
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(r.vta.d 04/]s/97) Paq. 10 or 10
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