HomeMy WebLinkAboutTitle V Inspection Report - 30 LACY STREET 8/2/1997 BATCSON CN-I-LRVIZISLS INC.
Septic Systems—Excavalhig--Waler&Sewer Lines
11 t Atgille Aosd
_ Andover, Massechubells 01910
(509)415.1414
Title 5 Inspection Report
Property Address :
Owner :
Date Of Inspection :
Pty report contained herein does not constitute a
guarantee of future usage and the functionality
of the existing septic system. Such report issued
Iterewith is merely based upon my obaervaLlanar
and I. hereby disclaim any futther operation of
your current septic system,
4
Neil J4 Bateson
Hateson Enterprises Info
10 Of to
Kto 6-is mia Commonwealth of Massachusetts
Executive Office of Environmental Affairs
rtment of
Environmental Protection
WiilUhm F.Weld Trudy Cox*
Governor secretary
Argeo Paul Cellucci David B. Struhs
U.Governor CommWsioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
Lgr ., J ` CERTIFICATION
Property Address;'i7 C-"2 ' �`� Address of Owner:
Date of Inspection: _p �f r (If different)
Name of Inspector. {QL
Company Name,Address and Telephone Number. BATESON ENTERPRISES, INC. TEL:(508)475-1474
Excavating-Water&Sewer tines-Septic Systems&Pumping Service FAX:(508)475-5451
CERTIFICATION STATEMENT 111 Argilla Road ■ Andover,Mass.01810
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
NeeAsf urther Evaluation By the Local Approving Authority
F S
Inspector's Signature: E.�'..�-., Date: ,)—97
The System Inspector shall su mit a 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 appravirrg authority.
INSPECTION SUMMARY:
Check A, B, C, or D;
A) SYS PASSES:
� ve 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,
inspection.
Indicate yes, no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why trot)
• The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exflltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a,ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street • Boston,Massachusetts 02108 w FAX(617)556-1049 s Telephone(617)292.5500
0 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CE�R�T�IFICATION (continued)
Property Address: 6
Owner. Q-
Date of Inspection:
Bi SYSTEM CONDITIONALLY PAST SES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(o)
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
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 4om 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.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
`
CERTIFICATION(continued)
Property Address: 3 �`i iv0j'`— k&
Owner.
Date of Inspection: C`
DI 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.
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:
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:
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 II 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 once of the Department for further information.,
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: d L_r'_C
Owner. c�" G I OS
Date of Inspeotiott:�C
Check if the folloo'' have been done:
_✓Pum ' information was requested of the owner, occupant, and Board of Health.
_N one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
j dd that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As 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
_v The site-was inspected for signs of breakout.
VA11 system components, excluding the Soil Absorption System, have been located on the site.
E�'I he 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.
_ e size and location of the Soil Absorption System on the site has been determined based on existing information of
approximated by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: jc) L'CI' Mc& 4�QQ-X-
Owner: � x ((DS
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: L414 gallons
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):
Laundry connected to system(yes or no). Ves
Seasonal use(yes or no):YQ ea Water meter readings, if available:
Last date of occupancy:(fo V(-tAAA—
COMMERCIAL/INDUSTRIAL:
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, itavailable:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: o ak-&�
System pumped as part of inspection: (yes or no) Ve T
If yes, volume pain ( o \ ,
Reason for pumping: �l)a AC-
TYPE OF,97FBTEM
/Septic tank/distribution boa/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yea or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPRQ,X,IMATE AGP of all components,date installed(if known)and source of information:
Y li I)r y 1aA,,-
Sewage odors detected when arriving at the site: (yes or no) "0
(revised 11/03/95) 5
a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address
Owner*. Da sc-�0S
Date of Inspection:
SEPTIC TANK l.�
(locate on site plan) <<
Depth below grade: t h`'�` CL ��
Material of construction: �ncrete_metal_FRP_other(explain)
Dimensions: k 6�
Sludge depth: ( _ It
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:�Q_,_ ll
Distance from top of scum to top of outlet tee or baffle:a l�
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pump' condition of' et outle tees o baffles, deptl,of li uiq 'd eve re i ,to outlet jn`ert ctur integrity,keA'de ce of 1 etc.) V L
GREASE TRAP.MIA
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scion to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
0
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 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION((000�ntiinnuad-)
Property Address:
Owner. Rc D z�
Date of Inapeetion:�y-
TIGHT OR HOLDING TANK V\0^4r-
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
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:
Comments: �^
(note if eve] and ril(u 'on is equal, evidence of soli carryover,eviden of leakage into or ut of box,etc.) c
C�
PUMP CHAMBER:jWA-Q�r�
(locate on site plan)
Pumps in working order:(,yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
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: r
leaching trenches,number, di length: ` �!�
leaching fields, number, dimensions: Li
overflow cesspool, number:
Comments: (note nditio f soil, si of hydrauli c fail level of pondin condition of vegetation,etc.)
Ylr ca`�• No Ski civs ��` 0r-4 ,
CESSPOOLS:%ADv,,,e
(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)
R
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.)
(revised 11/03/95) 8 e-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM I�NFO,(R�MATION, (oontinued)
Property Address:
Owner. \ f--�C1e�11 t C-1 C7s
Date of Inspection:
SICUMH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
el
/
- - a3' o.
as
DEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation: C Y��
(revised 11/03/95) 9