HomeMy WebLinkAboutTitle V Inspection Report - 50 HAY MEADOW ROAD 1/29/1998 107 Forrest St. FILE#
Middleton,MA 01949
(508)774-272
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNER'S NAME: r / �e
PROPERTY ADDRESS: t4nt4
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ADDRESS OF OWNER:
(if different)
DATE OF INSPECTION:
NAME OF INSPECTOR; u l mw
•THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY
107 Forest St. FILE#' Z Q
Middleton,MA 01949
(508) 774-2772
Cf1A2A11FJ TIC DRAIN
SERVICE
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: Neltoolva,, Address of Owner:
Date of Inspection: - ;yy/ gd` Qjve (If different)
Name of Inspector. _�pgdr"J� ho
am a DEP app f system i c op.pursuant tp Sect' 15.340 15.340 of Title 5 (310 CMR 15.000)
Company Name: C Ir @ h /V
Mailing Address; 10 r r C
Telephone Number; ��7 L
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:
asses
—,/
►' Condiuonally Passes
'seeds Further Evaluation By the local Approving Authority
Fail
Inspector's Signature: Date:
The Svstem 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 authorit}.
INSPECTION SUMMARY: Chec A�B, C, Or D: W� r -�f (U � INS ��/� £�
`� T"LM C J
A] SYSTEM PASSES: ftl CGO�tkulLv�
e 9�8 y75.t237�
es 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:
B] SYSTEM CONDITIONALLY PASSES: ! ��x QtP�i}Ce� f'/Zg�di` l�rl �oN,SJ1Q6��
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The syUrn, 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.
(revised 04/25/97) Page 1 of 10
DEP on the World Mae Web: http./iwww magnet.state ma.us/dep
0 Printed on Recycied Pacer
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner. SO 0 A Date of Inspection: �`"
f/z►lqbv 1122 8
BJ SYSTEM CONDITIONALLY PASSES !continued) T,>&x �— P 6r t``Uf(aNSTRUG-
Sewage backup or breakout or high static water level observed in the distri 'ution box is due to broken or obst
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
obaruction is removed
distribution box is levelled or placed
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:
4SS Ces spool 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) M 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:
The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supr))y'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 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) OT ER
(revised 04/25/97) Pay 2 of 20
FILE# 1-2,1 .2-1 4?-ff
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Propertv Address:
Owner.
Date of Inspection:
D) SYSTEM FAILS:
►I��Iqs�
l'ou s; indicate either "Yes" or "No' as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The oas
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to corre^
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or pondtng of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS c
cesspool
_
Static liquid level in the distribution boa 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 flov..
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipes;.
Number of times pumped _.
Any portion 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 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Anv portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with ra
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis fo•
cohiorm 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 following:
The following criteria apply to large systems in addition to the criteria above:
el The system serves a facility with a design flow o 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safe and the environment cause one or more of the following conditions exist:
Yes No
the system is within 400 f o urface drinking water supply
the system is within 2 feet of'a's
tr ibuta t a surface drinking water supply
_ the system is located in a nitrogen sensitive area i t,erim Wellhead Protection Area- IWPA) or a mapped Zone 11 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.
(revised 0{/25/97) Page 3 of 10
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FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner. 04d ^ /� �,(
Date of Inspection:sa �"�:/ /��lL�Z��!'1%!
IIa( f�8
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Ye No
/ Pumping information was provided by the owner, occupant, or Board of Health.
V _ None of the system components have been pumped for at least two weeks and the�system has been receiving normal
Y g
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 %vas inspected for signs of sewage back-up,
The system does not receive non-sanitary or industrial waste flow.
The site �sas 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:
The facilrtv owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. E . Plan, t 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) (15.301(3)(b))
(revised 04/25/97) pay 4 of 10
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertN Address:
Owner:
Date of Inspection:
RESIDENTIAL: FLOW CONDITIONS
Design fioH _P�•bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage g, der(Yes r no):
Laundry co--ected to system (ye or no):
Seasonal use iyes orCn _
Water meter reading if available (last two (2)year usage (gpd):
Sump Pump (ves ol,no)
Last date of occupancv:4k&eA4
COMMERCI,kUINDUSTRIAL•
Type of establishment.
Design flog+•. allons/da,
Grease trap pr ent: tves or n _
Industna! Taste Pfv&ing Ta - Dresent: (yes or not
'yon-sanitary v aste di r to the Title 5 system: Ives or no)
Water meter readings, if ble
Last bate of o cupancv
OTHER: (Describe
Last date of occuoanc�•
GENERAL INFORMATION
PUMPING RECORDS and source of informal
System pumped as part of inspection: (yes or&o1
If yes, volume pumped: __ ¢allons
Reason for pumping
TYPE,PFIYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Pricy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
. I
APPROXIMATE AGE of all components, date installed (if known) and source of information:
0a)
Sewage odors detected when arriving at the site: (yes orCnO >—
I°�
(towed 04/25/97)
Page 5 of 10
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: N�VV[[�//
Owner: � �
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC_other (explain)
Distance from private water supply well or suction hr-
Diameter �-'/
Comments: (condition of joints, venting, evidence of leak ge,-et )
SEPTIC TANK:_
(locate on site plan)
r�
Depth below grade:
Material of construction: /concrete _metal _Fiberglass _Polyethylene _other(explam)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(yes/No;
Dimensions:
Sludge depth-
Distance from top of sludge to bottom of outlet tee or baffle: 7-'t-
Scum thickness A/GMG-0-"
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outl t tee or ba le:_��
How dimensions were determined: J`I.ele— — rcv- L
Comments:
(recommendation for pumping, condition of inlet o let t or baffl s epth f liquid level n relati n too tlet invert,6t ctpral
integrity, evidence of leaks , etc.)
Uz keZ XIIEU,,'441�1
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of constr ion: _concrete _metal _Fiberglass _Polyethylene _other(explain)
D nsions:
Scu hickne s:
Distance top of scum to top of outlet tee or baffle:
Distance o bottom of scum to bottom of outlet tee or baffle:
Date of t pum
Co nts:
(re ommendation for pumping, conditio f,inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Property Address;
SYSTEM INFORMATION (continued)
O%A ner;
Date of Inspection:
TIGHT OR HOLDING TANK: Tank must /
(locate on site plan; Pumped prior to, or at time, of inspection)
Depth below grade: yy��
Material of constru o Oncrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacm-:�_ g Ions
Design flow: ga s da
Alarm level. Alarm in orkmg order Yes; No
Date of previous pumping
Comments:
(condition of inlet tee, conditi0 of alarm an loaf switches, etc.)
DISTRIBUTION BOX:-y—eS, 00
(locale on site plan; //
16 X(b), �k. , eE L
Depth of liquid level above outlet invert:� Q�W
� _ Rya,�7si237
Cc ents m
(no e if level and distribu i is equal Eiden of so liar G oll G
fie , r over evid ce (IQ kage into or ou of box, e(�c.) k Q
PUMP CHAMBER 21,"�/// "/ v'K/ �(J�iG �,r�t�d(
(locate on site plar(� A
Pumps in king order: (Y or No)
Alarms in wor order es or Nor /
Comments:
(note condition of p p c r, condition of pumps and appurtenances, etc.)
I
(revised 04/25/97)
Page 7 of 10
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: / GG /
Owner: S
Date of Inspection:
,�o)(
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 prese t, explain:
" ® ,
ct _
Type:
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:---�—
leaching fields, number, dimensions:_ t,.lye',S 24, X l;, .3 ZpO�pe ,
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS:
(locate on site plan)
Number and configuration-/
Depth op of liquid to i et invert:
Depth o lids layer-
Depth of scu v
Dimensions of c sp
Materials of co struction:
Indication of groundwater.
inflow (cesspool must be pum d as pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: JV
(locat on site plan)
Materia f con ruction:
Depth of s Dimensions:
Comments:
(note condition of so' igns of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page a of 10
FILE# d/2®
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r� SYSTEM INFORMATION (continued)
Property Address:?/6m 76wa "J ''
OK ner: a
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent refererrcey-[arnfma enchmarks
locate all wells within 100' (Locate whey p blic ater supply comes ' house) 70WA/
/ sI Gt,lt}��� Nawe-[-L
�Avip', N(S (D
°Tc/V
i
/,OSi
SWIM
TbOL
Ce
w�
(revised 04/25/97) Page 9 of 10
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Amen 0*0_'
Owner:
Date of Inspection: � �12ea�tTdt;j�C� ,r ��
Depth to Groundwater /J Feet
Please indicate all the methods used to determine High Groundwater Elevation:
O ained from Design Plans on record
✓Observation of Site (Abutting property, observation hole, basement sump etc.)
V Determine it from local conditions
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)
wo a fv
(revised 04/25/97)
Page 10 of 10