HomeMy WebLinkAboutTitle V Inspection Report - 50 HAY MEADOW ROAD 1/20/1998 �m
107 Forest St. FILE#
Middleton,MA 01949
(508)774®2772
& DRAIN
VICE
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNER'S NAME: MA r oe
/:�-o t4o, j 'q A/ IWIbvek
PROPERTY ADDRESS:
ADDRESS OF OWNER:
(if different)
DATE OF INSPECTION: '(� /
NAME OF INSPECTOR: (
THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY
107 Forest St. FILE#" •2„Q
Middleton,MA 01949 - -•
(508) 774-2772
Cl� SEPTIC & DRAIN
Ailliff
SERVICE
iI I��
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: /I /raouafoS Address of Owner:
Date of Inspect'
on:�O d 7)1o0X4&W, (If different)
Name of Inspector:
1 am a DEP appWicriffste t c op pursuant t Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: C r @ /►/
Mailing Address:
Telephone Number: ji
CERTIFICATION STATEMENT
I cenify that f 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:
K Conditionally onuonalh• Passes_
Needs Further Evaluation By the Local Approving Authority
_ Fail
Inspector's Signature: Q."w date: � I.
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 authority.
INSPECTION SUMMARY: Check A, C, or D:
AJ SYSTEM PASSES:
A/O I have not found any information which indicates that the system violates any of the failure criteria as defined 16�310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BJ 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.
v 06YL Z1z d cep.mat
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination an 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 Wide Web: httpJnvww magnet.state ma.usldep
0 Printed on Recycled Paper
poppow,
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: �Ik Mz4 w Al•
Date of Inspection: �� /��t;L f/z,/
Bj SYSTEM CONDITIONALLY PASSES icontinued
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
r
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' T
obaruction is removed y '' J� f '/ ,¢���/jL,�✓]2r,
distribution box is levelled or replacedy�
/vr✓� The system required pumping more than four tines 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 1S 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 tailing 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:
C end=or pion; t--withim so fees 0i a swsface vases
a1 a toare;C ng we+taoo C!tvr x salt"Wov,
2) M WILL-f-AIL1)%UE 5-1HE'8DMM OF"EAt?ti (ANDYUBUCWXTMSL"11MW M►mDmix-'MVMRMINMTHXT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
VThe system has a septic tank and soil absorption system (SAS) and the SAS is within 10 0 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 supnly'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
1
(revised 04/45/97) Page 2 of 10
FILE# t2,`,2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO.% FORM
PART A
CERTIFICATION (continued)
Propertv Address:
Owner:
Date of Inspection:
D SYSTEM FAILS: ''af I RSv
Y'ou st 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 s
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to come^
the failure,
Yes No
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 o•
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 112 day flov,.
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.
_ Anv portion of a cesspool or privy is within 100 feet of a surface water supple or tributary to a surface water supply.
_. Any portion of a cesspool or privy is within a Zone I of a public well.
Any port ion of a cesspool or privy is within 50 feet of a private water supply well.
Am,portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water suppiv well with r-3 acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copv of well water analysis fo-
coliiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
VO 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:
The system serves a facility with a design flow o 0,000 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 surface drinking water supply
the system is within 2 feet of a tributa a surface drinking water supply
the system is located in a nitrogen sensitive area ( erim Wellhead Protection public water supply well) on Area- IWPA) or a mapped Zone 11 of a
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 04/75/97)
Page 3 of to
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ti' I
aoo FILE# / Z,I R
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: �� ` / /7w dw
Date of Inspection:
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 e 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.mi ed. 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 "as inspected for signs pe g s 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 facilav owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. E . Plant B.O.H.
Determined-in the field iif anv of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) 115.302(3)(b))
I
(revised 04/25/97) Page 4 of 10
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FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Propert► Address:
Owner:
Date of Inspection:
RESIDENTIAL: FLOW CONDITIONS
Design flow •p broom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage gr,:.der(Yes r no!:
Laundry cor eked t system (ye or no):____
Seasonal use ryes orn _
Water meter readm rt available (last two (2)year usage (gpd);
Sump Pump Ives no)• �
Last date of occupancv:,C&rh`A4
COMMERCI AIIINDUSTRIAL:
Type of establishment:
Design flo►v. allons/dav
Grease trap pr ent: (yes or n _
Industna! Waste ding Ta - present: (yes or no?
Non-sanitary Haste di • r to the Title 5 system: (yes or no)
Water meter.readings, if ble
Lastpate of o-cupancv
OTHER: (Describe
Last date of occuoanc-v
GENERAL INFORMATION
PUMPING RECORDS and source of informal
System um q 7.
p ped as part of inspection: ryes or�o)
If yes, volume pumped: gallons
Reason for pumping
TYPE YSTEM
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)
I/A Technology etc. Copy of up to date contract?
Other
1
APPROXIMATE AGE of all components, date installed (if known)and source of information:
Ruts 9c.1)
Sewage odors detected when arriving at the site: (yes orP : .
(revised 04/25/97)
Pegs s of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM [. FILE# 0/ 'Z0CJ
PART C
SYSTEM INFORMATION (continued)
Property Address:
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 list
Diameter 7-I/
Comments: (condition of join venting, k ge,,et )
SEPTIC TANK:_
(locate on site plan)
Depth below grade:r r
Material of construction: i�Concrete —metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age
8 Is age confirmed by Cenificate of Compliance (Ye5/Ivoi
Dimensions: t- /N "/ff
Sludge depth-
Distance n
from TOP of sludge to bottom of outlet tee or barfle:�'f:
Scum thickness IOAte_4-1'
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 r/
How dimensi ��
ons were determined: �j�',,
Conmencs: --
6�
(recommendation for Pumping,
condition of inlet o let t
integrity, evidence of leaka , etc.) or baffl s epth liquid level 'n relati n to o tlet invert,it ct ral
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 baffler
Distance o bottom of scum to bottom of outlet tee or baffle;
Date of t pum .. —
Co nts:
(r° ommendation for pumping, conditio Linlet and outlet tees or baffles, depth of liquid level in relation integrity, evidence of leakage, etc.)
t on to outlet invert, structural
r
(ra-ined 04/2i/97)
Page 6 of 10
FILE# A0 IZO X,�'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
OH ner:
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: pp��
Material of constru o ancrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: _ ga Ions
Design floe: ga s%da
Alarm level. Alarm i •orking order_ Yes; _ No
Date of previous pumping-
it,
(condition of inlet tee,'conditi of alarm an loaf switches, etc.)
DISTRIBUTION BOX: CS,
(locate on site plan.
Depth of liquid level above outlet invert:_ Q�
Comments:r �y
(note if
LO(It level and distribu ion i�q al e(,iden of so i r ovt?r evid ce of I kage into or out of box, etc.) k IS fT
41 PUMP CHAMBER ZI XZ� 0-
(locate on site pla ) M O,/L &Ir
Pumps in king order: (Y or Not
Alarms in wor order es or Not
Comments:
(note condition of p p c r, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Pays 7 of 10
FILE* ��ZQ6O
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
417
SOIL ABSORPTION SYSTEf�1 (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;
Mang charnbers, number-
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions: / --// ,n��
overflow cesspool, number: �/ X G3 / 4l ZO01 ,
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation et
CESSPOOLS: /V
(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:
ndication of groundwater:
inflow (cesspool must be pum d as part of inspection)
omments:
cote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.
fl/Y:
at on site plan)
Trial f con ruction;
th of s
ments: Dimensions:
condition,of s igns of ,
level of hydraulic failure ponding, condition of vegetation, etc.) r
isd 04/25/97)
Pay a of 10
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FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Oµner:
Date of Inspection
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reierEnreytandma nch marks 7oWnJ
locate all wells within 100' (Locate wh� p blic ater supply-comes '�house) Gt.��G Na wcLL
N1S U'
chq-ir.1 lrnr/�..
&0JAL P( reNCG r1,d6,jcS
Tb M
IS Slops
1
~T
/
to 16J GJ
f(saviaad 04/25/97) Page 9 of 10
FILE#
SUBSURFACE SEWAGE DISPUSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner. � % LGaffl0A
Date of Inspection: �
Depth to Groundwater /V Feet 7- r
Please indicate all the methods used to determine High Groundwater Elevation:
�Ojuained 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)
tt. �+�
��rtl Wvte sn�d Ivy - 12
(revised 04/25/97) Page 10 of 10