HomeMy WebLinkAboutTitle V Inspection Report - 846 CHESTNUT STREET 10/24/2005 ri� f
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% TITLE V INSPECTIONS
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Dean G. Luscomb II & Sons
P.O. Box 135
Middleton, MA 01949
978-774-4065
Licensed Plumber#20285
SUBSURFACE SEWAGE DIST'OSAL SYSTEM INPSECTION FORM
ry
'j PROPERTY OWNERS NAME )Ci F)
W
PROPERTY ADDRESS / .
n c)
ADDRESS OF OWNER(if different) "X>0 y
DATE OF INSPFCTION C�. f B
NAME OF INSPECTOR .(r ,,... _., o � ,�,,..) ...
0
QUALITY IS NUMBER ONE TO US
%ii
aMNIONWEALTH OF SACHUSET Ts
xECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS
tl
DEPARTM,NT OF ENVIRONMEmrAL PROTECUON
F
DEAN G LUSCOMB II & SONS
5" P.O. BOX 135
MIDDLETON, MA 01949
1-978-774-4065
TITLE 5
OF'F'ICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTII+ICATION
Property Address:4(=, Chef-jbl,.t.f at ,
H, A r,dDye i- MA
Owner's Name: Gard i Ke.1:}'C.20
Owner's Address:.'"".mq"/
Date of Inspection:L-2!Z-`P"(2 b p_C Q 1.
Name of Inspector: (please print) Dean G. Luscomb II
Company Name:Dean Q. Luscomb II & Sons
Mailing Address:P.O. Box 1 3 5
Mi ddl Pfinn MA 01 949
Telephone Number: 97 —7 7 4-4 0 6 5
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 the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further.Evaluation by the Local Approving Authority
Fails
/N
C A �
Inspector's Signature: �, . �� �r - :�t ,+ hate: _.
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flaw,of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does riot address how the system will perform in the future under the same or different
conditions of use.
1
ueait uo vusc;cxuv 11 6E .5VI1`S
P.O. Box 135
Page 2ofII ' Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: g (0 CkC1:S+n LI S+
N. A.r,dever. MA
OWner:13�el+nn
Date of Inspection: I tJ
Inspection Summary: Chec"B,C,D or E/ALWAYS complete all of Section D
A. System Passes: tt ✓✓
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
Existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 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
ND explain:
2
Dean G. Luscomb II & Sons
Page 3 of 11 P.O, Box 135
Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: '�y (� C k e S4 h u-+ +
NI Ahdpt)Pr MA
Owner:
Date of Inspection: ! a
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 public health,safety or 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 manner which will protect public health,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 any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
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.
All The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
/) The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,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,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3.-- Other:
3
_ Uelwl U. UuIt-"Ru 11 Ot JVlib
P.O. Box 135
Page 4 of i 1 Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) ,
Property Address:?y (z� LZ�
� �1�IP� �pf
Owner:S k e-1°[ r-
Date of Inspection: L4 D
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
/0 Backup of sewage into facility or system component due to 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
A Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow
10_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped .
_ P-) Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of 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 1 of a public well.
_ /J 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. [This system passes if the well water analysis,
performed at a DEP certified laboratory,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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
/Ud (Yes No The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
Large Systems:
To considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd.
You must indic either"yes"or"no"to each of the following:
(The following critcn =400feet s in addition to the criteria above)
yes no ,--''
— the system is w face�drinkin�g water su pply's
the system is within 200 feet of=sensitive u 'ur�f/c/e drinking water supply
the system is located in a nitr a(Interim Weith=significan IWPA)or a mapped
— — y �g
Zone II of a public wat upply well
If you have
an were " es"to any question in Section E the system is conmeat,or answered
"yes"in Sect io above the large system has failed.The owner or operator of any large system cor�idered a
significant-t eat under Section E or failed under Section D shall upgrade the system in accordance with 3 -CMR
15 304'The system owner should contact the appropriate regional office of the Department.
4
vecul U. C,USCYJnIU 11 & JUILS
P.O. Box 135
Page 5 of 11 Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: gy (a Lh S4r) °f'
LJ r M A
Owner: (�I
Date of Inspection: JQ1Qqh5
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes o
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection'?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
jWas the facility or dwelling inspected for signs of sewage back up?
11' — Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
jZ— Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of'the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Jz_ Existing information.For example,a plan at the Board of Health.
�_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[3 10 CMR 15.302(3)(6)]
5
Ut!cul h.Lu jULAIU.I 11 Ot oull,
P.O. Box 135
Page 6 of I 1 Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: y Ch es hn
r M�9
Owner: 1+
Date of Inspection: !
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 7` Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage igrin e or no):yCS
Is laundry on a separate sewage systemdEe no): t fS[if yes separate inspection required]
Laundry system inspected y or no):k
Seasonal use:(yes or
Water meter readings,if available(last 2 years usage(gpd)) t�
: dawn x1--v r
Sump pumpCyesir no): ,S
Last date of occupancy:
OMMERCIAL/INDUSTRIAL
Type tablishment:
Design flow on 310 CMR 15.203): gpd
Basis of design flow / ersons/sgft,etc.): �-
Grease trap present(yes or no .
Industrial waste holding tank present no):_
Non-sanitary waste disch o the Title em(yes or no):
Water meter rea if available:
Last date.9n ccupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N°nip-,4i,ir ,(e6p.,--cfS
Was system pumped as part of the insp ction(yes or no):.�c-s
If yes,volume pumped./OJ gallons--How was quantity pumped determined? {-
Reason for pumping:
i
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)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date instal ed(if known)and source of information:
ZV 1 s7llh�cZ-�eca dtrr� � �r'
Were sewage odors detected when arriving at the site(yes oap)) /4✓�
6
LX�c3i1 U. tJUSL.LXtIU 11 a
P.O. Box 135
Page 7 of I I Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:g y (o C,k e—"-S4 h (.(4
Owner: ��e1 pl. �r,doyP T�
Date of Inspection: 10 I.t,) n
BUILDING SEWER(locate on site plan)
Depth below grade: —As
Materials of construction: ast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.): /
SEPTIC TANK:/ (locate on site plan)
<u
Depth below grade:
Material of construction:—concrete metal fiberglass_polyethylene /
_other(explain) `(�rec -� cW�+1 G�� GDU
If tank is metal list age:A�/—h Is age confirmed by a Certificate of Compliance yes oro :,J(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:-/4;;,
Scum thickness: IS"
Distance from top of scum to top of outlet tee or baffle:
�r
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: e
Comments(on pumping recommends ons,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
-g�
f
/��✓ems/1//l la 'rr"S` d/ v !'/ S�r L/ /1 ��°LrL'r'Q� flsiC [ / �[{i /iI /Y'C[
GREASE TRAP: (locate on site plan)
Depth bervo -g de:
Material of construe► concrete_metal fiberglass_polyethylene—other
(explain): _
Dimensions:
Scum thickness:
Distance from top of scum to to et tee or baffle:
Distance from bottom of to bottom of out tee or baffle:
Date of last pumpin
Comments oU`mping recommendations,inlet and outlet tee or baffle condifibrt,.,structural integrity,liquid levels
as relate duo outlet invert,evidence of leakage,etc.):
7
vCcul V. LjU.!:)t.\AIIV 11 Ct .7tJlib
P.O. Box 135
Page 8 of I 1 Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:g\1 k
h f
Owner:
Date of Inspection: )0
TIGHT or HOLDING TANK:/Uo(tank must be pumped at time of inspection)(locate on site plan)
Depth bel ww ggr'8da:`
Material of construction:a,concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons--y"
Design Flow: -Qa Ions/days
Alarm present(yes or n),-`
Alarm level: ."`Alarm in working order(yes or no):
Date of last-pu p:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:Ye-S(if present must be opened)(locate on site plan)
re
Depth of liquid level above outlet invert: Ze-17
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): ��--- / // 1
erleRld Gc)n,(ii(on /K;-7 ll Eric in �G o �-Be � �'ltn�9/ � �A
® s
&AI TIN f � . n (fir
PUMP CHAMBER: /"locate on site plan) .
Pumps in working ore es or no):
Alarms in working order(yes or n
Comments(note condition of pump chamber,cent s and appurtenances,etc.):
ueai1 lie LLLsL' xttu 11 Oc. JLJ11D r
P.O. Box 135
Page 9 of 11 Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3H(VI
Owner /
Date of Inspection: ZJ
SOIL ABSORPTION SYSTEM(SAS): :� (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
✓leaching trenches,number,length: ��fr� [�r h �� "1 U App�ok• ^�
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc. .
S7T��v /S t h �'Clo� Cj�+'}jQfGi[ t�aokl��iC�fh Z.nd� �/� �l��.� ol° t?f)l7cY '`/']4` �!'A �✓'�C�lGt9�v
CESSPOOLS: /- (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: - 14y>% fir'
Depth-top of liquid to inlet invert: l
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: 1PiVX skon-
Indication of groundwater inflow(yes mop
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
7�wipp`e Gre no Signs o7 c,i4 1h -ts M. i,,
L� �"l���t� Q•"t<;t{ dam;•--:•� ,
PRIVY:/',)9 (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition-osod;s gn of f hydraulic failure, level of ponding,condition of vegetation,etc.):
9
. Uc A
P.O. Box 135
Page 10 of 11 Middleton, MA 01949
1-978-774=4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: L h(L7
}�I. Ar,dnvr,-r,, M
Owner:n
Date of Inspection: 10 D L4
SKETCH OF SEWAGE DISPOSAL SYSTEM /
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or /
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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_. 10
Pagel] of 11 P.O. 'Box 135
Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: g+
Owner:
I��I �?�ri mA
Date of Inspection: I D
SITE EXAM
Vglope
t Aurface water Pc=rt {
P"Check cellar ,
�--'Shallow wells Poo-z—,
Estimated depth to ground water 5 l feet
Please indicate(check)all methods used to determine the high ground water elevation:
_Obtained from system design plans on record-If checked,date of design plan reviewed: IJ-1
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain: k),, Z/�e a�, 10 S
Checked with local excavators,installers-(attach documentation)
G' Accessed USGS database-explain: 1®i2_s�W_�4
You must describe how you established the high ground water elevation:
_
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. V INSPECTIONS
,. Dean G- Luscomb li & Sons
ref FO. Box 135
i iiddleton MA 01949
,
-978-774-4065
AAA �•� ����
1 i. E �SE
PLUMBER #20285
_ NNI
Al
UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTlOI� FORM
`'
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PROPERTY OWNERS NAME: o n 14( �t
PROPERTY �4DDRESS:
S� .
ADDRESS OF OWNER: ;�f n�----�����(®�') �� < �
{i different)
DATE OF INSPECT1Oiv: JY (: r C_h 6—A
NAME OF INSPECTOR:
Q U•A L I.T Y IS N U.M.B.E-R. O N.E TO. US