HomeMy WebLinkAboutTitle V Inspection Report - 351 REA STREET 6/2/2003 11MV
COMIVIONWEAl.,TI-1, OF MA.` I(N11,111y,
f I L EM
EXECUTIVE OFFICE' OF ENVIRONMENTAL AFFAIRS
DEPARTMENT ciii, ENVIRONMENTAL PROTECTION
A I
TITLE 5
OFFICIAL INSPECT ION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Properly Address:
Owner's Name:
Owner's Address:
Date of Inspection:
Name of Inspectoij (pleas( pi i lt)k)L `u t
`L u�-
Company Natue: I
Mailing Address:
Telephone Number:
CE11TI F1 CATION 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 lily
training and experience in the proper function and maintenance of oil 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:
csses
1,
onditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspectoj•'s Signatui-e: Date:
The system inspector shall submit a copy of this inspection report to the A
DEP)within 30 days of completing this inspection, If the system is a shark
gpd or greater, the inspector and the system owner shall subinit the report
DFP.The original should be sent to the system owner and copies sent to ti
authority.
Notes and Comments
****'Phis report only describes conditions at the time of inspection and
time. This inspection does not address how the system will perform in
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
mf | |^°
,Page 2 OFFICIAL &NSPECIJON FORM — NOTFOR VOLUNTARV ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART /&
CERTIFICATION (continued)
Property,Address:
Qv,nen
Date o[Inspection:
lxmpechooSummary: ^Ckcck A.D,C,Dor0/ALWAYS complete all u[Section Q
A. System [lasses: �
| buvcno( kmndunyin/hmnoLionwhiohinJiooteoiha(anyo[(kcCaUmcch»eriadexcrib«din3!0CK4K
|5.3O] or ill 3\0CkJK |5.3O4 exist. Any failure criteria riot evaluated are indicated below.
Comx`mnts
B. system CnndidouuUyPasses:
r more system components oy described in the"Conditional Pass"section need hm6o replaced cx
repaired.'I'lic system, upoll completion of(lie replacement or repair, as approved by the Board of Health, will pass.
Answer yes,nnnrno�d�(onn�cd(Y]N,N[Vio(bo for the �
. � �
explain.
The septic tank is nietal and over 20X, _qW the �
septic tank(whether metal or not) h structurally
Wsound, exhibits substantial infiltration r ex�Rtrati 11 tank failure is imminent, System will pass inspection if the
(Le 2f —j
existing tank is replaced with a complying scjitic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, riot 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 cvbreak out orhigh static water\ovc| in the distribution box due to broken or
4A
obstructed pipc(s)or due to a broken,settled or uneven distribution box, Systen) will pass inspection if(with
approval of Board oyHma|ih): '
'
broken pipc(u)are replaced
obstruction |oremoved
---
distribution box im leveled nrreplaced
ND explain:
�hcsyx�mruguimdpumping moothan 4hmomx year due\o broken nrn6stmuteJpipe(s).The oy*cmvvU|
'uaxioapcu|ion|[(widhuppomvu|nkbeHumndo[8oukb):
broken pipc(s)are replaced
Al obstruction iyremoved
-�-~-
ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM m NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART A
CERTIFICATION(continued)
Property Address: 3:5-1 R-0,3
Y2 6 � P\r�r�p uLS T i_Y1
Owner:
Date of Inspection: _6 '
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,
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic 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
Page 4 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI
PART A
CERTIFICATION(continued)
Property Address: (S
M III_
Owner: Y r, ,5
Date of Inspection: -� 3
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
__v°bischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
L,-" Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_J 'Liquid depth in cesspool is less than 6"below invert or available volume is less than %: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 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
_t, Any portion of a cesspool or privy is within 50 feet of a private water supply well
_ _Lf—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. IThis 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.]
_(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.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 lI of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:3. 1 C j
Owner: ✓{6e-S
Date of Inspection: 4 3
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
/ =I-YlS�a1�c� Q00 IZ Were any of the system components pumped out in the previous two weeks?
1Z_ 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?
t/ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
4/ Was the site inspected for signs of break out?
Were all system components,excluding the SAS, located on site?
t/ 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 ?
_ 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 Xo
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Pail C is at issue approximation of distance
is unacceptable) [3 10 CMR 15302(3)(b))
5
Page 6ofII
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: y J _C,
Owner: Y, , ,✓� (del.S
Date of Inspection: -
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): Y-116
Number of current residents:
Does residence have a garbage grinder(yes of no
Is laundry on a separate sewage system(yes or no):QjL,� [if yes separate inspection required]
Laundry system inspected(yes or no): —
Seasonal use: (yes or no :_per \ '
Water meter readings, if available(last 2 years usage(gpd)): I��c \� tg)Je V '-Y�V—e
Sump pump(yes or no):�W
Last date of occupancy:C I c*ce�V+
COMMERCIALANDUSTRIAL
Type of establislunent:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
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, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records l `
Source of information: � LYA�i C,
Was system pumped as part o the inspection(yes or no
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_�eptic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_ Privy
fjj�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 installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or.W::M
6
Page 7 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: '6-/ S
C
Owner: 1, l-r/)1P !S
Date of Inspection: �Q-Q,.3
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron 1,-14'0 PVC_other(explain):
Distance from private water supply well or suction line:
Comments on condition of joints, venting,evidence of leakage, etc.):
'tr:,An no e y', n c o rX
SEPTIC TANK:�ocate on site plan)
Depth below grade:_1,5
Material of construction: ►✓Eoncrete_metal_fiberglass____polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: -
Sludge depth: moo' .
Distance from top of sludge to bottom of outlet tee of baffle:3Q
Scum thickness:_ "�
Distance from top of scum to top of outlet tee or baffle: I +
Distance from bottom of sctun to bottom of outlet tee or baffle:
How were dimensions determined: T(1 I)g Yy_o A,.S t I C 0
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:n (locate on site plan)
Depth below grade:—
Material of constniction:_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(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: J6 j )
` n
Owner: Y-1
Date of Inspection:
TIGHT or HOLDING.TANK: iia (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity:---gallons
Design Flow:_ gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Conunents (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: t-�(ifpresent must be opened)(locate on site plan)
Depth of liquid level above outlet invert: J
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.):
As
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
8
Page 9 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3S-1 f-� a v d-
no , AnnnQe r/.
Owner: Igo
Date of Inspection: (,, 5 -03
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:
i/ 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.):
Nn
CN= 1)
CESSPOOLS:tguration:cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and con
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scu►n layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: �t(locate on site plan)
Materials construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
Page 10 of I I
OFFICLAL INSPECTION FORM[ — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM[
PART C
SYSTEM INFORMATION(continued)
k r
Property Address: 35_� �pr;
Owner _
Date 61 Inspection: - .3
c,J' 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 loo feet. Locate where public water supply enters the building.
r.
�. SKr,• ;�- �
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7736.00'70,
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C1 S 12' MCN
F.�.s67.49 USCS
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t00 F7 wr"ffos pwrf� ION
TTaTG- AfIS RAN 15 JV0 r A 14lRRAA
10
Page I I of 1 1
OFFICIAL INSPECTION FORM M —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
1 ,0 � rr\ps�T
Owner: K fc)e S
Date of Inspection:
SITE EXAM
Slope 0 own can 3 .51("s
Surface water ",Iv iron
Checkcellar c.\(,y no �v rr� �
Shallow wells ,�;�
Estimated depth to groundwater L/ feet
Please indicate(check)all methods used to determine the high ground water elevation:
L.-'Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet pf SAS)
L,-"Checked with local Board of Health-explain: IEO_V)' Ul yr
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
Y�o_u�m�usst describe how you established the high ground wat r elevation:
I1