HomeMy WebLinkAboutTitle V Inspection Report - 10 OLYMPIC LANE 5/27/1998 I
1QT Forest St, ---_.-._--
Middloton,MA 61949
(508)774-x772
AIN
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORh1
PART A
CERTIFICATION
r� , /,v �VAAkn Owrr
Property Address: Address of Owner:
Date of Inspection: �� x r/ (if different)
Name of Inspcctor:
1 am a pEP approved system ipcpet'to, pursuant to Section 15.330 of Title 5 (310 CMR 15,000)
Company *tame: /
Mailing Address: YSS
Telephone Number: 9 -4=7,7-7-
CERTIFICATION STATEMENT
I cert;f) that I have personally inspec'ed the seµage disposal system at this address and that the information rcported below is true, accuraii
and complete as of the time of;nspect;on. The inspection was performed basecs on ow training and expi<r;ence to the proper function and
maintenance of on-site sewage disposal systems. The s.stkm:
_ Passes
_ Condil;oral \ Passes
'tieeds -vrther E%af,,at;on By the Local Approving Awhor,t>
Faris
I .
Inspector's Signature 7?I � a Date,
The Svstem fnspecior shalt sub-ii a copy of this inspection report to the Approving Authority• within thirty 130i days of completing this
nspection. U the system is a shared wstein o, has a design now of 10,000 gpd or greater, the inspector and the system owner shalf submir
the report to the appropriate reg;or;ai oii;ce of the Department of Environmental PrOtect;or; The original should be sent to the system ohnt
and Copies sent to the buyer, if 2Polieable, and ine approving authonn.
INSPECTION SUMMARY. Check A, B, C, or
Aj SYSTEM PASSES:
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.
COMI.4ENTS:
131 SYSTEM CONDITIONALLY PASSES:
f
One or more system components as described in the "Conditional Pass' w(iion need to be replaced or repaired. The system, upo
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate no, or not determined (Y, N, or NO). L)escribe 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 (attachedl indicating that the tank was installed within twenty (20) years prior to the date of the inspection; of
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, pr-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.
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FILE#
0 a2 V 9,M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: la 0/,V WYC l,✓
Owner: J-rela) W
i
Cate of Inspection: J a
lv4y !C 9'?
6) SYSTEM CONDITIONALLY PASSES icontinued,
Se�sage backup or breakout or high static water level observed in the distribution box is due to broken or db4li j(',ed
p peis) or due to a broken, settled or uneven distribution box. The system will pass lnsptction if (with approval
Board of He i ). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system requirr6 pumping more than four times a year due to broken or obstructed pipe(s) The System wdi pass
Inspection ii(w th approval of the Board of Health):
_ oroken pipe(s1 are replaced
I_ oostruction is removed
Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH,
Conditions exist which reauire further evaluation by the Board of Health in order to determine if the system is fading to protect th
public health, safery and the environment.
11 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
N/
Cesspool or prise• is within 50 feet of a surface water ;•
Cesspool or pnv) is within 50 feet of a bordering vegetated wetland or a Salt marsh.
7) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THA
THE SYSTEM 15 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 sur-ace water supply c
tributan, to a surface water supply.
The system has a septic tank and soil absorption system and the $AS is within a Zone I of a public water supn'v 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 th
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to
less than 5 ppm. Method used to determine distance _(approximation not valid),
3) OTHFR
(revived 04/25/97) Page 2 of IO
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i
SUBSURFACE SEWAGE DISPOSAL SYSTEM IN'SPECTIO% FORM
PART A
CERTIFICATION (continued)
Property Address:v
Owner; ']-fit
Date of Inspeclion: j A14y 9 d Ct'
D] SYSTEM FAILS:
Yo U rr ,, indicate either "1 es or "No' as to each of the follo-.%,:ng:
/ '` I nave determinec that the system violates one or more of the following failure criteria as defined in 310 CMR 15 303 The oas
-70 for this determination is identi(ed below. The Board of Health should be contacted to determine what vili be necessary to cvrrK-
the failure.
Yes NO
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
A/ Oischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS e-
cesspooi
_ 5wic liqu.d level in the distribution box above outlet invert due to an overloaded or cloggea SAS or cesspool
T I r4 Liquid depth in cesspool is less than 6" below insert or available volume is less than 112 day floe,
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe:s-
Number of times pumper
km port on of the Soil Absorption System, cesspool or privy is below the hign groundwater elevalion
Any port on of a cesspool or privy is within 100 feet of a surface water supp!\ or ;-ibutan to a surface ssatet suppl)
Any port.on of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 fret of a private water supp!v ssel'
Anv por,:on of a cesspool or privy is less than 100 feet but greater than 50 feet tram a private tvaii:r supply well with rc
acceptable water quality analysis If the well has been analyzed to be acceptable, attach Copp. of well water analysis io-
colitorm :,acleria, volatile organic Compounds, ammonia nitrogen and nitrate nitrogen
�i\IIGE TEM FAILS;
cate either 'Yes' or "No" as t9.,each of the following,
following criteria apply to II tge systems in addition to the criteria above.
system serves a iaci ,ptvit h a design flow of 10,000 god or greater (Large System; and the system .s a significant threat to
kc,health and saiet and the environment because one or more of the following conditions exist-,
Yes No
th� sstem is within 400 feet of a surface drinking water supply
% the syst�T is within 200 feet of a tributary to a surface drinking water supply
zowne, the system i3 ocated in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone 11 of a
public water s ply welt)
/requirements perator of any such Sy t m shall bring the syglern and facility into full Compliance with the groundwater treatment program
of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised oU25/M Papa 3 of 10
F I L r# '7 j it
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FbR,%t
PART B
CHECKLIST
Property Address:I�
Owner: �/e1Cy•/��
pate of Inspectio ;
!!7 �¢
, 4
Check if the following have been done. You must indicate either "Yes" or 'No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the System components have been pumped for at least Two weeks and the system has been receiving, normal
floe' rates during that period. Large volumes of water have not been introdvCed into the system rpcentl) or
/ as par, of this Inspection
As built plans have teen obtained and examined. Note if they are not available with N.'q
The iac l h or dttieli,ng v as m5peCia0 for signs of sewage back-up.
✓/ The system does not receive non-sanitary or industrial waste flow.
V The stte �%as inspected ror signs of breakout
r _ All system (cmponems. excluding the Sol Absorption System, have been located on the site.
The sept,c tank manholes were uneoverb-d, opened, and the interior of the"p6c lank was inspected for condition of
baffles or tee<_, material of consiryci on, dimensions, depth of liquid, depth of sludge, depth of scum,*
The size and Iocat on of the 5oit .Absorption System on the site has been determintcl based on.
The facihr• o",ner tand occupants, if different from 0-men were provided with mformat,on on the proper maintenance of
SukrSuHace Disposal System.
Existing tniorrnauon. Ex, Plan at B.O.H.
Determined n the field i r anv of the failure criteria related to Pan C is at issue, approximation of distance is
unacceptable; [15.302 31(b'r]
(rowed 0a/25/61) Pay 4 of 10
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FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM I'.SPECTIOI fpk.til
PART C
SYSTEM INFORMATlp`
Properts Address;
Date of Inspeclion: /Wy y
a Flow CONDITIONS
RED ENTIAL- �`l,
design fia\• /4- O ,p. "bo:-droom to, S.A.S.
Number of bedrooms -1
Number of current residents
Garbage g,, der (yes or no!.
laundr`• co--ecterl to systerr, ryes or no;
Seasonal use 'yes or na:W
Water meter readings, if available (last two (21 vear usage (gpd):
Sump Pump cues or no):A10
last date of occupancy. 60 i7
MM RCI kUUN USTRIAL;
TYp t estab!rshment
Design i v gallons<oa�
Grease traesen(: tees or no
Industrial k%as e,Molding Tan resent tees or no,_
!ion-Sdnrtar% t+afire,d,scnaar Cd to the Title j SvStPrn. tyes or not_
\'later meter readin� 41-ailabie
Last fla;e of o ann
OTHER; escr�be -`�
Last a of occupancy M�
GENERAL INFORMATION
PUMPING RECORDS and syf,e of tn!ormalion -
System pumped as part of m5peCion; (yes or no)_U0
If yes, volume pumped eailpr,s
Reason for pumping --
TYPt OF SYSTEM
SepaG tank/distribution box/sod absorption system
Stng)e cesspool
Ove,flow cesspool
Prrh•
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc, Copy of up to date Contract?
Other
APPROXIMATE AGE of all components, date installed (if known)and source of information: 6(0 � '/ ci✓;. n��
Sewage odors detected when arriving at the site: (yes or no)ACS
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FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO.N FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
dvvner: �
Date of Inspection: ��� Ca?
BUILDING SEWER: /
(Locate on site plan) .
i�
Depth below grader
Material of construction: �cast iron 40 PVC _other (explain)
Distance from private water supply well or suction h--,
Diameter �. r
Comments, (coed ion of)o nt venpg, evidence of leakage, et /
SEPTIC TANKAM
(locate on site plant
Depth below grader
ti1aterial or constrvction: /concrete metal _Fiberglass Polyethylene _other(explain?
If tank is metal, list age ^ Is age confirmed bv Cenrf'cate of Compliance —Nes/No,
park
Dimensions i
Sludge depth
Dislonce from lop ut sludge to bottom of outlet tee or baffle:
Scum thickness
Distance from top of scum to lop of outlet I" or baffle, 1
Distance from bottom of scum to bongm of outlet ee or bard I
How dimensions were determined,`' >r' Cl rOler-
Comments:
'recommendation for pumping, conditio of inlet and utlp tee or baffles, depth f Ii id level in relation to out) t invert, StruR
rote r'ry, evidence of leakage, tc P. J> y -
! �z r
Yi e
"G9 EASE TRAP; A10
(locate on site plan)
Depth belo grade:_
Material of co si<vction: __ co rele metal _Fiberglass °Polyethylene �other(explain)
Dimensions:
Scum thickness:.
Distance from top of sic op of outlet tee or baffle:
Distance from botlo of scum bottom of outlet tee or baffle: .
Date of last pump'
Comments:
lrecommendaS on for pumping, condition o in and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, e i{lence of leakage, lit.) _
;y
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51.JBSURFACE SEWAGE DISPOSA(, SYSTEM INSPECTION FOR',t
PART C
r SYSTEM INFORMATION (continued)
/c c` 2A)Property Address: /
Date of Inspection:
c� r7
GHT OR HQIDt!�tG TANf{: Wank mus puroped prior to,or at time, of inspectionl
rfo to on srte plan;
depth low grade.
matersal �construction _concrete metal _Fiberglass _Polyethylene _ ,Othr:r(explain)
Dimensions:
Capacity' g ons
Design slow. gallonsfda\
Alarm level !harm n -orkmg order _ Yes; No
Date of previous p -iptng
Comments.
(condition of t et tee, cond+ii(Nof alarm and float switches, etc.)
DISTRIBUTION BOx�
(locate on site plain
Depth of t+quid level above outset invert
Comments.
{note +t�,�,el•tnd drstnbutson ss ua(, evidence f sotsds Garryov ,evidence of akage, into or Pvi nb x, etc, —.
PUMP CHA ABER,.A
tale on site plan)
Pum in working Or ►. (Yes or N0l
Alarms working der (Yes or No, _
Comments:
(note conditi f pump chamber, condition of pumps and appunenances, etc.)
R
(=pviaod 041]5/97) Part• 7 of 10
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FILE# 5?'A /4 _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO`, FORM
PART C
SYSTEM INFORMATION (continued)
Property Address,
Owner: to
Daly of InspCOlon;27 /CIM 9g
SOIL ABSORPTION SYSTE (SA s);
(IoGate on site plan, if possible; exca aeon not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
~G�nS�t r
Type:
leaching pits, number^•_,
leaching chambers, number____
leaching galleries, number-
_
leaching trenches, number,length:
leaching fields, number, orrnensrons: X
overflow cesspool, nurnber.�
Alternative system; _
Name of Technology
Comments:
(note condition of so )si s of hydraulic failp re, level pf p %ding, coedit' of vegetation, ,c.; }I e _�} t t_�PWV� i K�r o 1 t� chi? ��-
7'7
WPOOIS:
( ,tale on site plan)
Num rand configuration-
Depth
-t of liquid to inle riven:
Depth of s'i�lds layer:
Depth of scvM,layer;!
Dimensions of c�y'IooL•_
naatenals of c rY�rtru` ion:
indication 0 oundw see _
�f 0w (Cesspo�{ must be pumped as part of inspection) _
�+ L
Comments:
r (note condition of soil, signs of hydrae lic failure, level of ponding, Condition of vegetation, etc.)
IYY:
(! Asite plan)
material constr ion! Dimensions:
Depth of solids
Comments)
(note conditi ohtyoil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) —
s
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SUBSURFhCE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM 1'�FORNLATION (continued)
Prppertl Address., �C7 al�i�' Pl C--
O»ner: :,G—£fapD/
Date of Inspection-
SKETCH OF SEWAGE DISPOSAL SYSTEM;
include ties to at least two permanent references landmarks or benchmarks
iocat� all Wells within 100' (locate Where public water supply comes into house)
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LFILE4
SUBSURFACE SESVAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ � SYSTEM INFORMATION (continued)
Property Addrrss:IQ
0-,A ner: rtaI7
Date of Inspect-
ion:
27
Depth to Groundwater �?Feet
Please indicate all the methods used to determine High Groundwater Elevation:
NAObtained from Design Plans on record
Observation of Site tAbuttmg observation hole, basement sump etc.)
✓ Determine it from local conditions
Check with local Board of health
Check FEMA Maps
r� Cheek pumping records
Check, local excavators, instatlerS
Use USGS Data
Describe in your own words how you estabolt hed the High Groundwater Elevation. (Must be completed)
"YAW,
(roviood 09/25is7) POW* 10 of ao
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