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HomeMy WebLinkAboutTitle V Inspection Report - 1005 FOREST STREET 11/7/2017 Commonwealth of Massachusetts i"i1off.i Executive Office of Environmental Affairs Department 'of Environmental Protection #' Wllllam F. Weld } Trudy Coxe Gowmor A< so Paul Ceilucci SecreFary 9 bavld S. Struhs U,povemor Commiu,one1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATI N Property Addres ��J ���� s O d'-dress of Owner. Date of Inspeotion: �� "� �`� (if different) Name of Inspector. e`� , ales Company Name,Ad cess end Telephone Number. BATESON ENTERPRISES, INC. TEL:1508)a-5.F4-4 Excatatlnq•Water S Sewer tFnes-iepVc Systems&Pumping Service FAX:1705)4-3-54'"1 !1 1 Argilla Road N Andover,Mass.01810 CERTIFICATION STATEMEN 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-mite sewage • posal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority F Inspector's Signature: c ate: " The System Inspector shall ub 't a cop 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, B, C,or D. AJ SYSTEM -; 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, BI SYSTEM CONDITIONALLY PASSES.- One ASSES:One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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, 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 ponfornung septic tank as approved by the Board of Health. 3 (revised 11/03/45) 1 One Winter Street • Boston,Massachusetts 02108 .e FAX(617)SWIG49 ,• Telephone(617)292.5300 `J Pnmed on Recycled Paper - e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART A CERTIFICATION (continued)I ,� Property Address: Owner- Date wnerDate of Inspection: � �� "�L✓ BI SYSTEM. CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is clue to broken or obstructed pipets) or due to a broken. settled or uneven distribution box. The system will pass inspection f twith approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box,is levelled or replaced _ 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): i' 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: 3 ! 7 Cesspool or privy is within 50 feet of a surface water . + -' Cesspool or privy is within $0 feet of a bordering vegetated wetland or a salt marsh. v 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) s DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply well; The system has a septic tank and soil absorption system and is within,50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 fet r 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 lass than 5 ppm. 3) OTHER (revised 11/03/95) 2 �M1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: C W-�5 41�JeS�-<Z�, Owner. Date of Inspection: H D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15,303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. , Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. r 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, Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 60 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality ana.lysia. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen, El LARGE SYSTEM FAILS: The following criteria apply'to large syatems in addition to the criteria above; The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 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 11/03/95) 9 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST r i Properly Address: 00S �� t "Q� , OUCAF Owner. C Date of Inspection: �- j "_q Check if the following been done: Imprmation was requested of the owner, occupant, and Board of Health. _None of the s_0em.components have been pumped for at least two weeks and the system has been receiving normal flow rates d period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As bhave been obtained and examined, Note if they ars not available with NIA. _The f ' 'y or dwelling was inspected for signs of sewage back-up. The s does not receive non-sanitary or industrial waste flow e si ae inspected for signs of breakout. _All m components, excluding the Soil Absorption System, have been located on the site, The septic manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees serial of construction, dimensions, depth of liquid, depth of sludge,depth of scum. The size an ocation of the Soil Absorption System on the site has been determined based on existing information or app ro ted by non-intrusive methods. ` e facility owner(anti occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. i (revised 11/03/95) 4 y.,, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �QC N WIC Owner. ` 1� Date of Inspection: ' L ' FLOW CONDITIONS Designfluty (7 gallons C I Cir (x ®w n, 1 bec-\r!�cvv. Number of bedrooms: j V Number of current residents: Garbage grinder(yes or noky-es Laundry connected to system(yes or no):—Ye-S, Seasonal use(yea no): IVO ©V\ weA k u ja7C _ _ Water meter readings, if available: C� "�i� Last date of cy: occu an p � COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_ r�allons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: cq System pumped as part of inspection: (yes or no) QS If yes,volume pumpe�: Q?O ons Reason for pumping: i TYPE0S]�TEM . /eptic tasdrJdistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) © (revised 11/03/95) g r SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYS'T'EM INFORMATION (continued) Property Address: t cc) �� " Owner. Date of Inspection: SEPTIC'TANK: (locate on site pian) t- p U�� q Q�y Depth below grade.`l� r Material of construction: _rete metal_FRP �otherte:plain) Dimensions: RS Sludge depth- C5 _ r /I Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: ^ �! t Distance from top of scum to top of outlet tee or baffle: �r Aistsuco from bottom of scum to bottom of outlet tee or Tast c c� . Comments: (recommendation for pumpin condition of' et and outlet tees r baffle , depth of liqui level in relation to outl t invZ02�= eo) no evidence ge, etc.) C- e le LCAkc--a C42 1" n © Q52Q GREASE TRAE9fL�OR� (locate on site plan) Depth below grade; Material of construction: _concrete ^metal_FRP _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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet;invert, structural integrity, evidence of leakage, etc.) i (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oo tinu ) nas Property Addrrae: � Owner. `. w`'`� � Date of Inspection: TIGHT On HOLDING TANVO)0he"' . (locate on site plan) Depth below grade: Material of construction: ,_,,,concrete—metal_FRP�other(explain) Dimensions: Capacity:_ -xallons Design flow: uallons;day Alarm level: Comments: (condition of Inlet tee, condition of alarm end float switches, etc,)' DISTRIBUTIONX:BO (locate on site plan) T Depth of liquid level above outlet invert: Comments: (note if le 1 and rib tion ual, etvidence of solids carryover, videp e-of je*V into or out of box',etc.) C� © CDv C_7 %J v PUMP CHAMBER: (locate on site plant Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) OQ �' � r Property Address / ". ✓ � ? Date of Inspection: 4 r SOIL ABSORPTION SYSTEM (SAS): (locate on site plass. if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,lengthJ"��� leaching Gelds, number. dimensions: ovrrtlow cesspool, ntunber:_ mme to: (note ndition f soil, signs of hydraulic failure, lav of nding, con 'ti of vegetation,e .) SQ 1 • �` �� c�,� , +.t CESSPOOLS: O- W\e (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow,(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) r � PRIVY: (locate on site plan) Materials of construction: Dimensions: _ Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) (revised 11/03/95) 8 — `- i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued Property Address: r iSA, Owner. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' So �- =LyL/ 1 DEPTH TO GROUNDWATER Depth to groundwater:�1�►'1A�et ����e� r method of etermituition or apgroz' tion; e[ v p-C �Iftx,�4 0 s (revised 11/03/45) 9