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HomeMy WebLinkAboutMiscellaneous - 1058 JOHNSON STREET 4/30/2018 ` 1058 JOHNSON STREET bet 210L9D7A-0066-D000.0 r I I I f 1058 JOHNSON STREET JS-2003-0756 Proiect Detail Report Printed On:Wed Jun 11,2003 GIS r� '7374 Pro ec Noy ' J 7S 203 0756 Owner of Record$onasoto,7acueltne , Map 10A Date SuUixutted Tun ' ZQ03a 1058Tohnson Street Lot � orkCategory � � Work Locat><on 10587OHNSON STREE w: 3 Zoning Prop sedrtJse Distr�ct� �� land Used 10 Pro osed Us�Detad �h , 4 DecftjI r>Iptlon'FOttY1 U Stgn Off �� - � ofWtirk � ,O NIF s Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2003-0052 Wed.-6/11/03-Form U on table for Health Sign off. Processed and passed form and septic file to Brian for review and sign off. Building application submitted on 5/30/03.--p.d. GeoTMS®2003 Des Lauriers Municipal Solutions,Inc. Page 1 of 1 - LOT RELEASE FORM FORM U necessary a rovals/permits from i ' IONS: This form is used to verify that all nec ry pp and Departments having jurisdiction ance with any apple abled.een obtahor requirements.is does not e ! applicant and/or landowner from compln ppPLICANT FILLS OUT THIS SECTION PHONEY— APPLICANT I' PARCEL 61 LOCATION: Assessor's Map Number k'+ LOT(S) SUBDIVISION n h N s ST. NUMBER STREET G' .OFFICIAL USE ON RECOMMENDATIONS OF TOWN AGENTS: DATE APPROVED } ,{ CONSERVATION ADMINISTRATOR DATE REJECTED COMMENTS DATE APPROVED TOWN PLANNER DATE REJECTED II COMMENTS DATE APPROVED i FOOD QNSPECTOR-HEALTH DATE REJECTED i DATE APPROVED SEPTIC INSPECTOR-HEALTH DATE REJECTED pp TS t� Q: ���� t�t55.Cd\ COMMEN �. . . PUBLIC WORKS- SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT DATE RECEIVED BY BUILDING INSPECTOR Revised 9\97 jm 3 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:� � /1 �Jsz,r Owner's Name: �► Owner's Address: �nv��0� r11:�` Date of Inspection: Name of Inspector: (please print) J A h�) �yt Ce YL� A Company Names f- �C p Mailing Address: /Z S Telephone Number: 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 F er Evaluation by the Local Approving Authority Fail Inspector's Signatu/ubmit I Date: The system inspector shcopy of thisinspectionreport to a Approving Authority(Board of Health or DEP)within 30 days ofthis 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 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 not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 —— Page 2of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) AProperty Address: ��SO wl A a o S?'� Owner: Date of Inspection: O Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D n. A. System P saes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 di-in 310'CIvIR'15'304--exist:*Any-failute=criteria-not evaluated=are indicated=below:_ k,M --Comments: A �.r 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--"6r'-break out or high static-4-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 a 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: n.- 2 Page 3 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:&— o J S a'ja _j,6)d A.1 Owner: rtyl 1( 6 Date of Inspection: 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: sr{ 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 ti k 4 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 t *This,system..pas-sesfiif the well water-analysis,.perfornhedat;a DEPIcertified-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: d r b : 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address/0 6 N Q 0a S?- Ali 90;0 Owner Date of Inspections D. System.Failure Criteria applicable to all systems: t You must indicate"yes"or"no"to each of the following for all inspections; No za•, { Backuil`'of sewage intofacirity""of system component due to overloadeidor cogged SA S' cesspools _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or „ clogged SAS or cesspool M _ �� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool _ tiquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number g+ of times pumped —L...Iny 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. _ —VAny 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.] IVO (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. ITT Y'... 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 F 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 r Zone II 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 r 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. x 4 .. +. .. ...y, 1�-.,1�... .N,.a�N:,.., .l..x a .....ry, c `. _..__. ..... .. .. ..:�u:t ;'Yti A4Y. .. ..`ti p. . u-, _. e v .... ,. ♦. ly f... .. mss.. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j' PART B CHECKLIST Property Address: a w "" 4a Owner: r., z.: Date of Inspection: `/� —40/ i 1, Check if the.following have been done.You must indicate k`yes"or"no"as to each of the following: —�Pumping information Was provided by the owner,occupant,or Board.of Health <, ( erean'j=,6ftf6"iystem components pumpedout in the'previous two weeks Has the.syste"m 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? A�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? ,x Wasthe 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? Was the facility owner(and occupants if different from owner)provided with information on ttie'proper maintenance of subsurface sewage disposal systems? } thesiie`and location o> tfi'e SoilPAbsorption'Systeti(StlS)on th�e'site has keen defermittied based on: Yes no _L-rExisting 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)(b)] 3 t t ` Page 6 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:�0 .S Owner: - � ✓' / !/d ' Date of Inspection: /Z—61 ` FLOW CONDITIONS RESIDENTIAL Numberof bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CW 5.203(for example: 110 gpd x#of bedrooms): Number of current residents: ID6es residence haven ` ba 'ez '' der(yes r-nq . . pp Is laundry on a separate sewage system(yes or no). [if yes separate inspection required] rz' *� Laundry system.inspected,(yes or no Seasonal use:(yes or no):f V(� ` Water meter readingsif available(last 2 years usage(gpd)): Sump pump(yes or no): Last date,of occupancy COMMERCIALANDUSTRIAL Type of establishment: 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 Source of information: ( [, Was system pumped as part of the inspection(yes or nS� If yes,7volume uim ed: _ Q gallons---How as umPed d to�mmed? � , 7-0tty P. p Reason or pumping: .2.G Jei Ty7bF 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 ag o all components,sdate installed(if known)and source of information: CA Were sewage odors.detected when arriving at the site(yes or no): 6 env y+.a,,,.,,nq.s� -•, as1.��rra r,+'„^'. �rrar.,q Faa.»:14w:t„r{„aCq�'�„ear'."•,"'...... ,,;rr_ .Y.:«tiT.:4"3.;r+w... • Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S-T- 6j Owner: rc4l f Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: c7 Materials of construction. st iron 40 PVC othe (explain): ` _ - ... .. Distance"from private water supply well_`bTuctio'n brie: 1" ;l :``' Comments(on condition of joints,venting,evidence of leakage,etc.): b SEPTI ;'TANK:'"(locate on site plan) ..' Depth below grade Material of construction: T oncrete_metal_fiberglass_polyethylene —other(explain) t 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: ” Z>f Distance from top of edge to bottom of outlet tee or baffle: _ 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: How were dimensions determined: P— jZgCL.e, Comments(on pumping recommendatioet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): /vLer d'- ©vT-Gcr "T eS �C�o GREAS TRAP:�(locate on site plan) m ` Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene_other f (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 r; as related to outlet invert,evidence of leakage,etc.): �i 7 rl Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM P- PART C SYSTEM INFORMATION(continued) Property Address: . ,� � w. U N Owner:-&/' Date of Inspections ^/ r TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site.plan) Depth below grade: P $ Material of construction :': <concrete _-'netal�k )iii,` lass_, � olyethylerae othet(explain): Dimensions: r,....., " Capacity. . gallons `Design Flo' '. A gallons/day ` *Alarm present(yes or no ak Alarm level: Alarm in working order(yes or no): r ,•' Date of IA:t pumpmg ,.w f `Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:A&VIr" L --r•- Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leak a int or out of box,etc.): f . max � � �� s PUMP CHAMBER: n site plan) Pumps in working or er y ' or no Alarms in`wOrkmg bider(Yes�r nod.. - Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): s' x c t t y , 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:,/Q /nJ S T Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: E .v t (. leach g pits,number:_ _ leaclfuig chainbers�number: leacKing galleries,.dumber: leaching trenches,snumber,length: aAing fields;number,dimensions: ,Q Q X V O 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.): _t D G� LjL 1. G d'&vykQ CESSPOOLS: (cesspool must be pumped as part of inspect ion)(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 grpund�ater?iuflow Oyes or-"no) ti ` +! Comments(note condition of lsoi�,signs oflydraiaic'failure,level of ponding;condition of vegetation,etc.): 1 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.): 9 Page 10 of 11 f OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYS KM INSPECTION FORM r PART C SYSTEMINFORMATION(continued) Property Address: piel-i S7"' C) Owner: Date of Inspection: 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 10Oyfeet. l;,ocate wherejp4blic water supply enters the building. t v r 0 r k Page l l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / `SYSTEM INFORMATION(continued) ' Property Address: _/t!� ' �l C) iJSC> A110 A."i Owner: r�'~ Date of Inspection: --6 SITE EXAM Slope Surface water Check cellar ,C<t Shallow wells Estimated depth to ground water ,feet ' lease ind rte`(check);a hmethods used to determine the high ground water elevation: Obta' 'e'd from��system design plans on record-If checked,date of design plan reviewed: -- bs ry 'I ssite(abdting property/observation hole within 150 feet of SAS) Checked withl'ocal"Board of Health-explain: 'Checked.with local excavators,installers-(attach documentation) Accessed USGS database-explain: You ust des ribe}how you established the high ground water elevat'on: V If V ` h r � 9 ,. 1 1 AvIzver Q-a- AlOinCf 47 IRAAp�'IC TAS S�� WLe i6j NW 0 in Lie- 1835 978-372-7471. mom cr aocv ADaMs 7- S . � l3 Lg ray) l ScSv 7- t �5'ao � < fit/ Ipv 7- e �a /yt6 d5�o �a6v - 1 �� 71� .�a --�/�r6/e Sad • 6 � 74 Unum IQ�� . .�a tot /d°o PATRICK J. DONOVAN ASSOCIATES, INC. "CLAIM AND LOSS ADJUSTMENTS" P.O. Box 110 Wakefield, MA o1sa0 (617) 245-5540 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS. CHP. 139, SEC. 3B TO: Building Commissioner or Inspector of Buildings City or Town Hall RE: Insured: �lCt� (� F�ihAy C Property Address: Pol icy Number t -H pop,a J -75 Loss Types !G� ®tv-t S` U A-79f?_ Date of Loss: al(9$/eC Our File Number: Gj)gp g 1�07 Claim has been made involving loss, damage or destruction of the above- captioned property, which may either okcb6d $1,000 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen: Laws, Chapter 139; Section 313 is appropriate, please direct it to the attention of the writer and include a k6ference to the captioned Insured, location, policy number, date of loss and file number. b>-\`,�vc�Gco Adjuster Donovan Associates, Inc. Wakefield, MA On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. OF N IoTC. NdI�Th Aupovei-� MA, a '. VPL Citi I_ _/'etc ��CSTtN wEU- ,6PPl�oyEDDOT'C S5 ,S SEPTI C Sy S i EAj VES►C-� _... P r6- /JPRWI.,06 AuTmoi;�ITy ( DOASITIOws: D15APPPoVEp 1A Te Dw� Std--I c SySTE� ��s ti,ol���,u C7,CAUIQTtO1J ���c.l EGTip� U/JrG -t5 17 "N5S E] F4It_ FINAL 1 QSP6-i lord 4PPROOEP . Q/JTC�� ,�PI"'t�ovtn�G ��T�tOr�l�y 44c �E57iv DIS��Pt'�Uvt`V Da i C z R�So NS � FML 16PPIROVA