HomeMy WebLinkAboutMiscellaneous - 1565 SALEM STREET 4/30/2018 (2) 1565 SALEM STREET
210/106 000.0
1
Tt1E PROFE6ZS1QNAL.EXPERTS
IN THE SEPTIC AND
DRAIN INDUSTRY pF�`1N
rORM a --SYSTF-AI PUNTPI ;G RECORD .
Commonwealth of Massachusetts
i
Massachusetts
y tem , rn z X 6 rd
stem �A
System m ocauo>z .
i
G
Date of Pumping: Q > Pumpe uantit � p gallons
i
Cesspool: N0�❑ Yes •,
❑ Septic Tank; No ❑ Ye,S/❑ '
SystemPumped by ................ .... . .. ................................................
.. License,#: .................................................
Contents transferred to:
i
Date Inspector
i
i
IV
s,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: ( S ST
a ove-t
Owner's Name: u kcA, oca
Owner's Address:
Date of Inspection: 3 --�'�• o
i
Name of Inspector: (please rint j I l C�
Company Name: t_ All 'C
Mailing Address: - I�C1 l� 4t5 R-2-
/ !til 14-
Telephone Number: � :2k (47a 02(Qn
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 Authorit}
Fails
Inspector's Signature: DW(�e4
The system inspector shall submit a copy of this inspejn report to the Approving Authoritv(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of ;0.000
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.thejUWer i A �e-approving
TOWN Oauthority. F NINTH�u�h
BOARD OF HEALTH_
G Notes and Comments �ry
03 2
1
II
i
****Thisr �
report only describes conditions at the time of inspection avid-u -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 2 of 11
OFFICIAL INSPECTION FORM_
NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
avt
Owner:
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found anv information which indicates that anv 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.
Commepty
v, 2' D Wo/l L►
004.21,AJ
Pu►y`ki
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)inthe 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
obstructedpipe(s)or due to a broken,settled or uneven distribution box. System will ass inspection if with
Y P P
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
IND explain:
The system require tCM6ing fnore 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
i
ND explain:
2
P$ge 3 of i I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: /�
Owner:
Date of Inspection: —1 —a
C. Further Evaluation is Required by the Board of Health:
Conditions exi which require further evaluation by the Board of Health in order to determine ifAe system
is failing to protect public health, safety or the environment.
/3030 1. System will pass unieks Board of Health determines in accordance with 310 CMR I )(b) that the
System is not functions in a manner which will protect public health,safety an he environment:
Cesspool or privy is wi n 50 feet of a surface wa/and
_ Cesspool or privy is with 50 feet of a bordering ora t marsh
2. Svstem will fail unless the Board of Hea h (and Pubier, if any) determines that the
system is functioning in a manner that protec thepubland environment:
The system has a septic tank and soil abso ion sythe SAS is within 100 feet of a
surface water supply or tributarti-to a surface wate st ply.
The system has a septic tank and SAS and e S S is within a Zone 1 of a public water supply.
The system has a septic tank and SAS d the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and XAS and the SAS is ss than 100 feet but 50 feet or more from a
private water supply well". Met used to determine dist ce
"This system passes if the weX -ater analysis, performed at a EP certified laboratory, for coliform
bacteria and volatile organic;,6ompounds indicates that the well is ee from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to o ess than 5 ppm,provided that no other
failure criteria are trig$efed. A copy of the analysis must be attached this form.
i
I
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: /S� 'e
/V. -,
Owner: (Ze
Date of Inspection:_:� —4 ')- j
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
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 Y•_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.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_A, 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.)
(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.
i
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 Il 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 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address ,S(a e", -S
vLY
Owner: nc
Date of Inspection:` 3 — 7 —d/
Check if the followine have been done. You must indicate"yes"or`oto"as to each of the followine:
Yes No
— 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?
AHave 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)
Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out?
Were all system components.
u, excludm�o 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 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 n
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)(b)]
5
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: ,S� s��f 5 T
v��-
Owner:
Date of Inspection: —I "7—Q/
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):
Number of current residents: a
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes Ar no):A( [if yes separate inspection required]
Laundry system inspected(ye or no):
Seasonal use: (yes or no):f
Water meter readings, if avai able(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy: 0,g A
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): spd
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 nn
Source of information: 0,/RrLCL cS'tpte
Was system pumped as part of the inspection (yes or no):�
If yes, volume pumped:_gallons— How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box, soil absorption system
_Single cesspool
Overflow cesspool
Privy
z0ahared 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:
6WticV',,
I /
Were sewage odors detected when arriving at the site(yes or no):/�.!
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
�«
Owner: 26L,1 11
Date of Inspectio
BUILDING SEWER(locate on site plan)
Depth below grade: !e7dteS
Materials of construction: &cast 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:�L(locate on site plan)
Depth below grade:o2/
Material of construction: concrete_metal_fiberglass polyethylene
—other(explain)
If tank is metal Iist age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) r
Dimensions: X d'
Sludge depth: 3 i n c g!S
Distance from top of sludge to bottom of outlet tee or baffle: !:2
Scum thickness:
Distance from to of scum to to of outlet tee or baffle: /o�Z
P P �_
Distance from bottom of scum to bottom of outlet tee or baffle: / 7/f
How were dimensions determined: �_ &(S(A&.-
Comments(on pumping recommendations, inlefJand outlet tee or baffle condition, structural integrity, liquid levels
as lated to outlet invert,evidence of leakage,etc.):
� o
rrtXo X.Ld S •�r��' cs asi y'
S
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_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 11
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
/ A4 �.
Owner:
Date of Inspection:
r—
TIGHT or HOLDING TANK: (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:
Comments(condition of alarm and float switches, etc.):
513 AfT
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribtion to outlets equal, any evidence of solids carryover,any evidence of
lea45into or out of box,etc.):
(=S ke-v gj e,S ��/et C
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.):
i
I
I
i
8
•v Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: / -To S- SC."L.- J
,r� d L�
Owner•
Date of Inspection: '3 - 7—0
I
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:
t�[ leaching fields.number,dimensions: -zA x3a
overflow cesspool, number: UU
mnovativeialternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and confieuration:
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(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
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
y►" a
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: IL
Owner: AIZa
Date of Inspectio 3 —7'7—c
i
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.
j � ��-lei-• �
v
&d? e�
WAV d'.`fi
3
s��
—jej't,vts �ect.rv�� coCk�/
C , .A- 10
'149age 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water /.S--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:
A-Observed site(abutting properry/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you estahlished the high round w ter a vat' /
S o c
`T e-X,-v,7— �w
v / �-
llI!n4 kA N
�t2o/J-e A-I S c, 4 Gv e 1ti
o d /� �''( Cd 'tel
m� cw �..'s Cz L4wT � /U� �� f
AzS
T
>6 T �� 40
rrt^i
11