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HomeMy WebLinkAboutMiscellaneous - 595 FOSTER STREET 4/30/2018 595 FOSTER STREET `! 2Ia.104_s-oo2y 0000:o Addressz, �as� Ste' Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ Num. Action _Department Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Department NORTH AND HVER/ BOARD OF HEALT Commonwealth of Massachusetts i OCT L 41995 Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Governor Trudy Coxe Secretory,EDEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Q-<_ Address of Owner: Dale of Inspection: t I q—_4 1 (If different) Name of Inspector: Company Name, Address and Telephone Number: �� S S 8 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 in ection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewa Isposal systems. The system: _ Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority 4s Inspector's Signature: Date: /0' ILI V' The System Inspector shall submit a copy of 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 P ES: I have not found any information which indicates that (lie system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES: 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 noel _ 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 conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)292-5500 `�Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: � `7,s T���-` (�' Owner: C.�d� L VI C \ Date of Inspection: Lam- BI SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with 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): broken pipe(s) are replaced obstruction is removed Cl 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: _ 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ ii ,,, >�,, 1• u"•; ;1 a�su;plio: s)s;c. and is within 100 feet toast�fac^_ �„z'e• s i{ ht or surface water supply. The wslen, has a septic tank and soil absorption system and is within a Zone I of a public water supply well. Ilie system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system hay a septic tank and sof) absorption system and 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 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. DI 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. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15pC1, �- Owner:Date of Inspection: D] SYSTEM FAILS (continued): 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 1/2 day flow. Required pumping morn thnn 4 times: in the last year b=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 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. If the well has been analyzed to be acceptable, attach copy of well wator analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systerns in addition to the criteria above: The design flow of system is 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 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �"I "WX Owner: ( Date of Inspection: („- Check if the follo/wi���ave been done: _Znel minformation was requested of the owner, occupant, and Board of Health. _ of the system components have been pumped (or at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have.not been introduced into the system recently or as.part of this inspection. 4VIAAs bulk plans have been obtained and examined. Note if they are not available with N/A. — he f ' 't or dwelling was inspected for signs of sewage back-up. Y g _The m does not receive non-sanitary or industrial waste flow _T'S he site was Inspected for signs of breakout. II system components, excluding the Soil Absorption System, have been located on the site. _ l(/T,e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, m Tial of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _The size and location of the Soil Absorption System on the site has been determined based on existing information or approxi ted by non-intrusive methods. he facility O'..nrr (Xul occupants, if differow from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: s�r� .3k,- �k^ Owner. C. Dale of Inspection: (0— L{ FLOW CONDITIONS RESIDENTIAL: Design flow: 330 Qallons Number of bedrooms:-3— Number edrooms:Number of current residents: Garbage grinder (yes or no): Laundry connected to sy (yes or no):NO Seasonal use (yes or no).-IM A111+Water meter readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/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: YU o --oWlneA- System pumped as part of inspection: (yes or no) If yes, volume pompe I _�D gallons f e Reason for pumping._ t r^ rLct,�s �� •4ew -6 TYPE OF Pi1fM 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: —pcjjhy-. — Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMINFORMATION (continued) / ) Property Address: s -� s Owner: ( A W Date of Inspection: 0 SEPTIC TANK:_ (locate on site plan) Depth below grade: �'���" ��� `�ti / Material of construction: L-`E`6ncre1e _metal _FRP —other(explain) Dimensions: OX ( elX7,5- — GiK S Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: (3'e Distance from top of scum to top of outlet tee or baffle: 3 ,m p Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condi ' n of inlet an outlet tee or baf les, de th of Equi lev I i relation to outlet i vert, strudu al integrity, evide ce of leakage etc.) ��` - ��, x 609Q2�� -1 — ` Q oc v `- GREASE TRAP:110Y\4e- (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: Dt� tjncv trom how-, 1-11(lo' of 00!1P! If'i' VIhillll'. 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 leakagr, etc.) (revised 8/]5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C � n,c-�- SYSTEM INFORMATION (continued) Property Address:5gs ^`o -,l Owner: (-• 0 '- Date of Inspection: �� (�—GIS TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: a Comments: (note if I vel aid dis tibu iun is e(jual, evidence of solid carr)o%er, evidence of leakage intoo out of box, etc.) n C'.Q�o U C> PUMP CHAMBER: (locate on site plan) v Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C � SYSTEM INFORMATION (continued) Property Address:JS- © �p� ^ Owner. H f.� -� � (Jll� Date of Inspection: lo— "Z —g SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, 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: ( A� S01 1611 leaching trenches, number,length: � Ly-f• leaching fields, number, dimensions: overflow cesspool, number: L Comments: (note cor�dif,ion of soil, signs of hydra lic fail e, lev of ponding, SSo'n'dition of vegetation,etc.) C r Colo, 1001 S� EX o N CESSPOOLS: (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 groun(katel. 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.) PRIVY: t+ oyke- (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 8/15/95) 8 r e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM tt ,,INFORMATION (continued) Property Address: �� '" _ Iv . A,,, .7Qx Owner: � �( Dale of �Inspection: �O_ f + /)� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' I A- +�5� 3 �i0 si-a e) -,�*3 ,:-- 9 q f DEPTH TO GROUNDWATER Depth to groundwater:met ��� ��__ �„Cm 0-r- )6442)A-- �gA m5thod ofXrmination�approximati n: — eL\ -4- (revised 8/15/95) 9