HomeMy WebLinkAbout- Title V Inspection Report - 7 CARLTON LANE 10/11/2018 28
COMMON% EALTH OF MASSACHL'SETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET- BOSTO%-. 1-IA 02108 61:-`_9?-5S 0
TRUDY COXE
WILLIA%1 F WELD Seaetu�
G9YLm0: ,
DAVID B.STRUHS
ARGEO PAUL CELLUCCI Commissioner
Lt-Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: (°c-1 L170-A- I_.A). A) A�'J ll Address of Owner:
Date of Inspection: 71 ZO�rf (1! different)
Name of Inspector: BERJAMIN C. OSGOOD JR.
1 ern a DEP approved system inspector pursuant to 5cction IS.340 of Title 5 (310 CMR 15.000)
Company Name: NEW ENGLAND ENGINEERING SERVICES INC.
Mailing Address: 33 WALKER ROAD NORTH ANDOVER MA 0I845
Telephone Number: 508-686--1768
CERTIFICATION STATEtAENT r
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 tnspec ion. The inspection was performed based on my training and experience in the proper funatron and
maintenance of on-site sewage disposal systems The system:
Passes =
&ndtuonall,, Passes
Needs Further (valuation By the Local Approving Authority
_ Fails
Inspector's Signature: Date: Z6
The Svstem inspector shall submit a copy or this inspection report to the Approving Au(horitywithin 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 btfyer, if applicable, and the approving authority-
INSPECTION SUMMARY: Check A, B, C, or D:
A) SYST M PASSES:
71 have not found any information which indicates that the sy>tem violates any of the failure crdterca as.defined in 314 C`SR 15.303.
Any failure criteria not evaluated are indicated below. n n
COMMENTS: exS �clrCt�Crtce.i/ "'e _
3,5-
81 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.
Indicate yes, no, or not determined (Y, N. or NO). Describe 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 tnspcctdr with a copy of a Certificate of
Compliance tattached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is 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
14 approved by the Board of Health.
SUBSURFACE SEWAGE OISPOSAi SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address. `7 r t2 t Tc]v )—mil. N- F}A,'0cY ji f2-
Owner:
Date of Inspection: �v+
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
_ pipets) or due to a broken. settled or uneven distribution box. The system will pass inspection if'(with approval of the
Board of Health;. Describe observations:
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 pipets). The system wilt pass
inspection if(with approval of the Board of Health)
r broken ptpe(sl are replaces
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which reouue further evaluation by the Board of Health in order to determine it the system,is failing to protect the
public health, safe y 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 povy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS 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 surface water supply or
tributary to a sunace water supply. l
The system has a septic tank and soil absorption system and the SAS is within a Zone t of a public water supply 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 Io0 feet but 5o 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 irom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, method used to determine distance (approximation not valid).
3) OTHER
is
is
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION! (continued)
Property Address: f C,:t 12trj-o N J-/J. /V. A" 0 a-cr
Owner: 31;G i e ✓Yr c�r�
Date of Inspection:
DI SYSTEM FAILS:
You must indicate either "Yes" or"No"as to each of the following:
I have determined that the system violate$ 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.
Yes No
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
Static liquid level to the distribution box above outlet tnven 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 flogs.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
And- portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation
Anv portion or a cesspool or pfi%l' is within 100 feet of a surface water supply or tributary to a surface water supply.
Any ponlon of a cesspool or privy is within a Zone I of a public well.
An\ portion of a cesspool or privy is within So feet of a private water supply well
Anv 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 water analysis for
coltiorm bactg(ia, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS: I I
You must indicate either "Yes- or -No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 go 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.
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 U 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.
Y
i.
(ravifed 04/25/11, Pay 3 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE&ION FORM
PART B
CHECKLIST
Property Address:
Owner: 1 �} u_D—ItA0 Al
Date of Inspection:
Check if the following have been done: You must indicate either "Yes'or"No" as to each-of the following:
Yes No
t� 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
W flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection4 _
rl�t L As built plans have been obtaereed and examined. Note of they are not available with NIA.
_ The facility or dwelling was inspected (or signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout
R All system components. excluding the Sod Absorption System, have been located on the site.
�. The septic tank manholers were uncovered, opened. and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions. depth of liquid, depth of sludge, depth of scum.
The size and location of the Soi( Absorption System on the site has been determined based on:
The facility owner tand occupants, if different from owner) were provided with information on the proper maintenance of
/ Sub-Surface Disposal System
Existing information. Ex.tPlan at B.O.H. 1
T Determined in the field (if any of the failure criteria related to Par[ C is at issue, approximation of distance is
unacceptable) (15.362(31(b)I l
Ix.vi..A 0</75/771 1'aq. t or 30
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SUESURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORMATION
Property Address: Q r`LG-r'�'
Owner: a U4ic" L e r4r�
Dale of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: R.p.dJbedroom for S.A.S
Number of bedrooms:_
Number of current residents:
Garbage g=,r.der (yes or no): %A
Laundry connected to system (yes or no):
Seasonal use (yes or no): `
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (,yes or no):�
Last date of occupancy:, n�c�T
COMMERCIAUI N DUSTRIAL:
Type of establishment:
Design flow:. gallons/day
Grease trap present: tees or no)_
Industrial Waste Holding Tank present: rves or nol_
Non-sanitary waste discharged to the Title i system ryes or not—
Water meter readings, if available
Las[ date of o•cupanq-: t
OTHER: (Describe;
Last date of occupancy,
GENERAL INFORMATION
� r
PUMPING RECORDS and ource of tniormauon
System pumped as part of inspecror: (Yesii or no)AZ
If yes, volume pumped: t allohs
Reason for pumping
u
TYPE OF SYSTEM
_ ( Septic tank/distribution box/soil absorption system
Single cesspool
i Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
04/25/371 Ywq. 5 of 10
SUBSURFACE SEWAGE DISPOSAL" SYSTEM INSPECHON FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Ccz ai—TZ. — 11 -.A3, 1-)- A -600 C1L
Owner: T i�:cn 1.--cVVL.O/�
Date of Inspection:
BUILDING SEWER-
(Locate on site plan)
Depth below grade;
Material of construction: (cast iron r 40 PVC __other (explain)
Distance from private water supply well.or suction 1ir:-
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on Site ptani
Depth below grade: 19
Material of construction: Zoncrete _metal _Fiberglass Polyethylene _,othertexplain) r
If tank is metal, Irst age is age confirmed by Certificate of Compliance ^(Yes/No)
Dimensions: —
Sludge depth- �
Distance from top of stud e to bottom of outlet tee or bafflle: Z ?
Scum thickness: /- t`_ .'
Distance from top of scum to top of outlet tee or baffle. &
Distance from bonom of scum to bonom of outlet tee or bante:_B�
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outttt tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, g �' .✓Q '13ON . Sc(-C '
g ty, evidence of leakage, etc.) TAIV �cJ u
I
GREASE TRAP:N1°r
(locate on site plan)
Depth below grade:
Material of construction: _concrete —metal —Fiberglass ,,,,_Polyethylene -other(explain)
Dimensions:
Scum thickness:
Distance (ram 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:
(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
(r.v(a.Q 0�/]S/71! Awq• C of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: ,���:•* -[w�Drti
Date of inspection:
TIGHT OR HOLDING TANK: crank must be pumped prior to. or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: ,concrete —metal _Fiberglass ,,..Polyethylene _other(explain)
Dimensions:
Capaciry gallons
Design i!oK' gallon./dai.
Alarm level Alarm to working order _ Yes. ^ No
Date of previous pumping:
Comments:
(condition of inlet tee. condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
.c
Depth of liquid level above outlet irivert:�_
Comments:
(note ii level and distribution is equal. evidence of salid carryoi�er, evidence of leakage in
or out of box, etc.) t
cQ� ,^ 1� a r�. .fit. �3
n. 5 t oc P_ 4>r,i c Q C
u
PUMP CHAMBER: NIA'
(locate on site plan)
Pumps in working order: (Yes or Not
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
travi gad 04/2 S/971 paq• 7 a[ 14 '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7 CG,2(-t�N L", �j Y'"✓L�v�C
Owner. c, LP—v,1o•n
Date of Inspection:
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.
leaching trenches. number•length: /� r
leaching fields, number, dimensions:_Z/5 cV
overflow cesspool, number.
Alternative system:
Name of Technology:
r
Comments:
(note condition of soil.' signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
�e
t
CESSPOOLS: jR
(locate on site plan)
Number and configuration
Depth-top of liquid to inlet invert:
Depth of solids layer: i t
Depth of scum laver:
Dimensions of cesspool:
Materials of construction: I I
Indication of groundwater:
inflow (cesspool must be pumped as pan of inspection)
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:
friote condition of soil, signs of hydraulic failure, level of ponding, conddition of vegetation, etc.)
(r.vii.d 04/75/7I) Y.y. y of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: C�r7 t—i •rt 4- _ /U ���J✓
Owner: ✓��c. L-G v►z a
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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(r.rviud 04/7s/971 P.V. 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address- '-7 Cct 2!.�� 1 P-') I ir') v �L
Owner-. T.J1-14 L_e AA-0A,
Date of Inspection:
-7 1 zo 1uO
Depth to Groundwater '�— Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observanon of Site (Abutting p(operty. observation hole, basement sump etc.)
Determine it from local conditions
Check with loca' Buard of health
Chec� FEMA maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in v-au+ own words how you established the High Groundwaie+ Elevation;(Must be completed)
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(r.vi•.d Ol/]5/97S Pwy. 10 0( YO ,,