HomeMy WebLinkAboutTitle V Inspection Report - 1770 SALEM STREET 11/9/1995 � i FILE#
107 Forest St. �\� "
Middleton, MA 01949 -`"
(508) 774-2772 S���g� c
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNER'S NAME: �-
PROPERTY ADDRESS:
ADDRESS OF OWNER: +�
(if different)
DATE OF INSPECTION:
NAME OF INSPECTOR: I) �l i'� (- .<'.�rc<:>�J I✓�
s THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY •
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 1/7a . ,i��i ' ' Address of Owner:
Date of Inspection: ,v ' (If different)
Name of Inspector:
Company Name, Address and Telephone Number: Currier Septic & Drain Service, Inc.
107 Forest Street, Middleton, MA 01949
(508) 774-2772
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 inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
`I
Inspector's Signature: Z , Date:
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:
Checl&B, C, or D:
A) SYSTEM PASSES:
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.
B) 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 dtermination 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
conforming septic tank as approved by the Board of Health.
(revised 8/15/95) 1
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (co NTiNVEd)
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 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
N 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
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:
Cesspool or privy is within 50 feet of a surface water
,k-) 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:
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.
i� 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
1 well.
�J The system has a septic tank and soil 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.
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.
/N 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
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
D) SYSTEM FAILS(continued)
/U Static liquid level in the distribution box above oulet invert due to an overloaded or clogged SAS or
cesspool.
i
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
/v Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
/V 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. .. . .
/V 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.
t�5✓ 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 water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and
nitrate nitrogen.
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems 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�ondifions exist:
the system is within 400 feet of urf ce drinking water a
the system is within 200 feet of a tributary s ce drinking water supply
the system is located in a ni n sensitive area (Interim ad Protection Area (IWPA) or a mapped
Zone II of a public w er'supply well)
The owner or operator-ofy 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
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
m
Check if the following have been done:
rf Pumping information was requested of the owner, occupant, and Board of Health
_None of the system components have been pumped for 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.
ZAs built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
r!The system does not receive non-sanitary or industrial waste flow.
The site was inspected.for signs of breakout.
V All system components, excluding the Soil Absorption System, have been located on the site.
_Z The septic tank manholes 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.
I/ The size and location of the Soil Absorption System on the site has been determined based on existing
information or approximated by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper
maintenance of SubSurface Disposal System.
(revised 8/15/95)
4
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
r
FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms:-
Number of current resOn
Garbage grinder(yes : AA)
Laundry connected t3no
tem a or no):�°�5
Seasonal use (yes o 0
Wate r meter readings, if available:
i
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design-ffow:---- __ allons/day
Grease trap present: (�7tot)-. , _� _ _ -
Industrial Waste Holding Tank present. (yes or-ne}
Non-sanitary waste discharged to tIL Tjtle•5°5 s em: (yes or y)_� �
Water meter read ng§„.if-avia1bfii
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
`C / Quo c,r) lea
System pumped as part of inspection: (yes or Ny
If yes, volume pumped: gallons
Reason for pumping: Na /Vs
aa/ To tit, cLt° +lvi x T,,X, Vlk ;1 rn Joua�
TYPE 9F"SYSTEM
i-% 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:- 2-
Sewage odors detected when arriving at the site: (yes oro
(revised 8/15/95) 5
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SEPTIC TANK: Ye.5
(locate on site p an
Depth below grade:
Material of construction: ncrete—Metal—FRP other(explain)
Art— . jr re Fw, 02 a c. > Mel C:cA4'eE' r �✓e'r t! ,,i, �C!
Dimensions: /;?'L., 5 ' >u• �' Baffle Depth Below Outlet Invert:
Sludge depth: -C t"
Distance from top of sludge to bottom of outlet tee or baffle: a 6
Scum thickness: "
Distance from top of scum to top of outlet tee or baffle: f
Distance from bottom of scum to bottom of outlet tee or baffler
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outl,jt invert,
structural integrity, evidence of leakage,etc.) `•' .r;c- M..,is c. Vel-r ^,ot�� ; �/ €„''7.r :_� 7 ��. z .,�t s""h� •..
/1. S �..'J � �'r':1 r� .ry, r�'r� �2rU�� !r'�� �csc.�1^ .:�r.r��, e ��eA•'t �i•� Git-/,
GREASE TRAP: ��J
(locate on'site per)
Depth below grade;
Material ofconstructian;_ concrete metal FRP other(explain)
Dimensions: Baffle De ow Outlet Invert:
Scum thickness:
Distance from top of scum to top of outlet e,,�r baffle:
Distance from bottom of scum to bottom of !I tler1 i :
Comments:
(recommendation for pumpin g, condition of inlet and outlet tees or b ff s, depth of liquid level in relation to outlet invert,
structural integrity,-evidence of leakage, etc.)
(revised 8/15/95) 6
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
D
TIGHT OR HOLDING TANK: "C)
(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.)�_
i
V .�
DISTRIBUTION BOX: Yes
(locate on site plan)
Depth below grade:
Depth of liquid level above outlet invert:
Dimensions of D-13=40,:'?? tepth of Sump: va
Comments:
(note if level and distribution is equal, evidence of solids [carryov-ey, evidence of leakage into or out of Jbox, et/c.)
i d. '/-?f-,:;. .,`.",.,5 i' •e+ 'i ';�".-' 4���r y..�f-:(•' i( `�— r4-F �`� �--��0� /J /'(�fit..:/ t% i:�%l�d•�/9rl i�;r•
rf�' �- j �'°• p�`} -13-�� �x �,d..� ^�v!�:r(er .�;.ery.y_ !�Y +f'��' 1..�C�'K"rv�.:afi�y✓7 , �-,
+ !' O.. � - l,' d�' �y.:Q P'tt(4' i',A;, S`f" �'-•,Ira `',x �iPp'Q t' e p� / /
.. ,7 ' rQ'.�'Id! .s4 r + q � _.ay � ::1. `7 4�t�C,.rti -� ri•dr ..,�- � ,�'C:rl's 4 ::t.{"vJ•'?': i;Y/-- ro.,:'11C1j+ '';
r V C'
PUMP CHAMBER:
(locate on site plan
Depth below grade:
Pumps in working order.(yes_or no)
Comments: ~�
(note conditions of pump chamber, condition of p'Umpk and a nces, etc.)
(revised 8/15/95) 7
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM (SAS): Yes
(locate on site plan, if possible excavaEion not required, but may be approximately by non-intrusive methods) r
Depth to bottom of SAS: 5 4`(Stone or Pit)N
If not determined to be present, explain;
u , ' dot
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leach ing_trenches,_number, length:
Teaching fields, number, dimensions
Comments (note condition of soil, signs of hydraulic failure, level of onding, condition of vegetation, etc.)
�llis Aft• ,7 !"� 4_a�t
tf
CESSPOOLS:
(locate on site--p-1—an)
Depth below grade:
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer,.
Depth of scum layer. " ^°
Dimensions of cesspool
Materials of construction: "'°h°�•.
Indication of groundwater:
inflow(cesspool must be pum part of inspedbrn),
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of-Vegetation, etc.)
PRIVY: tj
(locate on site plan) K,
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of aulic failure, level of pond ing condition of vegetation, etc.)
(revised 8/15/95) 8
�c�n FILE#
P
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
i V A 17-70 S0.fer, S� i(� f/ndoves'
aponJ4/
S!' /c
Ton-{4
14faG= �?3'6'� �
4.z'7
Cfe,D: 3z•
DEPTH OF GROUNDWATER VA �
Depth to groundwater: it rY" feet /oa N
method of determination or approximation: As�u�/� /G'��s has /tva �oN s r�� 7��13ox T. .�✓� s :�
4-0 f�.r T�tn� ?�•e lc�cl�� r� /;,res it.�c.
✓e ' ���on clµfu• Sa f� .S/yne S/ro d, G '
v2
(revised 8115/95) 9