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Home My WebLink AboutTitle V Inspection Report - 59 WINDKIST FARM ROAD 12/15/2015 . • ',6 a • 9 w Y C., ON V Ma- MPARTMENT OF OF ENTMO 6$ ENTMONMENTAX,PROTECTION . •N YI OFFICIAL INSPECTION FORM 'NO FOR VOLUNTARY ASSE5 SUBSURFACE SEWAGE DISPOSAL SYSIZM FORM PART CERTMCATION Property 9 lNa� 6-ft F� K ou�z ut_.. s Addrem —Ne'r—r-h a w Data of Inspertioat : a q- p Name of Inspeetoa- &I L 1�t:F'FLF RSTA " Company Naumas Mailing Address_ IS"N tic-,3 C A I) s t, ANpau�-rx. Mp Tdephme Nwnben 9'7 $ - y-7 C-3 S CERTMCAT16N STATEMENT 1 this I hsvo persoully ftLVccW the at this ahn and that the below is mic,accurae and*=Ado as ofthe time of The faVation was'peribmed lbLW on my and c9aiam in the proper 2 and ao of on•slte mwase Y am a DEP approved ayatem Wspector purn&nt'te of va@ S(31opm 11000} The Needs'Purther B ustim by the Loaf Approving Autharity Pails' Inspector's Signature: ` v _ Date: 7'" 36 '63 The"em ' "mb6h a ccPY of this report to the Approving (Board ofHealth or DEPj withia 30 days of=pletin this h C.If tho q3tem is•dured mystam or ha:Yes do4p flaw of 10,000 t0d or add the 9stem owm ahaal th to the qmw of the DER The orighal should be aunt to the owner and copies amt to the buyer,if app and the approvbng authority. Notes and Cammma, •••• repon only deseribes eoa�l dm attire time of and tie of aw at d3mat time.M naf ' how 19r+a sydem trill perftm in the fWm=4jr the saw or Mmut condidons of me. k1 ' At PagC2 OMCIAL INSPECTION FO -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE E'WACE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(coatinueii) Property Ada 11 co INA ki�T Owner. 4L( Da tv of Yospecdom bspection Summary: Check A,B,C,D®r E/ complete an of Section D A. System have not found any inkirmadou which indicates that any of the fWwv criteria de=fbad in 310 CUR 1 5.303 or in 310 CMR 15.304 odst Any Whre criterianot evaluated are Indicated below. Comments: givS7cM S' bip,,re-rj. �e �( B. System Cooditlonany r, Passm- One or more rystem components as "bed in the"Conditional lies:"section need to be replaced or The synem,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer ycs,no or not determined(Y,N,ND)in the fof the following ents.If"not ' od"plaso explain The septic tank is metal and over 20 years old*or the septic tank(whoa metal of not)is stn= ally unsocmd,exhibits miWtantial infiltration or exSltration or tank failure is mea System will pass inspection if the exuring tank is replaced with a camplying•septic tank as approved by thoamd of Health. •A meal septic ink will pass inspectioa if it is structurally sound,not leaking and if a Catifimw of Compliance iandic]aing dw the tank is less thaw 20 years old is av&WIL ND explain: Observation of sewage backup or break out.or high static water level in the distribution boa due to broken or obstructed pipe(s)or due to a broken,settled or uneven distributloa bra.System will pass inspecdoa if(with approval of Board of Health): broken pipe(:)are replaced obgructloa is removed "distribution bra is leveled or replaced ND explain: The pumping more dm 4 times a year due to broken or obstructed pipc(s).The rystem will pass inspection if(with appvval of the Board of 161# broken lnPc(s)arc reps obstruction is removed ND explain: Page 3ofII YI OFFICIAL INSPECTION FO m NOT FOR VOLUNTARY ASSESSMENTS l SUBSURFACE SEWAGE(DISPOSAL SYSTEM INSPECTION FORM PART A C R CATION(continued) Pmperty W 1 N� �isT rO Rn �� J Or Owner. " " Da cc of ® • ` C, Farther Evaluation Is Required by the Board of Health: Conditions aist'which rcqtfwo fint er"u&tfw by the Board of Health in order to determine if the is 6dling to protect public health,safaty or the taykaomeat I. Sygem will pant unless Board ofErealth determines in accordance with 310 CM 1 0V)(b)that the system is not functioning in a mannerwhkb will proted public health,safety and the environment: _ Cesspool or privy is within 50 fed of a=6ce water Cesspool or privy is within 50 fed of a vegetated wetland or a salt mash r 2 Sysum will fail unless the Board of Health(and Public Water Supplier,if any)determines that the rfu m b functioning In a manner that protects the public health,safety and environment: _ The system has a optic tank and soil absorption system(SAS)and the SAS is within 100 foot of =fan wa ff supply or tattzry tot m6ov W&W wpply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _• The system has a septic tank and SAS and the SAS is within$fed of a private water supply well. The system has a se�tic tank and SAS sad the SAS is less them 100 fad but 50 fed or more from a private water supply well".Method used to detamine distanco. "This system pLucs if the well water analm. 4 performed at a DEP certifiod laboratory,for coliforzam bacteria and volatile organic compounds indieatemr that'the well is free from pollution from that facility and the preseee of ammonia nitrogen and nitrate b1trogen is equal to or leas than S ppm,provided that no other Suture criteria are triggered A copy of the analysis must be attached to this form. .............. 3. Other. "` " Page 4 of 11 OFFICIAL SPECTION FO ®NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM� PART A " CERTIFICATION(continuctl): Property Address: � W 1 N� Owner. LLY Date of Ins on: "7 —4. ® Q D. System Failure Criteria app"blc to all qstt You m W indicate"yes"or`no"to each ofthe following for ai ions: Yes No ® of sewage into facility or 0y3tem component duo to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surfice of the ground or awhice waters due to an overloaded or loggod SAS or 1 Static liquid level in the distribution box above o ct invert due to an overloaded or clogged SAS or 1 iquid depth in cesspool is less dtan 6"below invert a available volume is less than K day flow Required pumping more than 4 times in the last year=due to clogged or obstructed pipe($), — Number of times purtnpe d — �y portion of the SAS,cesspool or privy is below high ground water elevation My portion of cesspool or privy is within 100 feet of a sur&oe wets supply a tributary to a surace /Xater supply y portion of a o=pool or privy is within a Zone l of a public well. y portion of s cesspool or privy is within 50 feat of a private water supply well. ® �y portion of a cesTool or privy is less than 100 foeut but greater than 50 fed from a ivate water 1� supply well with no actoptable water quality analysis.rM'System Osses if the well water performed at a DEP laboratory,1br eoU6rm bacteria and volatili organlc compounds indicates that the well Is free&*01 pollution from that LeWty and the presence of axamonla nitrogen and nitrate nitrogen is equal to or leas than S ppm,provided that no other factlure criteria are triggered.A copy of the mast be attached to tuts form.) ® (YeslNo )The system&U I have determined that one or more of the above failure criteria eocist as dc=*bod in 310 CMIi 15.303,therefore the aystcm tails.The system owner should contact the Board of Health to determine what will be ncc=ary to correct the failure. 1? Large Systems: r To be considered a large systrm,the system must serve s facility with a design flaw of 10,000 gpd to 15,000 gFd- You must indicate either gees"or`ho"to each of the following: (Tbe following criteria apply to large systems in addidoo to the criteria above) yes no — — the system is within 400 feet of a surftce&tAing water supply e — the syst= is within 200 fbd 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 H of a public water supply well If You have answered"yes"to any guestioo in Smdou E the system is considered a significant threat:or answered "yes"in So ction D above the large system has filled.The owner or operator of any largo system considered a signi5c aht threat under Section E or Wlexd under Section D shall upgrade the its accordance with 310 CM 15.304. The system owner should contact the appropriate regional office of the Departmek ,. __... � a.. ... . Page 5 of I I OFFICIAL INSPECTION FORK!—NOT FOR VOLUNTARY ASSESSMENTS � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ou c(2_ Owner: t:ll Date of Inspection: Check if the following have been done You must indicate"yes"or"no"as to each of the following: Y No _ Pumping information was provided by the owner,occupant,or Board of HealthWere any of the system components pumped out in the previous two weeks? Has the system 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? 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,excluding the SAS, located on site? Were the septic tank manhofes 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? _V/ 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/' no Existing information. 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)] t Page 6 of I I " OMCIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL Y5 INSPECTION FORM PART C SYSTEM INFORMATION ' Property Address: I j I rJ IL I�� r,R ►� 6 r Owner C LLY 01 Dare of ins — — FLOW CONDMTONS r Number of bodroocas(design): Number of ( ); y r DESIGN flow based on 310 CW 15.203(for plc: 110 x k otbedrooms): D Number of curraat residents: Does residmcc have a gatago grinder(yes or no): AU D Is laundry on a sepuce sewage System(yam or no):fro [If cs SWRIC'�� (Yet or no): .Io inspection ] Seasonal use:(yes or no):&0 p Waaar maer readings,if available(last 2 years mgo(gpd)): 5,G G ATTp a r 2 F�-c- po+CT Sip pump(yes or no): 1t3 Q Last date of occupancy: �rr�N� COMMLRCLUjmusnU L Type of establishmaW- Desi Dow gn (based on 310 CMIIt„15.203):' god Basis of design Dow(seats/ 3yket): Gmw trap present(yes or no): Industrial waste holding facile present(yes or no): Non-sanitary waste dwhned to the Title 5 S>W=(yes or no):®, Water meter reading if available: Last date of occupancy/use: OTEER(describe): GENERAL UMRMA71ON Pimping Records Source of information: &cn jo6T -.P S)raC I Njap,AWT1.0" Was syu= pumped as part of the,irwaction(yes or n ): If yet volume pumped:_gallons—How was quantity pumped determined? Ronson for pumping: OF SYSTEM S�cpac tank, distribution box,soil absorption _ Single cesspool Overflow cesspool pri g, . — Shared sYgcm (yes or no)(if yes,attach previous" oa rccads,if any) innovati vc/Altanative technology. Attach a copy of the currant operation and maintenance contract(to be ob_ od from system owner) Tight tank ®Attach a copy of the DEP approval _ Odra(describe): Approximate age of all components,date installed(if known)and source of information: Ctq f� Were sewage odors'decected whim&wing at the site(yes or no):�TQ JU1 • 23 03 01 : 50p, P. 1 [NIXIE]MMIUM"IY73-9 I I �a � r. .7barW aNO� a om .ata � X J wNCID COT t]OLfYN NLf1rR Y • f . . • Y +0LA4r ® 0 -a 0. N w0. NrR ile r sd Yau1NrN Ya +lD0ar NOON M go W m:'� m ® n ® ® mrrrr ® dogo aaao 66W 000MMMM NNINN 9 tip000 LLJ r Tr ,- r ® ® ® imbn ® ® � a+ mn ® em � mm x w ++ t04Ra10 .35' M �' MrO+ M �' ® t'� IA �p CoNCCWWN N00 MCYCJm.0C1 J�J 6b OMB �OL11Y' TtO �S�rryylrOrMr4NO. Lh .Sf' mOC ! •` .. �i � .7' tALf16'VrT' LflSt � �N, �!' N6°19N � �' M t' L6 N C9 CJY '.7t? LV CA O+ GO r R R 0. C>S Qm Qp h4. t0 ' ien Jh� w 90NT hC3rrm4 � r oDTrr C6 W Q � b N T Qr T QY OC %a h o r m 4 a �p LA r � I 3 lai`loi l J � ud 0 LI't 10 10 No C N 0 04 4P4 C+ C+ r T T F- f11e� '`'d�.,,,I•.t� 37!!.F y�y�,,� c. W T T r can �I"J YLA0 S LLJ Ur1 p t3G a rMLt11d�1111 � b +0ti0r0aO�10M. � Tr I E., x; IL bw p o w Ch 04m ® o03oammao ® m ® � � mlm v >` �i1 H I Ca 4rNC11NNNNNNNNNNNNN I R F'' !/7 I u °+.•a�'tiy.""w "`a O ti"^v"+,°e'�4,1m"a 1 4,`a. 4. L '�" ," ':; r�-" S 1 C a' TCrrMCL1Q � Nt+ rrNNNN4 ° I W '+w`a�yy.. 4w 4.'^w�'y` a.'•o `w�`ry.`s'. "w rY ® .e Cl mr ® rcfr` rr- Ca � rmrs � Irr 4 r4r4rr4rrTr OCT- 44r o M o r N M V T N M 0 Q - N 0 4 � s3 lI g III m I W� I t I I rI I 11 I I I I I I I t z OC 1 d tlaaQa `ARQ+ 'aa" !, ? I } rr� a10s:aaap ®av ® ®a0Waaaa w wj Ga NNNNN04 NNNNNNNNNNN v:+ UI I qt r' NMV1 +Oh6Q 0. ® W) A* N W i ® , { P� YI , I f Page 7 of I 1 0MCIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Ad i m I S-r fA R K 6 rT wa p1hU G�fC Date of -1 BUILDING SEWER(locate oa site plan) Depth below grade: o� Materials of an: cast iron ®40 I'WC®,odic (explani): DLumcc from private water supply well or muctloo line Comm cam(on cooditica o!jo �ints, ovidenoa of leakago,etc.): Td, + T lTc V1 L C P iC S SEPTIC TANK:_ locate oa site plan) Depth below grade: � 6, Material of oreta®metal® --polyethylene If tarok is metal list ago:® is ago confirmed by a CaUcgic of Compliaaa(yes or no):®(attach a copy of ccti5oxzc) Dimezasions:��®v Shadgc deptfa: Distance from top of sludge to bottom of outlet too or baffle: 1 Scum thiclmcm: 0 To . rJ iN Dismcc from top of scrum to topyof outlet tee or baffle: Distance from bottom of scum to bottom of outlet too err baffle: w How were dime sioas ddaminad,v a Sea t^e N t Commcrts(on pumping cadations,Wet and outlet toe or baffle ;tura l integrity,liquid levels u related to outlet invert,rAdenoo of leakage,eta.): ®W N Lr- Li, Au M ip -TA►J�� 0 5 n®nJ GREASE TRAP:®(locato on i ho plan) Depth below MixWW of 'on:®odoavto—metal_ffbaghm_polyethylene—other (explain) Dimensioas: Seim thickness: Dis=oc from top of scum to top of outlet too or baffle: Distmc c from bosom of scam to bottom of outlet tee or baffle. Dec of last Co=o=(on pumping 'oat,inlet and outlet tee or baffle axiditloo,structural fatcga %liquid levels as related to outlet invat,evideaae of Ieakago,eta): .......... page 8 of 11 q OMCIAL,INSPECTION FO -NOT FOR VOA, Y I SUBSURFACE SE I► /yyAGE DISPOSAL INSPECTION ON FO y� PART C t ... . SYSTEM ,0 TION(000tlnuad) Addrm. l c2 pl TTGHT or HOLDING T (tank must be pumpod at time of bspectionVocata oa she plan) Depth below r mata'ial of 'oa: Concrete—WOW® ass yleae`otila( Dime sioos: Desip Flow: aziLms/da Alarm y (yea or-no): Alum Iced:® Alstm In Waidni ada(ya crno): Comm=(conditiod'of d Soar switches,eta,): DISTRM LrITON BOX.®(Ifprcmt must be ed)00mW 00'sito plan) Dew of liquid laud above outlet invert: Cammana(note if bout is level and oa to outicu equal,'any evidence of solids carryover,any evidence of leakip u,u,S or t L box,dp_): r IN PUMP ®00cate Go site plan) in wog aria(yeah or no): Alum is wail s ader(yes or no): Commas(note voadition ofpump&=bor,=dWw ofp=ps aad aP ce;vtQ): r PI YI a Page 9 of 11 YI OFFICIAL INSPECTION FO —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Ada W' N a 1ST" f1 R to Q ' you e fL Da cc Owner. 9 43 • v SOLL ABSORPTION SY (SAS):Zoocate on site plan,excavation not required) N If SAS not located explain why-.- Type _Irk g Pte.n=bcr:_ leading chambers,numbs• leaching galleries,number. leaching trenches,number,length: C _leading fields,number,dimensions: overflow cesspoolrnumber: innovative/alternative system ry*' namo of technology: Commmu(note condition of soil,'sigm of hydraulic fatflure,level of poading,damp soil,condition of vegetation, etc.): ,r- — X GA"3 aT10VJ C1,eprrot . t '��/ �J®�,C. V V CESSPOOLS: (cesspool mµst,be pumped as pert of inspoctionXIocate on site plan) Number and configuration: Depth-top of liquid to inlet invcq: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yp or no): Cor==ms(note condidoo of soil,signs of hydraulic failure,level of poodhi&condition of vegetation,etc.): , PRIVY: (locate ou site plan) Materials of construction: Dimensions: „ Depth of solids: Commenter(note condition of soil,signs of hydraulic Mure,level of poading,condition of vegdatioa,etc.): i 1 Page 10 of 11 OMCIAL INSPECTION FO -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM 0 TTON(cnntinuw) ny Ad : Daate of ®s: 7-0.9-03 SXrrCH OF SEWAGE DISPOSAL SYS'>rZH Provide a sketch oftho wwage dLVOUJ ry3t=incl dos to at last two pomanent rdwence landmarks or bca 1.4cara alr l foss.1=4W whao public walla supply enters the buildl4 H C H To L o / J� ��'aN TpINcQ L f"W ep- p w1j c X- ,11 (ho A r^era (� To C- 1 O N�•c A- yt A!Z.- O 0 C Q -T Pic I I of I 1 f OFF7CIAL INSPEC77ON FORM—NOT FOR VOLUNTARY ASSESSMFZM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Property .,SYSTEM INFORMATION(oontinuexi) . . Ad �7 �'►of a Owners E W a Date of hupectim.. 7 —M 7 b 3 SITE EXAM Slope ✓' w&W Cbe ck cellar ✓ Shallow welly ✓ I Estimated depth to ground waw,, feat Place indicate(chock)aU methods umd to ddarmine the high ground wafer olervatim: p pre P _ZObaunal from system dcs(gn plans or roa)rd•If c heC3 4 data of dcslp plan revrowed: site(ahming pWerV/oUavat1oa hole within 150 Soot of SAS) Cbcdod with local Board of&zhh-mcpleio: Cbecked with 1061 eaacav110M iwWlal-(aftch documentation) _ Ao=3cd USOS dstaba, lain: You must dc='bbe how YOU establisbe�d the y h10 p'oemd water elevation: re n ra7co '" —�$ csnJ r U V P ca Lib �Co237 r r I