HomeMy WebLinkAboutMiscellaneous - 290 Rea StreetINN
.n Commonweafth of Massachusefts
Execufive Office of Environmenfal Affairs
Department of
I- D ---E P- Environmental Prote�
VAIllarn F. Weld
Govmtrno
Argeo Paul Celluccl
U. Go%ornor
19
9
on"--,- 5
Coxe
David S. Struhs
I Comminionor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
aCto
Property Address: �J. Address of Owner.
Date of Inspection: R /0 (If different)
Name of Inspector- �Rzk-egLXN
Company Name, A�d!cssea:AndkTeli-phone Number.- BATESON ENTERPRISES, INC. TEL.- (508) 475-1474
Excavating - Water & Sevver Lines - septic systems & Pumping Service FAX: (508) 475-5451
111 Argilla Road Andover, Mass. 0 1810
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 fimction and
maintenance of on-sle�a
sew, �gesal systems. The system:
.s s
"Ses
— Conditionally Passes
— Needs Further Evaluation By the 1.4cal Approving Authority
Faills
Inspector's Signature:
The System Inspector a su it a co this inspection report to the Approving Authority within thirty (30) days of complet ing 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 Envirorunental 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:
A] SYSTEM §ES:
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 determination in all instances. If "not determined", expWn why not)
The septic tank is metal, cracked, structurally unsound, shows substantial irdlltration or exfdtration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforn-dng septic tank as approved
by the Board of Health.
(revised 11/03/95)
One VAnter Street 0 Boston, Massachusetts 02108 0 FAX (617) 5546A049 Telephone (617) 292-55M
40 Pnnied on Recycleci Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: (acl 0 peo'�
Owner. kA6
Date of Inspection: /-n _
n I S—qfo
Bl 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
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. I
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 ENVIRONMEN1%
I
— Cesspool or privy is within 50 feet of a surface water I -
— 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.
— 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 weU.
— The system has a septic tank and soil absorption system and in 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.
3) OTHER
(revised 11/03/95)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: act 0
Owner.
�-A'K% -\V0 V-k-ck
Date of Inspection; tQ _ ( '6
-5
DI SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as dermed in 310 CMR 16.303. 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.
— 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 112 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 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 60 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 water analysis for
coliform bacteria, volatile orgardc compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
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 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 I, of a public
water supply well)
1118 o�vner 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 Airther information.
(revised 11/03/95)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 0qC) P, "Uz"t�—
Owner.
Date of Inspection:
Check if the IfoUuo e been done:
le !7>�
Mpin i rmation 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.
A//k built ve been obtained and examined. Note if they are not available with NIA.
"e or dwelling was inspected for signs of sewage back-up.
::� f a �c
he 'vo6n
he does not receive non -sanitary or industrial waste flow
The a was inspected for signs of breakout.
�A III �s bee ocated
yetee components, excluding the Soil Absorption System, have n I on the site.
tic t
eseptic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
�rial of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
Thesie rnd location of the Soil Absorption System on the site has been determined based on existing information or
ted by non -intrusive methods.
app '�t
ZThe facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -
Surface Disposal System.
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: ago PQek'-12;V- v &k& LOX -
Owner. K�----Momqz"
Date of Ins pection-
RESIDENII&
Design flow:_qy.Q�_�Jong
Number of bedrooms- q
Number of current i�;ident,
Garbage grinder (yes or no): � �'E
Laundry connected to 2 (yes or no): �jo
no
Seasonal use (yes or
Water meter readings, if available:
FLOW CONDITIONS
— CeAOLAAAGOi- 8" V�
-3.,X ti "g = 611,5m
3-7T, Z7 = A �7 C4
a 4 0 QrK q0
Last date of occupancy: Luvre-4.
COMMERCIALANDUSTRIAL-
Type of establishment:
Design flow:_gallona/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:
PUMPING RECORDS and source of information:
GENERAL INFORMATION
I lcms 136-5-�
::�- =. (DOL4
q Lf - 0U'jV\Q-q-
System pumped as part of inspection: �yeg or no)
11yes,volumepumpeo: WOO.Kallw 4��
Reason for purnping: 'I Vk�
'A --
TYPE'LO"FSTEM
. -4
Septic tank/distribution box/sou absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection mcords, if any)
Other (explain)
.0.0
APPROXIMATE AGE Of all components, date installed (if known) and source of information C?
IA- I tl r7
Sewage odors detected when arriving at the site: (yes or no) PO
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 0 S' -V 0i
Owner.
Date of Inspection: /7-1�
n ts—Ctfo
S EPTI C TANK
(locate on site plan)
Depth below grade:
Material of constructio tZboncrete —metal —FRP —other(explitin)
Sludge depth: (,=, " - NJ 11
Distance from top of.sludge to bottom of outlet tee or baffle: ZG
Scumthickness: L4 11 f r
Distance from top of scum to top of outlet tee or baffle: G -to
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(reconunendation for
e%*,pce of.leakage, 4
GREASE TRAP,_
(locate on site plan)
condition of inlet and outlet tees or
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:
Distance from bottom of scum to bottom of outlet tee or baffle:-
in relation
integrity,
Conunenta:
(recommendation for pumping, condition of inlet and outlet tees or baffles, I depth.of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
(revised 11/03/95)
6
01Z.
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addremract o AA't-�
Owner. M �-- -S
Date of Inspection:
TIGHT OR HOLDING TANX- Y"'y
(locate on site plan)
Depth below gmde:_
Material of construction: —concrete —metal —FRP —other(explain)
Dimensions:
Capacity: gallons
Design flow:_________galJons/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:
Comments:
(note -if leffll ajjj 4ijqritution � equil, evidenceof solids carr7oveX evidencelof leakage into or out-ofbox, etc,)
C>
L — % � 011 Rd � K2 711% 9
E
PUMP CELAMBERX'�—
(locate on site plan)
Pumpks in working order:(yes or no)_
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
4A'IA__
Property Address: act 0 - V 6U
Owner. Rv-- - AAkQkkk-R S-1 U
Date of Inspectio---'�
nt�) — I -S'— 9
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plam 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:
leaching fields, number, dimensions: e- k
overflow cesspool, number:_
Comments: (note ndit' soiL signs of hy4raulic of ponding, popdition of vegetation,etc,)
';sNCjV"'-4' C>ar
-no'F�zu' P6 " !=`1LA42. A.16 "RNdikA(z
CESSPOOLS't0V\0
(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scurn layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
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.)
PRIVYNV-)V�e—
(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 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Property Addrem pwc�- sx- 0
Owner. V\0 Ott-jl�
Date of Inspection: ts- qk
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate al.1 wells within 100'
4 A0:51 .4,
A- Ao s;�,
A- A -o i> Q -x*(
B40 1r7
DEPTH TO GROUNDWATER
Depth to groundwater:.��Aet
method of determination or avnroxir
(revised 11/03/95) 9
I
System Owner
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
AJ lb
System Location
196 VL4- ST
/4
Date of Pumping: Quantity Pumped: b gallons
Cesspool: No Yes SepticTank: No F1 yc�
System Pumped by: 64&4" 469&0v�da License
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector: