HomeMy WebLinkAbout0026 ADRENA AVENUE - Health 12 Adrena Avenue,Centerville
UPC 12534
No.2-1153_
HASTINGS, MN
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs --f- -f
Department of
Environmental Protection ` p
Wllllam F.weld - VTC� 9 1g96
Gommor
Trudy Coxe
8eeretery.EOEA ' co
David B.Struhs pB+C
Comminioner r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM v ,`
�� �0/'ZdifI Avt-Nub PART o,
CERTIFICATION 14/t"L. Al f Ii
Property Address: Address of Owner:
Date of Inspection: (If different)
Name of Inspector: W.E. Robinson Sr.
Company Name, Address and Telephone Number: W.E. Robinson Septic Service
P.O. Box 1089
Centerville MA
CERTIFICATION STATEMENT ��77�77
I certify that I have personally inspected the sewage dispos l spsCertt t 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 r�
Inspector's Signature: �`�, Date: /& —�• 1 �7
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:
A]�SYSTTC PASSES:
1 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", explain wiry 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
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(611)292-5500
r `��}Printed on Recycled Paper /
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: �'� '9 0 °Q t— w- �y�''ni s/✓o t'
Owner: /qn
Date of Inspection:
B]SYST 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
Y
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] FU THER 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
ublic health, safety and the environment.
1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE''SYSTEM IS NOT FUNCTIONING IN A MANNER
RICH 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:
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 well.
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] SYS M FAILS:
I ve determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for is determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the ilure. '
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: f D r e h`a Ale- U/. 1 y.�hrn's •�t—
Owner: ,00 /P7
Date of Inspection: ) �L—;LC;-5 5
D]SYSTE 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 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 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 water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E]LARGE S STEM FAILS:
T e 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
a d 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 II of a
public water supply well)
The owner o operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements f 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:
Ave w Hyomsiaoer
Owner: '0 4 1,4 y1
Date of Inspection: / '2-4,
Check if the following have been done:
:i�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 nominal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
VAs 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.
//The system does not receive non-sanitary or industrial waste flow
14-e site was inspected for signs of breakout.
All.system components, excluding the Soil Absorption System, have been located on the site.
_Vrhe 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.
" 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.
he facility o�Nner (and occupants, if different 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: /.2 - 19,0ren.4 ,gee— w, k1y*n,4iJ/40rt
Owner: p° l Ar7
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:.3_26 _gallons
Number of bedrooms:
Number of current residents:,
Garbage grinder (yes or no):_�e!/
Laundry connected to system (yes or no):-
Seasonal use (yes or no):_.A/
Water meter readings, if available:
Last date of occupancy: )�L—', 4--9
COMMERCIAL/INDUSTRIAL:
Type of estab' hment:
Design flow: gallons/day
Grease trap pre ent: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary w to discharged to the Title 5 system: (yes or no)_
Water meter re ings, if available:
Last date of oc upancy:
OTHER: (D tribe)
Last date occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: "
J � 1V JOSS 2a�� ��6A- ,51e 7,1
System pumped as part of inspection: (yes or no)4/e
If yes, volume pumped. gallons
Reason for pumping:
TYPE OF STEM
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:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) 5
fi
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �O2 4oren A /eve_ 1R/. dy'llt14iS/9r f'
Owner: V e/Arn
Date of Inspection: ;L
SEPTIC TANK:
(locate on site plan)
Depth below grade: /
Material of construction: _concrete _metal _FRP—other(explain)
►t a 6 e a�s
Dimensions: -t'
Sludge depth:
Distance from top of sludge to bottom o e:�f outlet tee or bafflZ
Scum thickness: 1 1 i ►
Distance from top of scum to top of outlet tee or baffler_
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 outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRA
(locate on site Ian)
Depth below gra e:
Material of constr ction: _concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from t p of scum to top of outlet tee or baffle:
Distance from ottom ot From t- hOttOm of outlet tee or baffie:
Comments:
(recommendation f pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence o leakage, etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: l a- e 1 A ,11le
Owner: QOlA✓1
Date of Inspection: -P-q-q 6-
TIGHT-0 HOLDING TANK:_
(locate on s e plan)
Depth below rade:
Material of co struction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: al Ions
Design flow eallons/day
Alarm level:
Comments:
(condition o7__
tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments: � �
(note if level and distributiun is equal, evidence of solids carr�o�,cr, evidence of leakage into or out of box, etc.)/l/ y
PUMP CHAM _
(locate on site pla )
Pumps in working rder:(yes or no)
Comments:
(note condition of mp chamber, condition of pumps and appurtenances, etc.)
a
(revised 6/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4are- t A �q//e. l✓- k1,v1-9`/17/,f/o,.7--
Owner: Q p ��✓�
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): V
(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:
leaching fields, number, dimensions: ,.0 , G�
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) t)
CESSPO _
(locate on si plan)
Number and c nfiguration:
Depth-top of li id to inlet invert:
Depth of solids yer:
Depth of scum I yer:
Dimensions of c sspool:
Materials of cons ruction:
Indication of gro ndwater
inflow cesspool must be pumped as part of inspection)
CommentX( tecondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site an)
Materials of c struction: Dimensions:
Depth of solids:
Comments: (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
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DEPTH TO GROUNDWATER
Depth to groundwater:Bb , feet
method of determination or approximation: LS ) PO 1,�
(revised 8/15/95) 9
TOWN OF BARNSTABLE
LOCATION j ,(5---�,�` eiy�� �.•rC_ SEWAGE #�
VILLAGE ASSESSOR'S MAP & LOT_j
42- 130
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) � v o
NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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