HomeMy WebLinkAbout0463 BAY LANE - Health 463 BAY LANE, CENTERVILLE ,
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No. 4210 .1/3 ORA
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Commonwealth of MassachusettsC44 ,
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Executive Office of Environmental Affairs
De artment g,
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of Envir
onmental Protection1Afilllam F.Weldt3ovemorTrudy CoxeSecretary,EOEA
David B.Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `
PART A
CERTIFICATION
Property Address: 4 6 3 19 i9.f Lgrv,#_ C,etv�p.ry 1l�� Address of Owner:
Date of Inspection: 6=30-I (If different)
Name of Inspectorf- 6�5�_ �,,�
Company,Name, Address and Telephone.Number:
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:
1� Passes
_ Conditionally Passes
Needs.Further Evaluation By the Local Approving Authority
Fails,
Inspector's Sign 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 sen; tc, the system owner and copies sem to the buyer, if applicable and the appro�'ing authority.
INSPECTION SUMMARY:
Check A, B,C, or D: w
A]•SYSTT PASSES:
V
I.have not found any information which indicates that the system•violate.s 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 why not)
_ The.septic tank is metal, cracked,,structurally unsound, shows substantial infiltration or exfiltration,-or tank,failure is
1, ;:'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 - e Telephone(617)292-5500
i,Printed on Recycled Paper, .
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SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7 3 ay Lc V-o—"
Owner: pw-c,�r�, L
Date of Inspection:
B1 SYSTEM CONDITIONALLY PASSES (continued)
jy 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): t
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ year due to broken or obstructed pipe(s). The system will pass
The system required pumping more than four times a
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C1 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
Cesspool or privy is within 50 feet of•a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLES5.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 wstem has a septic tank anu soli absorption system and is within iw foci iG a sii�d�c.waici SiipjJ'� Gr trll)uiaij t0 a
surface water supply.
_ The system ha, 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 systen, has a septic tankand 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....
tem.component due to'an overloaded or clogged SAS or cesspool.
Backup of sewage into facility or.sys
ed or
„�
-Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload clogged SAS or
cesspool.
2.
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 'Y O 3 rs l UvJe— Geti.ti
Owner: 1�I�c.,rc�n ctil_
Date of Inspection:
D]SYSTEM FAILS (continued):
I`l Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
N 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] LARGESYSTEM FAILS:
The following criteria apple to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd orgreater (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 mapped Zone 11 of a
public watersuppiv 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.
(revised 8/15/95) 3
5 - .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 4163 -9 Uiv� C�ewZ'r
Owner:. rc.�r L
Date of Inspection:
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health,
k/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.
v/As 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
V"The,site was inspected for signs of breakout.
Z—All system components, excluding the Soil Absorption System, have been located on the site.
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.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by nun-intrusive methods.
he faci;it} c.•;.c ;r.:' occupants, if d"T-ent from,.ov:ner; 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: 416 3 ��y (-u. C-e,-
Owner:
r Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
W Design flow: 330 eallons
Number of bedrooms:_
Number of current residents:
Garbage grinder(yes or no): (ye(
Laundry connected to system s or no):�
Seasonal use (yes or no): /Y
Water meter readings, if available: hl
Last date of occupancy: QV'eG1LH7 'Wv\L
'COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial'Waste Holding Tank present: (yes or no)_ i#
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: -
#_ GENERAL INFORMATION
PUMPING RECORDS-and-source of information:
System pumped-as pan of inspection: (,yes or no)_
If yes,'volume puMfJed: _ gallons
Reason for pumping:.,..
TYPE OPSYSTEM.
V 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
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 a W�—1 1, ct� cry ,
Owner:. AO YLAn., __
Date of Inspection
SEPTIC TANK: 1� {
(locate on site plan)
F/0,
Depth below grade:_
Material of construction: ncrete _metal _FRP _other(explain)
s Dimensions: &4
Sludge depth: j2" y�S
Distance from top of sludge to bottom of outlet tee or baffle: .
Scum thickness: J l t
Distance from top of scum to top of outlet tee or baffle: `f yff
y
"A Distance from bottom of scum to bottom of outlet tee or baffle:_
Comments:
(recommendation for pumping;condition of inlet and outlet tees or baffles, depth of liquid level in relation to tie Eves structural
integrity, evidence of leakage, etc.)' U oo-0 S1" (�!- �Ztc��'�h' `Q
` U
GREASE TRAP: I
(locate on site plan).
Depth belowgrade: ^-_
I' f construction: concrete _metal _FRP other(explain)
Matena o _
Dimensions:
Scum thickness: "
Distance from top of scum to top of outlet tee or baffle:
m n
tt m t i tips tee 0'battle*
IC n P T f1 - i
�._ta..c_ fro... bolt.
` Comments:
,� (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
y integrity, evidence of leakage, etc.)
(revised 8/15/95) t 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: q&3 igo Y Lh v Cie w ii s
Owner:.
Date of Inspections
5 fp
TIGHT OR HOLDING TANK:/
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal FRP —other(explain)
Dimensions:
Capacity: gallons
r
Design flow: gallons/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: 6(o'2 ' �--
Comments ,
(note n ievei and dstribuu�,,, e�.dence of'sol;d: carr�o%er, evidence of leakage into or out of box, etc.) -
PUMP CHAMBER:
(locate on site plan)
Pumps in working•order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps.and.appurtenances, etc.)
rt �
(revised 8/15/95) �.• .
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:_
-3a 4
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: UA r) �-),
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS:
(locate on.site plan)
Number and configuration:
Depth-top of liquid to inlet.invert:
Depth of solids layer:
Depth of-scum layer.
Dimensions of cesspool
Materials of construction
indication of groundwate,.
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.)
PRIVY
(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 8/15/95) B.;
R.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: `( �0 D+
OwnersL—
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'41
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DEPTH.TO-GROUNDWATER
Depth to groundwater: Ic� feet o c ;a
method.ofdetermination or approximation: Il.
T W�. n✓ � vv
9
(revised 8/15/95)