HomeMy WebLinkAbout0005 BRETWOOD LANE - Health ol
5 BRETWOOD LANE, CENTERVILLE
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
John Grad
One winter Street,Boston,Ma. 02108
D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (508 564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F �!
PART A
CERTIFICATION '7jQ
Property Address: 55 Brettwood Ln.Centerville Address
of Owner: yF04, l9
Date of Inspection: 3/2198 (if different)
a Grendoak Rd. r ale �6ojr9B 98
Name of Inspector: John Graci
1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
8 G'
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:
x Passes This Inspection Is based on crlterla dented In Title V
_ Conditionally Passes code 310 CMR 16.303.Myflndtnas are ofhawthe system Is
performing atthe thne of the inspection.My Inspection does
_ Needs F h r Evaluation By the Local Approving Authority not Imply any vrarrantyor guarantee ofthslonilevltyorthe
Fails septic system and any of Its components useful life.
Inspector's Signature: Date: 312f98
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
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 NO). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank Is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Colhpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal, is 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 007197)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 55 Brettwood Ln.Centerville
Owner: Matione:2e Grendoak Rd.Forestdale
Date of Inspection:31219e
— Sewaue backup or,breakout.or hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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.
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 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 of water supply or tributary to a surface water supply.
— The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
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.
Yes No
_ — Backup of sewage in 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
cesspool.
— SAS is in hydraulic failure.
(revised 0427)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 55 Brettwood Ln.Centerville
Owner: Mattone:26 Grendoak Rd.Forestdale
Date of Inspection:312199
D]SYSTEM FAILS(continued)
Yes No
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).
Numbers 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 1 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 SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
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:
Yes No
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 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 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 55 Brettwood Ln.Centerville
Owner: Mattone:26 Grendoak Rd.Forestdale
Date of Inspection:312199
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_y_ — The site was Inspected for signs of breakout.
x All system components,excluding the Soil Absorption System,have been located on the site.
x 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.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)[15.302(3)(b))
(revised 007197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 55 Brettwood Ln.Centerville
Owner: Mattone:28 Grendoak Rd.Forestdale
Date of Inspection:312198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 220 g•p•d./bedroom for S.A.S.
Number of bedrooms: 2
Number of current residents: U
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if avaiiable:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: September
COMMERCIAL/INDUSTRIAL:
Type of establishment: Na
Design flow:o gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nra
Last date of occupancy: We
OTHER:(Describe) rds
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
rda
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: rda
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date Installed(If known)and source Information: ;
1991
Sewage odors detected when arriving at the site:(yes or no) No
(revised 04127187)
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 Brettwood Ln.Centerville
Owner: Mattone:26 Grendoak Rd.Forestdale
Date of Inspection:312199
SEPTIC TANK: x
(locate on site plan)
Depth below grade:2"
Material of construction:x concreate_metal_FRP_Polyethylene_other(explain)
If tank is metal, list age nle . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: LeW•1-157"w410"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness:o
Distance from top of scum to top of outlet tee or baffle:5"
Distance form bottom of scum to bottom of outlet tee or baffle:0
How dimensions were determined: measured
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.)
Septle tank and all components are structurally sound and fUnetloning properly.Recommend pumping everytwo years.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rva
Scum thickness:nla
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: Na
Date of last pumping;d.
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.)
We
BUILDING SEWER:
(Locate on site plan)
Depth below grade: e"
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction linet—
Diameter: 4"_
Qmments: (conditions of joints,venting,evidence of leakage,etc.)
(revlsed 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 Brettwood Ln.Centerville
Owner: Mattone:20 Grendoak Rd.Forestdale
Date of Inspection:312199
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: roe
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: rda
Capacity: rda gallons
Design flow: rda allons/day
Alarm level:—rda Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rds
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: nia
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
rda
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Yes
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
(revived 04f17r87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 55 Brettwood Ln.Centerville
Owner: Mattone:2e Grendoak Rd.Forestdale
Date of Inspection:312199
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
rda
Type:
leaching pits,number: 6x4leech ptt
leaching chambers,number:Na
leaching galleries,number: nia
leaching trenches, number,length: rda
leaching fields,number,dimensions:rda
overflow cesspool,number:Na
Alternate system:-rda Name of Technology:_nra
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Leach pR and all componentsa re structurally sound and tUnctlontng properly.System has been NO at one time.System to now empty.Unable to see under normal use.
CESSPOOLS:
(locate on site plan)
Number and configuration: rVe
Depth-top of liquid to inlet invert: n►a
Depth of solids layer: Na
Depth of scum layer: nia
Dimensions of cesspool: rda
Materials of construction: rda
Indication of groundwater: r9a
inflow(cesspool must be pumped as part of inspection)
nfa
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
nfs
PRIVY:
(locate on site plan)
Materials of construction: Na Dimensions: Na
Depth of solids: nla
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rig
(revised 04r17)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
55 Brettwood Ln.Centerville
Matlone:26 Grendoak Rd.Forestdale
312198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
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(rovived 04WI97) Page ! of 20
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
55 Brettwood Ln.Centerville
Mattone:28 Grendoak Rd.Forestdale
31VOS
Depth of groundwater 12.
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS maps and charts
I
(revised04WIDT) )aye 10 0[ 10