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HomeMy WebLinkAbout1125 CRAIGVILLE BEACH ROAD - Health 1125 CRAIGVILLE BEACH RD., PF CENTERVILLE A = a 1 r•r. d S JAI /J UPC 12534 No. 2�153L OILpcs.�ovS�� HAST146S,MN COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS S s DEPARTMENT OF ENVIRONMENTAL PROTEbN 8 ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 41R � © WILLIAM F.WELD Richard. Bla We1%, v .799TRUDY COXE Governor v /,`rY. �cretary ARGEO PAUL CELLUCCI �4 �AVID RUHS. Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM o issioner PART A' 4* CERTIFICATION ?' Property Address: 1125 Craigville Beach Rd.. Address of Owner: 5 Fred.erick Circle. Date of Inspection: Centerville ,MA (If different) Woburn, MA 01801 Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Servi c Mailing Address: PO Box 1089 , CentPrvi 1 1 Pr MA 02632 Telephone Number, 50 8 7 7 c,_8 7 7 6 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 s�ge disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: s , Date: 9 9 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] S PASSES: have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. DENTS: ny failure criteria not evaluated are indicated below. B SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Y*Tm Indicat 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (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. (r 04/25/97) Pago 1 of 10 DEP on the World Wide Web: http:ltwww.magnet.state.ma.us/dep ej Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1125 Craigville Beach Rd.. ,Centerville Own;r. " Richard. Blackwell Date'of,Inspection: — �-� v N-'� B] SY TEM 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). Describe observations: l 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: Co ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the p lic health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER HICH 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) SYS EM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENV RONMENT: The system has a septic tank and soil absorption system(SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OT ER (revised 04/25/97) Page 2 of 10 ;t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1125 Craigville Beach Rd.. , Centerville Owner: Richard. Blackwell Date of Inspection: 1,;o4,;_,q V DI S EM FAILS: You mu indicate eir,er "Yes" or "No" as to each of the following: have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis r this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct th failure. Yes No 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 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. El RGE SYSTEM FAILS: Yo must indicate either "Yes" or "No" as to each of the following: 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: 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 o ner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requ ements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) . Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1125 Craigville Beach Rd.. , Centerville Owner: Richard. Blackwell Date of Inspection: Check if the following have been done: You must indicate either "Yes" or"No" as to each of-the following: Yes No Pumping information was provided by the owner, occupant, or 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. 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. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. Y _ 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. !/ _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1125 Craigville Beach Rd.. , Centerville Owner: Richard. Blackwell Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: —70 p.d./bedroom for S.A.S. Number of bedrooms: -1 Number of current residents:, Garbage grinder (yes or no):.,4, d Laundry connected to system (yes or no):�f�� Seasonal use (yes or no):,Li,�,5 Water meter readings, if available (last two (2) year usage (gpd): 1998 30, 000 gal. Sump Pump (yes or no):4AL 1997 13 , 000 gal. Last date of occupancy: COMMERCIAUI N DUSTRIAL• Typ of establishment: Desi n flow: gallons/day Grea a trap present: (yes or no)_ Indus rial Waste Holding Tank present: (yes or no)_ Non-s nitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last d to of occupancy: OTH R: (Describe) Last ate of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 1,9 9 G System pumped as part of inspection: (yes or no)IL D If yes, volume pumped: gallons Reason for pumping: TYPE OF,SYSTEM 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: /b VS6 Sewage odors detected when arriving at the site: (yes or no) d (revised 04/25/97) Page 5 of 20 e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1��5 Craigville Beach Rd.. ,, Centerville Owner: Richard. Blackwell Date of Inspection: B LDING SEWER: (Loc to on site plan) Depth low grade: Materi of construction: _cast iron _40 PVC_other (explain) Distan from private water supply well or suction line Diame r Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_✓ (locate on.Site plan) r ' Depth below grade: Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: /„ 4c, Sludge depth: 7--3 Distance from top of sludge to bottom of outlet tee or baffle:L/ 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: l3 How dimensions were determined: e) Y'9,6 -I A n Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid le veI in relation to outlet i7vert structural integrity, evidence f leakage, etc.) /Ca r� � �,, �i+ /� J3o r /�- Co 's C/ � � P�r G)low TRAP: (l site plan) D grade: Mof construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) mensions: Sc thickness: Dist nce from top of scum to top of outlet tee or baffle: Dista ce from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Com ents (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integ ity, evidence of leakage, etc.) 1 (revised 04/25/97) Page 6 of .10 J - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1125 Craigville Beach Rd . ,Centerville Owner: Richard. Blackwell Date of Inspection:/—,Z;I_.? TI T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (Iota on site plan) Depth low grade: Materia of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimen ions: Capac' gallons y r Desig flow: gallons/day Alarm evel: Alarm in working order_Yes; _ No Date o previous pumping: Comm nts: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: " (locate on site plan) Depth of liquid level above outlet invert: (D Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP HAMBER:_ (locate site plan) Pumps i working order: (Yes or No) Alarms i working order (Yes or No) Comme ts: (note c ndition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1125 Craigville Beach Rd.. , Centerville Owner: Richard. Blackwell Date of Inspection: ` cl 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,Iength: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note c ndition of soil, signs of hydraulic failure, vel of pondin condition of vegetation, etc.) CE POOLS: _ (lo a on site plan) Num rand configuration: Depth-op of liquid to inlet invert: Depth f solids layer: Depth scum layer: Dimensi ns of cesspool: Material of construction: Indicatio of groundwater: inflow (cesspool must be pumped as part of inspection) Com ents (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materi Is of construction: Dimensions: Depth of solids• Com ents: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (ze eed 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1125 Craigville Beach Rd.. , Centerville Owner: Richard. Blackwell Date of Inspection: 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) ( ✓� r (revised 04/25/97) Page 9 of 10 , o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1125 Craigville Beach Rd.. , Centerville Owner: Richard. Blackwell Date of Inspection: /-Z 2 j Depth to Groundwater $� Feet 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 Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) I� r //d/ ', o� l �o i I9�" (revised 04/25/97) Page 10 of 10