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HomeMy WebLinkAbout0290 ELLIOTT ROAD - Health 290 Elliott Road, Centerville 1 L�. I Slll__�___-�f 2J�,CECYCIfp poym UPC 12543 �a No. R co HASTINGS, MN r - 4t DATE PROPERTY ADDRESS ww CGn�-ery 1 I e i On the above date, the4e00 system at the address above Was Inspected. This system consists of the following:• 1., 1-1000 ga eion ze/2t.ic tank.1 2., 1- Dizta.igut:ion Box., 3., 2-1000 gaiion ieach.ing p itz ' Based on inspection, I certify the following conditions: 4., 7h.iz .iz a 7.itiej.ive Se/zt.ic •sy-6tem (78 Code) 5. The heptic zyztem t,3 .in /22•opez woak.ing oadea at the p/Le sent time., SIGNATUR Name: Com Pan •y. �•+Qenh P. Macomh®r �Son Inc . j Address: P Dslox 66' t 1pj mass Phone:+ 60817 S--=8 or 508-_ZZ"- AC SEpli p. MACOMBER & SONS,INC: oh-ie�chfields Tanks-Ceupoe,.Installed TOWn•pu gamer•oonnewons 77lI+SS$ .7 6 centeNille, MA.02f,32.006 p,p. Box6 . 54412 f COMMONWEALTH OF MASSACHUSE'T'TS ExEcLmw OFFICE of EwiRoNiuiENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL.PROTECTION TTn,E 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CER ATION PhWqAddrem 290 E I I int Rd Ceni-.Arui l l e MA 02632 OwB's Nartre: c i R u hn a r Owner's Adder, Same Daft.o.finspeefim �. N=woflaWector.gdea epsiay Robert A Paolini C y.N=w. J_P_Macomber & Son Ind. M gfing Address: Ro x 66 Centerville MA 02632 TelepbDwNu*ft.-.50.8-775-3338 CERTIFICATION STATEMENT I certify that I have personalty inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performedhased on my training and experience in the proper function and maintenance of on site sewage disposal systems,I am a DEP approved sysl emam inspector pursuant to Seedaii 1a340 of Tale 5(310 CMR 15.OW The system: XXX Passes Conditionally Passes Needs Further Evaluation by the Ducal Approving.Authority F_ Inspector's Signature: Date: ' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEL)within 30 days of completing this inspection.If the system is a shamed system or has a design flow of 10.,00D gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional offence of the DER The original should be sent to the syMm owner and copies sent to the buyer,if applicable,and the approving authority_ Notes and Comments ***v11 s report only describes conditions at the thne of Inspecdon and under the eoudidons of we at dw. times This inspection does not address Irow the system wifl perform in the fetus under tti a same or diilbreat coudWoasof Title 5Inspection Form 6/151200D page I Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM,INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 290 Elliot Rd Centerville MA 02632 Owner: Steven Rubner Date of Inspection: 8/4/0 5 Inspection Summary.:. Check.A,B,C,D or.E/ALWAYS1complete all of Section;D A. System Passes: qcs NO I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303.or in 310 CMR 15.�04 exist.Any failure criteria not evaluated are indicated below. Comments: Sept.ie 4yztem ,ins .in R2ope¢ woltk.ing o2dea at .the . R2ehent time., B. System Conditionally Passes: NO 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. N0 The septic tank is metal and over20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent: System.will pass inspection if the existing tank is replaced with a complying septic tank;as approved by the.Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old"is available. ND explain: NO Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken.pipe(s)are replaced obstruction is removed distribution box,is leveled or tep la.ed ND explain: NO The system required pumping more than 4 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 ND explain: 2 h Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS -� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 4 0 P l 1 ;,;f RA Centerville MA 02632 Owner:. Steven Rubne_r Date of Inspection: 842.1 n S C. Further Evaluation is Required by the Board of Health: NO Conditions.exist whichrequire fiirther evaluation by the Board of Health in order to determine ifthe system is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(b)that the system is not functioning in a manner which.will protect public health,safety and the environment: no Cesspool or privy is within 50 feet of a surface water n oo Cesspool or privy is within 50 teet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: no The system has aseptic tank and soil absorption system(SAS).and the SAS is within 100 feet.of a surface water supply or tributary to a.surface water supply. no The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. no The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well. no The system has a septic tank and SAS.and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance. v isuaQ **This system passes if the well water analysis,performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT'FOR;VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM !�^ PART A CERTIFICATION(continued) Property Address: 290 F.11 int Rrl CPntarville MA' f12632 Owner: Stevan Rnhnp,S Date of Inspection: 8 f /o S D. System Failure Criteria applicable to all systems:. You must.indicate"yes"or"no".to each of the.following:for all inspections: Yes No _ X Backup of sewage into facility or system component due;to 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 X Static liquid level in the distribution box.above outlet invert due to an overloaded or clogged SAS or X cesspool _ Liquid depth in cesspool is less than.6"below invert or availablea.volume is less than May flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number X of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. .Any portion of cesspool or privy is within 100 feet of a surface water supply.or tributary to a surface X 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. �.. T Any portion of a cesspool or privy is less than 100 feet but greater.than 50 feet from a private water r supply well with no acceptable water quality analysis..[This system..passes if the well wateranalysis, performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this fornp,] . R'. NO (Yes/No)The system fails.I have determined that one or morOpf the above failure,criteria exist as described in 310 CMR 15.303,therefore the system..fails.The.system owner.should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: . To be considered a large system the:system must serve a facility with a design flow of 1.0,000 gpd to 150000. gpd. You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(1Tnterim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large.system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional.office of the Department. 4 .Page 5of11 OFFICIAL INSPECTION FORM-NOT-FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 290 E11_i of Rd Centerville MA 02632 Owner: Steven Rnhna Date of Inspection:.a Check if the following have been done.You must indicate`yes"or"no"as to each.of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewageback up? X _ Was the site inspected for signs of break out X _ Were all system componentspexcluding the SAS,located on site? X Were the septic tank manholes uncovered;opened,and the interior of the tank inspected for the condition of the_baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at Ehe Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J 5 Page 6 of I 1 �FF11 IAc.L IA�SpFy I? !I }�M-NO POR'V,OLIMT-ARY A3 OOMOMS •S !AGE DI"ma.-AY �EC'°T� .4 O.RZ i PART I; •3YSTEM:MOTIQA1 Propetty Address: g o o T�i 1 i.,i-_ R rl cpntpryilia ma no632 owner: ci-i-mT RnhnPr Date of Inspee ton: ,R/ej La 5- FLOW CONDM- ONS RUID NTUL D'ESIGNo'dlow basbd cn 310� 1'5:�03' or e�afibiipdleio'oI nIDg{padc lx#•6 NN.bgfboraRms deb&)' Hf b ovm e}: 4 0. � • Number of Current residents: .u,e nk n o w n Droestsidence.have a g$rba$ 8rinder(yes br no): Is latmdry.on a separate sewage•sxstem•(yes or•nc)R Of yes seP a tion required] . Laundry,system igspectec (yes or no):!_o 2 0 0 3- 2 8t O O O ga 2 2 o n GP[�=3 5 0 6 8 se onalLt3ei(yesorno): 20 ZOp4=12 t7= .8, OOOaai ons �j' '350. 68 Water meter r4adings,if available(last 2 years usage (gpd))• Sump pum (yes or no): no Last date o�occupaney: 122 e e n t' ML COMM STR Type of es Des fl�W. on 310 CMR 15.203):• ayd' Basb.of a Ci low(seatslpersonsfsgft,�tc.): Grease trap present(yes or no): Industrial waste holding tank present•(yes or no):_Non-saultary waste discharged to the Title 5 system•(yea or no)*.� WateF.meter readings,if available• Lased#of oecupancy/use: OTE(descjilta)t. CrMRA,,L MQAMAMON Pumping Records Source of information: was system pumped w part of the inspection(yes or no): 'i° If yes,volume pumped: Gallons.--How was quantity pumped determined? ReasoA for•p.Mping, TYPE-OF SYiTEM , X Septic tank,distribution box,soil absorptign Vj#SM • . eQ cesspool pool • Privy _Shared System or no)(if yes,attach prevldus inspection records,if any) • ImmvatIve/A1tOrna0ve technology.A ChB OOPy of the current operation and maintenance contract(to be btained from system owner) W _Tigbt tattk Attach A.copyof the DEP.approval _Other(doscrlbe): A�1rnxi�n ate�a�ge of all components,date installed(ifknown)and source of information: Z IT.—A e C.ed•-7 0/"Z5./8 P r 1.;: Were sewage odors detected when arriving at the site(yes or no): n oo . 6 - Page 7 of l l OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'C SYSTEM'INFORMATION(continued) Property Address: 290 F.1 1 i ni- Rd ('onto=Xi33e A4Ar02632 Owner: Stevr-+n Rohner Date of Inspection: R 12.1 p_5 BUILDING SEWER(locate on site plan) Depth below grade: 2 4" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: 20 f Comments(on condition of joints,venting,evidence of leakage,etc.): ao ant s a/2/2/2eaa .tigh.t., No zicinz of teak ge System vented 4-aaougn nouze ven SEPTIC TANK:y f-Alocate on site plan) ' 10 0 0 ga�e e o n Depth below grade: 18" ' Material of construction. concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age._ 'Is age confirmed by a Certificate of Compliance(yes or no):_.(attach a copy of certificate) Dimensions: 8' 6'X 5' 8"X 4' 10" Sludge depth: a a c e Distance from top of sludge to bottom of outlet tee or baffle: 2a c e Scum thickness: non e Distance from top of scum to top of outlet tee or baffle!z o n e Distance from bottom of scum to bottom of outlet tee or baffle: a o n e How were dimensions determined: m e a z u a e d Comments(on pumping recommendations,inlet.and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): Tank .shou ed U 12ym 12�d v 1jen.,A_jn.eet 9 out let tees at e ace. an .cs auc uaty .sound GREASE TRAP:n 0(locate on site plan) Depth below grade. Material of construction:_concrete_metal_fiberglass_polyethylene_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: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels a�S related to o}�tlet invert,evidence of leakage,etc.): aea se L za/2 ih not /22e sent 7 i Page 8 of I! OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: 9 A n F 1 i ;o t R d Cen _ervi11e MA . 02632 Owner: Steven R»bner Date of Inspection: 8/(2/0 5 TIGHT or HOLDING TANK:Nd (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass .:polyethylene other(explain)- Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes.or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): 7igh.t oa hoid.ing tankz aae not /zneienzi DISTRIBUTION BOX: y e'kif present must be.opened)(locate on site plan) �. Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal;any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Box .is eevei., flan 3 iateaaiz,- No .so2.id ca/t/ty oven oa .eeaka a .in oa 0 ut o 9.ox., PUMP CHAMBER: n o (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no):. Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 1 umI2 cham9ea .i s' not Rae sent 8 Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 290 E 1 1 i of Rd Centerville MA 02632 Owner:$even. Rubner Date of Inspection: 8/ /0 5 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Located .see page 10. Type leaching pits,number: Z •C leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, et1')0:amy to medium .sand. So.i.2z a¢e dsy., No zigns .off )ea.i.euae., vege a z.on 4_3 noam¢ CESSPOOLS:n 0 (cesspool must be pumped as part of inspection)(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 groundwater inflow(yes nr no): C�unments(no?condition of s H signs of hydraulic failure,level of ponding,condition of vegetation,etc.): e s.s12oo a t e no 122e sea PRIVY:2O (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.): l2.iVy .is not /22esent 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAG' DISPOSAL SYSTEM INSPECTION FORM ` PART C SYSTEM INFORMATI.ON(continued)' Property Address: 290 F 1 1 i n t_ Rd Centervil_1p MA 02632 Owner: Steven Rubne Date of Inspection: 8 S E TCH OF SEWAGE DISPOSAL SYSTEM Pro e a sketch of the sewage disposal system including ties to at least two permanent.reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. • I Jvl- I y7 f GR , 10 f Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:l9n Fi 1 i r,t Rd Centerville MA 02632 Owner: Date of Inspection: SITE EXAM . Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4)-' feet Please indicate(check).all methods used to determine the high ground water elevation: -NO Obtained from system design plans on record-If checked,date of design plan reviewed: y es Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:aA t� pt aad no . Checked'with local excavators,installers-(attach documentation) ®ccessedUSGSdatabase=explaink;ttp.town.�&aansta92e.-ma.,u!s �. You must describe how you established the high ground water elevation: Uhed : Cape Cod Commizzon ldat e4 7aa ee Coritoultz And l u&tic lJatea Su/�/��y re_�i head aoteet io-n aaeaz ma Se t 1995 Oate2 2esouaceh oP,�iee cape cod comm1,3,i0n.' up Of Ground Leaching Pit "eet Groundwater3T/Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is �S Z feet. 11 a•rnenr+r.—stre�rrsrnranrensen.s•nnrnfrsranst+-'rnr+n+ermnrn nr+•+tasna�rs�see �e'ns•��.'prmr :�-.r••�; TOWN OF BARD OF HEALTH «.�=�-r•.+..t--•"'w.SUBSURFACE SEWAGE DISPOSAL SYSTEM INACTION FORM - PART D•- CERTIFICATION�_'r_, � -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS _ 29:0 Elliot Rd ASSESSORS MAP, BLOCK AND PARCEL # 227-088 OWNER's NAME GtPVPA gli ner - PART D - CERTIFICATION NAME OF INSPECTOR Rogeat Paogilzi COMPANY NAME ;oaeph P Nacomge,4' Son Inc COMPANY ADDRESS Box 66 CenteltvtWe fla z 02632 Street Town or City. state ZIP- COMPANY TELEPHONE ( 508 !. 7:75 - 3338 FAX ( 508 1790 ;, 1578 CERTIFICATION STATEMENT I certify that I have personally. inspected the sewage disposal system at this address and that the information reported is true, accurate, rand omplete as of the time of.-inspection . The inspection was performed and any recommendations regarding upgrade , . maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: XXX Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the enviro:hment as defined in 310 CMR. 15 . 303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con cted has found that the system fails to protect the j-)ublic health and the environment in accordance with Title 6 , 310 CMR 16 - 30.3, and as sp cif lly noted on PART C FAILURE CRITERIA of this i o Inspector Signature Q Date ' Xne copy of this certification must be provided to the OWNER, the BUYER here applicable) and th±a BOARD OF HEALTH. * If the inspection FAILED., the Owner or operator shall . upgrade ' the system. within o'ne, year of the date of the inspection, unless allowed or required otherwise as provided in 3.;10 CMR 16 . 305 , ' r CCori morwveciffh of MOSSOChuSeltS John Grad W01 Executive Office of ErMorvnentai Affairs D.E.P. Title V Septic Inspector Department of P.O. Box 2119 Env rollnf4n2536 tal Protection Teat08) 5 MA 13 (51 564-GR 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART A /►c I' CERTIFICATION /�/ fCf�Pf_r 290 Elliot Rd.Centerville Address of Owner: �ijy -�9 '' Property Address: (If different) Of� v 9� Date of Inspection:4175197 Kurzberg:42 Hollingsworth AV.B n e Ma.02 Name of Inspector John Graci f 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: X Passes This Inspection Is based on criteria defined In Title V code 310 CMR 15.303.My findings are of how the system Is _ Conditionally Passes performing at the time of the inspection.My Inspection does _ Needs F e Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity or the Fails septic system and any of its components useful life. Inspector's Signature: rW' Date: 4130197 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. 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 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 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 290 Elliot Rd.Centerville Owner: Kurzberg:42 Hollingsworth Av.Braintree Ma 02194 Date of Inspection:4115197 _ Sewage backup or breakout or high static water level observed in the distribution box is 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 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. ER SUPPLIER,IF APPROPRIATE) 2) THAT WILL EIMtIS FUNCTIONING NLESS THE pRD OF HEALTH(AND PUBLICIN A MANNER THAT ROTECTV THE DETERMINES SYSTEM E 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 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 volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER 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. 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 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 290 Elliot Rd.Centerville Owner: Kurzberg:42 Hollingsworth Av.Braintree Ma 02184 Date of inspection:4115197 D) SYSTEM 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). Numbers of times pumped Any portion of the Sail 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: 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: 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 11115195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST property Address: 290 Elliot Rd.centervllle Owner: Kurzberg:42 Hollingsworth Av.Braintree Ma.021B4 Date of inspection:4115197 Check if the following have been done: X 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. X 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 existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 290 Elliot Rd.Centerville Owner: Kurzberg:42 Hollingsworth Av.Braintree Ma.02194 Date of Inspection:4115197 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 gallons Number of bedrooms: 4 Number of current residents: 0 Garbage grinder(yes or no): No connected to s Laundry con stem(yes or no): Yes Y Seasonal use(yes or no): No Water meter readings,if available: nla Last date of occupancy: M_Y 1990 COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 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: nla Last date of occupancy: Na OTHER:(Describe) n Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pum ed in the last two years. System pumped as part of inspection:(yes or no)No If yes,volume pumped:0 gallons Reason for pumping: n1a 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) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1985 Sewage odors detected when arriving at the site:(yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 290 Elliot Rd.Centerville Owner: Kurzberg:42 Hollingsworth Av.Braintree Ma.02194 Date of Inspection:4115/97 SEPTIC TANK: x (locate on site plan) Depth below grade: 1' Material al of construction:x concreate_metal_FRP_other(explain) Dimensions: L 9'6'H 5'7"W 4'10- Sludge depth:4' Distance from top of sludge to bottom of outlet tee or baffle: 23' Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:2' Distance form bottom of scum to bottom of outlet tee or baffle:n1a 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.) The septic tank and all components are structurally sound.Recommend pumping the system every two years for maintenance. , GREASE TRAP: (locate on site plan) Depth below grade: nla Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n/a Scum thickness:n/a Distance from top of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a 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.) rVa (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 290 Elllot Rd.Centerville Owner: Kurzberg:42 Hollingsworth Av.Braintree Ma.02184 Date of Inspection:4115197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: nla Material of con struction:_concrete_metal_FRP_other(explain) Dimensions: Na Capacity: n1a gallons Design flow: nla gallons/day Alarm level: nla Comments: (condition of inlet tee,condition of alarm and float switches, etc.) nla DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe. Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) Distribution box is structurally sound. 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.) nla (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 290 Elliot Rd.Centerville Owner: Kurzberg:42 Hollingsworth Av.Braintree Ma.02184 Date of Inspection:4115197 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: Na Type: leaching pits,number: 2-1,000 gallon leach pit leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number,length: n1a leaching fields,number,dimensions:n1a overflow cesspool,number:n1a Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The overflows are structurally sound and functioning properly.They were empty at the time of the inspection CESSPOOLS: (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: nfa Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n1a Na 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.) Na PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: nla Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Na (revised 11115195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 290 Elliot Rd.Centerville Owner: Kurzberg:42 Hollingsworth Av.Braintree Ma.02194 Date of Inspection:4115197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' a B ac E � AA Ali A 7 AD �'� � o q7 �A 29 4 D fig DEPTH TO GROUNDWATER Depth to groundwater: 12 feet method of determination or approximation: USGS Maps and Charts (revised 11115/95) 9 r �No p ._. .. TkT -COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH llJ................OF....1R1 . ..t-"! .................................. Appliratinn for Disposal Works Tonstrurtinn f rrmit Application is hereby made for a Permit to Construct (4�11/or Repair ( ) an Individual Sewage Disposal System at ................_____R �- -tD.:t-......�.�..p.......- ..........._....... ..................................... -.....1:` ........---.�............_.... ................_....__L` Locatl�7 ps $ as............................ .............................................or Lot•No......................------ -- Owner ............................................Address.. Installer Address Type of Building Size Lot.�q.t:;t .....Sq. feet U Dwelling—No. of Bedrooms............4..........................Expansion Attic ( ) Garbage Grinder ` �6-" 4 Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria ( a' Other fixture .............•----•-- W Design Flow..................... 't..._....... ._gallons per person per day. Total daily flow....................... . gallons. WSeptic Tank—Liquid capacity. Z4Qgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width......1............. Total Length..............I..... Total leaching area..... ......._..sq. ft. 3 Seepage Pit No.....��....... Diameter........ ....... Depth below inlet.............. Total leaching area 0..sq. ft. Z Other Distribution box ( ) Dosin tank ( ) Percolation Test Results Performed Date..._.q..= ..: -Z........ ,.a Test Pit No. 1....7.-...minutes per inch Depth of Test it.................... Depth to ground water........................ Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p$ ............................•................................................ .....................................................................•........ Description of Soil......_.... . ............................. ......._ ............................................................. x ...........-••................. .. w -----------------------------------•--.....---...-•-•----•-----------------------------••-----•---�--------------•-------------••..........----•-------........••--.......................-. ..... VNature of Repairs or Alterations—Answer when applicable............................................................................................... ..........................................................................................•---.......---.......--•------••-•----•-••-•----•-••----...---...----.............._...........---•--•-•...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.s; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bSjissued by the board of health. .. _.Signed_. .. ....... . ............................... ..............•-•-........-.... Date Application Approved B e ool � .... Date Application Disapproved for the f ollouring reasons:..........................................................................................................--- .......................................••-...... -•---....--•--••-•---•--••--•----...........-••••--------•---........................•----•----............................ • r•--....... Date _ PermitNo....................................................... Issued...................................................._ Date r4 THEE COMMONWEALTH OF MASSACHUSETTS -- BOARD OF HEALTH .................oF.... ! '.z.!J ` � �; ................................... Applutttiun for Disposal Works Tonstrixrtion 11prntit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ................--...... .. .... ......................... ..................................... :z-: I .._...--................._...... Location-Address or Lot No. ...................--TL'- 1.......�:�+�..� + ::�..........................•. --.........................---•----...-----.........._.......................... ... ... I E Owner .Address a ad.,Pt.----..i. ..u2. !....--•................................... .................................................................................................. Installer Address Type of Building Size Lot.-q.`.,1 1.....Sq. feet �..� Dwelling—No. of Bedrooms............... ...........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building .......... No. of persons............................ Showers — Cafeteria 04 Other fixtures . ......... W Design Flow...................`;?..................gallons per person per day. Total daily flow................... gallons. WSeptic Tank—Liquid capacity.1.7'.,�o;dlons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width......f............. Total Length.............T"*'* Total leaching area...................sq. ft. 3 Seepage Pit No................... Diameter........��......... Depth below inlet......Cc......... Total leaching area jC,.)Q..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ''" Percolation Test Results Performed by:�lJ�Q.LILA ,li . .._.. !....�f.! `�.f..p. Date....I.::.`.�� :�µ�........ a Test Pit No. I....-_E-....minutes per inch Depth of Test it.................... Depth to ground water........................ ti, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 --•••---•-•-•••.............•-•••..................................•--•-•--•.................................--••--....._.....---------........_...........•. Description of Soil..... _ -•--------------•----.....---........--•---•-----............-•••-------•------•- .................•--•-= ---------...... .......... Uf: �.0 ,I?1l�....._._. 1�� ........... �'! .( t . ,,...._........................................................ W ..................••-••..............•••--...........-•-••••...•••-••......•.................•... ......-••--.........................._..........-••••----......._..............•....... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..... ... .-•.. ...........•-••••--•-•••......--•••----••-•-•-................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITTLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed..tr ;%��... .... .................. .............------• --.--.... �yl / Date Application Approved By......,....... � / - ��?,l .S,/_.�..7....... Date Application Disapproved for the following reasons:................................................................................... ......._..-- ...----•.....................••••----....................._..••---•-•••--•••-•----•-----..........-•------•...--•......••-•-••••-•-•••-••••---••......••----•••---•--.......................-•-••-..._ Date PermitNo...................................................--- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... . TPrtifiratP of Tout tliana T IS I TO nCERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by..................�.---/!-:..... ,j :�.r�:�.......................................................-•-•......................-------•------•••............................_........_ GG% Installer at_.......................... :./..?....... �C�:: ... c....1! ----•................................................••------------•-........-•... has been installed in accordance with the provisions of TITS 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... ....?..-lr.c/U............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTPXED AS A GUARANTEE THAT THE SYSTEM WILje FUNCTION SATISFACTORY. � ............ Inspecto -------------•-••-------•--------------------.--------•------••--------- THE COMMONWEALTH OF MASSACHUSETTS ��. BOARD OF HEALTH ..........................................OF......................... No... ..`/U......... F=....... ..-........ Dispnstt Works Tonstrurtinn Itrrntit Permission is hereby granted...... :.�....... .+- ................•---•------..............................---..........................---- to Construct ) or Repair ( ) an ndividual Sew ' Disposal System at No....... r /r�...._ '�%e ..� .........C.����._....... Street ......- as shown on the applicatio for Disposal Works Construction Permit No..................... Dated.......................................... ... .. ---••------------------ ...... - DATE. Z soard of Health ....�....... ... FORM C-1255 CITY& TOWN FORMS, INC. 369-9708 0.1 c,,111 C,LE F'AM 1 LK •� �--Y�E-DQOO�K seslon C. T Ayk•P ,q-4 0')C \,so to zoo v15PoSA!_ ' PIT 'V$G� 2- 4c—.C>:• : : r .... ' eAui 'SCE � G, !'! X. \ . '� •�' O: `•Cs�P'i .I�►+. �•, � ::: •. I i ... . . . _ j�.� • .- 60 TtO/A t P�G -A o� 'CIow EaT�' 1 114 2 hUl.l oe LFf5. _ 1 i ilk 1 f J .f,'I GI.."• �� �.t,1„r • I .. t�\,\L I �'• liI!\�I��.rl - 4,.�1� •• •l•J � �JI'r i-J J .►!y � 1 •t •1 ' I / .. � . I ..' ., i ! ... 4•�rcr�i•.:;t:,.y . .. �:{�y�71�,�,.j/�k/[/J�/_���;+'/.�. +,I.j,�r.� � 1 : 1 TOP W o:�* o'^►,� ¢ST 5 '1. "PP6 alit 1&.v �t4&L.. lot.•-1 1 �ob0 101.5. 1ElV. U� /{• VJM41 G(�A E•L_ I wA51JaA I ' P,2 .E 0 F I L - . : LOIG AX 10" C.E.N T E.R.V \ E. As .N�rr`� l>A, /�3 I CacriFK T"AT 'r"--?lt0?WED VOVtkMAWASI 40' U 1... C"7-� 1 �� v.4 eec e-o� -CO AA p1_%(S w 1 r H -rues. It a►�►�. :1, t�! S '�N.Q AND 4tTBAC�C (L�Qu1�•MCzuT'S of 1'1••l� L-oGAT� wlTl.41l4 T E FLoob PI.AtQ, Iv=24:g3 BaX'rert L1�{� ILlC. T" S PLd l ter ' UOT BA 5 ED O LI A tJ 1". T P_U M E►u7 D�.TF.:�V 1 tJl-� AA A.5�a T►•►G OFFSET -5"0uLD UOT $E USeD APPLIGAuT R,�, NA`(�-S �t�1c—. Yo 'De-TrZMiN6_ %.07 LIWFig,;. V • �9 !7 9 sc,St o 3 4• 09 q k • EX P, � zxe� ' m _rp �• t'AI.PI 2- p�T S O` •\LSo 4^L i ^ ►0 STr� i \o\ \ (.AL I to � ►0'1 3 • �� � f► ►05.ES �w5�• a � � �,► �V CO 1FT. A. BAXTER F' Gp�p SL'�,1� :'� SH EE"T 71h' �290 LOCATION SEWAGE PERMIT. NO. VILLAGE INSTALLER'S NAME & ADDRESS /?jk S U I L D E R ON pp OWNER g i DATE PERMIT ISSUED © DAT E COMPLIANCE ISSUED 3 S 5� 17 C/N �('�,