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HomeMy WebLinkAbout0014 GINA COURT - Health 14 GINA COURT, CENTER VILLE A= 210 190 UPC 12534 No. 2-153LOR � HASTINGS, MN a. commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Govemor Trudy Coxe Secretary,EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A MR-9 2.10FAec,-S1_ 190 CERTIFICATION 181 1....tTTL G &A QoA-O Property Address: 14 �t�P' 4f nU2T CEt.A-�Y IL� Address of Owner: �utw►..�c�110, S UN tz �30 Date of Inspection: kol-Z 4/95 (If different) Ckt ELMS -0 PEA 01824 Name of Inspector: �%TC—tZ. 'SUL_-t\1 Ar PE _ Company Name, Address and Telephone Number: S Ulu V AA-A Z:"E70 I�l EC�ie.►IL C� �'L 3•Q ov I E2 V0—.V S O Z6 32 Co 40 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that thpi fo��m ati'on.reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my trairitng'*and,experience in the proper function and maintenance of on-site sewage disposal systems. The system: PETER SULUM X Passes K0•2133 _ Conditionally Passes Needs Further Evaluation By the Local Approving Authorityh� a oTY ' Fails �v�3 Inspector's Signature: O Date: C) 1 2� \9gS 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 a der 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 ap •i authority. es INSPECTION SUMMARY: O Check A,'B,C, or D: V A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure cri i fin 6 15.303. Any failure criteria not evaluated are indicated below. B] SYST ONDITIONALLY PASSES: One or more em ponents need to be replaced or repaired. The system, upon completion of the replacement or repair; passes inspect' . Indicate no, or not determined (Y, N, D). Describe basis of determination in all instances. If"not determined", explain why not) _ The septic tank is metal, crac tructurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass ins if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. 1 (revised 8/15/95) One Winter Street a Boston,Massachusetts 02108 a FAX(617)SW1049 a Telephone(617)292-5500 iJ Printed on Recyded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM PART A /' CERTIFICATION (continued) Property Address: )4 I KA A CO v err C-r✓nf �r L�-v Owner: W"• Date of Inspection: 10/Z4 1,9�5- B) TEM CONDITIONALLY PASSES (continued) _ age backup or breakout or h' static water level observed in the distribution x is due to broken or obstructedo e pipe(s ue to a broken, ed or uneven distribution box. The system will s inspection if(with approval Board of Hea broken pipe(s) are replaced o ction is removed distribute ox is levelled or replaced T system,required pumping more than four times a ear due to broken or obstructed pipe(s). The system will pass nspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 i iling to protect the p is health, safety and the environment. 1) SYSTEM L PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FU TIONING IN A MANNER WHICH WILL OTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or ivy is within 50 feet of a surface water _ Cesspool or priv . within 50 feet of a bordering vegetated wetland or a marsh. 2) SYSTEM WILL FAIL UN THE IN ARD ONER HEALTH THAT PROTECT PUBLIC THE PAT SUPPLIER, IF APPROPRIATE)LIC HEA TH AND SAFETY AND HDETERMINES THAT THE SYSTEM IS FUNCTIONING ENVIRONMENT: _ IhP wSiPm has a Septic ldhK and SUIT abSO IUeI SySI i dllu I W'liilir, �00 feci Lc, a surface water supp! G�t 1� :o'I' :0 .. surface water supply. n s m and is within a Zone I of a public water supply well. The system has a septic tank and soil absorp _ The system has a septic tank and soil abs tion syste nd is within 50 feet of a private water supply well. _ The system has a septic tank and soil sorption system an 's less than 100 feet but 50 feet or more from a private water supply well, unless a well water a ysis for coliform bacteria a volatile organic compounds indicates that the well is free from pollution from that f t ity and the presence of ammonia 'trogen and nitrate nitrogen is equal to or less than 5 ppm. DJ SYSTEM FAILS: I have determined th a system violates one or more of the following failure criteria as defined 310 CMR 15.303. The basis for this determina' n is identified below. The Board of Health should be contacted to determine wh ill be necessary to correct the failure. _ 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 or cesspool. 2 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 &(U A. C-OL)e.T L'e'-A Tr.�q—V(" E Owner: VJM. Date of Inspection: 10/ZA g5 D) SYSTEM FA (continued): St is liquid level in the distribution box above outlet invert due to an overloaded or cl ed SAS or cesspool. Liquid pth in cesspool is less than 6" below invert or available volume is less t n 1/2 day flow. Required pu ping more than 4 times in the last year NOT due to clogged obstructed pipe(s). Number of tim pumped Any portion of the it Absorption System, cesspool or privy is belo the high groundwater elevation. Any portion of a cesspoo or privy is within 100 feet of a surfa water supply or tributary to a surface water supply. Any portion of a cesspool or 'vy is within a Zone I of a ublic well. Any portion of a cesspool or privy within 50 feet a private water supply well. _ Any portion of a cesspool or privy isles han 0 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the w as been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compo ds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large stems in addition to the criter above: The design flow of system is 10 00 gpd or greater (Large System) and th system is a significant threat to public health and safety and the environment becaus ne or more of the following conditions exist: the system is thin 400 feet of a surface drinking water supply the syste is within 200 feet of a tributary to a surface drinking water suppl _ the ystem is located in a nitrogen sensitive area (Interim Wellhead Protection Are (IWPA) or a mapped Zone II of a blic water supply well) The owner or perator'of any such system shall bring the system and facility into full compliance with the g ndwater treatment program requiremen of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further ' formation. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: &XiA (�ZC9e_T CCNTEIZ�ltCLC� Owner: WO& M U(LP+-%`( Date of Inspection: l O/ZA/95 Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving 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. v'*'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 non-intrusive methods. ` The facility ov-n (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. 4 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Wtt+ M v 2PN� Date of Inspection: Ip ZIA 9Is- FLOW CONDITIONS RESIDENTIAL: Design flow: 3A gallons Number of bedrooms: Z Number of current residents: L• Garbage grinder (yes or no): � Laundry connected to system (yes or no): 1>✓s Seasonal use (yes or no): NO (op MO C�LL.O$-L-S 1646?R Water meter readings, if available: Ct=tikT-Ee-.[t LC-6 OSTZ;�J`(.C;E 199'J 199�{ f �Q,o©O <����o ems •�� ( 1'3'7 6 PV Last date of occupancy: ID/13/9S COMMERCIAUI N D USTRI AL• Type of establishment: Design flow:_$allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ 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 -Fo,j 9 eF't3rj20-)sTPA3 Ct >mP-nC FuanPochT {ZG'r-og.DS PUMPING RECORDS a d source of information: vp M0 �!t/BS'r+�eu'I/(0 95 1C�t g? t S�ZZ 9b System pumped as part of inspection: (yes or no)-y55 If yes, volume pumped: QDQ gallons Reason for pumping: MA t"ISAA 1-NC-C TYPE OF SYSTEM K 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: Cor`�ti7uArvcL fssub 8�8/S l Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) S i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION (continued) Property Address: \4 rua Cd02T CEtuc�—�/tct� Owner: \J,&\• 1M0z9" ( Date of Inspection: 1 f Z g 9 J SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP other(explain) `Dimensions: Y— v Sludge depth: ` '_%7-11 Distance from top of sludge to bottom of outlet tee or baffle: is Scum thickness: too DEv6 WptD \ �.9oS�u Distance from top of scum to top of outlet tee or baffle: 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 outlet �L invert, structural integri , evidence of leakageet ;) �'�O V'^^���6 �2 M r GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom rn 5ctifn t� bottom of outiet tee or baffie: 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.) 6 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1� ��� ►4 ou'�-� C��v �V`t Owner: V-1M, M��P►�� Date of Inspection: Z 4 4,57 TIGHT OR HOLDING TANK:_ (locate on site plan) J� Depth below grade: Material of construction: _concrete _metal _FRP other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) CbrXL f?c (F Depth of liquid level above outlet invert: �I`t t- C t Comments: (note if level and distribution 1� equal, e�idence ofU lids car`o� evidence f le leakage into to or out of box, etc.)� SOL-tp CA_�2Un PUMP CHAMBER:_ I (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc. 7 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: J Owner: vj wN, v l Date of Inspection: to/zq/g5" 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: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) SOIL- Comments: �. �o►�s.O t�10(v 00,U) 1PAjL0 2l PP X F U�OI�tiJ tl.� �t PrT 1 Ots D 1 p 195E Pe 2t5E2 CZ4" Ta S2Il?(c GCslEe rTitlN 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 groundwater 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) Dimensions: Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 8 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �q��A)A Co V a r CEr UTiS E�4 Owner: wl. M V e-F6� Date of Inspection: 10/Z4/g SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (� A L TDTA, �'2�rZoc�ou5 � D � TA�11C. ® �tT DEPTH TO GROUNDWATER Depth to groundwater:_ ___feet O 2 me--* method of determination or approximation: —fit` SEE C52161 KSA;C.. 1DE516 NA PEeC- �sT LDS U51" T 0 nF e SMABC (revised 8/15/95) 9 31 W PE RMIT NO.: ; LOCATION/ � � � SE A V I L L A G:t'...::.: 0600, INSTA%.:tlER'S NAME i A.DDRESS �ZtiS �F IUILDER OR OWNER J_ S fu DATE PERMIT ISSUED DATE • C.O:,MPLIANCE ISSUED ✓ 0 35 '` .7�0 OH z/ o HAP wo � c � 1'go 10-13-1995 05:41PM FROM Today REAL E5TH1L Cville lu t� ) �•l11�K��i.�•• .::-ram!�.li.i•:�': � .--- -,... ._ , ,�_. ••••---�•-----� .._._:.. t:x4 t i.-1 �.,•-)_ =-=-�- y1r4::+ •�.�.�y..... .�r.wwa.�/r.+.r.rr :�r. .....�nw...wr.... .� •W it j :t� - Z'J� .r . C�� WNW !�►�t of ���vl.�.Tta�1..J t2aT� . 1 1:.�1 �.��w u¢ E�.,S. .} � �•r.� � P elf :CS1Ci•• ,;tY �ti.t•/rY { i�/n�\\ii/�.i .�f/l..1'/ [. — :-%r•.ti p II,y N + Sc�SSOr►i (1 s+r�lA� 1 L`r.'r. - (CN. Cad1L.PA fe fJ Y f l=• Z ; L•'�-=^"'�....� '�C>y, 1I 1 '�y SEt'i"IC .'' ii! I •. fff i L.El+G��tI I t ATT. WC.:- �r � w � c vAj ,4TlaWC,. Q - t•iLi.'t:it`i�; �rri.��:T'bLt!`: 4l/ I T1�3c: +1L�� 1.11rE !i C- -lw 12 i Ul 16 '�1-��-�'� �r(._f./�-t r� t�rCi i {.'.Iy�"l=•rJ Ui,.4 1;�+� C)�'i'�C'.�, 1►..L�' C� 1`.1I�•*r`r• _l': 41 i TOTAL P.02 LOCATION SEWAGE PERMIT NO. VILLAGE INS TA LLER'S NAME i ADDRESS BUILDER OR OWNER �J S A4 irN DATE PERMIT ISSUED DATE COMPLIANCE ISSUED S, � '� i ...... Fizi3............................. THE COMMONWEALTH.OF MASSACHUSFTTS BOARD OF HEALTH �QS ...%........................................... ­�J_n...............OF......... Aplifirattlin for Uispwial Varks C Application is hereby made for a Permit to Construct (&,) or Repair an Individual Sewage Disposal System at: ....... f�j� ..... ................... ............ .........%........V ..G_V � �......................................... Lo.ytiort-Addr or Lot,Noy . . .... jot . ........... ................................. ................................. ................... A ....................................................... ........... ............. . ....................................................... Installer Address Type of Building Size Lot X�?, k ....Sq. feet U Dwelling—No. of Bedrooms........... . Garbage Grinder . ...........................Expansion Attic Other—Type of Building .............................No. of persons............................ Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow................a ..............__..gallons per person per day. Total daily flow...........33P..................gallons. Septic Tank—Liquid capacityi10L�q..gallons Length................ Width................ Diameter.-------._-__- Depth................ Disposal Trench—No..................... Width......._....._...... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.._................. Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box Dosin tank,(,g, Percolation Test Results Performed by., 'k.....*4..... ................... Date_..._.. ...... 14 Test Pit No. I................minutes per inch Depth of Test Pit.--._......_...._... Depth to ground water---__-...............--. Test Pit No. 2................minutes per inch Depth of Test Pit............-_..._.. Depth to ground water........................ ............................................................................................................................................................. V0 Description of Soil.....0.:.. ...............VX_0.0".t.r1.......... ............. . ............................................................ W .........4—.\., ............ Ir .......................... .... CIAL_-L...................................................................... .....................................................................................U............r............................................................................................. 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 TII Ti LE 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. Si ed.......�Cvfv-,_L&........yu----;.f ............... ..............Application Approved ................................................................... ........... Da Application Disap r d f the following reasons:............................................................................................................... ............................. ....................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date v. .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........\04 . .... ........OF.....-- ...................................... Appliration for Elisliviial Works, Tondrurtion "amit V Application is hereby made for a Permit to Construct � or Repair an Individual Sewage Disposal System at: 010 ............ ..... ........ W......C(.jp\ A T.. .... ... .................. ..................Q.k.........M.......kA......................................... L• t Addre or Lo No CON\, ............................................. O' ros Add sa....3 ............................. . e. .......................................... ..................CA�a�* g , Installer Address Type of Building Size Lot--- ....Sq. feet U Dwelling—No. of Bedrooms.............13...........................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons....._.._._..........__._... Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow................\X9..................gallons per person per day. Total daily flow........... ............gallons. 9 Septic Tank—Liquid capacityW9..gallons Length................ Width....__.__._...__ Diameter..._......_..... Depth.............._. Disposal Trench—No..................... Width..._.........__.._._ Total Length..................._ Total leaching area.....................sq. ft. Seepage Pit No..................... Diameter.............._..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...9)cLmAe1.1........4:...JJ01A................. Date_..... ...... 04 Test Pit No. L...............minutes per inch Depth of Test Pit..................__ Depth to ground water.___..__.__._._......__.. fi Test Pit No. 2................minutes per inch Depth of Test Pit__-_._......__...... Depth to ground water........._..._......_.._ ............................................................................................................................................................. 0 Description of Soil.... .............",-0-a-M. ----------S�............. ............................................................. ............ �7' ...................................................................... --------------------------- .. . ... ... ................................................................................................. .............................................................................. .. ....... 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 TIT12• 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. S ........ _rynt xtn................. 5j� ighed..... ...... ApplicationApproved-By..7 ............................................................................................ ....... Application Disa�roled r the following reasons:................................................................................................................ ...................................................... ................................................................................................................................................. Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....OF....... .......................... Tprtifiratr of Toutphatta Tj LJS 4S TO CERTIFY,-4at the Individual Sewage Disposal System constructed or Repaired by.............e'A0 ............ ............................................................................................................................. �_A \ at........ \3...........t�n&�t,......C.CuXV!..............C V, ............................. - X . ........ ...........7.......................... has been installed in accordance with the provisions of LE f o The State Sailitar Code,as'described in the �. .............. dated?' application for Disposal Works Construction Permit Not.......................... snkl ......................... 11 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... 1��. ......... Inspector./ .................................................................... ' �Iel------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD--0) F HEALTH ...................OF.......... !.............................. Nd......................... FEE: ......::.......... �i��aY v1 �rk� �nn� ttr�Uan rrmt� Permission is hereby granted---- to Construct or R�jr Individual Se age Disposal Syste ....................... at No........ .............................Saxa ........... Ar-------------- Street _)�V Dated�/) as shown on the application for Disposal Works Construction Permit Nt...................... .....................j................... ................................................................. Board of Health DATE. /� ��................ ----------------------------------- -- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 41 T.- TL i: -",D •A/., Al 9r.7 t— PX 9R.1 4,OMA- I r34> L- L-( 6.F-.T,. ifz ut-"s. Oat 24 94 7 f 7t.-:sT 14--t-ii- F,(, CoA A4 Dl�r I ;r-2ox 96,0 0 JV. Gat— 7- 14 d %,V P LL*-,-T P>L- 4,V-! 1z, LOCATIC)"- CIS 0-M F-v I L-LE Flo Wd 7-SZ _Q -_j CIF- WiTi-4 Tt4i.: LoT