HomeMy WebLinkAbout0066 HARBOR HILLS ROAD - Health 66 HARBOR HILLS ROAD, CENTERVILL
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UPC 12534
No.2153LOR `t�r�
HASTINGS, MN
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENT 3
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DEPARTMENT OF FawmoNMENTAL CTION
ONE WINTER STREET,BOSTON MA 02108 (617 500
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WILLIAM F.WELD B 1 8 UDY COXE
Governor ro ,e 199, Secretary
ARGEO PAUL CELLUCCI y �0 �� B. STRUHS
Lt. Governor Q� V Commissioner
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: b`i°Z ����S ] Address of Owner:
Date of Inspection: �y(If different)
Name of Inspector: Matte
Company Name, Address and Telephre Number:
ADZ ��,:;Vcz �w�► z. e`� �a�Z3 �� t�4. t"l v}_ .U_' L et
CERTIFICATION STATEMENT SUTe —L-VLp
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:
Passes
Conditionally Passes
_ Needs Further Evaluation B the Local Approving Authority
_ Fails /
'Ins ectors Si nature: � C v Date: rS
P g �
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] SYSTEM PASSES:
k1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
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 11/03/95)
A
t. Printed nn Rirded Pacer \
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART A n
f -�' ^�•� CERTIFICATION (continued)
f t3
Property:Address:
rt
Owner.-
Date of Inspection:
ection•
..
B] SYSTEM CONDITIONALLWPASSES (continued)
Sewage backup.or breakout or high static water level observed in the distributio ox is due to broken or obstructed
�► pipe(s) or due[ova.broken, settled or uneven distribution box. The system will ass inspection if(with approval of the
Board y f�ealth)
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 oken 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 HEAL
Conditions exist which require further evaluation by the B and 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 ETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH D SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet o a surface water
Cesspool or privy is within 50 feet f a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOA OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN NNER THAT PROTECTs THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic ank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a se tic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a ptic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, u ess a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pol tion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
3) OTHER
(revised 11/03/95) 2
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteri as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacte to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overl ded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or rface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet inve due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or ailable volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year OT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cess of or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 1 0 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is withi a Zone I of a public well.
Any portion of a cesspool or privy is wi in 50 feet of a private water supply well.
Any portion of a cesspool or privy is ss 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 mpounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large sy tems in addition to the criteria above:
The system serves a facility with a d sign flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the en ironment because one or more of the following conditions exist:
the system is within 40 feet of a surface drinking water supply
the system is within 00 feet of a tributary to a surface drinking water supply
the system is locat d in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water sup y well)
The owner or operator of any su system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 nd 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: ��j f m6g- I <<S
Owner:
Date of Inspection:
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.
4All 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 owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:' S
Owner: � �r,
Date of Infpec4f n:' �o ,
FLOW CONDITIONS
RESIDENTIAL:
Design flow. allons
Number of bedrooms:
Number of current residents:1,►Z:)
Garbage grinder(yes or no):IZV
Laundry connected to system (yes or no):J�� ,
Seasonal use (yes or no):_4t:�)
Water meter readings, if available: i•_ &
Last date of occupancy:S.)- .V—e-vL V(,r1 L,
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/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
PUMPING RECORDS and source of in rmation:
r—
Syst'e'm pumped as part of inspection: (yes or no)_
If yes, volume pumped: eallons
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)
Other (explain) :
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)-0
(revised 11/03/95) $
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
P Y
Owner:
Date of Inspection:
SEPTIC TANK:—,L)6
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP_other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
Comments:
(recommendation for pumping, condition of inlet and outlet t s or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP: qA
(locate on site p an)
Depth below grade:
Material of construction: _concrete _m I _FRP _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of utlet tee or baffle:
Distance from bottom of scum to ottom of outlet tee or baffle:
Comments:
(recommendation for pumpi condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leak. , etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK*-)0
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Capacity: sallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence f solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber condition of pumps and appurtenances, etc.)
I
(revised 11/03/95 7
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:,
Date of Inspection:;1
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excava ion 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,dimen ions:
overflow cesspool, number:4bkc—j
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of egetation,etc.)
CESSPOOLS: kj[,-)
(locate on site p an)
Number and configuration: 0-O0%
Depth-top of liquid to inlet invert: 'ZZ2
Depth of solids layer:NO i
Depth of scum layer:
Dimensions of cesspool:
Materials of construction::=*C4z'C2 Indication of of groundwater: V-)o
inflow (cesspool must be pumped as part of inspection),
Comments: (note condition of soil, signs of hydraulic failure, level of pondin , condition of getation, etc.)
�_, �, Y C
G — iV zvZ✓ti.c
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION (continued)
Property Address: b 1°riLZ�► S
Owner:NQ�4^r1
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater:�" �Z' feet t
method of determination or approximation
�Z1 NO
(revised 11/03/95) 9
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