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HomeMy WebLinkAbout0051 JACKSON AVENUE - Health 51 Jackson Avenue, Centerville =226 - 129 ,off 9 M � COMMONWEALTH OF ASSACHL'SETTS 8 n EXECUTIVE OFFICE OF ENNIRONMENTALAFF ,� DEPARTMENT OF EN-VIRONNIE\TAL PRO T Nherl'w '' .P 1 _ ONE WINTER STREET. BOSTON. MA 02106 6i'7-:9_-5:OC 1 ." � 199 T roof yfA(H"pTrAe(f WILLIAM F W'ELD A C0\I Govemc• ;retar% ARGEO PAUL CELLL'CCI E y 'ID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissior= PART A CERTIFICATION Ave, G�P .1111.- - Property Address: 15 l c-14'rm� .t' w Address of Owner: VviiTKc%L,e,_ Date of Inspection: (If different) At �QQi+1 IL � �p Name of Inspector: Hwclt cr e I1 E3ecec=ii te0m, .,gr-e zt ells, 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 13.000) 01 -15"% Company Name: &14-1-c C i .1 /"P r.4..,—/ Mailing Address: p Acnx -E_3s9! . H ASuoe_Q_ /mil /I} © 2e4L cl Telephone Number: r'5-e4) �j=¢:;1— /[f Zp CERTIFICATION STATEMENT I ceni� that I have personally inspected the sewage disposal system at this address and tha: the information reported below is true. accurate and complete as o'the time of inspec.o-. The inspection was performed based on my training and experience to the proper )unction and maintenance of on-sae sewage disposa systems The system: Passes _ Conc-tionaii\ Passes lseecs Further E�a!uat;on B\ the Local Approving Authorial _ F Inspector's Signature: Date: 1 The System Inspector shay' 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 floes of 10,000 gpd or greater, the rnspecaor and the system owner shall submit the repo-, to the appropriate regional orfice of the Department of Environmental Protenoc. The orig;na! should be sent to the system owner and copies sent to the buve,, if applicable, and the approving authority INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I 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. COMMENTS: 81 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. 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, 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 thedate of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure t u e s 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. (rovi,sed 04/25/97) Page 1 of 10 DEo on the Wond Wiae weo h=.rnvww magnet state ma.uyoec Printed on Recyved Pater F r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Property Address: CERTIFICATION (continued) Owner. Date of Inspection: B) SYSTEM CONDITIONALLY PASSES tcontmuod. r1 / Sewage backup or breakout or high static water level P'Peis; or due to a broken, a observed i the distribution box is due to broken r Board of Health;. Describe Observations:of uneven distribution box. he system will o obstructed broken pass inspection if(wit en , h approval P pets)are replaced of the obstruction is removed dis tribution bution box is levelled or replaced _ The system required um p pm m inspection If'(with 8 ore than four times t th approval a e r PP oval of the Board of H y due to broken or obstructed , broken Health): P Pe(s). The PrPets� are system will e replaces Pass obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF H — Conditions exist which r LTH: Public ions a require further evaluation by the oard of Health in safety and the environment. Order to determine if the system ishea failing to protect the �) SYSTEM WILL Pg55 UNLESS BOARD OF HEALTH WHICH WILL PROTECT THE PUBLIC HEALTH AN ERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN q SAFETY AND THE ENVIRONMENT: MANNER — Cesspool or pri%,% Is ,thin SO feet of a Cesspool or prn� ,s %"th n ' dace water ithi �0 feet of a ordering 2) SYSTEM KILL FAIL UNLESS THE BOARD OF THE SYSTEM 15 FUN vegetated wetland or a salt marsh. CTIONIN'G IN q EALTH (AND PUBLIC WATER SUPPLIER IF APPROPRIATE) DETERMINES THAT ENVIRONMENT: MAN ER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND III _ The s�•stem has THE a septic tank an soil absorption tributary to a surface water susystem (SAS)and the S The system has a septic tank n '�S is within 100 feet to a surface water supply _ The system has d soil absorption system and h PP y or a septic tan and soil absorption system and the SAS is within 50 feet of a private vat The system has Zone I of a public water su i a septic to and soil absorption p�Y well. Private water supply well unless a we►i s P system and the SAS the well is free from water anal sis for is less that, 100 feet but 50 f water supply well. Pot Lion from that facility Y coliform bacteria and volatile organic comp or more from a less than 5 prim. Meth tY and the presence of ammonia nitrogen and nitrate nitrogen isequal t that used to determine distance 3) OTHER (approximation not valid) equal to or (revised 0 1 4,2 S/9,) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following I have determined that the sys;em violates one or more of the following f lure criteria as. defined to 310 CMR 15.303. The bans for this determination is identified below. The Board of Health should contacted to determine what will be necessar to correct the failure. Yes No Backup of sewage into facile or system component due to a overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the groun or surface waters due to an overloaded or clogged SAS or cesspool. S,a;tc Mould level in the distribition box above outlet inv due to an overloaded or clogged SAS or cesspool. Liduid depth m cesspool is less than 6" below invert or vailable volume is less than 112 day floe. Recurred pumping more than 4 times in the last year OT due to clogged or obstructed pipes.. ~umber o*.times pumped _. Am portion of the So!! Absorption System, cesspool or privy is billow the high groundwater eievatior, Am porl:on of a cesspool or privy is .%ithir, 100 f t of a surface water suppl.• or tributar to a surface water supple. All _ Any po^ion of a cesspool or pray is v.ithm a Z e I of a public well. An% po^jo-. o;a cesspool or privv is within 50 feet of a private water supply well An\- por;,or o'a cesspool or prey is less tha 100 feet but greater than 50 feet from a private water supply well with no acceotable water qualrt% analysis. If the wel has been analyzed to be acceptable, attach cope of well water analysis for cohform.. bacteria volatile organic compou s, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes' or "No" as to each of the f lowing: The folio.+rng cn,eria app6. to large systems in 'dirior, to the criteria above: The system serves a facilin with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public hea!th and safer and the environment cause one or more of the following conditions exist: Yes No . the system is within 400 feet of surface drinking water supply the system is within 200 feet f a tributary to a surface drinking water supply the system is located in a ni rogen 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 s all bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. lease 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: t,1 Swc� Owner:Q.oNC�ONG.. Date of Inspection: �1�1�7 Check if the following have been done: You must indicate either "Yes" or "No" as to.each of the following: Yes !vo 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 pan of this inspection As bull: plans have been ob;a:ned and examined. Note if they are not available with N/A. �( The fac:ll;, or d,.+elling %+as inspected fo, signs o`sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site �.+as inspected for signs )f breakout. V _ All s\sterr components. excluding the So!! Aosorption System, have been located on the site. Y The septic tank manhoies Aere uncovered, opened. and the interior of the septic tank was inspected for condition of - f-1 baffies or tees, materia; o-' construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption Svsiern on the site has been determined based on: The facda', o\%ne ;ano occupants. r;difteren: from owneri were provided with information on the proper maintenance of Sub-Surface Disposal Svstern. Existing information. Ex Plan at B O.H. _ Determined in the held .r an% of the failure criteria related to Pan C is at issue, approximation of distance is unacceatabie [15.302.31 b`� (revised 04/25/57) Pag• 4 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:51 :SgGtCSor,) Owner: (to"Cotic Date of Inspection: $1��5? FLOW CONDITIONS RESIDENTIAL: Design floe. 560 p.d..1bedroo_rn for S.A. Number of bedrooms o3 Number a"current residents Garbage 9,. der (yes or not—t414 Laundry corrected to system (yes or no) Ae- Seasonal use Ives or no,. FJO Water meter readings. if available (last two ',? vear usage tgpd): _ND Sump Pump lees or no)jo Last date o;occupanc- sun ffW-V s 4t. COMMERCIAL'INDUSTRIAL• Type of establfshmen: Design fio%% eahonsoa\ Grease trap present Ives or no' Indus:na! \Taste holding Tani; present. ves or no Non.samtan v,aste discnargec to the T::,e 5 system ;ves or no %%ater meter readings if availabie Las:pare o: c, OTHER: Describe Last care of occudanc. GENERAL INFORMATION PUMPING RECORDS and source of information Nc.,J'-c ojwwea System pumped as par, of inspection: cues or no.&LO If yes, volume pumped eallons Reason for pumping TYPE OF SYSTEM Septic tank14KY , 'sojl absorption system Smgie cesspool Overflow cesspool Pn.�• Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: } 'LSW e-5 Sewage odors detected when arriving at the site. (yes or not (revised 04/25/91) page 5 01 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:$I. 5cgcV_&prV Owner: Qptxjb..,, Date of Inspection: g\%ttkct,l BUILDING SEWER: N� ' (Locate on site plan) Depth below grade. Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction Ir-� Diameter Comments: (condition of joints, venting. evidence of leakage. etc.) SEPTIC TANK:*C-S (locate on site plan �a Depth below grade Material of construction: -Lconcrete _meta _Fiberglass _Polyethvlene _other(explain If tank is metal, lis: age _ 1; age confirmec b\ Cen;fica:e o; Compuance _(Les"No Dimensions (OCT) !�&l Sludge depth)" .t Disiance from top o: sludee to bonom o` outlet fee o• ba-;;e Scum thickness 3" Distance from top o- scum to to:) o; outlet tee or ba^ie_ u .Distance from bottom of scu^-, to bor-oT: or outlet tee er ba*-.e is Now dimensions Here determined *l4tasuo2A. Comments. trecommendation 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.i di—UeA yr, eLip far Ti—, TiW JL, %V-�rpyct­ LAgl U a Gau t.,) 41 �Q oJ�1..T S YUAILK.T s TP�.IC.c?,w.wr.�—, 8o�r`�l ,.n v. o.• re . s�- a a. GREASE TRAP:-1—J0 (locate on site plan: Depth below grade: Material of construction: _concrete _metal Fiberglass _Polyethylene _other(expiain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bonom of outlet tee or baffle: Date of last pumping. 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.; (revised 04/25.17) page 6 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO ,%A PART C SYSTEM INFORMATION (continued) Propert% Address: O%ner: Date of Inspection: TIGHT OR HOLDING TANK: ?ank must be pumped prior to, or at time, of inspectio (locate on site plan, Depth below grade. Material of construction _concrete _metal _Fiberglass _Polyethylene _other(expla n) Dimensions: Capacm gallons Deng floes gahons-da, Alarm level karm in „orking order _ Yes, _ No Date of previous pumping Comments (condition of inlet tee, condi:ion o' ala,m and float switches, etc.) DISTRIBUTION BOX: 0ocate on site p.a-. Depth o; Iiou!d le e: aoo•,e out,e: ime^ Comments mote if level and des:,ib_:ior is eoua' evidence of solids carryover, /,,idence f leakage into or out of box, etc.) PUMP CHAMBER:_ (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 an appurtenances, etc.) (revised 04/I5/9,) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S% 3kAk46w)- Owner: r�r..iL Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):14t (locate on site.plan, if possible, exca%atjon not required, but may be approximated by non-intrusive methods; If not determined to be present, explain: Type: leaching pits. number.A- leaching chambers, number: leaching galleries, number. leaching trenches. number,length: leaching fields, number, dimensions over.'low cesspool, number Alternative s\,stem Name of Technology Comments. (note condition of sod. signs of hydraulic failure, level of pondmg, cond( n of vegetation, a c.). O % CESSPOOLS: (locate on site plar Number and coni,gura:-on. Depth-top of liquid to inlet Inver, Depth of solids laver Depth of scum layer. Dimensions of cesspool Materials of constructior Indication of ground\,`ate• inflow (cesspool must oe pumpeC as par, of (nspeciim Comments: (note condition of soil, signs of hydraulic failure, level of ponding. condition of vegetation, etc.) PRIVY: 'VO (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.) (revaaad 04/2S/97) page I of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION' (continued) Propert,, Address: S%-'n,CX. a. Owner: Q9�•tCc+t-+t 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) b 33� (zevi#04 04175!5') Page 9 o: 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properh Address: TC*L tWvJ Owner: QoNc,, Date of Inspection: Depth to Groundwater--la Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained iron Design Plans on record Observation of Site (Abutting propert), observation hoe basement sump etc.) Determine it from local conditions Cnec'K with local Board o- nea';r•. Chec� FEtiMA neaps Check purnping records Check local eacavaro,s. installers (_se .SCS Data r• Describe in vou, o�N,. %•.orcs no,,% ko- es:abh,s)ec the 1,igh Groundwater Elevation. (Must be completed (Jo waa?Ak P I T- RT '(`;5 lrw.ud 04,25'9-. Page 10 of 20