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HomeMy WebLinkAbout0025 JACQUELINE COURT - Health 25 JACQUELINE COURT, CENTERVILLE A= Y t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your V cursor-do not A. Riker use the return Name of Inspector key. Riker Land Construction Company Name, PO Box 726 Company Address South Yarmouth MA 02664 City/Town State Zip Code 508-776-6460 S14590 Telephone Number License Number B. Certification tU co I certify,that I have personally inspected the sewage disposal system at this address and that the Inform tion reported below is true, accurate and complete as of the time of the inspection. The inspection was prtormed based on my training and experience in the proper function and maintenance of on site a= sewage disposal systems. I am,a DEP approved system inspector pursuant to Section 15.340 of co Title 5(31=0 CMR 15.000).The system: CC) Cl. Or v ® Passes ❑ Conditionally Passes ❑ Fails © ❑ deeds Further Evaluation by the Local Approving Authority 08/01/2013 Inspector's Signature Date ' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under ' the same or different conditions of use. t5ins'-3/13 Title 5 Official InsVdSubsurface Sewage (sposal Sy ern•Page 1 of 1. 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: z:r ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: On observation of septic components there were no failures observed. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 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. ❑ Y ❑ N ❑ ND (Explain below): i t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Jacqueline Court Property Address lug Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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: ❑ The system has a septic 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. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ 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: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® 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 ❑ ® 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of 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 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone II of a public water supply well 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. t5ins-3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v.yr� 25 Jacqueline Court- Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been.introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling 'inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,•excluding the SAS, located on site? ® ❑ 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? ® 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 GPD t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. CitylTown State Zip Code Date of Inspection , D. System Information Description: System is constructed of a 1000 gallon concrete septic tank ,distribution box and 6'x6' leach pit Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2011= 162 GPD 9 ( Y 9 (gpd)) 2012 = 397 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unk. Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: unknown Date Other(describe below): General Information Pumping Records: Source of information: property manager Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: required biannual maintence 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yy� 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: installed in 07/11/1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.4 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments(on condition of joints, venting, evidence of leakage, etc.): dry with no stains or leaks observed Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon precast tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 9'6"x5'x5' Sludge depth: 10" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" 411 Scum thickness Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No obvious failures or defects observed. Grease,Trap(locate on site plan): Depth below grade: feet 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: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments t 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and'outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(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: r gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No , Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date t Comments(condition of alarm.and float switches, etc.): 'Attach copy of current pumping contract(required). Is copy attached?. ❑ Yes ❑ No t5ins•3/13 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert equal to single outlet 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.): On inspection of distribution box found misplaced cover that allowed soild to partiallt fill box. Soils were removed and box water tested and cover installed correctly. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 6'x6'w/2'stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leach pit was observed to be in working condition with 6"of standing water and stain line at 24"from bottom. Top of pit 12" below grade. Cesspools(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 ❑ No t5ins•3113 Title 5 official Insp ection Form:Subsurface Sewage Disposal System•Page 13 of 17 r • Commonwealth of Massachusetts . Title 5 Official . Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 • Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately s0� 9�cK =sb'. 3 s3 ° 3 - `/ SG 3� r�`'� V - �` �J t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page t f 7 pedi swag po 5 0 7 Y 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�' 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: > 10' no water observed at 10'feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from.system design plans on record If checked, date of design plan reviewed: 07/11/1996 permit on file Date ® Observed'site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: records on file" ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database explain: You must describe how you established the high ground water elevation: recorda on file aqnd hand augur on site Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .�� 25 Jacqueline Court Property Address Gegg-Kelley Owner Owner's Name information is required for every Centerville MA 02632 08/01/2013 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 LOCATION SEWAGE PERM T N0. ` VILLAGE Gam-7T& I N S T A LLER'S' NAME i ADDRESS BUILDER OR OWNER f/ DATE PERMIT ISSUED 02 40 DATE COMPLIANCE ISSUED �� �� O �� N 1� $,h� r -�----4 h -���d.4 s V Commonwealth of Massachusetts Executive of Environmental AffairsDEP t- s Department ofEnvironmental Protection �' a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � c PART A CERTIFICATION Property Address: 125 J ac uueline Court-Centeiville, M� Address of Owner: Michael S coblick (if different) Date of Inspection: 07/11/96 Name of Inspector: Michael D eD ecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - M ashpee Ma 02649. Tel : (508) 4771420 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 ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails Inspector ' s Signature: WAt Date: 07I11J96 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. I f 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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. IL r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) a Property Address: 25 Jacqueline Court. Centerville, M a. Owners : Michael S coblick Date of Inspection : 07/11/96 INSPECTION SUMMARY: Check A, B, C, or D A) SYSTEM PASSES: I I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 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 determinate (Y,N, or ND). Describe basis of determination in all instances. If "not determinated", 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 H ealth. ---- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). ----- broken pipe(s) are replaced ----- obstruction is removed ---- distribution box is levelled or replaced ---- The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ..... broken pipe(s) are replaced ----- obstruction is removed 2 r t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) .Property Address : 25 Jacqueline Court. Centerville, M a. Owner : Michael S coblick Date of Inspection : 07/11/96 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 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 of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING INAMANNER THAT PROTECT THE 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 water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I 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 analy- sis 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 notrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Jacqueline Court. Centerville,M a Owner: Michael S coblick Date of Inspection : 07/11/96 D) SYSTEM FAILS (continued) -- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. --- Static liquid level in the distribution box above outlet invert due to an over- loaded or clogged SAS or cesspool. --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. --- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). number of times pumped --- Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. ---Any portion of a cesspool or privy is within a Zone I of a public well. --- Any portion of a cesspool or privy is within 50 feet of a private water supply well --- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality ana- lysis. 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. Il SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Jacqueline Court. Centerville M a. Owner: Michael S coblick Date of Inspection : 07/11/96 E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 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 I I of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compli- ance 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. ' 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Jacqueline Court. Centerville M a. Owner: Michael S coblick Date of Inspection: 07/11/96 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 system has been receiving normal flow rates during the 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 S oil Absorption System, have been located on the site. --x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. --x The site and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Jacqueline Court. Centerville, Ma. Owner: Michael S coblick Date of Inspection: 07/11196 RESIDENTIAL: Design flow : S30 gallons Number of bedrooms : 03 Number of current residents: 0 Garbage grinder (yes or no) : PO Laundry connected to system (yes or no): vie Seasonal use (yes or no) :No Dater meter readings, if available: ►��,� Last date of occupancy : COMMERCIALIINDUSTRIAL : 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 information : 4..................... System pumped as part of inspection(yes or no) :.... ...... if yes, volume pumped: .................... gallons Reasonfor pumping :............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Jacqueline Court. Centerville, M a. Owner: Michael S coblick Date of inspection: 07/11/96 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).. p �c. . N`�.. ...� S.L .cRc ,�vr�..��.�... ......... APPROXIMATE AGE of all components, date installed (if known) and source of information ....................................................................................................... ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no)......NO SEPTIC TANK : ...I (locate on site plan) Depth below grade: ... ..... Material of construction: ..... concrete ......... metal ........ FR P ........ other (explain) ....................... ................................................................................................. Dimensions: : �.'� Sludge depth :... "....... , Distance from top of sludge to bottom of outlet tee or baffle:.....ZZ.................... Scum thickness:.....Q............. Distance from top of scum to top of outlet tee or baffle: .........!.b"........................ 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 invert, tructural inte rity, evidence of eal ,a , etc.)...................... .............................................. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION (continued) Property Address: 25 Jacqueline Court. Centerville,M a. Owner: Michael S coblick Date of inspection: 07/11/96 GREASE TRAP : ......P*Q.... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FR P........other(explain).... .......................................................................................................................................... Dimensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom 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 invert, structural integrity, evidence of leakage, etc.)........................ ................................................................................................................................................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:....0.0... (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FR P..........other (explain).......... ................................................................................................................................................ Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ............................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,Property Address: 25 Jacqueline Court. Centerville Ma. Owner: Michael S coblick Date of inspection: 07/11/96 DISTRIBUTION BO :..OQ (locate on site plan) Depth of liquid level above outlet invert:................... Comment: (note if level and distribution equal evidence of solids carryover, evidence of leakage into orout of box, etc.).................................................................................................................. ................................................................................................................................................ ................................................................................................................................................. PUMP CHAMBER:....... (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ SOIL ABSORPTION SYSTEM (SAS):...q:5........ (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: ..l.. .!�x.!c..P. leaching chambers, number:........ leaching galleries, number:........... leaching trenches,number ,length:..................... leaching fields, number, dimensions:................... overflown cesspool,number:.......... Comments: (Hoke ondikian of soil , si ns of by raulic failure, level of pondin , condition of v getation, Neel Fa9-wrx "04- f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION (continued) a Property address: 25 Jacqueline Court. Centerville M a. Owner: Michael S coblick Date of inspection: 07/11196 CESSPOOLS:...I ..... (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: ..................... Indicator of ground water: .................... 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 : ...60..... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . . .............................................................. ......................... .:.......:............................................... ................................................................................................................................................ � V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : 25 Jacqueline Court. Centerville, M a. Owner: Michael S coblick Date of inspection: 07/11/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100' U Z p�zas VZ- 5\ Pc J--\ 0 3 DEPTH TO GROUNDWATER: Depth to groundwater: ia.O.Jeet Method of determination or approximative: ll.S eo1 ..c�4:.. ............................................. ................................................................................................................................................ ................................................................................................................................................ l 30................. S �o BOARD z F HEALTH THE Ts O \ ...----....601(to....:..........OF............:...f AOITl .LAT..........................---..... Appliration for Disposal Works Toustrurtion Fierutit Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal System at: . ................1,(�GQV.65 � CT:....... .�._'... ---------_� i ...... ........................ - ..... ---- ---- - cation-Address or Lot No. -_--.�A.rn�...�--- L-----..Sm.. ,.. .............: .. 0.-n:-. .. ......................................... Owner AAdd1,re, w �1_S.c. C..�.nO ..4d..1 ....................... . .�.. !l... l am— .1.4 .........•....... Installer Address ,. UType of Building Size Lot.--5e07._ ._._._..Sq. feet �. Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) fla Other fixtures --------------------------------- . _ ------- --- ----- --- ------------------ Design Flow.....................�-�---`-5.. ....gallons per person per day. Total daily flow.................._. ©....._.._.gallons. WSeptic Tank—Liquid'capacity.[6W..gallons Length................ Width................ Diameter.----........... Depth................ x Disposal Trench—N ..................... Width.....,.............. Total Length....................Total leaching area...................sq. ft. Seepage Pit No.......... .......... Diameter.......g.--..... Depth below inlet........ ....... Total leaching area.. ..sq. ft. Z Other Distribution box Do ' tank ( ) I A Percolation Test Results 0.4 Performed b� -_ '_�"!_ $�._.:.-..Ct:. ©00 0�Date....D.. ..........................l a Y Test Pit No. I...Z.....minutes per inch Depth of Test Pit.......tom...... Depth to ground water......."'......... f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.---.................... 9 ----------------------------------------------•--....------------------..............----------••---......................................................... 0 Description of Soil----------------- . --------------.---- ---------------------------------------------------- x � 1�. -..... A. ........ . 1 .........S. ..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 TITLE 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 V. C\—\g - `:... ..i —8 0 Date Application Approved By................ °-• ' ............. Date Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------••-••------- .................................••-•-------•------••----------------•----------------.........----------...................------•-------------------------------------------------------------...._..-- Date PermitNo......................................................... Issued....................................................... Date No..l0:l!... Z¢ ~J Fps. Q... ........... THE COMMONWEALTH OF MASSACHUSETTS -- -� BOARD ,5QF HEALTH .......... .... `• ........ ,ApplirFation for Dispaa i al Works Tonstrurtion "rrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: . ................ .. `......1.�� �_.�---------- ........�------ ............................................ `+-� �•- �. ........----.....-----... .... . -. anon-Address or t No. ....-- .rn .�_ �r►.� Q r� . .......................................... Owner Ad es W �.�'. oC: .n�-.......:�.CU.-s-------------------- -------- . ---.....-----------------------... Installer Address UType of Building Size Lot-.!-' ?,�� ........Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type e of Building No. of persons............................ Showers (� YP g ---------------------------- P ( ) — Cafeteria ( ) a' Other fixtures W Design Flow•................. ....... gallons per person per day. Total daily flow....................... '?;,�____.___._galIons. WSeptic Tank—Liquid capacity.''V.gallons Length................ Width._.............. Diameter__._--__•-__-_. Depth................ x Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area....._-.............sq. ft. Seepage Pit No..................... Diameter......... Depth below inlet........ =?-..... Total leaching area... 42.t)..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) l�rt4 1 '-' Percolation Test Results Performed by... -'�.�� ......i. f.`...'t. ... ..................... Date f.� .._..'�....�:.:__ ... ��Date.......... .... � ...... ,a Test Pit No. 1._.. .....minutes per inch Depth of Test Pit........__�..... Depth to ground water..................... fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ M ••-•••-•--•------•-----•-•--••••--••••-•....•--•-••-•...-----•-••-•.............•--•--•-•--.................................................................. 0 Description of Soil......................e-----••--•••----....--••-•-•--•-•...•-•--.... x - V ------------------------- CT `ft`• t .:........................................l. 1-s ll t' �` = y�'7 W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... r' -------------•-----------------•--------------------------••---------•----------------.......----...----•-----............-•----------------•-------------------•-----------------------..........--••-- i Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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. ig�wj Date Application Approved B -•-••-•-••-••••-- . �h , 1 % 1-� d PP PP Y - ........_.. " a.1).... Date Application Disapproved for the following reasons:.........................:........... ............._ -------------------------------•---------...--•-.....•--•••••----•-••-•-•-•----•.._....-•----------....--••-•-•--•-•-----•-•-••••---•-•---•--•-•--•-•-•--•----•-----••••••••••-•••••---••-•••----------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TntifirFatr of (1 outpH atta TIJIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY---------. --...... .'a s----------------------------------------------------------------------------------------------------------------------------------- �• Installer (� A at A . 1 .......�!!v�QV�.-`'..W-'--------------- �.............`Z!�(A--V r�\........................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.........."...�5.Z.�`.............. dated....................................._.......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUU14CTION SATISFACTORY. DATE............. 1. '' ............................................. Inspector-------- ..................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD (OF HEALTH// e— kkkk y ` ev D 5 OF.................................................................. No.�....---••------... FEE. ::�:-':'.'�`....... Diaposat1 lark� �Otta�tratrluan rrutit Permission is hereby granted.......`+ ....__....---,qA :.--------------•----.................................................... to Construct (GK) or Repair ( ) an Individual Sewage Iisposal System ..... -.-.... v..-•-•••-•----••••--•...................................................... v Street as shown on the application for Disposal Works Constructio mit No..................... Dated.......................................... . 1 -------------------------------------------- DATE................................................................................ Bo ?'Aealth FORM 1255 HOBES & WARREN. INC.. PUBLISHERS S;L K--- 4 A4A,i L Zo cl, Z9, USIC---- k0�0 GAL— SuzWAL-L AZC--A = (SD S.P. 1 AzC4 AA� =EA= eo SF. IE>o S-'P D. r4AM Tc>-r,&L 'V>eSl6Kl = 42S &.Tl>r->. -roTA L. *r->A.k U-( F:LZ)VL1 LL - 70 Y%l C-t, L A ' A. ZF Tor V%4 t 4: 4 PtPp- DKT IW- -Boy, INV. T,ra w W- LaAr-" PIT Ap FgZOT=-1 LE—: LOCATIO" C> 7110 .90 pt.A Ij kj c cv-.iz-r1tr-,4 T14 Ar T14G- F-6Ut4t��TiCj-4.v51A0%4J'-J 6C%A,%PLI-eG WITIA JU-Tt--,AC-V- V7G0(Jl9ZGVE'-WT,; 0 F= T 14 -Tow P G 5-7 P A I rz 0 1.1"T L L,v L-LG o M AS.5, j,,-b,,mE-5 k. -SM IT 4 i k.-r CLn- ro