HomeMy WebLinkAbout0900 LUMBERT MILL ROAD - Health 900 LUMBERT MILL RD., CENTERVILLE
A= 124 017.008
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No 2 53LOR
HASTINGS,MN
ll
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld
' Governor
Trudy Coxe
Secretary. EA
David B.Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
�t'�f(�l.s CERTIFICATION �p rlJL'�'1Address of Owner: /e e �Ar S S t
Property Address: �� 3 3
Date of Inspection: — --�'j (If different) oic.,t/bttr
Name of Inspector: W. Robinson 'Sr.
Company Name, Address and Telephone Number: W.E. Robinson Septic Service
P.0. Box 1089
Centerville MA
CERTIFICATION STATEMENT ��77 777
I certify that I have personally inspected the sewage disposl s�sCerh�t 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 By the Local Approving Authority
_ Fails
Inspector's Signature: ��/, Date: 3^
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 10,00.0 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) SYSTEE ASSES:
t7 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.
B] ; STEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
asses inspection.
Indicate y s, 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.
(revis d 8/15/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)M-5500
10 Printed on Recyded Paper
t i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: C/ 0 D )"um b-er t M, 144)II S
Owner: ! 'e r D A-rl M 1 rl
Date of Inspection: 3_?-(? (i
B]SY EM CONDITIONALLY PASSES (continued)
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
C] FURT ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) S�STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
TYE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The cvstem has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tr;butary to a
surface water supply.
The systen, 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 systen, Has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D] SYSTEM AILS:
I ha a determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for his determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
th failure.
_ Backup of sewage into facility or system component due to an overloaded or dogged 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.
(revised 8 5/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: Go,'a-h ✓Ni lh
Date of Inspection: 3 _ 7
D]SYSTE. FAILS(continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
IRequired 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 a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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 analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LAR SYSTEM FAILS:
he following criteria apply to large systems in addition to the criteria above:
he 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 II of a
public water supply well)
The owner r operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirement of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
i 1 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: 6?QT t).P_0 (l i"/rl C-
Date of Inspection: 3 _r)
Check if the following have been done:
_t Pumping information was requested of the owner, occupant, and Board of Health.
_VNone 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.
I2As 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.
/ s not receive non-sanitary V The system doe or industrial waste flow
_L/fhe site was inspected for signs of breakout.
—All system components, excluding the Soil Absorption System, have been located on the site.
/he 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.
,"(he size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
VT/he facility o.%ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION 44
Property Address:
Owner: 62o r,"h Milh—
Date of Inspection: 3„'7 _c/ 1,
FLOW CONDITIONS
RESIDENTIAL:
Design flow: "53D allons
Number of bedrooms:3
Number of current residents:3
Garbage grinder (yes or no):-Az
Laundry connected to system (yes or no): Y
Seasonal use (yes or no):_t/
Water meter readings, if available:
Last date of occupancy:1=?--q1 G
COMMERCIAL/INDUSTRIAL:
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:
�Z'I - 6Y '-l' Pes�s Ow .� % 2
System pumped as part of inspection: (yes or no),�lU
If yes, volume pumped. gallons
Reason for pumping:
TYPE OF STEM
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: 1.U . i!L 5
Sewage odors detected when arriving at the site: (yes or no) L.-O
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
- SYSTEM INFORMATION (continued)
Property Address: q 0
Owner:
Date of Inspection:
SEPTIC TANK:_/
(locate on site plan)
Depth below grade:
Material of construction: _ oncrete _metal _FRP other(explain)
Dimensions: "1 q
Sludge depth: 3 "
Distance from top of sludge to bottom of outlet tee or baffle: 4/D
Scum thickness: j i
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 invert, structural
integrity, evidence of leakage, etc.) AJ
GREA TRAP:_
(locate o site plan)
Depth bel 'grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensto s:
Scum t ' kness:
Distant from top of scum to top of outlet tee or baffle:
Distance rom bottom of .rum t' hOttOm Ot OLMet tee or baffle:
Comment
(recommeridation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, vidence of leakage, etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 0 �_U4,n��� i�� ��0 M"S*4 S /YIDM
Owner: ,aeY7 M/'//7 2'
Date of Inspection: 3—7 r S ('
TIGHT OR HOLDING TANK:_
(locate site plan)
Depth below rade:
Material of co truction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: al Ions
Design flow: allons/day
Alarm level:
Comments:
(condition of i let tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:n
Comments:
(note if level and distribution is equal, e%idence of solids ca.r,o•,er, evidence of leakage into or out of box, etc.) gd o
PUMP CIA BER:_
(locate on sit plan)
Pumps in wo king order:(yes or no)
Comments:
(note condi ion of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
// SYSTEM INFORMATION (continued)
Property Address: qed Aam k, f
Owner: Al
Date of Inspection: 3 _ �g
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 vegetattiioon,etc.)
CESS OOL1 _
(locate site plan)
Number a configuration:
Depth-top liquid to inlet invert:
Depth of sol ds layer:
Depth of scu layer:
Dimensions f cesspool:
Materials of onstruction:
Indication groundwater:
i flow (cesspool must be pumped as part of inspection)
Comment : (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate o site plan)
Materials f construction: Dimensions:
Depth of lids:
Comment : (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
kA
(revised 8/15/95) 8
'I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
c l ', SYSTEM INFORMATION (continued)
Property Address: Cleo d-&" her
Owner: 6?d r op t 0 ro J`
Date of Inspection: 3—7 _94
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
` �wL
3° x
�b,-
DEPTH TO GROUNDWATER
Depth to groundwater:_feet '/ J
method of determination or approximation:
(revised 8/15/95) 9