The URL can be used to link to this page

Home My WebLink About0080 PARK AVENUE - Health { a 861PARK AVE, CENTERVILLE ,.et. A UPC 12534 N . •15 I.OR NAiTIM,UN t y I $ 8� $ORTOLOTTI CONSTRUCTION, 'IN,C. SEP 6 .1999 45 INDUSTRY ROAD, MARST ONS MILLS, MA 026 508-771-9399 508-428-8926 FAX: 508-428-9399 r� 9 ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION A E �, PART A CERTIFICATION Property Address: O t Date Of Inspection '7 Inspector' Name: � — jj! er's Name anji Address: AMffA ,CERTIFICATION STATEMENTe . I Certify that I have personally.Inspected the Sewage Disposal Systein at this address and that the Informa- tion reported below.is,true,accurate;and.complete as of the time of Inspection. The Inspectloin was perform-ed based on my Training and Experience in,the:Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.T e system: _Passes s.;; . :., . y. ' Conditionally saes `Needs Fur Ev lu n By the Local Approving Authority eYy t `-41?ailure a. "' , !� Inspector's Signature Date: r TheSystem Inspector shall submit a copy of this Inspection Report to the Approving Authority,;._with 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 submit1he Report to the appropriate Regional Oftie of the Departmentrof E.nvironmental,Protection:_ The Original should.be sent to the System Owner and copies sent to the Buyer,if applicable and the Approving Authority. f IN P . TION-:SUMMARY:, A) SYST `PASSES."i ' ':"iI have`not'found'any`Information'which i ndicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated'are indi- _,gcated below. x B) SYSTEM`CONDITIONALLYPASSES: One or more System,Components need to be Replaced or Repaired. The System,upon F completion of the.Replacement or Repair,Passes Inspection. Indicate yes,nor,or not detertmned,(Y,,N,,OR ND). Describe bases of deter mination all instances. if"not determined",explain why not. i The;SepticTagk Ys Metal,,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is iimminent. The System will Pass Inspection,if Existing,Sep tic Tank is Replaced,with;,F. onforming Septic Tank as Approved by the Board Of�Health,, 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): 1 - 1 tkBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , �• PART A CERTIFICATION (continued) �- - _ ,•ti't� Broken pipes)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): z, •i.�E . Broken pipes)are replaced -Obstruction is removed. 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 the public health,safety and the environment. 1)SYSTEM WEL PASS"UNLESS BOARD OF HEALTH DETERMINES-THAT THE s ° ' "SYSTEM IS'NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT"THE PUBLIC HEALTH°AND SAFETYAND'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)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLICiWATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM'I&FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETYxAND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface ` water supply of tributary to a surface water supply. The'system has'a septic tank and soil absorption system and is with a Zone I ofa publico r water'supply well:°,. The system has aseptic tank and soil absorption system and is within 50 Feet ofa private 3r{g ttt i water supply well. x .., a x: ,� _j, g 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 analysis;for,coliforW' u ^> bacteria and volatile organic compounds indicates that the well is free from po#utionfrom s. jhe.facility,and the-presence,of ammonia nitrogen and nitrate;nitrogen.is equal,to or less AgR ,PPm r $ D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria,as defined in 310 ChM 15.303.. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the.failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Y4, Static liquid level in the distribution box above.outlet invert due to an overloaded or clog Zr 9ed4AS orycesspool. x. 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 -2- >t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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. '�4'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).LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow:of a 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 or operator,of any such system shall bring the system and facility into'full compliance with`the gmundwater.,lreatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 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 atleast two weeks and the system has*` been receiving normal flow rates during that period. Large volumes of waterihave 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. /All system components,excluding the Soil Absorption System,have been located on site. _�The.septtc;tank,manholes were uncovered,opened,and the,interior of the septkrtank'was". spected for condition of baffles or tees,material of construction,dimensions,'depth of liquid;_ depth,of sludge,depth of scum: V 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. -3- s='x y 3fC•�` �4+hy� S ra�^"n��T, �'�,b r''E F��aki��/ '4 �` ICI SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) !LThelfacility owner,(and occupants,if different from owner)were provided.with information on the proper maintenance of Subsurface Disposal System SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTIOMFORM ` PART C ,,,;,�; ,; ;_ , •; ,.h, , SYSTEM INFORMATION ,,..; �. . FLOW CONDITIONS RESIDENTIAL Design Flow: 30 Sallons Number of Bedrooms: 3 Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use: A)O y�Water Meter Rea .. gs�lable:- LasfDate.of.Occupancy: t ,srt 4p4 t 17 -CO ME.RCIALI[ND 14T iAi : x Type of EstabLahmeent, , Design:Flow.:y .•.,t `R ons/day=:Grease MTrap Present: (yes or no) Industrial Waste Holding Tank Present: :Non-Sans Waste Discharged:To3he Title V System: T Water<MeterAeadings,,=If Available: Last Date of Occupancy: - a OTHER: Describe) Last Date of Occupancy: • K�Y x;'4:H it iR] rh {. ' - . 1 _ GENERAL INFORMATION . PUMPING RECORDS and source of information: � S System Pumped as part of inspection: A..91If es volume pumped: �.x '' Ions — Y Reason,for pumping:.—i ; ,- Y TYPE:OFIYSTEM:i Septicfflank/Distribution,Box/Soil Absorption System Single Cesspool !_Overflow,Cesspool ; Privy Shared System%fes,a lta revi ou n Pcedon re cord s if any )Other(explain): �X.P D.(LiII�L/171---C.-Qp_ is vs,!v•:.Y '! .r";,Yy:.ri s.'k. -tot", / _,�.5-• i,. .+ ;. r paa��.p�, AP ,ROXIIViATEZAGE of all components,date installed(if known)and source-of information: ; .- fw'1 •l,.q.ikni kiY` P 'Y:ln y;17'. ale -, {. f. L J. CS-q,;;.L.r;{ �X - .'•NK.f7 i. "gev rs detected when arriving at the site: ^ ' , —4 . lit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: A-)6 Depth below grade:. Material of Construction: concrete metal FRP Oth (expo) 11:1 -...,• _ . er — Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom 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,de1.pth of liquid level in relation to outlet�invert,structural integrity, evidence of leakage,etc.,). 'GREASE TRAP:—� DepthZelow,Grade: Material of Constriction: concrete metal FRP_Other,,j,. (explain) - — — Dimensions: 'Scum Thickness: Distance from top of scum to top of outlet We or baffle: Comments: (recommendation for pumping,condition of inlevan&outlei tees or baffles,depth ofligtudt ♦4 level in relation to outlet invert,structural integrity, evidence of leakage,etc.) TIGHT,OkHOLDING TANK:_ Depth Below rade G Material of Construction: concrete metal FRP Otiter(explain)';,. Dimensions: Capacity:p gallons Design Flo« gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alarm and float switches.etc.) 4 ` f DISTRIBUTION BOX:�v Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER:-.0,S— � PUMP' is'in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) 5 ` i / R� SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOEL ABSORPTIO14 SYSTEM(SAS):_y/ (Locate`on site plan,if possible;excavation not required,but may be approximated by non-intrusive,i methods) If not determined to be present,explain: Type: `Leachingpits number: Leaching chambers,.number: Leaching galleries,number: } Leaching trenches,number;length: Leaching fields,number,dimensions: .Overflow Cesspool,number: Co nts:(note condition of soil,signs of hydraulic fail re level o pondin ,co di 'ono vegetation, etc.) Q p - CESSPOOLS: Number and configuration: Depth-top'of liquid to'.,inlet invert:`, � 3, Depth of solids layer: Depth of scu layer.-' Dimensions of Cesspool: �J •Materials of construction " ' Indication of groundwater: Inflow(Cesspool must be pumped as part of inspection) Comm ts: (note condition of soilk, igns of hydraulic failure, I el of pondin ,;condition of�+egetation; Materials of construction: Dimensions: Depth of Solids: Comments:.(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) t A. 43V ' ... � ..... ... «.�.�.�.._.«.. a ...Y .`.. ....... .�... ....- ..........r.w...........«.. ...a. ,.... .,.. .+_.. —..3�... .. -6 - r 44, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to adeast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. 90 'DEPTH TO GROUNDWATER: Depth to groundwater: i 15r Feet Method of Pete ' on or Approximation: � f _7_ S