HomeMy WebLinkAbout0584 SKUNKNET ROAD - Health 584 Skunknet Rd.
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Centerville
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UPC 10259 '
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�. COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTE
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ONE WINTER STREET. BOSTON, MA 02108 617-292-5500kirl � y
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WILLIAM F.WELD -� 2 ,2 1998 TR COXEn
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ARGEO PAUL CELLUCCI Wv�rh p,STABLE DAVIES B4 TRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO. C issioner
PART A
CERTIFICATION \r" �j
Property Address. Address of Owner:
Date of Inspection: 7� S'r� (If different)
Name of Inspector: ErA G7 d'D
1 am a DEP approved system inspector pursuant to Section 1S.340 of Title 5(310 CMR 15.000)
Company. Name: oS'
Mailing Address: ,a 6 1-m-CY
Telephone Number: <b4'� ;,P
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:
asses
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: 711011,
The System Inspector s bm all suit a copy of this inspection report to the Approving Authority within thirty (30) days of competing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
V/1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 75.303.
Any failure criteriiiiiRot evaluated are indicated below. -
COMMENTS: j ?7J f3� �Ucr7a /!�-tea �2d f LsJjG�
BI SYSTEM CONDITIONALLY PASSES:
On re system components as described in the "Conditional Pass" section need to be replaced or re fired the system, upon
completion of t ment or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe ion in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the r operator has pr ' he system inspector with a copy of a Certificate of
Compliance (attach . . tang that the tank was installed within twenty nor to the date of the inspection; or
the septi , whether or not metal, is cracked, structurally unsound, shows substantial in i r exfiltration, or tank
re is imminent. The system will pass inspection if the existing septic tank is replaced with a conforms septic tank
as approved by the Board of Health.
(revised 04/25/97) Pago 1 0f 10
DEP on the World Wide Web: http://www.magnetstate.ma.usldep
i Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I
PART A
CERTIFICATION (continued)
Property Address:
Owner: J11u
Date of lnspectionc .
B] SYSTEM{CON DITIONALY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distributio x is due to broke or obstructed
pipe s a broken, settled or uneven distribution box.. The syst i I pass inspection if(wit, approval of the
Board of Health). De ' bservations:
broken pipe(s laced
r obstruction is removed
distribution box is ed.or repla
The system required mg more than four times a year due to broken strutted pipe(s). The system will pass
inspection if(w' approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Con ns exist which require further evaluation by the Board of Health in order to determine if the syste ailing to protect the
public hea safety and the environment.
1) SYSTEM WILL PASS ESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS N FUNCTIONING IN A MANNER
WHICH WILL PROTECT PUBLIC HEALTH AND SAFETY AND THE ENVIRON
Cesspool or privy is within eet of a surface water
Cesspool or privy is within 50 fee f a bordering vegetal etland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEAL PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM'IS FUNCTIONING IN A MANNER T PR S THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic to nd soil absorption system(SAS)and the S ' within 100 feet to.a surface water supply or
tributary to a surface er supply.
_ The system has ptic tank and soil absorption system and the SAS is within a Zone a public water supply well.
The system)rg a septic tank=and 'soil absorption system and the_SAS is within 50 feet of a p ` te.water supply well.
The s m has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 t or more from a
' p te'water supply well, unless a well water analysis for coliform,bacteria and volatile organiccom "nds in that
Zthe 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. Method used to determine distance (approximation not valid).
) OTHER
(revised 04/25/97) 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 system violates one or more of the following failure criteria as defined in 31 MR 15.303. The basis
11 this determination is identified below. The Board of Health should be contacted to determine w twill be necessary to correct
the lure.
Yes No
Back of sewage into facility or system component due to an overload r clogged SAS or cesspool.
Discharge o riding of effluent to the surface of the ground o dace waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the 'stribution box above tlet.invert.due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less n " low invert or available volume is less than 1/2 day flow.
Required pumping more th 4 times in last year NOT due to clogged or obstructed pipe(s).
Number of times pum _
Any portion o e Soil Absorption System, cesspool o rivy is below the high groundwater elevation.
Any rtion of a cesspool or privy is within 100 feet of a su water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public wel .
Any portion of a cesspool or privy is within'50 feet of a private water suppl well.
Any portion of a cesspool or privy is less than.100 feet but greater than 50 feet fro a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, a copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 1
RGE SYSTEM FAILS:
You indicate.either "Yes" or"No as to each of the following:
T (lowing criteria apply to large systems in addition to the,criteria.,above;:...
The system se s a facility with a design flow of 10,000,gpd or greater (Large System) a system is a significant threat to
public health and ty and the environment because one or more of.the followi onditions exist:
Yes No
the system is within 400 feet of a aced ' mg water supply
_ the system is within 200 feet tributary t . surface drinking water'supply
the system is I in a nitrogen sensitive area (Inter Wellhead Protection Area-IWPA) or a mapped Zone II of a
public wat supply well)
The owner or o or of any such system shall bring the system and facility into full co iance with'the groundwater treatment program
requireme of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Depa nt f r further information.
(revised 04/25/97) Page 3 of 30
� {..1,# 6 <a�.a.r �•��C ilk �'a:`S c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
n
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes"or"No" as to each of the following:
Ye No
_� _ 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 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.
Y _ The system does not receive non-sanitary or industrial waste flow.
JThe site was inspected for signs of breakout.
ul- _ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/ —The size and location of the Soil Absorption System on the site has been determined based on:
L/ The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the.field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Page 4 of 10 e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: w.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 0VAt- p.dibedroom for S.A.S.
Number of bedrooms:-,.?—
Number of current residents: 3
Garbage grinder (yes or no):1Q
Laundry connected to system (yes or no):1jL9T
Seasonal use (yes or no):-I�j
Water meter readings, if available.(last two (2)year usage,(gpd):
Sump Pump (yes or.no):
Last date of occupancy: /1(�11/T....
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: eallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title S 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:
System pumped as part of inspection: (yes or no),
If yes, volume pumped: gallons
Reason for pumping:
TYPE O YSTEM
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)
_I/A Technology etc Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: _ 1w f 7 .244-
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan) -
Depth below grade:
Material of construction: _cast iron 40 _other (explain)
Distance from private r supply wel or line
Diameter
Comme condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan) :.
/concrete
Depth below grade:Materialof construion: _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: IOGO V"AZ(�di�
Sludge depth: SLR'
Distance from top of sludge to bottom of outlet tee or baffle:
Scum-thickness:—(b 0 ��
;
Distance from top of scum to top of outlet tee or baffle: `� /V
Distance from bottom of scum to bottom of outlet tpe or baffle:
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,.structutal
integrity, evidence of leakage, etc.) 4,6Z2 T C�l//�E �UM �6 .q� 7Te,--P %rAA>
GREASE TRAP:
(locate on site plan) ,
Dept r de:
Material of construction. _ ncrete metal _Fiberglass _Poly�en other(explain)-
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or e. r
Distance from bottom of scum to bottom of ou tee or ba
Date of last pumping:
Comments:
(recommendation for pumpin , condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of lea e, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: ;•.
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to,or at time, of inspection)
(locate on site plan)
Depth below grade:
Mateiial' nstruYion: _conci:ete _metal _Fiberglass_Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order es; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, c ion of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan) M
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.)
,A1Q T LC- - W6, liQGu —Mdul�T a r?�'2�—°fG7/
PUMP CHAMBER:_
(locate •e plan)
Pumps in working order: (Yes or
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber ondition of pumps and appurtenance ,
a
(revised 04/25/97) Page 7 of 10
;s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C c
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
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:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPO :
(locate onsite 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 ( of must be pumped as part of inspection)
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 oil, signs of hydraulic failure, level of pon condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
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)
Or
to-to
� O
(revised 04/2S/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
Depth to Groundwater, Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how- you established the High Groundwater Elevation. Must be completed)
This information is available
m alternate format upon request
by contacting DEP's ADA Coordinator
at 617-574-6872
(revised 04/25/97) Page 10 of 10
LOCATION SEWA E PERMIT NO.
L.0 L-9-- /l ,S If un.rf A-E.7- /2
VILLA-cE
IN-STA LLER'S N-A ME i ADDRESS
EUILDE R OR OWNER
DATE PERMIT ISSUED- — �
DATE COMPLIANCE ISSUED
t4 1
4m
I�
E
No..... t1Ju Fps..........S'...............
V tD THE COMMONWEALTH OF MASSACHUSFTTS-
L'I� �Q BOARD-OF HEALTH
.
�.---
.............oF.........� ff' -............................
S AM111ration for Uisposal Morks Tomitrnrtion ramit
Application is hereby made for a Permit to Construct ( ✓j or Repair ( ) an Individual Sewage Disposal
System at:
...............5_ �.?.� ..........�a A•-------.........--.... ----••. - �...... .......- ..... ......-
Locatio -Addr ``
.........--•— .....M� .... ............................................(1 1 Y.. ......�_�l� /1 5—�.............No......-•---...............................
Owners w Add ess
W ..c ............. a.�.a.................... .......... !`-n---5— - ........................................
Installer Address
Type of Building Size Lot-.�2..3_.a1........Sq. feet
Dwelling—No. of Bedrooms............................................Expansion. Attic (N-) Garbage Grinder (09
a'k Other—Type of Building No. of persons............................ Showers —
yP g ---------------------------- P ( ) Cafeteria ( )
d Other fixtures ..
W Design Flow.............�\.P.......................gallons per person per day. Total daily flow...........7- :3 C:,..._................gallons.
WSeptic Tank—Liquid capacit*9 D..gallons Length................ Width................ Diameter.-.-----.------- Depth....--.......---
x Disposal Trench—No. .................... Vidth.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.........--......... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by---------13,. -k^.......d7.....N4e............. Date.....J` .�1:' ...........................
Test Pit No. 1................minutes per inch Depth of Test Pit.--................. Depth to ground water.------------.------.--.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ........................................................................................................--•-------••--•-----•---......----•---•........------
ODescription of Soil--•-•.... ............\,�_.G* k--- ...--5\) - --'--�--------•- -------------------------
U .....................•...... .\.?:-..---..-�-----------•--cn.&.�..------.�----- .--^ -------- ,saw 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 ITA ILE 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.
/ Date
Application Approved By....... �.. 1- . .. ,_
Date
Application Disapproved for the following reasons-----------------------------•-------------------------------------------------------------------------....------
......................................-----------•-----•---•-•-•----....------••------•---•-----------------•--•------------•--•-------------•---•------•-••---•--•---------••-------••-•••-----------
Date
PermitNo.......................................................... Issued_.......................................................
Date
.t
Y
1
THE COMMONWEALTH OF MASSACHUS;;,_rTTS%+
BOARD OF HEALTH
7�14?.n..............OF....... .Ct.n-. .: "G�- v�.
Applira#inn for Disposal World Tomitrurtinn Prrutit
Application is hereby made for a Permit to Construct ( ✓S or Repair ( ) an Individual Sewage Disposal
System at:
. ..........
- -------------
s Location-Addr
— (Y11 Y.- ...............�'LJ\n—S—�.....-r----t-No--•--•----•---_..........._....._.........
Owner Ad ess
Installer Address
Type of Building Size Lot.a .........Sq. feet
a Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder (09
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures
W Design Flow.............�\.�......:.__,�Q o_..gallons per person per day. Total daily flow._.........................-........_......gallons.
WSeptic Tank—Liquid ca.pacity.__.___.__..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..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
0-4 Percolation Test Results Performed by-__._..___10� u_ %'___.... `-'"........ Date................. .
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------•--- . ••-•---- --•-• ............ -----------------
•--••.........
.
O Description of Soil......... - �`---......... ..G^^ �---------- S v b s......
=--1-----•-------- ..................................
v -------.....................................................................
w
UNature 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'I'T`:;;;.
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been isssuue�d by the board of health.
LJ
Date
Application Approved By----- ``= ._ �11_..... ..... _ _ :✓ 2-:�./'
dJ......................•- •-----. Date
Application Disapproved for the following reasons----------------------------------------------------•------------------------•--•-----------------------••--•----
-•-------------------•-•----------•-------------•-........------•---------....--------.......------•---•---------------•--•-------------------------------••------------------------------------.._._...
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
''. .........OF............. 6"............................................................
w (f'rr$ifirtttr of T'TnutpliFaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( -j or Repaired ( )
by....................1.2.kt?. _`..1:�............... ......4..-•------------------•--•------------••------•..................._...._.._-•---_.....\---•.._..------••---
I staller
at................... -�` �r-------- ..................... - �-`.. ' -----------�C\ ?--•\--�'••------------
has been installed in accordance with the provisions of TITLE ` of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. /'.. .S �________________ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. _
DATE........... %� ................ Inspector.....�.��
------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
—cam BOARD OF HEALTH
fi r...............OF........�1
No.r..'. =•-`• FEE...:'....?............
�i��n��a1 nrk� �nn��inn rani#
Permission is hereby granted........... .............. 'S
to Construct (e,<or Repair ( ) an Individual Sewage Disposal ystem
at No.------.....7_._�........Ax - ._�S_�.1n� f? .. ---`---- ��...,.....
Street
as shown on the application for Disposal Works Construction Permit�No..................... Dated...........................................
/Z1 2.1- Board,of I�ealth
DATE ----------- .....
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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