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Home My WebLink About0065 THISTLE DRIVE - Health 65 Thistle Drive Centerville P A = 148 021 UPC 12534 A 44, No.2_ 153LORs HASTINGS. MN i 4�;z z% coo COMMONWEALTH OF MASSA a(F-9S) CHUS rl /As- EXECUTIVE OFFICE OF ENVIRONIV�)✓IVT ;ATAIRLE DEPARTMENT OF ENVIRONMENT t?FZ O : ,q VISION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A -'7 CERTIFICATION Property Address• �� / �l/S�le ,(��l✓G /� Owner's Name: L-grr o Owner's Address: S Nr 1, ,4 O/Qom Date of inspection: Name of Inspector: ease print)/' '/Gi^ Company Name: � k idv,O— ?''Ec Mailing Address: ef o-;C /,1 ,9 G�� Telephone Number/ 0 cf 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage di sposal 000 310 CMR 15. approved system inspector pursuant to Section 5.340 of Title 5( ). system: Th I am a DEP s Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:. &Lx- Date: The system inspector shall su"copys 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 DER The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of time.This ins inspection and under the conditions of use at that inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 8 CERTIFICATION(continued) Property Address: h rr� e Owner. Date of Inspection: d—o Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy asses: I 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 exisL Any failure criteria not evaluated are indicated below. Comments: m 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. Answer yes,no or not determined(Y,N,ND)in the for explain. the following statements.If"not determined"please The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is struchually 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 Co indicating that the tank is less than 20 years old is available. Compliance ND explain: 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 willpass inspection if(with approval of Board of Health): broken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed piPes).The system will Pas inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: r a , Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: I�� Date of Inspections 3--da— e— C. farther 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. I. 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 _ 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 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 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 mtrogeu 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: "'4' T�U Tg a, &J4 Owner: / Date of Inspection: �d2—p D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No,,--- facility Discharge of sewage into or system component due to overloaded or clogged SAS or cesspool _ or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ,.dogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or 1 quid depth in cesspool is less than 6"below invert or available volume is less than%x day flow Izequired.pumping more than 4 times in the last year NOT due to clogged or obstructedpipe(s).Number i6f times pumped ,_/Any portion of the SAS,cesspool or privy is below high ground water elevation c/ Any portion cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply A ny portion of a cesspool or privy is within a Zone 1 of a public well. 2 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 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 S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form..] (Yes/No)The system fats.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails,'Ile 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. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no k system is within 400 feet of a surface drinking water supply system is within 200 feet of a tributary to a surface drinking water supply system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped e If 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.SectionD.shall upgrade the system in accordance with.310L CMR. 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B /� -�— CHECKLIST Property Address: (� 1 bu#Q Q� /f v� Owner. Date of Inspection: —oil— o 5 Check if the following have been done.You most indicate`yes"or"no"as to each of the following: Yes No/ —/ g information was provided by the owner,occupant,or Board of Health W any of the system components out in the previous two weeks — Has system received normal flows in the previous two week period e 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) — — as the facility or dwelling inspected for signs of sewage back up as the site inspected for signs of break out Were all system components,excluding the SAS,loc .on site , — Were the septic tank manholes uncovered,opened,and the interior:of the tank inspected for the condition of i bal11 ar tees,material of construction,dimensions,depth of liquid;depth of sludge and depth of scum Was the facility owner(and oaWants if different fors owner)Provided with information on the proper sae of sewage disPr�d sgcnn;- The size and location of the Sort Absorption System(SAS)on the site has been determined based on. Yes no �xisting 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)P10 CMR 15.302(3)(b)J Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSM ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART C SYSTEM INFORMAT70N Property Address: 2w � Owner. J91j 40 Date of Inspechos: o2vZ—O') ��- lei �� FLOW RESIDkENTkIAi, LOW CNDIMNS Number of bedtuoms(design): 3 Number of bedrooms(actual}:—3 �7 wa i DESIGN flow based,oa:310 15.203(for-example: 1.10 x#of 0 Number of current residents: bedroomsr �a rn f�/�-�l / Does residence have a garbage grinder(yes or no): 0 d 4 C Is laundry on a separate sewage system(des or no):—Ap [ifYesseparateinspection required}. - Laundry system tad(yes or�),-,t/_l Seasonal use:(yes or no): Water meter readings,if=avwlable years usage(gpd)): Sump pump(yes or no):Last date of occupancy: COMMERCIAUINDUSTRIAL Type of establishment: Design flow(based on 310 CUR 15.203): and Basis of design flow(seats/persons/sgft,etc.): 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 avmjable: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: /1/ Was system Pumped as part of the inspecti (yes or no): Tf yes,volume pumped:____pllons— w was quantity Pumped determined? Reason for F 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) hmovative/Ahernative technology.Attach a copy of the current operation and maintenance contrat(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all compo date installed(if known)and souMe of in brmaiion: Were sewage odors detected when arriving at the site(yes or no): AV Page 7 of 11 OFFICIAL INSPECTION FORM—:NOT.FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:C SYSTEM INFORMATION(continued) Property Address: �� l��sf�e �✓ Owner: J�/s Date of Inspection: �- BUILDING SEWER Oocate on site plan) Depth below grade: 'V // Materials of constirnon iron _v 40 PWC_otter(ecplain): Distance from private water supply welt or suction twe: Comments(on condition of loin%venting;-evidence of leakage,eta.): SEPTIC TANK: � —(� to lam) Depth below grade: � Material of construction: other(explain) _concrete_metal—_fiberglass —po19 Y1ene If tank is metal list age:_ Is ape confirmed by.`a.Certificate of Compliance pfiance'(yes or no):_(attach a copy of Dim: ,r X D l #opo€ to bottom of outlet twe orbaffie: o?9 f Scum thickness: O V Distance from top of scum-to top of outlet tee or baffle: fc y Distance from bottom of scum to bottom :4F et tee or baffle: How were dimensions determined: oComments(on pumping recommendations, and outlet or baffle condi tion�,structural as to outlet invert,Pdenee ofintettYs liquid levels ge,etc.). J! a GREASE TRAP: L- on site plan) Depth below grade:— Material of construction:_concrete metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thidmc;i Distance from top of scam to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffie: Date of last pumping Comments(on Pumping recommendations,inlet and outlet.tee or baffle conchtioA.structuiaj,integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): S , Page 8 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �/� T Isole owner: Gj if 40 4 Date of Inspection• TIGHT or HOLDING TANK:/1/ (tank must be pumped at Unle of inspectionXkxm a on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity:--- tllons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping; Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:/Z(if present must be openeMoc ate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and di&fttion to outlets equal;any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER.-4eao ate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenance,etc.): f , • Page 9 of 11 f OFFICIAL INSPECTION FORM-NOT FOR VOLU NTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSP'EMON FORM SYSTEM INFORMATION(confinwo Property Mdnm- Owner. 9ij 40 Date of hapecllar SOII.ABSOR)!OR'SFSTEM(SAS): Q s*plan,awewatlw xwt. If SAS not located ogWn why. Type / leaching p leaching gaikries,mom: leaching try,per,lenghmunber , overflow cesspool,number: aftwn ive system .Typenam of technology: Co (mate condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.) A h n </ 01 ILL CESSYEI�4(oesspoad mint be pumped as part of insp�tion)(locate on site Plan) Number ands: Depth—top:of lito inlet invert. Depth of solids lam Depth of scm lager Dimes of : Materials of consbuctim. Indication of der ,(yes or may.- Commelts(noted ofsoil,sign of hyd is .L-4d ofponding,condkion ofv q etc). PRWY:"kj on she plan) Materials cf caaftwioa: Dimeasiow Depth of solids` Comments(note condition ofsmil,signs of hydraidic f time,level of paw,condition of vegetating etc.): Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oo Property Address: I Dr Owner: /J�S�o r` ✓✓� Date of Inspection: o�el y' SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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 Oe l/ III �1 At ��ler xa- /� " s Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6S -Tts 4 le d✓ Owner: 190 h Pp Date of inspection: 3 —iJ--or, SITE EXAM 9' Slope / P Surface water Q Check cellar i ��.q Shallow wells Estimated depth to groundwater feet co Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked,date of design plan reviewed Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the y high ground-water elevation: o Awl 6 .6 G4 G u 'Ah �f rI A 1 L0� 0 0 / I �_ 2 y��