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HomeMy WebLinkAbout0051 WEDGEWOOD DRIVE - Health 51 WEDGEWOOD DR., CENTERVILLE A = 189 144 EcrctFo i UPC 12534 No.2-153LOR HASTINGS. MN i COMMONWEALTH OF MASSACHUSETTS `1 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION T110tZI-1� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: WIe G?4t/pp 0//VG ou Owner's Name: 100 o,.vs i Owner's Address: 671_0_k-e c ,woo r s-e— Date of Inspection: ' O y�/f Name of Inspector: please print)�/ " /G��— ���/� � ��G 3 1 Company Name: L� /b — TOWN OF BA�1� �Mailing Address: O O-N /dSd ABLE NBALTH®EPfi, Telephone Number: os� 7 3—�7/04q/o 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 disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: oS // Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 2—S�� 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. Notes and Comments ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ERTIFICATION (continued) I I / erty , Prop Address: �/ ue C t✓voC Owner: Date of Inspection: tg Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: - 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: B. 'System Conditionally Passes: N 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 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. 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 will pass inspection if(with approval of Board of Health): broken pipe(s)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 pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r CERTIFICATION(continued) Property Address: J P 61� wo cc/ v1 ✓(r dot lO 3.Z Owner. Date of Inspection: p C.,/Further Evaluation is Required by the Board of Health: /V 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 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 an determines that the PP � y) 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 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �✓� /�c' �/` C' V V& 2 Owner: �DG,rS �' Date of Inspection: 0 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No o/ 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 ,,ciogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ squid depth in cesspool is less than 6"below invert or available volume is less than%i 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 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. _ ��///�y portion of a cesspool or privy is within 50 feet of a private water supply well. V 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 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)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. 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 _ the system is within 400 feet of a surface drinldng 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 11 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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: S 11 4 e,--c( a, Owner. p WS( l� se✓ 6 3oL Date of Inspection: o? o Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes o Pu ping information was provided by the owner,occupant,or Board of Health V Were an of the y system components pumped out in the previous two weeks Xthe system received normal flows in the previous two week period � IHve 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 ( ey 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: l Yes 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(3)(b)] Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Y� SYSTEM INFORMATION Property Address: �l/ t"�,4 e 6,o o d 52, ce,,4c vvi l r,3,? Owner. JLI O&✓S 4-1 Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): (-f qo Number of current residents: 0 Does residence have a garbage grinder(yes or no)/am Is laundry on a separate sewage system(yes or no):W [if yes separate inspection required] Laundry system inspected(yes or no):A10 Seasonal use: (yes or no):WS n Water meter readings,if available(last 2 years usage(gpd)): /9Y�- O00 o?C00- /3 0O p Sump pump(yes ora no):/�/� Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Bpd 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 available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: lnS T- 3 S O 1.✓✓��^ Was system pumped as part of the ' tion(yes or no): 4,'V If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: Tl'r,E-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) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed Sif known)arrd�spurce of information: (o - !f,o �1 Were sewage odors detected when arriving at the site(yes or no):/—(/'O Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM (INFORMATION(continued) Property Address: Le 4g,,OoG' i r- eville Owner: Date of Inspection: 91, o/ BUILDING SEWER(locate on site plan) Depth below grade: ,35 ' Materials of construction: cast iron _v40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: 30 Material of construction: Vconcrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) 5x g Dimensions: Sludge depth: 311 Distance from top of�udge to bottom of outlet tee or baffle: 3� Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto 9f outlet t or baffle: C, How wereo dimensions determined: _ e �A 9 c.1 e yr e-el Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evide of 1ea4ge,e/tc/.): N N1 I M h eQG f�Ci O1 1 T'!5 /'n'i Fi y L�N L� C7G�/ iGS �✓1 i - v /0 GREASE TRAP:A60ocate on site plan) Depth below grade:— 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): f Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C rSYSTEM INFORMATION(continued) Property Address: W1 Co ew"i a— I Owner:J20 L'/5 If 1" Date of Inspection: C of / 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: gallons 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: d/(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage' to or out of x, p0:, / - / ,� o j ox e' he d i 1Q u'1 �o ��� PUMP CHAMBER (/ (locate 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 appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMf INFORMATION(continued) Property Address: Qe GGeh Pf v O �3�L Owner:Sa w 1 Date of Inspection: d SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: co leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc. : /� -7� Ql f o' 0Ji� 5T,4"hed/ Svr' A&4 //S Ne Giroun t1-A K an o �XCe S ecj%�•��vy, /j/, r�r Glr e.r,- .r ✓ 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:j4!�(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.): Page 10 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �/p�C Gf 6-W al— Owner: wS Date of Inspection: 0 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 building. 47 ��`�I c6e- o A- 101 G , ,43_ 3dt �/- C,2 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: we J ewva) d� ,4 tyr IVIII C?,((P Z Owner: ows Date of Inspection: O SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30,y�feet 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: To wh vvAG XZX Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You ust cribe how you estol�hed the high group wat r elevation: ve f row It c.. ToF 1-7 /000 alloy 4 r z% Tot.,4- Vf jai 9,5 - �7elv�. oracle ' SeD�ro.�tOr1 from ' I / I I _! Zone - r a le o,-` a ' oT�°n►�t SUBSURFACE � ZWVftARY ASSESSUBSURFACE$SWAGE Dy�pp�, ,t,gyg _ r nrsrEcr�orr Foy N�QY'��'+� SY3'1��RMATIoi1t �r fir, AmpervAMMm Daita[SXVPM7 of S2WAGa DMOWAL SYST m tam a��or , loc�6e aloe p���eeoas rb ar yip 40C tv A•S C�' �✓ /�.�' Sat L0= TION 9; SEWAGE PERMIT NO. 1tIL-LAG E INST LLER,'S�-N E & ADDRESS 8 U.It E R OR d/ OWNER WNER A ` DATE PERMIT ISSUED DATE C ® MPLIANCI ISSUED g . i I , i Q ,� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAULCELLUCCI DAVID B.STRUHS Govemor Commiss' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION 4C Property Address: 51 WEDGEWOOD DR. CENTERVILLE MAP 189 PAR 144 L 8 Name of Owner ALDONA DOWSKI f Address of Owner: STELLA STAPELIS 86 TAYLOR RD.PORTSMITH R.1.02871 �' o IV Date of Inspection: 6/11/99 Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: n/a Mailing Address: n/a Telephone Number: n/a 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 The inpection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Evalu ion By the Local Approving Authority performing at the time of the Inspection.My inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:6/12/99 The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 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. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 51 WEDGEWOOD DR.CENTERVILLE MAP 189 PAR 144 L 8 Owner: ALDONA DOWSKI Date of Inspection:6/11/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: Wa 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. Indicate yes,no,or not determined(Y, N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is 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 complying septic tank as approved by the Board of Health. nLa 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 nLa 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 revised 9/2/98 Page 2 of 11 I ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 51 WEDGEWOOD DR.CENTERVILLE MAP 189 PAR 144 L 8 Owner: ALDONA DOWSKI Date of Inspection:6/11/99 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 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: The system has aseptic 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS 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,Method used to determine distance nfa_ (approximation not valid). 3) OTHER Wa revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 51 WEDGEWOOD DR.CENTERVILLE MAP 189 PAR 144 L 8 Owner: ALDONA DOWSKI Date of Inspection:6/11/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 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. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: _ The system serves a facility with a design flow of 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: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 51 WEDGEWOOD DR.CENTERVILLE MAP 189 PAR 144 L 8 Owner: ALDONA DOWSKI Date of Inspection:5/11/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or 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 that 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 Soil Absorption System,have been located on the site. X 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: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 11 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 51 WEDGEWOOD DR.CENTERVILLE MAP 189 PAR 144 L 8 Owner: ALDONA DOWSKI Date of Inspection:6/11/99 FLOW CONDITIONS RESIDENTIAL Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):.3 Total DESIGN flow: IU Number of current residents:11 Garbage grinder(yes or no):XG Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): n/a Sump Pump(yes or no): KQ Last date of occupancy: 12/1/98 COMMERCIAL/INDUSTRIAL Type of establishment: Wa Design flow: n1a gpd(Based on 15.203) Basis of design flow: n1a Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): rlQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:Wa Last date of occupancy: Wa OTHER: (Describe) n& Last date of occupancy: WA GENERAL INFORMATION PUMPING RECORDS and source of information: n1a System pumped as part of inspection:(yes or no):t)LQ If yes,volume pumped n/a_ gallons Reason for pumping: Wa TYPE OF SYSTEM X 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.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n(a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1976 PEMIT#76-650 Sewage odors detected when arriving at the site:(yes or no): MQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 WEDGEWOOD DR.CENTERVILLE MAP 189 PAR 144 L 8 Owner: ALDONA DOWSKI Date of Inspection:6/11199 BUILDING SEWER: (Locate on site plan) Depth below grade: X Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) n/A SEPTIC TANK: X (locate on site plan) Depth below grade: Z Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ n/a Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 3 Scum thickness:3 Distance from top of scum to top of outlet tee or baffle: 2.6! Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle:_n/A Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a 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.) n/a revised 9/2198 Page 7 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 WEDGEWOOD DR.CENTERVILLE MAP 189 PAR 144 L 8 Owner: ALDONA DOWSKI Date of Inspection:5111/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Wa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLd Dimensions: Wa Capacity: nLa gallons Design flow: n& gallons/day Alarm present: NQ Alarm level:jibL Alarm in working order:Yes_No_: NQ Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n& DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet Invert:n& Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nta PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n& revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 WEDGEWOOD DR.CENTERVILLE MAP 189 PAR 144 L 8 Owner: ALDONA DOWSKI Date of Inspection:6/11199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: j3La leaching galleries,number: j3La leaching trenches,number,length: Wa leaching fields,number,dimensions: Wa overflow cesspool,number: nLa Alternative system: Wa Name of Technology: ji& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.PIT HAD V IN IT AT THE TIME OF THE INSPECTION.NEVER MORE THAN 3, CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: Wa Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: a& Materials of construction: nLa Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:nla Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 WEDGEWOOD DR.CENTERVILLE MAP 189 PAR 144 L 8 Owner: ALDONA DOWSKI Date of Inspection:6/11/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a �►�ra D G14 ,qA a sy 2� l� revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 WEDGEWOOD DR.CENTERVILLE MAP 189 PAR 144 L 8 Owner: ALDONA DOWSKI Date of Inspection:6/11199 NRCS Report name: n& Soil Type: n& Typical depth to groundwater: nLa USGS Date website visited: n& Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS AND VISUAL-12+ revised 9/2198 Page 11 of 11 LOV T ION SEWAGE PERMIT NO. VILLAGE INSTA L,LER'S.:�' N E & ADDRESS B U I'L D-E R OR OWNER p A ' DATE PERMIT ISSUED ti DATE COMPLIANCE ISSUED �� � y � ', t �� I, . �, f� . �� ti � ; e �,� �: ,. No............_ 1 ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD O H ALTH 1-.............OF....... ... . .... .. P'................----- Appliration -for Uiipooal Workii Tonitrnrtion Vrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syste�m y_e_ .�_� , ?rV ._.. i � � �1 Locatdiion 4d(dd�ress pQ``'�' oXddre No. -•--••••---•-•.............................. Installer Address UType of Buildin Size Lot...... ..__.....!_/_......Sq. feet DwellingkNo. of Bedrooms........ ..............................Expansion Attic ( ) Garbage Grinder a`4 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )� a' Other fixtures --------------- W Design Flow............ ... ...................gallons per person per day. Total daily flow........7..,a d..___..._..........gallons. WSeptic Tank 4-Liquid capacity allons Length---------------- Width................ Diameter_ _-.--------__ Depth................ x Disposal Trench—No..................... Wi tl .... Total Total th--------- ___._. To leac ng area----.--._-.-..------sq. ft. Seepage Pit No. / ...._... Diameter:-/ LAekh btr tla..._ nt 14in area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ®/b— fO C I& Id- / V76 a Percolation Test Results Performed by------- ----------------------------•-----•------------------•---....---- Date--------------------------.............. a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water_---------------------- G14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ �V -4 O Description of So ® - fo ._..., _ 1°� /�---- ----- --­--------------- U :�,.�t UG"1 ------------- 1�=-'--------- --- ------------------------------------------- -------- -------------------------- Nature of Repairs or Alterations—Answer when applicable.----------------------------------------------------------------------------------------------. ---- ----------------•--------•-------------------•----------------------------•--------------------------------•---------------------------------------------------.....---------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witli the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Nissu by hoar f health igne . ............. ------------------------------------- -- <.-'.. .. . ate Application Approved By----- ... ; • ....... .74----- Date Application Disapproved for the following reasons-------------------------- -----... ------------------------------------------------------------ •-••-•--•-•------------ -----------•----•--••--------•-••--------••--•----------•-•--•---------•.••••••--•-•------••-----•-----•---•---•---------------•-----------------_-•-•--••----.......---- Date PermitNo......................................................... Issued...................... ----------...................... Date J `j �J No........... .- F,s.... ......�f^ .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE�AALTH (s -s 'i..............OF........ s'�4 CL•!lil�r.-� c,�- � ............ Iirtttintt inr i n ttl lard Towitrurtion V rrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System'a�: rr!.' �y,c u10 dci` Y/ f�'. -=P}t•l. }!t!t ( p _r1/ (5 CG Location.Address or Lotl No. .. ------•-- -�� r 5--------------------------------------- --------- .r_f_ sf.ay.__..................................................... OvIne, Address' , ------------------------------ -•.------.._._...---•-------•-•-_-----•---- Installer Address U Type of Buildin � OyG �Sq. feet Size Lot---------'------------------ �, Dwelling�No. of Bedrooms---------.-�____________------------------Expansion Attic ( ) Garbage Grinder (�c� aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) G4 Other fixtures ----------••------------------ W Design Flow............. +�J_----•-____-�__�___ M g ons per person per day. Total daily flow........ .� J------------------ allons. WSeptic Tank-L Liquid capacity/i)-E i!gallons Length------------_- Width-.-.-.-------. Diameter-/..... ......... Depth----------.----. Disposal Trench—No- -------------------- Width.............. Total Length_.........:- Total leaching area..___._...._.--_....sq. ft. x rr Seepage Pit No........ Diameter_?Y� .�4e_p_'th below inletF..._/_. 76tal•leaclfing area------.-----------sq. ft. z Other Distribution box ( ) Dosing tank a Percolation Test Results Performed by-------- --- -------- ---------------------------------------------------- Date---------------------------------------- Test Pit No. 1----------------minutes per inch Depth of "Pest 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------- nest : -l:k-.. ..',•/�n.---- ...... -'!_-�..�`.rc..---- `� ` "F�:..�•�,y � ' �� -------- •--•------------ ''�r�.-s.�-------.-J-l?�- --------•Vic.------`---'--•- --------•----------------------------------------••--•--•---. -•--•----- 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 Article XI 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.i J�,�%J Signed= ---�--`^-•---•--•----`-��-.---�---_`�.-,.�.`".�-�_'_ ---� .n� .��t-'-°'.. Application Approved B J r / ,/�� ate PP PP y---------�r Ls,I... t:.......l Y����t�'1�'i/,s/.1-------------- 1� ... -- Application Disapproved for the following reasons____________________________ _ f/ •--•----••-•----.----•--- ---------.--•---------Date ------------- --- -------- ------------------------------------------------•--------------- ------------------ Date PermitNo......................................................... Issued-----_--------------------------------------------•-• Date THE COMMONWEALTH OF MASSACHUSETTS BOARD QFl HEALTH 1.....:: ..........OF............ ................................................................r........ (Iertif rate of f.T.>ampliatta THIS,IS TO CERTIFY,/That the Individual Sewage Disposal System constructed or Repaired ( ) /Ll 1 /# i ...........................................................1 Installer r at --- -- ✓..... ............. ... has been installed in.accordance with the provisions of rA"rt qle XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit 6).......... dated'..... _____________•_-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Inspector. DATE f/------- - ------------------- //r -- THE COMMONWEALTH OF MASSACHUSETTS ��OARD5,F HEALTH.OF.........!,Z... '..'". . ....�w ,'.` No-------------------_-- FEE,_ ..................i� vttirk�'(nntt ritr�tttt rrmit Permission is*hereby granted-----;------------- -=�-• •--•--•---�----_.k�___ _ -' _.l. ............................................................. to Con str�,u�t� �f or, Rep it�(�� ) an Individual Sewage iisposal System at No...p'-� _ -1© `= ...tea-- ..•--.b-".- Street as shown on the application for Disposal Works Construction ermtY No...,_./ ....!_'_Dated-------� ------`��`-� �. .F.t.� .� �►-_C�-ti- . ••. - - --•-•--- •--............ _ Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS toy � 0 tan. Ali..$ P � e D Q 0� .00 + .J O •'p1 b T : cere6j c9AJ the_ .ex sang . C}:c`�li on .l0ca��oh-.i�s� Gorr��i_��-=:..�hUwn�-.. 1. ' ..'��.�rio. �;::r,� � !�.