HomeMy WebLinkAbout0048 WHIDAH WAY - Health 48 Whidah Way, Centerville
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No. 42101/3 ORA
ESSELTE
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O O O O
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.Y {
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld Trudy Coxe,-%
Gonmor
Arpm Paul Cellucci
u.Goarnor CoininlMlornr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
• PART A -
�� CERTIFICATION
Property Address:-Pi4fi-1-U! Address of Owner.
Date of Inspection: 7--/ (e (If different)
Name of Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
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 sew disposal systems. The system:
_ Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspeotoes Signature: Date: Or—'9
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 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:
A] SYS ASSI�:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal, cracked,structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
�A1 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner.
Date of Inspection:
B) TEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) THER 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.
SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
D INES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
S AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply.or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The 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 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.
8) O
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner.
Date of Inspeetion
D) SY TEM FAIL:
have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
Backup of sewage into facility or system component due to an 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 clogged SAS or
cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
_ 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
)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:
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 U of a public
water supply well)
The owns or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requireme is of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for ftuther information.,
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner.
Date of Inspection: g 4
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 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. ,
system does not receive non-sanitary or industrial waste flow
Lfie
site was inspected for signs of breakout.
11 system components,excluding the Soil Absorption System, have been located on the site.
�'he septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of bales or
tees,material of construction,dimensions,depth of liquid,depth of sludge, depth of scum.
size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
lz%/e facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised ii/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Design tlow:_33® gallons
Number of bedrooms::3
Number of current residents:
Garbage grinder(yes or no):—e
IAundry connected to system Ves or no):,Y,s
Seasonal use(yea or no): di,o-
Water meter readings,if available: C/ Q`
S - 7n aoa 9_
Last date of occupancy: g 4
COMMERCIAL/INDUSTRIAL•
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yea 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:
Lest date of occupancy:
OTHER(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
A.,If
System pumped af part of inspection: (yes or no) Jt.
If yea,volume pumped: gallons
Reason for pumping:
TYPE OVSYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yea,attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: 5 /J PAW
Sewage odors detected when arriving at the site: (yes or no)�0
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner.
Date of Inspection: g=g
SEPTIC TANKv
(locate on sits plan)
Depth below grade: f
Material of constriction:=✓ ncrete_metal_FRP—other(explain)
d
Dimensions: 'a,-
ShWp depth:_ y
Distance from top of sludge to bottom of outlet tee or baffle: 3�! a
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 balfle:�
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.) /L�6 ���� e ldo n--►w c� e. ® a
G E TRAP:_
(locate •n site plan)
Depth be ow grade:
Material f construction:_concrete_metal_FRP--other(explain)
Dimens' no:
Scum
Distance m top of scum to top of outlet tee or baffle:
Distance bottom of scum to bottom of outlet tee or baffle:
Comments:
(recomme tics for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence o leakage,etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner.
Date of Inspection
TIGHT OR HOLDING TANK:
(locatesite plan) —
Depth rude:
Material construction:_concrete_metal_FRP_other(explain)
Dime ns:
Capacity: ons
Design flo gallons/day
Alarm 1 1:
Comme 1
(conditio of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carfyover,evidence of leakage into or out of box,etc.)
PUMP C BER:_
(locate on si plan)
Pumps in wo king order:(yes or no)
Comments:
(note co n of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: �� ffi 0 IU✓ ' �f' ��%� i'✓/���
Owner. 11,"n j
Date of Inspection: �'�-� 9 LI
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,if possible;excavation not required,but may PP iadmated
be a by non intrusive methods)
If not determined to be present,explain:
Type:
leaching pits,number:v
leaching chambers,number:_
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number: ff
Comments: (note condition of soil,aigns of hydraulic failure, leve Lof ponding,condition of vegeeta ' n,etc.� �' �{' �',� „��
-� / `dye G ! 1 c- ,r�'�u�u � 3
CESS IS:_
(locate on a plan)
Number and r<fisuration:
�p�th'of
top of to inlet invert:
of solidslayer.
scum yer:
Dimensions of pool:
Materials of n:
Indication of water:
w(cesspool must be pumped as part of inspection)
Comments: ( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:
(locate on site p )
Materials of n Dimensions
Depth of so
Comments:(cote n of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Add,,,-
Owner.
Date of Inspeotion:
SIMMH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
C
DEPTH TO GROUNDWATER
Depth to groundwater. Y a-"-feet
method of determination or approximation:
Y
(revised 11/03/95) 9
65 -
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0CTEWAC E PERMI� NQ.
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INSTA LLER'S,.--JNA E i ADDRESS
J �scod 1917d o✓�
a
S U I L D E R OR OWNER
cy
DATE PERMIT ISSUED
D A T E COMPLIANCE ISSUED
L.V+ a�
d
Sae �
No...
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
T
. a .. ..weV
.................oF....
Appliration for UWVviia1 Workii Tomitrnrtion ramit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
.1'.07..-----Z...--....W.J iL A&,,/,AY-..... ciF— &' R2 kV1 —e-----------------------------------------•--------..............------.
l , Location-Address or Lot o. .........................
wner Address
Installer Address
Q Type of Building Size ......Sq. feet
Dwelling—No. of Bedrooms..... .................................Expansion Attic (N-) Garbage Grinder (n�)
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ................................................
W Design Flow......�.............................gallons per person per day. Total daily flow.......... Q•..................gallons.
WSeptic Tank—Liquid capacity............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 ( )
Percolation Test Results Performed by.......................................................................... Date---------------.......... -- ---•----
'�a Test Pit No. 1...,,_Z..minutes per inch Depth of Test Pit----- ....... Depth to ground water...
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
p4 ----•••--------------•-------------•------------•'-••-••-••----•-•••---.........-----------------....._....-----.....-----•------••------............._.
O 2' •----•-•--------•_..
Description of Soil-----�---•--.. �. ,�c ---�_..�G�.S�.(.�-.._..-•------------------------------------------•---------------
......................................�{_---1� ...............5--7.Amp..---•----------------------------------------------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable._..__..........................................................................................
---------------------------•----------------------------------------------------------.._.......-•-•-•------------------------------•--------•----------------•----------•---------.................---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
It
the provisions of TITLE 5 of the Star Sanitary Code= The undersigned further agrees not to place the system in
operation until a Certificate of Compliar ce hasabeeid by Cand of health.
Signed- •---- .................... .•-•---- �Z-rate
..------
Application Approved By----• ......... .--•--------....•------ ........;? �_. ..........
111
Application Disapproved for h following reasons-------------------------------------------------------------------------------------•---•---- -----------------
.........................•-...--•------•----------...._..._.....--•---•--•-----•-.......---.....----..:_...----•---•--...---••------------------•------------------------------•-----......••----------.
Date
PermitNo......................................................... Issued............. .. . ............----•-.
Date
,r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.a .............................................
Appliration for%"`Disposal Workii Tonstrurtion rtrutit
Application is hereby made for a Permit to Construct ( .) or Repair ( ) an Individual Sewage Disposal
System at:
. T. .... 1�3. 41:!l ! .....fit :..... �41 A� -------------------•--..-.----.--.------.------.--.--.-.------.--------
Location Address /} ror L^oty�aN�o. ^
..................... .m+��--- _. !�:4m>....-�...a:..'=&:. �d.�.�.�r.r.Aue... •..........................
caner Address
rW-a 9 �t .................. ........... ~_ ` `.��........ ...........................................
Installer Address
d Type of Building Size Lot. =7 _4�_._;...Sq. feet
U Dwelling—No. of Bedrooms-__- ---------------------------------- p ( ) Garbage Grinder ( ),..., Expansion Attic �s
aOther—Type of Building ............................ No. of persons............................ Showers (; ) — Cafeteria ( )
QI Other fixtures ..................---------------•-•------
Desi n Flow S.........................:: allons per person per day. Total daily flow------------ .' '............... gallons.
W g g. P. P P Y Y
W Septic Tank—Liquid capacity............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 ( )
'-. Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1... ....minutes per inch Depth of Test Pit.___j ...... Depth to ground water._, ... ._.
(i Test Pit No. 2.........�"".minutes per inch Depth of Test Pit.................... Depth to ground water-------.................
•---•...........................................................•-------.........--•---•---------•-.--------••-.....................•••---........--•--------
D ,. d .Description of Soils - + �r `' -- •------------------------------
W ----••••-------------------------•--`- ................. t l" ......................................----------------------------•------••------•----........................----••--
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 TITL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be9-issued by the.board of health.
Signed..:. ._....••• p _-: ��'--------------------------------- zz��2'. ..._....
Date
Application Approved BY E �-• --- - -Is] ...........
Date
Application Disapproved f o t e following reasons--------------------------------------------------------•--------•-----------------------------=------.....---•--
--.........••-•---••••-••-•...-----•••-•••-•-•••••-•-••-••-•......•••...---•--.......•--•..............-----------------------------------------•-------------------------------------------------•-•---
Date
Permit No............................................. - Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1. ' 1..................OF.... r'10K S.�7feer ..........................................
(Irrtifirate of Toutplianrr /
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (/) or Repaired ( �)
....... X.AS6;� _......•-•.•••-
Installer
at-------------•-------------------------•--------------------•---------------•------------------------------------------------•---------------•-•--------------------------
--------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.......... S`_..7__L' -....... da.ted...... ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
-ql
DATE.................... . .'... .A.._....5-`'S.-................................ Inspector........... .W. .1`0....-&A--== ..........................
THE COMMONWEALTH OF MASSAC SETTS
BOARD OF HEALTH
....... CAW. A'.... .........OF.....�A..Ae.5rAB ..................................... ?
'.'.Ica_
FEE .........�,�:!.�....
Dulposal: orko Tu union rruti#
Permission i hereby granted.........` t ........P� ! co :.................................................................
to Construct ( or,Repair ( ) an ItMivldual Sewage Disposal System
at No... t;6' e.1_4
treet
as shown on the application for Disposal Works Construction Permit No5M_"?AS,._ Dated..........................................
•---••-----------• .......................
Board of Hea th
DATE....-- a 7. . �--------•............................
F�RM 1255 A. M. SULW INC.. BOSTON _ �*;
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LEGEND
ELDREDGE
,El�1s�TIN0 SPOT .E`L.EVATION : OAO �, No:.�9367 n Ltd
�: BXfSTINO: CONTOUR -'-- 0 --- o q CERTIFIED PLOT PLdN
E FCrSTER
''Fi�ItSHED , SPOT,' ELEVATION (� sr s�� L.r7 r 2 /�//� %
III�IIiHED CONTOUR ; 0 : °NA�:�. s. , Z Gu' r --
¢ 1*1Q 'E ;The .location :of 'any existing tnrou sewerage,
*, we. ls,t or other'-utilities shown' on,tr,zs plan is `approx- I N
r �tpatexonlyr as ,determined, from records and/or verbal
information The. contractor is responsible: for the ��-
trvex f cation of.the,` exI t ng locations in`the field; . SCALES / 40 DATE +
QRED6C. ENGINEERING Ca IN
CLIENT. ,,..., .._.. I, CERTIFY ` THAT THE PROPOSED
EafSTERE • RE418TE"REO �pS,N0. 3 BUILDING SHOWN' ON: THIS PLAN r
LAND _ CONFORMS TO THE ZONING LAWS
kr DR. x.
a�,ta 0 E RV r t H OF BARN8TiA8LE MA38.
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