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HomeMy WebLinkAbout0036 SECURITY STREET - Health 36 SECURITY STREET, HYANNIS R -- - A= 268 144 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments #36 Security Street Property Address Florence P. Stevens, TR Owner Owner's Name information is West Hyannis MA 02601 April 7 2011 required for P every page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A General Information When filling out A. forms the computer, r,use 1. Inspector: I V only the tab key to move your Luis Coelho cursor-do not Name of Inspector use the return key. Holmes and Mcgrath, Inc. Company Name VQ 362 Gifford Street +t Company Address Falmouth MA 02541 �D Cityrrown State Zip Code 508-548-3564 Telephone Number License Number B. Certification 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 16.340 of Title 5(310 CMR 15.000).The system: } Q ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority rf2A�, 20%/ ,� DateI ecto s Signatu t ri t 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. ****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. t5ins-11I10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal Sys •Page 1 of 17I � r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments #36 Security Street Property Address Florence P. Stevens, TR Owner Owner's Name information is required for West Hyannis MA 02601 April 7, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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 exist. Any failure criteria not evaluated are indicated below. Comments: B) System 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. Check the box for"yes", "no"or"not determined"(Y, N, ND)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. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11110 TrOe 5 ONidat inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - a Title. 5. Official Inspection Form Subsurface Sewage, P y Disposal System Form-Not for Voluntary Assessments ' 9 _ o #36 Security Street Property Address _ Florence P. Stevens,TR Owner Owner's Name information is West.Hyannis MA 02601 April 7, 2011 required for y _ __ _. _._P every page. City[Town State Zip Code Date of Inspection B Certification (cont.) : B). System Conditionally.Passes (cont;) El 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.: ❑ Y. ❑ N ❑ ND (Explain below): ' ❑ obstruction Is removed ❑.;Y ❑ N ❑ ND (Explain below):, distribution box is leveled orreplaced ❑ Y ❑ N 0 ND.(Explain below): 0 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 ❑ Y ❑ N ❑ 'ND(Explain below): ❑. obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 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 t5ins-I itio Tide 5 officiai Inspection Form Subsurface Sawaae Disposal System-Page 3 of 17 t Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments 9 P Y ry #36 Securi Street Property Address Florence P. Stevens, TR . - Owner Owner's Name information is required for , West Hyannis MA 02601 April 7, 2011 every pages City(Town - State Zip Code Date of inspection B. Certification (cont) 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 fecal; coliform bacteria indicates absent 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. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following;for all.inspections: , Yes -No ® 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 clogged SAS.or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ❑' or clogged SAS or cesspool 0 ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '%2 day flow t5ms•..... TWO 5 Official tnspecUon Form:Subsurface Sewage Disposal system Page S of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments #36 Security Street Property Address Florence P. Stevens,TR Owner Owner's Name information is required for West Hyannis MA 02601 April 7, 2011 every page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ® 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. ❑ ® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. 15ins•11110 Title 5 Official Ins on Forth:Subsurface peGi Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form- Not for Voluntary Assessments #36 Security Street Property Address Florence P. Stevens,TR, Owner Owner's Name information is West H annis MA 02601 April 7 2011 required for _�y _ _._.� _ ._P � � every page. _City/Town < State zip Code Date of inspection C. Checklist Check if the following have been:done;You must indicate"yes''or"no" as to each ofthe.following Yes No ❑ Pumping information was provided.by.the owner, occupant, or Board of Health ❑ Were;any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have 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 NIA) ❑ Was the facility or dwelling inspected for signs of sewage backup? ® ❑: Was the site inspected for signs of breakout? ® ❑ Were all system components,excluding the SAS, located on site? 0. ❑ 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: ® ❑ 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 0 , ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based.on 310 CMR 1.5.203 (for example: 110 gpd x#of bedrooms): 330 t5,ns•ill Title S 0iAcial InsocQon Form:Subsurface Sewage Disposal System•Paga 6 of t7 <. _ " Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form= Not for.Voluntary Assessments #36 Security Street Property.Address Florence P. Stevens, TR Owner _...:.__.. Owner's Name information is - West Hyannis MA 02601 Aril 7 201:1 required for y .p every page., Cityfrown State Zip Code Date.of Inspection D. Systelm Information Description: Number of current residents: None Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?.[if yes separate inspection required] ❑ Yes ® Na _ Laundry system.inspected? ❑ Yes ® No Seasonal use?, ® Yes ❑ No Water meter readin s,if available last 2 ears usage d 62 gal/day 9 ( Y 9 (god))- Detail:: Sump pump? ❑ Yes ® .m Last Summer Last date.of occupancy: Date Commercial/industrial Flow Conditions: Type`of Establishment Design flow(based on 310 CMR 15,203); Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No l Water meter readings; if available ESins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System.•Pags 7 of 47 Commonwealth of Massachusetts .- ....i Title .5 Official Inspection Farm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments #36 Security Street Property Address Florence P. Stevens;TR. Owner Owners Name information is West Hyannis MA 02601 Aril 7 2011 . required for y 1' every page. CityfTown State Zip Code: Date.of Inspection D. System Information (cont.} Last date of.occupancy/use:: Date Other(describe below); General Information Pumping Records: Source of information: :...__. Was system pumped as part of the inspection? ❑ Yes Z- No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: A - Type;of System: ❑ Septic tank, distribution box,.soil absorption system El Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or,no) (if yes, attach previous inspection records, if any) , ❑: Innovative/Alternative technology. Attach a.copyof the current operation and maintenance contract(to;be obtained;from system owner)and a copy of latest inspection of the I/A system by system operator under contact ❑ Tight tank. Attach a copy of the DEP'approval. - `( ❑ Other.(describe): l } i t5ins: t tlS4 Title 5 olfcial inspeetion.Form:Subsurface Sewage Disposal System-Page':8 o1.17 _. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y f #36 Security Street Property Address Florence P. Stevens,TR Owner Owner's Name information is required for West Hyannis MA 02601 April 7, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Approximately 40 years old Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2.5 feet feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) First Cesspool used as a septic tank which is constructed in concrete blocks If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: V diameter by 6'deep Sludge depth: 1/2" t5ins-11110 Title 5 Dthdal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r #36 Security Street Property Address Florence P. Stevens, TR Owner owner's Name information is West H Hyannis MA ' 02601 'April 7, 2011 required for Y W every:page. City/Town State Zip Code Date of Inspection D. System Information (cont) Septic Tank(cont.). r. 56 Distance from top of sludge to bottom of outlet tee or baffle -- Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 1411 Distance from bottom of scum to bottom of outlet tee or baffle -- How were dimensions determined? Measuring tape. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):The structural integrity of the cesspool,which was constructed in block was in fine The tank was just about emptyit t only consisted of about 1"of sludge at the;bottom. Grease.Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete Elmetal ❑fiberglass. ❑ polyethylene- ❑ other(explain): Dimensions` Scum thickness Distance from:top of scum to top of outlet tee or baffle j Distance from bottom of'scum to bottom of outlet tee or baffle Date of last pumping` Date t tsfns 1 ill 0 TtGe S:Official inspection Form:.Subsurface Sewage oisposat System-Page l0_of 17 Commonwealth of Massachusetts _ Title 5 Official . Inspection Form _ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments c #36 Security Street Property Address Florence P. Stevens, TR ._...... Owner � Owner's Name information is MA i n West Hyannis 02601M Aril 7, 2011 required for � _ April every page. CityrFown - State Zip.Code Date of Inspection ; D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle.condition, structural integrity, liquid levels as related to outlet invert; evidence of leakage,_etc.): 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 [I other(explain): Dimensions: Capacity: gallons Design Flow:' gallons per day Alarm present: ❑ Yes. ❑ No Alarm level: Alarm in working order: ❑ ;Yes ❑ No Date of.last pumping: Date Comments(condition of alarm and float switches, etc:): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 or 11 Commonwealth of Massachusetts _ w Title 5 Official Inspection form Subsurface Sewage Disposal System Form Not for Voluntary Assessments:. .�V #36 Security Street Property Address Florence P. Stevens, TR Owner _.. _.. Owner's Name information is West Hyannis MA 02601 „' : April 7 2011 required-for _,....._-_Y _._._._. .,:_ p + every page. City/Town State Zip Code _Date'oflnspection Q. System Information (cont.) ' Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments (note if box is lever and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box: etc:.): - Pump Chamber(locate on site plan),- Pumps in working order: : - El Yes ❑ No Alarms in working order: ❑ Yes < ❑ No - Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):. Soil Absorption System(SAS) (locate on site plan, excavation not required), If SAS not located; explain why: t5€ns t t/tD Title 5 Official Inspection Forme Subsurface Sewage Disposal System-Page 12 of 17 i _ 3 Commonwealth of Massachusetts ax W_ Title 5 Official Inspection Faun Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments #36 Security Street Property.Address Florence P. Stevens; TR' Owner Owner's Name information d for on is reqequired West Hyannis MA 02601 April 7, 2011 every page. City/Town State; Zip Code Date of Inspection. D. System Information (cont.) Type: ❑ leaching pits number ❑ leaching chambers : number: . _� .......: ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: 1 ® 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.). Overflow cesspool pit had 40" below the inlet pipe of storage volume remaining. The pit was:a 600 a��which the structud intregity of the tank look good at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 in"series 40° Depth top of liquid to inlet invert Depth of solids layer Depth of scum layer 0" Dimensions of cesspool 600 gallon pit Materials of construction Concrete Indication of groundwater inflow ❑ Yes ® No t53ns•1 116 Title 5 official Inspection Form;Subsurface Sowago Mposat System•Page,.13 of 17 ( s Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments #36 Security Street Property Address. Florence P. Stevens, TR owner Owners Name information is required for West Hyannis MA 02601 April 7, 2011 every page. Cityrrown State. Zip Code. Date of Inspection D. System Information. (cone.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): The structural integrity of the pit was in good shape.There was no.signs of hydraulic failure:and no op ndin9 around the pit. Privy (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,): i i5;ns-•11110 T1Ue 6 official Inspection Form;Subsurface Sew oge Disposal System,•Page::14 of 17 - Commonwealth of Massachusetts: Q Title: 5 Official Inspection Form - n Subsurface Sewage Disposal System Form- Not for.Voluntary Assessments.. .y, #36 Security Street Property Address Florence P. Stevens, TR, - __.._ ,_..... __.....-........... ....................................... Owner O ._..... wner's Name information is W 2011 required for West Hyannis. MA 02601 April 7, ._ ._.._ ry � .-. every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below [] drawing attached separately ATr Sr Cu ' i5 ns t t1i0 Title 5 Orricial Inspection Form;.Subsurface Sewage Disposal Systoirr•Pape 15pf 17 j Commonwealth of Massachusetts �l 10_=_ Title 5 Official, Inspection Farm Subsurface Sewage Disposal System Form- Not for Voluntary Assessments * � #36 Securily Street Property Address Florence P. Stevens, T.R Owner Owner's Name information is West H annis MA 02601 A ril 7` 2011 required for Y _...�_ _P every page.. Cityffown State. Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope _ ® Surface water ® Check cellar ❑ Shallow Wells Estimated depth to high ground water: 10+ _.__._ _-_._We feet Please indicate all methods used to determine the high ground water elevation: ❑: Obtained from system design plans on record If checked, date of design plan reviewed; Date 0 Observed site(abutting propert&bservation hole within 150 feet of SAS) - ® Checked with local Board of Health -explain; ❑ Checked with local excavators, installers-(attach documentation) z Accessed USES database-explain: You must describe how you established the high ground water elevation: Check with local board of health and checked ground water resources of cape cod map Before filing this Inspection Report;please see Report Completeness Checklist on next pale. # t5ms•11t1(} Title 5 O(riciat Inspection For Subsurface Sewage Disposal System•Page 16 of 17 i I� a -\ Commonwealth of Massachusetts Titic .5 Official Inspection form Subsurface.Sewage Disposal System Form- Not for Voluntary Assessments #36 Security Street Property Address; Florence P. Stevens,TR Owner. Owner's Name information is required for West Hyannis MA. 02601 April 7, 2011 every page: Cityrrown " State: Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, G, D, or E checked - Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System'fnformation-Estimated depth to high groundwater. ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5;ns•11(10 - Title Official inspection Form'Subsurface Sewage.Dispgsal System Page.t7 of 17 :. .. ... F � xt VANCE S. YOUNG TITTLE.V SYSTEMS INSPECTOR Department of` ri-Wronmental Protection CertUlied 508-224-8332 ' SEP 5 j`u, qSUgSUItFACj SEWAGE DISPOSAL SYSTEM INSPECTION FOwN L y' PART A CERTIFICATION X Proosttty Address; �,` ��� 5'o'"��T Address of Owner. `Olt, pl different) `'Iy ` Dale of Inspections $/g�rG. ' [EItTIFIGlT11 TATEMENT I cenily 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 lime of inspection. The inspection was performed based c,n my training and experience in the proper(unction and tt nlenance of on-site sewage disposal systems. The system: t . Passes , Conditionally Passes .._. Needs Further Evaluation 8p the local Approving Authority Fails ltbpeclor'� Si`nalure:// Date: �///�� ' yr The Sy>te•m Inspector shall submd a cups-of this inspection repon to the Approving Awhonly within thirty(30)days of completing this 1ml,pct,nn If the system o a shared s�•slcm or ha.a design flow of 10,000 gpJ or V01cr, the inspector and the system owner shall submit 11w rqu,rt to[lie appropriate reg,uwl ufiur of Ihr 04,panment of Envuonmentsl Pruu c tun low-ru,1;,1>.,1 kluudlf IH• %Coll I.-Ow s•11'nj r,►vu-r.►►.1 come•• U-111 it;div bup•I, d apple al,IC and t1w aniline:ins atdhurily ,JgSPECTION SUMMARY: , Check A.8. C,or 0: Aj SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure ctiteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated helo+ov. RI SYSTEM CONOITIOt"LLY PASSES. One or more system components nerd to be r:,aIaccd or repaired. The system, upon completion of fill replacensem or repair, Fames,inspection. Indic-at yes, no, a not determined P:', N, or ND). . I/"not determined', explain why noel Describe basis of determination in all instances The septic tank is metal, crackeJ, structurally unsound, shows subslanlial infillmhon or eltfillration, or tank failure is . imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tusk as awtoved by 111e gaud of Health. ltrwieN•iIts/fsl . POST OFFICE BOX J592 • AMANONE ; niaSSACHVSF,TTS 02345-1592 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:S4A1- Owner Date of inspection: B) SYSTEM 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 boy, is levelled or replaced. The system required pumping more than four times a year due to broken or obstructed r (s). The system will ass Y q P P S Y P•Pe Y P inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CJ 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 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 wRhin 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THL BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ I he wSlefII Ilds d s(Illll Id11h dllu soli du�ulpllull SySi Ulli dlld I! wltlllll 'I JO fCti to a surface watci supp!-, or tilJu*a,-j• surfac( water supply. The system ha, 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 sy>tenl hao a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private wale, 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. Dj SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. 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. (revised 8/15/95) 2 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D)SYSTEM FAILS (continued): 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. E]LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised a/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: Zumping information was requested of the owner, occupant, and Board of Health. , one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates Z that period. large volumes of water have not been introduced into the system recently or as part of this inspection. �/ t plans have been obtained and examined. Note if they are not available with N/A. fi 'he facility or dwelling was inspected for signs of sewage back-up. he system does not receive non-sanitary or industrial waste flow ;4(he �ite was inspected for signs of breakout. �`Allsystem components, excluding the Soil Absorption System, have been located on the site. /heeptic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees aterial of construction, dimensions, depth of liquid, depth of sludge, depth of scum. he size and location of the Soil Absorption System on the site has been determined based on existing information or ap oximated by non-intrusive methods. The facility o%%nc. sand occupants, if different from owner) were provided %vith information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /lca/ Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: *,'gallons Number of bedrooms: Number of current residents: a Garbage grinder(yes or no): Laundry connected to system (yes or no)/l1� Seasonal use (yes or no):Z". Water meter readings, if W ailable: Last date of occupancy: COMMERCIAL/INDUSTRIAL: 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 5 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: O System pump4d as pan of inspection: (yes or no) If yes, volume pumped gallons Reason for pumping: TYPE 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) treviaed 8/15/95) S - it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:S2Z4i Owner: Date of Inspection: SEPTIC TANK; )(4 (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP_other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: 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.) GREASE TRAP�i� (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Scum lhickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom nt -ntm try hnttnn+ of owlet tee or battle' 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.( (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: s` Owner: Date of Inspection: TIGHT OR HOLDING TANK . (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: Rallons Design flow: Qallons/day Alarm level: Comments: • (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX-44 (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution i,equal, evidence of sokdl carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/9s) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:'6 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:_ Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) CESSPOOLS: !/ (locate on site plan) Number and configuration: l Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: A _ Dimensions of cesspool: r Materials of construction: Indication of groundwater. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of ydraulic failure, level of ponding, conditi n of vegetati n, et .) MA PRIVY: (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. trevlsed 8/15/95) s 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' CNOT To m4a) i r 'I 36 DEPTH TO GROUNDWATER Depth to groundwater.�(f—/AZDeet method of determination or approximation:�d (revised 8/15/95) 9 l ASSESSOR'S MAP NO. PARCEL &4� LOCATION SEWAGE PERMIT NO. VILLAGE i INSTA L ER'S NAME i ADDRES,S � C8� � y S U I R OR OWN R -e,7* DATE PERMIT ISSUED Cof G DATE COMPLIANCE ISSUED � �ce- Z a -r o e►. � I 3 o w �`` - mow No.. -_- Fxs...5..":............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH owl ....................O F.....�A�r.71441ek...................................................... Appliration for M-4p ottl Works Tongtrnr#inn Vamit Application is hereby made for a Permit to Construct ( ) or Repair PJ-) an Individual Sewage Disposal System at: ..�.rt�set �5----------------- ------------"-----•--•-•-------•--••-------•-----------...-------------------•--............----- Location-Address or Lot o. .....SN E Aj'T ° -- -...-------'••............. . ..3(0_. Gca�x` .. .t*i_�.<z►r_.. ax�z�.i ...... ............ Owner nnnn 'Address + +� _...__-^................•--...._..---......----_^_-'---.....-' (/ ........... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms________________.......................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( -) — Cafeteria ( ) W Other fixtures ------------------------'-••-•-- - W Design Flow............................................gallons per person per day. Total daily flow............................................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........................................ Test Pit No. 1................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........................ tx -•••--'--••-•-------•••--••••-••----._....•----•----•••.......................•-•---•--...-'•--"•'-......................................................... 0 Description of Soil......................................................................................................................................................................... W V •--•---------•-----------------------------------------------------•---•---------••-----•--________--•------•---•------------------- ------------- __-------------.......________------------------ W -------------------------------------------............................................................--•-• ------ ---------------------------------•----__.- -t---- ........... VNature of Repairs or Alterations—Answer when applicable.='ys_4 ___&OQ. .__ 4� t.�.(Y__ut............. .- ___ate-e• �_---r- c ired------•---------=--------------------'-------•---------------------------------------------------------------------------.....----.........----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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. / ed. :- Q ..................... = �P Application Approved By.......... . ._"........................•---•-----._.............._..-----... ... Date Application Disapproved for the following reasons:.............................................................................................................. ------'........--•------'-'..._-------••.............•--------....----------•--------'-"--..._'-•--'------....------•-------------=.-.-•-..-•---•-•-•-•--•----------------••'---•------•-----_._....._. . Date PermitNo._ �--------------------------------------- Issued-....................................................... Date {Y z• THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH .tint... ..................OF.�cer»3`k�e� �................_....................................... Appliratinn for Diopnottl Works Tonsfrurtion Frrnti# Application is hereby made for a Permit to Construct ( ) or Repair ( -) an Individual Sewage Disposal System at: •---3�?_.5.,ecu� ,_�.. iAUG ... � nY1 5........-••....... .--•--•................ --................-• --••---••-••--............................. Location-Address or It o •--•SN E a1 ontg�:........................................................... n - Owner y { Address a 1G3.M 4�.......••-•-•.................................................. �..© I�lCktVl �+f'2. Installer Address U Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms......................_......_..._..........Expansion Attic ( ) Garbage Grinder ( ) 4 Other—Type T e of Building No. of persons............................ Showers Gv YP g P ( ) — Cafeteria ( ) 0.1 Other fixtures ..-----•---------------•-------------..............._.... __ d -----•-•------•-•-----•-••------------------ Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet--.................. Total leaching area..................sq. ft. tan Z Other Distribution box ( ) Dosingk ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .................... ----... -....... -......... _... ...... -.......... .... •-•---_-------•--- •.... •-•--.................... •••---------------- __... 0 Description of Soil.........................................................•-----•----...--------•---..._...-•-•--......------................_...._............_-----•--•-••......----••• V ------------------- ...-•-•---•---------------------------------------• --•------------------------------•...........--------------•--• = .................._......:.... U Nature of Repairs or Alterations—Answer when applicable. '?.sc+ CnOo c? ' ._�rcech�✓i � . ..... ................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ed by the board of health. ------Signed.... ....:. ............ t te Application Approved By..- --'j'....�.�.---......-•-•--•--.......... ... - C .. Date.............. Application Disapproved for the following reasons..............................................................................................................._ -•-•------------••--••-•-•---.............%..-•--•-•-••----•-•----•----............................•-•----..........................--------•-•---...........---------..........--•--•-••-......._...._.._. 5 �g . Date G. �•_._.j ' Permit No...... ......... --_.... Issued_..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ��- BOARD ,�OF HE ALTH 1 OF........' 6t? rvl s�Fa6t1l� .......................................... ................................................................... (Irrtifirate of fIomplionrr THIS IS TO CERTIFY, Tl}at the Individual Sewage Disposal System constructed ( ) or Repaired (�) by.......... ...............��-- � ?1 ?.Jv:. ._.... - ...... .................................. ---......_........ ._...._ at..........................Knr ................. :- �`�.L..t. �'�' � 'tv`e' has been installed in accordance with the--provisions of TITLE-5 of The State Sanitary Code as c}ep-ib in.the application for Disposal Works Construction Permit No............... ..... ............(`N"`�" :._..... dated-----------------'• ...._..:....--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTE W LL F NCTION SATISFACTORY. l ................................................. Inspector........= -------•-••-•-•-•-----•---........---•----........................ 1 THE COMMONWEALTH OF MASSACHUSETTSI cl! BOARD OF HEALTH }.r t x z �--- ` OF ........ ................................................... No. '.. -. Fas...:.�'�.J�-.:�........ Disposal Works Tono#rnrfion Prrntif Permission is hereby granted--------------•.--•�..�. -•-�f ..........__.. to Construct ( ) or Repair ( ) an Individual Sewage-Disposal Sx em at No....................... .............. `vex- t-ttl ►�nl ......j. .. . Street rr ' as shown on the application for Disposal Works Construction Permit No ated...._.......`n a —� ...... .............................................. 4k Board of Health D. IS-1................ Ni...................... r FORM 125 A. M. SULKIN, INC., BOSTON