HomeMy WebLinkAbout0897 MAIN STREET (COTUIT) - Health 897 MAIN STaC,-C�,
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== COMMON WEALTH OF IMASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
.l DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108' (617)292-5500
J TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI IJ DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
m��J ls6 CERTIFICATION
Property Address:489V7 mil Name of Owner
Address of Owner:
Date of Inspection:
Name of Inspector:(Please Print) EOlt t4/1D C 80&S1C1C6A0-.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: 8t7t1SF1ECO
Marring Address: 6 k W 0 1/45r 1V,0411 l-/M S t!3
Telephone Number: a0s axly1✓3�3
CERTIFICATION STATEMENT
1 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:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
oe
Inspectors Signature: ' C Date:
The System Inspector shall submit 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
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revised 9/2/98 Paget of11
ii Printed on Recycled Paper
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r PART A
CERTIFICATION(continued)
Property Address:89 1 M 4l vu sT r
Owner: -SugUa64K) POK RE►$I.TY -t4V51
Date of Inspection:7^30-M
INSPECTION SUMMARY: Check�A�, B, C, or A
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:
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.
Indicate yes, no, or not determined(Y, N,or NO). Describe basis of determination in all instances. If "not determined",explain why not.
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.
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
revised. 9/2/98 Page 2of11
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
�
Pro
perty ddress•897 fnA1915'r
Owner: UBuRAN }R� R T
Date of Inspection: -7_30-CIS
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 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 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 (approximation not valid).
3) OTHER
i
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Pr Address: O I MOST.
N S Property
owner: sugvl28l+6v PARK I2154ir(
Date of Inspection:
D. SYSTEM FAILS: J
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
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.
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
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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information. '
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
y PART B
CHECKLIST
Property Address: M R W STr
Owner:SU8UP'',30J Pap,K R64L Y TRUST
Date of Inspection:
Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following:
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health.
- None of the system components have been pumped for at least two weeks'and the system has been receivingttormal 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 NIA.
x _ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components, V911have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b))
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 5orn
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
4, PART C
SYSTEM INFORMATION.
Property d
7 Address•• �4ou 5t.
�(
Owner: Sveuk MtJ PARK RM-TY T OLF
Date of Inspection:'7_ _(5yy
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms(design): Number of bedrooms(actual):
Total DESIGN flow Ll'40 .
Number of current residents:Q t
Garbage grinder(yes or&: 0
Laundry(separate system) (yes or n3: a; If yes,separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or 00.
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
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 urce of inform tion:
j I►4S Ajor ya ion: P�MP��
System pumped as part of inspection: (yes or�gDl1fC�
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) `
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other y� "
APPROXIMATE AGE of all components,date installed(if known)and source of information: /y y/S
Sewage odors detected when arriving at the site:(yes or Uo !_W
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
q, PART C
SYSTEM INFORMATION(continued)
Property Address:��{'j A141I0 �
owner: 5v3,06411t) 0E41:Ty' TRU&
Date of Inspection: 7.So-114 J l
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting, evidence of leakage,etc.)
SEPTIC TANK:.X
(locate on site plan)
Depth below grade: 1�+C){S
Material of construction:•concrete_metal_Fiberglass _Polyethylene_other(exp(ain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions- 10'e L k S's0ox-5
,610
Sludge depth: I i PV
Distance from top of sludge to bottom of outlet tee or baffle:3oUU15
Scum thickness: NO SCi)AI
Distance from top of scum to top of outlet tee or baffle:'
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles;depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) 4LL t0y M 6,000 0' urtc-T ts (f roe 16= 641rL67
1C P(1,+,S77L TT� r C t(�i3f D �T QI TR?M [�F �`TtET P[mg
GREASE TRAP:
(locate 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:
(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 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: A1 q r u STi
Owner: SU13UR194 J .R64LIY 'TRUST
Date of Inspection:
`091
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: T- eb—mm 0 f- P/PC—S
Comments:
(note if level and distribution is equal,evidence Hof solids carryover;evidence of leakage into or out of box, etc.)
,Va soc SOS OisrRfB�nofU rs Ec�Ja�
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.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
e. PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: Svgu,2e4nj papK QE,4ay tieusr,
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS)
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Type: •
leaching pits,number:_
leaching chambers,number:_
leaching galleries,number:_
leaching trenches,number,length:
leaching fields,number,dimensions: ARET12obc 30
overflow cesspool,number---
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.)
SOIL fS D /U0 Si&'SOFAN,9IPAULIC Rlw► 6 i Ne MIUDi/).'C
CESSPOOLS-_
(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 (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
s
- s
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
4• PART C
p� SYSTEM INFORMATION(continued)
Property Address:
Owner: susuegRN ff-K 9C-gLty TQuST
Date of Inspection:
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)
On
O
revise 9/2/9 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
!• PART C
SYSTEM INFORMATION(continued)
Property Addresslq 7 rn igiuS Ii
Owner: &*Opmfu PIKV-
Date of Inspection:
i
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
'Surface water _
Check Cellar
Shallow wells
Estimated Depth to Groundwater-�i Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
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
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed) t
/w ink 69clu vq cv-4tFK m 410/7aro MAP
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revised 9/2/98 Page 11of11