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HomeMy WebLinkAbout0201 OXFORD DRIVE - Health 201 OXFORD DRIVE, COTUIT A = 021 035 0 j d r RdivEO FE IB 8 19 96 96 ao II It'1 0 O LO'I"1'1 1p4 ('ONS'I'R 1 �"I' 6F 765 WAKEBY ROAD, MARSTONS MILLS, MA 412648 s 9 9r - ' 5118-771 )3)) 5118 428 8)26 FA`(: 5118-428- ' 9�. ..93. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:_,2.�0 . �e C�__ v avt(l ✓am ��c ---------- Date of Inspection: / — luspector' rJJU�Lj ' Own ppr's Name and Address: / lc �•U �_�j0,�. ? Yr 1�aG�cJr r�, ` 21V PIIS-S' '-CERTIFICATION STATEMENT. certify that I have personally inspected the sewage disposal system at this address and that the iirfornra lion reported below is true,accurate and complete as of the lime of inspection. 'The inspection was per- formed based on my training and experience in the proper t'nnclion and maintenance cif on-site sewage disposal stems. The System: V Passes Conditionally Passcs Needs Further E uation By the veal Aproving Authority 's Fails -- Inspector's Signature: _ Dale: � The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 sysleni owner and copies sell(to the buyer, if applicable and the approving au(hority, 1NSPECTI N SUMMARY: A)SYSTEX PASSES: I have-not found any information which indicates that Ure system violates any of the failure criteria as defined in 310 Clk111 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 coruple- lion of the replacement or repair, passes inspection. Indicate yes, nor,or not determined(Y,N,UR 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 lank failure is imminent The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by'The.Board of tleal tit. Sewage backkup 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 Heal(h): f + a SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART•A CERTIFICATION (continued) Broken pipe(s)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)FURTHER EVALUATION IS REQUIRED I1V TIIE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of I lealth 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 HEALTIJ DETERMINES TI AT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WIIICII WILL PROTECT IIE PUBLIC HEALTH AND SAFETY AND TIIF 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEAL'VII AND SAFETY AND'I'HE 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 with a Zone l 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppnt. D)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 efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than G"below invert or available volume is less(hall 1/2 day flow. Required pumping more than 4 times in the last year NO.I due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM, INSPECTION FORM PART A CERTIFICATION.(continued) 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 Peet 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 a large system in addition to the crilcrin above: The design flow of a 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(lie following conditions exist: The system is within 400 Feel 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 ll of a public water supply well The owner,or operator of any such system shall bring the system and facility into full contplrance 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. " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 13 CIIECKLIS'1' Check if the following have been done: F V—Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for atleasl 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. v-'Fhe facility or dwelling was inspected for signs of sewage back-up. — The system does not receive non-sanitary or industrial waste now. __,-The site was inspected for signs of breakout_ ,,-All systern components,excluding the Soil Absorption System, have been located on site. V/The septic tank manholes were uncovered,opened, and the interior of the septic tank was in spected for condition of baffles or tees,material of constriction,dimensions,depth of liquid, /. depth of sludge,depth of scum. . [� The size and location of the Soil Absorption System on life site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORM PART B CIIECKLIST(cooliuued) --,.—,/The facility owner(and occupants, if different front owner)were provided with information ou the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION / FLOW CONDITIONS RESMENUALL � Design Flow: edroollm Nuutber of C'urrenl Residents: �� gallons Nunthcr of 13 l�CtC_Gr_D' Garbage Grinder•_ Laundry Connected To Syslclw j� Seasonal Use:yVL ___ Water Meter Readings, if available: Last Date of Occupancy: Af4, f5� COMMERCIAL/INll TRI L�IVU Type of Establishment: - Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Tille V System:_ Water Meter Readings, If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of inforntatiott::Cc�1�/.I} System Pumped as part of inspection:__ if yes, ume pumped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy hared System(If ryes, attach previous inspection records, if any) Other(explain): �J "P#0XIMATE GE of all components, date installed(if kuown)and source of information: /?7Ag S, — 0 r (c 72zi/ SIB Sewage odors detected when arriving at the site: -4- SUBSURFACE SEWAGE DISPOSAI,SYSTEM INSPECTION FORM PA R'I'C GENERAL INFORMATION (confinned) SEPTIC TANK: Depth below grade: Material of Constriiclion:zconcrete metal FRP- Other (explain) Dimisions:_�,5'XCo' xS' Sludge Depth: ScumThickuess: oil Distance from top of sludge to bottom.of outlet lee 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, ,qco I e-CYp r'C%G n "�Gf'l/ (2o( crs Id",�/ �d e- 4)l dh �(?eV2?e-'� GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP Other' (explain) — — — — . Dimensions: Scuni'Thickness:__ Distance from top of scum to top 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.) TIGHT OR HOLDING 'TANK: ��U Depth Below Grade: Material of Construction: concrete—_metal FRP_Other(explain) Dimensions: Capacity: 'gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet lee, condition of alarnrand'lloal switches, etc.) ?° r DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box,etc.) PUMP CHAMBER: A 16 Pump is in working order: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) R , SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (conlinued) SOIL ABSORPTION SYSTEM (SAS): a� (Locate on site plan, if possible; excavation not required, bm. may be approximatcd 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, ctc.ctyS Q %00 ' )ql�c�11 _. —a����. 5'0 --.1 . 'C¢-C'G=�_..1� ',a_/--(-ol:2 , -.— - — CESSPOOLS: Number.and configuration: Depth-top of liquid to inlet invert Depth of solids layer: Depth of stunt Gayer:__ Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic lailurc..level of ponding,condition of vegetation, etc.) --- PRIVY: A/6 — — Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) — -- ------ -6 - SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART(" SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, laWmarks or be►rchmarks. Locate all wells within 100 Feet. Of u I$ . DEPTH TO GROUNDWATER: Depth to groundwater: Z.h Feet Meth 9.d of Determination or Approxy nation: -7- No......................... F1z$.. ............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF I-BEA T OF..-.. ... .. ..... Applira#ion -for M-spo l Works Cnowitrurtion Prrulit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: t• ,� �� --------------- y DAY S ' ------ ------ '�'1 v��---------............................... L ation-Address or Lot No. ---------------------------------------------------- Owner �� -------------------••---•-•----•-------.....Address a ------------------------------*�O.R `113 ..AYA�7�------------ -----•-------•---•-•--------••......•--•--. Installer Address UType of Building Size Lot----- __- ,P5!!:; ..Sq. feet Dwelling—No. of Bedrooms........... ............................Expansion Attic (tw Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons_-_____---_______--.._----- Showers ( ) — Cafeteria ( ) Q' Other fiat res --------------- -------------- - - W Design Flow.................. .4......................gallons per person per day. Total daily flow----------17 d_-___--____--. ---..gallons. WSeptic Tank—Liquid capacity_/_/�_--gallons Lengt ............... Width................ Diameter................ Depth.--.--.---.----- x Disposal Trench—No- ____________________ Wi .-. f���_��;_�� 0 1�Length_.__-_--_-:_-___-.-. Total leaching area. -_--.---.-----_-sq. ft. Seepage Pit No----//.-1....... Diameter. .'....�._._ ep"t bel i et- .-------_------ Total leaching area..................sq. It. z Other Distribution box ( ) Dosing to ( Percolation Test Results Performed by.-..' - - --- ----- - -- ----'.................... Date----------------------------.----------. a Test Pit No. 1----------------minutes per inch Depth of Tes Pit.................... Depth to ground water....---------.-.--.----- f= Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ --- -- ------------------------------- -- _.. LT x ° Descri Descri ;iiption .. U - W ---------------------- --------------------•--------------------------------------------------------- --••-•---------------------•-----------•---- --•--•------------------------------•---------------- UNature 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 NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b i sued by the oard al Signe --- --. . Date v Application Approved B A....................... Date Application Disapproved for the following reasons--------------•-----•---•---------------•---------------------------------•................................ •. ......-•-•-------•------------------------------•-•-•-----••------•------•••-•--•---------•--•--•----------------------------------•------------•-•-•------------------------------•----•-------------- . Date PermitNo......................................................... Issued.------ . -------------•---.. ..............-- Date z� 3 THE COMMONWEALTH OF MASSACHUSETTS y—� BOARD OF HE�0 T JQ'Ll�1..... -------OF...../ .�1 . I . ..._... ................................ Appliration -for Dhqpviial Workti Tongtrurtion Vrrnait Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _Lo ation-Address _ or Lot No. • ...Jt�1r.....5-j=-=...----------.•......._ Owner Address Installer Address Type of Building Size Lot..... -31_0---v__Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic (/ZZ) Garbage Grinder ( ) pA4 Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------------------------- W Design Flow................%-------------------------gallons per person per day. Total daily flow..........,2�.�;!----------------------gallons. WSeptic Tank—Liquid capacity./li----gallons Length_______________ Width................ Diameter---------------- Depth---_______._... x Disposal Trench—No. .................... Wi ,i,_I__� opal,Length_-__-__-_.._____--.- Total leaching area-------------.------sq. ft. � Seepage Pit No....,�.�'`:�....... Diameter_ _.___�_ ept below Inlet_ __________________ Total leaching :trea...-----------.---sq. ft. z Other Distribution box ( ) Dosing to ( ) C J- ~' Percolation Test Results Performed b �t -i = --- -----= =---•---------------- Date--------------------------------------- W Y---- - �-- = Test Pit No. 1----------------minutes per inch Depth of Tes Pit____________________ Depth to ground water........................ Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water__.__________-_._____--- r: --; � � � a �--- xDescription of Soil---- --------- 1 ... --------------------------------------------------------------------------------------------------------- �OW VNature 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 b -n issued by the board �-'al Signe --�-----� .............................. ............ r.....------. Date Application Approved BY-------- . ..! ... ----C----------'-----------=----•-------•-- ---- �,�,.�_L/ �._. Date Application Disapproved for the following reasons:___________________•__--__________................................................................... ---•--•-•---••-•----•-----------•----•-••-•-----------------•---•-------------------•--------•--------•---•-----••-•-•----•----•--•-•--------------.....-•-----•---•----••-•......_..--••-------•-•---•- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD (�f� HEALTH ` G -...L►..............oF.......... ....................... Trrtif irate of TIMptitturr THj. IS TO CERTIFY, That they Individual Sewage Disposal System constructed ( ) or Repaired ( ) by..'::...../V. . l 0 � Installer Jz 1 = TX ' -•--�--`-`-�--- --�•- at----` = ! ti/__ 7i has been installed in accordance with the provisions of Artie]" I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.-__�J`_..._2.11�.•__•-_-___- dated.-..7`._14.1 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................................................... ........................... Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS �s BOARDF ,HEALTH e� ....... ..........OF....`v....... .... .. .... -......... ........................ %splolli tt k ntxa�rti�aaarrmit Permission is ereby granted__________ _______'_ _ ,4__. :--.--.___-_- to Con. •r�c ( ) or ep yin tdua Se ages Dispos System at N .`� ..�!.t ¢._... �! Lc a "=`t----- /'__�:----- treet 1 as shown on the application for Disposal Works Construction rm No____ ___________ Dated--- ............. y . - � ---------------------------- L� o'B and of Health DATE............................... ------------------------------------------•----- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS t 1 - I i I „ t j , i .� / /r-• r� - -- ' r i i�� z I 4 z4x-jW5.— ;.aim-?N!S-f3�4�1 1 -{-i- I I il—I--i� Fi_C�iY7 T Yt[.�.Ei. -' , JSt_�iC�4T�D �._Sf>� �•.-I > N OF ANDi�sucf �_t..oNFoR�S-Tat .ALA 7byv� owL ,� + I I °r1VAL� i � Tn . ■CCCCCCCCCCCiCC®®CCC®®®iC®CCCCCCiCMiMMN ' ■■■EONow MEN ME NONE C■■Mill OMEN MEMEM■NMMEMEM mMMMMMM■■■■■■■ MEMMEMEMMEMME ME ■■■■■■■■■® ■ ■■■■■■■■■■M ■■■■�■■■■■■■■■■■■ ■■■■■ ME MONSOON MMEMEMMEM M■■■NNE®■■■■■M■■■ ■ EMNMMEM■■EEMEM■MM■■ ON vMMmMMMmMMMM MMESMOMMEEM ME NEEMMEMEOMME ■■■ M■■■■■■■■mMMMMMlMMl MOMMEEMEMMEMME ■■■ BEEMENO !SOMEONE SOME MEN■ ■FEMME■ SEE ■MMMM■MMMMCN■ iNEEMEMN ME,M MMEEMEMCN l■■■■■n■■■�- NNMMMMN■nMMNN®�IOI�NN®M M■®® ME■■E■ MSC■■i■C®C■C■®�i■C®®®■®CC®i C®�C®®■CiCC■i ME NONNI MENNE■■■■ME■■■■■■■■■■■E■■E■MMMM■■E■■E■ ■■MME■E - NONE �- NMM■M E■■■■■■ N■NNNNN ■MMM■MMMMMM MMOMMEMMEMMUMME ZENN NNE INS IMMMMMMMMMMM■MM■ MEMM■M■®NiNMMEESE■ 1 t _ _ M TOWN OF RARNRTART.F `.LOCATION r� i SEWAGE# Y'LLAGE /© ASSES R'S MAP&LOT6,-) ,02c- T�isi�cc��S NAME&PHONE NOr /dr SEPTIC TANK CAPACITY /!AGO CiCQ/. �P./J�JC LEACHING FACILITY: (type) //7L C/) (size) DU NO.OF BEDROOMS BUILDER O OWNER rK U PERMIT DA COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �6 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching cihty) ' /�� Feet Furnished b �!�y - >PJ»J'��U,2, -T�/C- 1 ��-, � '� � � 0 �, s ��- � � dam\ LOCATIOPI 5E &C,E PERMIT UO. VILLAGE u IWSTALLER•5 W&ME e, ADDRESS BUILDER 5' _ Q &MF- ADDRE-`SS DL1`CE PERNA VT ISSUED DATE COMPLI ,&IACE ISSUED : r 4 � ` � r g-, T I rA.. H�C�