HomeMy WebLinkAbout0085 PINE RIDGE ROAD - Health 85 PINE RIDGE ROAD, COTUIT
LA=109 018
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' CO%1%10\%%'EALTH OF NLkSSACHI SETTS .
EXECUTIVE OFFICE OF E?�ti'IRONNIE�TAL AFFAIRS `.
DEPARTMENT OF EN-'IRO��IE�TAL �ROTECTIO
VW
ONE STREET. BOSTON. AtA 02106 617-2S_•.':QG. =�
UZLL]A%?F.WELD
...MAC' 1 1998 �� CO.,-
ve:ac• ' ' ' = ~.. 0.._-__ TO HEALTHp��LE DA S i RU F---
ARGEO PALL CELLI'CCI " ' • " -
LLGawmar SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOii�0 rnn:issiarr.
PAR7A ' :
CERTIFICATION
Property Address; ' �S '1 ,I'•P_ K� '—"�t +a\ Address of Owner
Date of Inspection (ttv i l V different) T)60l4e; ..,-E
Name of Inspector. HI A, I= 40 ►1 E�tC�� - ' '• ' Miffi i� r f'
I am a DE? ap roved system inspector pursuant to Section 13.3.30 of Title S (310 CMR 13.000)
Company Name:&/Z r r�r'e E1 J" r, « -)L�/
Mailing Address: -P e-) A enx C_3??Ct H.Ie,- 0 2-E'C,c-q
Telephone Number: -rSG2�'-z O ry _
e
CERTIFICATION STATEMENT
I cer:t� that I have pe-sonally trspee-ed the sewaee d:s*,osa, system at this ddress and tha: the information re.one-d be:c%- is true, accurate
and comele:e as a:the time of tnspec:.o-. The tnspec:on Nos pe^crrne-_ based 01 my training and experience to the proper fucctcn and
maintenance cf on-s-te sewage dtsposa; systems. The wimr.:
Pay e!
_ Ccncit-onai:% Passe:
_ ♦eec; Furthe- Eva!uat a% e ora► Appro.•tng Autharim
F
Inspector's Signatur Date: F t
T:ie Svi-,e-r Insre^o• sha" subm,: a co;.%- of this inspecion reccn to the Apercvir.g Autherim. within thin.•: (301 day$ of cnrnpleting this
inspecton. It the system, is a share: wstem o- ha: a cevgn flow of 10.000 g:c or greater, the tnscecor and the system owner st a!l submit
the repo- to the accroprtate re_,oral c::tce of the E)e,anment of E-wircnmeata' Frctecten. The orig:na! should be.sent to the system 0—Me-
and
a
copies :-•t: to the buyer, ii applicable, and the aperoving authority
INS?ECTION SUMMARY: Check ~A; E, C, or D f '
Al SYSTEM PASSES:
F
I have not found any information which indicates'that the system.vieiates any of the failure criteria as de,tned in 310 CMR 15.303.
Any failure criteria not evaluated are indicate^ below. .
COMMENTS: -• - tN
81 SYSTEM CONDITIONALLY PASSES: 151
One r ma're system componentsv tem ueor-
oi ♦n Iµ i n h s s as described in the 'Canditia a Pass' seZ o ne-d to be replaced r -i The ,
Ye e aced o repaired.? pd
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes. no, or not determined (Y, N. or NOt. Describe basis of determination in all instances. If'not determine''. explain why not.
The septic tank is metal, unless the owner or apemtor has provided the system tnsxcor with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (201 years prior to the date of the inspection; a'
the septic tank, whether or not metal, is cracked. structurally unsound, shows substantial infiltration or exfiiltratton, or mni
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic r•nk
a! approved by the Board of Health.
lr•.•:..d 0�/2�:7') )sq. 1 of 10
SUBSURFACE S'E*yVAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property.Addros:
Owner: /J
Date of Inspection:
Bj SYSTEM CONDITIONALLY PASSES tcontinj�d
Sewage backup or'breakout or high static water level observed in the distribution box is due to broken or obstructed
pipesi o'r due to a broken, settled or uneven distribution box• The systemill pass inspecion ff(with approval of the
Board of Healthi. Describe observations: _
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 oken or obstructed pipes). .The system will pass
insaecion if twith approval of the Board of Health): „
broken pipets; are replaced
obstructon is removed
Cj FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which recuire furthe•evaluation by the Board f Hearth in order to determine if the i}-stems is failing to prate the
public health. saiery and the environment. _
1) SYSTE.M WILL PASS UNLESS BOARD OF.HEALTH DETER, INES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SA F AND THE ENVIRONMENT:
Cesseoal or prnti is within 50 ieet of a surface water .
Ce<_spoot or prt.,- is within 50 fee: of a bard ing vegetated wetland or a salt marsh. _
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HE. H (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE: DETERMINES THAT
THE SYSTEM IS FUNCTION-I.NG*IN A MANNER T .AT PROTECTS THE PUBLIC HEALTH AND SAFETY A-O THE
ENVIRONMENT:
The systern has a septic tank and sail bsarpticn system (SAS, and the SAS is within 100 feat to a surface water supply or
tributary,to a suriace water supply.
The systern has a septic tank and s •i absorption system and the SAS is within a Zone I of a public water supa'y we!I.
_ The syste-n has a septic tank and ii absorption system and the SAS is within 50 feat of a private water supply well.
The system has a septic tank and sal) absorption system and the SAS is less thar." 100 fee: but 50 fee: or more from a
private water supply well, unie-, a we![ water analysis for coliform bacteria and volatile organic compounds indicates tha
the we!I is free from pollution rom that faci)iry and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. method u _ to determine distance (approximation not valid).
3) _ OTHER
trwia•d 0�:25/!7) ).q• 2 o1 IQ
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.,-i.
PART A
CERTIFICATION (continued)
Propertv Address:
Owner:
Date of Inspection: -
D] SYSTEM FAILS:
You must indicate either "Yes" or 'No' as to each of the following: `
I have determined that the system violates one or more of the following failure criteria as defined in 10 CMR 15.303. The oasis
for this determination is identified below. The Board of Health should be contacted to determine hat will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clo SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters ue to an.overloaded or clogged SAS or
cesspool.
Static hauid level in the distnb.ition box above outlet invert due to an.ove oaded or clogged 54,5 or cesspoo!
Liquid depth in cesspool is less than 6" below invert or available volui is less than,1/2 day flay.
r
Recuired pumping more than 4 times in the lastye'ar NOT due to cl gged or obstructer pipe S
Number o'times pumped _.
An%- portion o'the 500 Absorption System, cesspool or pnv,)• is low the high ground,-vate,eieyation.
Am por.:on o'a cesspool or privy is withir. 100 feet of'a sur, ce water.supoly or tributan to a sunace water supply
Any portion of a ce<_svoo' or prv.-y is to ithir. a Zone l of a blic'well. `
Am pc^,io- c*a cesspool or privy is within 50 feet of private water supph well
Am• por,.or. o*.a cesspool or privy is less than 100 f _t but greater than 50 feet irem a private water supply well with no
acceatable water qualm anahvsis. It the well has _n analyzed to be acceptabie. arach cb.ov of well water analysis for
coliform. bacteria volatile organic compounds, a monia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes` or "No` as to each of the follo ing.
The iolio\:r.g criteria app;. to .arge systems in ad 'ition to the criteria above:
The system serves a facilm with a design=floes• i 10,000 gpd or greater (Large System; and the system is a significant threat to
public health and safety and the environment cause one or more of the following conditions exist.
Yes No .
the system is within 400 feet f a surface drinking water supply
the system is within 200 f t of a tributary to a surface drinking water supple
the system is located i a nitrogen sensitive area (Interim Wellhead Protection Area IWPA) or a mapped Zone II of a
public water supply ell)
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 Ch1R-3.00 and.6.00. Please consult the local regional office of the Department for._funher.iniormatioa:— - _ __.•_.__. -_
(revised 04/75/91) Page 3 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: IL
Owner:�',,f2GV
Date of Inspection: L I t719
Check if the following have been done: You must indicate either "Yes"�or "No" as to each of the following:
Yes
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 receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as pan of this inspection..
As built plans have been oo:ained and examined. Note if they are not available with N,A.
The fac:li-,.. or dvvellmg was inspected far signs of sewage back-up.
The s\•stem does not receive non-sanitary or industrial waste flow.
X _ The site %%as inspected for signs of breakout.
_ All sstem. components. excludine the Soil .Aosorpuon System, have been located on the site.
The septic tang manhoie� were uncovere:'. opened. and the interior of the septic tank was inspecte-d' for condition of
` C bafiies or tees. matena� o: cons-,ruction. dimensions, deptn 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
The iacdLn 0%%nee ,ano occupants. r,•difteren: from owners were provided with information on the proper maintenance of
Sub-Surface Disposal Svsterr..
Existing information. Ex. Plan at E.0 H.
Determined in the field uc am of the failure criteria related to Part C is at issue, approximation of distance is
'G unaccea:abie 115.3023i,bIl
(r.vla.c' 04/:5/51) page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.-vt ;
PART C . .
SYSTEM INFORMATION
r �-
��
Properts driress:A J � �
Owner: CJry
Date of Ihspection:dJ
FLOW CONDITIONS
RESIDENTIAL:
Design floN Q) p.d.!bedroom for S.A,S
Number of bearooms0
Number o:current residents
Garbage g•::der (yes or no:: 1.5
Laundry co-•^ected to system (yes or no!
Seasonal use (yes or no-:
Water meter readings, if avai able (last two i2 year usaee igpo):._ LS7W
Sump Pump (yes or nor
Lai: date of occupancy SQVAW'Ac ,
COMMERC,4L'INDUSTRIAL:
Type of establishment
Design fio%% eahonsida%
Grease trap present tees or no
Ind-as-ma! \'6aste Holding Tani; present Ives or no
':on-sanita. Kaste d,scnarged to t(ne T:;ie S s,,•s;em ;res or no
\later meter readings if a.ailabie
Las:pave o: o :.rand. ,
OTHER: .De:cribe
Last care of occuoanc.
GENERAL INFORMATION
9
PUMPING RECORDS and source of info mauon
System pumped as par, or inspection: tves or no.
.If yes, volume pumped tzalloris
Reason for pumping
TYP F SYSTEM
Septic absorption system "
Single cesspool
Overflow cesspool
Pn.j _
Shared system (yes or no) (if yes, attach previous inspection records, if any) -
I/A Technology etc. Copy,of up to date contract? _ ..
Other - -
APPROXIMATE AGE of all components, date tns;alled (if known) and source ofinformation:
Sewage odors detected when arriving at the site. (yes or no)� -�.-=:=- : �•• ---•• : .� ••:::=• = •• -
- 1
(revived 04/25/91) Page S gL 10
SUBSURFACE SEYVAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property�Ayddress: j�
Owner: C
Date of Irnpection:
BUILDING SEWER: 17
(Locate on site plan)
Depth below grade.
Material of construction. _cast iron _40.PVC _other texplain)
Distance from private water supply well or suction Irt
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK.UIN
tlocate on site p1a:11
y 6'
Depth below grade
material of construction Aconcre:e _meta _Ftoergiast _Pohethylene _othenexplain
If tani is meta;. Iis: aee _ Is age con.rmec o% Ce-:•fica:e o: Compi;ance _('res.-No
1 _
Dimensi �-)"7 ons _�
Sludge depth �/^e f
Distance from top o: s:udee to boron of outie: tee o• ba�:;e —Z3
Scum thickness h a� ,,c�
Distance from top of scum to top of outle: tee or bake es
Distance from bosom of scurn to bono o ouuet to o• bare
Now dimensions mere determined Gt,�1-L1i
Comments
trecommendation for pumping. condition of inlet and outlet tees or baffles. depth of liquid level in relation to utl t invert, tru ural
integrity, evidence of leakage. e:c.t l "'
n
GREASE TRAP:—t-
(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 ie let and outlet tees or baffles, depth-of liquid level in relation-_te-oWet4nvert-structur-al--
integrity, evidence of leakage, etc.;
(r.,:..d P.q. 4 of 10
s
M '
SUBSURFACE SEA'AGE DISPOSAL SYSTEM INSPECTION FOR.'Nt
PART C
SYSTEM INFORMATION (continued)Y
Propert% Address:
ONner:
Date of Inspection:
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:
Capacm•- gallons
Design fio�% gal)ons'da.
Alarm level Alarm in %:ork)ng crde� _ Yes. _ No
)
Date of previous punping
Comments
(condition of inlet tee. conditicr. o- a!a,rr. and float switches, etc.)
DISTRIBUTIO'. BOX:_
(locale on site p`a-
Dea:�i o licuid le%'el ao0,e oulle: in�e,7
Comments
(note :f leve! and dis;ribut-or is eaua' evidence of solids carryover, /idence f leakage into or out of boa, etc.)
PUMP CHAMBER
(locate on site plan.
Pumps in working order. (Yes or No'
Alarms in working order ('res or No
Comments:
(note condition of pump chamber, condition of pumps an appurtenances, etc.)
(r.vis.d 04/25!97) Page 7 of 10 '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
� a.�� SYSTEM INFORMATION (continued)
Property drfr-ss: � Apt cyc
Owner: •-�
Date of Inspection:�
SOIL ABSORPTION ,SYSTEM (SAS):
(locate on site.plan, if possible. exca. ion not required. but may be approximated by non-intrusive methods
If not determined to be present, explain:
Type:
leaching pits, number. r X�
leaching chambers, number:_
leaching galleries, number.
leaching trenches. number.tength:
leaching fields, number, d.rnensions
overflow cesspool, number
Alternative s•stem
Name of Tecnnciog,.
Comments
(no(e condition of soli, sgns of hvdraul failure, level of onding. condition fwegetati etc.(
ii
1
CESSPOOLS:
(locate on site plar.
Numbe, and configura:.cn
Depth-top of liquid to inlet Inver,
Depth of solids lave•
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of ground\,,ate-
inflow tcesspool must De pumpet: as par, of inspections
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 pondtng, condition of vegetation, etc.):
(r.�i,.d o,;zsi9') Page 8 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION* FORM
PART C
SYSTEM INFORMATION'(continued;
Property Address:
Owner.
Date of Inspection: I I17 hr
I U
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks '
locate all wells within 100• (Locate where public water supply comes into house?
l
pz- °iS
�9nE Ty Bo.,.,A
i
(z.vl,.d o�'2s1s71 Pogo, of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO-N FORM
PART C
pp SYSTEM INFORMATION (continued)
PropertN Address' PI NC
Owner: Q(j&zo C
Date of Inspection:
1tti
Depth to Groundwater?i3 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained irom Design Plans on record
Observation o;Site lAbutting property. observation hole, basement sump etc.)
Determine it irom local conditions
Cnec" %%rth local 53ard o• nea!tr
Chec. F:MA Mae!
Cheo, purnping records
Checl, local eua,.a;o•s ins;alle•s
use LS_S Da-z
r
Describe n %or o„- ,•o cs ro•., %o_ es:aol:snec tie 67:g'-. Cround�ate• Elevation iMust be compietec
V�G� (fDfC 13'Gu NO wc�z� � Llvrvt+,o{= ptI AT
Page 10 of 10