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HomeMy WebLinkAbout0162 PINEVIEW DRIVE - Health 162 Pineview Drive, Cotuit IA_ ---A3 o i V COMMONWEALTH OF MASSAC14USETTS ` ExECt'TIVE OFFICE OF ExVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONME\TAL YROTECTiON •W' p 1 ONE WINTER STREET. BOSTON. AIA•02I08 8 199, W`ILLIAN:F W'ELD RUDl CONT Govemc• O �� Se;rctar% ARGEO PAUL CELLL-CCI � � 1 DAVID B STRL'HS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address:AbZ Address of Owner: Date of Inspection: `Z9-01 (If different) Name of Inspector: /(,�"et o -P I 1 E�E,-Cill'=> I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name:f}16y 41-71-1 e En v'r'r1.1 rl Nit P Mailing Address: p e3 osgn x e_3;�P!�f 4-C/ Telephone Number: e-Se Cf.j t;— /4& Zo CERTIFICATION STATEMENT I cer,i� that I have personally inspected the seAaee disposal system at this address and tha: the information reported beloN is true. accurate and complete as of the time of inspect,o-... The inspection was performed based on my training and experience to the proper iunction and maintenance of on-site sev`age disposa systems The system: Passes _ Co-)c,t,onaii\ Passes ',eec: Furthe! Eva!uat;on B� the Local .Approving Authorir) Fa.-! Inspector's Signatur Date: � 1 The Svste^r Inspector sha!' submi: a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspector.. lithe system is a shared -,-stern o, has a design floe, of 10,000 gpd or greater, the inspector and the system owner shall submit the repo^ to the appropriate regional office of the Department of Environmental Protector. The orig:na! should be sent to the system owner and copies sent to the buyer, if applicable. and the approving authority. INSPECTIO% SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: _-Is:_[ have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 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 NDt. 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 (attache-?; indicating that the tank was installed within twenty (20; years prior to the date of the inspec.!on; or the septic tank, whe:her or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiitration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank w approved by the Board of Health. (revised 04/2S/97) Page 1 of 10 DEo on the Wond Woe WeD h=Itwww magnet state ma.uyoec Pnntec on Retycied PaDe! r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES tcontin,j-d _ Sewage backup or breakout or high static water level observed in the distribution box i due to broken or obstructed ptpets),or due to a broken, settled or uneven distribution box. The system will pass irtspection if(with approval of the Board of Health;. Describe observations: broken pipets) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken r obstructed p*(s). The system will pass inspection if (with approval of the Board of Health): broken pipets) are replaced obstruction is removed 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 protea the public health, saiery and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNED WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY/AND THE ENVIRONMENT: Cesspool or priv% is vvithin 50 feet of a surface water Cesspool or prw� is %♦;thin 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 7MT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: l i The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supplyar tributary to a surface water supplh. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water suprt'v 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, uniess a well water analysis for coliform bacteria and volatile organic compounds indicatesiat 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 (revised 04/]5/97) Page 2 of 10 @s- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC/in PART A CERTIFICATION (continued) Property 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 trCMR 15.303. The ter?.for this determination is identified below. The Board of Health should be contactill be necessam, to co-rect 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 r surface waters due to an overloaded or clogged SAS or cesspool. Stanc houid level in the distribution boa above outlet invert due to an overloaded or clogged SAS or cesspool. Liouid depth in cesspool is less than 6" below invert or'available volume is less than 1/2 day floe. Recurred pumping more than 4 times in the last year/NOT due to clogged or obstructed pipe's Number of times pumped _ Any portion o`the So!l Absorption 5-stern, cesspool or privy is below the high groundwater eievatio-. T Am portion of a cesspool or privy is within V00 feet of a surface water supply or tributary to a surface water supple. Am" portion of a cesspoo' or pri��'.• is %Ithir. a Zone I of a public well. An- pe-�io- e-a cesspoo' or pri"• is ",4 50 feet of a private water supply well An\ pon,or. of a cesspool or prr.A, Isffess than 100 feet but greater than 50 feet from a private water supply well withass acceptable eater qualir\ analysis If,the well has been analyzed to be acceptable, attach copy of well water analysis fErr coloorm bacteria. volatile organic,compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes' or "%o" as to each of the following: The folio".rig criteria app;% to large systems in addition to the criteria above: The system sen-es a facilm with a) design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public hea!th 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 I 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 - NVPA) or a mapped Zone II of a public water supply well) The owner or operator of ain 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. t (revised 04/25/97) Dag• 3 of 10 SLIESURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �oZ ►PAC Owner: C0470S 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 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 k As built plans have been obtained and examined. Note if they are not available with N/A. The facilln or dwelling .%as inspected for signs of sewage back-up. �( The system does not receive non-sanitary or industrial waste flow. — The site %%as inspected for signs 13i breakout. — All s\stem components. excluding the Soil Absorption System, have been located on the site. — The septic tank manholes "ere uncovered. opened. and the interior of the septic tank was inspected for condition of banes or tees, materia, o'construction, dimensions, depth of liquid,.depth of sludge, depth of scum. The size and location of the Soil .Absorption 5vsiem on the site has been determined based on: — The iacda\ o�%ne• tano occupants. c difterent tram owner were provided with information on the proper maintenance of Sub-Surface Disposal System. g i Existing information. Ex. Plan at B.O.H. Determned in the field Af an., of the failure criteria related to Pan C is at issue, approximation of distance is unacceatab�e (15.302.3;:b`l (revised 04/25/5?) Page 4 of 10 r v : SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR..M PART C SYSTEM INFORMATION Propert% Address: k07,, ` iL x V1ew Owner: WT—O6 . . Date of Inspection: �kZCa., FLOW CONDITIONS RESIDENTIAL: Design fiov% gao p.d./bedroom•, for S.A.S Number of bedrooms -1 Number of current residents Garbage g•, der (yes or no,: w�p Laundry co-•^ected to system (,yes or no'. \f-s Seasonal use (yes or no,:k3') `' Water meter readings, if available (last two i2: year usage tgpd): eJn Sump Pump Ives or not fir' Las date o-*occupanc-,(>?1105 PST COMMERCI41-9tiDUSTTTRI''A''L::``'' Type of establishment Design fio�% galions da% Grease trap present (yes or no_ Indus,rial %%ante Holding Tani; present. -ves or no_ Non-sa.nitan Naste dscnargec to the T!,ie 5 system Ives or no_ \later meter readings if a�-ailabie Las:Fate o, o --p2^c. OTHER; Describe Las( oate of occ,:canc, GENERAL INFORMATION PUMPING RECORDS and source of mformatior. Sul 'N- V-�Wj �-o 0()v \O Arl T w\k Svstem pumped as par, of inspection: tees or no. J If yes, volume pumped gallons Reason for pumping TYPE OF SYSTEM Sepuc tank!distnbunon box soil absorption system Single cesspool Overflow cesspool Prn�• Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: (O1. t.F' Sewage odors detected when arriving at the site. (yes or no) (� (revimed 04/25/97) Page 5 of 10 r u SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION' FORM PART C --� SYSTEM INFORMAT10% (continued) Property Address: (OZ ''1r►� ��$� Owner: Qo Date of Inspection:m�. _`�� BUILDING SEWER: NO (locate on site plan) Depth below grade. Material of construction: _cast iron _40 PVC _other (explain` Distance from private water supply well or suction Ii Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site pii,) Q Depth below grade Material of construction: iconcre:e _meta _Fibergiass _Polyethylene _otheriexplam If tank is metal, lis: age _ I;age confirmee b� Ce^,,iica:e of Compuance _(ties`no Dimensions 1006' C Ii Sludge depth ` ' t� Distance from top o: sludge to bottom of outie: tee o• ba�;e Ak Scum thickness 011 Distance from top o{ scum to top o+ outlet tee or ba^ie \i lc ►t Distance from bottom of scurn to bo-, o n ci outlet tee c, bane 11 How dimensions were determined A1A(Jh0t&.A Comments. trecommendation 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.) QVT� (01 WM � 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.; (revimed 04/25.17) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert. Address: 102. �I&W- caner. Date of Inspection: 5�7-0, 1 ? prior r time, f in cti n TIGHT OR HOLDING TANK: ank must be pumped p o to, o at t e, o spe o (locate on size plan, Depth below grade. Material of construction. _concrete _metal _Fiberglass _Polyethylene _,other(explain) Dimensions: Capacity: gallons Design floN gahons,da, Alarm level Alarm in working order_ Yes. _ No Date of previous pumping Comments (condition of inlet. tee. condmon o! alarT, and float switches. etc.) DISTRIBUTION BOX: (J�S (locate on site Pan ' •� 1 ' 1 Dept^ o' liouid le e: aoo�e oune: in,e �`OWE VeC' Comments note a level and d!strib.:l,or. 1s eat evidence of solids ca6rryover evidence-cii leakage into or out of box, etc.) ,n f n ta-t � +J��_�.��,�ern �P�(R'a�/, e. .t , n�a� t �� - `�Ot_co1 r9 J+n L sir-\.79 J—, �� C a a k Y n c)Q. i -f PUMP CHAMBER: tNV (locate on site plan. Pumps in working order: (Yes or No' Alarms in working order (lees or No Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (ravaaad 04/25/9") Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT10% FORM PART C SYSTEM INFORMATION (continued) Property Address: I.LV A&ti Owner: _L_d_T`rU_S Date of Inspection: m SOIL ABSORPTION SYSTEM (SAS): (locate on site.plan, if possible, excaJtion not required, but may be approximated by non-mtirvsive methods, If not determined to be present, explain: Type: leaching pits. number.`(.&t' leaching chambers, number:_ leaching galleries, number: leaching trenches. number,length: leaching fields, number, dimensions overflow cesspool, number Alternative s•stem !game of Tecnrolog\ Comments. (note condition of soli. s!grs of hydraulic failure, level of ponding. ondiuon of vegetation, etct of 'T l..&i krg won -k rta)t^0 V y i CESSPOOLS: Al (locate on site play. ~umber and coniigura:,on Depth-top of liquid to inlet Inver, Depth of solids laye- Depth of scum layer. Dimensions of cesspool Materials of constructior Indication of groundwate- inflow tcesspool must oe pumpeC as par, of inspections Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc( PRIVY: y v (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, sigrs of hydraulic failure, level of ponding, condition of vegetation, etc: (revasad 04/25/91) Page / of 10 4w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properri Address: Owner. L454r Date of Inspection: (2) too � SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reierences landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 6 i OZ L (revise: 04!25/5") Page 9 of 10 t a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert% Address: Jc�Z� Owner: L4 fTus Date of Inspection: Depth to Grounc1water�a0 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation o,' Site (Abuning property. observation hole, basement sump etc.) Determine it from local conditions Cneci. with Iota! Board o' nea!,,- Check FE.MA neaps Check pumping records Check local exca,ato,s. installers )( 1,se L SCS Data r• Describe n your own. •.orc, no•,% \o- es:abLshed the 6^igh Cround�,%ater Elevation. (Must be complete D•4• 10 of 20. tr�v:sad 0�,25'9'.