HomeMy WebLinkAbout0400 POPONESSETT ROAD - Health (2) `400 Poponessett Road
' Cotu it F
_19007
-- - -
i
i
I
i
FAILED INSPECTION "S,
COMMONWEALTH OF MASSACHUSETTS
^ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
PARCEL L O
TITLE 5 LOT. y
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's.Name :.
Owner's Address:
Date of Inspection:
Name of Inspect • (p)ease print) rw0g41
Company Name ;
Mailing Address:
Telephone Number: t1�
`C?
Ar €. co ,
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that t e inform atjan rCa
� rted
below is true; accurate and complete.as of the time of the inspection.The inspection was perf med based on tsi,
training and experience in the proper function and maintenance of on site sewage disposal s 's ms.I am a Dive
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 18.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the'Local Approving Authority .
Fails
Inspector's Signature: - Da
te: 0�
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.
Notes and Comments
****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.
Title Inspection Form 6/15/2000 page 1
Page 2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner
Date of Inspection:
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.
Answer yes,no or not determined(Y,N;ND) in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
2
Page 3 of 1'l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Propert Address:
Owne
Date of Inspection ¢�� �
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.
L System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(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
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 aseptic 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 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,provided that no other
failure criteria are triggered. A•copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: C
Owne ,
Date of Inspection f aaoS�
D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to each.of the following for all inspections:
Ye No
7 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
f Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
i -7 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 groundwater elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
/ water supply.
_ V 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 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, provided that no other failure criteria
are triggered. A copy of the analysis must be attached.to this form.]
(Yes/No)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 now of 10,000 gpd to 15,000
gPd•
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).
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.
4.
Page 5 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
_PART B
CHECKLIST
Property Address: 6 oni(
Owne
Date of.Inspection: '
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes , o
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 N/A) .
_ Was the facility.or dwelling inspected for signs of sewage back up
Was the site inspected for signs of breakout?
Were all system components,excluding the SAS, located on site
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:
Yes
Existing information.For example, a plan.at the Board of Health.
Determined in the field(if any of the failure criteria related to Fart C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION-FORM—P40T FOR VOLUNTARY°ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_FORM
PAIN C
SYSTEM INFORMATION
Property-Address: V IQP— ` ,
Owne r,
Date of Inspection: E�._�/,
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):- Number of bedrooms(actual):
DESIGN flow based on 310 C R 15.203 (fore example: 11.0 gpd x#of bedrooms):
Number of current residents:
Does residence.have.a garbage grinder yes or no):
Is laundry on a separate sewage system (ye or no U.[if yes separate inspection required]
Laundry system inspected(yes r no):�"``�
Seasonal use: (yes or no):�... z �g
Water meter readings, if av ilable(last 2 years usage(gpd)):DZ-65,ODO 03-6d�(!�
Sump pump(yes or no):
Last date of occupancy: 01
COMMERCIAL/INDUSTRIAL./Vo
Type of establishment-.
Design flow.(based on 310 CMR.15.203): gpd
Basis of design.flow('seats/persons/sgft,eic.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the i spection(yes o o):
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason Tor pumping:.
TYPE OF SYSTEM
Septic tank, distribution box,soil absorption system
_Sin gle cesspool
_Overflow cesspool
Privy
_Shared system.(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation.and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy'of the DEP.approval
Other'(describe): 4 V r
roximate ge of all components, date installed(if known)and source of information:
h�� �
� � p/
Were sewage odors detected when arriving.at the site(yes or no
6
Paae 7 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Propert Address:
Owne
Date of Inspection: C30o
BUILDING SEWER(locate on site plan)1/U
Depth below grade:
Materials of construction:_cast.iron _40 PVC_other(explain):
Distance from private water supply well or suction liner
Comments(on condition of joints, venting,evidence of leakage, etc.):
SEPTIC TANKO/6(locate on.site plan)
Depth below grade:
Material of construction:_concrete_metal fiberglass polyethylene
other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance (yes or no):_(attach a copy of
certificate)
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:
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.): V
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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 00
Owne •. /),/-V jjy
pe Date of Insction: �i
A` y tank must be pumped at time of ins ection)(locate on site plan).
TIGHT or HOLDING TANK. ( p p P
Depth below grade:
Material of construction: concrete metal fiberglass ._polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc,):
DISTRIBUTION BOX: /V (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments (note if box is level 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(yes or no):
Alarms in working order(yes or no):
Comments(note.condition of pump chamber,condition of pumps and appurtenances, etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Properi ddress: ( �
Owne
Date of Inspection zal, no
SOIL ABSORPTION SYSTEM (SAS): (locate on siteplan, excavation not required)
If SAS not located explain why:
TYPe
leaching pits,number:_
leaching chambers,number:
leaching galleries;number:
leaching trenches,number,length:
"hinQ fields, number, dimensions:
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.
CESSPOOLS: (cesspool must be pumped as part of inspect ion)(]ocate on site plan)
Number and conflauration: .I - ` x
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool: C'
Materials of construction:
Indication of groundwater inflow(yes or no):
ments(note condition of , signs of ydraulic f i urejevel of ponding, cond•�ion of vegetation, etc.)
J/
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.):,
LAY)-"� �
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Own
Date nspection:
SKETCH OF SEWAGE DISPOSAL.SYSTEM
Provide a sketch 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 t building.
i
1�
y'
%c� ' -�
10
Page 1 1 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION (continued)
Property Address: ' /C
Owr
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water./ feet
Please indicate(check)all methods used to determine the high,ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
/Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation: q
i5i ` D
es61 175 —
I
11
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
�r�G✓GS� ���� Ld �l / Lot No.
Site Locations
Owner: !� Address: �✓
Contractor: ���� / . -1/d.�1 Address: Z-115-1
Notes:,
STEP 1 Measure depth to water table /��l
tonearest 1/10 ft. .........................................................:.................... .Date `� G
month/day/Year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine: n
OA Appropriate index well.......................
OWater-level range zone .....................................................
STEP 3 Using monthly report"Current
Water Resources Conditions"
determine current depth to j�cJ/ / q/Z_
water level for index well ........................... month/year
STEP 4 Using Table of Water-level Adjustments
for index.well (STEP'2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B) Cif
determine water-level adjustment .......................................................................:.....:............ C�
STEP 5 Estimate depth to high water
by subtracting the water
level adjustment (STEP 4)
from measured depth to water 17, 7
levelat site (STEP 1) .............................................................................................................
Figure 13.--Reproducible computation form.
15
�.
��
C
- �
II
(� or
-� `--.�.
� �
� - �
� �.
c�' �. .;�
�� � �
�- \ti.:.Q
O � '
� �
,�
�� . ���
,_