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HomeMy WebLinkAbout0068 WHITMAR ROAD - Health h' TnT.�ii tiii x' o a., Uotuit —I 1 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 7/2/14 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: �I Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address t East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 Telephone Number B. Certification I 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 the inspection. The inspection was performed based on my training and experience in the proper function and mainteg nce of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Secti In 15.34kbf —� Title,5(310 CMR 15.000).The system: ` -' ® Passes ❑ Conditionally Passes ❑ falls 01. El Needs Further Evaluation by the Local Approving Authority A _ Y � 5. ( � 7/2/14 InspeAdrs Signa Date 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. A ""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. 68 Whitmar Rd•03/08 Title 5 Official Inspection Form:S urf Sewage Disposal System•P e 1 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 7/2/14 Citylrown State Zip Code Date of Inspection B. Certification (cont.) 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: Pumping suggested every 3 yrs to prolong the life of the system 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: n/a ❑ 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 68 Whitmar Rd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 712/14 City/Town State Zip Code Date of Inspection B. Certification (cont.) j B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ 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: n/a 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. 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 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. 68 Whitmar Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 iL Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 7/2/14 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic 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 indicates absent 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: n/a D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 ❑ ® 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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 68 Whitmar Rd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,M SVB'a 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 7/2/14 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. 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 ❑ El 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. 68 Whitmar Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 7/2/14 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ 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 break out? ® ❑ 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 stem Absorption S SAS on the site has P Y (SAS) been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 68 Whitmar Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 7/2/14 City,7own State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3+ Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: OccupiedDate Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a 68 Whitmar Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Whitmar Rd Property Address Shanks Owner's Name . Cotuit MA 02635 7/2/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No recent pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe):, Approximate age of all components, date installed (if known)and source of information: 1986 per age of the home Were sewage odors detected when arriving at the site? ❑ Yes ® No 68 Whitmar Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts w . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 7/2/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500g Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle >12 11 Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle >2„ Distance from bottom of scum to bottom of outlet tee or baffle >211 How were dimensions determined? Measured 68 Whitmar Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 7/2/1.4 CityiTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a 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: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): n/a 68 Whitmar Rd•03108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 7/2/14 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): D-Box 2' below grade and in average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 68 Whitmar Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 7/2/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching 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.): Leach Pits were video inspected. Pit"C" is 2/3 full and Pit"D" is dry, no indication of past backup 68 Whitmar Rd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` Gty 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 7/2/14 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (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 ❑ Yes ❑ No 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.): n/a 68 Whitmar Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection on Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Whitmar Rd Property Address Shanks Owner's Name Cotuit MA 02635 7/2/14' City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 the building. C- 5 G 68 Whitmar Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 68 Whitmar Rd Property Address Shanks Owners Name Cotui: MA 02635 7/2/14 City/Tcwn State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: [per elevation of home 68 Whitmar Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 0 ,50 `7 113 •\ COMMONWEALTH OF MASS.ACHL'SETTS EXECUTIVE OFFICE OF ENVIRON]viENTAL AFFAI >� DEPARTMENT OF ENVIRONMENTAL PRO ON 10 ONE R'INTER STREET. BOSTON. NIA 02108 617-292-5:50� Rf�E U� `o 1997 WILLIA�":F.V1'ELD "FRL' 0XE Govemo: 'vHppr�lt retar. ARGEO PAUL CELLUCCI D. TRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM $ missioner PART A W h '/�M�� CERTIFICATION Property Address: � f��-ice-- - Cp7�-�� Address of Owner: �jh Date of Inspection: t!5> Gj (If different) Name of Inspector: C � S���v•='tee-t�� I am a DEP ap/p,roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name:A �E&J"C Mailing Address: A O Telephone Number &_ �6 CERTIFICATION STATEMENT I certify th:lt 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 '-eeds Fu er va ation y the Local .Approving Authority Fads Inspector's Signa _ Date: The Svstem Inspector shall submit a copy of this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I 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 ND). 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 conforming septic tank as approved by the Board of Health. (zavimod 04/25/97) Page 1 of 10 DEP on the World Wide Web http.Nwww.magnet.state.ma.usJdec 0 Printed on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ( ; CERTIFICATION (continued) + Cow - Prop.erty Address: Owner:QO '' ,Date of Inspection: _B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)_or;,de to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board fHealth). 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 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 CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of F'ealth 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or priory is within 50 feet of a surface water Cesspool or priory 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 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 to 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 (zevieed 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /��t CERTIFICATION (continued) Property Address:OlS tf—u..o� /mil CQt�' Owner: Date of Inspection: DJ SYSTEM FAILS: l l 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 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 boa 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 112 day flov;. 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. An, -onion of a cesspool or privy is wot in 100 feet of a surface water supply w tributary to a surface water supply. . Any portion of a cesspool or privy is within a Zone I of a public well. Am pontor. of a cesspool or privy is within 50 feet of a private water supply well. Anv portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water suppiv well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copv 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" as 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 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. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: lie Owner:CAZ 00 Date of I nspection�,c/Z C / l 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 part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. k _ The system does not receive non-sanitary or industrial waste flow. The site �%as inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have 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 o'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: _ The facility owner (and occupants, if dinerent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. N'Iti Existing information. Ex. 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)J (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: —1 Owner: U�--Q— Date of Inspection p ` G FLOW CONDITIONS RESIDENTIAL: Design flow:(.Gn p.d./bedroom for S.A.S. Number of bedroorns: _ Number of current residents:Q Garbage g•,r der (yei or no): . LA-. Laundry co-,nected -o system (yes or no):-4S Seasonal use (yes or no): s � Water meter readings, if available (last two (2t year usage (gpd): r.Jp Sump Pump (yes or no): N tl Last date of occupancy COMMERCIAUINDUSTRIAL• Type of establishment Design flow: aallonsiday Grease trap present: (yes or no,_ Industrial Waste Holding Tani; present: (yes or no)_ Non-sanitary v%aste discharged to the Titie 5 system: (yes or no)— Water meter reading,:-, if available Last date of o cupan--\ OTHER: (Describe Last date of occuoan--\. GENERAL INFORMATION PUMPING RECORDS and source of information: -ST�w� VA th%w�t'A System pumped as pan of inspection: (yes or no)_�ld If yes, volu-ne pumped: gallons Reason for pumping TYPE OF SYSTEM Septic tank,.-distribution box/soil absorption system Single cesspoo Overflow cesspool Privy 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 installed (if known) and source of information: Sewage odors detect--d when arriving at the site: (yes or no) t-30 (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) Property Address: O Owner: IN Date of Inspection:��, BUILDING SEWER: Nv (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction Ir-� Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANKS (locate on s�[e p ni r Depth below grade:( Material of construction: concrete _metal _Fiberglass _Polyethvlene _other(explain'i If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No: Dimensions K00 a.v el Sludge depth: C)"' W Distance from top of sludge to bottom of outlet tee or baple._� Scum thickness: 72, t Distance from top of scum to top of outlet tee or baffle %Zr Distance from bottom of scum to bottom of outlet tee or baffie:k_ 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.) g GREASE TRAP:1 (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 04/25:97) Page 6 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ! l�I..--cc,,. 'fC/ Owner: C-C:C I Date of Inspection: 694/Lav� TIGHT OR HOLDING TANK: A :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 floes-: gallon&,da\ 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:-4e5 (locate on site pian: I Depth of liquid level above outiet invert jvj (iJI G�R�T�/l1JGtG� Comments: ` note if level and distribution, is eoual, evidence of solids carryover, evidence of leakage into or out of box, etc.) NJ v 1 PUMP CHAMBER:_IJO (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 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) ` Property Address: �� �c..�cs� 10:4 Owner: C'C(A. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): ( 1�A (locate on site plan, if possible; excav tion not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: I leaching pits, number: (m. leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: In to condition of soil, signs of hydraulic failure, level of pond, Bondi on r,vegetation, e ) Zia 5 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.) (raviaod 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4 L4A--&..•_ e.,I. Owner: &U_ Date of Inspection: 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) 2 Os ►�3 3 ,b� y Lsk\. P s"51 51 (revised 04!25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) T Property Addr s: 6Q2f—�� Owner: Date of Inspection: Depth to Groundwater Feet Please indicate all the methods used to-determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, obsen•ation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA heaps Check pumping records Check local excavators, installers. r X Use LSGS Data Describe in vour o,,%•n \%ords how you established the High Groundwater Elevation. Must be completed) (revised 04/25/97) Page 10 of 10 ASSESSOR I.S M P 0.S PARCEL A* I 6 spkai-T L0CATI SEWAGE PERMIT NQ.� VVILLAGE C-0 4tT INSTA LLER'S NAME i ADDRESS r 0 U I L D E R OR OWNER DATE PERMIT ISSUED DAT E C 0 M P L I A N C E ISSUED 3 � . .a r 2,: � � .. . — � � `'�' — �I � �� � l�� � � � -� ASSESSORS MAP NO: .� ARCM. NO.: N �-"' (o _...9' Fss.. _............... THE COMMONWEALTH OF MASSACHUSETTS r a BOARD OF HEALTH -5.1 3- ....................................... Appliration for Diovoottl Workii Tondrnr#inn Frrmi# Application is hereby made for a Permit to Construct K) or Repair ( } an Individual Sewage Disposal System at: - " /3 wH'L �l .._.�-�.......� t f .. ......................................... Location-Address or Lot No. ..fUPS-a =-!'`��kl t�?c!F.h?fc......ff ... 6f------------------- .ag2 i rAz+novsN ..MA 1PN5 m 1ws, n?A °z.,`e� .... ......... a1 Owner Address W - �'"� i o...-•-•............................ ................................ a InstdTlel- Address dType of Building Size Lot.43 S6..�........Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic (A d) Garbage Grinder (NLU5 aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Ga Other fixtures ........................... W Design Flow........... -�.......................gallons per person per day. Total daily flow___....�_4Q......... ....._._....gallons. WSeptic Tank—Liquid capacityl*9...gallons Length....110:70 Width_G-.Q._ Diameter________ __ Depth.-119-L-4..... x Disposal Trench—No. _-_---.----•----_- Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No------Z-_.__-__ ._. Diameter.._.....e�.--..... Dep -i below inlet.....4?........... Total leaching area...'I ..... ft. Z Other Distribution box Dosing tank (VJ i9i ~' 85- Percolation Test Results Performed by.....��1�JE .N4 c........................................ Date--��I.i 31 ,tea Test Pit No. l..A .....minutes per inch Depth of Test Pit---11.LS........ Depth to ground water_1- @T �,iIG�lAsI CJ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ v ---------------------------------------------- •-•------------- -------------•------•- ------------- 0 Description of Soil_Z:1 S:.&&f-1-N1�.... -10 ...........•..............................------------------------------------------------------------------------------ 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 TLHL% of e State Sanitary Code The undersigne rees not to place the system in operati til a C t to orpliance has n issue y the board f healt . Signed.....:..:........ .... ......... •--•-.......... at� - Application Approved By--- -••••--•------•-------••---•--.•-• ,�-•---•. ----- ----- ------------ D- ��.. -� Date Application Disapproved for the following reason -------------------------------------•-------------------•----------------------•------------•--•.......-------- ----------------------------•------------------------------------------......------........--------=•----I-----•-----•-••--••-•--••---••--•••••----•----•--••-•-••-••••-•-••----••-•-•-•---•-----........ Date PermitNo....................................................... Issued........................................................ Date No.........--•••------.... Fjms............._.... .rr '' ` THE COMMONWEALTH OF MASSACHUSETTS t 4 BOARD OF HEALTH .................:........................OF.......................................................................................... Appliratiun for Disposal Works Tonstrurtion rrruti# Application is hereby made for a Permit to Construct K) or Repair ( ) an Individual Sewage Disposal System at: ....:--•---.....-_......-...................................................................... .................................................................................................. Location-Address or Lot No. ......................---................:...................................................... . ......................................................__......................---_•_-............ Owner w Address a ............................. - ,:2tt! �. 4i.Q-------......------•----.._....... -------.......-,----=-----...-•------......_........--•- .... ......................-- Insta er Address SCo Type of Building Size Lot...cl3.............1......_..Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic C�a Garbage Grinder Other,-' Type of Building No. of persons............................ Showers — Cafeteria P4 ;_• - Other fixtures --------•..............................••-....•--•---.- --- Design Flow.:........ __•gallons per person per day. Total daily flow....... ......... ............gallons. Septic Tank—' Liquid capacity............gallons Length...XOr Width. ::Q_ Diameter_..__ ".. Depth..S'` ..... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..... ....�...).... Diameter.._.:__......... Depth below inlet.._............ Total leaching area..`� �.....sq. ft. CC Z Other Distribution box 1�oy Dosing tank (� '-"1 Percolation Test Results Performed by....................... _.......................•----------•- -•---. Date.........-----...._.. _ ----•----------._.. 1.4 Test Pit No. 1_.Z.��--__.....minutes per inch Depth of Test Pit--)A!.,.......... Depth to ground waterAA0 Q-C Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ aJ. o°••---------•................ ................................................................................................... 0 Description of Soil_ _L..i................. ...........I................................................................................................................ W ................ ...... ........------•_----- -•----------------------------------------------•--..__....-----------------------•----...---•----------•------------•-----------------.._._..._.__...----------......_.._.......--•--.................. U Nature 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 TITL>; of e State San' ry Code The undersignel,#�rrte rees not to place the system in operati ntil a C rtte� Cor> pliance has n issue y the board f healt t ✓✓ Signed ... ...... ... .......... _______-•------•----- •- --.. .... / ..............� 'Application Approved By...f................................... . . to 1 Date Application Disapproved for the following reason _____________________________________________________________:______________________.......................--- .........................•-----••----.........__...•••--••-•----•-•---•-------.. ........•-------.....__.........---------••••---...•. ----......._..-------................ -----•---.- Date — PermitNo......................................................... Issued......................................................- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD AF HEALTH ..... K .............OF....... ......................................... Trrfif irate of Tomplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X) or Repaired ( ) by............ - ..... - -----•---------- :c:........... ............................................_ Installer at............... .................•-...-------------LQI------ - -•-•---....W..9llt-1 141-C......(emu-1......mam 1"..................--------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as escr•bed in the application for Disposal Works Construction Permit No.__.` ..�. ' �`'� ......... dated_______________.}__1. _! ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA EE HAT THE SYSTEM WILL FUNCTION S TISFACTORY. t � Z LCj DATE............... ......... Inspector.....- •----- •.................. ......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH S-7 ...........................................OF..................................................................................... No.....� F E.... . Disposal 1coqs Tons#riulion Permit Permission Is hereby granted...... - - j�..:........................................................... to Construct (�* orRepair ( ) an Individual Sewage Disposal System ,# at No....:..................... _ t �!ftl`� .?`!�.ti.C.....-�...- ----CC--�'Tv....._..-•-•----••--------..........---......................... Street as shown on the application for Disposal Works Construction Permit No... Dated.._________.f t ..g$......... •••----•--•------•--- ..._•--_.._.. ....: t Board of Health DATE............... ' FORM 1255 A. . SULK N, INC., BOSTON g�F. GACC�oG1=i 6:R1�.1D \t U tt:Q tDk&IL%'? 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