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HomeMy WebLinkAbout0364 LAKESIDE DRIVE - Health 364 LAKESIDE rXVG MARST.MILLS, A= e P cc�s�'r cLOsr_`T Ll OVI CID 1 rj is 00 3 Y L,+ k(�--s 1 v/." �P, 1'1/-I-I2 ,5 OIV 111' 11-5' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. 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: U Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth . MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification ar,,l 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 e.r, was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of p�Title 5 (310.CMR 15.000).The system: CM _ ) =1 ® Passes ❑ Conditionally Passes ❑ Fails o ❑ Ne,dds Further Evaluation by the Local Approving Authority 1-15-10 Inspector's Signature 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. **"*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. Both Cesspools empty and in good condition at inspection. Recommend pumping annually for maintenance and to prolong life of system. System operating at about 80% capacity. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 LO o / D Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. City/Town 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: System is in good working order with no sign of failure. Recommend pumping annually for maintenance and to prolong life of cesspools. 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 year's 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 t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced t 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: 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 mannerwhich 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. City/Town 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: 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 + El ® 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. t5insp official document-03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes - 'No j ❑ ® 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 El ® 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 ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. City/Town 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? El ® Were as built plans of the system obtained and examined?.(If they were not available note as NIA) ® ❑ 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 Absorption System (SAS) on the site has 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 CM 15.302(5)] t5insp official document•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 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. City/Town State Zip Code Date of Inspection D. System Information- Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 220 Number of current residents: 0 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: 10-09 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10, every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: ' N/A 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: ❑ 1Septic 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. z ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1960's Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 24" . feet Material of construction: ❑ cast iron ❑ 40 PVC Orangeberg ® other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: Cesspool 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: 6x6 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? t5insp official document•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 ,M 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. City/Town 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.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle I 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.): 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): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. City/Town 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.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 1 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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 ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): t If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 2-inline ❑ 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.): Both cesspools were empty and in good condition at inspection. Stain line in second cesspool is at 30" below inlet invert. System is operating at about 80% capacity. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I M 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. City/Town 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 2-inline Depth—top of liquid to inlet invert n/a Depth of solids layer n/a Depth of scum layer n/a Dimensions of cesspool 6x6 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Both cesspools empty and in good condition at inspection. Stain line at 30"below inlet invert in second cesspool with no sign of groundwater infiltration. 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.): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form _Not for Voluntary Assessments ' 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 '1-15-10 every page. 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. I i Op- f t5insp official document•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 364 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Marstons Mills MA 02648 1-15-10 every page. City/Town 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: 20' 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: Town maps show no groundwater at 20'. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 COBIONZWEALTH OF MASSACHLSETTS _ L EXECUTIVE OFFICE OF E:�'VIR0N.,IEN AFF.AIP.S DEPARTMENT OF ENVIRONMENTAL PROTECTION O\'E 1lZ\'TER STREE .BOSTO\�1.�0210r 161 232-Sal►t TRH DT COL Secreta_ry ARGEO PAUL CELLUCCi DAVID B STP.-'L7S Governor Cort=ssione- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTFICA71ON Property Address: 364 Lakeside Drive N'**f 01 Ra�37��rews • Date of Inspee6wM a r s tons Mills Address of Owner 15 Peter Par-_ Name at inspector:(Pfease Prinu ft. E. Robinson S r. Boston I am a DEP approved systeM inspector to Section 15-W of Tide S 1310 CMR 15.000) Company Name: Wm. E . Robinson Seep is Service MagiingAddress: PQ BOX 1.0 9. Centerville MA Telephone Number: 77 5_8%7 0 CERTIFICATION STATEMENT 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 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: -LIPasses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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. NOTES AND COMMENTS of 1R01VE6 OCT 2 ° 2000 rev.-Lsea 9/2/9E Papelof11 ZZ: -,.^ud o^Reai KC Pang• C� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART A CERTIFICATION (continued) NopertyAddress: 364_ Lakeside Drive, Marstons Mills *)wnw: Andrews Date of Inspeeoon: INSPECTION SUMMARY: Check B, C, o/ D: A_(L_ PASSES: 1 have not found any information which indicates that•sny of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. YSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon ompletion of the replacement or repair,as approved by the Board of Health,will pass. Indicate ye ,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 lattached)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 complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). 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 pipels). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised, 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Own Property Address: Owner: 364 Lakeside Drive, Marstons Mills Date of IrupaA6rdrews 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 the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. Cesspool or privy is within 50 feet of 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 IAND PUBLIC WATER SUPPLIER,IF ANY)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 of 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 1 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 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Property Address: 364 Lakeside Drive, Marstons Mills Owner: Andrews Date of Inspection: D. YSTEM FAILS: You m st indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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 orebgged 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. RGE SYSTEM FAILS: You m st indicate either "Yes" or "No' 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 11 of a public water supply well) The o net or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office f the Department for further information. revisec5 Pagc4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Owner: Address:O 364 Lakeside Drive, Marstons Mills Owner:: 1��,r�', Date of Insp"&jr e W s 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. t! _ None of the system components have been pumped for at least two weeks and the system has been receiving"urmal 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. _ The system does not receive non-sanitary or industrial'waste flow. V _ The site was 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 of 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: _ Existing information. For example, 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) f15.302(3)(b)) I The facility owner (and occupants,if different from owner) were provided with information on the propernwintenaarj-0f Subsurface Disposal Systems. rei'_seC 9/2/96 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION 'Top"Address: 364 Lakeside Drive, Marstons Mills Owner: Andrews Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:--!Z(3 g.p.d.lbedroom. Number of bedrooms (design): Number of bedrooms (actual): Total DESIGN flow ,3 G O Number of current residents: Garbage grinder Iyes or no):_LI.0 Laundry(separate system) (yes or not A- If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):V-t:� S Water meter readings, if available (last two year's usage(gpd): 1 CI ci 9 d y of)n ga 1 Sump Pump(yes or no):/-v 1998 10,000 gal. Last date of occupancoz——c-� COMM RCIALIINDUSTAIAL: Type of stablishment Design fI w: gpd ( Based on 15.203) Basis of esign flow Grease tr p present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no) Non-san a►y waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last da a of occupancy: OTH :(Describe) Last d to of occupancy: GENERAL INFORMATION PUMPING RECORDS ands yx of information: System pump asass part of inspection: (yes or no)�' If yes, volume pumped: gallons r Reason for pumping: 2'4-s.a 1 6R (5poU���6 �,c TYPE OF SYSTEM Septic tank%distribution boxisoil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records;if any) VA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed fif known)and source of information: gs� Sewage odors detected when arriving at the site: (yes or no) -cviseC Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontimmd) %ropertyAddress: 364 Lakeside Drive, Marstons Mills Owner: PAnlrews Date of Ins BU DING SEWER: (Loc to on site plan) Dept below grade:_ Mate al of construction:_cast iron_40 PVC_other(explain) Dista ce from private water supply well or suction line Diam ter Com ants: (condition of joints, venting, evidence of leakage,-etc.) It SEP IC TANK:_ (Iota. on site plan) Depth low grade:_ Material f construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is etal,list age_ (sage confirmed by Certificate of Compliance_(Yes/No) Dimension Sludge de the Distance tr m top of sludge to bottom of outlet tee or baffle: Scum thic ass: Distance fr m top of scum to top of outlet tee or baffle: Distance fr m bottom of scum to bottom of outlet tee or baffle: How dime sions were determined: 'omment : (recomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evident of leakage, etc.) GREAS TRAP: (locate n site plan) Depth b low grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimens ons: Scum t ickness: Distan a from top of scum to top of outlet tee or baffle: Distan a from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Comme s: (recomm ndation 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.) 42 re Se4 G/2/9E Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cattinued) 'roperty Address: 364 -Lakeside Drive, Marstons Mills Owner: Alr drews Date of Ins on: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate site plan) Depth be ow grade:_ Material f construction:_concrete_metal_Fiberglass_Polyethylene other(explain) Dimension Capacity: gallons Design flo gallons day Alarm pres nt _ Alarm level Alarm in working order: Yes_ No_ Date of pre ious pumping: Comments: (condition f inlet tee, condition of alarm and float switches, etc.) DIS BUTTON BOX:_ (locate n site plan) Depth of liquid level above outlet invert: Comment Inote if le el and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) - PUMP C AMBER:_ (locate o site plan) Pumps working order: (Yes or No) Alarms n working order(Yes or No) Com a is: (note co dition of pump chamber, condition of pumps and appurtenances,etc.) revise" 5/2/5C Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 364 Lakeside Drive, Marstons Mills Owner: Andrews Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_ Ilocate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits', number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS:_ (locate on site plan) G Number and configuration:— �° O Depth-top of liquid to inlet invert:_ s'/�l+ /o i Q fi 2 1'/o A7 R y Depth of solids layer: /'-'`/1, )epth of scum layer: 5-4' Dimensions of cesspool: ( 4 Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspections V�� Comments: (note condition of soil, signs of hydraulic failure, level of onding. condition oegetation, etc.) "O a 1� f v 3 S S A a L s' I te plan) construction: ids: Dimensions: on of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Paps 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icoet rand) ; Address. 364-- Lakeside Drive, Marstons Mills Jate of Insp.Apdre s _ �" Crt7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) �1L i i 1 rel,.i seC G '2 /GG Page 10 of 11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM MISPECTION FORM PART C SYSTEM INFORMATION(con*xJedl ropeMAddress: 364 Lakeside Drive, Marstons Mills Owner: Andrews Date of Inspection_ 9 a—G--U NRCS Report name Soil Type_ Typical depth to groundwater i USGS Date website visited Observation Wells checked Moderate Deep Groundwater depth: Shallow SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater,2�a Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property,observation hole. basement sump etc.) Determined from local conditions ,/Checked with local Board of health _Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Y revised- 5/2/9E Page II of II / / Tow14e 132 ABLE ,OCATION fo�` L Cs �es +r (. SEWAGE # JII,.LAGE�/47ati'e S '71 S i i ASSESSOR'S MAP&LOT _ NSTALI.ER'S NA.ib-&PHONE NO. r 1- ;EPT IC TANK CAPACITY CAS S .EACtTYNG'P,AC .I'I"Y: (type)�� 'e5 S (sizc) - d'O.OF'BEDROOMS MILDER OR OWNED. 'E ITDATE; COMPL ANCIr DATE: separation Distance Between the: � dlaximurn Adjusted Groundwater Table to the Bottom of Leaching Facility ee� aivatc Water:supply Wcll and Leaching Vacility (If any we.Us exist on site or within 200 feet of leaching facility) :dge of Wedand and Leaching Facility(if any'w lands exist within 300 feet 9f ieacwng f cilsto ,urnishcd by y� W�i `�l' c' - A / (� r � 1 r � .