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HomeMy WebLinkAbout1204 OLD POST ROAD (CT & MM) - Health [204 Old Post Road, Marstons Mills ----- -- - - - - - _ - --- — ------- A= -E �Os`�D6 i E I r COMMONWEALTH OF MASSACHL'SETTS 8 9 EXECUTIVE OFFICE OF ENvIRONME\TAL AFF. A �� DEPARTMENT OF ENVIRONMENTAL PROT ION ,rfCEl�V ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 `luN r 1 6 1997 OwNor", toHEq(rHONEN%tE W'ILLIAM F.WELD TR ' l Govemo: A cretan ARGEO PAUL CELLUCCI . E D B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 684 04 Jed. C—_-C, Address of Owner: Date of Inspection: e95/3p 1;P- (If different) Name of Inspector: �_r�&, r D �p -p (� �'�/— 1 am a DEP ap roved system inspecto pur�to Section 15.340 of Title 5 (310 CMR 15.000) 19 o �.5 Company Name: ja+ Ct".A-j'C JFak yr'rrt)u &t. e_ -,L Q Mailing Address: O t,?n,c O 3,?4- aill4iiiH ejeg rro-a O-e�Cf Telephone Number: 5-8T 4- Ci- 2 0 CERTIFICATION STATEMENT I 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 penormed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes !seeds Further Eyaluat n By the Local Approving Authority Fads Inspector's Signature: 4Date: S 156 ct The System 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: Aj 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. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web http:uwww.magnet.state.ma.usldep > Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ti PART A �Ifll� CERTIFICATION (continued) Jr� Property Addres'sl 'I-e A4 6 C/ �osri Date of Inspection nZ 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 due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the c f ;Board of Health;. Describe observations: '` - broken pipe(s) are replacep obstruction is removed distribution box is levell or replaced The system required pumping more than fo r times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of ealth): broken pipe(s) are repla obstruction is removed C] FURTHER EVALUATION 15 REQUIRED BY THE BOAR OF HEALTH: Conditions exist which require further evaluation y 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 HFA H DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER ., WHICH WILL PROTECT THE PUBLIC HE AND SAFETY AND THE ENVIRONMENT: Cesspool or priv�• 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 (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANN R THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and so 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 s it absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and s it absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and s it 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 (revised 04/25/97) Page 2 of 10 r C, Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /Z0 tt f)os�l-- / I- �—fLl,'71— Owner: 9 - Date of Inspection: / D] SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 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 du to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the round or surface waters due to an overloaded or clogged SAS or cesspool. t Static liquid level in the distribution boa above outl invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below inve or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last y ar NOT due to clogged or obstructed pipets). Number of times pumped _. Am• portion of the Soil Absorption System, cessp of or privy, is below the high groundwater eievation Anv portion of a cesspool or privy is within 100 eet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or pri%), is within a Z ne I of a public well. And portion, of a cesspool or privy is within 5 feet of a private water supply well. Any portion of a cesspool or privy is less tha 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the we� has been analyzed to be acceptable, attach copy 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 10,000 flow design of g god or greater (Large System) and the system is a significant threat to public health and safety and the environment cause one or more of the following conditions exist: Yes No the system is within 400 feet 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 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) Fag* 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B , CHECKLIST Property Address: ILO 4e C- t /Po S-/F d— co�Z r Owner: LS)M-ur / Date of Inspection: os�3o�y� Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. large volumes of water have not been introduced into the system recently or as pan of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling .vas inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ 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 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 different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. 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)) I (reviiad 04/25/97) Page 4 of 10 t 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C aa SYSTEM INFORMATION .Property Address: 41 GTc./ (�9 8J- 12.1, Owner: 12 , �' l u►S ✓s^y Date of Inspection: os13a FLOW CONDITIONS RESIDENTIAL: Design flow:-SBG .p.d./bedroom for S.A.S. Number of bedrooms: 0 3 Number of current residents: Garbage g,,:der (yes or no): NI4 Laundry cormected to system (yes or no): � Seasonal use (yes or no)jJ0 Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): b Last date of occupancy COMMERCIAIJINDUSTRIAL• Type of establishment: Design flow: gallons/day Grease trap present: ryes or no!_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary Haste discharged to the Title S s,stem: tees or no'._ Water meter readings, if available Last pate of o cupanc\ OTHER: f.Describe' Last date of occuoanc-%-. GENERAL INFORMATION PUMPING RECORDS and source of information: N t �y95t'�wv'1 LS 1ut� � F�C� IN.►e,� � ��uytr�'Q �� ��'�S��tr�� System pumped as pan of inspection: (yes or no)— If yes, volume pumped: eallons Reason for pumping T`!PE OF SYSTEM _ Septic tank/distribution box/soil absorption system Single cesspooi Overflow cesspool Pri-q 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 detected when arriving at the site:,(yes or no) (revised 04/25/97) Page 5 of 10 r 4 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: —4�20 4- �� t/OS �c�— �c�'fz.�• t Owner: �1 91AA.--S y Date of Inspection: osj3oj�� BUILDING SEWER: %Z6 (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction 1i Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: WAS (locate on site plan) 4 Depth below grade: 1-2 Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed bv Certificate of Compliance _(Yes."No: Dimensions IQ0)0GA1 Sludge depth: S>-q Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 42>0 Distance from top of scum to top of outlet tee or baffle 10 ti Distance from bottom of scum to bottom of outlet tee or baffie:NO How dimensions were determined. N<aSUV—a. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relationto outlet invert, stryyural integrity, evidence of leakage, etc.) gl (/J �1V GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /� SYSTEM INFORMATION (continued) Property Address: . e o4 �� Ash) tom{ Owner: Date of Inspection: © $/TIGHT OR OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallonsida\ 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: (locate on site plan. (� Depth of liquid level above outlet invert Comments. (no a if le et and �stribunon is ual�evidence of sol s carryover, evidence of leakage into or out f box etc.l PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or Not Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: le-4>4F OY�( Owner: /Z- x?— '-a 1j✓r y Date of Inspection: as�3plrIf� SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excava ion not required, but may be approximated by non-intrusive methods) If not determined to be present, 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 oil, si ns of hydraulic failure, level of ponding, condition f Sege c; W 0 CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert. Depth of solids layer: Depth of scum laver: 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.) (revised 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ,,(2-<� (FCs� �•`7`— Owner: /Z, Date of Inspection: / SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two.permanent references landmarks or benchmarks locate all wells within 10'0' (Locate where public water supply comes into house) � g E Ea (revised 04/25i97) Page 9 of 10 . 4 •• Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �P-�' Owner: 9 yx Date of Inspection: • -7 Depth to Groundwaterh Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of site (Abutting property, observation hol , basement sump etc.) Determine it from local conditions Check with local Board o�health Check FEMA Maps Check pumping records Check local excavators, installers Use LSCS Data r. Describe in your own words how you established the High Groundwater Elevation. Must be completed) N1►Ah ccr� °t2 �.`-�4, c; It (revised 04/25/97) Page 10 of 10