HomeMy WebLinkAbout0160 MARSTON AVENUE - Health f(��? d��-�-'ins �ve.�t�s�
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
De artment of RECEIVED
Environmental Protection BAN
4 1995
William F.Weld i ► t % HEALTH.TH�
Govemor \r / C 7MN OF weYISTn C
d � aZ.y ,
David B.Struhs J
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
p CERTIFICATION
Property Address: Address of Owner:
Date of Inspection: i "'" 3'�1 (If different)
Name of Inspector: W.E. Robinson Sr.
Company Name, Address and Telephone Number: W,E Robinson Septic Service
P.O. Box 1089
Centerville MA
CERTIFICATION STATEMENT �77 77�77
1 certify that I have personally inspected the sewage dispbs�l spslrt t 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
Needs Further Evaluation By the Local Approving Authority
_ Fails �e '
Inspector's Signature: Z</ Date:
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 SYSTE ASSES: j
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.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
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, 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 8/15/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-SS00
40 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: *k���'l'®�
Owner: •-O m j'OAr/,,g h.1 n
Date of Inspection: j .2.3_g
B)SYSTEM CONDITIONALLY PASSES (continued) "
wage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed.
pi (s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Boar of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The syste required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspectio if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUA ON IS REQUIRED BY THE BOARD OF HEALTH:
Conditions a 'st which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, s fety and the environment.
1) SYSTEM WILL PA S UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PR EC THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or rivy is within 50 feet of a bordering vegetated wetland-or a salt marsh.
2) SYSTEM WILL FAIL U LESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNC IONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system as a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface wat supply.
_ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The syste has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The syst ns Via: a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply ell, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free m pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm
D) SYSTEM FAILS:
I have determined that t e system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is entified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
_ Backup of sew ge into facility or system component due to an overloaded or dogged SAS or cesspool.
F
Discharge o ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool
(revised 8/15/95) Z
4
r .
b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ���or
Owner: ni 6Z* e,4 h,4 n
Date of Inspection: j .—a 3--
D)SYSTE FAILS (continued):
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]LARGE SY TEM FAILS:
e following criteria apply to large systems in addition to the criteria above:
T design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and t environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
e system is within 200 feet of a tributary to a surface drinking water supply
e 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 o rator 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 9/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: rh
Date of Inspection:
Check if the following have been done:
,
Pumping information was requested of the owner, occupant, and Board of Health.
L/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.
v
//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.
,�he system does not receive non-sanitary or industrial waste flow
_L/fhe site was inspected for signs of breakout.
_L"All system components, excluding the Soil Absorption System, have been located on the site.
_L/(he 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.
4 he size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
VThe facility ov ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION
Property Address: r!'4/ �rd'��� / � '��/s
Owner:
Date of Inspection: t;L -�.'�
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ;!;tl 0 allons
Number of bedrooms: 6
Number of current residents: 0
Garbage grinder(yes or no): X"
Laundry connected to system (yes or no):�
Seasonal use (yes or no):�
Water meter readings, if available:
Last date of occupancy:
COM ERCIAUINDUSTRIAL:
Type of stablishment:
Design fl w:_gallons/day
Grease tra present: (yes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-sanita waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of ccupancy:
OTHER: (D scribe)
Last date o occupancy:
GENERAL INFORMATION
PUMPING RECORDS al source of information: )
System pumped as part of inspection: (yes or no)
If yes, volume pumped. gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
ow cesspool
,Ifrrivy
Shared system (yes or no) (if yes, attach previous inspection or%orals, if any)
Other(explain) C le'.�-c'- 5
APPROXIMATE AGE of all components, date installed (if known) and source of information: >17—P✓ram S
Sewage odors detected when arriving at the site: (yes or no) �
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address:
Owner: %p to p-czf'/'4- h1A 17
Date of Inspection: 3- y
SEPTIC TANK:—
(
locate on site plan)
t
Depth below grade:
Material of construction: t/concrete _metal _FRP—other(explain) !!�� �
. 1 O -B A/ Pie Si C d s `?
Dimensions: 6 Z 3 1 L
Sludge depth: O `
Distance from top of sludge to bottom of outlet tee or baffle:�L
Scum thickness:_ ,
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom of outlet tee or baffle: 4,
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, d th of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) P� +�- l �+- 6 d e- e �-
GREASE P:_
(locate on sit plan)
Depth belolco
gra e.
Material of nstru ion: _concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of cum to top of outlet tee or baffle:
Distance from bottom of «um M hottom of 011!let tee or baffie:
Comments:
(recommendation for umping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of eakage, etc.)
(revised 8/15/95) 6
{
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT HOLDING TANK:_
(locate on 'te plan)
Depth below ade:
Material of con ruction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: Izallons
Design flowjinlettee
allons/day
Alarm level:
Comments:
(condition ondition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distributiun`is equal, evidence of solids carr�over, evidence of leakage into or out of box, etc.)
PUMP CHAM R:_
(locate on site p n)
Pumps in workin order:(yes or no)
Comments:
(note condition o pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: (�.-.'L3 S_
SOIL ABSORPTION SYSTEM (SAS):v
(locate on site plan, if possible; excavation 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:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, ndition of vegetattn,etc.)
CESSP OLS: _
(locate n site plan)
Number a d configuration:
Depth-top f liquid to inlet invert:
Depth of so ids layer:
Depth of sc m layer:
Dimensions f cesspool:
Materials of onstruction:
Indication of groundwater:
infl w (cesspool must be pumped as part of inspection)
Comme : (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on sit plan)
Materials of onstruction: Dimensions:
Depth of so ds:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �l/�r pi 11���l �l WlV'��171`-levy 7-
Owner: -7�-m
Date of Inspection: -7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
96 ;dd
ILI
Lo G
C O v C'+L S e
l
s. Sf✓6,e
l
—
!i�
DEPTH TO GROUNDWATER
Depth to groundwater:_,2,0 feet _
method of determination or approximation: ), 5 j I�o�t�S l ct _ I 01 3
(revised 8/15/95) 9