HomeMy WebLinkAbout0165 LAKE SHORE DRIVE - Health 165 LAKE'SHORE DRIVE, M M_ILLS
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street' D.E.P. Titl ee V Septic Boston,Ma. 02108 •titlepti
c Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Gavemor
ARGEO PAUL CELLUCCI
Lt.Governor �#`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION v
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Paoperty Address: 165 Lakeshore Dr.Marstons Mills Address of Owner: '✓
Date of Inspection: 7114198 (If different) `
Name of Inspector: John Graci Mr.Davies
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number: r9
CERTIFICATION STATEMENT e 1
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:
x Passes This Inspectlon Is based on criteria dented In T@le V
Conditionals Pass s code 310 CMR 16203.My findings are of how the system is
y performing at the time of the Inspection.My Inspection does
— Needs Furt r Ev uation By the Local Approving Authority not Imply any warranty or guarantee ofthe longevity ofthe
Fails septic system and any of Its components useful life.
Inspector's Signature: lit
Date: 7114198
The System Inspector shall sub copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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:
x i have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
CdThpliance(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 of extiltlatiol►,or tailk
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 007197)111111111111111
One Wlnter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 is Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 165 Lakeshore Dr.Marston Mills
Owner: Mr.Davies
Date of Inspection:7114199
_ Sewaae backup or.breakout.or. hiah.static water level observed.in.the distribution box is due to a broken,
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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
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 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 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 APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
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 in 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
cesspool.
SAS is in hydraulic failure.
(revised 04117)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 165 Lakeshore Dr.Marston Mills
Owner: Mr.Davies
Date of Inspection:7114199
7]SYSTEM FAILS(continued)
Yes No
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).
— — Numbers 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 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portibn 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 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:
_ 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.
pevlae d 0412TAT)
C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 105 Lakeshore Dr.Marstons Mills
Owner: Mr.Davies
Date of Inspection:7114199
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant,and Board of Health.
X None of the system components have been pumped for at least two weeks and the 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.
x As built plans have been obtained and examined. Note if they are not available with NIA.
x — The facility or dwelling was inspected for signs of sewage back-up.
X — The system does not receive non-sanitary or industrial waste flow.
_c_ — The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System, have been located on the site.
X 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.
X 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 Systens.
X Existing information. Ex. Plan at B.O.H.
X Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)[15.302(3)(b)]
I
pevIsed 041171871
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 165 Lakeshore Dr.Marstons Mills
Owner: Mr.Davies
Date of Inspection:7114199
RESIDENTIAL: FLOW CONDITIONS
Design flow: 330 g•p•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 2
Gartage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available:(Iast two(2)year usage(gpd):
n1a
Sump Pump(yes or no): No
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL
Type.of establishment: nla
Design flow:o gallons/day
Grease trap present:(yes or no) No
Indusrrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nre
Last date of occupancy: n1a
OTHER:(Describe) rya
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
9yetem was last pumped 10 years ego.
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: Na
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
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 Information:
1972
Sewage odors detected when arriving at the site:(yes or no) No
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(revlesd 04l27197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 165 Lakeshore Dr.Marstons Mills
Owner: Mr.Davies
Date of Inspection:7114199
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 15"
Material of construction:x concreate metal FRP Polyethylene—other(explain)
If tank is metal, list age oia . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L9'6"H5'7^w4'10"
Sludge depth:5"
Distance from top of sludge to bottom of outlet tee or baffle: 29"
Scum thickness:3"
Distance from top of scum to top of outlet tee or baffle:5"
Distance form bottom of scum to bottom of outlet tee or baffle: 15"
How dimensions were determined: Measured
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.)
Sepgc tank and all components are structura0y sound and runctloning property.Recommend pumping every two years.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rda
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: nla
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.)
n/a
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2'
Material]of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction lineP—
Diameter: nla
Qmments: (conditions of joints,venting,evidence of leakage,etc.)
tea®
(revised 04r27)97)
I
F .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: t85 Lakeshore Dr.MarstonsMills
Owner: Mr.Davies
Date of Inspection:7114198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: We
Capacity: Na gallons
Design flow: Na gallons/day
Alarm level:-.Na Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Na
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: Na
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)ves
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,etc.)
Na
04127/97)111111111111111111
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 105 Lakeshore Dr.Marstons Mills
Owner: Mr.Davies
Date of!Inspection:7114199
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
rda
Type:
leaching pits, number: rda
leaching chambers,number:No
leaching galleries,number: rda
leaching trenches,number,length: rda
leaching fields,number, dimensions:rda
overflow cesspool, number:&W block
Alternate system: rda Name of Technology:_rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
The leach plt was structurally sound and 11Nnc0oning properly.The leach pft had I'd water In ft.
CESSPOOLS:
(locate on site plan)
Number and configuration: rda
Depth-top of liquid to inlet invert: rda
Depth of solids layer: rda
Depth of scum layer: rda
Dimensions of cesspool: rda
Materials of construction: rda
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
rda
PRIVY:
(locate on site plan)
Materials of construction: rda Dimensions: rda
Depth of solids: rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
rda
(revlaed 0427197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
105 Lakeshore Dr.Marstons Mills
Mr.Davies
7114198
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)
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(revised 04f27197)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
165 Lakeshore Dr.Marstons Mills
Mr.Davies
7114199
Depth of groundwater 12.
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(re�vlaea04127A7) paps 10 of 10