HomeMy WebLinkAboutInspection Report 2004 Oct 12 �
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� , Co�oivw�.� oF MassAexus�-rs
�� EXECUI`NE QFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTM$NT OF I�11iVIRONMENTAL PROT�CTION
Gu � 'a ���s ;i ���� �� �.� :
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HE�lLTH �EP?�.
TITLE � '
OFFICL4►I,INSPECTION FORM--NOT FOR VULUNTARY ASSESSMENT�
3UBSURFACE SEWAGE DISPOSAL SYST'EM FQRM
PART A
CERTIFICAT'�UN
r��ey��z�w,rs Ao�n,w.Y�ov�,�rw� '
OwMer's N�:CARLS AND SAHARON FORTE '
Owner'a Addreas:Z2 LE'1�f$ROAD,W.YAiiM4iPTI�,MA
l�tte+o�I�a:tX,7C/BER 1?,Z11�4
Nsme af Ia�ector: REIA C ELI.uS � i
Ca�ay Namez ELLi3 BA(?THERS CONST.C4).
Maeiting Addt esa: 23 EN'ILR�SE RUAD, '
�!Q BOX 3+9,YARMQUIB PUR1',MA 8Zb7� ':
T�oae Na�ber: SOS-362�6Z37
� CERTIFICATIUN STATEMENT
I ce�tify that I havB p�sona!!Y insPeded the sewaSe disPosel syst�n at this address and that the infarmation reported
below is true,aocurate and c�mplete as of the time of thc inspection.'ihe inspection was p�formed besed on my
trainin�and expaience in the proper fiu►ctian and maintenance af oa site sewage disposai sy�s.I sm�DEP
aPPr����'Pa�rs�nt to- _ 15.340 at THIe S(31�CMit 15�000}. Th�system:
�c�,
�_ ,
Conditionally Pa4sts '
Needs Further Evaluation by the Local Appraving Autharity
Fails
�nspector's Signatsre• __r�� �L=�� Date: /U -"G/— O �
. �
�
The syst�n insp�shatl sub��t a rropy of this inspec�ion repart ta the Approving A�o�i'ty(Board of Health or
DEP)within 30 c�y�af canpleting this inspedion.If the systena is a shared syst�n or has a�siga flow of 10,Q00 '
gpd or Sne�r,the inspector and die syst�n own�x shall submifi t�e report to the apg�'a�riate regiona!office of the '
DEP.The originai shoe�ld be s�aat to the sy+�mvtter a�xl copies s�at to the buy�r if applic�able��d the approving
authaity. '
Ncrtes and Cornmeuts
'"**"T6is nPa't ua1Y d�cri�res a:oed[dms At We d�af�s�ui ander d�e�ot eae�C t�at
coedltto�a af��de�s aot addre�s�v t�e�wiil perform ia t6e fhtare a�kr tl�aqme a�di@'erent
1
� Page 2 of 11
� ' UFFICIAL INSPECTION FORM—NOT FOR VULUNTARY ASSESSMEATT5
� SU�SURFACE SEWAGE DI3P03AL SYSTEM IN3PECTIUN FORM
PART A
CERTIFICATION(coutinued)
Property Addrars:22 T.�VIS ROAD,W.YARMOITI�i,MA.62673
Owner:CHRiS AND SSARON FORTE
Da�e a[In�Ctiort:OC'TnBEB 12,29�4
�iion Samm�rys G�ck A,B,C,D or E I A�WA�comPl�e�A of 5�xtta�D
A. 3ystem Paa�es: (�Q,� � '
,�, I have not found�y informatian which indicatc.s tha�any of the failu�e cxit�ia da.scn'bed'm 310 CMR ;
25.303 a in 310 CMR 15.304 e�ist.Any faihne�ianot evatuated are indic�ted belor,v,
Goa��eats:
B. Sqe�ean Ca�ditioa�lly P�c: N�� .
One a more systexn ca�mpone�ts as de.�cxIbod' d�e"C�didonal Pgss"section need to be replacsd ar
r�air�d.The system,upon completiva of the r�l� t ar repair,as apjxov�by the Baard of Health,will pass.
Answ�yes,no ar not determined(Y,N,ND)in the fa t�e following statemcnts.If"not�eimined"ple�
. explain,
'ihe s�tic ianlc is m�l�d over 2U years old'� the septic tank(whether metai ar not)is sdvcx�nally :
uasamd,exhibits substantial infittratian a exfild�etic� tsnk failt�e is immin��Syst�n wilt pass insspe�cxion if the
pcisting t�qk is r+�laced with a oomPlying septic tank approved by the Board of Health.
*A metal sepUic t�k will�S i�ecti�if it is saind,nat leaking and if a Certificate af G�tpliance
indic�ting that the tank is less tl�20 y�rs oid is a ' le.
ND explain:
Obser�ati�of sevirage b�dcup�or b�reak out a static wst�level in the distritx�tion box due to broken�
obshuded pipe(s)or due to a broken,sdtted or on+even 'stributi�n box.Sy�d»will pess inspedion if(with
ap�raval of Bo�rd of I3calth}:
brdcar pipe(s)are lacaed :
ob�ion is rem ved
distrib�ti�brnc is eveled or rep�ced
ND eacplaia: �
The systean required p�g more than 4 tien a year due to broken ar ob�ed pipe(s).The system will
Pess in�ian if(with a�ro�l of ti�e Bo�rd Of H ): '
brdcen pipe(s}are �c�ed
ob�on�s rem ed
ND e�cptain:
2 ,
• � Page 3 of 1 t
� ' 4FFIGIAL INSPECTION FURM-NOT FOXt V4LUNTARY ASSESSMENTS
� SUBSURFACE SEWAGE DLSPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(caatinuod}
r��y Aaa�:zx�wrs�oAn;w Ya�ov�i►�t.�.��
Owuer.CRR.IS AND SHARON FURTE
Date of Inspec�toa:OC'PO$LR 12,2004 , / �,
/1/
C. Fnrttier Evale:t�q�R�eq�by the Ba�ard� .
�
Conditions eutist which require fiuther evalt�ation by e Baard of Healih in order to d�ermine if the system '
is failing to prc�tect public heaNt�,saf�.y�the�virunment.
1. S�+Stem w1�llll�as anleas Bo�atd�HeaitL d�e ia accardagce w�th 310 CMR 15�343(Ij(b)ffiat We
system b aot fi�actia�iag ia s mnaaer w6ich w�l pablic Leatt�,safety and t�c ranviro�meah
� Cesspool or privy is within 50 feet of a�
_ Cesspoal or}�ivy is within 50 f�uf a barderin vegatated wetland or a salt marah :
2. 3ystem a�7t f��the Bo�rd uf Healt6(a�l Water�Iier',if saY)determises t�at tLe
system�faactioaing ig s�oaer that protects t� �eslt6,satety aad esvironma�h
The system has a septic taak and soil absaptian (SAS)xed the SAS is within 1 t�feet af a
• stufac;e water suPP13'or Ln'butary to a s�tace water ly.
� The syste�n has a septic tank and SAS end the S S is within�2one l of a public watcx supply.
____ The systan has a septic t�ilc�d SAS and the S is within 50 fioet of a private water supply wsll. :
The system has a se�ic tank and SAS and the S is tess� 1t�f+e�tnet Sd fe�or more from a
private water supply we11**.Methad used to determ' e distance
'*This syst�n passes if the wdl water analysis, �a DEP c�tified laba�atory,for colifa�nm
bacteria and volat�e or�ie c�npaa�nds inefieat� thg vwell is fi�ee frv�poilurion from t�at facitity and
the presence of ammonia nitrogea a�nitrate ' is equat to o�Iess than 5 pp�n,lx�ovi�rd that no other
fail�re criteria are trigg�ed.A cx�py of the analysis m be attached to this form.
3. 4t�er:
3
� �Page d of 1�
' � OFFICIAL INSPECTIUN FQRM—NOT FOR VOLUNTARY ASSESSNIENTS
SUBSURFACE SEWAGE DISPOSAt.SYSTEM iNSPECTION FORM '
PART A
CERTIFICATIUN(continued)
r,�ercy�aare�:n�wrs Ro�w Ya�to�,�rn�
owger.CHlus A1�ID S�IARax LEWtS ':
Date�`Inapaxiou:t)C"I'OBER IZ,ZOA4 '
D. System Failure Cri�eria app�iCable to all�a: '
"Y�x r�,t indicate"yes"or`Snd'to eac�of the fc�llllc�wing for�,inspections:
Yes
Backup af sewage into facility�system cbmpo�nent dae to overlo�ed ar clogged SAS or cesspoal
` '�ge or pond'mg of efguent to die s�aface of the gcamd a s�f�ce waters due to an overloaded az ;
clogge�t SAS ar cesspoal
- - Stahc licptid level in the distribution box above artlet�v�t d�t�an overloaded�clogged SAS a
� _+, 1
1Y[a iquid depth in oe.cspool is less than 6"below invert or available valume is l�s than'l=day flow
_ �P�P�B more tbaa 4 times in the last�ear N�,T,�to clogged or�pipe(s}.Nwnber
of times pumpad ;
Y P�an of the SAS,ces�Ool a�r pnvy is below higlt gound wate�r elevarion.
� Y po�rtiar of c�spool or privy is within 100 feet of a swrface wat�supply or in'initary to a s�rface
ter�pply. :
_„_ y portion of a c�spool a��xivy is within a Zone 1 of a public well.
� ,/�y portion of a ces�o�l ar�ivy is whhin SO feet of a private water supply vNell.
�. .._]L �Y P�ar of a cesspool or�ivy is less th�100 fe�birt greafer lhan 50 fieet fr�t a pzivate water
� supply well with no a�ble wat�c�uality analysis. [T�is sy�em�es if tke wieU water saalys?�, :
pertoraied�tt a DEP�oerfiRed bbora�ary,fer�bacberf�sad vob�t�te org�tn�c compoemda :
iadica�aa that ttie w�eH�fr�e fl�poUation from tiu�t fncitity and ttie preseace�ammoaia '
- ai�rogea sad��e�u is eq�si to or k�tln�n 5 ppm,pro�v�dad tLat ao other failare cri�a
are fi�red.A�opy of t�awly�ia mast be�ttAcLed b t�is forn�.] :
/�� (Yes/No)T4e system�.1 have determined that oaie aa�mare of the above failure criteria exist as
descaribed'm 310 CMR 15.303,th�efore the syst�n�aits.Thc system owner should contact the Board of
Health to determine what will be necessary to carec�the fail�e.
/v �
E. Large sysUems:
To be�de�a Isrge sysUem tbe sy�em ma�ec s�Cility w�a desiga Ha�v o�18,000�xl to 15,800
� :
You must indicate either"yes"or`5no"to eadi of the foll ' g:
(The f�llowing caitaia apply to lsrge systerns in addition the cri�taeria abave) :
yes na
— ____ 1�►e system is witi�in 4�f�eet of a su�face " g water supply :
._ i the system is withia 2�feet of a tribUtary W a drinking water supply :
.� _.._ �e system is located in a nitrogen sea�sitive (Int�rim Wellhead Pru�ectian Area–IWPA)ar a mappe�t
Zane II of a public water�pg1y w�ll
If you have answered"�es"to any questia�n in Section E e systean is considered a signific�nt threat,�answered '
"yes"ffi Soction D above the l�ge sy�em has failed.The er ur�of any large sy�em consid�ered a
signifx�nt threat unda Sedion E or f�iled unc�Serxion shalt upgisde tf�e system ia acr�dance with 310 CMR
1 S.3Q4.1'he system ovm�r should�ct the ap�ropriate egiaial office vf the Depmt�nex�� ;
•, �Pa�Ce 5 of 11
� . OFFICIAL IN3PECITON FORM—NUT FOR VQLUNTARY ASSESSMEN'TS
SUBSURFACE SEWAGE AISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
�rey Aaare�:n LEvvrs�oax�w.Y�►x�ov�r�e�,�►a��
Owner:CHRtB AND SHARON FOSTE
Dste of I�on:OGT4BER 12,?A04
Check if the followin�have�b��Yai r�ast indicate"ye�"or"no"as to each of the Eoltowin� , '
Ye,�l No
1/ Pwnlrin8 informatian was provided by the owner,occuPan�a Board of Health
, cre any of the system campanea�ts pumped out in the previous twa weeks? :
,! the systc�n rec�ived narmal IIovvs in the�evicws two wedc period?
i Have large volumes of water b�introduced to the systean reoe�tly a as pa�rt of this inspecti�?
` 'Were as built plans of the systcsn obtained and examined?(If they wesre not avaiiable note as N/A) .
^ Was the facility�dwelling inspected for signs of sewage back up?
� Was the site inspeded far signs of lxeak aut`t
,_ Wae att system c�npone�nts,cluding the SAS,located on site? ;
_ Were the septic tank manhales w�covered,opened,aad the interior of the tanlc inspected for the conditia�
oP ba��or tees,mat�ial of oonstrudion,dimensions,depth of liquid,d�th of sludge and de,pth of scum? '
Was the facility owner(and occupants if diffex��t fram owner)provided with info�m�i�on die proper
maintenance af subsurfaoe s�wage disposal systans?
Tlte size aad locAfiiog aR'tlre Soil Ab�orp�oa System(SAS�oa the site has bee�c�ta�mined�an:
Yq� no
Y ` Existing informatian.For exampt�,a plan at the Board o�I�ahh.
_ Detesmined in the field(if any of the faihue cxiteria related to Part C is at issue approximatiaci of di�ance
is�a�avce�tabte)[310 CMR.15.302(3xb)]
5
, ,Feb 07 05 09: 24a Sharon Ellis 508-362-6266 P. Z
. Page 6 of 11
OFFICIAL 7AiSPECTIOPt FORM—NOT FOR VOLUNTARY ASSESSMENTS
SiTBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI011T FORM
PART C
SYSTEM INFORMATION
Pr'vperty Addres�:2Z LLWLS ROAD,W.YARMOUTS,MA U2673
Qvimer.CffitIS AND 3HARUN FQRTE
Date of Inspecdo�:OCTOBER l2,2004
FLOW CONDITIONS
RESIDENI7AL
Number of hedrooms(design):� Tlu�ber of bedrooms(acival}: �
DES[GN 8ow!�d on 31 D CMR 15203 (far example: I 7 0�pd x#t of bedrooms)__�� ,�C Z f��p
�,Numb�,r qf s��t �,
t�separ sei�rage system(yes�r no: � i y�v separate iaspectioa reQuired)
Laundry system inspe�ted(yes ar no):��!!
Seasonal us�(yes or no3: i�':� �r�,,,i i �,�.c-,.�. f;- ,-,�.. �d' ./J .
� � J c.^...�'0�;�� .G7•y iQ r.y'�tiGG��^�erij
Water meter readings,if ave�able�last 2 years usaSe(g�di )): �'v/��i..y�s�
SumP P�F f3�s or na):�f� �2°..� �003 �ol ic.._ ll
Lasc date of occ�epancy: �-1�--��;= vZ o p4� f z��.
CUl►�I�RC
'Type of esrabtishmen� 3`� l���l�+-v�''ir'
DesiBn flow(based on 310 CMR 15.203):
Basis Qf design$ow(sCatS/per5ons/sqft,etc.): ��.rr�i<�:c �r- .��r,,. •/�s� o� ��--�.�Q-�+..
Grease trap�esent(yes or no�.,�/v
lndustrial wasfie hold'mg tanlc�sent Cyes or no):�c7 7 �e�1 E-�,.,,s. � L- /�'"�o
Norrsanitary rvasbe discharged to the�fle 5 syste�(yes o�no):,�/�C�
Water meter readings,if available: oZ���£3 Z I� a-�o 3 �1!� �o� l t_.8 L
. Lastdateofoccupnncy/use: �-�'-_.-!}�.—r��.
�--�-��
OT�R(desaibe): ��-
GENE.RAL INFORMATTON
Pumping Rec�ds
Sonaccofinformatiom �/�95� �i.Ji��.� �—;�--- ��%
Was system pumped as part of the iaspectio�(yes m�no): iF
If yes,volume pumPed�llons-13ow v�as 9usntiiY P�P�determined? ��✓�I�- 4�i ��/WL�
Rtason for P�P�g�_ .�%'f/'-�-iit/'i�.+�/-�-rVt.�- ..�P�'O, � +/'�,.5��`'�r r ��i����'
TY�E OF SYSTE�I �r �
�5eptic tgntc,distribution bax,soil absorption sy.coem
Smgte cesspool
�Overflow�ool
Privy
_SF�ed system(yes or no)(if yes,afitach previo�inspection records,if anY)
lnnwative/Alteroative teclsnology.Attach a copy of the c�ent apaatia�and maiQtenanee contrad(to be
oirtained fro�system ownes�)
,Tigh[tank ^Attach a copy ofthe DEP apprwal
__.__Ott�er(descr�e):
Apprfl�' ate age of all c�poaent/s��date install�(if lmown)and source of in/f��rmatio�na: ,/'
/,� � ./ LfS�i'- 1��:��1J ,,�� 3.`�'"' �� �!/S �rJf/��� % O 'Y� .�fi n � n
. !� � e� __� �TT��f�yr �'1!" y�_/Q�
IV � f7
Were sewage odas deEe�d when arriving at thc si#�(yes or ffo)::l�
u
� 'Page?of 11
� OFFICIAL INSPECTIUN FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DLSPOSAL SYSTEM INSPECTION FORM
PA►RT C '
SYSTEM INFORMATION(c�,tin�ed)
r��a�w�:n�xow�w.Y.�ov�,�a�r3 :
Owuer: CHRIS AND SHARON FORTE
Dste af Iaspecbto�: OCPUBER 12,2Q04
BUIGDING SEWER(locate am site plan)
N
Depth below grade:
Materials of constructi�: c�st ircxi 4Q PVC Wher(explain):
Distance from private wata'suppiy well or�ion line: 3�S�
Commeats�an cxindition af joint4,veating,evidence of leakage,etc.): • '
s i•✓4 �+,,{// � � ,r�,� 2ic/ %l/ �-
�—� '
SEP1'IC TANK:,l��loc�te�site p�)
I.�pth below grade: /� �� D?�'l�`�
Material of constr�b�cx�ncrete metal_fiber81ass�pO�Ye�Ylene
other(e�cPla�)
���If taak is m�al list age:_,_,_, Is age oonSrmed by a Ca tific�te of Compli�ce(yes c�no}:_(attadi a cc�y of
) / '
Dimens�'��s:/�� �- c�i'o�L�J�- �� /�/.S�t� .D-2N��r.t/s��r.�
Sludge depth: �
Dist�nce fran t�of sludge to ba�to�of outiet tee ar ba81e: � :
- Scum t�uickness: C7
Distance from top of sc�n to tap of auttet tee a b�le: � '
Di�tce firom bottom of scum to botto�n of aut1�tee�baffle: C>
How were d'ua�stons detexmined: 6.c._ i
Commgnts(on P�I�S reaomm�dati inl�and outle�tse or b�ffle conditiam,�a�l integritY,liquid levels
as related w outiet ffivat,evidence of leakage,e,tg.): �
_�,ir/.�.�' �'��-�"Za� ��T— A A �at�N� it/��.�',Ge,¢,Lq
,
/r/�
G�tEASE TRAP:(loc�te on site Pla�►)
Depth below grade:
Matrriat of c�struction: c�nc�te m�al fi __poly�hyle�e otiter
(exPtain):
Dim�ensians•
Sc�mi tbidmess:
Distance from top of scum to top of artlet t�e or b�le:
Distaince fran bottom of scum to bottan of outl�tee� e:
Date of last pumpin�
Comments(on punnPiuB recommeadatio�ns,inlet and c�utl tee�baffie ca�ditiat,�1 urtegritY,liquid levels
as related to outl�invert,evidence of leakage,etc.): ,
7
� Page 8 of I 1
. 4FFICIAL INSPECTXON FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PA►RT C
SYSTEM INFORMATIUN(continued)
property Address: 22 LEVVIS ROAD,W.YARMOUIB,,MA 0"1673
Owaer: CHRTS ANIa SHARON FORTE '
Dste of Iuapectioa: CICTOBER 4,2004 ��
TiGHT or HOLDiNG TANK: (tank mu�be pum at time of inspectionxlocate on site plan)
Depth below gr�de:
Materi�l of cx�nstruc�iac�: c�nc�e raetal fi lass__��Y��e �her(exptau►): ,
Dima�sions•
Capacity: �allons
Desiga Ftow: gatlonstday
Alarm presertt(yes or no):
Atarm level• Alacm in working or�r(yes�n
Date of la�pumping:
Comments(c:onditiun of al�n and flo�t switcfies,etc.):
DLS"TRIBUTION BOX:�(if present must be�enedKlocate on site plan} .
' Depth of liquid levei above c�utl�inveat: �n �
Cvmme�rts(note if box is level and distribution to outlets equal,any evid�ce of solids carryover,any evidence of
leakage iato�art of box,etc.):
- �, t3c>>c Cs �.o.�.�P.L- rN���-� � �d✓.�l.Q�.s � G�l� . 41/l�/ �19�t7
� '
/y �
PUMY CHAMBER: (locate on site pl�►)
Pumps in working a�der(yes or no):
Alarms in working arder(yes�no): ,
Comme�ts(nde condition of pump chamber,condition f pumps and appiutenances,etc.): ;
. 8
• t
. t'Ag6 Y OI 11
a�CIAL IlVSPECTIQN FORM—NOT FQR VOLUNTAgy ASgESSMEIYTS
SUB3URFACE SEWAGE DISPOSAI,gYST�iVI INSPg,CTI4N FQRiVi
PART C
SYSTEM INFORMATION(candn�t} :
��Aaa�: zz�a�s aoa�w Y�o��►.es��
°�r c�s��utax��,
n�c�o�r�; ,�v�B���,�
SOII.ABiSpRP1TON SYSTEM(S,A3):
(bcate oe ske p�ts,e�v�ttio�t sat regairedj
If SAS n�locatecl e�cplain why: '
�'t�
l���5�' � ba�: /I
�B p ,n�ba . ,
leaching t�mnbe�,number:� �,k� C.l►� 1r� i�' �" Gi't/t-� �MQ�t7��
��8 8��es,number• � �
�n8 h'�dies,ntenb�,tength; t
���8 fields,aumber,camaisims: i�'�'t-L7-k ` �
overflow c�poo�l,number: � '�-
inu;avativeJalteaaative system Typ�y�e of technology: '
Commarts{nate conditiae of soil,si�s of h�c fail��Ievel of
� �� ` �'�&�P��c�ortdition of vegexati�,
r'�'t-'' /t�a '��v N.�C.14�� �.. t„3G�.� �'
. '6�' �ll.�� �� /��t,�.� k � d�" t�w�'
� 3� �� � � a �
e�sr+oorrs: t�l��t��,�a��c ;�
��x�«�«�s�p���
Number�d c,�n8guration:
�-�op uf liquid to intct inv�t•
�h of sdids layer:
�of sc�m 1aye�.;
Materials of con��,i�;
Indic�ion of gY'oumdwater�$rnr(yes or no):
Cc�mm�ts(ncxe oonditi4n of soil,si�gns of hydrautic fail le�ve!of
P��ng,conditian of v�etetipR,�c.j:
PR1vY: (locate on site P�) �f'"
Materials of oonstru��on: :
Di�measions:
I�pth ofsolivs: �-` '
Co�nm�nts(note caonditian ofsoil,sig�na ofh
3�lrautic ' level ofponding,con�ition ofve�e�suon,e�e.):
9
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