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HomeMy WebLinkAboutInspection Report 1997 Mar 18 if/ COMMONWEALTH OF MASSACHUSETTS • -==jet EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS VI •-•=- _ DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 ??=.- C {F:1\Ji m. WILLIAM F.WELDn TRUDY COXE Governor • APR 1 7 1997 Secretary ARGEO PAUL CELLUCCII AVID B. STRUHS Lt. Governor HEALTH DEPT. Commissioner MAI() �3S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Lot CERTIFICATION Property Address: lite /2 S. ' (f14--A-t 7 Address of Owner: CPG�.e_1 /P u://y Date of Inspection: p 3/I t77?— (If different) Name of Inspector: 1.-\ Company Name, Address and Telephone Number: -V.c.-.7esc. a��y nSreks..� Mr'• 02-L'1/4°1 C.S'';' \1' U, -1`1/42-d 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: ,2S,_ Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails ' Ins ectors Si nature: (� -` 1 P g `����1 Date: 1 t\41 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: A] 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. 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 11/03/95) 1 i,Printed on Recycled Paper • • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:To.? A 2f. 5 . y/¢/-0 v L Owner: Pct! g�Q.{f Date of Inspection: B] SYSTEM CONDITICfNALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the di- ribution box is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The sy em will pass inspection if(with approval of the Board of Health): broken pipes) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year •ue 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 •LTH: Conditions exist which require further evaluation byte 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 HEALT DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALT AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet f a surface water Cesspool or privy is within 50 fee 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 PROTECTs THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic t k and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septi tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a sep c tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a se tic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unles a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollutio from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3/492. / er S. 74-72-ko Owner: /3 e" Date of Inspection: 03//8l,2- D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as d: fined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to d- -rmine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded ,r clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface aters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due t. an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or availa. e volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT ue to clogged or obstructed pipe(s). Number of times pumped . Any Any portion of the Soil Absorption System, cesspool o privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 f-•t of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within .ne I of a public well. Any portion of a cesspool or privy is within 0 feet of a private water supply well. Any portion of a cesspool or privy is less 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If tl}e well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic coynpounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large sy tems in addition to the criteria above: The system serves a facility with a esign flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the vironment because one or more of the following conditions exist: the system is within 0 feet of a surface drinking water supply the system is withi 200 feet of a tributary to a surface drinking water supply the system is to ted in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water pply well) The owner or operator of any uch system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5 0 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: P y 9'O2 /L el: S. Owner: 107, p'_ bey Date of Ins ectior Check if the following have been done: 4t,_Pumping information was requested of the owner, occupant, and Board of Health. -1,.- 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. LAs built plans have been obtained and examined. Note if they are not available with N/A. j, The facility or dwelling was inspected for signs of sewage back-up. 4 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 of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ,r The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. . The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Q2_ g-11"!f- S • l i4-/-f0 cJ • Owner: )P, A e�Ef Date of Inspection: / 03/le7,P- FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of bedrooms: Number of current residents:_ Garbage grinder(yes or no): •_ Laundry connected to system (yes or no):_ Seasonal use (yes or no):_ Water meter readings, if available: Last date of occupancy: COMMERCIAUI N DUSTRIAL: Type of establishment: - bTv&.crs� Design flow:III'S gallons/day Grease trap present: (yes or no)_4g,S Industrial 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: uje.s 6 f3°f Last date of occupancy: \7 mr QwoirL. OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION • PUMPING RECORDS and source of information: catulac,e.' Pro QUvnp..A yt &4L to �w ecTh .J t ctc . System pumped as part of inspection: (yes or no) w)O If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM )( Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 1 q L S Sewage odors detected when arriving at the site: (yes or no)�v (revised 11/03/95) 5 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: riae ,/ fP 5 • V#-ArtC"��" ' Owner: P /5 e« Date of Inspection: 03/x,—/yam SEPTIC TANK: cg (locate on site plan) Depth below grade:A,Ttw►DL Material of construction: _Aconcrete _metal _FRP _other(explain) Dimensions: Sor_.- Gv%cvN. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: C")k Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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.) - _ . . _ a,t w ep,Ork 2T 140 \ ‘4.lTr-ctkv2 v acJ .i`Zo 61-e t ` GREASE TRAP: 1.5 (locate on site plan) Depth below grade: AT Material C Material of construction: concrete _metal _FRP_other(explain) Dimensions: \cxpo gal Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: (-34' Distance from bottom of scum to bottom of outlet tee or baffle: O' 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.) S _ z �. ... _ .. -, - 11' . - . ar t • t►J ,ar y- lalrj I 5_1.1tl1QAr� 9.a�io. -t T__��� try r— • (revised 11/03/95) 6 • 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property•A�ddress: p�e /-' Z�, s• y111l-/7'0✓7 Owner: T ' �ea-/../y Date of Inspection: ©Y//777.72- TIGHT OR HOLDING TANK:jO (locate on site plan) Depth below grade: Material of construction: _concrete metal _FRP_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: 4.S (locate on site plan) Depth of liquid level above outlet invert: 2..+:\vc.1 ij 4 e .ina �NJe�c Comments: (note if level and •.stribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) 41.1� 21.1Cs>✓ off- PUMP CHAMBER: 1-3O (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: gal Xi" 87T . ' ri4-2/to • Owner:" Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):,_ (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: Lk 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, condition of vggetation,etc.) 36/ CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: 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 11/03/95) 8 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION (continued) Property Address:fA2- 17. s. //3-/LA-o c r7 Owner: 7, 7S Date of Inspection: ,v3//77 7 -- SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ZtS lJ ,2. Ave let_Nictrc..\c1 ie. ' --- f . III 3 1" y /Mu-40W_ S 1111 • O Q�Taw.�• pTsat $ y Wr e!!o\e i G 'i`% ,�.y.3cF� c3.a:T�+h �t p:r +ar 2` DEPTH TO GROUNDWATER A011,4 Depth to groundwater: 1 07 feet method of determination or approximation: C\cz ,- q+T h, _ 'R 6I r i. ‘A-c\ 1ES`` • �p ,A--. {' "''"ot .Lsb Rf�,vST.tA ktcy� \�iZC'.4i:lY tt.�'.��,�G.I,IL_ ikT ge yIs ao_c err__Rta1r FT p �� i • ` . S�{sr v.���Cy.� ��ri w� gtr�Geh 104 p� 4L3 �uS�TT( (\ Ck1 .3A a+�7�6Tc� et. `I2 Ss_.e vtc is.ar uA 1 \f. cvtc:v+ sec Na), . ,.)T, (revised 11/03/95) 9 • Permit Number: Date: S`I p t9.1 Completed by: e w HIGH GROUND-WATER LEVEL COMPUTATION Site Location: CA09. 2._S Lot No. Owner: Address: Contractor: Address: Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. Date 3't Sl 1. month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well............................ µmw-ah (03 Water-level range zone A . STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ' 11 1 .S —month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment .. ' STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water $ 4 b level at site (STEP 1) Figure 13.—Reproducible computation form. 15