HomeMy WebLinkAbout0139 BUCKSKIN PATH - Health 139 BUCKSKIN PAT H
Centerville , . � i.i, ,
'SMEAD
Na Z-MIL,OR
UPC 12M
Wnad. o n • Us&In M
i
C®gym®nweallth Of Massachusetts /-70_ O&q
Title 5 (Official Ins
Subsurface Sewage Disposal System pecti r
9 � for Voluntary Assessments
Pro e
P rty Address
Owner
information is Owner's Name
required for every CE,N `/ �
page. Cityl lwn
State Zip Code Inspection result. must be
of In pectic'
be submitted on this form. Inspection forms may not be altered in
way. Please see c:ornpleteness checklist at the end of the form. any
Important:When „
filling out forms A- General I�1�®tla on the computer, matio 1
use only the tab
key to move your 1• Inspector: l cZ yL f
cursor-do not /use the return G r h- J/
key. Name of Inspector �—� o /S e-
Company Name
% g
mpany Address
Co
City/Town DJ b V )
�a V � q(9 State Zip Code
Telephone Number / L- (v O , .
License Number
�o csrtificati®III
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 the inspection. The in
was performed based on my training and experience in the proper function and maintenance of on
sewage disposal systems. I are, a DEP a inspection
Title 5(310 CMR 15„()rO0). The system: pproved system inspector site
pursuant to Sectioet 15.340 of
Passes
❑ Conditionally Passes ❑ Faits
❑ Nees Furthor Evaluation by the Local Approving Authority
Inspecto s Signature `�Ll
Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the a
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the a appropriate
approving authority.
""This report only describes conditions at the time of inspection and under the conditions
of us
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
r�
C®Ir`Monweaalth of Massachusetts
Title 5 Official Inspection
Form Subsurface Sewage Disposal System Form o Not for Voluntary Assessments
�M L �
Property Address �`s��t h
Owner e ✓N o
information is Owner's Name
required for every G „i jpyv Ile-
page. Oa 6
City/I own Certi faca'tl®n (coat.) / /� (o 3 J/
�
State Zip Code Date o Insp cttt/on o
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) Syste sees:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.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.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic:;tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
f
COMMonwealth of Massachusetts
H F Title 5 Official Inspection ®�
Subsurface Selvage Disposal System Form -Not for
Voluntary Assessments
Property Address `YS 4-r P7 /�a
Owner �✓cjo
information is Owner's Name
required for every 1 / /e page C.�'�t-fie✓r 4 G l/
City/Town 001
® Code
State Zip
®° Cel't9�ICial$s®n (cont.) Date fens ction
❑ Pump C%hamber pumps/alarms not operational. System will pass with Bo
pumps/alarms are repaired. and of Health approval if
B) Systems Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health): box due
❑ broken Pipe(s)are replaced
f1 Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed
❑ ` ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ND❑ (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system wish pass inspection if(with approval of the Board of Health):
❑ brooken pipe(s)are replaced ❑ Y
❑ N ❑ ND (Explain below):
❑ obstruction is removed � Y
❑ N ❑ ND (Explain below):
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 public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
El or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc-rev.6/16
. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
i
®MM®nwe,a0th of Massachusetts
Title 5 Official Inspection
Subsurface Sewage Disposal System Form - Not for Voluntarys
Assessments
M r, /�/
Property Address /3 9 �u /�j
Owner
information is Ot�ner's Name
required for every C—e-, ,Ile-
page. City/I own
State Zip Code Date of rnspecfion
Bo certification (cont.)
2• System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The;:system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indiicate"Yes" or"No99 to each of the following for all inspections:
Yes No
❑ ❑� Backup of sewage into facility or system component due to 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 SAS or cesspool
❑ F--1 -' 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 '/day flow
t5ins.doc-rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
COMMonwe.alth Of Massachusetts
Title 5 OfficialInspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I 39
Pr /
^M /
operty Address
Owner ��'R✓r'�t7c7
information is Owner's Name /-�
required for every (,.ernyj�y 6 ��
page. City/Town /� co
State Zip Code Date f Insp ction
� CertificaltiOn (coot.)
Yes No
❑ ]]5r," Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ �.J Any portion of the SAS, cesspool or privy is below high
g ground water elevation.
❑ � Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
.❑ �B`�Any portion of a cesspool or privy is within P y a Zone 1 of a public well.
r•�
❑ �. Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ PJ 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. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ The system fails. I have determined that one or more of the above
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow Of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
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
❑ Elthe system is located in a nitrogen sensitive area (interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
C®mmonweal th
f Massachusetts
Title 5 Official Inspection
Subsurface Sewage Disposal System Form _ Not r
or Voluntary Assessments
139
Property Address 6�C
Owner
information is 6"mer's Name / 6;0, 0c�a
required for every
page. Ax ,-)6 �
- City/Tovvn - 0 G a /
�o Checkffiijt State Zip Code
Dat of Ins a ion
Check if the'Following have been done. You must indicate"yes"or"no" as to each
Yes of the following:
0
C-I 'Limping information was provided by the owner, occupant, or Board of Health
❑ �! ere any of the system components pumped out in the previous two week❑ s.
R as the system received normal flows in the previous two week period?
❑ �i Have large volumes of water been introduced to the system recently or as part of
this inspection?
i Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
/ been determined based on:
d Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System In•forrna�ta®n
Residential Flow Conditions:
Number of bedrooms (design):
Number of bedrooms (actual).-
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
I
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Ins ecto
Subsurface Sewage Disposal System F�m -Not for Voluntary For
9 Assessments
Property Address — �''+'r
Owner
information is Owner's Name
required for every
page. City/Iown
State Zi Code a /�
®, System Jnformatlon P Date of Inspection
Description:
/000 "'41 C G a 4,
r
17 �o
Number of current residents: Q
Does residence have a garbage grinder?
Is laundry on .a separate sewage system?(Include laundry system inspection El Yea rJo
information in this report.)
❑ Yes No
Laundry system inspected?
❑Seasonal use? Yes No
❑ Yes No
Water meter readings, if available(last 2 years usage(gpd));
Detail:
Sump pump?
❑ Yes No
Last date of oacupancy: y
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present?
❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system?
❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Foy
Subsurface Sewaget Disposal System Form -Not for Voluntary Assessments
MM yVOy`ev /✓ / � � �/
Property Address
Owner �p v/
information is Owner's Name
required for every
page. City/Town
State Zip Code Date of Inspection-
D. System IlnforMation (cont-
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: �� �� C)
Was system pumped as part of the inspection?
❑ Yes No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of S trn
Septic tank, distribution box, soil absorption system
LJ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
z F Title 5 (Official Inspection For
o
Subsurface sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is 1I
required for every A�A O.)61 S 6
page. City/Town / ,/�/'
State Zip Code Date o nspection
®. Sy/stern 9nfoa'matson (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage!odors detected when arriving at the site?
❑ Yes No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron 40 PVC
❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: U
feet
IVlateri of construction:
concrete ❑ metal
❑ fiberglass El polyethylene ❑ ether(explain) i
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)) ❑ Yes ❑ No
Dimensions: J X
Sludge depth:
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
COMMonwe,11th of Massachusetts
Title 5 'Official Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M /39 ��L�s� �7
Property Address
Owner Owner's Name �t�N
information is
required for every L�2vt�?.VV/ /�4
page. City/Town
State Zip Code Date of Inspection
® system 9nformation (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
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 /
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Gv.�4,1 R►� c� S (t/I Jp�
--- co-1 C t Tr p
Z-f
Grease Trap (locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑ metal ❑fiberglass 9 ❑ 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:
Date
t5ins.doc•rev.&16
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17
CornrMonwealth of MassachusLitts
Title 5 Official Insecti®n Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address / G 4 S L,v7
Owner C^ C/o✓�
information is owner's Name /
required for every C 2vr�`�rv` /1'e
page. City/Iown
State Zip Code Date of Inspect' n
® �yster� Ilnf®�mation (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped 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:
gallons per day
Alarm present: ❑ Yes
❑ No
Alarm level: Alarm in working order: ❑ Yes
❑ No
Date of last pumping.
Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
I
t5ins.doc-rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
C®MMonwealth of Massachusetts
Title 5 (Official Ins ecti
on
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,�Property Address s,
Owner Owner's Name �a,—C/o 1-7information is
required for every ce: G
page. CitY/I own
Sta Zip Code
D. System O te Date of I
,n rmation (cont.) pectin
Distribution BOX(if present must be opened) (locate on site plan): _
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, an
evidence of leakage into or out of box, etc.): y
---------------
a'v'v fo It c'f
A/V zee �f
Pump Chamber(locate on site plan):
Pumps in working order:
❑ Yes ❑ No-
Alarms in working order:
❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in
working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
.Title 5 Official Inspection Form
a Subsurface Semmge Disposal System Form - Not for Voluntary Assessments
Property Address dcl, G 4-2r
Owner Owner's Name e ca✓C/O �
information is
required for every '17 �
page. City/ / ��"own
State Zip Code Date o® inspection o System linformation (cons.)
Type: / `^�/ 7-4 s ,�
leachingits
p O number:
❑ leaching chambers
number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: --- -_—
❑ overflow cesspool number:
❑ innovative/alternative system
Typeiname of technology:
Comments (noise condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc:.):
Cesspools (cesspool must be pumped as part of inspection) (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 ❑ Yes ❑ No
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System^Page 13 of 17
C®P4 Mo
nwealth ®f Massachusetts
N Title 5 Official Inspection Form
Subsurface Semiage Disposal System Form - Not for Voluntary Assessments
Property Address � �
Owner _ /" ci. CI✓/
information is Owner's Name / /� //�
required for every Ce 4 // �� G c�page. City/I own
® �ystei� I��f®�mat�®n (cont.) State Zip Code Date of lAspectioti
Comments(note condition of soil, signs of hydraulic failure, level of ponding,
etc.): condition of vegetation,
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.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
COMMonwealth of Massachusetts
Title 5 Official Ins
pect-on Fom
Subsurface Sewage Disposal System Form - Not for Voluntary Assessme
-Address
/2 / s / nts
M ¢/�
Property
Owner
information is Owner's Name �2w ��
required for every m---
. page. CitY/Town - � vd
State Zip Code
®° ���tei� IIInformation (cont.)
Date of Inspection
Sketch Of Sewage Disposal System: Provide a view of the sewage disposals stem i
at least two rmanent reference landmarks or benchmarks. Locate all wells within 100 feetnL ties to
where lic water supply enters the building. Check one of the boxes below: t. Locate
hand-sketch in the area below
❑ drawing attached separately
Sc�f L
6
r
s4-o VLC---
cz C
/ -.33 � -
1,13- 3 2 1,43 23
i
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 15 of 17
Commonweakh of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner /P-e
Owners Name ��w / `l/l
information is le.- �� � 63oL
required for every -ei C,
page. City/Town State Zip Code Date of nspection
D. System information (cost.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated death to high ground water: -- —
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ bserved site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
ElAccessed USGS database-explain:
You must describe how ou established the high ground water elevation:
�o c�V" aT �� �� ! S nrC7
L'/ )-e
/V �o � 0�
_ � l
1�21cj1,7 ,
_ �. � - .S is ol/L—. l7► G, ��,����
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary 39 n � ry Assessments
SZ,-/
Property Address �`� "�
Owner e � C o v)
information is Owner's Name /
required for every Ce0TL'j,,-1,6 i��/4 ('off G �02 (o
page. City/Town o1 /
State Zip Code Date of spect'.n
E. Deport Completeness Checklist
Inspection Summary:A, B, C, D, or E checked
21nspection Summary D(System Failure Criteria Applicable to All Systems)completed
:�Sketch
em Information —Estimated depth to high groundwater
of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
1L-IC V-- TSr=z>2ooM
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