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Home My WebLink About0053 HADRADA LANE - Health 53 Hadrada Lane (Centerville) A= O�tiENt 0 Y d h��YiMW ® CC tLO O OW a CL ►- `�6 x COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT QF ENVIRONMENTAL PROTECTION �M See. 1 I TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name ' Owner's Address: IQ� AJA % Date of Inspection: Name of Inspect*ease print) r �,Company Name "` �Mailing Addres `� Telephone Number: 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 oft the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant7Passes ction 151340 of Title 5(310 CMR 15.000). The system: Conditionally Passes �..rJaR eds ;her Evaluation by the Local.Approving Authority _ ils / Inspector's Signature: .__ Date: 7 A) 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 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 DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I i i Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:. i Own.e °2 Date of Inspection:. OU/ / Inspection.Summary: Check.A,B,C,D or E./ALWAYS1complete all of Section D. A. stem Passes: i 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: i ' I B. System Cori ditionally•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. Answer yes,no or not determined(Y,N,ND).in the forj the following statements. If"not determined"please explain, i 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.! ND explain: Observation of sewage backup'or break out or high static water'level in the distribution box due 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): broken pipe(§)are replaced obstruction is removed distribution.box is leveled or;replaced 1 ND explain: The system.required pumping more than 4 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 ND explain: I - i 2 : Page 3 of 1'l OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: AeZA Owne Date of Inspection: /70 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. 1. 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 whichwill protect public health,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 any)determines that the system is functioning in a manner thatprotects 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 cer i tAd laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: /i p D. System Failure Criteria applicable.to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N Backup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool Discharge or pond,ing of effluent to the surface of the ground or surface waters due to an overloaded or clogged'SAS or cesspool Static liquid level in the distribution.box above1outlet invert due to an overloaded or clogged SAS or / cesspool . i _j Liquid depth in cesspool is less than 6"below invert or available volume is.less than %Z day flow lff'' Required pumping more than 4 times in the lastlyear NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high 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. ; _ 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 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,fori coliform,bacteria and volatile organic.eompounds indicates that the well is.free from pollution from that facility 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 belattached.to this form.] (Yes/No)The system fails: I have determined that one or-more of the above failure criteria exist as described in 3.10 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• You must indicate either"yes"or"no"to each of the followin : (The following criteria apply to large systems in addition to Ith:e criteria above) yes no the system is within 400 feet of a surface drinkingl water supply _ the system is within 200 feet of a tributary to a surface drinking water supply i — the system is located in nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone lI of a public water supply well If you have answered"yes"to any question in Section E thelsystem 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 s.ystem.in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. I 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. 'PART B CHECKOST Property Address: Owne . Date of Inspection: 7, ,. Check if the following have been done.You must indicate"yes"or"no"as to each of the following; Yes No V',� Pumping.informadon.was provided by the owner,occupant,or.Board of Health VWere.any of the system components pumped out in the previous two weeks? tl� Has the system received normal flows in the previous two week period? ✓Have large.volumes of water been introduced to the system recently or as part of this inspection? 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 breakout? L,1'_ 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? J— 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: Yes no — 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(3)(b)] 5 Page 6 bf 11 OFFICIAL-INSPECTIONTORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM ORM PART C SYSTEM INFORMATION Property Address: W2'w'� �� Owner. Date of Inspection: p j FLOW CONDITIONS RESIDENTIAL Number of bedrooms.(design): . Number of bedrooms(actual): DESIGN flow based on 31 O.Cv1R 15.203 (for example: 14.0 gpd x#of bedrooms): 2 Number of current residents: 02 Does residence have.a garbage grinder(yes or no) Is laundry on a separate sewage system (yes or noif yes separate inspection required] Laundry system inspected(yes or notAo_ Seasonal use:(yes or no):. Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no : ,��Z�.�B Last date of occupancy: ('A COMMERCIAL/INDUSTRIA Type of establishment, Design flow(based on 310 CMR.15.203): gpd Basis of design flow('seats/persons/sgft,ete.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged,to the Title 5.system(yes or no):_ Water meter readings, if available: Last date of occupancy/u"se: OTHER(describe): GENERAL INFORMATION ) Pumping Records Source-of information: L3;acnr� Was system pumped as part of the inspection(y or no): If yes,volume pumped: gallons-=How was quantity ptinped deteiniined? Reasoh'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) — Y Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy'of the DEP.approval �thet'(describe): S . t Approximate age of all components,date installed(if known)and source of information: . .0 In, Weie sewage odors-detected when arriving.at the site(yeslor no): 6 I . Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /xc Owner Date of Inspection: BUILDING SEWER(locate on site plan)i`'� Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: ` Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: locate on site plan) ) Depth below grade:S—X— Material of construction:�oncrete_metal_fiberglass__polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: �� 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 baffler Distance from bottom of scum to bottom of outlet tee or baffle' How were dimensions determined; tgl�y,,4M�vhL Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,a .): ' /a v al GREASE TRAAP;i�(locate on.site plan) Depth below grade: Material of construction:_concrete_metal fiberglass_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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): i Page 8 of l l j OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSA�i, SYSTEM INSPECTION FORM .PART C SYSTEM:INFORMATION(continued) Property Address: Owne Date of Inspection: > TIGHT or HOLDING.TANK: y Xtank must be pumpe�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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): j Date of last pumping: Comments(condition of alarm and float switches, etc.): i i DISTRIBUTION BO✓� (if present'must be opened)(locate on site plan) Depth of liquid level above outlet invert: j Comments(note if box is level and distribution to outlets equal, any evidence of solids carry- over,any evidence of leakage into or out of box,etc.): l PUMP CHAMBER: ,O'(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no):. Comments(note.condition of pump chamber,condition of pumps and appurtenances,etc.): i I • I I j j I 8 5 Page 9 of 11 OFFICIAL INSPECTION FORM �1OT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: }� Owner. -Date of Inspection: CP yf/ AD l SOIL ABSORPTION SYSTEM (SAS): locate on site plan,excavation not required) If SAS not located explain why: Typ✓leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: ' leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil;condition of vegetation, 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 or,no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY-Iocate 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.): 9 } l Page 10.of 11 OFFICIAL�INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address:. Own ' Date of Inspection: CA 11/,16 I SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the.building. t t s 10 Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION(continued) Property Address: JK► `� Owner. oa.,4,tl�� Date of Inspection: I SITE EXAM Slope Surface water Check cellar Shallow wells i Estimated depth to ground water�feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-Iflchecked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database,-explain: { d water elevation: You must describe how you established the high groun i i i i i i I i 11 I