HomeMy WebLinkAbout0057 HOLLY POINT ROAD - Health 57 Holly Point Road
Centerville
A= 233 -037
UPC 12534
No.2-153LOR
HASTINGS,MN
'�J
Commonwealth of Massachusetts
a Title 5 Official Inspection Form l
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r Mt
/tea /� y
G M S'( 7 /�
® /7 D /�1#1 4- �C "
Property Address .0
��trot Owner Otvner's Name &0"1 !"
information is
required for every +�'(A
page. //'% ®a 1;
Ciryiii own State ZipCode
Date of Inspecti n
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:when A. General Information
filling out forms
on the computer, A
use only the tab 1 Inspector:
key to move your
cursor-do not /
use the return 6
key. Name of Inspector /g !!!
Company Name 1-120
Company Address --
C4S AAA w, off.�_�_a
;ele'ph�o
i TState® ZtpCodene umber / / V
License Number
13. Certification
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 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 pursuant to Section 15.340 of
Title 5(310 R 15.000). The system:
Passes ❑ Conditionally Passes
❑ Fails
❑ Need Further Evaluation by the Local Approving Authority
inspector,I Signature
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 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.
****This repast 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.
t5ins.doc•rev.6/16
Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Po 14
Property Address ®e
Owner
Owner's Name I
information is
required for every
page. City/Town State Zip Code Date of nspec ion
I�. 6� fic cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) stem Z ses:
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.
❑ '' C N ❑ ND (Explain below):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
I
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner
Owner's Name
information is
required for every
page. City/Town _ State Zi Code
—- P Date of Ins ection
B. Cerdficati®n (cunt.)
❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if
Pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
Obseriaticn 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(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ 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 will pass inspection if(with approval of the Board of Health):
I ! broken pipes)are replaced ❑ Y ❑ N ❑ ND (Explain below):
LI obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Fuirther 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 which will 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
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonweaifth of Massachusetts
F
CLle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner
's
information is Owner Name
A�(required for every aou �R✓'t�� y R .�
page. Clty/Tcwn— _ State Zip Code
--- P Date of Insp6y tion
Bo Cerdficat on (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:
El The system has a septic tank and soil absorption system (SAS)and the SAS is within
It 00 feet c° surface w:�tai-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,
❑l 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 pastes if the water analysis, performed at a DEP certified laboratory, for fecal
coliforr;, bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than, 55 pprn, provided that no other failure criteria are triggered. A copy of the analysis must
be at.ached to this form.
3. 0 c;r:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ r Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ 'k Discharge or ponding 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 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
Commonwealth of Massachusetts
t Title e 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M _ ►I
Property Address
Owner I 40
information i
Owner's Name
required for every i ��'�
page. City/Towi State Zip Code Date oyinspe1tion U
� - i®n (cont.)
Yes No
Required pumping more than 4 times in the last year N0T due to clogged or
/obstructed pipe(s). Number of times pumped:
El ! A.n/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.
E Any portion of a cesspool or privy is within a Zone 1 of a public well.
I 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 )rivate 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,
prrvl,ded that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.] -
rhe system is a cesspool serving a facility with a design flow of 2000gpd-
0,006gpd.
P The system fails. I have determined that one or more of the above failure
criteria tsxist 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 nn q,t rfdlcate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
G El the system is within 400 feet of a surface drinking water supply
L� 0 ti ie systeni is wick:n 2,30 feed:of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area--M!PA)or a mapped Zone II of a public water supply well
If you have anc,wered "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 vi th 310 AMR 1.5,304. 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 M Sy0``'V
PropertyAddress ® G/#'!�
Owner Owner's Name
information is /�
required for every _�� `���,r 6ry'� y ®� ! �� t. 1-
C.page-
State Zip Code Date oon
Checkiast _ —_-----
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes o
�- ❑ -Pumping information was provided b the y owner, occupant, or Board of Health
L' ""Were any of the system components pumped out in the previous two weeks?
❑ as 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!Mans 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?
❑ re all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for ifie 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
een determined based on:
❑ Existing information. For example, a plan at the Board of Health.
❑ Determines 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)]
De System Info rlr a—fl i-Il
Residential Flow Conditions:
Number of bedrooms (design): — — Number of bedrooms (actual):
DESIGN flow based on 310 Civll:� 15.203 (for example: 110 gpd x#of bedrooms):
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
subsurface Sewage Disposal System Form Not for Voluntary Assessments
Propert A,y Address 04
0210
Owner Owner's Name � �(��
information is
required for every Vi��'� 'd -;:a�9L�' �'_' �• �� ��
page. CIty/To,wt State
Zip Code Date Inspe ion
D. System Wormataon ---.
Description:
Number of current residents: (�
Does residence have a garbage grii-ider?
❑ Yes No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes No
Laundry system inspected?
❑ Yes No
Seasonal use?
Yes ❑ No
Water meter readings; if available (last 2 years usage (gpd)):
Detail:
Sump pump?
❑ Yes No
Last date of occupancy: Cl/
Date
Commercial/lndustrial Flew 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:
t5lns.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface sewage Disposal system•Page 7 of 17
Commonweaath of Massachusetts
W� Title i i l Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner � ®
's /�information is Owner Name
//�� 0.4 1 3 ✓S�
required for every 1°0 �,,"���
page. Clty/Tomm State Zip Code Date Ins ction
D. System information (cunt.;.
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records: / ,�� 0wL
Source of information:
v i
Was system Nurrlped as part of the inspection? ❑ Yes [ to
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ �tttte 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):
t5lns.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Titleicial Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address AUX , —"01
Owner Owner's Name f�e
information
is ty r"7
® �le'd
1 " 19� ��required for every .. 0 m,-e�v tt" o v
a e. Ci !To ro i __State Zip Code Date of nspec' n
®. ���� 9nformatoon (cons.) —
Approximate age of aii comp ents, date installed (ifXn)and source of information:
Were sewage odors detected when arriving at the site?
❑ Yes No
ISuilding Sewer(locate on site plan):
Depth below grade: /
feet�astironc
onstruction:
❑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:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins.doc-rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System For
m -Not for Voluntary Assessments
G M ge,
Property Address
Owner "1041 t�
Owner's Name �1
information is
required for every L�� ots� �!,
page. City/To ror1 _ P State TiCode sL
---- _ Date of Mspectron
D. System Information (cons.)
Septic'Tank(coat.)
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.):
Grease Wrap (locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass 9 El 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.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
x Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is e
required for every ,/ L
�. `,
page. City/I cwrl _
State Zip Code Date of nsp tion
D. System Information (cons.)---
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Fight 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
Alarrn 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
Commonwealth of Massachusetts
4J W Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/�®�/
Property Address S !
Owner 1 0
Owner's Name '
information is ,p
required for every 6 � �a7�+ '�� 1/�,/� 0;
page. City/Town State Zip Code
— -——.------. P Date of I pectin
D. System driformation (coot.)
Distribution Sox(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, any
evidence of 162kaq�into or out of box, etc.):
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.
SoH 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
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`M `S A®l� 2�
Property Address • _�0�
Owner / ®
'
information is Owner s Name
required for every n41,a
page. Clty/Tow't State Zip Code Date o Inspe ion
D. Sysuerly, Infolr ad' (cons.),
_ P
Type:
❑ leaching pits number:
❑ leaching chambers number:
�..) leeching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
overflow cesspool number:
❑ innovative/alternative system
`hype/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Cesspools (cesspool must be pt.tmped as part of inspection)(locate on site pla
Number and configuration 14.qf J?
e
Depth--top of liquid to inlet invert I �e
Of Jr
Depth of solids layer
Gt Jt Ce 1
Depth of scum layer
Dimensions of cesspool
Materials of construction /0 C
Indication of groundwater inflow ❑ Yes No
t5ins.doc-rev.6116
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
CoMMOnwealth of Massachusetts
L Title icial Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
`M ®/X
Property Address U2
Owner
Owners Name
information is
required for every
page. CirylTownState Zip Code Date of specti—�
D. System Information (cons.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): �®
— ve �s ✓� r✓1 46eer�oy
.s� ®o
/ o
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of oli-ds;
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 Inspection Form
Subsurface Sewage Disposal SystemjFrmP - of for Voluntary Assessments
l O«,�
Property Address
Owner
information is Owner's Name
required for every (� ,�`rd'3�G /¢ 0a6 3d-
page. Clty/Tewn State Zip Code Date of I specti n
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where p, c water supply enters the,building. Check one of the boxes below:
hand-sketch in the area below
drawing attached separately
i
I
1'� /
[C(1✓
t51ns.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 15 of 17
'Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 4
Property Address
/?--:9 aY"
Owner Owner's Name
information is
required for every �' ey�`a. ��'_,
page. City/Town State Zip Code Date of In ectio
D. System Inforii1 aijun (coni.l.
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
Coo
❑ Shallow wells
Estimated depth 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
❑i Observed site (abutting property/observation hole within 150 feet of SAS)
19 Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describ ow,yylu established the high groun water elevation:
er
t9 74
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
° Subsurface Sewage Disposal System Fora -Not for Voluntary Assessments
' M � // s _•� �C)
Property Address
Owner i 2. -C,1 eM
Owner's Name
information is
required for every L'D1g`.may Y 6 .7,1 ? /�
page. CitylTcw;l State Zip Code Date of l pecti n
E. RePOri Co paetene5s Cna- 9-kl st —
Inspection Summary:A, B, C, D, or E checked
[Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
stem Information—Estimated depth to high groundwater
[.I Sketch 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
r,
Commonwealth of Massachusetts
ffi ial Inspection Form
Title 5 O c p
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
o A /--01
Property Address
Owner
Information is Owner s Name �N-fie✓v/ //� ,� , oa 6 3� /O 1d, /
required for /! —
every page. City/Town State Zip Code Date of'Inspectron
Inspection results must be submitted on this form. Inspection forms may not be altered In any
way. Please see completeness checklist at the end of the form.
ImpoWhen filling A. General Information
When filling out
forms on the � I
computer,use 1. Inspector: /
only the y b key R] ✓ O /.S ///
to move our cursor-do
use the etumt Name of Inspector ,/t/ � ^
key. c l o ,7
Company Name
Company Address b
�i�/f/y DpC 7
CitylTown / i LL'— State /7 Zip Code
1.
Vic Z
Telephone f4umber _ License Number
B. Certification
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 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 pursuant to Section 15.340 of
Title 5(310 MR 15.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority � � :Cr—:)
Inspector's SI ature Date
The syste inspector shall submit a copy of this inspection report to the Approvinb Authorityy
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system oP
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit-the m
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.
""*"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. i / .LU b
t5ins•t tno TMe s offlchl hapectlon Form:sot suneoe sewage Dbposal sydwn-Page i or t y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage
Disposal System Form-Not for Voluntary Assessm—ents
/X
YL
Property Address cc�p
Owner Owner's Name /_
information is GPN?G►��j� ,� / /¢ Od(0 301 101141a,
required for State Zip Code Date of pe n
every page. Cityfrown
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System sses:
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 11110 Title 5 Onklal Impedes Form:Suhwrtam Sewage Dlspoael Systwn•Pap 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm_ •Not four Voluntary Assessments
- Od O&
Property Address /
C11—
Owner Owner's Name
Information Is `le //;�j� oc�4,?a /O 4 /�
required for — ------
every page. Cltyrrown State Zip Code Date of Inspe tlon
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ 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(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ 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 will pass inspection if(with approval of the Board of Health):
❑ broken 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.
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 which will 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
t5b�9 11/10 TO*5 O1B I hupwbon Form:Subsudk4 SmV Npowl sy*m-Pop 3 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal)System Form•Not for Voluntary Assessments/
1,7
Property Address -t•��-(,`-
-le
Owner Owner's NameC
7
Information Ise�` ram` p /�� O ) /J 1 lO /a drequired for l.r ����T o�.b pC, '.
every page. Cityrrown State Zip Code Date bf Inspection
B. 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 indicate"Yes"or"No"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
❑ 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'/2 day flow _
L51ns%'11/10 Title 5 OftW Form:Subsurboe ^Sawapa Dlqwsal BysEsm•Pape 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
Property Address
Owner Owner's Name / 1 Information is 0 /02 /C
required for _ _
every page. City/Town State Zip Code Date of epe n
B. Certification (cont.)
Yes No
❑ �/ Required pumping more than 4 times in the last year NOT due to clogged or
,...,/ obstructed pipe(s). Number of times pumped:
❑ L� Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Er 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.
❑ Er"" 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 failure
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
❑ ❑ 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
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.
t61ns•1,no Tltle 5 Misr Mopectlon Form:Subsurrm Sewspa Ole =1 System•Fape 5 of 17
Commonwealth of Massachusetts
9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
0 /�o/xi
Property Address
Owner Owner's Name
Information Is l0 —
required for CeO —
every page. CWTown State Zip Code Date of I pecdon
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
�❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ [Er Were any of the system components pumped out in the previous two weeks?
21j ❑ 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?
Q/ Were as built plans of the system obtained and examined?(If they were not
N El 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?
e size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
/ A/ --[� Existing information. For example, a plan at the Board of Health.
fah
❑ 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 Information
Residential Flow Conditions: 2
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
tins•+v1 o rme s omGai Impadw Form:subwdus SoNW DWp*W system•Ppo a a»
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
o//('
Property Address
Owner Owners Namevv //e `q
information is -IQ `/ �,� V pt 6 J� l� /� 14
required for �_ —�_
every page. Cltyfrown State Zip Code Date of Inspecdon
D. System Inform 'o
Description:
ASS oo�
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ErNo
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes No
Laundry system inspected? ❑:Yes
es No
Seasonal use? ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes B-140
Last date of occupancy: o W4 17 —
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: --
Sins•11M0 Title 6 Of ial Inspwfim Form:Subwrfus Sewee DW)ml Sydem-Peps 7 of 17
Commonwealth of Massachusetts
fu Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not pot9
oluntary Assessments
�`/ —
Property Address
Oel �
Owner Owner's Name ],, l
Information is 7�✓!/d Q� la ��
67
required for State Zip Code Date 0 Inspection
every page. Cityrrown
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records: 0 wy��
r Q nl mac✓'
Source of information:
Was system pumped as part of the inspection? ❑ Yes ^
If yes, volume pumped: gallons
How was quantity pumped determined? -----��
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)
❑ Innovative/Altemative 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):
>a�s•t f n o Me s om*i irapecdon Form:$050e0e SOWNP 06POSW SYSbm•PSP 8 a t 7
Commonwealth of Massachusetts
• Inspection Form
Official Ins
Title 5 Offic ec p
Subsurface Sewage Disposal System Form•Not for Voluntary
/Assessments
r � /�4
Property Address /Iq
Owner Owner's Name ���
��a���
information is Ce�
required for — state Zip Code Date of Inspection
every page. ChylTown
D. System Information (cunt.)
Approximate age of all components, date installed(if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes e''�o
Building Sewer(locate on site plan):
Depth below grade: feet
Material nstruction:
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: feet —
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
IBlra•11/10 Title 5 Official InspecWn Form:Subeuoace Swap Disposal System•Pop 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
S / ! O e
Property Address C
Owner owner's Name
Information is / QN4'Y-V
j `� ��required for l_.
every page. City/Town state Zip Code Date of nspecdo
D. System Information (cunt.)
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.):
Grease Trap (locate on site plan):
Depth below grade: feet
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: Date
Sns•11110 T1tl9 S OBcWl nspactlon Form:Subxufaa&owapa Syetam•Pop 10 d 17
I
Commonwealth of Massachusetts
101561111001 Title 5 Official Inspection Form
W
Subsurface Sewage Disposal System Form•Not forVoluntary Assessments
S� /'V// / v117
Properly Address l" I
Owner Owner's Name repinformation Is
required for
every page. City/Town State Zip Code Date of Inepecdo
D. System Information (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
fts-1111 o Title 5 OftW Inapwfion Fore:Subsudew Sevrepa Dia mW SyMa•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments)
v//
Properly Address , �-
Owner Owner's Name r/
information Is �eo
required for
every page. Cltyfrown State Zip Code Date o(Inapecion
D. System Information (cunt.)
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, any
evidence of leakage into or out of box, etc.):
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.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
1S)ns•11l10 TI"5 Oftel Inspection Form:Subow1wo Sowogo Dlepooal Sydom•Peye 12 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
Property AddressC>/1
—
Owner owner's Name
information is required
�P ✓V l //� L/�� Qa�p� �� �� ��
required for
every page. CMyrrown State tip Code Date of In ectio
D. System Information (cunt.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ le ing 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, etc,):
Cesspools (cesspool must be pumped as part of inspection) (locate on site pla
Number and configuration
105)
Depth—top of liquid to inlet invert P o 4
Depth of solids layer
Depth of scum layer �x
Dimensions of cesspool
Materials of construction 'V
Indication of groundwater inflow ❑ Yes No
t5trns•11/10 Tltla 5 001olal Inapodbn Form:Subawfau DlapoaN Syuan•Papa 13 or 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
-- - doll o,'-pi //�
Property Address Si/
Owner Owner's Name CeN-k // 1j 4 OQb Information Is r✓� ( ,e � �/ /0//01-
required for
every page. Cityfrown state Zip Code Date of lr*pecdofi
D. System Information (cunt.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): n1 -
® �� �M��✓� /�U' SSA ✓1 Z/0-e
d
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.):
t5m•11110 8@JFraNdr lcanAvrmc: �s m•A4ytatkredfiP
IL
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
o,
Property Address
Owner Owner's Name /
Information Is C,,eo 4e✓vl 6 ��
required P8
e of er
every Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where lic water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
G�IaS
coy-ev*
6-e to
t Mns•11/10 Title 5 ORiatai tmpedhon Forth:Subsurface Sewage DiopmW SyMm•Page 13 or 17
� 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
Property Address 5�> . /�-O//C7 9- -�rq'
__qlc/)
Owner owner's Name
Information is
required for �Qvti ✓V/` /---= — -
every page. Cky/Town state Zip Code Date of Inspectt n
D. System Information (Cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells C)
Estimated depth 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 —
❑ Observed site(abutting property/observation hole within 150 feet of SAS) t f 9
�J o
ldY Checked with local Board of Health-explain: q�?�w
—_/"v_/�S' CIO 17
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:�r /
.DtI H ita f� 2
/0 C
o� .�
� � e s � � rs o� �
-P /n�i✓ 0 G c�
/ 0 �/C
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t51nc-11H0 rr"6 Ofrwial IrrspecMorr form:Subsurface Sewage Dbpml System•Pays 16 of 17
I
1.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
Uiiv
s
Property Address / r
Owner owner's Name l /oL
Information is ✓vt // �O
/
required for ce", /
every page. CkylTown State Zip Code Date of I ecdon
E. Report Completeness Checklist
El'I'n-spection Summary: A, B, C, D, or E checked
inspection Summary D (System Failure Criteria Applicable to All Systems)completed
V
stemInformation—Estimated depth to high groundwater
ketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
0ON•11/10 Title 5 MW Inspection Form,Subaurteoe Sewepe Dapaml System•Pape 17 of 17
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