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LEACHING FACILITY: (type)2i �-('j J )00/'L'/ (size)
NO.OF BEDROOMS
BUILDER O OWNE �
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility / Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching f i ity) / Feet
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' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Maple Avenue, Centerville M -207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is 52 Maple Avenue, Centerville MA 02632 August 26, 2014
required for every 9
page. City/Town State Zip Code Date of Inspection
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 filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Troy Williams
use the return key. Name of Inspector
Troy Williams Septic Inspections
,Q Company Name
19 Hummel Drive
Company Address
South Dennis MA 02660
Cltylrown State Zip Code
(508) 385- 1300 S1682
Telephone Number 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 ofgn site'
sewage disposal systems. I am a DEP approved system inspector pursuant tocSection 15:340 of
Title 5(310-CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority ��'
E;.
August 26, 2014
Inspector's 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 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.
****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.
t5ins-3/13 Title 5 Official Ieon Subsurface wage Disposal System-Page 1 of 17'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Maple Avenue, Centerville M-207 P 35
Property Address
Jane Baxter
Owner Owner's Name
information is required for every 52 Maple Avenue, Centerville MA 02632 August 26, 2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
52 Maple Avenue, Centerville M-207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is 52 Maple Avenue, Centerville MA 02632 August 26, 2014
required for every p 9
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ' 52 Maple Avenue, Centerville M-207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is every
52 Maple Avenue
required for eve , Centerville MA 02632 August 26, 2014
page. Cityrrown State Zip Code Date of 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 m❑ e system has a se tic tank and SAS and the SAS is less than 100 feet but 50 feet or
Y P
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 day flow
t5ins•3/13 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
52 Maple Avenue, Centerville M -207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is 52 Maple Avenue, Centerville MA 02632 August 26 2014
required for every 9 ,
page. City/Town State Zip Code Date of Inspection
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:
❑ ® 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,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.
t5ins•3/13 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
52 Maple Avenue, Centerville M-207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is every
52 Maple Avenue
required for eve Centerville MA 02632 August 26, 2014
page. City/Town State Zip Code Date of Inspection
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 b the owner, occupant, or Board of® ❑ p Health
9 p Y p
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ 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 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:
® ❑ 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 Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 2 to 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
52 Maple Avenue, Centerville M-207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is 52 Maple Avenue, Centerville MA 02632 August 26, 2014
required for every g
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse?
® Yes ® No
Water meter readings, if available last 2 ears usage d 13=36,000 gals.
g ( y g (gp ))' 12=32,000 gals.
Detail:
Sump'pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/lndustrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): N/A
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
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: N/A
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Maple Avenue, Centerville M-207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is
required for every 52 Maple Avenue, Centerville MA 02632 August 26, 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: N/A
Date
Other(describe below):
N/A
General Information
Pumping Records:
Source of information: No pumping info was available.
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 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/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 b system operator under contract
P Y Y P Y
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
IM Title 5 Official Inspection Form
RUV;
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
52 Maple Avenue, Centerville M-207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is 52 Maple Avenue, Centerville MA 02632 August 26, 2014
required for every g
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Cesspool is original to home built approx. 45 years ago. Pit added later.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18'0+
feet
Material of construction:
® cast iron ®40 PVC ® other(explain): Orangeburg
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Lines were found clear at the time of inspection. Orangeburg pipe was found settled and in need of
repacement.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
N/A
If tank is metal, list age: N/A
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
N/A
Sludge depth: N/A
t5ins•3/13 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 Form-Not for Voluntary Assessments
52 Maple Avenue, Centerville M-207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is Avenue,52 Ma
required for every P , Centerville MA 02632 August 26, 2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
How were dimensions determined? N/A
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/ADate
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
rY 52 Maple Avenue, Centerville M-207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is 52 Maple Avenue, Centerville MA 02632 August 26 2014
required for every 9
page. City/Town State Zip Code Date of Inspection
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: N/A
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
N/A
Capacity: N/A
gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments(condition of alarm and float switches, etc.):
N/A
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Maple Avenue, Centerville M-207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is required for every 52 Maple Avenue Centerville MA 02632 August 26, 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
N/A
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.):
N/A
* 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
52 Maple Avenue, Centerville M-207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is 52 Maple Avenue, Centerville MA 02632 August 26 2014
required for every 9
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 6'X6'with stone
❑ 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, etc.):
Pit was found with water level 6" below invert on inspection with walls found stained above inlet line.
This is evidence of leaching being full and in hydraulic failure in the past. System does not have a 1/2
day flow available at this time.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration main cesspool
1„
Depth—top of liquid to inlet invert
Depth of solids layer
2"
Depth of scum layer none
Dimensions of cesspool 5'X 5'
Materials of construction Cesspool block
Indication of groundwater inflow ❑ Yes ® No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
up
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Maple Avenue, Centerville M -207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is 52 Maple Avenue, Centerville MA 02632 August 26, 2014
required for every 9
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Cesspool was found with the walls found stained above inlet line.
r
Privy(locate on site plan):
Materials of construction:
N/A
Dimensions
N/A
Depth of solids N/A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
52 Maple Avenue, Centerville M-207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is 52 Maple Avenue, Centerville MA 02632 August 26, 2014
required for every �
page. Cityrrown 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 public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
go-a'
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i
I �
I �
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I
r 2 S� ' {
v�
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 52 Maple Avenue, Centerville M -207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is required for every 52 Maple Avenue Centerville MA 02632 August 26, 2014
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20.0+
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)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show groundwater to be estimated at 48.1'. Bottom of cesspool at 9.0'was found not to
be located in the high groundwater elevation at the time of inspection.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 52 Maple Avenue, Centerville M -207 P-35
Property Address
Jane Baxter
Owner Owner's Name
information is
required for every 52 Maple Avenue, Centerville MA 02632 August 26, 2014
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17
� , ;x"i
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RICEAV19
DEC 2 l 19.9� -
BORTOLOTTI CONSTRUCTION,INC. y
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 , �EAtIH�p
508-771-9399 508-428-8926 FAX: 508-428-9399
t�e
SUBSURFACE
.SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION
Property Address:
Date of Inspection: Inspector' arnc: 9e />✓�F'r^f Sl_��,fc� c�ei`fir
�er's Name and Address:-
CERTIFICATION CTATEMENT•
I certify that I have personally inspected the sewage disposal system at this address and that the informs- .
tion reported below is true,accurate and complete as of the time of inspection.The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal stems. The System:
Passes
Conditionally Passes
Needs Further Ev uation By the Local Aproving Authority
Fails
Inspector's Signature: Date:_
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(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 C MMARY•
A)SYST�M PASSES:
_ V 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 comple-
tion of the replacement or repair, passes inspection.
Indicate yes,nor,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 sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
- 1 -
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four 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
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 the public health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank 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 septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent 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 clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
III - --
I ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is witlun 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 I 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. if the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
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 11 of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CNM 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner,occupant,and Board of Health.
_None of the system components have been pumped for atleast 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.
As-built plans have been obtained and examined. Note if they are not available with N/A.
v The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
v- The site was inspected for signs of breakout.
All system components,excluding the Soil Absorption System, have been located on site.
The septic tank manholes were uncovered, opened,and the interior of the septic tank was in-
spected for condition of baffles or tees, material of construction,dimensions,depth of liquid,
J/'depth of sludge,depth of scum.
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.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 11
CHECKLIST(con(inued)
The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.
FLOW CONDITIONS
RESIDENTIAL: V
Design Flow: gallons Number of Bedrooms:_ Number of Current Residents:
Garbage Grinder: U Laundry Connected To System: Seasonal Use:
Water Meter Readings, if ilable:
Last Date of Occupancy: d _
COMMERCIAL/INDUSTRIAL:
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings, If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informatsion:
System
PumpedP P �as art of inspection: /d If yes,volume pumped: gallons
-
Reason for pumping:
TYPE OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption Systein
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes attach previo s inspection records, ifany)
�Other(explain):
ex : L eSS CD �-P
�PPRO TE AGE of all componep�ts,date installed(if own)and spur o information:
L! wo S G �r c /n
Sewage odors detected when arriving at the site: O
-4-
v.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: Material of Construction: concrete metal . FRP Other
(explain)
Dimisions: Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom 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.)
GREASE TRAP::
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top 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.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction:—concrete—metal FRP_Other(explain)
Dimensions: Capacity:—gal Ions Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: Q
Depth of liquid level above outlet invert:
Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into
or out of box,etc.)
PUMP CHAMBER:
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
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: Leaching chambers, number: Leaching galleries,number:
Leaching trenches, number, length:
Leaching fields, number,dimensions:
Overflow cesspool, number:
Comments: (note condition of soil, si ►s of hydraulic failure level of pondli g,condition of ve,�etaa9on,
,etc.)ZAS CL /Go ,, ( ' - n o� Cie
►� �Co ej_ CP ��
c-
CESSPOOLS:z� -
Number and configuration: - ( ' S 'Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:6o',I) y 5 Cc)
Materials of construction 6 1i,J'*A ck ndication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments:(note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.) a 'fir 25 --B/O6t v MCI,)L-^ C'f'm Co �►}�� �
10 �• G� �-C�l P - G
i ..
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6 -
J"
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM. INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.e t.
P_C9.r /
.
Y 3y
DEPTH TO GROUNDWATER:
Depth to groundwater: Feet ,
Method of Determination o Approximation:
-7-