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Home My WebLink About0714 OLD STAGE ROAD - Health 714 Old Stage Road Centerville A= 191—062 5 M EA6 No.2.153LOR UPC 12534 amead.com • Made to USA ill - bcvv CO1.11/10N5,1 E_-`,LTH OF AiNSSACHUSETTS ENECUTI T OFFICE OF ENVIRONMENTAL AFF_A.IRS a I�EPAR.TMENT OF ENVIROI\TVfENTAL PROTECTIONT TITLE 5 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY;ASSESSI•`TENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR-AT PART A CERTIFICATION t Property Address: 7/ �/J r 7 d�L1 S�a �I "/—lj lQ I .v� � d63aL Owner's Name.• C4i0f Owner's Address: Date of Inspection: ay Name of Inspector�: glease print,)"ark/ /41xSG//, Company Name: L`-/W%p7 FGY: Mailing Address: Telephone Numb erLS02 CERTIFICATIONT STATEMENT I cer-LLfy that I have personally inspected]the sewage disposal system at this address and that the information reported below is true, a curate and complete as of the time of the inspection.The inspection was performed based on my uIrainib'_0 and exj erience in the proper function and maintenance of on site sewage disposal systems. I am a DEP E�Ipprb ed syste rn inspector pursuant to Sec ' n 15.340 of Title 5(310 CMR 15.000)�;Tlie system: ` - Passes w Conditionally Passes Needs Further Evaluation by the Local'Approving Authority G �: r Fails Inspactor's S gnature: Date: a2 ` �7l X The system inspector shall submit a copy of this inspection report to.the Approving Authority Board 6� _ea'th o Z DEP)v,,ithin 30 days of,com completing this inspection. If the syste system d t -`P � � p m is a shared s tem or has a design i1o'R =10;00 , gpd or greater; the inspector and the system o wvner shall submit the report to the appropriate regional o t 1 e of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable; and he cpro,ng, authority. Notes and Comments t ****This report only,describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address hog the system will perform in the future'under the same or different conditions of use. , Title 5 Inspection Form 5/15/7 Pase 2 of I 1 OFF'ICI4L INSPECTION FOR_ -NOT FOR VOLUNTARY ASSESSILEN TS SUBSURFACE SEWAGE DISPOSAL SYSTEM TNSPECTION FORNI PART A CERTIFICATION(continued) Property Address: Owner- Date of Inspection: 02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D. A. Sys asses: I have not found any information which indicates that any of the failure criteria described in 3 in CNIR 15.303 or in 310 CNIR.1-5.30.4 exist. Any failure criteria not evaluated are indicated below. Comments: B. Sv em 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. «rill pass. Answer ves.. no or not determined(Y;1T?,NTD)in the_ for the following statements.If`riot determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal;or riot) is struc-n-7aliy unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System)&=iil piss inspectien i f the existing tank is replaced vpith a complying septic tank as approved by the Board of Health.:, *A metal septic tank will pass inspection if it is structurall; sound,not leakina,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 broker:,or obstructed pipes) or due to a broken. settled or uneven distribution box.System will pass inspection if( rith approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced tiD explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The s�st=rn V%`11 pass inspection if(«-ith approval of the Board of Health): broken pipe(s)are replaced Obstruction is removed ND explain: T;flo Z 1.- T Page 3 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM L'•VSPECTION FOR11 PART A CERTIFICATION(continued) Property-Address: 14a .e- H r-v-1 Ile 0.2 63� Owner ► Date of Inspec ion: a? C. Further Evaluation is Required by the Board of Health: Conditions exist which_require fiuther evaluation by the Board of Health in order to determine it"'1e _. .;-en_ is failing to protect public health; safety or the environment 1. System will pass unless Board of Health determines in accordance vdth 310;CNIR 15.303(1)(h) that the system is not functioning in a manner which will protect public health,'safety and the en«ronment: Cesspool or privy is within 50 feet of a surface water Cesspool or prim-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 an 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:w-ithin 100 feet of a surface water supply or tributary to a surace 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--k=-e11. The system has a septic tank and SAS and the SAS is less than 100 feet bnt.50 feet or more tom 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 colitbn bacteria and volatile organic compounds indicates that the well is free from pollution from that facili .�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 rust be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FOR — NOT FOR VOLUNTARY ASSESSITENTS SUBSURFACE .SEWAGE DISPOSAL SYSTEM INTSPECTTOI' FOR_ °I PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: D. Svstem Failure Criteria applicable to all systems: You must indicate "yes"or"no"to each of the following for all inspections: Yes No of sewage into facility or system component due to overloaded or clogged SAS or ces r;ool ✓ Dischar,e or ponding of effluent to the surface ofthe around or surface waters clue to an overloaded or ,<logged SAS or cesspool V Static liquid level in the distribution box above outlet invert due to:an overloaded or clogged S a S or �/�esspool j�quid depth incesspool is less than 6"below invert or available volume is less than',day flow Required pumping more than 4 times in the last year NOT due to clogged or.obstructed pine(s). \umber �tunes pumped y 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 /dater supply. : Any portion of a cesspool or privy is within a Zone 1 of a public well. _ A y portion of a cesspool or prw is within 50 feet of a private water supply.weli.. !/ Any poition of a cesspool or privy is less than 100 feet but greater than 50 feet from a prrva:e v.°ate_ supply-well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified 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.] /V ;Yes/No) The system fails.I have determined that one or more of the above faihiie criteria exist as described in')!0 01vM 1 305,therefore the system fails.The system owner should contact the Boar" 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 a to 15.000 gpd- You must indicate either"yes" or"no"to each of the following: (The foilo«1ng criteria apply to large systems in addition to the criteria above) yes the system is within 400 feet of a surface drinking water supply the systern is, ithin 200 feet of a tributary to a surface drinking water supply the system is located ir, a nitrogen sensitive area(interim Wellhead Protection Area—1, P or=n_= one II of a public water supply}yell if you have answered "yes"to any question in Section E the system is considered a significant treat, or "yes"in Section D above the large system has failed. The o«ner or operator ofany lame system consid ec significanr threat under Section E or failed under Section D shall upgrade the system in accordance z=th 1 04. The system o«rer should contact the appropriate regional office of the Department. Page > of 11 OFFICI_AL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS NIEN TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC1F101 FOR-Ai PART II CHECKLIST Property Address: I eg led, Owner (� ),T Date of Inspection: Q Check if the following have been done. You must indicate "yes"or"no"as to each of the follow ng: Yes No Pumping information was provided by the owner,occupant, or Board of Health Mere any of the system corrmonents pumped out in the previous two weeks? Has t -system received normal flows in the pre-,ious two week period? Have large volumes of water been introduced to the - '� system recently or as part of this inspection A��Were as built plans of the system obtained and examined?(If they were not available note as\/A) C/ _ Was the facility or dwelling inspected for signs of sewage back up.? Was the site inspected for signs of break out ��ere all system components; excluding the SAS, located on site? erer,he sebtic tank manholes uncovered; o erred, and the interior of the tank inspected for the Lo�luition P P of the baffles or tees, material of const-ruction. 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: Yes no� t/ xisting 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 approxi_ ion o d i;t nce is unacceptable) [310 C`✓fR 15.302(3)(b)] r Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSIIEN TS SURSURFACE SEWAGE, DISPOSAL SYSTEM INSPEcTr0 1 FoR:Nj PART C SYSTE�'1 INFORMATION Property Address: /L( Owner Date of Inspection: ,2 0 FLOW CONDITIONS RESIDE\TIAL \umber of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 Upd x fi of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):/" _ Is laundry on a separate sewage system(yes or no)�j/t'J [if yes separate inspection required] Laundry system inspected(yes or no):Z419 Seasonal use: (yes or no): Water meter readings. if available(last 2 years usage(�od)): Sump pump (yes or no):/ Last date of occupancy: COFill ERCIAL/IN DUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): - cod Basis of design flow(seatsipersons/sgft,etc.): 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 use: OTHER(describe): GENE INFORMATION Pumping Records Source of information: Was system pumped as part of the inspecti (yes or no):— If yes, volume pumped: gallons --How was quantity pumped determined? Reason for pumping:— T T F SYSTEM _ Septic tank; a Y 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 con_rar(to obtained from system owner) —Tiaht tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components. date installed(if kno«n i and source in radon: ►�� L Were sewage odors detected when arriving at the site(yes or;.o Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SENVAGE DISPOSA>L, SYSTEM INTSPECTION FORM PART C SYSTEM INFORMATION(continued) Property address: D C L N ✓v� �63� 01vner: (iJ✓�l T Date of Inspection: 09 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: ast iron _v0 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: 113 /f Material of construction:_ oncrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:- Is a Lye.confirm,ed by a'Certificate of Compliance(yes or no):_(attach a cops of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Z'e_5 /✓� �j Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bOtt9yi of outlet tt or baf`e/: ii How were dimensions determined: o h f�a e'ley4Ce� Comments(on pumping recommendations,inlet anc utlet tee or baffle condition,structural integrit<, liquid lei.=is as rela ' to outlet invert; evidence of leakage; etc.): JJ __/// 1 'T' �'►V n /1707 /7 �� ;� T4krAA/77rvg, / G'r+ G+, 4 o Ov V17, X-w GREASE TRAP locate on.site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass�nolyethylene_other (explain): _ Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or bade: Distance from bottom,of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pump ng recomr,:�endations, inlet and outlet tee or baffle condition,,structural integrity. l I :C. 1 as,related to outlet invert, evidence of leakage, etc.): Patre 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSATENTS SUBSURFACE SEWAGE DISPOSAL SVSTE-M INSPECTIO-N FORM PART C SYSTEM INFORMATION(continued) Property Address:' ! -tc, Owner: U 11 Date of Inspection: TIGHT or HOLDING TANK: /// (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of constriction: concrete metal_fiberglass_polyethylene other{explainl: Dimensions: Capacity: gallons Design Flow: _gallons/d . av Alarm present(yes or no); Alarm level: Alarm in%vorkiiw order(yes or no): Date of last pumping:_ Comments(condition of alarm and float switches, etc.): I DISTRIBUTION BOX: L-11"{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 carrvover,.ar_y evidence of leakage into or out of x, etc.):/ cc 4[^mot �✓1 G:l��Cj PLAIP CHAMBER: (locate on site plan) Pumps in Nvorking order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): k a Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT PART C SYSTEM INFOR1NIATION(continued) PropertN, Address: K ✓ 6 � Owner: �i[ ►� Date of Inspection: SOIL ABSORPTION SYSTP;NI (SAS): (locate on site plan,excavation not required) If SAS not located explain why: 2-'�PI` aching �pits, number:L �—, leaching chambers,number: Leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: / overflow cesspool, number: innovative/alteniative system TN oe!name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of eeQeta ion, etc.): S� . p NCl✓1 M�v► — CESSPOOLS:4-1 (cesspool must be pumped as part of inspection)(locate on site plan) Number and confivuration: _ Depth—top of liquid to inlet invert: 1 Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of j oundwater inflow(yes or no): Comments(note condition of soil, suns ofhvdraulic failure. level ofponding,condition of vegetation. is PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: t Comments (note condition of soil, signs of hydraulic failure. level of pondina, condition of w2etation. . i Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTT_a,RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued); Property Address: // o G Owner: Date of Inspection: g' SKETCH OF SE«'AGE DISPOSAL SYSTEM � Provide a sketch of the se-,A-age disposal system including ties to at least two permanent reference'_andmarks or benchmarks. Locate all wells within 100 feet.Locate«here public water supply enters the building. nq a l Q F . s a/0CA- 0 0 v py" belo v ale eJe S Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS:�`IE\TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C f SYSTEM INFORMATION(continued) Property-Address: e,• rv, P, 14143VOoZ6ioL Owner: Date of Inspection: Lf SITE E ZA1VI Slope Surface water Check cellar / 0 Shallo«-wells Estimated depth to ground water feet co Please indicate (check) all methods used to determine the high ground:eater elevation: Obtained from system design plans on record-If cbecked, date of design plan rey-iewed: �rved site (abutting proper!t/obser�ation hole z hi 1 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must d scribe row you established the hiah around Nz-ater elevation: i Ti,io T„c_4:i,„