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Home My WebLink About0004 SOUTH EAST LANE - Health (2) South East Lane Centerville A= 189-045 r SMEAD No.2-16LOR UPC 125U anraad.eam • Yada In USA WftWMa�IWIRTW SFI � ;,, I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pro ` ntw,ess V Owner e Na mar-�—e ��!/ required ffoor� wT� >2 Vd L�>° >� A o�32- Wry. 4 �� i3 every page. Cityr 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. 'p°'l"t When filling out A. General Information 1 W 1 tl forms on the I computer.use 1. Inspector: only the tab key to e cursor o not — use the return of Iedor _ key. MrAr>sp h E t S xa C 5eerl c- .yextl I C e Company Name i 2 7- KTI Corn nyAddress �" CitylTown state Zip Code 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 of on site sewage di I systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ s Further Evaluation by the Local Approving Authority l3 ins s lure 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.- EP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the The authority. Q ****This report only describes conditions at the time of inspection and under,'tho conditions of tWo at that time.This inspection does not address how the system will perfoi�rt in the future unde?, the same or different conditions of use. c" i !Sire•1 V7o Tme S oadai kaspedw Form.s sppsel system•'Pi9e t bf 1 Y:;p 1 t I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments PropArty Address z � n Omers Name information is /ieWI-e rc V�/ _ W& _( // 3 required for l� �LLQ 0 2(�32. (,r/"` > every page. CityrTown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) ;p1havenot Passes 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: OLL _ a `/el j i 1 3 ii ,3 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-I WO Tige 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I ILIU U VI1111.4 /1 11I*IJC%.iILIVl1 rWIIII Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 Y So vT SOS i L4 ry 2 Property Address EST. o � Owne , oM F,6& infbrr ation te is Name required for °'Lexv-re e VW ,Q �'►'ta 2p G 3 Z �l�-. it �3 every page. CiWrown State Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cunt.): ❑ 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 i me a uynciai inspection rorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Ad res �J nnG --- --- --- Owner MrA- every 'tVXf/Yn'_�_'_information is /Y� C 2-63 Z required for page. cityfrown state Zip Code Date of Inspedion B. Certification (cunt.) 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 ❑ E/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Lg' Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow [Sins.11l10 Tille 5 official Impaction Forth:Subsurface Sewage Disposal System•Page 4 of 17 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '30 r 14 C--/ .4 Ive- Propertv Address Owner OwneP Name information requ red forts t!eW j-e C U/LL E- Q 3,(a every page. Cityrrown 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. ❑ CO/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 21 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. tSrts•11110 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pro rt� Owner Addres — J 1• - s Name information is e ,/1� �, 07 0/-�_� required for V +P J'�—__ every page. Cityrrown 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 El Pumping information was provided by the owner,occupant,or Board of Health 1 OD L ale ❑ Were any of the system components pumped out in the previous two weeks? f CAL ❑ 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 WA) ,t—y"// ❑ Was the facility or dwelling inspected for signs of sewage back up? Q' ❑ Was the site inspected for signs of break out? I� ❑ 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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•11110 Title 5 Official hspecdon Form:Subsurface Sewage Disposal System•Page 6 of 17 i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments &vrp 1--x5T. tole Pro rrty✓Arddress `,�/� Owner Ow�=e 5N O r -99C J x%2Mz iequiredfo is (rj2(p z_ — required for g�/�L- every page. Cityrrown State Zip Code Date of Inspe on D. System Information Description: Number of current residents: O Does residence have a garbage grinder? ❑ Yes fia'O'No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes [t/No Laundry system inspected? # ❑ Yes ❑ No Seasonal use? ❑ Yes �o Zo,i =4 1 2 O Po Water meter readings,if available(last 2 years usage(gpd)): 2,0+Z III Grp Detail: Sump pump? ❑ Yes Tr No Last date of occupancy: i i 3 ate 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•11110 Title 5 OMdal hmpecdon Forth:Subsurface Sewage Disposal System-Page 7 of 17 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments OUT14 C,ASTlop Property Address ry11� �,t, oo^,,, - Owner l�.s T /�' / 9'�W/''1 -�C ame information is required for QN P�U, �� O2/ 3 2— M� ll.. IA` 1O // 13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: I �3 Date Other(describe below): General Information Pumping Records: Source of information: _< � Was system pumped as part of the inspection? es ❑ No If yes,volume pumped: vd J Ions How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank,distribution box,soil absorption system ❑ Sinjle cesspool v— X 55f00 LS ElOverflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 official trupection Form:Subsurface Sewage Disposal System•Page 8 of 17 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _ _SoyTi� f'AST �Q1Ai� Property Address �/ Ls o f � m ��Ve/4 Owner owners Name ) information is _e�t�ej& �V J,-L£, Q1 /�l03 z- �required for l _ every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed(if known)and source of information: 150 ,,.�qq Were sewage odors detected when arriving at the site? ❑ Yes ff No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: st iron 8/40 PVC ❑other(explain): 1154 Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septie.Teinlc(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•11/10 Title 5 OfBdal hspecton Forth:Subsurface Sewage Disposal System•Page 9 of 17 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments q Suql5H FAST I -AVe- Prop Address Owner 01NneP Name IC/JU�`n"y� information is required for �/YI Q�-1�7 �m every page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): -3 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 t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r Owner Owner's ame information is 0�j j required for — Ci !Town state Zip Code Date of Inspection every page. tY P P� 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 t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 i �� VVnu�wnwCa�ur v� maaaaa.rwacaw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ��%r� Owner ownMm information is Vyt- required for every 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 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 10610 IL t5ins•11!10 -itle 5 Official tnspection Forth:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sew a Disposal S tem Form-Not for Voluntary Assessments r• Pro dress � C Owner Own N�e & ------—— --- information is required for �1 13 every page. City/Tom, State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields 'number,dimensions: overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer off 0 — x Dimensions of cesspool X / Materials of construction 3 Indication of groundwater inflow ❑ Yes No t5ins•11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,r P ro ddress Owner rs a � a2 G32, man"& 1/ l3 information is required for 07C every page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydrauli x4 failula re, ve of ponding,condition of 7ve tation, etc.): �/f 2 l ! Privy(locate on site plan): Materials of construction: Dimensions Depth of solids - Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): t5ins-11110 Me 5 Offidal Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal S tem Form-Not for Voluntary Assessments Pro"rty ddress �j�� (C.' r ✓L. ��lC Omer s me information is required for " " Z6 5 Z eery page. CA own State Zap Code Date of Inspection D. System Information (corn.) 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 Twhe ublic water supply enters the building.Check one of the boxes below:. hand-sketch in the area below ❑ drawing attached separately A 15` 3 t5ns•11/t0 Title 5 OMW kmpecfion Forth:Subsurface Sewage Disposal System•Page 15 of 17 Title 5 Official Inspection Form Subsurface S age Disposal System Form-Plot for Voluntary Assessments Pro Ower informapon is required for every page. CityRown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Slope Currace water heck cellar ❑ 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 ❑ 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: Before filing this Inspection Report,please see Report Completeness Checklist on next page. Ons•11/10 Title 50MCW UMperbon Pmm:Sutsurfece Sewage Disposal System-Page 16 of 17 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pr Owner required'fo is required for every page- Citylrmn state Zip Code Date o Inspection E. Report Completeness Checklist inspection Summary.A,B,C,D,or E checked i ❑ Inspection Summary D(System Failure Criteria Applicable to All Systems)completed 19 /System Information—Estimated depth to high groundwater L5d Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins•i vto Title 5 ORtial bewecOM Fonm Subswfaw Sewage Oispo System•Page 17 or 17 i i