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HomeMy WebLinkAbout0031 SHUBAEL GORHAM ROAD - Health 31 SHUBAEL GORHAM ROAD Centerville A = 171 — 133 . : Commonwealth of Massachusetts Tithe 5 Official'°In`spectfion For Subsurface`Sewage. !sposal System Form Not for Voluntary Assessments T: w n v Property Address //. �tcLf�l/LnlnlLg•?�/jIY'ifr �41tt�it�'_ � Owner Owner's,Name information is required for every lirr � ;.bGZL'!2 j/sf�iy► p age. Clty/Town !�L A r Qt 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 Impohant:.When fillingoutforms A. Inspector Information. . on the computer, use oniy key 20 move,your Name of InsNector }' cursor do-not use;the.return �p Li /G.J1�� /�?�p� keY• Company Name y� 'v�T p xi�F /.Z 1;'4-4ff Company Address City/Town G�6�t State Zlp Code -- State Telephone Number. 72 T'o License Number i B. Certification I certify that: I.am a DEP a pproved system inspector m full compliance,with,Section 15.340 of Title 5 . (310 CM R 15.000); I have personallyinspected.the sewage disposal system at the property address listed above the;Information reported below is true;,accurate and complete as of the time of my inspection, and the inspect ion`was performed based on my.tralning`antl experience in the proper function and maintenance of on=site sewage disposal systems.After conducting this.inspection I have determined .that the system: 1. Passes 2. ❑`Conditionally Passes 3..' ❑ Needs Further Evaluation by'the Local Approving Authority 4. ❑ Fails Inspectors 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 inspectorand the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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 cond-itionsof use. t5insp.doc.-rev.7/25f2018 Till e_5Official Inspection Forth:Subsurface'Sewage Disposal System•Page 1 of 18 y tr i .. Commonwealth of Massachusetts �n Title 5 Official, Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for ..- page. City/Town State `Zip Codd Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) System Conditionally Passes: Am" ❑ 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 ❑ IaD (Exola..! below): 95insp.doc•rev 7/25/2018 Tit: 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 - Commonwealth of Massachusetts; Title 5ffi;ci1al Inspecton 'For 4 4.: Subsurface Sewage'DIsposal System Form Notfor Volunta y'Assessments _ ... 'Property Address Or Owner wnes Name information is regwred for every page. City/Town, State • Zip Gode Date of Inspection C InSP.&C 10h Sullnlinalry (cont.) y 2) System Conditionally Passes(cont). ❑ ;Pump Chamber pumps/alarms not.operatlonal System will.passwith Board of Health approval.if pumps%alarms'are repaired. x ❑ Observation of sew bac%kup or break out or high static,water level in the distribution box due to broken or obstructed pipes)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): ppO p ❑ Y ❑ N' ❑ ND(Explain below): ❑ broken i e s are replaced ❑ obstruction is removed. ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. 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: t5insp.doc-rev.7Y15/2718 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v� Property Address Owner Owner's Name information is C —fy�v�44J required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will ail 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. ElThe s tic tank and SAS and the SAS is within a Zone 1 of a public water system has a septic 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 DER 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool El Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts Title Offi itafl h 's c section Form ° Subsu-dace Sewage Disposal System For m Not`forVol'untary'Assessments Property Address �lt•y �pcll.,rj' y`:�/�iTl+�°'.SGILLJvr� Owner Owner's Name. information is required for every 7lr�UtLL� /r'f .f` e,'2 v z 5 4v-Tr page; Clty/Town State Zip.Codep., Date of Inspection . C. Inspection.Summary (cost.) 4) System Failure Criteria Applicable to All Systems (cont) Yes No Stafiic liquid'level in.ithe distribution box above outlet inverf due to an overloaded or clogged.SAS or`cesspool ❑ a Liquid depth m cesspool is less,than 6'below invert or avail.ab.le:volume is less than'/z dayflow ❑ Q =:Omping more than 4,times in the last year NOT due to clogged or d pipe(s).Number of times pumped: 777 ❑ Any portion of th`e SAS cesspool`or privy is below highground water elevation. Anyportion;of cesspool oc:pnvyis within 100 feetof a surface water supply or ❑ tributary t,o a surface water supply- An❑ Any;portion'.of a ce.,spool.or privyis within a Zone 1 of a'public water supply well. ❑ ❑ 144 Any.portion of a cesspool or privy is within 50 feet'of a private water supply well. El ❑ � 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 sysfem 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 Elie analysis and chain`of custody mus,.. a attached to this form:] The system`is a cesspool serving a,facility with'a design flow of 2000 gpd- 10 000 gpd The system fails I have determined that one.or more of the above failure criteria exist.as described in 31 O,CMR 15.303,therefore the system fails. The system owner`sho'uld contact the Board'of Health to determine what will be necessary' to correct the failure. 5) 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 CA. 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 t5insp.doc-rev.7/25@018 Title'5 Ofhdal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 1 " Commonwealth of Massachusetts Title 5 Of Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u Property Address 1 ✓L/GL//J Alti Owner Owner's Name information is y 5- 62 63z. 6/y//r required for every page. City/Town State" Zip Code Date of Inspection C. Inspection Summary Cont. p rY If you have answered"yes"to any question in SectionC.5 the system is considered a significant threat, or.answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The.system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes or"no"for each of the following for ay inspections: Yes No [A ❑ Pumping information was provided by the owner, occupant, or Board of Health El Ik Were any of the s components pumped out in the previous two weeks? system ❑ ❑ Has the system received normal flows in the,previous two week period? ❑ [g Have large volumes of water been introduced to the system recently or as part of this inspection? El ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) Co--VsT dZ- [4 ❑ Was the facility or dwelling inspected for signs of sewage back up? 91 ❑ Was the site inspected for signs of break out? [Q ❑ 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)) t5insP.doc-rev.7I2512 018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Tithe 5 ° 'f#icia�l Inns e'cton$ F rm Fw Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name. information is required for every C9�%Tl/t!i/GLf i°Y/�1: G?� �.x S`g��r page. CltylTown State-, Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310-CMR 15.203(for-trample 110 gpd z#of bedrooms) 33�' Description: . Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes FA No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report) ❑ Yes No Laundry system inspected? El Yes ❑ No S' Seasonal'use? ❑ Yes No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gp ))� Detail Sump pump? ❑ Yes M No Last date of occupancy: 4<<un:,E v Date t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is 1"'r-1/7—fr2J��� y�f5�c required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) P 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ES, No If yes, volume pumped: gallons °,.How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/25/2018 Title 5 Official Inspecfion Form:Subsurface Sewage Disposal System-Page 8 of 18 A Commonwealth of Massachusetts a Title 5 official I' +h s`�� ecton Form Subsurface Sewage Disposal System Form Not`for Voluntary Assessments Property Address Owner Owner's Name. information is required for every page. cltyaown State Zlp.Code Date of Inspection D. System lnformatio,W(cont.) 4. 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 by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. -'VE] Other(describe): v -Approximate age of all components, date installed (if known)and source of information: tv 7.3 14ei :'O eV410M i0A Zf Weresewage odors detected whan'arriving at the site? El Yes ❑ No 5. Buildwing Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron EA40 PVC ❑ other(explain): Distance from private water supply,well or suction line: feet 0 Comments (on condition of joints, venting, evidence of leakage, etc.): t51nsp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments Property Address ',4 l U�iw i��L f N �yGGY.L!� �!rlsire, . SuL . Owner Owner's Name information is GZG9 Z C'�s.�1T y!zv�Gc� �y��x�. required for every page. City/Town State Zip Cone Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: [A 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: Distance from top of sludge to bottom of outlet tee or baffle D` 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? �f�s. ST�Gr Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): G azo 12 t,17Wmole- 6-�' feuwr ✓ /4lye t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Tithe 5 ffiiciallns ` ect ©n Form Subsurface Sewa D e is osal S stem`Form Not for Vol 9 p . ; y• ,., untary`Rssessments .5?/ 101A LJ.. Property Address s �f�iZS.y loGG/LrJ c/C/>/7E•.SilL�/ux� Owner Owner's Name information is required for every y�7 SrZt�l j�C GZG page. City/T4wn State Zip Code Date of Inspection D. System Information (cont.) ; §} 7. 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 Comments(on pumping recommendations; inlet:and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): wag 8. 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 ❑ pot eth Y Y lene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/25/2018 Title 5 Official Inspection Form:Subsurface-Sewage Disposal System•Page 11 of 18. Commonwealth of Massachusetts ,p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `J Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 7 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.): /j el 15 1715111, L%"NTL 9 IICtv?dc >�L' t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 { Commonwealth of Massachusetts Title 5 Offi�ciYal Ifns�pecton Form Subsurface Sewage Disposal System Form Noffor Voluntary Assessments Property Address Owner Owner's Name information is 6 '5;'1y-7-A4-t1ja cr �1�5 s G2G�Z s�3/�P, required for every page. City[To ? State Zip.Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site.plan): Pump`s in working order: ❑ ,Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note 'c ondition of pump chamber, condition`of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 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: t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 01' Property Address ,/�L�l� /GuLv r� ,�i1,�T6r. Jfl/L l`T Owner Owner's Name information is �'rr�Y7 ��1�JlLLE /l�Z�S� v1G'lZ 5'/3j�y required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): I✓O [k S'y/�, f s �.�.ti�►y 6a r�6� Nam+ 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): P ( P Number and configuration Depth—top of liquid to inlet invert . Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 ilciz al Ilnsprectilon Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every �:FAV-i U2632 5131�9 page: City/Towri, State, Zip;Code Date of Inspection D System information (cont.) 13 Privy (locate on site plan); Materials of construction: Dimensions Depth of solids Comments(note condition pof'soii,''signs of hydraulic failure,;level of ponding, condition of vegetation, etc.): • - it ! w' t5insp.doc-rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts , �� Title 5 Official Inspection Farm RSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 7� c. A4V Property Address Owner Owner's Name information is �'��,7 t���G� .fp�$� c26�!lr Z 113ll f required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties tout least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public.water supply enters . the building. Check one of the boxes below: hand-sketch in the area below drawing attached separately ?p � ` A jrz t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 • Commonwealth of Massachusetts. _ � Tithe 5 `Ofificila°I' Iknspe`cton Form (-" Subsurface.$ewag`e Disposal System Form Not for VoluntaryAssessments u . Property Address Owner Owner's Name, , information is required for every �/2lJIGl. //�jS G ZG�Z. ST3��p page, - Clty/Town Zip Code Date of Inspection D. System Information (co' t:) 15.:Site Exam: Check Slope T-6 : Surface watero N� ER Check cellar Y�rf Shallow wells..ilrb.4'' 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 1 So 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. t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •�v Property Address Owner Owner's Name information is �/g t�f S 6.26J4 61�01 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Q A. Inspector Information: Complete all fields in this section., M B. Certification: Signed & Dated and 1, 2, 3, or checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 15: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 16: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7125/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 [ s� ! !`o J 1D C�A� 33D G•pt7. r� J S l OOC> t D oa P1T c.)SC I •grrrrox� AQ� _ SCO C�.RD. � �' id ov. p�g2Gflt.QT10�.1 Q ` TIC chi t WD A. 4't•9'� 4°�J ..r 4�.'`11,`` � J1�V.'� iitj;� .._ .-�f ... . /,�t��tt� �..K/{�I'Wli� ��•l.7 �, or F,ro s ioa.o . �oAnt` ,: � �,pp� �' ��- Sic t� ��' • . dd y ? 1DOD 95 1MV. t4hl• GPA -L-- gG•o- Rb 1 w i ru o • .�, ::�,:;�. ._.. T t-1 G -G J� G.h 1�"i C11 chi-�pvV tiJ 1 G17;Z t 4-tu2.Cas,1 GPt_`lSc3itZEc�T� ®z= T+-a L Ls Oar pA`i'E ...�.--..�-`-- 1- ';,r.:. .:r' •,QG G I S t'GiZ�� q�1.l i7 -t-t�ls pt..A�► 's , - k'kC-- , Ay��k-kg A " h Your Septic System and How it Works ,t.,�711 It is important to understand how works and how this your system wo treatment affects it in order to protect your investment. The typical syster'n consists of three (3) main components. The Septic Tank The Distribution Box The Drainft"eld The Septic Tank Waste exits the house and enters the septic tank where solids settle to the bottom, grease and scum from the household detergents float to thetop, and liquids stay in between. The solids olids that settle create their own bacte- ria which decompose the solids naturally. There is no need to add additional enzymes and bacteria to the tank. The tank eventually fills with solids and scum requiring it to be pumped.'A septic should be pumped every two (2) years. The Drainfleld The liquid(gray water) flows to the distribution box where it is evenly di spersed.into the drainfield.. Finally, the drainfield begins treating the gray water. Microorganisms in the soil consume organic pollutants in the gray water and the pure water is absorbed by the ground below. How Problems Start From the first day of use, the drainfield of your septic system begins to deteriorate. Some solids, grease, and scum always pass through the septic tank into the laterals. This is because of natural solu- bility or the lack of setting time in the septic tank during periods of heavy use. Problems especially arise when the septic system is not maintained and the septic tank fills with solids and scum that overflow into the drainfield. As the drainfield becomes clogged, the water flow becomes restricted. Since the water cannot drain into the soil, it filters upward causing ponding, foul odors, wet spots in the yard, and an unhealthy envi- What Causes Problems What you don't read about is that bacteria has a waste called biomat, and they also create a gas,bacteria eats human waste. It does not eat,hair, wool,polyester and other particles. The biomat is like grease. The gas cre- ates bubbles and this causes particles to float up the T and into the distribution box and into the leeching fa- cility,plugging up the stone. Septic tanks should be pumped every two (2) years. Cesspool Cesspools were made by digging a hole in the ground and walls were made of stone then later on they were built with concrete blocks. The waste entered the cesspool, and solids settled to the bottom, the liquids seeped out the sides into the soil. Cesspools should be pumped every year. State Environmental Code Title V Chap. 5 Inspection Procedures Guidance on Completing Inspection Form Part A Certification. The Certification Section has two principal functions. First it provides identification information on the property being inspected and the inspector. Second, it presents the results of the inspection relative to the failure criteria outlined in 310 CMR 15:303. In the certification statement,the inspector is certifying that the conditions existing at the time of inspection are accurately presented in the inspection report. The inspector is not certifying that the system is adequate for the current use of the system nor for the future use of the system. TONY CAPONIGRO 216 North Main Street Mansfield, MA 02048 Title V Inspections Corr monwea6th of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form Not for Voluntary Assessments ~x Property Address XzU Owner Owner's Name information is ✓ �15 a��31 '�/2��7 required for every page. City/Town State Zip Code Date of Inspection , h+7 Inspection results mast be submitted on this form. Inspection forms may not be altered in-Ay way. Please see completeness checklist at the emit of the form. Important:Men A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not ®. CApb O use the return key. Name of Inspector Company Name zip Company Address ei�A, City/Town State Zip Code ej 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 disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 6(310 CMR 16.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2v//-v 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 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 AMR pWorm in the future under the same or different conditions of use. t5ins.doc•rev.5/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal SVStem-Page 1 of 17 Commonwealth of Massachusefts Title -cal Inspection For o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 3/ Property Address Owner Owner's Name information is �fi2vyC�9 /d��5�, Q261Z required for every page. Ciry/Town State Zip Code Date of Inspection B. Certification (cant.) 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 310 CMR 15.304 exist. An in 310 CMR 15.303 or inY 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 repaired. The system, upon completion of the replacement or repair, as approved by replaced or p P P P Y 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.doc,rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I� J Commonwealth of Massachusetts Title 5 Official Inspection Fir Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Af Property Address Owner Owner's Name information is £¢,/V1r zd U/LGF ij F� U2 4 g2 '//Z v/y required for every: page. .City/Town State Zip Code Date of Inspection B. Certification (cunt.) tv-4 ❑ 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): 0 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 dotormines in accordance with 310 CMR 16.303(i)(b)that the system is not functioning in 2 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 i Commonwealth of Massachusetts, W Ile 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name r information is f,v?� �/�� ��, 42/_5? 2ct/67 required for every page. CitylTown State Zip Code Date of Inspection Be Certification (cont.) . ry 4 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: 0) System Failure Criteria Applicable to All Systems:. You must indicate "Yes" or"No" to each of the following for all inspections: Yes No [j G t t. . t d I Backup of sewage into fdcl{Id�u{ �yv v' m c -ponen�.t�ue:=over!oa.J�e•d� or ❑ ® clogged SAS or cesspool ❑ [A Discharge or ponding of effluent to the surface of the ground or surface water 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 0 ❑#JA Liquid depth in cesspool is less than 6"below invert or available volume is less tha;°i i2 day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 1 i Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M Property Address gfL4ry Owner Owner's Name information is L�1'4v,f4?v`zz f p��2 y�Za�iy required for every page. CitylTown 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. ❑ ❑ //A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ 1,N/fit Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ yd Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ N 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 6 ppm, provided that no other failure criteria are triggered.A copy of the analysis and-chain of custody must be attached to this forma I . ❑ 0 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 16,000 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 El ❑ 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 u ❑ the Sy ate 11 i� 100 ed In a nitrogen sensitive area (interim lilbe6lheard �rote`tion Area- IWPA) or a mapped Zone Il of a public eater supple 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 15.004. The system owner should contact the appropriate regional office of the Department. 5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 _s Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is ey,S,�fxzylLj-f /r"i. SS G2G32 s/`ZD�/9 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You merit indicate "yes" or"no" as to each of the following: Yes No ( ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ [�f 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? FA ❑ 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: 0 ❑ Existing information. For example, a plan at the Board of Health. E ❑ 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.doc-rev.6/16 Title 5 Official inspection Form:Subsu-ace Sewage Disposal System•Page 6 of 17 Commonwea fth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forgo - Not for Voluntary Assessments .4�M yV By`v Property Address Owner Owner's Name information is required for every State Zip Code Date of Inspection page. CityFrown D System Information Description: 2 Number of current residents: 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 Al* Seasonal use? ❑ Yes r❑ No Water meter readings, if available last 2 ears usage ( d g ( y� g gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date /VACommerclai ndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: ;5ns.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 ufficial Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Property Address Owner Owner's Name information is G 1L 32 Al./z�j required for every �Srf�y/uf ' page. City/Town State Zip Code Date of Inspection D. System information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of'information: Was system pumped as part of the inspection? ❑ Yes �{'] No If yes, volume pumped: oauons How was quantity pumped determined? V 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 by system operator under contract El Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): '.5ins.doc•rev.6,116 Title 5 Official Inspection Form:Subsurface Sewage Oisoosal Sysiem Page 8 cr 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Dislxosal System Form - Not for Voluntary(assessments Property Address Owner Owner's Name information is ��y7fjp4/1zzj- � f'1� required for every page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: 411>10J as 11 AZg +tC Al4"f 7T Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): 2,N. Depth below grade: feet Material of construction: ® cast iron [1 40 PVC ❑ other(explain): Distance from private.water supply well or suction line: feet „J0 Comments (on condition of joints, venting, evidence of leakage, etc.): i Septic Tank (locate on site plan): �` '� /jSI�,�r fir,7'•.�rs 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 5 .X :riJr' tbao01 Dimensions: Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage DisposalSystem Fogaurs/ Not for Voluntary Assessments 5� fL Property Address &,"bu29 14;27-9 Owner Owner's Name information is �fsZyILCF f�ES G2G 3Z �/�gbf required for every 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 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.): ,o ACC 7WI-/k n7 4244,Aa0C-" .1114 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 iaSt 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 For s Subsurface Sewage Disposal System Forage - Not for Voluntary Assessments Property Address 61W/y,Ae Owner Owner's Name information is G2 G Z 3 t�fZ dfi7 required for every page. CitylTown 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: 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.doc•rev.6/16 Title 5 Official Inspection;Form Subsurface Sewage Disposal System°Page 11 of 17 Commonwealth of Massachusetts Tide 5 Official Inspection For " Subsurface Sewage Disposal System Form - Not for Voluntary Assessments AV 4H Property Address /s Owner Owners Name information is �f�,/7�/2�J/LCP ,4�5� 02G3Z y/2vJ/J required for every page. Cityrfown 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.): * 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.doc•rep`6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal Svstem•Page 12 of'17 Commonwealth of Massachusetts W Title f icial Ins-pectIon Form Subsurface Sewage Disposal System Form -blot for Voluntary Assessments All„ Property Address 9 t;;re9 7-%Sutudr�' Owner Owners Name information is !y required for every O ZL 32 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: 14 leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: ❑ 9 9 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: i ❑ 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.): L O �Y-YP Noyr Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater Inflmu ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Forrn:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusefts W Title 5 Official Inspection Form Subsurface Sewage Disposal System.ForQVI Not for Voluntary Assessments �M Property Address Owner Owner's Name information is required for every rw�"f�2t/lLL�' /�/ESS page. City/Town 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.): �p N/1 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.doc.rev.6/16 Title 5 Offirial Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwea0th of Massachusefts W Tide 5 Official Inspection For Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every �5��?f/�IJILG f 1�1 • page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 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 t5ins.doc-rev.6116 -itle 5 official lnsp=cticr,porn:Subsurzece Sewage Disposal Svstem•Page 15 of 17 Commonwealth of Wssaohuseft W Title 5 Official Inspection Form Subsurface Sewage DiisP®sai System Form - foot for Voluntary Assessments Property Address / Owner Owner's Name A information is L 5,12411 LLf' Al 0-SS required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont-) Site Exaam: [� Check Slope. -,70%a /L J/4^ (] Surface water W0AJ f 0 Check cellar Shallow wells /A.4'`'k 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: = .- 6a Ie� tG is ta�mpec io Repor69 p�s�se see P®po Completeness Chet-Wise on next page, t5ins.doc>rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 1 c� Commonwealth,of Massachusefts 'io Fa , . Subsurface Sewage 6@sp®sall System Form - Not for Voluntary Assessments M Property Address /V fz0; Owner Owner's Name ` information is ifi G�L5, required for every Vl�� lSS page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Ej 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 !Sin=_.dec rev 5116 Tine 5 Offidal Inspection F C,- ulsu:facc>Se..-,rage D;sCosa!S,-:3T°Page ;o. Your , ,1 1' and How it Works, It is important to understand how your system works and how this treatmeiit affects-it in order to protect your investment. The typical system consists of three (3) main components. The Septic Tank ® The Distribution Box The➢rainfield The Septic Tank Waste exits the house and enters the septic tank where solids settle to the bottom, grease and scum from the household detergents float to the top, and liquids stay in between. The solids that settle create their own bacte- ria which decompose the solids naturally. There is no need to add additional enzymes and bacteria to the tank. The tank eventually fills with solids and scum requiring it to be pumped. A septic should be pumped every two (2) years. The Drainf eld The liquid (gray water) flows to the distribution box where it is evenly dispersed into the drainfield. Finally, the drainfield begins treating the gray water. Microorganisms in the soil consume organic pollutants in the gray water and the pure water is absorbed by the ground below. : How Problems Start From the first day of use, the drainfield of your septic system begins to deteriorate. Some solids, grease, and scum always pass through the septic tank into the laterals. This is because of natural solu- bility or the lack of setting time in the septic tank during periods of heavy use. Problems especially arise when the septic system is not maintained and the septic tank fills with solids and scum that overflow into the drainfield. As the drainfield becomes clogged, the water flow becomes restricted. Since the water cannot drain into the soil, it filters upward causing ponding, foul odors, wet spots in the yard, and an uiflaealthy envi- What Causes Problems What you don't read about is that bacteria has a waste called biomat, and they also create a gas, bacteria eats human waste. It does not eat; hair, wool. polyester and other particles. The biomat is Iike grease. The gas cre- ates bubbles and this causes particles to float up the T and into the distribution box. and into the leeching fa- cility, plugging up the stone. Septic tanks should be pumped every two (2) years. Cesspool Cesspools were made by digging a hole in the ground and walls were made of stone then later on they were built with concrete blocks. The waste entered the cesspool, and solids settled to the bottom, the liquids seeped out the sides into the soil. Cesspools should be pumped every year. State Environmental Code Title V Chap. 5 Inspection Procedures Guidance on Completing Inspection Form Part A Certification. The Certification Section has two principal functions. First it provides identification information on the property being inspected and the inspector. Second, it presents the results of the inspection relative to the allure criteria outlined in 310 ' CMR 15:303. In the certification statement, the inspector is certifying that the conditions existing at the time of inspection are accurately presented in the inspection report. The inspector is not certifying that the system is adequate for the current rise of the system nor for the future ase of the system. f TCNY CAPCNIGRC TMIansfieId. T 4 A 0'1 0 9 .itie `v is_—C 11101-!; '•`lp w 1 t b 'c 3 t 33 b G.r� %i!r" ..• ,J t�-�c:., r ='.i USA L OOU 6a�- �(� ,t 2 S �S �•P•�' t cam- M `'v �` Sao Sp r 'P ->-i,To tea►��f r-tow Y ! Fri P`GQGDt.bT QAT� ���tU 2Mtu OR �ZSY,. �tf TV- aQT l7 i1 tv r r: �Fill s1 ; ,49 j _ 4a,95 4o dy _•3 �.-•\'--.......• .'.lf.*1:(;: Ci'} ...�- q'�F Cp Tor Fuo a.o rim.• tuv4 R'�,v IW ,, �� l.oAn1 ... �,paw 'DISY IIN• s C Rlo� �: • -6oX ? IDOO t S �6 t►tV• kwv PIT VlIT" • WAS41Efl ,? ' �E;tJb � � C6QTtP c�czTt��! 9A.7 Tt-iG-. ; v!" !:,1�"iG!'t ;Uo*r✓�+ �'Tp ��/� `'���a`� �pNlPt_�!5 W t'rt-� TNT::. �6�E..c...t►--lam b.i�' SETS us ,, ,IovjQ A` S , �� -$'l-{�5 pC...l�� ('S ��/r�Q�„ ��[3F�5��r� i6-��6bd6.� �}atzd.el�,�.!r..l� J� �� �• ��t��' S ..r...-.^r .w C`►�j�' 6iU�`.`�•-•+ .�•Y 1 i L_L i=°ci f 1 LOCATION SEWAGE PERMIT NO. VILLAGE Cg,V -CA2,V)4J-.�5 , APW, IN.STA LLER'S NAME S ADDRESS BUILDER OR OWNER , DATE PERMIT ISSUED DAT E COMPLIANCE. ISSUED �_ y � � ice. �v, .�° � ��� y,J ��i No.......�7__�0�.... Fss ............... THE COMMONWEALTH OF MASSACHUSETTS ,,� BOARD F HEALTH i � s:............... _Sh F.............. - TVpliration for Disposal ,irks C�nnstrnrtion tirrntit is hereby made for a Permit to Construct. ( ) or Repair ( ) an Individual Sewage Disposal system at: ,off !�,�ir"N .-------------------------•--.........--- " ••-••----•-•-•---•-•.......---•••-•---••-•--•...............•- ��' .Location Address 'p& Y✓ or Lot No. .......................................................... -•----••--• �h.. ...........•••••-•-•-•...... Address .................. ................y .................................... :......----•----------.............._ ......... Installer � ' Address Q Type of Building Size Lot__- .....Sq. feet Dwelling—No. of Bedrooms______ _________________________________Expansion Attic ( ) Garbage Grinder (^rQ aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures -----••••--•••. -•-•--•--•----• - Q W Design Flow________ _ _ _________ ____gallons per person per day. Total daily flow......5�1_4...........................gallons. WSeptic Tank—Liquid capacity -gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. Width... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....... .......... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date....................................... aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water__________________...... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----•-••••--••-•••.-----.-----•-----------------------•---....-•----•--•--....-• - O Description of Soil ----'5...... kvGG-_... 0 .... - r x U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------•-••-----------------------------------------------.................---•-••••-•-•--•••---••••••-•-•--•-••••••••-•--••••---••---•••-••-•--•--••••--•-••-.._.........._.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the bo, rd of health. Signed. ....__'-`' % k t - •--•----•-•-•••••••-...•-•- Date ApplicationApproved By•••---•-•• •---------------•--•--•-•--.........-------------------•-•-•---.......••- Date Application Disapproved for the following reasons:................................................................................................................ ............................•-----•-•-•------------••---._...---•--------...._...._....-•--•-•--••-------I••-••••••--•-••-••••--••-----------•---•-------•-••••••-•-•••••••--•-••-----••-•••••••...•-•-•- Permit No.._........ 1�.............................. Issued._.......... /_.. `� -----._._...Date... Date F \; No........ - .... Fx$ ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF "HEALTH �..........................OF..... r :: _...... . Appliration for Disposal Works Tonotrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System .at: ........ ............................................� _.�.. - ........................................................... ,e--• »1.....t Locat.i�on...ddress r Lot No. ............................................................. ..._...... ...•----...••••••-•---•••••...........•................ Or �"' Address Installer Address atw U Type of Building Size Lot_.� _g_`k.".._..Sq. feet M-1 Dwelling—No. of Bedrooms.......3.................................Expansion Attic ( ) Garbage Grinder (,i°ttK Other—Type of Building � yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ------------•-•-•---------------------•--•-••-_.... •-------=-...------------... W DesignFlow.........:... ..........................-;,,-.gallons per person per day. Total daily flow......Y..9. ...........................g P P P Y Ygallons. WSeptic Tank—Liquid capacity _ `'_gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .). 's.__ :____. Width... ,t... -, Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (s. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fYi ...................................................................................................--- D Description of Soil------------------� w....'-*'----__ �.p-vz./r. .......--• •---- . ��� = °7 W ..................................;.............•----------•-•-----....-- •......•--•---•••---•--•••-••------•--•-••--•--••••••-•--.................--••---•-----•••-------••. .._.. V Nature of Repairs or Alterations—Answer when applicable.............................•._.__......__............................._.......__.._.......... ................•------••-------------------•----------•-•-------•-------...........------------..............•-•--• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE; 5 of the.State,S nrtary;:Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. t 1 41t Signed + .f.. - A ..... - Date ApplicationApproved BY..............,��~�__'_/t........................................................................... Date Application Disapproved for the following reasons______________________________________________ -_.•:.--•-_-•- ..............••----•........•••-•------...........---•--••--•--••---......-•--•-...----•-••••-----•----•I...........................-••................................................................. te r Permit No............. .................................. Issued._.. f ................................. Date F THE .COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. 1!!'* G ..............OF............. ✓/ �u 39'`rdP !�r"'.:4................................ y Tnfifirttte of TompliFanre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( 7() or Repaired ( ) r by � r� t-'l c!! . ---•-•-- ------------------••------------._.........._....---........................._......-----------•--------•--- Installer at.................../.&T..t----•- ` = . -c / w .r-5 -•---------------- has been installed in accordance with the provisions of TI`�I E 5 of The State Sanitary Code as described in thg application for Disposal Works Construction Permit No `_ ...................... dated--------- , _.......__?_ f THE ISSUANCE OF TH15•CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......../ .. 4W..4W..1'4'' ...:.." ......................... Inspector.•. ..._......•..: THE COMMONWEALTH OF MASSACHUSETTS p` r '.y BOARD OF HEALTH .......... t:....OF...... yYt,+1 .......................................... �? No.......... FEE ... .... r_ Disposal Works %nnotrnr#ion Uprrutit Permission is hereby granted............. fL-A.Kd...........Ir-4'lt--fl.......................•-------•-••................. to Construct ( � ) or Repair ( ) an Individual Sewage Disposal System at No................ d t'/ f ._ €- t !CtG......._ .✓_�'TS •• --------------------•-•--------•••......---•.._--• ......•-•................ � --,�- Street as shown on.,the application for Disposal.Works Construction Permit No......ZY.K.... Dated..... ��' ' ' Board of Health DATE................................................................................. FORM 1255 HOBBS & WARREN. 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