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HomeMy WebLinkAbout0236 STONEY CLIFF ROAD - Health 236 Stoney Cliff Road Centerville A= 190-157 SMEAD No.2-153LOR UPC 12534 &M&W-COM • US&in USA 1 � mM um M W I�OOUQ W SFImmusamm �—L\, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 36 s� ye C/,�c Property Address CC110riol �Or'✓t't a ✓� Owner Owner's Name information is �e0 v.v,e//� /yJ/¢ Od 6 ?� required for every 1� /% I a�v/a, page. City/Tovm state Zip Code Date of Inspectidh Inspection results must be submitted on this form. Inspection forms may not be akered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1, Inspector: key to move your cursor-do not k/ use the return key. Name of Inspector _ �I Company Name A-) Company Address City/Town State ) Z-/0�t�- Zlp 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 disposal systems. I am a DEP approved system Inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority )Inspecto s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DER)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP, The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of Inspection and under the conditions of use at that time. This Inspection does not address how the system will perform In the future under the same or different conditions of use. Itilns•11110 Tilfe 6 OR�dw InepedionMForfaoo Sewopo Disposal 9y ern•Paps 1 or 7 `4 Z\ Commonwealth of Massachusetts y1111111111WIMTitle 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments v ti e C�! �� le c'Property Address Owner �'� A Information is Owners Name required for every t�2�►-�Q✓lr! l/� /� O�G 1 '1 �� page, City/Town State Zip Code o� Date of I ec p podlo B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System saes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist, Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as the Board of Health, will pass, approve d by 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): 16ina 11170 TRIe 5 oMldd In"etion Foam S-bourfe"$ a Mepoew eydem Pope 2 of I? Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner .._.... D►!ii"� � �/ ---- information is Owner's Name/' I� required for every l/.xr�� �vr �6 �� page. Cityrrown State Zip Code Date of peetion B. Certification (cost.) 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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(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 pipes) are replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(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 16.303(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 lama•i wo T-ale 6 omeW In ePealon form:suow/tooe sOvrps owl sygam•Paps 3 d 17 commonwealth of Massachusetts movTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C� 3 Yohe Property Address Q/•t"?ah Owner owner's Name Information Is required for every 6ell, / AX, �p2 6�� 6 page. City/Town State Zip Code Date of pedion B. Certification (cont.) 2. System will fall 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 ❑ 2r� Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters LM due to an overloaded or clogged SAS or cesspool ❑ f tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Ys day flow 181rN 11N0 TMb 8 OMOW I nepsotion Form:8utruAeoe 8evwpe 0fepoeel 8ydem•Pepe 4 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage olsposal System Form-Not for Voluntary Assessments 3 C 411e 0/ -Y , 1 =Propertyddress Q/1/`7 R ✓f Owner Owner's Name I,, - _ e6 - Information Is6?,(.4 required for every J page. City/Town State Zip Code Date Inspe on B. Certification (cant.) Yes No ❑ Er-- Required pumping more than 4 times in the last year NOT due to clogged or ,_, / obstructed pipe(s). Number of times pumped; E] 09 Any portion of the SAS, cesspool or privy Is below high ground water elevation. ❑ y` Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ L/Y Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ tad" 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. (Phis 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 2000 10,0o0gpd. g gPd- ❑ The system al s. 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 I_or failed under Section O shall upgrade the system in accordance with 310 CMR 15.304, The system owner should contact the appropriate regional office of the Department. 161n6 t t�t� TH6 6 Orfldd 1Aft04 16h Fom,:CA wfa e 9ev�o 156ve.ol 8ydwm•Pape 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection FormSubsurface Sewage Disposal System Form - N Not for voluntary Assessments Property ..0 t,�� owner ©✓w� Information is Owners Name required for every a6 / Page. City/Yown o� State Zip Code Date Ins on C. Checklist Check If the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ �Pumping Information was ,...,/� provided by the owner, occupant, or board of Health ❑ ll7 Pumped ou ere any of the system components pum p t In the previous two weeks? ❑ H s the system received normal flows in the previous two week period? 0 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) i�� Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees Material Of dimensions, depth of liquid, depth of sludge and depth of sc m? trucUon, 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. L� U 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): 3�0 DESIGN flow based on 310 CMR 15,203(for example: 110 gpd x#of bedrooms): ------._._. islm i w o RIO 5 Mow Invedbn form:sub"dae.9"4 ply,A o wn*Pop e of I -C—\, Commonwealth of Massachusetts Title 5 Official Inspection Form W Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner Ownet's Name � /� / ' information is�uiired for every ACT CltylTown State Zip Code Date Irtspoct n D. System Inform ' Description; � S Number of current residents: Does residence have a garbage grinder? ❑ Yes [�No Is laundry on a separate sewage system? (if yes separate inspection required) ❑ Yes No Laundry system inspected? ❑ Yes @--ko Seasonal use? es ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sumpump? P ❑ YesNo Last date of occupancy: Date Commercial/Industrial 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 6 system? ❑ Yes ❑ No Water meter readings, if available: roi�.•„n° rna a omaW i nepeotpn Form:5uhaurlaoe swApe DbDoeal system-Pape 7 0(17 Commonwealth of Massachusetts Wli Title 5 Official Inspection Form Subsurface Sewage a�Disposal System Form -Not for Voluntary Assessments C Property Address 0✓v�la ✓J Owner Owner's Name Information Is required for every 6 S page. Cityrrown 7State Zip Code Date of In pectlon D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: S l� Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons i How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): tgins 11110 This 5 otrioet inspealon Form:subsuriwe sewage D"mi syetsn-pope a or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a Disposal System Form Not for voluntary Assessments Of-11� :0%Ynees perty Address f'f0-7 A Owner Name — Information Is required for every ✓''117Wv6 page. Cttyrrown State Zip Code Date of nspectlon D. System Information (cont.) Approximate age of all components, date installed known)and source of information: dam! V7 5 � - (if_ot--- Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: — feet e Material onstruction: cast iron 40 PVC o r R� the (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc,): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludoe depth: t61ra t 1r10 Me 6 OfOdd I napedion Form:Subwrfew SwqP Dapaal grpWn•peyp 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System orm - Not for Voluntary Assessments =PropeAddrew! Owner Owner'sOwner's Name f� ez V7 information is Ima R� _ required for every —_ ✓V page. CltylTown State Zip Code Date o nape on 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.): 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 loins•11110 Tula 5 0910 Inapaabri Donn:Subsur(ew Sempe IMe wl Sydem-Pape to or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14P CAI�� /? Property Address <V�U Or�2 a✓� Owner Owners Name required Is m 0,2 C 3 requiredaired for every page. Cit ffown State Zip Code Da4ofnspeotW1oni ::—. 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 ISlna•11110 This S oMoW insp ection Form:SubauAooa 3ewepa Disposal 8ydam•Paps 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System orm-Not for Voluntary Assessments Property Address Ofi/"t a vs Owner Owners Name Information is required for every page. City/Town State Zip Code Date of-Asinalon 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.): Boll Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: IBIn�•11110 T,�R o,,,,,,,l„- p-ab„F-•mi OulnuAwe Oevrape Olyxwol OVgMn•PYps 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J �6 p vl P lam// Property Address Owner owners Name Information Is � � v �6�~ required for every 0�6 /' page. cityrrown State ZipCode fr+ Date of nepectlo D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ le g 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 Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Al Depth of scum layer Dimensions of cesspool X �X Materials of construction Ple " ��S 4 fie' �aS� Indication of groundwater inflow El Yes No IOlns•11/10 This S OMOW Inspection Form:3ubsuffoos Sswop Dhpossl syslsm•Paps 13 sf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ?6* k 'e Property Address Owner ®rv''1�✓) Owners Name Information Is required for every e"r "`'1 �� `A14: page. cityn own State Zip Code Date of I pecti D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): One 11/10 This 5 Motel Inspedion Form:Subsurface Sw We Disposal Systems Pape 1/or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage osal System FOrtft -Not for Voluntary Assessments Property Address —� ✓`7 G � Owner Owner's Name O Information Is ttr�1 / �/J� L/ off /�,/,� � required for every 6 / '/� -._-L l. page, Cityfrown State Zip Code Date o flaps Ion D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system. including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p ater supply enters the building. Check one of the boxes below: hand-sketch In the area below ❑ drawing attached separately r l o� ISIM-11/10 We 5 Of"InWatbn Form:Subsurface Somps Dispml Sydem•Pope 15 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Form-Not for Voluntary Assessments Property Address Owner Owners Name Ce� ` /4 Information Is ! J[ ��3� ^Id �Aj, required for every �/' '/ page. Cftyrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high round water: p g g rest 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) 2 --�Checked with local d 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: v V17 de A5 /9 Before filing this Inspection Report, please sea Report Completeness Checklist on next page. 161m•11/10 '7ftoomdw trmpeafon Form:suDaullaoe sawpa oapoasl spdem-Pop 18 of 17 Commonweaith of Massachusetts Title 5 Official Inspection Form Subsurfa ce Sewage Disposal System Form -Not for Voluntary Assessments ry Property Address Owner Owner's Name (�Information is �� ��G /� required for every ` zzlf- 00-Le 42- page. CftyfTown State Zip Code Date of I pection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed rSys "Information—Estimated depth to high groundwater tch of Sewage Disposal System either drawn on page 15 or attached in separate file Wine•11/10 inspection Fonn:SubsuAece Sewage Disposal System-Page 17 of 1y