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HomeMy WebLinkAbout0052 SOUND VIEW ROAD - Health 52 Sound View Road Centerville A=227-051 Anuft 001 UPC 12534 2.13L�53LO . i I f Commonwealth of Massachusetts ,p . Title 5 Official inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments S� Properly Address �I — ,J Ow ner Cw ner's Name / / / information is required for every C2 d14ITV///`'e / "'�/f 14 page. Cityrrown State Zip Code Date of 10spectiorf 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. t"p°outfo^r. A. General Information fllfmg out forms on the computer, e only the tab ve 1. Inspector keyto mro our Y cursor-do not �/�/ Is-e- use the return key. Narne of Inspector L-yV� o Company Name /44 O O Company Address �'aS��►Ck r►'J /014oil Atyfrown L__, n0 State �D 0 Zip Code Telephone Nurr ` 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 5(310 16.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Ins or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 god 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. tens-3M3 Title50ffidal InspectonFam SubsLeacesexwageDisposal System•Page 1 W17 r Commonwealth of Massachusetts Title 5 Official Inspection Form %VjSubsurface Sewage Disposal System Form -Not for Voluntary Assessments Q 10(4401y1,OV led- Property Address Q Cw nor Ow noes Name w information is 6 &4 k 1 �/1 requ�edfor every t��/f � page. Cityrrown State Zip Code Date of lApecten B. Certification (Cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: al—have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for°yes° "no"or"not determined'(Y, N, ND) for the following statements. ff"not determined,"please ex,0ain. s 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 Hearth. *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): 4 s f5rs•3M3 Title50ffidal lrs pecticn Form suWilace sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form kv Subsurface Sewage Disposal System Form -Not for Voluntary Assessments DS014plej/'/-eP✓ Jed Property Address Dr�r of Owner Ow nees Name 7 information is �� required for every 4eij Ile— A� page. City/Town State Zip Code Date of WApeefiM B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerwhich 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 tyre-3M 3 rfie 5Officiat trspecficn Fmrz SubsWace Sewage oispoW System•Page 3of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J d ,SoN r,d V1-e tj/ Kri Property Address Qnr Her ON Hers Name / N y �/ Al da 6�� 9 'trtformation is (� required for every / page. City/Town State Zip Code Date of Inspec n B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 fleet 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 ❑ ®�_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5m•3M 3 Title 50ffidal Inspacfim F mm Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,Q S—O—C4 0 &J— Property Address �✓�l OS ON ner Oar ner's Name information is CeoJeKP-i Ile M required for every page. City/Town State Zip Code Date of I peatan B. Certification (coat.) Yes No ❑ ff--� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ L� Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surfiace water supply or —/ tributary to a surface water supply. ❑ L�' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ L�' y 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 colifornt 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 nd chain of custody must be attached to this form.] ❑ e 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 CM 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. t5ns-T13 Title 501fiaal Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lc` sG�hc�y�ec✓ �cl Property Address / Om ner Ow ner's Nameinformation is / !1 required for every page. Ckyf row n State Zip Code We of Vspecti6in C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes ❑ PPping information was provided by the owner, occupant, or Board of Health ❑ L7 Were an of the system components um in weeks? y y po pumped out the previous two eeks ❑ CS zs the system received normal flows in the previous two week period? ElHave large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) —/❑ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? ❑ re all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank /f inspected fir 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 n determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (f 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: 2 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t9ns•3n 3 rrde 50fficial Ins pecfimFom[SutsvfaceSewdgeDisposel System-Page 6of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not/for Voluntary Assessments 5�— Property Address Owner Ow ner s Name J information is H / required for every e ✓� 'e �✓ page. CRyNown State Zip Code Date ofhd*tiorf D. System Information Description: L12 I v D Number of current residents: ,� �-- Does residence have a garbage grinder? ❑ Yes L—No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes to— Seasonal use? ❑ Yes 0� Iho Water meter readings, if available Oast 2 yea rs usage . 9 � � Y 9 (gPd))' Detail: Sump pump? ❑ Yes o Last date of occupancy: oat Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gabon per day(gpd) Basis of design flow(seats/persons/sq.t., 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: tSns•sn 3 rile s officiai inspecton Fom[Subsurface se%*ge Disposal System-Page 7 of n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Oro sou✓ Property Address Ow ner Ow ner's Name l� / l information is �0_' eel f � required for every page. Cityfrown State Zip Code Date of I spec mon 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: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): trxrs•3n3 rite sOFtdet Urepectan Farm Subsurface SevegeDisposal system•rage sot n I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a � �G �� L✓ �C� Property Address Q"rer ON ner's Nameinformation is ' required for every 'L - /�l /Q//3/ page. Cdylrown State Zip Code Date of insp ction D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Cessn"9ol ©Jz'S1NPL - P71 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;��4O ❑ cast iron PVC ❑ other(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: Sludge depth: Mrs•3h 3 Tine 50fftdal Ire pectin Form Subsrfaoa Sewdge Dispasat System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form kvivow 1� Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments '-sa Olin Property Address Ow her ON her s Name c_-eo �Vvi / / �� information is 6 b required for every page. Cdy/rown State Zip Code Date of In ection D. System Information (cunt.) 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 tyre•3H3 TifieSAFfidal lrepecfionForm SubsWaw Sewage Disposal System•Page 10 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Nv� Property Address K �Of ON ner Om ner's Name information is VI Va��� 11 h?- 1 required for every page. Wrown State Zip Code Date of Ino wtion 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 worldng 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 tyre-3M3 TiBe50rfidat IrepecfianForm Subsuieee SevMeDisposd System-Page 11 d 17 i' 4 Commonwealth of Massachusetts QVIRWO Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments so� ��,��• 2'd, Property Address rc��o.S Cw rer Ow ner's Name Ar— information is ) li— A� required for every Page. City/rown State Zip Code Date of I specti n D. System Information (cont.) Distribution Box (f 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: trns,31$ r&50ftal trspectonFam Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �9 �sO yHdt/et" ,ed Property Address Ow ner ON ner's Name information is required for every C-nH page. City/Town State Zip Code Date of pectic D. System Information (coat.) / Type: t0 Y C leaching pits / number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ eaching fields number, dimensions: overflow cesspool number. ❑ innovativetaltemathe system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,.condition of vegetation, etc.): 21.4 s r� Z" '2_i " � z o Jl ✓,.S' 01 c44 0k l tii,c I Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): / Number and configuration 1 Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer T;" Dimensions of cesspool elnG / Materials of construction Indication of groundwater inflow ❑ Yes No Mrs•3M 3 Tile 5 Official Inspection Form SubsLeace sewage Disposal System•Page 13 d 17 I Commonwealth of Massachusetts wM Title 5 Official Inspection Form BMIM Subsurface Sewage Disposal System Form -Not for Voluntary Assessments %Vj Property Address J Owner Ow ner's Name information is required for every � page. Cityf row n State Zip Code Date of Inspeefion D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy pocate 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.): t5ns 3M3 Title5011cial inspection Form SubsWim SewrageDisposal System.Page 14 d 17 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage 1Disposal System Form -Not for Voluntary Assessments Property Address P �o Ory ner Qv nees Namehforn required is lief ✓< l x Oo2.6.;O- I1 1q / required for every page. C tyfrown State Zip Code Date of s*Wn D. System Information (cost.) 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 ;,reand ublic water supply enters the building. Check one of the boxes below. _sketch in the area below ❑ drawing attached separately F"io { '06) 6 _ � 3 , 63 - I ;. haza3--+a-�,,.aLu+ .Sx W�r,>rk,a-"� `a .�ln J 3" Fib t k ¢_ ,dz`�� ". `,,� `�' " -t+ gy EZFvrW'.rw�� �'' - i-ew-o.s 4. .H K/ - .'++.c..-Yips ru.' i t'*P..h� yA '^�(r '^K+'.�'F• u ' ,ua?*,d 'a�y'"�k%r�✓�t��Gh V�, V'�n j Y¢.a�Cz` xu-y Tr6e51RSpBCiQIFC[18".�![#!�r r 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5� LS70C',hC)v1ec✓ Property Address Ory ner Cw ner's Name /4 /%w/f/f ry information Ceo 4,yt! required for every / page. Cdyfrown State Zip Code Date of Ins lion D. System Information (coat.) Site Exam: ❑ Check Slope ❑ Surface water , � ^� to ❑ Check cellar ✓ � a ❑ Shallow wells r�l✓ Estimated depth to high ground water. feet U 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: 6090p47 D ST /�$V�e d 7Z; / cl 8 77, C /o L4 ✓��G1/`d L// Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ns•3N3 PU501`ficial InspectionFonrt Subsurface Sewage Disposal System-Page 16 of 17 I r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments \V,J 6D� S�140�vi�e�,/ lei Property Address di f' rdrof ON ner ON ner's Name /J/f infomstion's required for every page, Cityrrown State Zip Code Date of Ins ea*n E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed C� Sy em Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file L5ns•sns rite 5Official Iris pectionForm Subsurface SevMeDisposel system•Page n d n COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' a DEPARTMENT OF ENVIRONMENTAL PROTECTION • Y TITLE 5 f • OFFICIAL INSPECTION FORM—NOT FOR VOLUNT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ASSESSMENTS PART A CERTIFICATION Property Address: ✓ SO a vt t7 Vie L/ C-i Owner's Name: q e �'� L Jd% Owner's Address: no Date of Inspection: �� p psi Name of Inspector: (please print) 71�GI r-4 ' Company Name: Mailing Address: Telephone Number o t�a 6 ag CERTIFICATION STATEMENT 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 SeS , 15.340 of Title 5(310 CMR 15.000). The system: �� Passe s Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa Inspector's Signature: 1 • Date:.. ps- The system inspector shall submi 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 low of bQ,A00 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office he DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,a id the apg�eving a authority. 1 c) Notes and Comments- N • co tz q erg A ****This report only describes conditions at the time of inspection and under the conditions f use aMat r co time. This inspection does not address how the system will perform in the future under the s me or different conditions of use. Title 5 Inspection Form 611512000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: S u H C OF 9 I ✓vi t�ozd6 J Owner: d7 C ,L Date of Inspection: a 0 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys Passes: I have not found any information which indicates that any of the failure criteria described in 310 CNR 15.303 or in 310 CNR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B• System Conditionally Passes: , One or more system components as described inPass" section need to be repaired.The system,upon completion of the replacement or epair,as approved by the Board of Health,laced wor ill will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"mined"please 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 ' existing tank is replaced with a complyingpp imminent.System will pass inspection if the *A metal septic tank will pass inspection if itPs s structurally Soun d n t�leakin Board of Health. indicating that the tank is less than 20 years old is available. g and if a Certificate of Compliance ND explain: Observation of sewage backup or break out or high static water level in the distribution box due t 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pies .The Pass inspection if(with approval of the Board of Health): p ( ) system will broken pipe(s)are replaced, obstruction is removed ND explain: T:flo C InCnA,#-inn 7 nr.„�iici�nnn 2 Page 3 of I 1 OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: i^� 0 ti H Owner: e Date of Inspection: 0 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Heal th is failing to protect public health,safety or the environment. in order to determine if the system 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 1 b that system is not functioning in a manner which will protect public health,safety and the environment:the _. Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System win fail unless the Board of Health(and Public Water Supplier,if any)determines that t system is functioning in a manner that protects the public health,safety and environment: he _ The system has a septic tank and soil absorption system(SAS)and the SAS is wi surface water supply or tributary to a surface water supply. thin 100 feet of a _ 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 — The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or mor well. private water supply well**.Method used to determine distance a from a ---------------- "This system passes if the well water,analysis,performed at a DEP.certified laboratory,for coliform bacteria and volatile organic compouns indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Tiiln � fncnnnhinn �nrm!/1 G/�MII 3 ' Page 4 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOXM PART A CERTIFICATION(continued) AProperty Address: O4t H /eta R� Owner: ? t o Date of Inspection: 0 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No -_ ckup of sewage into facility or system component due to overloaded or clogged SAS or Discharge or ponding of effluent to the surface of the ground or surf o cesspool surface 4bgged SAS or cesspool e waters due to an overloaded or L-' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool quid depth in cesspool is less than 6"below invert or available volume is less than%:day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s .Number 'mes pumped gg p p ( ) y portion of the SAS,cesspool or privy is below high V y portion of cess ool ri ground water elevation or P p vy is within 100 feet of a surface water supply or tributary to a surface ,-Water supply. _iRny portion of a cesspool or privy is within a Zone 1 of a public well. My 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 colIform bacteria and volatile organic compounds indicates that the well is free from pollution from,that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria • �/n are triggered.A copy of the analysis must be attached to this form.] V (Yes/No)The system fails.I have determined t as described in 310 CMR 15.303,thereore the system fails.rThe e ofsystem°owner should contve failure'criteria act the Board o Health to determine what will be necessary to correct the failure. f E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 d to 1 gpd. l;P 5,000 You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) es 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—MPA)or a mapped one 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. Title C incnon►inn �nrnr 4/1</Innh 4 Page 5 of 11 OFFICIAL INSPECTION FORM . —NOT FOR VOLUNT ARY ASSE SSMENTS ENT SSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: J�o y►t v*ew Owner: Date of Inspection: �. Check if the following have been done. You must indicate"yes"or"no"as to each of the folio win ; Yes o Pumping information was provided by the owner,occupant,or Board of Health — ere any of the system components pumped out in the previous two o weeks . ✓ Has the system received normal flows in the previous two week e 'p nod . Have large volumes of water been introduced to the system recently or as part of this inspection') Were as built lane o p f the system obtained and examined?(If they were not available note as N/A) Was the facility or dwellinginspected f msp or signs of sewage back up 7 Was the site inspected for signs of break out? Were all system components,excluding the SA g S,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 um. Was the facility owner(and occupants if di maintenance of subsurface sewage disposal systems?fferent from owner)provided with information on the proper The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes nq JExisting 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(3)(b)] Title S fncnui.tinn pnr F/1 c/7nnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLU NTARY ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address' O A N dV Q W 1�j ev�t. 4 0' '-6 Owner: �Pr 10 Date of Inspection: I FL W C NDITIONS RESIDENTIAL Number of bedrooms(design):—2— Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: c)— Does residence have a garbage grinder(yes or no):'A/'O Is laundry on a separate sewage system(yes or no):,4LV(if yes separate inspection required] Laundry system inspected(yes or o): Seasonal use:(yes or no): ejP LV Water meter readings, if alXalble(last 2 years usage(gpd)): Sump Pump(yes or no): /6/0 Last date of occupancy: N ii+e,.✓� COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gad Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: . f7.0 7L �a f+ of f' Was system pumped as part of the inspection(yes or no): a�- If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septi -tank,distribution box,soil absorption system a ' gle 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) —Tight tank _Attach a copy of the DEP approval —Other(describe): C Appro imate age of all compone s,date//installed if known) nd source of' o�nation: 9207 Were sewage odors detected when arriving at the site(yes or no):&10 Title Incnnrtinn Gn'.n A/15/innn 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C f_l) SYSTEM INFORMATION(continued) Property Address: Jo` �'M► lei e1w l n ` Owner: P?/' t o s �V &PLiC D-' Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: a 1� Materials of construction: ast iron 0 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:/locate on site plan) Depth below grade: Material of construction:.concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: 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:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tihla fncnartinn Fnrm �ii Snnnn 7 - Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5� VL r, //���� f ew�, * Owner• l�Ydt.a � Date of Inspection: /0 075 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:Z(ifresent must be opened)(locate on site plan) Depth of liquid level above outlet invert: #1 D//`7 m►L-, Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakag,�*into r out of bqx,etc.): AV PUMP CHAMBER:&(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): T;tlo 8 Page 9 of 11 OFFICIAL INSPECTION FORAM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATIOf N(continued) Property Address: 5� u 6n do ew Rd /� I vi �g Od-6 3�- Owner: i`e�''d�0 Date of Inspection: a O r SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type / �( e �leachingpits,number: l ` leaching chambers,number: koel 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.): // /0 N Cr ✓! — h.l �e /✓1+ oC "1 N eii V _ 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: O Depth of scum layer: / Dimensions of cesspool: X 5 Materials of construction: q c 4 Indication of groundwater inflow(yes or no): Comments(note condition of soil, of hydraulic failure,level of�onding,condition of vegetation,etc.): 1 Cex"oo 4t 2igns 114, 5 y e- PRIVY:k6locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level ofponding,condition of vegetation,etc.): T:tlo G lnenonhinn Rnrm 411;ilnnn 9 I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ✓t?' 14#1 41 ew �v Owner: Pe✓C6 10 lk' �If Date of Inspection: O 05 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. F-o 5s ' -�% 63 S 0 Tirlo G Incn—t;nn P—M 4/1;/11)0n 10 page 11 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS '- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC TION FORM • PART C SYSTEM INFORMATION(continued) Property Address: r «r d vc t,� 02j Owner: Date of Inspection: SITE EXAM _? b Slope Surface water Q Check cellar Shallow wells Co�,1.�4� c Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: 0 F Obtained from system design plans on record-If checked,date of design plan reviewed: 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 h w yo established the high ground water elevation: r � �. /Ofc��i�• l o� 6, G, 15 �f p 0 190 1 t � t pOt9v '� -'rJ10 0 4" T410 G lncnontinn 11 LOCATION SEWAGE PERMIT N0.250 PILLAGE INSTA LLER'S NAME i ADDRESS /q(//LCAle-- F. E LLIS je. \� 1( 1?�-fMS C-`�( O B UILDER OR OWN R Mlq/z L/ kc . 0 U&fiA/ i DATE' PERMIT ISSUED DAT E COMPLIANCE ISSUED � �- � r /6 i .. l r l � THE COMMONWEALTH OF MASSACHUSETTS BOARD H L I-� A'_. .......... .......OF........ .. _ Appliration for Mipaii al Workti T.an,itrurtinn Vantit �Y1 Application is hereby m e for a Permit to Construct ( ) or Repair ( ) an Individual Sewage sposal System at: .�,� ........... -- IJ V -•-------••-. ------------�� -------------- ........................... W k� /LC� Owner •-• �LL�p ...�.Jf-L.l.{ -- a ............................ . ....... — ...... :.._... Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) U Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ............................... . . W Design Flow.................................-----------gallons per person per day. Total daily flow____-___-___---__---_...........,.........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 ( ) Dosing tank ( ) Percolation Test Results Performed bY........................................... .............................. Date........................................ Test 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........................ -----------------------------------•-------------------------------•-----•--------------•--•-••--••----------------------- --.-.........•---------- •---------- 0 Description of Soil----------------------------------------------••-------.............-----------•-----------------=---------------=----------.....------ ------------------•-•--•--- x U ---•••••-----------••--...-•-=••••-•••••••-•---•-----------•-----••-•-••••••••••-••---•--•----•-----•--•--•-•••-•--•----•---•--------•---•-••-----•----••-••-•-•-•..................................... --------------------------------------------------------------------------------------------- f V Nature o pair or Alterations—Ans er when appli b _``7���. � ____.. b._____�� S .fo? ..._. dc1C Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu d the board of health. Sie .- . �Q ............................. Date Application Approved BY -• .............................. /2=—g----.7 Date Application Disapproved for the following reasons:............................................................................................................. ---------••---------•-----------------•---......------------......_..-----•-----------.......--------------------•---.------------------_---_-_.................................................... Date PermitNo......................................................... Issued-- /X......-/--......... ----------- Date Y�.... FR,�.......`................ THE COMMONWEALTH OF MASSACHUSETTS ,,. BOARD F H T ...OF.... .. ._.... ............... i t ....... Appliration for Disposal, Works Tonstrudiiuit Prrutit f W" Application.is hereby made for a Permit to CStruct ( ) or Repair ( ) an Individual Sewage 'Disposal System at, ..:Y...- --Y•��1�=' --- .. ..... --•- -•-•...... . ............. Q Location•Addresse�t_ or Lot No. ...... Owner- :;?' Address Installer - � Address UType of Building Size Lot...:............ x .....Sq. feet �.� Dwelling—No. of Bedrooms_._...?'.....................................Expansion Attic ;� ) Garbage Grinder aOther—Type of. Building _______-__._•_•__._.____..- No. of persons............................ Showers ( ) — Cafeteria ( , ) dOther fixtures .------••-----•------------------------•--•---•------------------•--- -------------.................•----.....-•---=-•---•----- WDesign Flow';...........................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid*capacityi...........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. ( ) Dosing tank ( ) Percolation Test Results Performed by...................... --•...............•----...-•-••---•------•--......• Date----r- 4 Test Pit No. I................minutes per inch Depth of Test Pity-------:.......... Depth to ground water........................ 44 Test Pit No. 2.-,-,............minutes per inch Depth of -Test Pit.................... Depth to ground water....._.................. a' ------------•••••-----------••-•-•--•--••-......=w------..:.••-•-------.----•--------------------•-----------------•--.----••-----•------...... s, ODescription of Soil ---•••---•••-•-------------------•--••-----------------•-------•--•-----......................................................... U ......---•.............•---••••---........._.....----•-•-•------•--......--••----••---.............._.....---••-••------_....---••-----•--•--------------•---•---•---•----•-•----•--•-•-•---------------• W x Nature of Repairs or Alterations_ =`=---------------------------------------------------------------�-----------------------•------...------------------._...---•------- U P Answer when applicable................................................................................................. ` ------------ - --------•-•-..........._...................--•••••---------••-----------........----•-•-•----------------•-----•----••-----•--•--••-------------•---•----------•-••......-••••...._. Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT LIZ V5 of the State Sanitary Code—The•undersigned further agrees not to place the system in operation until a Certificate of Com liana hass been issue the board of fllie lq th.0 a -_=----- - ¢g.. �..._. (v Date+ Application Approved By •f.................................................... ' ---------------------------- ........................................ Date Application Disapproved for the following reasons:............... '------------------------------•-----------------------•-----------------•------------- 3 Date Permit No................................." . , Issued........................................... Date THE COMMONWLALTH•OF MASSACHUSETTS 1 BOARD d, HEALTH . ...........:`.............................OF....... ................................................ .................. rr#ifirtt#r ilf (pia t lianrr 'lie Ali TQ Jndividual Sewage D•sposal System onstruct d ( ) or R aired ( ) by---;•--•-- ..................• -•--- ----- �,L..: V W..------ .. ............... at........................ --- -------•------------- ........................................... ---.....-•-•--.............----•-----_. :-•• --- ------•------••----•---•--------•-- .................................. has has been installed in accordance with the provisions of T gZf e State Sanitary C/F� Aser in the application for Disposal Works Construction Permit No................ da.ted_. ..__ ._. -_.____.__________,_...._..._....... 1. THE ''ISSUANC•E-OF THIS CERTIFICATE SHALL NOT B 1CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......7.:2.---- ` `'^ ........ .... Inspector 7._U .......•... THE COMMONWEALTH OF MASSACHUSETTS BOARD* H A S"d fi - ............................. J *...........................0F....................................... No.•....................... tiFEE....•-•................. Maps � � ion rae mit ' - Permissio is hereby gr' te ---.....~ a... a 4 ...... to Constrti/01 r e i ( p j Sm,a Zispos }4 at No . .. ... ......--^•--------...^ ........................._.. treet as shown on the application for Disposal Works Construct•o mit OR _ . ......................................... -- •------•--•-------------- i Boar f Healtl4N DATE. FORM 1255 HOBBS& WARREN. INC., PUBLISHERS - - s'