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HomeMy WebLinkAbout0102 LINCOLN ROAD - Health 102 Lincoln Street Hyannis '`P -A 27.0 ,0.59 i v e A i9 1 M p I7 y , i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .°r 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 page. Cityrrown 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. Important:When A. General Information filling out forms use the computes, ►^ use only the tab 1. Inspector: I "✓J key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections Company Name PO Box 896 Company Address East Dennis MA 02641 Cityrrown State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification F I certify that I have personally inspected the sewage disposal system at this address:and that tkte information reported below is true,accurate and complete as of the time of the inspection.The';mspection was performed based on my training and experience in the proper function and maintenance ofton site' sewage disposal systems. I am a DEP approved system inspector pursuant to"Section 15.340 off Title 5(310 CMR 15.000).The system: _. r ® Passes ❑ Conditionally Passes ❑ Fails 7 '71 ❑ Needs Further Evaluation by the Local Approving Authority j 10/27/12 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 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. 1 (11 U t5ins-11/10 Title 5 Official' Fonn: ubs ce Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Foram-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 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.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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 wins•}1i}p Tide 5 Of5ctal Inspector,F m1:Subsurtace Sewage Disposal System•Page 3 of 17 I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 page. City/Town State Zip Code Date of Inspection 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 mannerthat 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: I Yes No El ® 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 day flow t5ins-11/10 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for,every Hyannis MA 02601 1U24112 page. Cftylrown 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 oftimes pumped: ❑ ® 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 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. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following,in addition to the questions in Section D. Yes No 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 ❑ ❑ 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. t5ins•11/10 Title 5 Official 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 y�Y 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 page. City/town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant,or Board of Health ❑ ® 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? a ® ❑ 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: ® ❑ Existing information. For example,a plan at the Board of Health. ® i❑ 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): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 t5ins•11/10 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 II, Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 page. CityrFown State Zip Code Date of Inspection D. System Information Description Number of current residents: 2 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 ® No Seasonal use? ❑ Yes ® No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis.of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 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: 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/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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 7 i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 30+years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.6 feet Material of construction: ® cast iron ❑40 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: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 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.): 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 i Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 page. Cityrrown 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 1024/12 page. City1rown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments \Vi��j 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ® overflow cesspool number: 2 ❑ 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.): This system has 5'x5'drywell block pit and a 5'x4'drywell block pit,both are overflow pits. Both pits were dry the 5'x5'pit had a stain linel4"up from the bottom,the other had a stain line half way up. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 3 tee shaped Depth—top of liquid to inlet invert 3" 3„ Depth of solids layer Depth of scum layer 2" Dimensions of cesspool 5'x5' Materials of construction Drywell block Indication of groundwater inflow ❑ Yes ® No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information fo is Hyannis MA 02601 10/24/12 required for every y page. Cityfrown 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.): The cesspool wasa 5'x5'drywell block pit with a stain line at the outlet inverts. there were tees on the outlet pipes. 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.): 4 �p I 4 r t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i, I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 Page. Cityfrown State Zip Code Date of Inspection 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 public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �g l t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 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: USGS maps show an elevation of over 20.0 feet. i Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5lns•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Lincoln Road Property Address Jamal Bittar Owner Owner's Name information is required for every Hyannis MA 02601 10/24/12 page. City/town State Zip Code Date of Inspection E. Report Completeness Checklist ® 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 I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i 2� Op { Commonwealth of Massachusetts Title 5 Official Inspection Form�.�, � .4 ..3. Not for Voluntary Assessments Subsurface Sewage Disposal System Form y Inspection results must be submitted on this form or on the official Title 6 Inspection Form dated 6115J2000 Inspection forms may not be altered in anyway. A. Certification . Important When fi14ng out 1. Property Information: forms onthe computer, b Z s G,u h sue._computeto r,use _ only the tab key Property Address -..- -- - to move your Z) C— e% lc/ t c -T cursor-do not Owner's Name use the return key. Owner's ++Address CityfrO State Zip Code Date of Inspection: Date 2. Inspector. Name of Yispector n cn:"L- Company Name Company Address Cityfrown State Zip Code c.6 6— �6 b Telephone Number Cert! cation 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 Section 1&340 of Title 6(310 CMR 1&000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ eeds F Evaluation by the Local Approving Authority '2/ Ins 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 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. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 _ 1 f I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Property Address w,z S M L A Z O C—ityiTTow? State Zip Code i' lt Owner's Name Date of Inspettion 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 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. Answer yes, no or not determined (Y, N, ND)in the❑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 k�V existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspectiop I it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. p Explain: t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 I ' i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Prope Address Cityrrowrt State ( Zip Code Owner's Name Date of Ins ection 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 ❑ 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 pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5insp.doc•11/2004' Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 i Commonwealth of Massachusetts vim Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) zL. c-, -s-r- Propfrly Address CityrrOW6 State Zip Code Owner's Name Date of In pecti C) Further Evaluation is Required by the Board of Health(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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached. to this form. 3. Other: t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form A. Certification (cont.) ) oz / 1��-T- Property Address _ Cityrr w'n Stated ZipCode Date of In e1 e) 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%day flow ❑ ❑ 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. ❑ ❑ 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. ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No ❑ ❑ 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. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form A. Certification (cont.) O Z S'T Property Address "'Y ,.,,"f /V� ®z O cityrrowh State Zip Code Owner's Name Date of I pecti n 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. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist Property Address C4fr, n State Zip Code nt� /,,,1 \-ci(/— Owner's Name Date of I on Check if the following have been done.You must indicate°yes°or ono'as to each of the following: YES NO V ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ [� Were any of the system components pumped out in the previous two weeks? [[Jf ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available note as WA) ❑ 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 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. L/ ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CHAR 15.302(3)(b)) t5insp.doc•112004 Tde 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information Pro Address �G�H.S ZLo Gtyl1'o ZIP Code �r�- K)4vJ r �� Z I. o e Owner's Pa me Date of I Residential Flow Conditions: Number of bedrooms(design): Number of bedroorns(act: --�- DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): P6 Number of Wment residents: j Does residence have a garbage grinder? ❑ Yes Qf No Is laundry on a separate swage system?[If yes separate irispsc Lion requIreq ❑ Yes [/No Laundry systern inspected? U/Yes ❑ No Seasonal use? �/ Yes Cv7 Plc Water meter ridings,if available(last 2 years usage(gpd)y l9 Sump pump? ❑ Yes U(tdo Last date of occupancy. Data CommenciailindusbW Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gagons per ft(gA Basis of design flaw(sedWPersonslsq R.,etc): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank pmsew ❑ Yes ❑ No Non-sanitary waste discharged to the Tine 5 system? ❑ Yes ❑ No Water meter Headings,if available.- Last date of ooalpancylt1w Date Other(describe): t5iM.doc•11/20Q4 Tft 5 015"inspection Fmm:StftwCaw Sewage Dispow System- Page 8 of 16 i Commonwealth of Massachusetts Title 5 Official . Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) �+ VZ \ C- S�— Pro`perty Address M ,A _L, �Z �Q CitylTo State __Zip Code b � Owner's Name Date of dtio General Information Pumping Records: Source of information: - U h f hAd SWj-jm OWA12�f✓��31/ Was system pumped as part of the inspection? ❑ Yes 9"'No If yes,volume pumped: g How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank,distribution box,soil absorption system Single cesspool L� Overflow cesspools ❑ 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) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Info ation (cunt.) t n Z "rC, S-r- Propertty Address /► Cityfrown State Tip Code Owner's Name Date of Ins 'on Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron ❑40 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. year Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes El No certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of oullet 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? t5insp.doc•1 WON Title 5 Official inspection Form:Subsurface Sewage Disposal System- Page 10 of 16 Commonwealth of Massachusetts . up Title 5 Official Inspection Form P Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Inforrmation (cunt.) C'— ProrAddress ! -41, A- City/town# state Zip Code Owner's Name Date of Ingpection 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 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); t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form. C. System Information (cost.) Property Address p� } 1t-�! v,t- !'• 6l�to c cityrromi state Zip Code Owner's Name Date of I on Tight or Hokting Tank(cunt) Dimensions: Capacity: gaflons 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.): Distribution Box(if present must be opened)(locate on site plan): Depot 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 t5irrsp.doc•1 U2004 Trde 5 Official Inspection Form:Subsurface Sewage Disposal system Page 12 of 16 Commonwealth of Massachusetts UITitle 5 Official Inspection Form Not for Voluntary Assessments Subsurfabe Sewage Disposal System Form C. System Information (cont.) CO2 L %- hc . vs S-T' Pro Address CityRo�-' State -,-,—rip Code ,J d C., �cy •�J\� L Owner's.Name Date of Irlsoectiort- Comments,.(pRtp condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not'located,explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number- leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/aftemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): t t5insp.doc•11/2004 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 I X Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 1 o2— /— � -,C-, Property Address �A />hv.- S /A C5Z e City'/row ' State Zip Code I (e 6 Owner's Name Date of I 'spection 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 IVIA G Depth of scum layer Dimensions of cesspool GD Y G `w conr-Ir,ZT Materials of construction I OC lc Indication of groundwater inflow ❑ Yes No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Sol 1 MPST)\/ srt-vd n0 SI'�nS Crf 170►r Al \0% of- L ' Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Info_ r tion (cont.) O Z Cti,� Sri Property Address CityfTow State Zip Code c>--c_ D 2— t 4 G Owners Name Date of 1 pection 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. �'nr✓n wA�'ZJ�i H 9�t5 I r A A_ a 3 6-2 -'9 6-3 93 3 t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) • Property dress 1- �%I-- AAA ozL L Cityrrown State Tip Code Owners Name Date of Rpiction Site Exam: Slope ' Surface water Check cellar Shallow wells Estimated depth to ground water. 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: hUkgS4 EIM , M AQ You must describe how you established the high ground water elevation: I C �Cl"1<1 sl-IA, 4, t5insp.doc•112004 Title 5 Official Irupection Form:Subsurface Sewage Disposal system Page 16 of 16 V