HomeMy WebLinkAbout0046 LONGVIEW DRIVE - Health 46 Longview Drive
Hyannis _
A= 251 —069
p P
rr TOWN OF BkRINSTABLE
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06CATION b C® SEWAGE #
VILLAGE iOr ASSESSOR'S MAP & LOT�- I
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY [A-X
LEACHING FACILITY: (type) r (size) ak
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between,the: c
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Fcc'
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Fee'
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet o leaching facility) t� Fr.
Furnished by C.�
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PAL- K3 162-32'
C;;�s
Commonwealth of Massachusetts
Title 5 Official Inspection Form a .
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your wayne Archambeault
cursor-do not Name of Inspector
use the return
key.
Company Name
r� box 914
Company Address
Hyannis MA Zip 01
Co
'edOA CitylTown State Zip Code
5087751362 355
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of On site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2/20/2012
pector'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.
t5ins•11/10 Title 5 Official Inspection o .Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. Cityrrown 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:
system consists of 1 block style cesspool used as holding tank with pvc tees on inlet and outlet and 1
6x6 precast leaching pit used as overflow this pit shows 2, of liquid in bottom and no signs of failure
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or breakout or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety,and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. Cityfrown 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 manner that protects the public health,
safety and environment-.-
The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ 0 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
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
t5ins•11/10 Title 5 Official Inspection Form: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
� 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® 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.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
El ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section 'D shall upgrade the
system in accordance with 310 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11110 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
M 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. CityrTown 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?
❑ ❑ 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.
El ❑ 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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
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 e d na
9 ( Y 9 (gP ))�
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: 2/20/2012
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 3.10 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 Fo=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
�M 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
' owner
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 I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every 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:
cess pool late 1960,s overflow installed 7/29/99
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5'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)
cesspool
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
�^M 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. City/Town State Zip Code Date of Inspection a
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.):
this first unit is not a septic tank it is a block cesspool and in compliance with title v
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 scum of to to of outlet tee or baffle
P
Distance from bottom of scum to bottom of outlet tee or baffle
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
46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. Cityfrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert none
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.):
no distribution box required at time of installation
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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owners Name
information is required for Centerville MA . 02632 2/20/2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length: - -
❑ Teaching fields number, dimensions:
❑ overflow cesspool number:
El 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.):
single 6'x6' precast leahing pit with appoximatly 2' of stone around
pit has 2' of standing liquid and shows no sign of hydraulic failure
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
Depth—top of liquid to inlet invert
4"
4"
Depth of solids layer
3
Depth of scum layer
Dimensions of cesspool 6'x6'
Materials of construction concrecte block
Indication of groundwater inflow ❑ Yes ® No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owners Name
information is required for Centerville MA _ 02632 2/20/2012
every page. Citylrown 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.):
cesspool in good condition and is used as holding pit for solids only has no leaching ability
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. Cityrrown 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
' o
IvE
W
t i ®z
t"i ,T
i
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. City(rown 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
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:
town ground water maps 20'
bottom of leaching pit 9'
ground water seperation 11'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 Official 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
�^M 46 Longview Drive
Property Address
Charles and Mary Ellen Bangs
Owner Owner's Name
information is required for Centerville MA 02632 2/20/2012
every page. Cityrrown 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
t5ins-11/10 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 17 of 17
CONINIONWEALTH OF I�LNSSACHt;SETTS
_ 1=
EXECUTIVE OFFICE OF E\•VIR0N11ENTAL A i.aIF
'_ = 1 DEPARTMENT OF ENVIRONMENTAL PROTECTIOI\
';(•. r•
ONE RINTER STREET. BUSTON \L-% 02106 (617�
• TRUDY COXE
Secretan
DA\'ID B. STRUHS
ARGEO PALL CELLLCCI Commissior,e:
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: ILA
1k �p�C v\tom ti Name of Owner �f�1Q*3\-K 1" 0l
Address of Owner:
Date of Inspection: ,\. � EL//
Name of Inspector:(Please Pnr�it C f+a cy C I�U
1 am a DEP approved system inspector Fur want to Section 15./340 of Title 5(310 CMR 15.0001
m
Company Nae: ��r. �r i C k t�r'v�r r_ H �FI� ULCY-�
Marling Address:�'r' L�� �
Telephone Number: �So —� ;2C
CERTIFICATION STATEMENT t
certify that 1 have personally inspected the sewage disposal system it this address and that the information reported below is true. accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the al Approving Authority
_ Fa'Is
inspector's Signawre Date:
��)
r
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this Inspection. It 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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer.if applicable. and the approving authority.
NOTES AND COMMENTS
3
1999
revised 9/2/98 Page IofII
0 Pnmed on It"Ied Paper
1 �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART A
} � CERTIFICATION (continued)
'roperty Address: �v
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
Y— I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
Indicate yes. no, or not determined (Y, N. or ND). Describe basis of determination in all instances. If "not determinec", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltraticn, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) ere replaced r
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four 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
revised 9/2/98 P2ge2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection: -
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
t III
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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private wa(ereupply well.
_
_ The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for eoliform 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. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or -No" to each of the following:
1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correzt the failure
Yes No
_ Backup of sewage into facility or system component due to en 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 thar 6" below invert or available volume is less than 1/2 day flov..
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(si. f
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
'coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10.000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
+ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: (� �C NJ
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
receivirtg normal flow
� _ None of the system components have been pumped for at least two weeks and-the system has been
IL rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. ,Note if they are not available with N:A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout. t
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees. material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
r1�1J� Existing information. For example. Plan at B.O.H.
_ related to Part C is at issue, approximation of distance it unacceptable)
Determined in the field (if any of the failure criteria
115.302(3)(b)1
The facility owner (and occupants,if different from owner) were provided with information on the propermaintenaa"-0f
SubSurface Disposal Systems.
revised 9/2/98 Pace.,oft)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION
'roperty Address: A� �VLC.�
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: Zv g•p•d./bedroom.
Number of bedrooms (design): Number of bedrocros (actual): 3
Total DESIGN flow_
Number of current residents:
Garbage grinder(yes or no):�
Laundry(separate system) s or no): &3 ; If yes, separate inspection required
Laundry system inspected (ye or no)
Seasonal use (yes or no):
Water meter readings, if available (last two year's usage (gpd):
Sump Pump (yes or no):-
Lest date of occupancy:T t�
COMMERCIALfINDUSTRIAL:
Type of establishment:
Design flow: 9Pd 1 Based on 15.203)
Basis of design flow
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:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
r �
PUMPING RECORDS and source of infoorr�tion:
System pumped as part of inspection.(yes or no)_ (�
If yes, volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known) and source of information:
3U��s .aw C�aa� l
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/98 Page 6(if II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
►ray Address:
Owner: /
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_ /
other (explain)
Material of construction:—cast iron_40 PVC_
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:_
etal_Fiberglass _Polyethylene_oth�lezplain)
Material of construction: _concrete_m
I If tank is metal,list age_ Is age confirmed by Certificate of Compliance_ • es/No)
t
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 dimensions were determined: `
/ r �
comments:
pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert. structural integrity.
(recommendation for
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 6f outlet tee or baffle:
Date of last pumping: /
Comments:
(recommendation for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98
Prue 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
pate of Inspection:
TIGHT OR HOLD�NG TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade\
Material of constructio�y: —concrete_metal_Fiberglass_Polyethylene _other explain) -
Dimensions:
Capacity: gallons,
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of a rm and float switches, etc.)
r DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
I �
Comments: -
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
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.)
\ it
II
revised 9/2/98 P.ccsorn
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
I , SYSTEM INFORMATION (continued)
lroperty Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excava ,on not required.location may be approximated by non intrusive methods)
If not located, explain:
Type:
leaching pits, number:L(Q)�'(o
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology
Comments:
(note condition of soil, s' ins of h draulic failure, level of ponding, damp soil, condition of vegetatio etc.
ILA 9
u --
CESSPOOLS:
S
(locate on site p an)
Number and configuration:
Depth-top of liquid to inlet invert: l
Oepth of solids layer: 4' r
)epth of scum layer:
Dimensions of cesspool:
Materials of construction: Q-1-Y'!"_kAt&
Indication of groundwater: tik'�,
inflow(cesspool must be pumped as part of inspection)
Comments: 1
(note condition of soil, si ins o�'hQydraulic failure,level of ponding, c dition of getat on, etc.)
l
PRIVY:
(locate on site plan)
Dimensions:
Materials of construction:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page9of11
it
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: ��,�^VKVJ
)wner: , J
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
• t
g
O �
0
z
_ 30 6r -32
revised 9/2/98 Page 10of11
f '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address: .40 // u5 / \<"v
Owner: [�
Date of Inspection:
NRCS Report name -
Soil Type_
Typical depth to groundwater_-_—_ _ ---
USGS Date website visited 0-1)
Observation Wells checked Deep
Groundwater depth: Shallow Moderate
SITE EXAM Slope biK
Surface water
Check Cellar W,
Shallow,wells`"n/')'//��
Estimated Depth to Groundwater}�J Feet
Please indicate all the methods used to determine High Groundwater Elevation:
, t
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole. basement sump etc.)
Determined from local conditions
I
Checked with local Board of health
Checked FEMA Maps r
Checked pumping records
Checked local excavators. installers
i
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
I
revised 9/2/98 Pace 11of11