Loading...
HomeMy WebLinkAbout0781 OLD STRAWBERRY HILL ROAD - Health 7 ;I Old Strawberry Hill Road Hyannis A= 253-013-004 6MEAD "2453CR UPC 17734 smAadaom 9 Yado In USA OEM% O �u�n�ataoouetw SFI arla� 1 p 1 i 1 R C-4 S I � 2 G ,v I TN7-1 - c�- BOILERa O WATER UNFINISHED BASEMENT 1 FIRE O ALARM ELEC. PANEL BASEMENT EXISTING LAYOUT SCAL'Ej I INCH = 10 FEET ID: PROPERTY ADDRESS PARCEL DESIGNER AND CONTRACTOR BUILDING PERMIT APPLICATION 253-013-004RE 781 RESIDENTIAL ADDITION CENTERDLLE STRAWBERRY HILL ROAD g00 PAGE WILLIAM F. O'ROURKE, P.E. 1 OF 4 18136 333 OWNER DECK (900 SF) FULL BATH DINING ROOM KITCHEN PLACE TINS O FIRE L) GARAGE 0 FIRE FIRE PLACE ALARM, LIVING ROOM p N 9 BEDROOM 2 FOYER WITH VAULTED CEILING LANDING FIRST FLOOR MSTING LAYOUT SCALE, I INCH =10 FEET PROPERTY ADDRESS PARCEL ID: DESIGNER AND CONTRACTOR BUILDING PERMIT APPLICATION 781 253-013-004RE CENTERVILLE, MA RESIDENTIAL ADDITION OLD STRAWBERRY HILL ROAD BOOK/PAGE WILLIAM F. O'ROURKE, P.E. 2 OF 4 18136 333 OWNER PORCH PORCH CLOSET WINDOW ABOVE N ACCESS HATCH SITTING ROOM o CHIMNEY TO ATTIC U FULL BATH BEDROOM 1 8 FOOT OPENING TO OFIRE DOWNSTAIRS FOYER ALARM FULL BATH BALCONY UNUSED ATTIC SPACE CLOSET SECOND FLOOR EXISTING LAYOUT SCALE, I INCH = 10 FEET PROPERTY ADDRESS PARCEL ID: DESIGNER AND CONTRACTOR BUILDING PERMIT APPLICATION 253-013-004RE 781 OLD STRAWBERRY HILL ROAD RESIDENTIAL ADDITION B00 AGE WILLIAM F. O'ROURKE, P.E. 3 OF 4 CENTERVILLE, MA 18136 333 OWNER CS PORCH PORCH [CLOSET PROPOSED FIRE SITTING ROOM o OAL.ARM CHIMNEY FULL BATH BEDROOM 1 PROPOSED B FOOT OPENING TO OFIRE OAiARM DOWNSTAIRS FOYER ALARM FULL BATH PROPOSED BALCONY BEDROOM 3 (21 FT X 12 FT) (OR 252 SF) CLOSET ATTIC SPACE SECOND FLOOR PROPOSE® LAYOUT SCALEr 1 INCH = 10 FEET PROPERTY ADDRESS PARCEL ID: DESIGNER AND CONTRACTOR BUILDING PERMIT APPLICATION 253-013-004RE 7E OLD STRAWBERRY HILL ROAD BOOK/PAGE WILLIAM F. O'ROURKE, P.E. 4 OF 4 RESIDENTIAL ADDITION CNTERVILLE, MA 18136 333 OWNER Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments d 0/d// S�q w,er" A Property Address &14rlro, Orr ner Owner's Name Information is 0�6 O / required for every GN✓1ls � �/j � ! D page. Uyrrown State Zip Code Date of I spe tion 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. Inn po :out f A. General Information filling out formsrrns on the computer, use only the tab 1. Inspector: JILL key to move you keye the return Name of Inspects �T Conpany Name _ o /go� d Company Address �- I a wt /�/� ocl c 4 oZ Clty/Town — / Q state Zip Code Telephone Nu fter License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. i am a DEP approved system inspector pursuant to Section 16.340 of Title S �1015.000). The system: Passes ❑ Conditionally Passes Fails ❑ Needs Further Evaluation by the Local Approving Authority it Inspector s Signature n.� i r7 The system inspector shall submit a copy of this inspection report to the Approving A thority (B(&d 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. t5ns•3113 Title 5 Official Ire pecton F am,Subsu lace Sewage Dispoeel System•Page 1 of 17 q Commonwealth of Massachusetts Title 5 Official Inspection Form ` b Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 0 76/ Ol✓ S��a w6e�� N,�/ �✓ Property Address ON ner ON ners Name VI a►�01`rG information is [� S Dd 60/ required for every / �� 404 I // page. Cftyrrown 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) ;Sy7ste 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): Ons-3113 Title 5 Official Ins pec don F am Subsurface Sewage Disposal System•Page 2 of 17 i - Commonwealth of Massachusetts IVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P '9/ 0/c� wi t22� ixed Property Address R00 Ow ner Owner's Name /� information is �G✓101 S �� �a 6 0 /O a required for every — page. CityfTown State Zip Code Date of Insp ctlon 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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ P ( P ) ❑ 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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): C) Further Evaluation Is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines In accordance with 310 CMR 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 One•3113 Title S Of lcial Inspection f am Subsul ace Sewage Disposd System-Pape 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / / Property Address Ora ner cl✓1 o 1194 Information is Owner's Name /J required forevery C,00 i f /i% 0 d 6 a / A? page. WrTown State Zip Code Date of nsp ction 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 ifl 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 ❑ Ey Liquid depth in cesspool is less than 6" below invert or available volume is less than'/Z day flow t5ins•W3 Title50t8cial Inspecilon Form Subsurface Sewage Disposal System-Page 4of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address q✓1ole;lc Cw ner Ow ner's Name /��/ Information is N��j required for every D.)G O page. Gtyrrown 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: ❑ ET Any portion of the SAS, cesspool or privy is below high ground water elevation. I ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ L'� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E 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.] Cl 0­_� The system is a cesspool serving a facility with a design flow of 2000gpd- 10,00 0g pd. ❑ The system falls 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 CMR 15.304. The system owner should contact the appropriate regional office of the Department, One•3r13 Title 50rfieial IrepectlonForm Subsurface Sewage Disposal System-Page Sol 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 2vOlcj.- Property Address Owner �✓I07� Information is Owner's Name required for every / 1140 II dd 60 page. Clry/Town L7 State Zip Code Date of Inspe tion C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes o Li Pumping information was provided by the owner, occupant, or Board of Health El ere an of the e system components pumped out in the previous two weeks? l ❑ 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? Q/ 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 een determined based on: ❑ Existing information, For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)) D. System Information Residential Flow Conditions: 2 3 Number of bedrooms (design). Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): -Uy Mns•3/13 Title 5 official Ins pec tlon F orm Su bsuiece Sewage Olsposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2-1 o/P Rd Property Address l Ow ner ON ner's Name Information is required for every page. Cityfrown C71 State Zip Code Date Ins action D. System Information Description: 44 Number of current residents: Does residence have a garbage grinder? ❑ Yes Eli No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes o Last date of occupancy: ' " Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: i t5ins-Y13 Title 5 Official Ins pac Lion F arm Subsurt ace Sewage Disposal System-Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments lug 26 /G JWA Property Address AN ner Ow ner's Name information is h �3 required for every / eq.), 0� page. City/Town State Zip Code Date of Idspifetion 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 (��� o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S m: 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): 15ns-3113 Title 5 official Ins peo uon F am S.ub$VI ace Sewage DispOsal System-Page S of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ow ner O,v ner's Name information is required for every page. C yrrown C7, State Zip Code bate of Inspection D. System Information (cont.) Approximate age�f all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;'40 El 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): c;2 Depth below grade: feet Materia 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: s x� Sludge depth: tams•3/13 7iue50fBcisl InspecdonFam SubsuHacs SewegeDisposel System-Page 8of17 f Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '?b1 o/d 1_�r4w411711 #1 � Property Address ✓1 0 �-IG Ow ner Owner's Name information Is �� Da 60 Al)for every G{►?hlt page, City/Town C71 State Zip Code mate of rnspe6tion D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness /Y e4 ✓`) 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? o ole-- Q, CeyGl i Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): / ct ;o.J 1�nS t 1/! 45ooezl 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 t5ins•3113 Title 50fAciai Inspection Form Subsurface Sewage Disposal System•Page 10d 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 n / a / 1 0�� �G c✓b ear /�'// /IE� Property Address Ow ner O+v ner's Name information isA?required for every / A4rlIf c 0 //-7 page. City/Town State Zip Code Date of Mspection 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 CO 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 Mrs-M3 TO SOfOcial InspectlonForm Subsurface Sewage Disposed System-Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •//Not for Voluntary Assessments Property Address Owner Information is Owner's Narne " required for every `J G r1 w1 f I Q�(o 0 l0 ZYJ page. Wfown State Zip Code Date of Insoectiati D. System Information (cons) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert �-20 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.): O-011 L2✓e-/ Az PumpChamber locate on site Ian( 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: Mns•W3 TiVeSofflaal InspecticnForm Subsurface Sewage Disposal System Page 12 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lug.; Property Address a✓10-►F Ow ner Owner's Name Ainform ation is Q�6�� �O required for every G✓�h�I page. Cityfrown State Zip Code Date of In ,echo D. System Information (cont.) TY p e: leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): PN ell n 07'-" Z� Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to Inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No *ns 3113 Title 5 official Ins pectlalForm Subsurface Sewage Disposal System-Page 13d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for/Voluntary Assessments I Property Address (Information is Oaf ner's Name required for every page. Clty/Town State Zip Code Date of frispefetion D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I Privylocate on site ( to plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5lns•3113 Tille 5Offcial Iro pocUmFarm Subaurface Sewage Disposal System Pepe 14 U 17 f N Commonwealth of Massachusetts IVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /2�1/ lo/� r/ p� Property Address �Ci00 Ow ner Cw ner's Name information is required for every ari4Ir O.-60/ page. City/Town �D — State Zip Code Date o Inspection D. System Information (cant.) 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 ater supply enters the building. Check one of the boxes below: ❑ nd-sketch in the area below drawing attached separately thins-3113 Tile5Ol6clal Iris pec Von Form SubsLeace Sewage Disposal System-Page 16of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26/ o/d Property Address info ner rmation is CW ner's Name required f or every page. 5 /Town State Zip Code Date of l6spection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells r Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: auj� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t9ns-3H 3 Title 50fficial 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 a 26PI 0/j /- // WC Property Address G✓10�� Ow ner Cw ner's t4lame Information Is required for every G�1✓1tI dc�60� /D �� page, Cltyfrown State Zip Code Date of Insp6ction E. Report Completeness Checklist Inspection Summary: A, B. C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems) completed LSystem Information— Estimated depth to high groundwater U1 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ns-3113 Title$Official Ins peclionForm Subsurface Sewage Disposal System Page 17 d 17 I ;. Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner G 40 T Owner's Name , information is /17/ ' required for G V7 y f every page. Cityr Zip State Date o spectio� 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 I i i I I i i i i i 4� r i RLSP✓ -- core i Q�IVL i i :`ins• :9/C8 'ide:ptfdai nsoeclor.'.r n:Subsurface Sewage Disposal System,Page 15 of ., � Y �. . .. � �, f � . ' : ', Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �] r� r Property Address rIOA✓c� �t✓107�r Owner Owner's Name /� information is required for ' Av1 every page. City/Town oC_ State Zip Code Dat of spection 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 filling out A. General Information forms on thecompu ' r,use only the tab key 1 Inspector: to move your cursor-do not Name of Inspector use the return key. Cit/�/i o — %EG�} Company Name Company Address os "� City/Town State Zip Code Sob) �7IV`� �o8dl Telephone umber 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 Inspect is Signature Date The system inspector shall submit a copy of this inspection report to the Approving Ath y(Board of'Health or DEP) within 30 days of completing this inspection. If the system is a shared s�: tem or ; has a design flow of 10,000 gpd or greater, the inspector and the system owner sh&'316ub— "the report to the appropriate regional office of the DEP. The original should be sent to th ystsm owner and copies sent to the buyer, if applicable, and the approving authority. N —1 "'"This report only describes conditions at the time of inspection and under the coeitio�k of use at that time. This inspection does not address how the system will perform in the'quture under the same or different conditions of use. (Sins•Moe LD Tdle 5 Official Insoechon Form:Subsurface Sewage DisposTysiern•Page I of Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79/ Old Property Address Owner Owners Name l informat6on is required for a N� S every page. City/Town C7L 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): E t5ins-09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 2 of 17 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address /114 Owner Owner's Name information is A N6/ Oo�L 0/ 2111 ) D required for every page. City/Town State Zip Code Datelof In pection 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 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 15ins•os/oe 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 // 2,91 old Sfroi h/6err- 14,-11 ,a h Property Address Owner Owner's Name Q` information is col 6 0 required for every page. City/Town State Zip Code Date f 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 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: F 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 ❑ L—�'/ Liquid depth in cesspool is less than 5" below invert or available volume is less than Yz day flow t5ms•os/oe Title 6 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 i� 261 old Property Address Owner Owners Name information is required for A4 fI — _— every page. City/Town State Zip Code Dat of I spection B. Certification (cost.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . ❑ Q/ 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. ❑ L� 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.] ❑ 21Z The system is a cesspool serving a facility with a design flow of 2000gpd- 000gpd. ❑ LK he 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 15,0.00 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. l5ins-09/08 Tille 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 s/ old id Property Address Owner Owner's Name information is Gi000 required for � 0�60/ 2111/� every 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 2X'1�0 Pumping information was provided by the owner, occupant, or Board of Health ❑ Q/ 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 vollumes 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? L1� ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? �❑ Was the facility owner(and occupants if different from owner)provided with information on'the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation�of distance is unacceptable) [310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 115.203 (for example: 110 gpd x# of bedrooms): t5ins-09108 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 2YI Old Property Address Owner Owner's Name information isDol b required for *I bp every page. Cityfrown State Zip Code Date of Intpection D. System Information Description: A) O Number of current residents: Does residence have a garbage grinder? ❑ Yes 2 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes E-_'N'o Laundry system inspected? ❑ Yes ff--No Seasonal use? Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: 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: !Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments old '-�4 Property Address Owner Owner's Name �n information is �1 required for of tit N r'! every page. cityfrown State Zip Code Date ohnsoection D. System Information (cant.) 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 S m: 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): 15ins•osros Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 26,1 old gC1 Property Address tu Owner Owner's Name information is required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cant.) Approximate age of all com nents, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No 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 Materia 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: S x Sludge depth: 1-2 i/ 15ins•0Sroe Title 5 Official Inspection Form:Subsurface Sewage Disposal Sposal System•Page 9 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is Dol 6 0/ required for every page. City/Town State Zip Code Date of mpection D. System Information (court.) Septic Tank (cont.) l 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? Cey/ G� 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 ----- -- t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 '4 LOCATION SEWAGE PERMIT N.O. VILLAGE INSTA LLER'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �'� i r.. _f e �I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2�1 / , / �? Property Address Owner Owner's Name information is �j p required for Gr s')y11 /,-7� every page. Cityfrown State Zip Code Date hf Ins ection D. System Information (coat.) 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 mustibe 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: bate Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No l5ins•OW08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property Address Owner Owner's Name information is required for // Pik,I f every page. City/Town State Zip Code Date Inspe lion D. System Information (cunt.) 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.): '/'0 So /iCs //o Ze I— 4'-s 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•owo8 Title 5 Official Insp ection Form: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 �J 7F/ © d S / 0 tatV44 ' UV Property Address Owner Owner's Name /� information is / /'v/i� 0oZ60/ required for Q���f every page. City/Town State Zip Code Date 6f Ins ection D. System Information (cont.) G _ Hc;W Type leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching 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.): L9 S-�A,-1 Z, 4,e_ 0 I -t 01 N! c�,, /c' 74�Z /94rle- Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth -top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No ISins•09X18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �-Y/ o/d lei Property Address aofo�� Owner owner's Name - information is required for every page. Citylrown State Zip Code Date ofAnspefction D. System Information (coat.) Comments (note condition of soil, 'signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts WOM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v !mod �t Property Address gr1o��` Owner Owner's Name information is ELT/ Af�A� required for �lG✓�►'!�f L" '/j 19d6 0/ every page. Citylrown 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 �r�rn�y ` Ha0 33 ' ores G 15ins•09/08 Title 5 Official,Inspection Form:Subsurface Sewage fDisposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Systeem Form - Not for Voluntary Assessments -2-gl ol Property Address Owner O 0 wner s Name information is required for A 4 K h t,I IM/insp every page. City/Town State Zip Code ection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high round water: g 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: to AA ch/ Ate' Ct /f r. Before filing this Inspection Report, please see Report Completeness Checklist on next page.(Sins•Moe Tille 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 / / V Q C ��/C,t✓ r Property Addre s Owner Owner's Name information is 00L6Dt 9 M/ /P required for every page. Cityfrown State Zip Code Date of fnspe6tion E. Report Completeness Checklist 0"'Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed stem Information — Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•oeioe Title 5 Offidal Inspection form:Subsurface Sewage Disposal System•Page 17 oft 7