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HomeMy WebLinkAbout0082 SAINT JOHN STREET - Health F82 Saint John Street Hyannis A=291-035 1� o Commonwealttt of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-riot for Voluntary Assessments 2pd "5cilk74 J e l ki S)L Property Address ) ON ner Owner's Name °requ for every r /'�/� 11�60/ 7 4s7 page. O3yfrown c7Z State Zip Code Date df Insowtim Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checidist at the end of the form. �,9�� A. General Information on the conputer, use ony thetab 1. Inspector. key to move your cursor-do not use the return Name of Inspector Company Name Company Address .S 44 a IN/ 1111,7' OOL"� Zo, Cr1ylrown Ue ` �V /��non � , D p� Zip Code Telephone Number pj / J v 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 W Section 15.340 of Title 5"10R 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority tns s Sgname 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 DER 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 t5m•3M 3 Mfle Mfici m•Page 1 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Di45saI System Form-Not for Voluntary Assessments Property Address � ,�A a,,y G/I 4ow ner Ow nees Name dui ed for every 11 a✓�h i S / �� !7a lO lI/ 7 r" page. Cityrrown DA State ZiP Code Date of tns tion B. Certification (cunt,) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: ;:�Ihave 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 ex$ain. 1. The septic tank is meta)and over 20 years old'or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or eff tration 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): a t5ris•3M3 Title 5 official Inspection F am:SubsWace Sa*%e Ois WrA System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S — TO r ✓I c s� Property Address G aadxe� for reaon is oar nets name A4 Od 6 0 required for every 14�A441f page. cityrrown State Zip Code Date of-ftWxtbn B. Certification (com) ❑ 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 pipes)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 t5rs•3M3 TitleSDfticialhspectmFamSubsuface Savage Disposal Syft m•Page 3of17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments &� IT Jo� lj_ _ Property Address G owner ON Name �� oa 6 of info1_7�a;44(j required for C4y/Town State Zip(:ode Date of Inspection page. B. Certification (corn.) 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. i 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 fl ow tsm,3M3 Title 50ffiaal trspection F amc SuDsrface Sewage Disposal system•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address J Cw ner ON nees Name idornution is A�a V1✓1 f I / '✓¢ o p 6 0 / requvedforevery pageyrrown State Zip Code Date of trfspeo ion B. Certification (cons.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . ❑ (�J 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 coliforrn 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 fires°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 `fires'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. tars•3M 3 T(tle 5 officW ftpecUm F am%ibmiace sewage Disposal Sysbm•Page 5017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address aH Om ner ON ner's NameWormation is /-1(7454 requveedforevery r 4t f M od 6 0/ page. Clyfrown State Z7;)Code Date of In pec' n C. Checklist Check if the following have been done. You must indicate"yes'or`no'as to each of the following: Yes ❑ :Z�:mping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ 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 NIA) 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. ❑ Determined in the field (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (actual): Number of bedrooms (design) DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5m.3M 3 Title 50f6cial Uspection F onrt Subwrfaae Sewage Disposal system•Page W 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address /j v1 of 2✓ information ner Owner's Name Air, ✓14' �, oc�6�� �/���� requkvtion is S` requaedforevery Me, Cdyrrown State Zip Code Date of inspection D. System Information [ascription: a. Soo 6 4 C4C'k"4-4'z;r 1 `/' f-fo---. Number of current residents: -- Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes 0 No information in this report.) ,� �� Laundry system inspected? Yes Ld' No Seasonal use? Yes ❑ No Water meter readings, if available past 2 years usage(gpd)): Detail: Yes Sump pump? ❑ Last date of occupancy: Date CommerciaVindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): GaRm 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: Mrs-3M 3 Title 5 Dfficiail lispecfion Form Subsrfaoe Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments SS i TO l�✓I `S f Property Address G /4r.d 41� Ow ner Ow ner's Nacre 0 / infomlation is / ,A 41 f L11'?h requ'tredforevery CRY/TownState zip de Date bps n pne- D. System Information (cost.) 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: gagons How was quantity pumped determined? Reason for pumping: Type of Sy 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/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(descri be): tyre•3H 3 1 iue s official Inspection Form Submdace savage Disposal SYSMM•PM9 8of 17 I Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C� To 4" Property Address G 4'Nd'�✓ av ner ow r>er's Weinf off refion is reqt& / / �� 6 O/ /r ed for every City/Town State Zip Code Date ofeeWfi D. System Information (conL) Approximate age of all components, date installed('if known)and source of information: /9 E 0;/ '- Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): �y Depth below grade: feet Material of constructi%40 ❑ cast iron PVC ❑ other(explain): /� c 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): J Depth below grade: feet Material onstruction: 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 � Rio Dimensions: Sludge depth: One-3M3 Title 50fficial hmpecfion Form Subsufaca sewage Disposal System-Page 9017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments IT 7 0 417 Property Address aH �� Ow ner Ow nets Name informWon is required for every page. Cityfrown State Zip Code Date orinspecti6n D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle /VO SQL 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? 0 Le Cie 117 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): O 1.-�✓1 C j�O l .A/y tfS 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 t9re.3n3 rme 5Oftidel uspection Form:Subsurface sere Disposal System•Page 10 or 17 Commonwealth of Massachusetts v Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -4 ST ToAP7 S�- Property Address / ON rler owners Name A4 op 6 0 atforretion is �N f s g C�yCRY/Townedforevery pagAe. State Zip Code Date of Ins Lion page, D. Sysfem Information (cost.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng order. ❑ Yes ❑ No Date of last pumping: pie Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No ISM•W3 TiWOffidd fngpecbmForm SubsWaw SevMeDispoW S)Mm•Page 11 d 17 F' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 61 Jo �� s Property Address GH l�V ON r,e< Owner's Name Dot 6 0 /� etforrtation is Q,✓►h/S / �I required for every CAyrrown State Zip Code Date of lnspe tan pap ::! 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.): <So l 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.): ff 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: 15rls•31 3 Title 50f6eial Inspection Fomc Subsufaoe Sexryge Disposal Sysbam•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address G /a 1 7 Ow ner Ow pees Name informations 67q c441 f �yj0':�6 0 mqueedforevwy Me. Cdy/rown State Zip Code Date of ks s pecw D. System information (coat.) Type: U,>— ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/aftemative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 12 10tM Cho v✓.? , !;( ors �tj C.Aw /C 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 tSM•3/13 Tifte 50fidd bspecTim Form Subsufaee Ssw Me 0isposd System-Page 13 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments apP ' 57 To�►h s7� Property Address Ow ner Cw ner's Name / infom ftn is required for everyt�0� page. CRy/rown State Zip Code Date hs n D. System nformabon (coat.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of constriction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I tUM•31 3 Title S Official Ws pectimFam Subsurface Sexrageoispasal System-Page 14 of 17 Commonwealth of Massachusetts ISM Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SST ,T o Si-- Property Address Owns information is Owner's Name information 1 0 6 0 J '�z1f': requiredforevery Me. aty/Town State Zip Code Date 6f ins D. System Information (coat.) Sketch Of Sewage Disposal System: ProH de a view of the sewage disposal system, including ties to at least two per ent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where pu ' water supply enters the building. Check one of the boxes below. hand-sketch in the area below ❑ drawing attached separately 3` a 14 /P A) A3- 93- sl� tsm•313 Title 50ffidaI kspecficn Fam:Subsuface Sewage Disposal Sydam•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �� �ST JoG►n .S� Properly Address k:'i-1 Ow ner ON nets Name eefomnf isN c1 �/f 0016 0/ /2// required forevery page, O'ty/rown State Zip Code Date of Impectioh D. System Information (cont.) Site Exam: ❑ Check Slope r ❑ Surface water ❑ Check cellar ❑ Shallow wells n / 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 ❑ bserved site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:_ S� A 4 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must descog how you tablish/ed the high ground water elevation: /jv 0 ,( C74O C ,.,Ie d• • � ��, o` C��� -ors' �, �f l�✓ C�v Lv p r D Before filing this inspection Report, please see Report completeness Checklist on next page. tsus 313 Title50f5cW mspeotianForm SubsWaoe SewageOisposal Syftm•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments JT ✓OAS S� Property Address C�anAPy- Owner Ownees NWm q is 1� Dmpdredforevey ✓ N i t0 Pap. Cdy/rown state Zip Code Oats of UpdoWn E. Report Completeness Checklist L'f Inspection Summary:A, B, C, D, or E decked 99 6pection Summary D(System Failure Criteria Applicable to All Systems)completed System h*rmation—Estimated depth to high groundwater C Sketch of Sewage Disposal System either drawn on page 15 or attached in separate Ile Sm•M3 TM6Ct5M k1SF 41 f' F0rM SUbU81 O uS&WW isposel Sy"-Pepe V d 17 TOWN OF BARNSTABLE BOARD OF HEALTH 2 i i i ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date `, 11 120 0 1 2- Time: In Out Owner t (� —'� l� `J(�l�5 Tenant V AC-A Address40 OA Up&006 1 g-&0tN Address V- 'S l - -TO ; R l P, -'16s*GV4A4 MR q\'IA rJ 0 s MA Compliance Remarks or Regulation # Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities ' 1 �z 4.. Water Supply 5. Hot Water Facilities 6. Heating Facilities o It I i oYi 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use - 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allow x) Ali Number of Persons Allowed (max) Person(s) Interviewed �""'��� Inspecto 62C P V V— If Public Building such as Store or Hotel/Motel specify here it' tt Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments r LL sCiinfi 1J0 �1✓t S T Property Address 1�re►M I �-- - Sesw Owner Owner's Name / information is Qo16 0 1 required for if' , every page. Cityrrown 671 State Zip Code Date of Ino ecti n 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 (U( computer,use Inspector: only the tab key // / fr A to move your a rK CS Pi l cursor-do not Name of Inspector use the return key. �,//vlv _ G /i Company Nam o Company Adds -11 Cityfrown State Zip Code Telephon umbe License Number B. Certification �., --11 2 C) 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 "1R 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails 7 Needs Further Evaluation by the Local Approving Authority 41nspect 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. �JV �/'Jof Title 5 official inspection Form:Subsurface Sewage Disposal tern•Pag 1 15ins•09108 Commonwealth of Massachusetts Title 5 Official Inspection Form USubsurface Sewage Dispos al System Form -Not for Volunrtary Assessments SG , � 0 vi Property Address S s i e {� lev'Ir2r Owner Owner's Name / / Dd 60 information is C, V1 h IS Date f Ins ction required for State Zip Code every page. City/Town B. Certification (cont.) inspection Summary: Check A,B,C,D or E/ always complete all of Section D P A) r1ehavenot'fSound:any ss : 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 as to � by be replaced or repaired. The system, upon completion of the replacement or repair,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. hether The septic tank is metal and over 20 yearsinfiltration oe exfiltration o septic tank r tank failure tas�mminent. System r not) is structurally unsound, exhibits substantial by the will pass inspection'if the existing tank is replaced with a complying septic tank as approved Board of Health. *A metal septic tank will pass inspection if it is than structurally old is available.tlking and if a Certificate of Compliance indicating that the tank s ❑ Y • ❑ N ❑ ND (Explain below): Titre 5 otfitlal Inspection Form:Subsurface Sewage asposal System.page 2 of 17 tsins•09108 f Commonwealth of Massachusetts Title 5 Official inspection Form nts Mat Subsurface Sewage Disposal System Form -No/t for Voluntary Assessments �oC �q�✓i � �0 VI✓1 S� Property Address QED�IP✓ /�S�e Owner Owner's Name Dd 6 f) information is � ��� �� required for — State Zip Code Date of In coon every page. City/Town 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): ❑ N ❑ ND (Explain below): broken pipe(s)are replaced ❑ Y ❑ ❑ N Y ❑ ND (Explain below): obstruction is removed ❑ ❑ 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 public health, safety or the environment. the system is failing to protect 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 Title 5 Official Inspection Form:Subsurface Sewage DiSPOsat System•Page 3 of 17 t5ins-owoe Commonwealth of Massachusetts DI Title 5 Official Ispection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form - o � Property Address S V17fP✓ Owner Owner shame 3 information is G VIA If Date Insp ction required for State Zip Code every page. city/Town 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: ry, for "This system passes if the well waer analysis,of ammon a n�rogen at a DEP certified and n t ate nitrogen�s equall tto or bacteria indicates absent and the presence less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ,-,/ Discharge or ponding of effluent to the surface of the ground or surface waters UU due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded Elor clogged SAS or cesspool Liquid depth in cesspool is less than 5" below invert or available volume is less El than '/2 day flow Title s offiaal Inspection Form:Subsurface Sewage Dsposal system Page<of 17 tsms•Owe Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments TO 41 Property Address Owner Owner's Name / FGode information isrequired for State Date of nspe bon every page. Cityrrown 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 El 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.] ❑ he system is a cesspool serving a facility with a design flow of 2000gpd- lJ 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist a's 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— IWP°A)or a mapped Zone II of a public water sup ply 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 the iled under system in accordance ce with 3a10t threat under CMR 15 304. Theion E or sys system owner should cotion D nttactt the apppr appropriate system in acco regional office of the Department. Ttle S Official Inspection Form Subsurface Sewage Disposal Sys 'Page 5 of 17 15ins•09/08 Commonwealth of Massachusetts Title 5 official Insipection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address I'lepVILev- Owner Owners Name - Fd6 ginformation is ,ij required for State Z Date o nspec' n every page. Cityr town 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? ❑ [v]/ 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? CEII 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. ❑ 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 15.203 (for example: 110 gpd x#of bedrooms): Title 5 Official Inspection Form:Subsurface sewage oisposai system Page 6 of 17 i5ins-09/08 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System'!Form •Not for Voluntary Assessments a Property Address Q / , Owner owner's Name ©d 601 information is N required for State Zip Code Date Ins ction every page. City/Town D. System Information Description: / A � 41C Q a Sow GG A-, CG��, �^' S o 0� d Number of current residents: /o ruder? ❑ Yes L,,� N Does residence have a garbage9 Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes Q�No ❑ LJ N Laundry system inspected? Yes Erro ❑ Yes 0 No Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: ❑ Yes. No Sump pump? 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.): ❑ Yes ❑ No Grease trap present? Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Tine 5 official Inspection Form!subsurface Sewage Disposal system page 7 of 17 t5ins•09M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Property Address ��►�✓ ��� Owner Owners Name Od-6 d� g /� information is required for State Zip Code Date f Ins on every page. City/Town D. System nformation (cunt..) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: /V 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 Sy 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. i ❑ Other (describe): Tide s official inspection Form:Subsurface Sewage Disposal system•Page 8 of V tsins•09(06 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 1 S Property Address Owner Owners Name /�/J� b C �C" information is G�✓7 i1 �'"�I Date f Ins ction required for State Zip Code every page. City/Town D. System Information (cone.) Approximate age of all components,idate installed (if known) and source of information: Were sewage odors detect ed when ,arriving at the site? ❑ Yes No Building Sewer (locate on site plan): aV Depth below grade: feet Material onstruction: 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 onstruction: c metal ❑fiberglass ❑ polyethylene ❑other(explain) co, ❑ 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: Title 5 Official Inspection Form:Subsurface Sewage Disposal system°Page 9 of 17 t5ins•09108 Commonwealth of Massachusetts Title 5 official inspection Form Stsbsurface'Sewage Disposal System #orm -Not for Voluntary Assessments jo �� Property Address f Q s Owner Owner's Name �,� 0a 6 p ky information is �J Date o Inspection required for State Zip Code every page. City/Town D. System Information (cont ) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle �/Z 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 Ile C-4vr! How were dimensions determined? integrity, Comments (on pumping recommendations, Inlet and outlet tee or baffle condition, structural 9 tY liquid levels as related to outlet invert, evidence of leakage, etc.): GV1 � Q C) � � O � LPA s Grease Trap (locate on site plan): Depth below grade: feet Material of construction: concrete metal lass ❑ polyethylene ❑ other(explain): ❑ ❑ ❑ fiberglass 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 Dis SYs�n.Page 10 of 17 Title 5 Official Inspedon Form:Subsurface Sewage P i&ns•OWS Commonwealth of Massachusetts Title 5 official Inpection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �� ��/h4,IF Property Address �J f�✓ Ile ,Owner Owner's Name information is G f / �1 ��D r' required for State Zip Code Date f Ins p ction every page. City/Town D. system Information (conf) 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 ' Title 5 Official Inspection Form:Subsurface Sewage DisPosal System Page 11 of 17 t5ins-09M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address IP!/ j�sse Owner Owner's Name information is �,�r /I required for State Zip Code Dat of I pection every page. Cityrrown 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: El Yes ❑ No Alarms in working order: ❑ Yes [I No Comments (note condition of pumplichamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins 09/08 Tide 5 official Inspection Form:Subsurface Sewage Disp05al System Page 12 0f 17 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal SystemlForm Not for voluntary Assessments i _ s Property Address P"e�'e �l Owner Owner's Name 0a 6 0 information is required for state Zip Code Date o Inspe 'on every page. City/Town D. System Information (cone.) Type: e soo ❑ leaching pits number: leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: i leaching fields number, dimensions: Cl ❑ 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.): L�Vl A0 i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): i Number and configuration Depth—top of liquid to inlet invert; Depth of solids layer Depth of scum layer I Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official inspection Form:Subsurface Sewage Disposal system-Page 19 of 17 15ins•owe r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Po Not for Voluntary Assessments OC>/— Properh Address V44r e S I �rnfo=afion Owner's Name /�/�.C� O�is ✓i N�I i v�//ired for City/Town State Zip Code Date Inspe lion very page. j D. System Information (cont ) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I I i I i i ' Privy(locate on site plan): Materials of construction: I I Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I i I I - ` I { i i i 1 i l I ; I t Tale s official inspection Form:Subsudace Sewage Disposal System'Page 14 of 17 !tsins-OW8 » I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;Owner's erty Address ��] �-�� er hame nformation is equired for A�� �� very page. Citylrown State Zip Code Date of nspe lion D. System Information (cont.) Sketch Of Sewage Disposal System Provide a view of the sewage disposal system, including ties to at least o permanent reference landmarks or benchmarks. locate all wells within 100 feet. Locate whey ublic water supply enters th6 building. Check one of the boxes below: i hand-sketch in the area below ❑ drawing attached separately I i i i i Av �_ 9 �4 I i I I i i i I ,15ms,09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a Disposal S stem Form - Not for Voluntary Assessments g _ U � V Property Address ��i-e✓ �ss� er Owner's Name q nformation is , Af �� 6�/ / squired for State Zip Code Date of nspection very page. CityRown D. System Information (cone.) i Site Exam: t ❑ Check Slope ❑ Surface water ! b 0 ��Aj / ❑ Check cellar Cow ❑ Shallow wells / I Estimated depth to high ground water: feet i I 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 (abutting1property/observation hole within 150 feet of SAS) Chec ed wit local BoaFd of Health - explain: _ I , 1 I ❑ Checked with local excavators, installers - (attach documentation) i I Cl Accessed USGS database -explain: I I i You must describe how you established the high ground water elevation: I c� I e/0w i I I I. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins owe Title 5 Official Inspection Form:Subsuffatt Sewage Disposal System+Page 16 of 17 Commonwealth of Massachuseits Title 5 Official Ira�pection Form Subsurface Sewage Disposal SystemiForm Not for Voluntary Assessments 11L Property Address Sse S � •e V''l l2�/ i Owner owner's Name information is ,��l I 6�Lg D/ �� iequired for State Zip Code Date of Ins eotion j very page. Cityfrown E. Report Completeness C ecklist i Q�Inspection Summary: A, B, C, D, or E checked Inspection Summary D (Systemf Failure Criteria Applicable to All Systems)completed Er System Information— Estimate . depth to high groundwater i 2/sketch of Sewage Disposal Sy�tem either drawn on page 15 or attached in separate file i i f 1 I I I I l I I � 4 1 I I i I I I i � l �t i I 1 I I I I I I I t5in5.09M i Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 � �� j J �. .cc c�:��sm f '�.+.. �'� -.. iE