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HomeMy WebLinkAbout0102 PINEVIEW DRIVE - Health 102 PineviF-'-vJ Drive Cotuit - -. - A = 040 093 i Commonwealth of Massachusetts =- Title 5 Official Inspection Form IV 7Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Coe (Q u 14 +- a oN n �1 o�ner's Name information is , Da 0 /° -' �� C O�' required for every State 'Zip Code Date of In pection page. City/Town Inspection results must be submitted on thisform. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: y///. key to move your G / 0/S�i/ �1 cursor-do not use the return Name of Inspector l" key Company Name Company Address C1y/Town StateD Zip Code �oo Telepho'—ne er 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�10R 15.000). The system: , Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 41nspectore' ignature 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 If0,000 god or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5olrwtai irupectionF or subsurface Sewage Disposal System-Page 1 of 17 t5ins•3113 II ( � Commonwealth of Massachusetts - Title 5 Official Inspection Form =, Subsurface Sewage Disposal System Form Not for Voluntary Assessments pi yl e Vie w 0/ f Property Address Co� 6�,-1 � ON ner Owner's Name information is C O 40 1 / "/✓7 �°� 6-7-5 /0 required for every page. City/Town State Zip Code Date of In pection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: 1 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 exPin. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits subsjantial 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). t5irs,W3 Title 5Official InspoctionForm Subsurface Se wage Disposal System-Page 2of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Co-2QL'i Ij �- Ory ner CW ner's Name / information is required for every 0 TK 1 �,4 D�6 yJ/ /0 � �� / .� page. City/Town State Zip Code Date of I specti 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(Wth 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 3113 Titlo5Dfficial Inspection Form:Subsurface Sewage Disposal System Page 3of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments - _ ? / o�- Property Address C Q'e U Ow ner Ow ner's Name information is / o required for every l� page. City/Town State Zip Code Date of I spection 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 cdteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than ''/Y day flow t5ns,W 3 1-iue 501ficia Vu pecuon F orm subsuf ace sewage Disposal System•Pain 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - 6 Subsurface Sewage Disposal System Form,- Not for Voluntary Assessments Property Address Coe Ow ner Ov ner's Name information is required for every page. City frown Slate Zip Code Date of Insp ction 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: ❑ tR 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. ❑ E9 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.] ❑ l�' The system is a cesspool serving a facility with a design flow of 2000gpd- 10.0009pd. ❑ all The system fLl . I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ (] the system is within 200 feet of a tributary to a surface drinking water supply El ❑ 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. y1� TWe 50ffici Y lmpectl or)Form:Subsuiaco Sewage Uspc�sel System Page 5of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form .6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , Property Address (f cle.CO-� ON ner Ow ner's Name information is o- i� 4 01)&I S /U a a required for every page. City/Town State Zip Code Date of Ins ction C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes o ❑ Pumping information was provid ed by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as 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 i this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) II 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: L`7 y❑� 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: -3 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x #of bedrooms): !Sins•3113 Title 5offlcir7InspectionFamSuDsurfece Sewage Disposal SysPagetem- 6ol17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ON ner ON ner's Name Q u f /� Odl 6 3j information is (� required for every page. Cityrrown State Zip Code Date of In pection D. System Information Description: / /0w /'(j�� //0� �.P TI Number of current residents: Does residence have a garbage grinder? ❑ Yes 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? ET Yes No C r�e� Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/personslsq.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: 6M 3/13 Me bofficial Inspec OmForm Subsurface Sewage Disposal System-Page 7of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -- i I y row �r�_a a j Property Address 4— -- Ow ner ON ner's Name information is C p required for every page. City rrown State Zip Code Date of Ins Ilion D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons Howwas 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 (descd be): r51ris•3113 Title 5 Official ins FectionForm subsurface Sewage Disposal system•Page 8of 17 7 Commonwealth of Massachusetts a-: = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments _ 0� I kle t/v Property Address 0 2 C vt 41 (� Ow ner ON ner's Name information is � required for every page. Gty/rown State Zip Code Date of Idspectioff D. System Information (cost.) Approximate age of 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 n: ❑ cast iron PVC ❑ other(explain): �O 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 Mate 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 certlficate Yes ❑ No Dimensions: Sludge depth: tans,3713 Me5 Official trispocticr,Form Sutsulace Sewage DIsposa System Page 9of17 f Commonwealth of Massachusetts Title 5 official Inspection Foram Subsurface Sewage Disposal System Form - Not for Voluntary Assessment* Property Address C�eQI� Ow ner Cw ner's Name information is O N 1 �- /� 0���5 /Q , required for every lll�i� page. City/*Town State Zip Code Date of I spectio D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or-baffle Distance from bottom of scum to bottom of outlet tee or baffle n // How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �Ivlv'lgi V7 mac% en✓+ Doi l Jn I l0011 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 tare•3/Q _ TiI]e 5Officlig ns pecticn.F orm.Subsirface Sevaga Oisposal System•Page to of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� f Property Address 60, 2 Qvt Ow ner Owner's Name O �o v'�J / information is -�"" /-/✓T e� J required f or every State Zip Code Date of Ins ction page. Gty/Towm D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels.as.related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per dad. Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worlang order: ❑ Yes ❑ No Date of last pum ping: Date Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No TiUe 501ficial im pecti on Form:Su bsui ace Sewage Disposal System•Page 11 of 17 Os•3/13 Commonwealth of Massachusetts L Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessment's 7zoo)- Property Address L O aU Ow ner ON ner's Name information is required for every State Zip Code Date of Inspe ion; page. Citylfown D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): ,zL— l/-e vl 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.): T So/ Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass, Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 501fici;4 Insprx:tiaiF orm SUbSIfIeCe Sew39e0iSPOS81 System-Page 12 of 17 ' t5ns-3113 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Oro nerrm Orr ner's Name I i I l /14 information is -j- 'f' / , required for every State Zip Code Date:oof in pection page City(Tow n D. System Information (cont.) Type: leaching pits ( number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ 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.): 0 Z ✓tom.. ,5, lam/ c'��' ► �, ! �I r�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 Title 5 officia ospectionFam.SUbslrface sewage Disposal system•Peg 13of 17 15ins•3113 Commonwealth of Massachusetts _ - Title 5 Official Inspection Form Subsurface Sewage Disposal System For . Not for Voluntary Assessments Property Address Ll O,v ner Cw ner's Name � / information is CO U j 6�L61 ! 0 oZ.2 rpegeredforevery Cy/Town State Zip Code Date of Insp ction D. System Information (cont.) 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.): t9ns•Y13 Tibe50fficiai Iris peclionForm SuburfacoSowageDisposal Systom•Page U of 17 f ' Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Properly Address V-C � l/1 Cw ner Owner's Name information 1 4N i ] r1"�) �j� /r� oLoL information is 1` iT required for every page. OW n State Zip Code Date of Inspection W7T D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least t o permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where ublic water supply enters the building. Check one of the boxes below: 5 hand-sketch in the area below ❑ drawing attached separately ��s Q Riser O d t5ns-Y13 Tits50fficial l(r-^ticnForm Subsulace Sewage Disposal System Page 15of 17 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 60e QU Ow ner O+v ner's Name /' information is (gyp nt required for every page. City/Town State Zip Code Date ol Inspect on D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check ceilar ❑ Shallow wells / Estimated depth to high ground water: feet Jo Please indicate all methods used to determine the nigh ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ —Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: le- El Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database- explain: You must describe how you/established the high ground water elevation:d / — G Y I a vt d A N e �O N/60 ' '— �� D ✓7 C(✓i� /0 C4- Agol/Z= (o Ll', W.-jell Before filing this Inspection Report, please see Report Completeness Checklist on next page. tins-Y13 Title501ficial impecuonForm suDswace sewage olsposal system-Page 16of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ow ner CW ner's Name information is required for every page. CityrTown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary; A, B, C, D. or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed IJd' S em Information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5iro-3113 Title 5Official Inspection Form Subsurface Sewage Disposal System-Page 17 of 17 AsBuilt Page 1 of 1 LOCATION SEWAGE PERMIT NO. Lot aS Qu�view �F. ��— 733 VILLAGE INSTALLER'S NAME`` AAA ADDRESS S ery 7hr0A,-QL1 1S S• `�+9Yi17ev% I U I L D E R OR OWNER Ce��9h the �g /uS� .5 ou DATE PERMIT ISSUED B AT E C O M P L I A N C E 15 S U E D �13°t q 3 3a D L afi as ` http://issgl2/intranet/propdata/prebuilt.aspx?mappar=040093&seq=1 6/25/2019 B Ile, Tf LOCATION SEWAGE PERMIT NO. Lot a� Q�i� view ��. gam- 73"3 4 VILLAGE C ay"f I N S T A LLER'S NAME S ADDRESS T I s eI- 1 e®�e91 /�i� S y�r•Y,0 B U I L D E R OR OWNER ��// eioigh c.re #,&/T` fus/ S • a® ,wog DATE PERMIT ISSUED DATE COMPLIANCE ISSUED L�t as-