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HomeMy WebLinkAbout0038 OLDHAM ROAD - Health OIL PV OAI) ° HA 120-104'' OSTERVILLE �r s f s t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Oldham Road _ Property Address Mathew&Tracy Kiely Owner Owner's Name information is required for every O.sterville MA 12/29/10 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out forms A. General Information on the computer, I use only the tab 1. Inspector: I key to move your cursor-do not Carmen E Shay `{J use the return Name of Inspector key. Shay Environmental Services, Inc. _ • ,ee Company Name 111 Thornberry Circle Company Address eturn Mashpee MA 02649 City/Town State Zip Code 508-539-7966 3080 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: , __41 ® Passes � '❑ Conditionally Passes ❑ ;Fails a :;F!: p ❑ Needs Further Evaluation by the Local Approving Authority C_ 12/29/10 �' ' Inspector'sN ignature Date , r The system inspector shall submit a copy of this inspection report to the Approving A�uthorityO(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. 11 38 Oldham Road,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Oldham Road Property Address Mathew&Tracy Kiely Owner Owner's Name information is required for every Osterville MA 12/29/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A). System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Leach pits have no liquid at time of inspection. Leach pit#1 has 3 foot stain line, Leach pit#2 has 1' stain line. Top of both pits are 18 inches below grade. Seasonal Use. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if 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. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 38 Oldham Road,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts t= r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °p 38 Oldham Road Property Address Mathew &Tracy Kiely Owner Owner's Name information is required for every Osteryille MA 12/29/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 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 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. 38 Oldham Road,Osterville•03/08 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 3 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 38 Oldham Road Property Address Mathew&Tracy Kiely Owner Owner's Name information is Osterville MA 12/29/10 required for every — , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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: 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 '/2'day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 38 Oldham Road,Osterville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Oldham Road Property Address Mathew&Tracy Kiely Owner Owner's Name information is required for every Osterville MA 12/29/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No, ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ 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. 38 Oldham Road,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts �W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Oldham Road Property Address Mathew& Tracy Kiely Owner Owner's Name information is required for every Osterville MA 12/29/10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 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)] 38 Oldham Road,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 38 Oldham Road Property Address Mathew&Tracy Kiely Owner Owner's Name information is required for every Osteryllle MA 12/29/10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based'on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: None Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ® Yes ❑ No Last date of occupancy: September 2010 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: Last date of occupancy/use: Date Other(describe): I 38 Oldham Road sterville•03/08 Title 5 Official Inspection Forms Subsurface Sewage Disposal System-Page 7 of 0 ,0 , p g p Sys g 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Oldham Road Property Address Mathew&Tracy Kiely Owner Owner's Name information is required for every Osterville MA 12/29/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records:. Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): , Approximate age of all components, date installed (if known) and source of information: April of 1977 - BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 38 Oldham Road,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Oldham Road Property Address Mathew& Tracy Kiely Owner Owner's Name information is Osterville MA 12/29/10 required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by.a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 6' x 10' 1000 gallon Sludge depth: 6 Distance from top of sludge to bottom of outlet tee or baffle 23" Scum thickness 2 Distance from top scum of to top of outlet tee or baffle 4' Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 38 Oldham Road,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 9 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Oldham Road Property Address Mathew& Tracy Kiely Owner Owner's Name information is required for every Osterville MA 12/29/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank.in good condition,lnlet tee in good condition, outlet Baffle iin good condition.. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): / Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t 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): 38 Oldham Road,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachu - setts Title 5 Official Inspection Subsurface Sewage Dis osal System Form _ Form g p Not for� Y Voluntary 38 Oldham Road Assessments Property Address Owner Mathew& Tracy Kiely information is Owner's Name required for every Osterville page. City/Town MA ate Zip Code 12/29/10 Date of Inspection �• System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity. Design Flow: gauons Alarm present: gauons per day ❑Alarm level: Yes El No Alarm in working order; Date of last pumping: ❑ Yes ❑ No Comments (condition of alarm and floatDate switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes El Distribution Box (if present must be opened) (locate on site plan): No Depth of liquid level above outlet invert D-Box Present 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.): D-box has one outlet to it#2. Leach it number one Piped direclty to tank Pump Chamber(locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No I 38 Oldham Road,Osferville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 1 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Oldham Road Property Address Mathew &Tracy Kiely Owner Owner's Name information is required for every Osterville MA 12/29/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ® leaching pits number: 2-6'diam x 6' D ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: f Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pits have no liquid at time of inspection. Leach pit#1.has 3 foot stain line, Leach pit#2 has 1' stain line. Top of both pits are 18 inches below grade. Seasonal Use. 38 Oldham Road,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "< 38 Oldham Road Property Address Mathew& Tracy Kiely Owner Owner's Name information is required for every Osterville MA 12/29/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): 38 Oldham Road,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /¢t 38 Oldham Road Property Address Mathew & Tracy Kiely ---.--. .......... Owner ------------------�------------------------ ------ Owner's Name information is Osterville MA 12/29/10 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties f to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. *5r,� - 38 Oldham Road,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Oldham Road Property Address Mathew & Tracy Kiely Owner Owner's Name information is required for every Osterville MA 12/29/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam.- Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ feet 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.- El Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Inspector has performed perc tests in the area. 38 Oldham Road,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 L0- 10N � -`� W P 0 S E G E PERMIT N0. (.1J Piq 900,1,3 ,g VILLAGE ®S—YFR v I IIF 1h iq INSTALLER'S NAME & ADDRESS O r'H -11 Qo R 7 ru re rn.g,4 B O R D E R OR OWNER DA T E PERMIT, ISSUED .3_/�--_�� DATE COMPLIANCE ISSUED ! /P7*7 r - - �����'r �S �� .r COMMONWEALTH OF MASSACHUSETTS ' EXECUTIVE OFFICE OF ENVIRONMENTAL ^ E FAIRS�}�; r(3� DEPARTMENT OF ENVIRONMENTAL PROTECTION Vi TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: Owner's Address: 4 v v. �� (i,"► Date of Inspection: Name of Inspector: (please rint) tw!'1✓� ��''�J Company Name: Mailing Address: Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: r Passes Conditionally Passes . Needs Further Evaluation by the Local Approving Authority Fails � Inspector's Si-nature: Pate:: 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. Ifthe.system`is,4 shared system.or.has a design flow of 10,000 gpd or greater;the inspectore 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. Notes and!Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that ` a time. This inspection<does not address how the system will perform in the future under the same or different ;codditions,of use. Title 5 Inspection Form 6/15/2000 page I Y Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 0/ 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 1 303 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 b the Board of Health will ass. PP Y , P Answer yes,no or not determined (Y,N,ND)in•the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if 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. , ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box:System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due.to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART A CERTIFICATION(continued) Property Address: 0S t Owner: Date of Inspection: 2� 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 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 tartk and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP'certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3 Owner: Date of Inspection. ) 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 _X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface . water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, , performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as. described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 Il 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: � o`� • .ems/, Owner: Date of Inspectio f(} Check if the following have been done. You must indicate"yes"or"no as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period.? Have large volumes of water been introduced to the system recently or as part of this inspection? _ Were as built plans of the system obtained and examined. (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? Were all system components, R� .n*' �" , 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: 4 Yes no _ 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(3)(b)J . r . 5 Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMS INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes o no Is laundry on a separate sewage system{yes o no :_ (if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes o no : Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or� Last date of occupancy: COMMERCIAL/WDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION- Pumping Records Source of information: 't-L`'�Z✓/U � Was system pumped as part of the inspection(yes or o _ If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: PE OF SYSTEM Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any)' _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Ap r ximate age of all components,date installed(if known)and source of information: 3 � rc- We sewage odors detected when arriving at the site(yes o • Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C tSyYy�S,TEMI'N�FORMATION(continued) P Y Pro ert Address: 3 Oz%!l� m Owner: Date of Inspection: 8; 3 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: �j Sludge depth: Z �� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:. 7 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to out et invert, evidence of.leakage, etc.): GREASE TRAP:_(locate on site plan) Depth below grade:— Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels ' as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 C)44/1 Owner:_ Date of Inspection: 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no); Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: '- Owner: Jt.:+C. Date of Inspectio : 5✓ -31zd,�j SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Ty e leaching pits,number: leaching chambers, number: leaching galleries,number:, leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: 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.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and confieuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): 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.): 9 Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: o`er✓ Owner: �y Date of Inspection: '7 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 3 r C� . -77 10 Page I I of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: v /l Date of Inspectio : SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 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:Ui - R No..-...../yy E...... Fua... ....... THE COMMONWEALTH OF MASSACHUSETTS /l BOARD F HE L H /.. . ........OF. Appfiration-lor R-4posal Works' TonstrurXSewage Application is hereby'made for a Permit to Construct ( ) or Repair ( ) l S st at: -----------CUB.�?r�.. .l'...........:13__o. _D----------------------------�--2T � S Location`'ddr s or Lot No. er ddr ss ----------- -_ - = �... s 5x Installer Address �] Q Type of Building Size Lot----------------------------Sq. feet U Dwelling-v�No. of Bedrooms.._._________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P-4 Other fixtures --------- ------------------------------------------------------------------------------------------------------------------------------------------- W Design Flow........5_.D 5_.0........................... per pet-son per day. Total daily flow--------------------------------------------gallons. WSeptic Tank-,-Liquid capacityl.5_ Length................ Width.---_....._..__ Diameter-_._............ Depth....-----.------ x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No.....�............ Diameter____________________ Depth belo; inlet.................... Tota leaching area-------.----------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ® ' 3' — �" Percolation Test Results Performed by----------................................................................ Date------------------------------------:_.. W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..----.------..-- 44 Test Pit No. 2.............:..minutes per inch Depth of Test Pit-------------------- Depth to ground water_.__-._--__----.--_-.._. a' •---- if la . Description of Sol - *�.n �� x _.._ . — 1` } V ------------------ ------------- ----- = = -----------.---------------- W UNature of Repairs or Alterations—Answer when applicable.---------------------------------..........----------------------------------.----------------- ---- ---------------------- ...............................-....................................... ----------------------------------------------- --. ---------------------- --------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signe -----Q- \ ----- ...... -/_.y7 7 Date Application Approved By...... �•6• - _. .. ....,Y--'-7-�-- Date__ ate Application Disapproved for the following reasons----------------------------------- ............................... --------••-••-•--•---•-•--•------------------------------------------------------------------------------- ---------------------------------------------------------------------------- Date PermitNo......................................................... Issued............................................. te...---- Date �-- -- - - - ------------------_-_ -- --------=---------------------- r THE COMMONWEALTH OF MASSACHUSETTS BOARD ° F HE L H OF _ . .... ..... 4. --- --- Applirdt att -for 43i ipm I rk Cn>�tt rttrtilatt rr tit Application*is hereby`made for a Permit to,Construct ( ) or epair ( ) an Individual Sewage Disposal S st at: t1 :-: r Location dd " s or;Lot NO. Arss Installer • Address Q Type of Building Size Lot.............................Sq..feet U a DwellingNo. o -------- --- Ex ansion';Attic . ) (Garbage Grinder (K)f Bedrooms---_ _ :_ — CafeteriaOther—Type of Building __-_--_ No. of persons Showers d Other fixtures ----------------•--------------- ) ) -- ------------ W. Design Flow------- .(°,� gall°oris per pei son per day. Total daily,flow -_ gallons. P; Septic Tank 4-Liquid capacity j�Q Q.gailons Length ______________ Width------.... .._ . Diameter-------......... Depth--.------------- Disposal Trench .No -------------------- Width._ -_-. Total Length.................... Total leaching area------------.-------sq. ft. x Seepage Pit No___ __ Diameter _ _________ Depth Belo% inlet ____ ........ Tot leach-n area.. ___:---__-_sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �a Percolation Test Results Performed b - Date-:-___.,_.... .........Y - ------. Test Pit No. .1♦_______________minutes per inch Depth of Test Pit.................... Depth to ground water-------................. (Xq Test Pit"No. 2................minutes per inch " Depth of Test Pit____________________ Depth to ground water------------------------ -------- 40 Description of S.o}1 tt "� '-` �y r ' P !� -------------------- --- U ------------------------------------------------------------ ---------------------------------------------------------- W UNature of Repairs or Alterations—Answer when applicable.-.__--------_______________________._.._.------------------.-------------..___-..--___--._ ------------------------ -------------------- ------------------------.----------------------------------------- ---------------------------------------------••---- ---------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions.of Article XI of the State Sanitary Code.—:Theundersigned further agrees not to place the system in operation until a Certificate of Compliance has lieen issued.{by the board of health. Signe17 ! ___ - _S2yt ---_ -- � 19' t NO Date Application Approved BY----- --- . . 1 '1 :- - ....... --- -'----77- /! Date Application Disapproved for the following reasons-..............................--............................................................................... ....................................................•...........................................------------------------------------------------------------------------------------------------------- Date PermitNo..................=..............-------------------------- Issued........................................................ Date 4 THE,COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1..........OF.... ...... :.: -t ........ (ITrrtif irate of 01111mlitiartrr T T C RTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by ..... 1 •. •. •..... ............ . - ------------------ X at � f i Z #--In---�°/ Y�+ I '---• has been installed in accordance with the provisions of Articl of State Sanitary Coe as deseri-ed„�yi the application for Disposal Works Construction Permit No._."'__ _________ dated ._._. `"? ................... ......... THE ISSUANCE OF.THIS CERTIFICATE SHALL. NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION, SATISFACTORY DATE.... ' ----- ............................ Inspector--.. . -- .......................------- THE COMMONWEALTH OF MASSACHUSETTS : BOARD OF EALTH OF.... :.:.. ....-- No. ..... FEE... .. ,". .`'.. m a tt a� witru`di in Permit Permission :i reby granted_______. ........... to Construct ( epair ( n ividual S e p 1 st m �r f at No..... `T`--•-- � ------ r----- --------- ---------""--�r ) �} street �ae*f' � % 7 as shown on the application for Disposal Works Construction Per D- .k ........ .......... ..� o. oa f Health rrr - - -. ... B rd o " DATE FORM 1255 HOBBS & WARREN. INC.. 'PUBLISHERS r ;j i t i \ ZeA4 A) ' EEC P. /-/5a0 444 j _... SEPTIC i 1�4 ------ LOCATION '#'S""t ER V i L Ucl �A i, , I Gl.RT1F14 -r"AT . TH lst7tJLATIOF-.II -5WOww _A1.1 R�1=�Kc�IGE, %4sR(OW COAAPLVS W I TN THE- 51 DMSLI WF-- AW > SETI3,ACv_ REQuiZeME ITS ot= -rOWU Ol~ `BArZNST4St_.G- `'ILL NO RCX)< Z (--Z PSGC BAXTEIZ ►-i�t'E 1�•1G_ REGIS�TE.IZED 9.-Al-•►p SU2vi=YoiZS TN15 t7LAW IS LJOT BASE'S a%J AN oSTt=rZvu..>_E a �4taSS. 04,9 E)AAENT ZW ZVE`{ 4 Tt4E Sl-40ww APPL l GAtiJT ~` K6T Be USCcJ To iDm:rEeM%N& lOT LllJi-S �j.. l... G�iU$ i, i1,1^, + 1 �N it CCn ST fY I- Q, f !ab' Y '/0' } flo O 1 l L I 31�1 vV, l ( Lao R 4? L i ;'ems