HomeMy WebLinkAboutTitle V Inspection Report - 1312 SALEM STREET 3/18/2005 t C(.I MC.I WEA1,11-1 OF"M.A ACTT-JS 1rIvr
EXECUTIVE OFFICE OF E VIRC1 TMEN"iAI.,AFFAIRS
DEPARTMENT Try CAF ENWRONMENTAL PROTECTION ✓a
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TITL E S
OFFICIAL INSPECTION ION FO —NOT FOR VOLUNTARY TARP ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERT'IFICA'TION �
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Property Address: A-/
R / }
Owner's dame: '°
Owner's Address: 7OWN OF jgo)d rtl�I ANr rt,)Vt.mt:,�,
Date of Inspection: �
Name of Inspector: (please print) ,F t ✓ ✓� "✓ ✓ F
Company Name: ✓ 1,'11,1/,//esm,i J",M "e f�✓E� i� ✓t �j ✓
Mailing Address: � w„ � � ✓`�
Telephone Number:
CERTIFICATION ST'AT'EMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Inspector's Signature: Dater' ,� r
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 10,0410
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.
Notes and Comments
****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 tinder the same or different.
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION F0 R- M,.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
T'AR'T A '
CERTIFICATION (continued) Z,
Property Address;
77
Owner: e""
]Gate of Inspection:
Inspec ion 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
1 5.303 or in 310 CMR 1 5.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: /
One ormore system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion ofthe replacement or repair,as approved by the Board of Health,will pass.
n
Answer yes, no or not determined (`r',N,ND) in the for the following statemeriits.If"not determined"please"
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is strnctural'ly'
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�h is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank,is less tharf 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 of pipe(s)or Board of d-le to,a broken,,settled or reven distribution box. System will pass inspection if(with,
_
approval
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
AS
Page 3 of I I �
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OFFICIAL INSPECTION ION O a NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION ION(continued)
Property Address:
k
Owner: �
Date of Inspection: ����;T'�
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(l)(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 mariner 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
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 I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen.an nitrate nitrogen-is equal tooraess than 5.ppm,,pr'ovided that no other,
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
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Page 4 of I I
OFFICIAL INSPECTION FO —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM ]INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
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 pending of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid lev�l in the distribution box above outlet invert,du 'to an overloaded or clogged SAS'or
cesspool
_ 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
i I'. of times pumped
LAny portion of the SAS, cesspool or privy is below high ground water elevation.�i
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
r Any portion of a cesspool or privy is within a Zone I of a public well.
.e rdr �, Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of 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,
pet-formed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free front 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.]
es/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 6—MR, 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.
F. large Systems: A X44
To be considered 41arge syst rn the system miustserve°a facility with,a design flow 64°16;060 gpd to1'5,000
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 inapped
Zone 11 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 I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_ /"/2.
2.
Owner:
Rate of Inspection: r
Check if the fallowing have been done. You must indicate"yes"ar"no"as to each of the fallowing:
Yes Na
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous t !o 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:
o
Yes no - 9
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) [3 10 CMR 15.302(3)(b)]
5
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Page
OFFICIAL INSPECTION FO —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:--z `, �` „
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: l 10 gpd x#of bedrooms):
Number of current residents: ,"
Does residence have a garbage grinder(yes or no): �A
is laundry on a separate sewage system(yes or no): /I [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): 0, k �
Water meter readings, if available(last 2 years usage(g d)): i '
Sump pump(yes or no):
Last date of occupancy;
COMMERCIAL/INDUSTRIAL °
Type of establishment:
Design flow(based on 310 CMR 15.203): _gpd
Basis of design flow(seats/persons/sg ft,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:
Was system pumped as part of the inspection(yes or no): r
If yes, volume pumped: .,"t gallons - How wjs quantity pumped determined?
Reason for pumping:
TYPE,OF SYSTEM
�Septic tank,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):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):�A-
6
11age 7 of I I
OFFICIAL INSPECTION IO FO NOT FOR VOLUNTARY RY ASSESSPt NT'S
SUBSURFACE SEWAGE DISPOSAL YSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2,.
Owner: lo'),�
Date of Inspection:
BUILDING SEWER(locate on site plan)
F;
Depth below grade:
Materials of construction: 9,c st iron i, ,-4O PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
41 �g ,, 41,
SEPTIC TANK: (locate on site plan)
Depth below grade: /gip'
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) fl
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle "
Scum thickness: �" 2 f
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: : 'Al!' '75 °g
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert, evidence of leakage, etc.):
GREASE TRAP:_„_,(locate on site plan)
Depth below grade:
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$of l l
OFFICIAL INSPECTION FAD -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION TIION(continued)
Property Address:
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 6
Design Flaw: gallons/dad
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 ION BOX: ���(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert "u ? ,�a
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.):
a�
PUMP CHAMBER: / � ' Iocate 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.),
g
Page 9 of ]l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
i
Property Address:
��y
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
" leaching fields,number,dimensions: X q
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.):
� r
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 or no):
Comments(note condition of soil,sins of hydr, ul c failure,,,Iev l of pondiri condition of;,regetation,etc.):
PRIVY: i
�� / locate on site plan)
Materials df 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 I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION(continued)
Property Address: ,_2/ ')............... AI/
Owner:
Date of Inspection: '/'(. ......
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.
All
10
Page 411 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7-
Owner:
Date of Inspection:
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:
,_—Obiained 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 LJSGS database-explain:
You must describe how you established the high ground water elevation: