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HomeMy WebLinkAboutTitle V Inspection Report - 285 REA STREET 7/26/2013 / Commonwealth of Massachusetts � Tm=de 5 Offida0 Inspection Form \ ' Subsurface Sewage Oimpoae| System Form Not for Voluntary Assessments Property Address -�' uwner Ow ner's'Narne �— inf ormationis required for every D8A - page� Civ /mwn o\mo Zip Code Date o/Inspection Inspection |t must be b ittod on this form. Inspection way. Please see completeness checklist at the end of the form. onpouunt:when A. � f0|non�fnrns . .. ���o»�x�u Information on the use only ~the`~~ 1 �ymn�veyom '''~r~~ � cursor-donot use the return � key Nan-le,' Inspector Ell ~""'"'» ' a"= Co rnpany Address I ILI" A—AXI-Ifl Zity/Town State Zip Code Telephone Nurrber License Nurnber B. CertifiGation I certify that I have personally inspected the sewage disposal system at this ad5J;e s and that the i nformati on repo rted below is true, accurat e and com plete as of the time of t i spection. The ins pec ion was performed based on my training and experience in the proper functio and maintenance of on sit sewage disposal systems, / nma uEr approved system inspector p suant to Section 15.340 of Title 5 (310 CA0R15.000). The system: | U Passes El Conditionally Passes Fails | El Needs Further Evaluation by theLocal Approving Authority | � Inspector's Signature Date The systern inspector shall sub/mit a copy of this inspection report to the Approving Authority (Board of Health orDEP)within 3O days of completing this inspection, |f the system iaa shared system m has a design flow of1O.UOD Qpdor greater, the inspector and the system owner shall submit the report to the appropriate regional office ofthe DEP. The original should be sent tothe system owner and copies sent to the buyer, if applicable, and the appmvingauthority, ""This report only describes conditions mtthe time of inspection and under the conditions nfuse at that This inspection does not address how the system will perform in the future under . the same or different conditions ofuse. / �m q� Title50fficial/m==m°p=m:Su^sunacc.Sewage Disposal orwm'Page,w`/ Commonwealth of Massachusetts Title e Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Cw ner Ow ner s Name �, (. information is r f F �. 4 ;� required for every � -= � �it, � � `- 0 Ir page. City/Town State Zip Code Date of Inspection B. Certification (cost.) 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 CM R 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Healt h. *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): t5i ns-3/13 Title 5Official Ins pee-tion F rn:Subsurface Sewage Disposal System-Page 2 o 17 Commonwealth of Massachusetts Title i i Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments IS r I Property Address I Cif C,v ner Cw ner's Narre information is required for every page. City/Town t,—te Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/al arms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ 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 mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 50fficial Inspection Form:Subsurface Sewage Disposal System Page 3 o 17 Commonwealth of Massachusetts Title II I Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C3 `� tom. L�� � �• Property MATS Ow ner Owners IJarrie information is required f or every l� page. City/Town State Zip Code Date of Inspection B. Certifioation (cont) 2. System will fail unless the Board of Health (and Public water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No M ❑ 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 t5ins•3/1 3 Title 5 Official Inspection Form:Subsurface Sevrage Disposal System•Page,1 0 17 '.. Commonwealth of Massachusetts Official Title 5 i lSubsurface Sewage Disposal System Form Not for Voluntary Assessments '` o '} `L'r . � t Property l!ress 1� 4m r,-� Cw ner Ow ner's Narre information is required for every C)c z'rte page. City/Town State Zip Code Date of Inspection B. Certification 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 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. ❑ 0. 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 Ix 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. 5 ns•3113 Title 50fficia]Ins pec bon Form.Subsurface Se�rage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title l Inspection �n1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address o�-�� Owner O,vner's Narre- information is p `���� y required for every ��`j,(,. r T l� 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/A No Q` ❑ Pumping information was prodded by thefo occupant, or Board of Health i� ❑ Were any of the system components pumped out in the previoua two weeks? eve (� !�e"a ata� � '�trl` E r`Spcg�ac ❑' ❑ Has the system received normal flows in the previous two week period? ort� Ly 1_6 i [ zgl� h Y"- 6 J_t'— ❑ ti, Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ EO 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? ,f 1, ❑ Was the facility owner(and occupants if different from owner) prodded 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. N t' ❑ 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): "T t5i ns-3113 Title 50fficial Inspection Form subsurface sewage Disposal S}stem•Page 6 o 17 '... Commonwealth of Massachusetts Title i i r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Ad r s Cw ne Cw ner's Narre _ information is Q.. t . ` ! Z required for every eL( E 7 C C -� �l 1�' page. City/Town State Zip Code Date of Inspection D. System Information Description:_ { Number of current residents: Does residence have a garbage grinder? /- Yes ❑ No is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes lR No information in this report.) Laundry system inspected? ❑ Yes El No Seasonal use? ❑ Yes L No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: i p y Date Commercial/Industrial Flow Conditions: a` Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sci t., 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: t5ms•3/13 Title 5Official Inspection Form.Subsurface Sewage Disposal System•Page 7 o 17 Commonwealth of Massachusetts Title Official Inspection Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address ON ner Cw ner's Nam information is _ }�. f�,r '� required for every \� � I V ` t° r A page. City/Town, State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: x� 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: zr 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): t5ins•3/13 Title 5Official Inspection Form'.Subsurface Sewage Disposal System-Page Bof 17 Commonwealth of Massachusetts Title i I Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Addr 1<'A X51/_) Cvw ner Cw ner's Narr>e information is 1 required for every �' rTf�G'v��� i�' page. aty/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: i Were sewage odors detected when arriving at the site? ❑ Yes L No Building Sewer (locate on site plan): Depth below grade: feet Material of construction: cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): _'Idc { k Septic Tank (locate on site plan): Dept h bel ow g ra de: feet Material of construction: ❑r concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 0 o I—N � l 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: f �' t5ins•3/13 Title 5 Official Ins pection F orm:Subsurface Sage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title O Inspection Subsurface Sewage Disposal System Forst Not for Voluntary Assessments Property Address") �`'t� $vi c'S Cw ner Ow ner's Narrie information isj G required for every �t- Zip Code Date of Inspection page. City/Town State D. System Information (cost.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle C) Scum thickness Distance from top of scum to top of outlet tee or baffle ,t Distance from bottom of scum to bottom of outlet tee or baffle I am' k i-c 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.): Grease Trap (locate on site plan): d� Depth below grade: feet i 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 l5ins•3113 Title 5 Of fici a]Ins peclion Form.Subsurface Semage Disposal System,Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Addr es n Q^'ner Cw ner's Nam information is 11 4 I � required for every' 1 DC 't L 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.): Pv �C r Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): �� tr Depth below grade: t 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 t5ins•3/13 Title 5 OfLci al Ins pec bon Form'.Subsurface Sevage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official I i r Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address-) ON ner Owner's Name- information is required for every i� � f,t` C� 4 Lr page. City/Town State Zip Code Date of Inspection 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.): 3 cv i s E I o c', TO E t r c i Pump Chamber (locate on site plan): El Yes El No* Pumps in working order'. 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: 6 oII­, �Pi`2. Pie V t 0 -t, F= ���Q� � v 'Ire C� ' t5ins•3/13 Title 5Official Ins pec lion Form:Subsurface Seviage Disposal Slstem-Page 12 of 17 Commonwealth of Massachusetts Title Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow ner Cw ner's Nam _ information is required for every Gil.( ,p} t' �°T P�C� %t "r Ad ( p page. City/Town State Zip Code Date of Inspection t 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.): f oca17) E tt 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 t5ms•all Title 5Official Ins peclion Form.Subsurface Sevsge Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official I ci Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Addr ON ner Ov ner's Nam information is ii t l s required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): {� g f t Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 TiBe 5 Official Ins peo bon Form'.Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title Inspection Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Cw ner 0✓a ner's Nam_ Information is t required f or every I� "` tl C'� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below drawing attached separately f E d " U LL I LO i t5ins-3/13 Title 5Official Inspection Forms Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Inspection Title 5 Official r Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Addr Ow ner Cw ner's Nam _ information is ` f} c required for every !V�%� i � `"�� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope Surface water a2 c,o tZ 0 f-L c ❑ Check cellar ❑ Shallow wells 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 L I 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address L<, \ 10 5 Cw ner DA,ner's Narrtz_ information is i required for every \�0 l ' ` }�s 1�t' V i l�L II E� page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Of Inspection Summary: A, B, C, D, or E checked Q Inspection Summary D (System Failure Criteria Applicable to All Systems) completed D` System Information— Estimated depth to-.high groundwater I`���'�E7 L fj L V.J S i'1t�'1 ILL�`✓ `c,5 ,I _ [9"'Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file V tti ns•3113 Title 50fficia Inspection Form.Subsurface Sewage Disposal System-Page 17 of 17