Loading...
HomeMy WebLinkAboutTitle V Inspection Report - 415 SALEM STREET 4/30/2015 R E C 11V Commonwealth f Massachuseth, T® I`'v�yr' Ti11i M F i i I Subsurface Sewage Disposal-System Form Not for Voluntary Assessments 9�i:�r�� �[y� � ��i M 1,. , �I�r rty ddress e Owner er's am information is �Ov` �" ___ r-__!_.C�._. �1 'l ✓ ?Jr _��_ required far every page. CityfTown State Zip Code _ Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist,at the end of the farm. Important. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your a rr l X cursor-do not Name of Inspector use the return ,. ,' key. G1 1' � lJ �. Company Name ` a Company Address,-- Cit fro n State ^ Zip ode Y W A a— q a�_ �7 �. ' p Teleph ne Number License Number B. Certification I certify that I have personally inspected this 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: 0, Passes ❑ Conditionally Passes ❑ Fails ❑ Needs urther Evaluation by the Local Approving Authority Z z Ins r`s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applimble, 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 mot address how the system will perform In the future under the same or different conditions of use. Title 5 Official InspecWi Palm:Subsurface Sewage Disposal System•Page 1 of 17 t5ins.09119 Commonwealth of Massachusetts Title 5 Official Inspection Form 92 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments S� em `� Property Address Owner Owner's Name V Information is required for _ every 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: a u yrn I V1 G1 r e,66-01 Yvl of ( Aq.Lj�k 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)f following statyements. If"not determined, " please explain. The septic tank is metal and over 20 years old*or the r�tfic 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 yvith 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. i ❑ Y ❑ N ❑ ND (Explain below): Z-- Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 17 t5ins•03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 se Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.); ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND Explain below): ❑ obstruction is removed ❑ Y ❑ N ND (Explain below): El distribution box is leveled or replaced 1:1 Y El ❑ ND (Explain below): ❑ The System required pumping more,t an 4 times a year due to broken or obstructed pipe(s). The system will pass inspec/reced pproval of the Board of Health): ❑ broken pipe(s) ❑ Y ❑ N ❑ ND (Explain below): obstruction is r ❑ 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 He determines in accordance with 310 CMR 15.303(1)(b)that the system is not fu Toning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is hin 50 feet of a surface water ❑ Cesspool or pri is within 50 feet of a bordering vegetated wetland or a salt march Title 5 Official Inspecllon Form Subsurface Sewage Disposal System•Page 3 of 17 t5ins•03113 Commonwealth of Massachusetts Title 5 Official Inspection r t Subsurface Sewage Dis oral System Form - Not for Voluntary Assessments s e W) _ ti roperty Address Owner Owner's Name Information is required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) deterimes 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 (S and the SAS is within 100 feet of a surface water supply or tributary to a surface ater supply. ❑ The system has a septic tank and SAS and the SAS i ithin a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS.and the AS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS a 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 watt analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that n other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable Ito 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 ❑ 9"" Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ El' Static liquid level in the distribution box above outlet,invert due to an overloaded or clogged SAS or cesspool ❑/O/A0 Liquid depth in cesspool is less than 6" below invert,or available volume is less than % day flow t5ins•03113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J °~ roperty Address Owner Owner's Name Information is required for _ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 2� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipes). Number of times pumped: ❑ [D' Any portion of the SAS, Cesspool or privy is below high ground water elevation. El 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. ❑ ❑`'r Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E� 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.] ❑ Q' This system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ Z" 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 ch of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 et of a surface drinkiing water supply ❑ ❑ the system is wit//hi j 00 feet of a tributary to a surface drinking water supply ❑ ❑ the system is�)dcated in a nitrogen sensitive area (Interim Wellhead Protection Area - IWP/Xor a mapped Zone II of a public water supply well If you have answered "yes" C any question in Section E the system is condidered a significant threat, or answered "yes" in SepZn D above the large system has failed. The owner or operator of any large system considered a fanificant threat under Section E or failed under Section D shall upgrade the system in accordan6e with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-03M3 Title 5 Official Inspection Forth Subsurface Sewage Disposal System•Page 5 or 17 '.,. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name Information is required for every 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 d ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ EZ Were any of the system components pumped out in the previous two weeks? Q" ❑ 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? IT ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 2' ❑ 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? This 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. Q' ❑ 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 V Residential Flow Conditions: Number of bedrooms (design): Y Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.:203 (for example: 110 gpd x#of bedrooms): 4 'vL Title 5 Official Inspection Form Subsurface Sewage Disposal System Page 6 of 17 t5ins•03113 '.. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 5c 5 Property Address Owner Owner's Name Information is required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes 0'No Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes d No Laundry system inspected? ��� ❑ Yes ❑ No Seasonal use? ❑ Yes EJ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/Industrial Flow Conditions:. Type of Establishment: Design flow (based on 310 CMR 15.20 Gallons per day(gpd) Basis of design flow(seats/persons/ q.ft.,etc.): Grease trap present? / ® Yes ❑ No Industrial waste holding tank resent? ❑ Yes ❑ No Non-sanitary waste disch rged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•03113 Me 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Gi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments roperty Address Owner Owner's Name Information is required for every page. Cityfrown 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: 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: n 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): Title 5 Official Inspection Form Subsurface Sewage Disposal system•Page 8 of 17 '.. 15ins•03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments vyl �a Property Address Owner Owner's Name Information is required for — every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: dC� l� Were sewage odors detected when arriving at the site? ❑ Yes Ef 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: 11 110 _ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1, -� cc) - Depth below grade: ` feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) --7 If tank is metal, list age: �1 years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: ,-) /Ox o� Sludge depth Title 5 Official Inspection Form Subsurface Sewage Disposal System•Pape 9 of 17 t5ins•07117 Commonwealth of Massachusetts - Title 5 Official Inspection r ' Subsurface Sewage Disposal System Form _Not for Voluntary Assessments PYY1 Property Address Owner Owner's Name Information Is required for every page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle � f 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 D How were dimensions determined? �)l Uc�l Q i LA6 — Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Wcf-T Y4 V 0 l ,0 q� LO U G re cows>n,6V�L- � Grease Trap(locate on site plan): / Depth below grade: __ feet Material of construction: ❑ concrete ❑ metal ❑ fiberglas ❑ polyethylene ❑ other(explain) Dimensions: / Scum thickness Distance from top of scum to top outlet tee or baffle Distance from bottom of scurry o bottorn of outlet tee or baffle Date of last pumping: / Date t5 ins•03/13 Title 5 official Inspection Forth Subsurface Sewage Disposal System•Page 10 of V Commonwealth of Massachusetts; Title Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �1 J roperty Address Owner Owner's Name Information is required for _ every 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.):: 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 ❑ p ethylene ❑ other(explain) Dimensions: Capacity: Ilons Design Flow: gallons per day Alarm present: El Yes ❑ No Alarm level: �_ Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of al /and float switches, etc.); Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Title 5 Official Inspection Form Subsurface sewage Disposal System•Page 11 of 17 '... t5ins•03113 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments S P>� L _ Property Address Owner Owner's Name Information is required for — every page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 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.): P— ()Cbk. t 5 v,Q a "jD-r 0Vk` t e5 PV ' b ^Wl V11 Y�1 l c r�� o Vet'f 0 5 l(� vl S 0 rLLar(i e k s -Y-,y Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condit/pumps purtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation notquired): If SAS not located, explain why: �� Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of W t5ins•03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments a , — 5gt Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection 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/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SJ o ,5 r u L U-Y2 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,i flow ® Yes ❑ No Title 5 Official Inspection Form Subsurface sewage Disposal System•Page 13 of 17 '... t5ins•03/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface S wage Disposal System Form - Not for Voluntary Assessments �Vvl Property Address Owner Owner's Name Information is required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cons:.) 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, sigZhyaulic re, le vel of ponding, condition of vegetation, etc.): Title 5 Official Inspection form Subsurface Sewage Disposal s�stem•Page 14 of 17 l5ins•03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property a Address P Owner Owner's Name Information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cons:.) 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 ve- 7 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 15 of 17 t5ins•03113 Commonwealth of Massachusett-s Title 5 Official Inspection Form lug Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner — Information is Owner's Name required for every page. Cityffown 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: D feet Please indicate all methods used to determine the high ground water elevation: 6 Obtained from system design plans on record If checked, date of design plan reviewed: ae ❑ 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 USG$database-explain: You must describe how you established the high ground water elevation: h��A t Before filling this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Mist Inspection Forth Subsurface Sewage Disposal System•Pape 16 of V t5ins-03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments roperty Address Owner Owner's Name Information is required for — every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist +r Inspection Summary: A, B, C, D, or E checked " Inspection Summary,D (System Failure Criteria Applicable to All Systems)completed Ef System Information - Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 l5ins•03113 s �oorNOC UT o°p,1 Q � � .50.8' W N co, 36"M v/ Q) co QSp FOp NO S '10/v1-� � � 25.1' - - Q A 16.0' 2 WD-. ST 96.2' 1 CONC Q ROOFED APPROXIMATE~GAS GAS SCREENED SERVICE LOCATION METE PORCH 0 28.5' c � =1?,L5010 GALLON Q 4 BEf SEPTIC TANK CONC. PAD TOP OF f W/ 2 AC 100 F'00 7,39, UNITS BUrF� T Q V = O 10.7' TH 1 COVER TO GRADE __ 4 4.0 PT1 o ROOFED PORCH CONCRETE D-BOX- T712 O (ON SLAB) c 20�' 44.0 4" PVC INSPECTION 10.0 PORT TO FINISHED z2.6___i PT2_ GRADE. L, �s ` SOIL ABSORPTION AREA ! 1 - Lam--- LEACHING BED 18'W X 501 (900 S.F.) W/ 3 DISTRIBUTION LINES APPROXIMATE LOCATION OF 6" PVC ` __ FUTURE RESERVE AREA PIPE TO BE USED FOR FUTURE ,� SEWER SERVICE CONNECTION WHF_N �. 34 9' TH4 181 WIDE`X MUNICIPAL SEWER SERVICE BECOMES PT3 A VAI LABLE -�-` TH6 off, !I I `9 -_ __ __ GRASSED AREA EOP 12"W----- -- . . . WA TER SHUTOFF S A L E 1IC SCALE 40 80 ■ Pa- m GRASSED AREA GRASSED AREA v 4lj 2 WD. STEPS � C 1 CONC STEP 4, WIDE PAID WALKWAY \ ROOFED SCREENED DECK 7.0' 0 30.0' l ! Q PORCH BH t CONC. APRON , O o� AROUND BH BIT. CONC. Q/ d 28.5 8.0 3 CAR DRIVEWAY a 4 BEDROOM DWELLING ll ---- TOP OF FOUNDATION = 105.57' GARAGE ' 22.5' I q,' 1.0' 30.0' PORCH SLAB __ WS 48.4' • 0' C PA\I s AVERS— 1 PAVEr,,S WIDE C THS�, W/ 4" PE IN FILTER v �' - W �• IS CONNE L S -` 10' IE AREA P?3 ' - --- -- \ 'A G , - STONE MASONRY HEADWALL S53°39'12"E_ BIT. CONC. SID'EWALK-- -- G u cB Eo EOP BENCHMARK2 I L E M S r R E E T PK NAIL IN SIDEWALK ELEVATION = 94. 19' (ASSUMED DATUM)