HomeMy WebLinkAboutTitle V Inspection Report - 17 LACY STREET 5/23/2007 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the o nisi T 6 thisodc'tlon'Formf dated
6/16/2000,Ins Ion form me not b�e altered in an wa .
A. Certification A(Ri - 2O(g
Important:
When filling out 1. Property Information: i rn�I i..�i
towns on the
computer,use .°•° �,
only the tab key Propgrty Add ss
to move your acs �u j'&
cursor-do not Owners Name
use the return
key.
Ow rs Address
7�ti Qov(.r 110th
Cltyfrown State Zip Code
&nw Cate of Inspection: 2 .
Date
2. Inspector:
a PhtS �f-6 CL�
Name of inspector /
t9 r C't-,-'c/�S i,�- 7f _Wc,/'V
Company Nam -------
c.l✓t 1,5��`mot /4•{
'
vas
Cityfrown state Zip Code
Telephone Number
certification Statement:
I 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 experisnoo In the proper function and maintenance of on site
sewage disposal systems, I am a®EP approved sy tem Inspector pursuant to Section 15.340 of
Title 6(310 CMR 16.000),The system:
® Pusses ® Conditionally Passes Falls
® N s Further Evaluation b the Local Approving Authority
rvvt>;". 5-23'-x,'
Ina ors Signature Date
The system Inspector shall submit a copy of this Inspection report to the Approving Authority(Board
of Health or cEP)Wthln 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 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,
t6insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface sewage Disposal System o
Page 1 of 16
Commonwealth of Massachusetts
Title 1 1 I Inspection
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
l7 �1 w S f
Propa Address
/V-#V over / 01'ej Cts'
City/town I l
S Co f f R U Ul Y /I state S 23 07 Zip Code
Owner's Name Date of Inspection
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:
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 exfiitration 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.
NO Explain:
t5insp.doc 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Title Official In i
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
17 Lr�c�i
A/ sf
Property 4 ti Qu C( 1114 t
Cltyfrown State Zip Code
co# c�lt ll S--23-Y)
Owner's Name Date of Inspedion
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
❑ 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($). 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
t5k".doc•11/2004 TRIO d ORldal Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title Official In 1
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
7 Cfi cy S�-
Property Address
/V--ftN
Cityrrown T State Zip Code
SCG# i2��,���I! �-r23,u-7
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
2. System will fall 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 onalysis,'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:
t5insp.doc•11/2004 Title S Official Inspection Form:Subsurface Sewage Disposal System-
Page 4 of 16
Commonwealth of Massachusetts
Title 1 I I Inspection
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont)
n Li c7 sl
Property Address
/-t4�"WL/
5^22-07
Ciown-S cc)#- }'�y�pl �l – — state zlpcode
Owner's Name 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
❑ 14* Discharge or ponding of effluent to the surface of the ground or surface waters
'T 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 %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.
❑ 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 collform 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
El The system falls. 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.
t5insp.doc•11/20N Title 5 OfNal Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
Commonwealth of Massachusetts
Title i i l Inspection
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
Property Address
CitylT CG �(J1JC�t'I '--^---- State ^23 Zip Code
(�
Owners Name Date of Inspection
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,
t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title I I Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
Property Address
MA
SU("fn L 41 S'L)'6 Zip Code
Owners Name Date of Inspection
Check if the following have been done. You must Indicate"yes"or"no"as to each of the following:
YES NO
❑ 'z' 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?
❑ JC;3' 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?
�l ❑ 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(3)(b)J
t5inap.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
Title I I Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
Property Addrsss
cltylrown State Zip Code
�S cam- a S� -3`0`7
Owner's Name Date of inspection
Residential Flow Conditions:
{�Number of bedrooms(design): 41 Number of bedrooms(actual);
DESIGN flow based on 310 CMR 15,203(for example: Wgpd x#of bedrooms):
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 0 No
Laundry system inspected? ❑ Yes a No
Seasonaluse? ❑ Yes ❑ No
Water meter readings, If available(last 2 years usage(gpd)):
Sump pump? ❑ Yes ,e( No
Last date of occupancy: C 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):
t3lrtsp:dec•1112004 TWO 6 Mcal Insp#Oon Fort;Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
Title Inspection
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
I`? LA cy at,
Property Address
City/Town � �V��GI' Sta S 2�J, Zip Code
S ca - �
Owners Name Date of Inspection
General information
Pumping Records:
Source of information: No
Was system pumped as part of the Inspection? Yes ❑ No
If yes,volume pumped: A
gallons
How was quantity pumped determined? Sc
Reason for pumping: g6f',,V ^Mt Cl
Type of System:
Septic tank, distribution box, soll absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ InnGvative/Altemative 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:
- n -16`/
Were sewage odors detected when arriving at the site? ❑ Yes E� No
t5irup.doc•11/2004 Title s OMdal .... . .. ge plspo System
Inspection Form:Su ace Sewn sal S tem
Page 0 of 16
Commonwealth of Massachusetts
Title it Inspection
Not for Voluntary
Subsurface Sewage Disposal System Form
C. System Information (cont)
L c• 1
Propedy Address ,I/
Citylrown state Zip Code
C'd p c kj r u 5-2,3 7
Owner's Name Data of Inspection
Building Hewer(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: Zo/
feet
Comments(on condition of Joints,venting,evidence of leakage, etc.):
,A
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
*oncrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain)
If tank is metal, list age: years
It age confirmed by a Certificate of Compliance?(attach a copy of
certificate) El Yes El No
Dimensions: �° f5—
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
35 /r
Scum thickness
Distance from top of scum to top of outlet tee or baffle
:r
Distance from bottom of scum to bottom of outlet tee or baffle 7
M e45v��
How were dimensions determined?
t5k►cp.doc•11/2004 Tito b Oflldal Inspection Form;Ubsurfooe Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title i i l Inspection
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
/7 cv �r
Property Address
Ill-fjnr00Vcr
Cityfrown State Zip Code
Scot}�11(j 1 s�23
owners Name Date of Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
lilid levels related to outlet invert, evidencQ of� le. etc.):
A,/ �b�I �D✓f l�f ETC [Sa /5J
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.):
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):
t5insp.doc•11/2004 Titlo 5 official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Title - Inspection' Form
Not for.Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (coot.)
Property Address
City/Town state Zip code
S CG� f ZcJn�c�c Cr
Owner's Name Data of Inspection
Tight or Holding Tank(cont.)
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.):
Distribution Box(if present must be opened)(locate onl�s//ite plan): �
Depth of liquid level above outlet invert 1/tea (t `�`��` u ''k/ �e4�
Comments(note it box Is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of l9akage Into or out of box, etc):
�SSi Sol s.__� ?11V
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5lnsp.dx 11/2004 TMIa¢ORidpl Irtspecdon Form:Subsurface Sawage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title i it Inspection
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
17 (1 cy 5/-
Property Address
��^ ve,r
atyiTown �� stag� Zip
5c4 PQ&(t1 5-1Y(-'.?
Owner's Name Date of Inspection
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:
❑ leaching chambers number:
❑ leaching galleries number:
leaching trenches number, length: ty
❑ 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,):
VS�c�h .S pt<p IU G�n- Atgvyso1(d/3 ►I•,
t6insp.doc•1 M004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title Official Inspection
Not for Voluntary.Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont)
Property Address
A/-4N1Dowpr /t t-
Cltylrown State Zip Code
Owner's Name Date of Inspection
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.):
tSinsp.doc•11/2004 Title b Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
itle b Uff icial inspection
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt)
J7 �4Cj S�
Property Address
Citylrown State Zip Code
owner's Name 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.
Pte«
I
- -�V 001-U
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/plU P
I' V
I
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t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
Commonwealth of Massachusetts
ifilmo Title Inspection
UIV Notfor Voluntary Assessments
'Subsurface Sewage Disposal System Form
C. System Information (cont.)
Property Address
A4 0/'M
Gty/rown ( (� State ,Zip Code
SCCr,� '`UVC C S 23--07
Owners Name pate of Inspeclon
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water: /.S r ,flu (01f 7�
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:
❑ Checked with local excavators, Installers-(attach documentation)
❑ Accessed USGS database-explain: '
You must describe how you established the high ground water elevation:
t31r►cp,Aoa 11/2004 1?tlp b Oftldal InspeCtlon Fprm;Subwrf aop Sewage Disposal system.
Page 16 of 16