Loading...
HomeMy WebLinkAboutTitle V Inspection Report - 199 STONECLEAVE ROAD 5/6/2007 ,1111. -19-2007 `['HU 11 :;10 AM Pr i,iden 1, i�t I H oi�e &D) )he 1,1,y FV NO, 9784755101 P. 02 S(:'wa,_) � ,r'e �11s )o sc:f1 '`�.\/stc!rn Form i,,rk1.�,5 iii Irrt..irr:r.atior°1 G,t,rrltr,e must t-,t; r5nliir�tkr;ri on this torn or on the riffit-ial Title 5 InspeDtion 1°orm elated ---- k Gertification �. �tvhr�n filling hilt I t rater rl.y Ilrlrrrtil�riiori �^� ,��._ � 1� � I (sL#I liriLll�'�r,bad P � �� Y✓ ,�('.?'r ..,. _'.- ^� it`7",° only ttrr.tah key i kr�pnlly Add[PET, tiraailJ�rrs `iat9r - - � ma - aiar°r�r crarrot [rvnc'�_ltatrrn -.- � � _ - �IJ�E.tt1 e=Y-�'.t Ul[l -1wnei ° c 1__�.'r.7_._—...,..�.....�— (;Ityf1�awn gate zip COCIE� �reirr �r�� I-)atf:, of Ir7.'ii:7C7Ctlf:)w 2. 1 i"i,".i p(­'earn r: s Marne,of In,pe4;tol' G0rk7pr$ny Nurne (`ornprkrry(+ddret,, _ — _ ------ _— City/Town / { --- Srate Zip C,ade ri nlGrl7ltone Number I ccartify that I hay c;' Personally insper-fed the sewage disposal syslorn at this address and that the information reported below is true, accurate and cornplote as of the time of the, inspection. The inspection vvas perforrned base=d on rriy tmining and experience, in the proper,function and maintenance of on site sowage disposal systems. I arir a DFP appr°ovor:l system 111apeCtur pursuant to Section '15.340 of Title 5 (310 C M 'tS,000).The systern: F asses [ (;ondlhorlolly Pasties mails wi Evclllr)t%an by the Local Approving Author'ii:y ' nelurr; The r;ystein in.poctor shall submit ra copy of this inspectian report to the Approving Authority (Board Of 1.1ealth or DE P) within :�If) rt,ys of c,ornplefinq this inspection. If the system i:3 a shared system or his a rlr-'>a ignIrrw ol` °1 CJ,t7fip i pd or greater, the inspootr,r arrdihe syster'n owner shall submit the report to tho appropriate reginnai Dffioe of the DEP,Theo aricjinal should he sel7t to the system owner tiru:i copies sent to t.ho buyer, if applicable, and the, approving auth0ty, report a n1v dr acrlbes conditions at the time of inspeiaaion and under the conditions of use at thatt t:inar . 'T1ris inspection moos neat address how the syGtDna will petfornri in the future Linder the carne or different (-onrlitiorvs of use, r:>in r>,tirrr -11/20x'4 Title`i Offldmi Inepect*n Farm: Subsurface SmAge DispaGAr System Page 1 of 16 JUI.-19-2007 THU 11 :30 AM Prudential Howe &Doherty FAX NO. 9784755101 P, 03 }_ Title 5 OffiGial Inspection ri NO-[ for Voluntary Assessments Sub`}l. face Sewage Disposai System Form A. Getlifac ation (cola. I el Property Addr�s� s !! ) owtt -_----- � _5t�te — _ .. zip Owner's Name pats,of ln ln:;pei%on A) System Fusses,. A,, have nQt found any information which indicates that and; of the failure criteria described In 310 CRAB 15.303 or in 310 CZAR 16.304 exist. Any failure criteria not evaluated are indicated below. Cornrnents: R) System Conditionally Passes: ❑ One or more system components as de�cribed in,the"C:)nditionat Pass" section need to be replaced or repaired.The system, upo completion of tht, replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determin (Y, N, D) in the❑ forth s following statements, If"not determined," please explain, ❑ Th© septic tank is metal and o\ r 0 years old* or the septic tank (whetilier metal or not) is structurally unsound, exhibits su stantial infiltration ore„filtration or tank failure is imminent. Giystem will pass inspection if t xisting tank is replaced with a complying septic tank as approved by the, Board of Idea h. A metal septic tank will pa inspe Lion If it is structuraiily sound, not leaking and if a certificate Of Compliance indicating t t the tan is less than 20 years old is availat)le. IVD Explain: t5insp.60c, 110)OD11 Title 5 0010al Inspec,iion Form:Subsurface Snwgge Disposal System Page�Of 16 JU1.-19-2007 THU 11 :30 AH PrLidenI, I j I Hot-ile Ooherty FAX NR 9784755101 P. 04 -U W U,L I U I I V I 111 Not ftir° Voluntary Ass-rear me-rite Subsurface Sewage Disposal System Form If M 11�62xll? ----------- .... ....... Y'; -,/ 3 `may em omit Mena ill, basses con ❑ Observation of sewage backup o break ut or high stotic livater level in the distribution box due to broken e t or Qbstruct6d pipe(s) or b,ro k en, settled or uneven distribution box, Systern will pass inspection if(with approval o Bo d of Health): ❑ brokom pipe(s) are replaced ❑ obstruction is removed ❑ distribution box 1,5 leveled o re laced NIA Explain: The system required pumping more tha 4 timos a ye ir di.je to broken or obstructed pipe(s). The system will pass inspection if( ith app val of the Board 'if Health): ❑ broken pipe(s) �ire reply ed required 7pumpin tha v4 t Os e'lr d g more jn_j im Y ect ion it( ith app '91 of the Board Pipe(s) I n Fe 9 ed ❑ pl' obstruction Is removed Na Explain, C) Further Evaluation is Required by the B rd of Health: ❑ 7 1 re further r eval by the Conditions exist which requi�re fnaher eva ation bythe Board DT Health in order to determine if the sy,,tern is failing to protect public he h, safety or tfie !'11invironment, 1 Systern will pass unless B -rd o Health determines in accordancie with 310 CMR public. rd c 0 e fv h Health B15,303(l)(b)that the system is t f nctioning in a manner which will protect public health., safety and the environmerit; ❑ Cesspool or privy is within t of a surface water -El of a bordering vagetaied wetland of a salt rnnrsh El Cesspool or privy is within 50 fcEl o Title 5 OffiQial Insportin!)Farm: SupsmlaGe Sewage DISPDsal System- Page 3 of 16 JUL-19-2007 THU 11 :30 AN Prudential Howe Ho her ty FAX NU. 9789755101 P. 05 T ftle 5 OffiGial Inspection '�,orm l� Not for Voluntary a AsseSS OIIIS Submirface Sewage DiSPu�al System F tn-i A, Certif 1catiQt1 -...,. Propedy.Addr.us -- Stale Zip Code -Owner's Name �1ake❑f I sl_eaki❑n — — C) Further Evaluation is Required by the Board of Health (cant.); Z. System will fail unless the Board of ealth (and Public water Supplier, if any) determines that the system i"fr.rnction nq in a manner that protect.$the public health, safety and environment: The system has a .septi tank a d soil absorption system (SAS) and the SAS is within 'i DD feet of a surface water suppl or td utary to a surfac water supply. [� The system has a septic t nk and SAS and the ��AS is within a Zone 1 of a public water supply. [ The system has n septic t and SAS and the t'.AS is within 50 feet of a private water supply well. ( The system has a septic tank and SAS and the !)AS is less than 100 feet but 50 feet of more from a private water supply well �. Method used to determine dislance; This system passes if the well water analysis; perfomled at a DEP certified laboratory,for collforrn 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 jS equal to or less than 5 ppn7, provided that no other failure criteria are triggered, A copy of the analysis must be attached to this form. 3. Other; t5insp.dQG- 1112004 Title G DI'flcial InsportiQn Farm:Subsurface Sewage Disposal SystM Page 4 of 1 E jU[-19-2007 THU 1l :30 AM Pruden I, ia| Howe Hoharty FAX N{ 9784755101 P. 06 NotfQ[ Voluntary �G0�5Dl�Dt� /\ SUbSU[face Sewage Disposal SVs\eDlFOrOl Inn D\ System Failure Criteria Applicable b) All Systpn8� You must \nUicate ' S" u/"No" to each mf the following for Llbospo%ctkons: Yes No BacKupDtsewage into facility or system oornpoAentUUe to overloaded or rlogged SAS urcesspool ro/ Disrhupge N dingo[��u� to|hvouemnonfNeqmondorsw�auowote� due to an overloaded or clogged SAS urm:oopoo| Static liqWd level In the distribution box above outlet invert due,to in overloa.ded o[clogged SAS orcesspool ' Liquid depth in cesspool is less than G" hm|»w invert or available vo|umn is less thun IV,d�iyf!uw Required pumping mom than 4timesin the last yaar Nor due io clogged o, obstrxciedp|pe(s), NU0herof times pUKi,ped:_____ Fl �l Any portion oYtho SAS, cesspool o[privy ie be|ow/high ground water elevation, �nyporUunofcesapoo� orpAvyiswi�hin1O �Ceo10 anu�ece water supply nr - ^~ �~ tUbuta[yto a yurfuue water supply. Fl �� Any portion oYu cesspool uF privy is within �i Zone 1ofa public well, Ll [�l Any portion of cesspool or privy is within SD feet ofm pr)vute.xvnter supply well. [l �]/ Any puNonoƒm cesspool urpUvy \s less than-1UO feet but greater than 50feet �~ �� from a private water supply well with no aooeptab|nwatnr quality analysis. [This cyutenU�pass us �the vvu|} water ana|ymis. pm�onnedataDEPow�Mfie4 |aburat�ry, for co\if»rm hactcriwand volatile organic compounds indicates, that the Well infmefrom po|1mtion from that facility and the p reeenueof ammonia nitrogen and nitrate nitrogen is equal tuorless than5ppm, provided that nn other fmil1u/a criteria are triggered,A copy uY the analysis must hm attached to this 0mrnn'] Yes No | The system fails, { have determined that one urmomof the above failure `� ~~ crIteria exist as described in 3,10 CMR 15.303,therefore the system fails. The systom owner should contact the Board mf Health to determine what will be necessary(ocorreottho fail u/e . � /0nspAm:' 11c2004 TNt,uoffiuW\r�pi�cN;"io Form:su*5urfmm,Suw* "uis ' � ,"w~~.. .° JUL-19-2007 THU 11 :30 AM Prudential Horne Hoherty FAX 140, 97B4❑5101 P, 07 Title 5 Official Inspection lForm Not tor Voluntary Assessrnents Suhstir[ace Sewage DiSPOSal System Form A. CerfifiGation (cont.) Zin Code 7- L Ian of W'pec Ion Dat( E) Large systems To he considered a I arp sys tem the system must serve a facility Wfth a design flow of I 0,DDO gpd to '15,000 9Pd. For large systems, you MOst indicate either,,y s,, or"no"to each of the following,in addition to the questions in Section D. YES NO the SYMOM !�withln 40 feel. of a surfac:a drinking water supply ❑ the system is w,j .11,2) D feet of a lribuWry to a surface drinking water supply El ❑ the system is lora d in i nitrogen sensitive area (Interim Wellhead Protection Area —IWPA)or a pped Zone It of r. water supply well if you have answered "Yes"to any questi n I Section E the system is can,5jdlered a significant threat, or answered "yes" in Section D above th larg system has fi.,Aed.The owner or operator of any large system considered a significant threat u der S Oion E or failed under Section D shall upgrade the system in accordance with 310 CKAR 1 '304 T` system owner should contact the appropriate regional office of the D(epartrnent. Title 5 official In5rinction Form: subwffwe Sewage 015POsal system- Nip 6 of 16 JUL--19-2007 THU 11 :31 AH Prudential Hoge &Doherty FAX N0, 9784755101 P. 08 Not for Voluntary A5--sessrnents Subsurface Se\rrage Disposal System Form __ f�rolaertY.r�ddro•-^ � _., -----------. .�., r --_ __-.— _,— -- ---- .. ,.. ._. --- r' tatP ode ovanor'-� Name -— --- _ _ -----Pate df In_ potion,... __._.._. . .. - . _., . Be, aw fir have Pert one.—You mutindica��e yes o�°no a o e'3c o e o owlnq YES NO �] humping Information was provided by the owner,.occupant., or Board of Wealth ❑ �' Were any of the system components pump!A out in the previous two weeks? ❑j Has t1je system received nonrral flows in thl" previous two week.period? Hove 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 NIA) ❑ Was the facility or dwelling inspected.for signs of sewage hack up? ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding ttirr SAS, located ran site? ' ❑ Were the septic tank manholes uncoverecll, opened, and the interior of the tank inspected for the condition of the baffles at,tees, material of construction, dimensions, depth of liquid,depth of sludge, and depth of:3cum? (I, �, ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of:ubsurfaoe sewage disposal systems? The size and Location of the Soil Absorption System (3AS) on the site has been determined based on: ( ❑ Existing information. For example, a plan lit the Board of Health. ❑ Determined in the field (if any of the failur:, criteria related to hart C is at issue approximation of distance is unacceptable;:) ('310 CMR 15.302(3)(h)) 115Insp.doe• 11/2DD4 Titlo 5 official Ir)spectit n Form:Subsurface sewage Disposal Systern Page 7 of 16 JUL-19-2007 `I'HU 'I 1 :31 All Pruden t i a I Howe &Do lie r t y FAX I1I0, 978475510/ P, 09 Inspection Official r� Title ssosst41its Not far ur�4urtt�ry' A er Y r Su ui ce Sew t � Di posal System Form - „----- _ Zip Code GityfTovdn _—m f �� -- ..— -✓ r�_.a �----�°-�� D�ld u fnsll�ction owner'5 PIMP- Number . - - of bedrooms (design)' — Number :�f bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gFd x#of bedroDms): Number of current residents: DOES residence have a rdarbagri gtindor? ❑ Yes 71'No Is laundry on a s0llarate sewage system? [If yes separate in:.ipectian requiretj] ❑ Yes No unrt in ected? ❑ Yes No ndry system p F] Yes R—No Seasonal use? \Hater meter readings, if available (last 2 years usllgp (Opd)): Yes No dump pump? ❑ Fast date of occupallcy: Q i# crommorciallindustrial Flow canditions: Type of Establishment: Design flow (based on 3,10 CMR 15.2 3): Gallons tier day(00) Basis of design flcAf,�3entslpersonst,q.ft,, etc,): Grease trap present Yes? � � ❑ Q No Industrial waste holding tank p ent? ❑ Yes ❑ No [� Nan-sanitary waste dise.h a arged t�Title 5 system? Yes 0 No water meter readings, if avail ble. Last date of Occupancy/use Date Other (describe): tSYn.p,dec 11/''poq Title 5 Ofticlal Insiaechbrn Form; suhsurlace SewaBe r]Isposalq�yost fr1 F JUL-19-2❑7 THU 1131 31 M Prudential Hotje Doherty FAX NO, 9784755101 P. 10 o rm i me 5 utticial inspection F Not for Vc)luntary Assessments Subsurface Sewage Disposal System Form C. rft—1 LA M-atkffl fcontj. [Qr. Property Address ...... ------ Pumping Recarft: SOUMC-1 Of iFifUrnatl0n: Was system pumped as part of the inspection? Ya--�es ❑ No If yes, volume pumped: dal1pns How was quantity pumped determined? RBOSOn for pumping: Type of BVstern: Coptic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow Cesspool ❑ Privy El Shared system (yes or no) (if yes, attach previi:)us inspection records, if any) ❑ Innovative/Alternative technology.Attach a coley 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 (it known) and source of information: 1�0 Were sewage odors detected when arriving at the site? ❑ Yes KT No t5imp.dw•1112004 Tjilc 5 Official lnspeptityn Form:$ubsurfznp Sewage Dispasaj System- P-400 9 of 16 JUL-19-2007 THU 11 31 AN Prudential Ho,,ae &Doherty FAX NO, 9784755101 P, 11 :)n 1��--orm �i: Title 5 Official Inspecti( Not fc)r Voluntary A sa s-rflents . .., - Subsurface Sewage Dispas al System Form L'ityfl"Qwn �'t-' ,.✓� f f/x-s?/�. -�— State ,��`7 !_r_� ?I�CodrJ bat�A,,n' eotlon owner's flame------ - Depth below grade: - T teat Material of construction: cast iron V, 110 PVC }] other(explain): Distance from private water supply well OF suction line: (uet cornments (on condition Of joints, venting, evidence-©f leakage, etc..): C" r✓ Septic Tank(locate on site plan): Depth below grade: feet Material of construction: °onerate metal Q fiberglass polyethylene L] other(explain) If tank is metal, list age: yearn is age confirmed by a Gertificafe of Gompliancer (attach a rrepy of (J Yes E] No certificate) Dimensions- Sludge depth: Distance from top of sludge to bottom of outlet tae or baffle scum thickness Distance from trip Of scum to tap of outlet tee or baffle fs Distance from bottom of scum to bottom of outlet tee or bai tle Plow were dimensions determined? t5ln�p.doc• 1 IY?o44 Title 5 Official InspSntlan Form:Subsurface Sewage Disposal System Page 10 Qf 1 C JUL-19-2007 TH U 1131 31 AH Pruden 1, 1 a I H ot.je Doherty FAX K 9784755101 P. 12 51"; A I uV 0 W I C!,I I I I Z3k JJ Vt.;Ll U 11 1-U U1 I I Not for Volutitary Assessirnents - ------- Form -e Sewage Disposal Syj Stem Sub u c,srfa Prme11V Addm'li'2i-- ------------ ------ 0 �Slff, -IMIMMPV -, WNGt0TaM 'e nry, I? Growso Trap (locale on site plan): Depth belov,i grade: feet Material of construction: L1 concrete El r zeta U fiberglass [:1 polyethylene other(explain), Dimensions: DiStanCe from top Of S Unj top Of outlet fee or baffle in, tt Distance from bottom o - rn to bottom of outlet tee or baffle I Date of last purnping: Data Comments (on pumping be mmandafions, inlet and outlet tee or baffle condition, structural integrity, IT liquid levels @s related to, out ut et invert, evidence of leakage, et:,): Tight or Holding Tank (tank must b pumped at time of inspoction) (locate on site plan): Depth below grndo: Material of construction: COnCre-tE'. F1 metal fiberglass polyethylene ❑ other(explain): t5insp-dDC' 111200,1 TNr,-5 Official 1m;perti,Dn Form:Suhsurfac(A Sewage Djapasol Sptarn- Page 11 of 15 JUL-19-2007 THU 11 :31 AN Prudential Howe 0oherty FAX NO, 9784755101 P. 13 Title 5 official inspection Fbrm r4c)t fc)j,Voluntary A550SSMents SUbsu rface Sewage ► ispOSal System Form c. Svstem informatiOn.(cOnt) .. PrDpErty kddre- —------ State Dimensions: capacity; Design FICIVI: gaiiQns por day Alarm present: ❑ Yo; 0 N AlanT) Alarm in workling order: Yes[] No Date of last pumping: cornments (condition of aiarm Lind floc Switche-r, Distribution Box(it present Must be opened) (locate on situ plan), Depth of liquid level above outlet invert Ads carryover, any Comments (note it box is level and distribution to outlets equal, any evidence of s evidence or leajcage into or out of box, etc.): auixk —e5�- Purnp Chamber (locate on site plan):,, PLIMPS in Mrldrg order: Yes C=1 No Alarms in working order: Yes No TIN 5 official ln�:;ipaction FDTM:Subsurface Sewage njsposa�s2 ysten) 115insp.don - 11/2004 Page 1 of 1l JUL-19-2007 THU 11 :31 AM Prudential HOIJe &Doherty FAX 110, 9784796101 P. 14 I I LN U 10 W ltt t 1 111 t��N 1 ! � 1 tl � Not for Vr�lL`t�fi ty Assessments Subsuffne Sewage Disposal System Form �� vit}/l�wR SkaGe �TP-Codo comments (note condition o pump chamber, condition o pumlrs,and appurtenances, etc. Soil Absorption System (SAS) (locate on sito plan, excavation not required): If SAS not located, explain why: d � T Type: [� leaching pits number: leaching chambers number: 0 leaching galleries number: El leaching trenches nuu-iher, length: leaching fields nuriuber, dimension,: L1 overflow cesspool nurribor, innovativelalternahve system Typelnarne of technaiogy: —� Comments (note condition of soil, signs of hydraulic failure, 1e+„+el of ponding,clamp soil, condition of r vegetation, etc.): t6lnsp.doc• 1112004 Tifle 5 Official Inspeciiion Form:subsurface Sewage mspms l System Page 13 of 16 JUL-19-2007 THU 11 :31 AN Prudential Howe Holierty FAX N0, 9784755101 P. 15 Title 5 official Inspection � I"W t k- Not for Ur�lur�fary As,—se t tt s Subsurface Sewage DiSP05@1 System Form u 't ail 1�1$ 1 nta$:ion (cant.) -- _ --- - _ Property Address-— -- ---"---- - - - Zip Code Number and configuration Depth—top of liquid to inlet invert Depth of Solids layer Depth of scum layer m Dimensions of cesspool Materials of construction Indication of groundwater inflow Q Yes ❑ No Comments (note condition of soiVcofyd c failu re, level of poliding, condition of vegetation, etc.): privy (locate on site plan). Materials of construction: Dimensions Depth of solids comments (note condition of soil, signs of h raulic failurci, level of pondincg, condition of vegetation, etc.): t5insp.d❑c • 11/2004 TRIP 5 Official INSP'-ction Forrr'subsurface sewage DispossallSystem JUL-19-2007 THU 11 32 AM Prudential Howe Doherty FAX W. 9789755101 P. 16 �..= MLM WORM INK5P PUL Nc)t for Volontary Assessr-nents aG ~ ' Subsurface Sewage Disposal System Form - . ' Properly Ity/TflWII Mate Sketch Of Swage Us{�osal SEstern:Provide a sketch of the s�waq, 42sal ��rstem including_ties � - to at least two permanent reference Ifandmorks OF benchmarks, k,ocate all wells within X00 feet. Locate where public Water su frilly enters the building. t5insp.doc• 1112004 Title 6 Official Inspection Form subuurface sowage❑ispmal system Pagn 154f 1B JUL-19-2007 THU 11 :32 AM Prudential Howe Doherty FAX NR 9784755101 P. 17 Title 5 Official InspeGbon orm I Not for Voluntary As5es--rne-nts UI)sLif-fac Sewage Dlsposal System Form e , S property Address StafF. f Code Ity qWn Rate of JnF f AI& Vs Name.... _....... Slope Af. ,91AFfaCe Water /NU Check cellar "4/-1/ 6113110W"Afells Estimated depth to ground water-. Please indicate all rnetho65 rased to determine the high Of"DUriJ water elevation- ol)-lgined from system design plans on record It chocked,date 0 design plan revjewcd: Observed site (abutting pro pe rty/Dbse rvation hdp.within 150 feet of SAS) LI Checked with local Board of Health-explain: Checked WO local excavators, installers- (attach documentation) Accessed USGS database- explain: yow vnust describe how you established the high ground Willer elevati011: Title offirw impection rOrM:Subsurface Femoge Disposal 9ysteni l5insp-doo- 11120(34 Page 16 of 11