HomeMy WebLinkAboutTitle V Inspection Report - 95 OLYMPIC LANE 10/15/2004 a 4. q
COMMONWEALTH OFMASSACHUSE17S �
EXECUPIVE OFFICE OF ENVIROf MEi' TA.L.L- FFAIRS
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DEPARTMENT OF ENVIRONMENT '
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TITLE 5
OFFIC'IAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PAIN A
CERTIFICATION
Property Address: �� r1���
9
Owner's Name: 57'
Owner's Address:
Date of Inspection-- m'�
Name of Inspector: (please print) Lli'uz��t�
Company Name: I ��e"� �°�. a 7 '51o/ z;— JECTED
Mailing Address: 7 �
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal syst 't hIsla res t tie information sported
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
Fads
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Inspector's Signature: a1e: n�b
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,O00
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.
tandry°Copmments �'n !�y p r 4Y , ,�p.. �p,ppi p
Notes A/ f?VFr k. PJ_ � o /` tl/ UA
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****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.
Title 5 Inspection Form 6/15/2000 page I
"J'age ; f I I
a
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OFFICIAL INSPECTION FO NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
PART A
/
CERTIFICATION (continued)
a
Property Address;_ a "r�
r�
Date of Inspection;
°
Inspection Summary: Cheek A,B,C,ID 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
1 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated belmN.
Comments;
i'
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 tile, Board of Health, will pass.
Answer yes, no or not determined ,Y,N,ND in the for the ol� e
p ( ) � lowi�g s�atem�nts If"not,d�terrnined'",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 Hoard 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.
ND explain:
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(s). The systern will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURF ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
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 asurface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
I Vol
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.
,file 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 colifonn
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:
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OFFICIAL INSPECTION F PJW—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFITCATION(continued)
Property Address: A,
ipp
Owner: 7
7�
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
o 'S
"",,13ackup of sewage into facility or system component due t overloaded or clogged AS 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
V Static liquid level in the distribution box,above outlet invert due to an overloaded or clogged SAS or
,cesspool
1,/`,Liquid depth in cesspool is less than 6"below invert or availablei volume is less 'than 1/2day flow
Required pumping more than 47 mes 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
X water supply.
Any portion of a cesspool or privy is within a Zone I 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 coliforin bacteria and volatile organic compommds
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.]
(Y
The system fails. I have determined that one or more of the above failure criteria exist as
ibed in 310 C—MR 15.303,therefore the systern 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 sys em the system must serve a facility with'a design flow of 10,000 gpd to 15,000
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 mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the systern 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.
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OFFICIAL INSPECTION FO w-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE; DISPOS.AdL, SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: "� �'� " e°tip a>�
Date of Inspection:
Check if the following have been done. You must indicate"yes"ar"no"as to each of the fallowing:
Yes No„
Pumping information was provided by the owner, occupant, or Hoard of Health
Were any of the system components pumped out in the previous two 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:
Yes „no
i Existing information. For example, a plan at the Hoard 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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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL AL SYST"EM INSPECTION FORM
PART
SYSTEM INFORMATION
Property Address:
(�u
Owner:
Date of Inspection. 771
FLOW CONTDITIONS
RESIDENTIAL
Number of bedrooms(design); Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):
Number of current residents: i
Does residence have a garbage grinder(yes or no): "
is laundry on a separate sewage system(yes�r no):_.Z�Z;.[if yes separate inspection required]
Laundry system inspected(yes,or no): �
Seasonal use; (yes or no):
Water meter readings, if available(last 2 years usage(gpd)):
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: o
Was system pumped as part of the inspection(yes or"no): U
If Y volume pumped: g allons--How w was quantity pumped determined? K,
Reason for pumping:
-
TXPE„OF SYSTEM
eptic tank,distribution box,soil absoVhon 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): /
6
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSME NTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:—cast iron 40 PVC—other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: e 1`16ocate on site plan)
Depth below grade: /,/("'? "I,,,,,,
Material of construction: i '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)
Dimensions: , e/
Sludge depth: ✓ 2
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 3"
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
(.. . .......
Ax" w"'I .
GREASE TRAP: _(locate on site plan) kl//A-
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.):
..........I.................. .........................
7
Page 8 of'I I
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
TIGHT or HOLDING TANK: 4 must be pumped at time of ins pection)(locate on site plan)
Depth below grade:_
Material of construction: concrete metal fiberglass____polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
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 BOX: 1// (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.):
rM
PUMP CHAMBER: (locate 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,):
8
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: .........
'J(11
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): t,""(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: y
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.):
CESSPOOLS: 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, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY:4`11 ("(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.):
9
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OFFICIAL INSPECTION FO NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM S T I O FORM
1
PART C
SYST E F" A OPT(continued)
.Property Address: 9S- 641.101 r.
Owner° 13 5
Date of Inspections
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 mater supply enters the building.
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Page I I of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
7-7
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:
1;z
V"" Obtained 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:_r , ) J,"
Checked.with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
/4 "r
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