HomeMy WebLinkAboutTitle V Inspection Report - 170 OLYMPIC LANE 10/26/2001 ALTH OF MASSACHUSETTS
COMMONWE
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
yyh
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
P12
Property Address:
Owner's Name:
Owner's Address:
Date of Inspection:
Name of Inspector:_ lease print) ...........E)V),k/
Compan3
7�471
Mailing Address:
47//Z,
Telephone Number:
CERTIFICATION STATEMENT
I certify 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 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 C 15.000). The system:
asses
Condition fyPasses
�eeds uler EvaluAtion by the Local Approving Authority
ails
I I / 111111')
....... ................. jtl)
Inspector's Signature: ..............w._ /
ate:
The system inspector shall, J�.mit a copy of this inspection report tothe Approving Authority(Board of Health or
0,;
DEP)within 30 days of c, pleting 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 buy'&'1#a0pljcable,and the approving
authority.
...........
Notes and Conunents fi v
.", k
****This report only describes conditions at the time 6f inspection and under tiiillc'onditipps of use
k
; that
time. This inspection does not address how the system will perform in the future under the'sa/mc'oi different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
r
Page 2 of I I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
.............
Owner:
Date of Inspection: XZ,,` LL )
Inspection Summary: Check A,B,C,D or E ALWAYS complete all of Section D
A. System Passes:
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 followinc,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 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 I 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 system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: h..........
Owner: 'Ai,
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 wi I pass unless Board of Heal,th determines in accordance'I , cc with 310 CMR 15.303(1)(b)that the
system is not'junctioning 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
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 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 coliform
bacteria-and�volatile,organic,compounds indicates that the welljs free froth 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:
3
Page 4 of I I
OFFICIAL INSPECTION FO —NOT FOR VOLUNTARY ASSESSMENTS
S
SU BSIr +ACE SEWAGE ISPOSAL SYSTEM INSPECTION FORM
PART Y A
CERTIFICATION ION(continued)
Property Address 1 i � ".
Owner. �
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 f„
_ "&ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
— ,,o,,ODiscbarge or pondihg of,effluent ti6 the surtke of the ground or surface waters due to an overloaded or
dogged SAS or cesspool
y 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 ''/s day flow
— ,,,j equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
9f 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.
— ,,,,o ny portion of a cesspool or privy is within a Zone I of a public well.
— y portion of a cesspool or privy is within 50 feet of a private water supply well.
m1ny 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 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.]
� ) (Yes/No)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. ' Urge System$t t .
To be considered a large system 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 riMped
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.
4
"0V
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
A"lv
Owner 67r-
-777'
Date of Insp ection: 3
Check if the following have been done. You must indicate to each of the following:
Y No
Pumping information was proviclod by t4q,,owner,occupant,or Board of Health
JL 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?
J 1/"
,olo' — Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
Thesize and location,pf the S I Absorption System(SAS)on the site has,been determined based on:
Yes no
Le!� _ Existing information.For example,a plan at the Board of Health.
"011h,
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)]
Page 6 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSME NTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
]Property Address: ��'" ��, Q�°��R���",t„� �� ����"� :;.,.
Owner. "
Date of Inspection. ) °
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): '
DESIGN flow based on 310 CMTt 15.203 (for example: 110 gpd x#of edrooms):
”
Number of current residents: odo,w�
I residence garbage grinder )
laund1Y ona separate sewage system(Y s ono
. ,
[if yes separate inspection required)
Laundry system inspected(yes or na):
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/sgft,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 11
Source of information: ' .t, gym",e � i � )
Was system pumped as art thevinspection(yes or no): "
If yes, volume pumped w iga(lons--Haw was�,quti riamped determined?
Reason,for pum,pin
TYPE OF SYSTEM
J,,.,Sceptic 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)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate e of al[,components, date installed(if known)and source of information.
Were sewage odors detected when arriving at the site(yes or no) °^� �'
6
'/V/",`!FO""i 1'
vm""- "Oo,""Oft""k' Oyu
Page 7 of I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INY ORMATION(contipued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cl~i iron 40 PVC other(explain):
Distance from private water supply well or sustioti line,:
Comments(on cond,tion of joints,venting,evidence of leakage',etc.):
SEPTIC TANK:-L"I'll"Oocate on site plan)
Depth below grade:
Material of construction: concre t
e—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;:Q; ... .....
Sludge depth: ....... III
Distance from top of s)ydge to bottom of outlet tee or baffle el
Scum thickness- of I
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom
outlet tee or baffle:
4
How were dimensions determined:
Comments(on pumping recommendatiolie, inlet and outlet tee or baffle condition,structural int9grity,liquid levels.
at
as d to outlet evid Te d of age etc.):
,, e
, invel,
�d
el
7 7'
Vo,
GREASE TRAP:,4L--(locate ou,4ite plan)M,
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.):
7
Page ofll
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: /j,
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:—concrete metal berglass .polyethy Fne �her(explain):
`1 q
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:
_LLf(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
leak inta or but of bG
c.
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 chambe f,condition of pumps and appurtenances,etc.):
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
?
Property Address: y
Owner:
,L:"&" Yp "1,/,
Date of lnspeci'16u-" 7/7-
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not-required)
If SAS not located explain why:
A, fa 4,
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.):
AVel &Z
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 or no):
Co'nunents(note condition of soilA Iiigns of draulic fiI
lure,level of ponding,condition of vegeytion,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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION(continued)
Property Address:
Owner
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 w,ithin 100 feet. Locate where public water supply enters the building.,
................. ...............................................
............
"x
0
-.................
h.
.........
2 0
10
; Page 11 of 11
OFFICIAL INSPECTION FO —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SY'S'TEM INFORMATION(continued)
.. M.
Property Address:
n
Owner.
Date of Inspection: 7777
STTE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground wate"t„��"�� feet l
Please indicate(check)all methods used to determine the high ground water elevation:
checked,tained from system design plans on record-If of
design
Observed site(abutting property/observation hole within l 0 feet of SAS)
reviewed
r
Checked with local Board of Health-explain:
Checked.with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must de scribe how you �
ou established th h round water elevation:
11