HomeMy WebLinkAboutTitle V Inspection Report - 151 CARLTON LANE 12/3/2003 COMMONWEALTH OF MASSACHUSETTS
X EXECUTIVE O "FICE aF ENVIRONMENTAL AFFAIFS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE S
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: cla
Owner's Name,° ° ^
Owner's Address:
Date of Inspection:
Name of Inspector (please pant)
Company Name:
Mailing Address: ° N„
Telephone Number: 55',--!
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 j
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 t
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
t
Inspector's Signature:
2L Dates �
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.ifthe 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.
Notes and Comments
****This report only describes conditions at the tine 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 1
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
V , Property Address: " �a �� � �x ,w .
Owner: 1'
Date of Inspee ion. i
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: Xlt,
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.3,04 exist, Any failure ,riteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: "° dw
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
u0ound,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 fpetal 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 r break d or uneven distribution water level in the distribution box due to broken or
f obstructed pipe(s)or due to a brokensettle. 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
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ND explain:
i
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
k ,
ND explain:
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
` Property Address: n
Date of In � ���
specti n: """ °°"'T
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.S03(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 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 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 analysis,performed at a DEP certified laboratory,for colifonn
bacteria ano volatile,organic compounds indicates that the well is free"from pollution from that facility and
r} 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 FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: ."
Owner: I"
Date of Inspecti n: �W
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No p clogged B4ckup of sewage3inta facility or stem cor[t pn nt1due to overloaded or clo ed SAS 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
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 1/2 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 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
?1k 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.]
rrF�
(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. r *
To be considered a largeystem the system must serve a facility with a design flow of 10,000 god to 15,000
gpd.
You must indicate either"yes"or"no"to-oacli of the following:
(The following criteria apply to large systems in addition to the criteria above)
yeg�,, 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 Wrapped
Zone 11 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.
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
'. a �� :.�� �� .�
Property Address: � / .. , , r."
Owner:'w (r
Date of nspe ion
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
-.
Pumping inforrnatiort"was provided by the owner,`occupan4 or Board of Health
° Were any of the system components pumped out in the previous two weeks 7
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?
Y p g
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
tf he baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
11 1 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 Sail Absorption System(SAS)on the site has been determined based on:
Tres ,,,fi
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)[31"0 CMR 15,302(3)(b)]
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner; – ..,o �
Date of Insp ion: l "c"'? —�
FLOW CONDITIONS
RESIDENTIAL
°"'I Number of bedrooms 4
Number of bedrooms(design): (actual):
DESIGN flow based on 31.0 CMR. 15.203 (for example: 110 gpd x#of bedrooms):
_ _.. Number current
td
Doe residence have ag arba a�L 'inder(yes
Is laundry on a separate s`ewa ups s t m(y es ar,
�nno o)�� '�1f esse ar a
te ins ection required]
ired
Laun dry
�
system inspected(ye or no):
Seasonal use: (yes or no):
Water meter readings,if avai able(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy: (d
Type establishment:NDUSTRIAL j
Design flaw(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:
,1CITHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part.of the inspection(yes or no):
Reason far volume loped: all o s--How was quantity pumped determined
P
p
TYPF SYSTEM
,"Septic tank,distribution box,soil absorptim system
Single cesspool
Overflow cessaol
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
tained 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):
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1,If A
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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".5y K,111
Owneri,I
Date of Inspokiion:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron PVC other(explain):
water —or su�tion 1.
Distance from private wat sup V", �11 1 11
ply well me:
Comments(on condition'of joints,venting,Evidence of i7eakaje,etc.)
SEPTIC TANK:L(locate on site plan)
Depth below grade: 1;
Material of construction: I doncrete—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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3 �z
Scum thickness: z � I�
Distance from top of scum to top of outlet tee or baffle: Z
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: c7"" ""°
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Z2-
GREASE TRAP.,� (locate on site plan)
4
Depth below grade:
Material of construction:—concrete—metal—fiberglass___polyethylene—other
(explain)
Dimensions:
Scu m thickness:
ljistanc, e from'top,of scum to top of outlet tee or baffle:
Eistance from,bottom of scum to bottom of outlet tee or baffle:
ate 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.):
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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: A �1. Carl
Date of Inspectioak4ja&�=c,"
TIGHT or HOLDING TANK JL,14' (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
I I fiberg s Olyethyl6e, x
Material of construction: concrete__.me _.other(e plain
Dimensions: 7
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: ".S12(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: �a
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.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Co mments(note condition o f pump Jiamb'er,1'cdndit'ion of pumps and appurtenances,etc.):
o.
f
ip
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: AS
Owner:
Date of Ins pOtion:
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.
.............
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE ]DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: w �. C •.'
•
Owner: _�������'. �' (� � �', �t ,��„..•��� i
Date a ns'pee ion:4 r ."
SI'Z`E EXAM
Slope e;, ,,,1-r
Surface water llo#
Check cellar
Shallow wells
/� , ji -
Estimated depth to ground"water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within ISO feet of SAS)
Checked with local Board of Health-explain:_
Checked,with local excavators,installers-(attach documentation)
Accessed'USGS database explain:
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You must describe how you established the high ground water elevation:
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