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Home My WebLink AboutTitle V Inspection Report - 703 MIDDLETON STREET 1/5/2017 Commonwealth of(Massachusetts REE-Can Title 5 Officicell Inspection Form .wj , 3061J1RIGO SeWagl?DISPOSelSystem Form-Not for voluntary Asse s nts f dd Property. ddressMfAdC (, Owner C is ame requited is requited'for ' every page. City/Town Strafe Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not:be altered in any way. Please see completeness checklist at the end of the form. Important: A. General information When filling out forms on the computer,use 1. Inspector. onlya flab key _. _C1�r uset to move your cursor-do not Name of Inspector use the return `e key. _ r U l_. Company Name - TA at Company Address ,—, @ � CityfroWnState Zip Code Q � � 4 Teleph ne NumtKir License Number _ B. Certification 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 CMR 115.000). The system: [d Passes ❑ Conditionally Passes n Fails ❑ Needs Further Evaluation by the Local Approving Authority I ctor's Signature Date 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 10,000 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. ****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 d I ferent conditions of use. Title 5 Official Inspection Foffrc Subsurface Sewage Disposal System-Page 1 or 17 t5ins•od/13 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Seivage Disposal System Form -Not for Voluntary Assessments Property Address Owner — --- Information is owner's Name required for every page. City/Town State Zip Code Date of Inspection B. Certification (cant:.) Inspection Summary: Check A,B,C,D or E:/always complete all of Section D A) System Passers: 1z'I have not found any information which indicates that any of the failure criteria described in 310 CIMR 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. Check the box for"yes", "no"or"not determined"(Y, N, ND)for a following statyements. If"not determined, "please explain. The septic tank is metal and over 20 years old'or the , tic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration oyexfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced rth a complying septic tank as approved by the Board of Health. ; f "A metal septic tank will pass inspection if,if is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. r� ❑ Y ❑ N ❑IND (Explain below): Title 5 official Inspection Form Subsurface Sewage Disposal Systern• Page 2 of 17 t5ins-03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sevivage Disposal System Form -Not for Voluntary Assessments Property Address Owner - - — Information is Owner's Name required for every page. C41'rown State Zip Code Date of Inspection �T B. Certification (cont.) B) System Conditionally Passes (cont.); ❑ Observation of sewage backup or break out or high static water level in the distribution boy: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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ D (Explain below): f ❑ The System required pumping more than times a year due to broken or obstructed pipe(s),. The system will pass inspection if(with app oval of the Board of Health): El broken pipe(s)are replace ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remov- ❑ Y ❑ N ❑ ND (Explain below): 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 Hea determines in accordance with 310 CMR15.303(1)(b)that the system is not fui coning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is w In 50 feet of a surface water ❑ Cesspool or prl'vy' within 50 feet of a bordering vegetated wetland or a salt march t5ins-03/1Tllle 5 Official Inseectlon For Ci ih—rf—c,.,......_11--- -.-- - - .._ Commonwealth of Massachusetts Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner - — -- Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) deterimes 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 w er supply. ❑ The system has a septic tank and SAS and the SAS is wi in a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the S is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and th/e SAS is less than 100 feet but 50 feet or more from a private water supply well" Method used to determine distance:;7z- This � `*This systern passes if the well water nalysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the pr ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no . her failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 ❑ / 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 % day flow t5ins-03/13 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form- Not for Voluntary Assessments (21 l 48 M �.:1� ---- Property Address Owner — — — -- Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E-1 Any portion of the SAS, Cesspool or privy is below high ground water elevation. ❑ C_f Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ I'T Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ F-J` 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 feel: 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ This system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. i ❑ ❑ 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) 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 systerns, you must indicate either"yes"or"no"t each of the following, in addition to the questions in Section D. / Yes No ❑ ❑ the system is within 400'feet of a surface drinkiing water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply /' ❑ ❑ the system!;ir(ocated in a nitrogen !sensitive area (Interim Wellhead Protection Area - IWA or a mapped Zone II of a public water supply well If you have answered "yee to any question in Section E the system is condidered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered ''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. t5ins-03113 Title 5 Officlal Insoection Fnrm Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments pie 6�dle�6y) Property Address Owner — --- Information is Owner's Name required for every page. Cityfrown State Zip Code Date of Inspection C Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑f ❑ 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? ❑ 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 E this inspection? !�I ❑ Were as built plans of the system obtained and examined? (If they were riot available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Z ❑ Was the site inspected for signs of break out? 2" [:1 Were all system components, excluding the SAS, located on site? 2' ❑ 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? 1 ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? This 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(5)] D. System Information Residentiat Flow Conditions: Number of bedrooms (design): \'— Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ,I Title 5 official Inspection Form Subsurface Sewage Disposal System•page G of 17 t5ins-03!13 Commonwealth of Massachusetts Title 5 Official Inspection Form lug Subsurface Sewa�gje�Di�sposal System Form-Not for`Voluntary Assessments Property Address owner - ---- — Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: �� Does residence have a garbage grinder? ® Yes No i' Is laundry on a separate sewage system? [if yes separate inspection required) ® Yes ® No Laundry system inspected? �'� � ❑ Yes ❑ No Seasonal use? / ❑ Yes &No Water meter readings, if available(last 2 years usage(gpd)): Detail: \` I �! v S Sump pump'? TD^Yes ❑ No l Last date of occupancy: � 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.);f Grease trap present? f'` ❑ Yes ❑ No f Industrial waste holding tank present? ❑ Yes ❑ No i Non-sanitary waste discharged tothe Title 5 system? ❑ Yes ❑ No Water meter readings, if ava pile: _ [Sins•03/13 i nue 5 Official Insnwri—c....,.c..r-..w..--e_.-._-_ _- •_ _ -._. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for voluntary Assessments Property Address Owner Owner's Name Information is required for _^ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): i 7Z General Information Pumping records: Source of information: Was system pumped as part of the inspection? Q Yes ❑ No --- If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: >>C Type of System: Septic 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Title 5 Official inspection Form Subsurface seHege Disposal System•Page 8 of 17 t5ins-03113 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage JDis oral System Form - Not for Voluntary Assessments Property Address Owner Owner's Name Information is required for every page. City/town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? Yes No Building Sewer(locate on site plan): �1 Depth below grade: feet Mate ' I of construction: cast iron ❑ 413 PVC ❑ other(explain) i Distance from private water supply well or suction line: _et AJ� feet Comments I(on condition of joints,venting,evidence of leakage, etc): LZ- VI Septic Tank(locate on site plan): Depth below grade: feet Material of construction: Ey concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance:? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: F Sludge depth lltle 5 OtYiclal Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 t5ins-03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage [fisposal System Form-Not for Voluntary Assessments Property Address Owner — --- Information is Owner's Name required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 D Now were dimensions determined? St U�Ct Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: Z feet Material of construction: ❑ concrete ❑ metal ❑ fibergl ❑ polyethylene ❑ other(explain) r Dimensions: Scum thickness ,� _ Distance from top of scum tot p of outlet tee or baffle Distance from bottom of um to bottom of outlet tee or baffle _ Date of last pumping: Date t5ins-03/13 -- - Commonwealth of Massachusetts Title 5 Official Inspection Form lugSubsurface Sauvage Disposal System Form -Not for Voluntary Assessments Property Address Owner — -- ---- Information is Owner's Name required for every page. City/Town ,State Zip Code Date of Inspection D. System Information (cent.) 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 ❑ polyet ene ❑ other(eXplain) Dimensions: Capacity: gallon Design Flow: lions per day Alarm present: �, C] Yes ❑ No r Alarm level: _ Alarm in working order: ❑ Yes ❑ No Date of last pumping: _ Date Comments (condition of alarmarid float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Tltle 5 Official Inspeellon Form Subsurface 8ewaae Disoosal Svstem•Pana+1..r+l t5ins-03113 Commonwealth of Massachusetts Title 5 Official Inspection Form h Subsurface SeN/age Dryisy1posal System Form -Not for Voluntary Assessments c '� � .J �� 1,1 ��l I U n •l�^ Properly Address t [(- Owner — --— Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection D. System Information (cent.) r Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert L' 14 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.): y l � l O i J �1/ i 1� Oj, � a Q-G� y 4 05 1� n 5 ��g iG, 0 is S L rckGrG`� " 4 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: `'J ❑ Yes ❑ No Comments (note condition of pump chamber,pond ition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: '` f Title 5 Official Inspection Form Suhsudnee s—.a t5ins-03/13 Commonwealth of Massachusetts Title 5 Official Inspection Form n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: _ ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typekaame of.technology: _ Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): v Ic50 i, V- . I 6,-p&y rLi Cesspools (cesspool must be pumped as part of inspection) (loe9te on site plan): Number and configuration _ ^ Depth -top of liquid to inlet invert Depth of solids layers Depth of scum layer Dimensions of cesspool f Materials of constructioro Indication of groundwater inflow ❑ Yes ❑ No t5ins•03/13 Title 5 Official Inspection Fnrm Rttha-.s�.a c.,.....__.._____.....-•. _ .- - - Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a , oA�P o r` Property Address Owner Information is Owner's Name required for every page. Citylrown State Zip Code Date of Inspection T D. System Information (cont. Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r� r f / T Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydF'aulic failure, level of ponding, condition of vegetation, etc.): f F f �r f Title;i Official Inspection Form Subsurface Sewage Disposal SVstem- Pana 14 M 17 t5ins•03/13 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �6 - zi Property Address Owner Owner's Name Information is required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 15 of 17 [sins•03113 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope CI Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet 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: LJ Checked with local excavators, installers -(attach documentation) ❑ Accessed USG$database-explain: You must describe how you established the high ground water elevation: + T Before filling this Inspection Report, please see Report Completeness Checklist on next page. Title S Official Inspection Form Subsurface Seviage Disposal System•Nos 16 W 17' t5ins-03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Z // eta:d 5+ Property Address Owrier Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 2" Inspection Summary:A, B, C, D, or E checked 0' Inspection Summary D (System Failure Criteria Applicable to All Systems)completed 53"System Information - Estimated depth to high groundwater LD Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 17 of 17 t5ins.03113