The URL can be used to link to this page

Home My WebLink AboutTitle V Inspection Report - 742 BOXFORD STREET 6/24/2017 Commonwealth of Massachusetts Title 5 Official Inspection lForm Subsurface Sewage Disposal-System Form Not for Voluntary Assessments Property Address er's #rme ialuired for KA_ '[ _Ciod Date of Inspection--- overy page. CitytTown 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. When filling out A. General Information forms on the mrnputer,use 1. Inspector only the tab key tX)move you), -do not Name of Inspector use the return key. Company Nam Company Address cftyrroWn Z� state Zip Code- �4o Q V4- I Telsphbne Number Lioense Number El. Certification 1 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 16.340 of Title 5(310 CMR 15.000).The system: Passes El Conditionally Pamms El Fails ❑ Needs Further Evaluation by the Local Approving Authority Ins ors'&gnature The system inspector shall submit a copy ofthis inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspec.tion. 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 tho 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. -nos 5 01ficial lnspecffon Form:Subsurfaces S")e VjapoW SystoM.page 1 of 17 Commonwealth of Massachusetts 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments iProperty Address Owner Owner's Name Information is required for every Page, Cityffown mm State Zip Code Date of Inspection EK Certification (cont.) Inspection Summary: Check A,B,C,D 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 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: V L) LJV")YIC ow U k 13)System Conditionally Passes: El 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. 17 Check the box for"yes", "no"br"not determined"(Y, N, ND)for the owing statyements. If"not determined, " please explain. The septic tank is metal and over 20 years old*or the sept* ank (whether metal or riot) is structurally unsound, exhibits substantial infiltration or e tration or tank failure is imminent. System will pass inspection if the existing tank is replaced wit a complying septic tank at,approved by the Board of Health. A metal septic tank will pass inspection if it structurally sound, not leaking and if a Certificate of Compliance indicating that the tank Is lass,tfian 20 years old is available. ❑ N Y El ND,(txplain below): -11111e 6 01ficial inspatilon Form Subsurface Sewage m3posal system age 2 of 17 t6ins Commonwealth of Massachusetts Title 5 Official Inspection Form I.. k 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.) B) System Conditionally Passes (cont.); ❑ 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 D Y 1:1 N ❑ ND (Exaln below): ❑ obstruction is removed ❑ Y N ❑ ND Tx"plain below): ❑ distribution box is leveled orreplaced ❑ Y N 1),"NI) (Explain below): ❑ The System required pumping more thar,I '4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with apOroval of the Board of Health): El broken pipe(s)are replEff/d EJ Y E] N n ND (Explain below): ❑ obstruction is rern�YQ El Y E] N 0 ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist whichre further evaluation by the Board of Health in order to determine if re the system is failing to protect public health, safety or-the nvironment. i 1. System will pass unless Board of Health deterpilnes in accordance with 310 CMR 15.303(1)(b) that the system Is not functioning 1t a manner which will Protect public health, safety and the environment.* El Cesspool or privy is within 50 fed(of a surface water El Cesspool or privy is within feet of a bordering vegetated wetland or a salt march t51ns-owu Tilia 5 Official inspection Form Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Form Not for Voluntary Assessments Property Address Owner Jnformalion is dw-ner-s-Name required for every page. 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: Cl The system has a septic tank and soil absorption system (SAS)�Wd the SAS is within 100 feet of a surface water supply or tributary to a surface wait r supply. SAS El The ply.system has a septic tank and SAS and the SA S is with[n'a Zone 1 of a public water sup EJ The system has a septic tank and SAS and the SAS is4'iithin 50 feet of a private water supply well. The system has a septic tank and SAS and the�/S is less than 100 feet but 50 feet or more from a private water supply we Method used to determine distance, ✓ This system passes it the well water ana�6/js, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presencd of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other/ra"ilure 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 El 12/ 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 CJ E3' Static liquid level in the distribution 13OX 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 Title 6 Mum Inspection Form Sut'surracs Sewage Disposal system•Page 4 of 17 Commonwealth of Massachusetts ��K�� 0 N��^��°�� N°8�� Nm�U�� n��NN0��0��N Inspection �~~"rmwmo Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 13 xao_° |- �npoxr4uunsu Owner Owner's ---------------��----__--' ____________ ` |n�/mauon|o `~'~' ~ '`^'''~ mqu)red for every page. c|tynown o/a/e--- ZIP Code -Date of Inspection 13, Cort^f^cat-oU0 (cont.) Yes No No [� r� ^� �� Required pumping more than 4 times in the last year MOT due to clogged or obntructodpipa(u). Number nft|meopumped: ____. �� [� �� Any portion of the SAS, Cesspool or privy is below high ground water elevation. [� [J Any portion of cesspool or privy is within 100 fest of a surface water supply o, tributary to m surface water supply. ET Fl �� u� Anyportion nfocesspool nrprivy inwithin oZone 1 ofmpublic well, Any portion of a cesspool or privy is within 50 feet of a private water supply well. �� l � ^� �. Any�o�|nnnfovouapon|orprivyim |enmthen1OOhoodbutgnoatarthan5Ofemt � from mprivate water Supply Well with nuacceptable water quality analysis. [This system passes |fthe well water analysis, performed at o DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence mfammonia nitrogen and nitrate nitrogen is equal tomrless than 8ppm, provided that no other failure criteria at,(?triggered. A copy of the analysis and chain mfcustody must beattached N»this Gmrmm.Y This system iaocesspool serving afacility with mdeai8nflow of2OD0gpd' 1U,000gpd. �� l ' ^~ �. The system fails. | have determined that one or-more of the above fm||unn criteria exist oodescribed in310CNiR 15.803. therefore the system haUn. The system owner should contact the Board ofHealth todetermine what w|Ube necessary tncorrect the failure. �) Large Systems: To be considered a largo symhmrn the wyntwnn must serve 'facility with a design flow mf1O.QOOgpdtmi5.0O08pd. For large oynhemm, you must indicate either'yna"or''nn'' to ''^the[oUpw|nQ, in addition to the questions )nSection D. o Yeo No [� [� .� �� hwsystem |wwithin 4UOfeet ,onosurface dr|nk||nQwater supply F7 [� ^~ �� the system is within 20O/f&t of a tributary to a surface drinking water supply El the systern is locatedina nitrogen sensitiVE?area (interim Wellhead Protection Area- I%NPA or aj�apped Zone 11 of a public water supply well If you have answered "yes"to any 46estion in Section E the system 'is condidered a significant threat, or answered"yes" in Section D Xve the large system has failed. The owner or operator of any large system considered a signific t threat under Section E or failed tinder Section D shall upgrade the system in accordance wit 10 CMR 15.304. The system owner should c0r1t8Ct the appropriate PIS regional office of the Department. */""'m/,` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Information is 6-wnoisNarne required for every page. City[Town State Zip Gode 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 til El 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? El 9 Has the system received normal flows in the previous two week period? El 9' Have large volumes of water been introduced to the system recently or as part of this inspection? Ff El Were as built plans of the system obtained and examined? (If they were not available note as N/A) 2 El Was the facility or dwelling inspected for signs of sewage back up? Ef EJ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located an site? Pr El 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? This size and location of the Soil Absorption System (SAS) on the site has been determined based on, 10/ El Existing information, For example, a plan at the Board of Health. P/ El Determined in the field (if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) D. System Information Residential 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 lb tsins Mlle 5 Official tnspecllon Form Subsurface Sewage Disposal System Page 6 of 17 Commonwealth of Massachusetts Title 5 ®fficia.l Inspections Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - o • Property Address Owner Owner's ]nformsli€on is Owner's Name ---~ --- regtilred for — every pale. City/Town state Zlp Code Date of Inspection D. System Information µ� Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes [� No Is laundry on a separate sewage system? (if yes separate inspection required) ❑ Yes L'1 No Laundry system inspected? 4 ❑ Yes ❑ No Seasonal use? Yeas No Water meter readings, if available(last 2 years usage(gpd)): Detall: ! Sump pump? ET Yes ❑ No Last date of occupancy: i Commercial/industrial Flow Conditions: ate u Type of Establishment: / Design flow (based on 310 CMR 15.203): � r �;' Gallons ptsr day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.)Y Grease trap present? ' El Yes ❑ Na Industrial waste holding tank present, El Yes ❑ No Non-sanitary waste discharged to/he Title 5 system? ® Yes ❑ NO Water ureter readings, if avaltable: sins•a3l13 Title 5 Of dal Inspeeuon Form Subaufface Sewage❑Iaposal system•Pege 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form l�. Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments Property Address - — - Owner Information is Owner's Name — required for every page. Cityfi own - —� State zip Code Date of inspection D. :System Information (cont.) Last date of occupancy/use: Date "- Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes E� No If yes, volume pumped: How was quantity pumped determined? W _ Reason for pumping; 'T'ype 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 lat4ast inspection of the VA system by system operator under contract ❑ Tight tank. Attach a copy of the DFP approval. ❑ Other(describe): 45ina-D3113 7Iiie S Official inspection Form:Subsurface Sewage Disposal System.page 6 of 17 Commonwealth of Massachusetts w � Title 5 Official Inspection Form❑ a — 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 (cant.) 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): Depth below grade: " feeE �`- Material of construction: cast iron ❑ 40 PVC ❑ other(explain) Distance from private water supply well or suction line: _ � T feet / Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): j Depth below grade: Material of construction: feet 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: Sludge depth gins-03113 Title 5 Official IIlsPecllon Form Subsurface Sewage tilspasal System• Page 9 of 17 Commonwealth of Massachusetts Title 5 Official 1nsp(:J.1ction Form Subsurface Sewage Disposal System Form Not for Voluntary AssessrYlents Property Address Owner Owner's Name Information is required for every page. CitytTown Zipode-- Date of Ins -e—ction 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 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.): & on 6 -C te Grease Trap(locate on site plan): Depth below grade: Material of construction: concrete E-1 metal ❑ fibergla El polyethylene other(explain) Dimensions: Scum thickness Distance from top of scum t Dp/OffflutfOt tee or baffle to bottom of outlet tee or baffle Distance from bottom 0;-�cum Date of last pumping: ISirrs-43173 Date T19a 5 Of rjal Inst)ection Axm Subsurface Sewage t)jspout System.PagO 10 of 17 Commonwealth of Massachusetts Title 5 Official In � Inspection ct�o r� F c�rm Subsurface Sewage Disposal System Form Not for Voluntary Assessments -- - �'> red, Property Address Owner Owner's Name IrlformaUon is required for _ every page. City/Town State Zip Code Date of Inspection D. System information (cont.) - Comments (on pumping recommendations, inlet and outlet tela or.baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etgy r 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 ❑ polyethylene ❑ other(explain) Dimensions: - – �— Capacity: ' �-•--inns Design Flow: rr gallons pe F day - `-- I Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: /x _ Date Comments (condition of alarn�and float switches, etc.): *Attach copy of current pumping contract(required). is (:opy attached? ❑ Yes [] No Tille 54111dal Inspection Form Subsurface$swage umpmaf system•p<rge 11 of ty r5tre5-03113 Commonwealth of Massachusetts Title 5 Official In's ection Form -- p Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments Al Property Address — — Owner Information Is Owner's Name — required for every pane. C4/Town _ State Tip Code Date of Inspection D. System information (Cont,) - Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert W 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.): C� `�i..tom.--._%1�?��fC�� •? �- /�%"c� _-_-._.�._..4> Pump Chamber (locate on site plan): Pumps in working order: Yes No J Alarms in working order: C] Yes El No Comments (note condition of{pump chamber, condi ' n of pumps and appurtenances, etc,): 0 u Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: i Mos•oa713 Title 5 Official Inspecllan Form Subsurface Sewage disposal Syslom.pege 12 of 17 Commonwealth of Massachusetts Title 5 Official Ins-opection Forma Subsurface Sewage DisposalSx—s -tem Form Not for Voluntary Assessments F(ropehy Ad-dress Owner Owner's NameI nformation is required for every page. �5_t /Town Slate Zip Code Date of Inspection D. System Information (cont.) Type., leaching pits number: ❑ leaching chambers, number: El leaching galleries number; El leaching trenches number, length: 0 leaching fields number, dimensions: El 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.): �A,n 51. Cesspools (cesspool must bg pumped as part of inspection)(locate on site plan).- C:� 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 ❑ No tGN15-03113 TIIie 5 OffIcial Inspection rOfm Subsurface Sewage D)sposaj System P912F)13 of 17 Commonwealth of Massachusetts ` x 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. CitylTown Slate Zip Code Cate of Inspection D. System Information (cant,) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic faire, level of ponding, condition of vegcitation, etc.): r s.. i 15ins,aan a 7itte 5 Official Inapecllon Form Subsvrface sevmga usposai System•Rage 14 of 17 Commonwealth of Massachusetts X Title 5 Official Inspection Form Subsurface Sewage Dispasall SY5 t M Form Not for Voluntary Assessments q ............... Property Address Owner in Owner's Name Infarrnationrequired for every page. Gityrrown State Zip Code Date of Inspection ID. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system including'lies 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 Vi El drawing attached separately 10 V-3 I. Title 5 Off clat Inspection Foun Subsurface Sewage Disposal System-Page 115 of 17 !Sins•03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments F�roperty 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 El 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 LJ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: RJ Checked with local excavators, installers - (attach documentation) El Accessed USG$database- explain: You must describe how you established the high ground water elevation: Before filling this Inspection Report, please see Report Completeness Checklist on next page, Ifflesomdal Ons^llan FOM)Subsurface Sewage Disposal Syslern•Plige 16of 17 03M, Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form Not for Voluntary Assessments Y, Property Address Owner - -w—neP-i-Name — Informationt is 6 required for every page, CityfTown Elate Zip Code —Date of inspection E. Report Completeness Checklist ED"' Inspection Summary:A, B, C, ID, or E checked Er inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information - e=stimated depth to high groundwater 1: Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file [Sins-030:1 Title 5 Official inspection FormSub-MI(aCe Sewage Disposal Syslorn-Page 17 of 17