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Home My WebLink AboutSeptic Pumping Slip - 2240 TURNPIKE STREET 5/14/2018 Commonwealth of Massachusetts RECEIVED `title 5 Official Inspection Form R - 11AY 14 Subsurface Sewage Disposal System Form -Na for Voluntary Asses ents � J . r,J T l WHEAL 11A �ui fl �i �o�P Property Address t_,i' - ! ------ 66_x 7 -- Owner — Owner's Name r' information is required for every __1 m. _._............ ._.... ......_ '' page, City/Town State Zip Code Date a Inspection V _ 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 A fillinggout forms . General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not use the return Name of Inspector 61key. Company Name Company Address ,ems ��'l��?✓L�r� , ��. City/Town,, State r Zip Code l 5 `� Telephone Number 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 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's S' n/at Date The sys m ' Spector shall submit a copy of this inspection report to the Approving Authority(Board of Healt 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 different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm m== Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every _ __.._._....._---____-- �.�___�__._.w ___.._.....—_. _.____ page. 6t-yfTown State Zip Code Date of Inspection B. Certification (cant.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) Syst 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: 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 ealth, will pass. Check the box for"y ", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please a Iain. The septic tank is metal a over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantia ' filtration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is \(Explain omplying septic tank as approved by the Board of Health. *A metal septic tank will pass insructurally sound, not leaking and if a Certificate of Compliance indicating that the tan0 years old is available. ❑ Y ❑ N ❑ Nw): ------------ t5ins•3113 Tiffe 5 official Inspection Form;Subsurface Sewage Disposal System•Page 2 of 17 ' Commonwealth of Massachusetts - Title 5 Official Inspection nspecion F orm Subsurface Sewage Disposal System Form ~Not for Voluntary Assessments Property Address � � Owner gwnWoNama information is � required for every page. City/Town State Zip Code Date vfInspection � B. Certification (cont.) E] Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) S > F-1 orhigh n static water level inthe d|o�ibuUunbox due to broken nzhen. metdedoruneven dinhibuUonbox. System will paoeinmp Health):D b Fl Y Fl N Fl NO (Explain be|ow>: Fl obstruction ioremoved 0 Y El N 0 ND (Explain be|ow\: � distribution box isleveled mreplaced [l Y n N Fl ND (Explain belmv): ------------ Theoyebemrequirodpum 'ngmonethmn4bmesoyeerduetobrnkenorobatructedp|pe(a). The system will pass inspection |f(with approval ofthe Board ofHea|th): F1 n y Fl N Fl ND (Explain below): F1 obstruction moved F1 Y D N F] ND (Explain below): ------- C\ Further Evaluation |sRequired bvthe Board ofHealth: F1 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is fai blic health, safntyorthe environment. 1. System will determm|nesinaccordance vv|th310 ��0l�� 16.303n|n0lmammmnmermrhichxvi|lprotect public health, mmfe�/and the mnv� is �� <�ma�poo| o�privy|ewit feet ofasurface water F1 Cesspool orprivy iswithin 5Ofeet ofmbordering vegetated wetland ora salt marsh t5i",^3/13 TRW oOfficial Inspection Form:s"b""m,ceSewage Disposal Sysmm'Page om,r Commonwealth of Massachusetts Title 5 Official Inspection Form :T .A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �_y _-...--- ...--------- — —— — PropertAddress Owner Owner's Name information is required for every page CitYfN own State Zip Code Date of Inspection B. Certification (cant.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines th t the system is functioning in a manner that protects the public health, safety and envi nment: ❑ The system ha septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface ater supply or tributary to a surface water supply. ❑ The system has a s tic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic nk and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank an SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply 1**. Method used to determine distance: **This system passes if the well water analysis, p armed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence o ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure crit ria 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 ❑ TA, 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 �t r� Liquid depth in cesspool is less than 6"below invert or available volume is less Vin '/2 day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . M 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 ,m ...._ _ _.__.__.._ _ _..._. .--_..__._ page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No © Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ lel Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ r� 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 1 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 j 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.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ 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 systems, you must indicate either"yes'or"no"to each of the following, in addition to the questions in r ction D. Yes N ❑ ❑ e system is within 400 feet of a surface drinking water supply ❑ ❑ the syst s within 200 feet of a tributary to a surface drinking water supply i El Elthe system is loc d in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA)or a m ed Zone it of a public water supply well If you have answered "yes'to any question in Sec' E the system is considered a significant threat, or answered"yes" in Section D above the large syste s failed. The owner or operator of any large system considered a significant threat under Section E or ' d under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system own hould contact the appropriate regional office of the Department. t5ins•3/13 Title 5 official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ------- Property Address Owner #wnor'vNnm* |nfonnadonie required for every ------ pmg*. CMyKown G,om Zip Code Date ofInspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yea No 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? �J' 0 Has the system received normal flows inthe previous two week period? Have large volumes of water been introduced to the system recently or as part of � this inspection? VVoroasbuUtplans nfthe system obtained and exarnined? (If they were not �� ava||ob|e note as N/A) Was the facility ordwelling inspected for signs ofsewage back up? �1 Was the site inspected for signs ofbreak out? Were all system components, excluding the SAS, located oosite? h~� [| 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 ofliquid, depth ofsludge and depth ofscum? ~-~/ �l VYanthe faoUityowner(andoccupants ifdifferent hnmnwner\ providedwith [� `� in[ormediononthepro `ermainhmnmnnenfoubsu�ooaeawag' disposal systems? The size and location mfthe Soil Absorption System (SAS) onthe site has been determined based on: Fl Existing information. For example, aplan otthe Board nfHealth. Determined inthe field (if any ofthe failure criteria related toPart C |amtissue approximation ofdistance iaunacceptable) [31OCMR 15.3O2(5)] D. System Information Residential Flow Conditions: Number ofbedrooms (design): --- Number ofbedrooms (actual): DES IGNflow based on31OCN4Fl15.2O3 (for example: 11Ogogx#mfbedronmm): w/ns.o^o Title mOfficial Inspection Form:Subsurface Sewage Disposal System'Page 6un Commonwealth of Massachusetts M .m . y Title 5 Official Inspection Farm ------ 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every ------------- _�__.......m__.._.___._.__.._ page. City/Town State Zip Code Date of Inspection i D. System Information 1 Description: ------------- Number of current residents: - — Does residence have a garbage grinder? ❑ Yes M-)No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) F-1 Ye ` -~No Laundry system inspected? r ❑ No Seasonal use? ❑ Yes ] No Water meter readings, if available (last 2 years usage (gpd)): --- -- Detail: --- C Sump pump? © Y No Last date of occupancy: _Datl te Commercial/Industrial Flow Conditions: Type of Establis t: ---.-.-- Design flow(based on 31 MR 15.203): Gallons per day(gpd) — Basis of design flow(seats/person ft., etc.): - — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: _ __...... t5ins-3/13 Title 5 Offaeial inspection Form:Subsurfaca Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address _ Owner __-------- _ __..-. _..._---- ._-- Owners Name information is required for every page. CltylTown State Zip Code Date of Inspection I D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): ------------------ General Information Pumping Records: j Source of information: - ------------- "-�'" u - Was system pumped as part of the inspection? ❑ Yes❑No If yes, volume pumped: 11 g..-allons-----_. ------ How was quantity pumped determined? _.._...,.__,_...-- Reason for pumping: __._.__.._---------. _-._----- Type o ystem: h Septic tank, 6/s1ribution box, soil absorption system p } ❑ Single cesspool ❑ Overflow cesspool 0 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 j ❑ Tight tank. Attach a copy of the DEP approval. I ❑ Other(describe): 15ins-3113 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form Not for Voluntary Assessments -—---------- Propertv Address ---------- Owner owner —- �s Name Information is required for every page. -671t—yffown !�tate� 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? F] Yes . No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: El cast iron �40�PVC El other(explain): Distance from private water supply well or suction line: --- - feet Comments (on condition of joints, venting, evidence of leakage, etc.)- V) ---------- Septic Tank (locate on site plan): Depth below grade: Te-et--I..--- CQ Material of o-ncroefte ❑ metal ❑ fiberglass polyethylene F1 other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Y Dimensions: I Sludge depth: isms 3f113 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts 4 - u Title 5 official Inspection Form Y 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r Property Address Owner Owner's Name information is required for every _ __-... page City/Town State dip Code Crate Of Inspection D. System Information (cant.) Septic Tank (cont.) l Distance from top of sludge to bottom of outlet tee or baffle r 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? .....1 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): V0. -- ry L.! Lout Grease Trap (locate on site plan): Depth below grade: Material of co traction: ❑ concrete metal ❑ fiberglass © polyethylene ❑ other(explain): I Dimensions: I 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: L3ate t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f <L",\ Commonwealth of Massachusetts wu -y 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 Cityn'own State Zip Code Date of Inspection D. System Information (cont.) Comments (on purnking recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as relate outlet invert, evidence of leakage, etc.): Tight or Molding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: --..- _-- Material of construction: 0 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ---- Capacity: gallons Design Flow: --- gallons per day Alarm present: ❑ Yes ❑ No Alarm level: - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): i i i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address ----------- Owner Owner's game Information is required for every page. City/Town State Zip 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 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.): o- --------------- Pump Chamber (locate on site plan): Pumps in working order: tes [:1 No* Alarms in working order: es E] No* Comments (note condition of pump chmber, condition of umps and appurtenances, etc.): �-il)-Ki m --CM-4- If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: ..................... t5ins-3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 � � Commonwealth of Massachusetts _ ��N�� ^��'"��0 0�� N°0�� Title �� /@ � ��N�� Inspection N—�.m � mm Subsurface Sewage Disposal System Form ~Not for Voluntary Assessments --------- PropertyAddmae $mmvr Owner's Name information is required for every ----- ------�— pm80. City/Town State Zip Code Date ofInspection D. System UK8fm`r00at~on (cont.) Type: �] leaching pits number: ------- leaching � || |eaohingchonmbere number: �] leaching galleries number: leaching trenches number, length: F] leaching fields number, dimensions: R overflow cesspool number: El innovativa/a|tmrneUveayatenn Type/name oftechnology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): L-L-ff--N- NO Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liq *d to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool -- Materials of construction Indication ofgroundwater inflow El Yes 0 No m/ns`3113 nv°5Official Inspection 'o"".Subsurface Sewage Disposal System`Page mun Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ------------ —--------- Property Address ...... ..... Owner bw�ners Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 s�o`il, s s of hydraulic failure, level of ponding, condition of vegetation, etc.): ---------- 15!ns 3113 Tide 5 Official inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts { R_ _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 Property Address 1 OwnerOwner s Name Information is required for every _--__-- �._. ___.__..._.............-_- page. City/Town 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: M/hand-sketch in the area below ❑ drawing attached separately r 6 I _I I t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y Property Address OwnerOwner's Name information is required for every -__..-.-- page. Cltyffawn State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope 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: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: - - ------ 1-77 ---- icy r- - _.._----- - ° ---_._m_ ------------- .......... Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address ----—_------- Owner Own—e—CsNan�;--- -- information is required for every page. City/Town State Zip Code Date of Inspection E. Re rt Completeness Checklist 7ESystem ection Summary:A, B, C, D, or E checked ection Summary D (System Failure Criteria Applicable to All Systems)completed Information —Estimated depth to high groundwater M— ketch of Sewage Disposal System either drawn on page 15 or attached in separate file thins-3/13 Tiffe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17