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Home My WebLink AboutTitle V Inspection Report - 79 LACY STREET 7/11/2018 Commonwealth of Massachusetts �� Title 5 Official Inspection Form �� = Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments Address Owner •.__. —a--��_—__.._..______ n �. r s me _... _.__.._ Owner is required for every _,_-. __._. � s1_ h I page. ty own ___. State Zip Cac o C)atc: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:when filling out farms A' General informa tion on the computer, use Only the tab 1. Inspector: key to move your cursor-do not Charles J Roux use the return ._.._ _..___— ____.._ —_-- --_,-- key. _._ ke . ane of Inspector y y Charles J, roux LLC Company Name _...._....�..._ 1. 3 .Patten Road rllaA Tewksbtgy .l. °7�:) Ctty/Town - _—_ .Stake —_— ----- �.._..__ Zip Cade '78 640-9984 X1891. e ep ane 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 ofi7n 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 Conditionally Passes FI Fails ( ] Needs Further Evaluation by the focal Approving Authority C 'f l / tom -4 ins peatac s Signature Dato The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 34 days of completing this inspection, If the system 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, ****Thi;r 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 futulre unrler the same or different conditions of use. I 1 61116.010c rev.6116 Title 5 Official InspecUon Form;Subsurface Sewage f)Isposal System�Page t of 17 ' Commonwealth wfMassachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form 'Not for Voluntary Assessments Property Address Owner --------- iomvmon^xin required for every ----- ------��- -------- page. wx�/wwn a�� z�pomov om * ofmopvrovn B, Certification /cOnt.\ Inspection Summary: Check A.8.C.Dor E/a/ways complete all of Section D A) System Passes: ~/ | have riot found any information which indicates that any cfthe failure criteria described in 310 CK4R 15.303orin 310CK4R 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: / 13) System Conditionally Passes: Fl One ormore system components uadescribed | the''Cd|d 6o ^section need to b Commonwealth mfMassachusetts ��"�Q� � ��0 8��~�� Title �� v& N0~~Nm=0 Inspection N-��ummn Subsurface Sewage Disposal System Form ~Not for Voluntary Assessments ----__�__ Property Address Owner u— o ---- -- � �n mmnn=nvn|* required for every ----- ------�-- --'------ pnop. Q4f[owo ntmv Zip Code Date ofInspection B, Certification /cnOt.\ n Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (oonL): [] Observation of sewage backup or break out or high static water level in the distribution box due to broken bef dod i ( )or due to a broken, tt|ed or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced E] Y E-] ND (Explain below): obstruction is removed j Y /NE01 ND (Explain below): El distribution box is leveled or replaced N [I ND (Explain below): ----------- LI I-he system required pumping r re than 4 times a year due to broken or obstructed pipe(s). *The system will pass inspection if/ith approval of the Board of Health): eplaceci broken pipe(! eplaced 0 Y F1 N El ND (Explain below): obstruction Y CIII�oved 0 Y Ej NEI ND (Explain below): | C) Further Evaluation ioRequired bythe Board mfHealth: � Cnndi��whi� r�uim��hermm|u�on ��e Boo� �Mee� inmdar�de�r�� the system is failing to protect public health efety or the nvi 1. System will pass unless Board of)4ealth determines }maccordance with 31OCNlR 15.303that n|ng |namanner which will protect public health, safety and the environment: Fl Cesspool or privy is ithin5Ofeet ufaSurface water Fl Cesspool or pri iowithin 5Ufeet nfmbordering vegetated wetland ormsalt marsh Commonwealth of Massachusetts .: Title 5 Official Inspection Farm A = a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address I Owner Owrter"s M1rame information is required for every --_—. __.. _ ___..... __ _.._— -.-_ __.. _.. �_.. .._..._ page, CitylTown state Zip Code Date of Inspection Be Certification (cont,) 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 soli absorption system (S )and the SAS is within '100 feet of a surface water supply or tributary to a surface wf r supply. The system has a septic tank and SAS and the SAS is Rhin 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 the S is less than 100 feet but 50 feet or more from a private water supply well**. f✓ Method used to determine distance: **This system passes if the well water ar/ysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and t e, presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that r,6 other failure criteria are triggered. A copy of the analysis must be attached to this form, r 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 E�` 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 volurne is less EAA than '/z day,flow 151ns.doo-rev.6116 Tktle 5 Motel Inspection Farm:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts =N=��K�� ^��~��N 0��°�� U�� mm�m�� wxm��m��N Inspection �-��mmon Subsurface Sewage Disposal System Form 'Not for Voluntary Assessments - Property Address ---Owner Owner's nwne/xNm-- --------------- information Is required for every - page.. City[/own lState -- -------- Date-.Inspection B. Certification (cont.) ��-------- Yeo No Fl r�/ Required pumping more than 4times |nthe last year/V<�Tdue (oclogged o/ -~ �~ obstructed pip*(o). Number oftimes pumped:____.. LJ �� 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 toasurface water supply, Any portion of commpno| or privy is within a Zone 1 of public well. Fl �� =� Any portion of a cesspool or privy is within 50 feet of a private water qLlpply Well. Fl [� ^~ �� Any portion of cesspool or privy is |amn than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis, [This system passes ifthe well water analysis, performed ataDEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to nrless 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.] �l ,`/ Thesyotam |uauoaap*o| aeminUafaoU|tywithodaaign8owof200Agpd- ^~ �~ 10.000gpd� [l ��, The myst*n*f�|s. | have determined that one ormore ofthe above failure -- �� critehoexiotoodaaoribodin310CyNR15.3O3. thonmfonathemyu1omhyi|m. The system owner should contact the Board of Health todetermine what will be necessary tocorrect the failure. E) Large Systems: Tmbeconsidered alarge system the system must serve efacility with m design flow of1Q,O00Qpd to15.O8DQpd. For large systems, you must indicate either^yoo^or'no^toh of following, i ddiU i th questions in Section D. Yes No the systern is within 400 fe of a surface drinking water supply E] the system is within P feet of a tributary to a surface drinking water supply El F] the system is loc J in a nitrogen sensitive area (Interim Wellhead Protection Area---IWPA) Pal la(iapped Zone 11 of a public water supply well ~If You have answered x°" "' ° ummmconsidered oranswered 'yes' | bnckm above the large system has failed. The owner oroperator cdany large system considered ntthreat under Section Eorfailed under Section Dshall upgrade the system iOaccorUoOo OCk4R15.3O4. The oy�emowner should contact the appn>pdokn regional o�oaofthe0�pa�mant m°o-**'rev,ono Title»Official inspection Form:Subsurface Sewage Disposal System'mgosm,r Commonwealth oJMassachusetts ��~4�8�� "��=��Q N��^=�~�� N°N�� 0 ��N�* �� UN0��N�� Nwm��Q��wp Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments pmnmnvxoxnoo" / aw^m Owner's Name information is required for every ----' - ----------- page. ooam oncuuo Date mInspection ____________ C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health Were any ofthe system components pumped out inthe previous two weeks? Fl Has the system received normal flows inthe previous two week period? Fl c�/ Have large vo|un�paof vvu1erbeen in�oduoadtothe system r*omndyoraopa� uf ^~ co this inspection? Were mubuilt plans ofthe system obtained and examined? (If they were not available note aoN/4) [d Fl Was the facility ordwelling inspected for signs ofsewage back up? [l Was the site inspected for signs ufbreak out? Were all system components, excluding the SAS, located onsite? Were the septic tank manholes uncovered, opened, and the interior of the tank ~� ^~ inspected for the condition ofthe baffles urtees, material ofconstruction, dimensions, depth ufliquid, depth ofsludge and depth ofscum? Was the facility owner(mndoccupants ifdifferent�omowner)pmvid with d* �� Fl information on the proper` maimtenenow of subsurface sewage disposal oyubema? The size and location wfthe Soil Absorption System (SAS)onthe site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any ofthe failure criteria related to Part is at imnue Fl �] ^� approximation is unacceptable) [310 CMR 15.302(5)] ID~ System Information Residential Rovx Conditions: ----/---- Number nfbodnonm�(actual): ----�----- Numbero[badnoomo(de�ign)� , � DESIGN flow based cm318CMR 15.2O3 (for example: 11Ogudx#ofbodnxoms): \ ^' t6lmcloc,rev.6116 Title oOfficial msp"uw"p°" Subsurface Sewage Disposal oysmm'Page o*,, ComNnonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments .~'".`/"°".""" Owner owneroN-- � ----'-------- information is mmqm=ufo,e,ery - vxse u��rvwn ��—Information S�u — -- ---''— ion D. System �----------- -----'------- Description: Numberofcurrent residents: Does residence have mgarbage grinder? R' Yno Fl No Is laundry on a separate sewage system? (Include laundry systerni inspection �l Yes rr( N information in this report.) �� T o Laundry system inspected? 1L111q [l Yon Fl No Oeosona| uoo? F7 Yes [1 No Water meter readings, if available (last 2 yoem usage (gpd)): ~ Surnp pump? El Yes F1 No Last date ofoccupancy: Date 4, Cwnornemc|oK|ndustr|a} Flow Conditions: Type o/Establishment: Design _ `----_ _n _1- -''^' '-~`~/' oa||vowper day(gP«) / Basis Grease trap t? Fl Yes n No Industrial waste holding tank [] Yes E No Non-sanitary waste discharged tVihe Title 6system? [l Yeo El No Water meter readings, ifaveU4b|e: Commonwealth of Massachusetts ��N�� ^��N 0��°�� U�� m�m�~ �� mmm��m��w Inspection N-��mmmm Subsurface Sewage Disposal System � rm -NwtforVo|untaryAaeeosmnnts — pPo - --------__ Owner owm°,'sName ---------'-- -------- infonnaUnn|m mqu|mdfor mvery tion n^y*. ' it*/^wv State-- D. System Information (cont.) �---- Last date ofoonupanoy/uoe: Date _-�----' Other(describe be|mw): General Information Pumping Records: SouroemfinformoUon: -__-__-- Was system pumped mapart ofthe inspection? Fl Yes No |fyes, volume pumped: ----' --__-_-_- gallons How was quantity pumped determined? -------_ R*esonfurpumping: Type ofSystmm: �� Septic tank, distribution box, soil absorption system [l Single cesspool Fl Overflow cesspool Fl Privy [l Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology, Attach a copy of the current operation and maintenance contract(to beobtained from system owner)and acopy oflatest | inspection ofthe |V\system bysystem operator under contract | LJ Tight tank, Attach ucopy ofthe DEP approval, Fl Other(describe): tblns,doc-rev.&16 Title 5 Otficlat Inspection Form:Subsurine Sewage 01sposal sysiem,F�ege a ot 17 | � � Commonwealth of W55wchwsetts Title 5Official Inspection nse =tionF orm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Pr6perly Address Owner - -------- inw,mutw"ia � required for every page. City/Town m�� Zip Code ont°orm"ponmon D. System Information /c0DL\ Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving ekthe site? Fl Yam [i;� No Building Sewer(locate on site plan): Depth below grade: Material of o[construction: . / '/ Fl cast iron ��4O PVC Fl other(explain): - -------- Diobanrehom private water supply well or suction line: feet -------- Comments(on condition ofjoints,venting, evidence ofleakage, ob.): /I/OA"- - (;:c, - Septic Tank(locate onsite p|an>: Depth below grade: feet K4ot*he| of construction: / concrete [J metal F]fiberglass Elp'-olyethylene' other (explain) If tank is metal, list age: years |sage confirmed byeCertificate ofCompliance? (attach ecop of certificate) E] Yes No Dimensions: Sludge depth: —� Commonwealth of Massachusetts Title"��U� � ��N N�� »� � ��m� �om��m � 0-��m � mm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -------' -------------- Property Address Owner mwnn,'ow"ma -------- information is required for every -------- l�J�— � page. �2��____ -_ - -� Codo Date of Inspection K�_ ��ysteK� Information /C0Dt.\ Septic Tank (cont.) Distance from top ofsludge tnbottom ufoutlet tee orbaffle -�------ SCUM thickness �------ Distance from top ufscum totop o[outlet tee orbaffle --~----------� (} Distance from bottom ufscum tobottom ofoutlet tee orbaffle -_��----- How were dimensions determined? 7--------- J Comments (on purnping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �u Grease Trap (locate cmsite plan): Depth below grade: eat Material of construction: El concrete metal El fiberglass/ EJ polyethylene � Dimensions: Scum thickness - ------ Distance from top of scum to top of ------- —'��---' Distance from bottom ofonu UnmofouUuttee orbu0e — Date oflast pumping: / Date ---�------ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal "Rysterri 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.) Comments (on pumping recommendations, inlet and outlet ted-or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, c.): ----—--------- v _/idenlieakage ce of Tight or Holding Tank (tank must be umped at time of inspection) (locate on site plan): Depth below grade: Material of construction: El concrete [I metal El fiberglass polyethylene [j other(explain): Dimensions: ___ ._...---_...._.......___.___ - Capacity: _.._._ __............. ________._gallons Design Flow: gallons per day Alarm present: El Yes El No Alarm level: Alarm in working order: E.1 Yes EJ No Date of last pumping: Date Comments (condition of alar i and float switches, etc.): ........... Attach copy of current pumping contract(required). Is copy attached? El Yes E' No t5ins.doc-rev.6116 Title 5 Official lnspeclloj Foam:Subsurface Sewage Disposal Syslurn-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ITLa C.-V........ -j— Property Address Owner dW--n—er's"N-a-rn—e ---' information is required for every ------------- page. cityrrown 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.): cr� -41 Pump Chamber (locate on site plan): Pumps in working order: El Yes 0 No* Alarms in working order: El Yes El No* Comments (note condition of pump chamber, conditio of pumps and appurtenances, etc.): ----------- -----------If pumps or alarms are not in w/rkirg order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t6lns.doc•rov.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 OffNicNaN Inspection Form Subsurface Sewage Disposal System Form 'Not for Voluntary Assessments '5�- gc___ __ _L -------- Property Addres Owner o�nar'nNamv information is required fo,vvmry - ------- page. =^r'~''^ State- Zip Code Date of Inspection ---------- D. System Information (cont.) Type: 11 leaching pits number El leaching chambers number: � [l leaching galleries number: ------��----- leaching trenches number, length: Fl leaching fields number, dimensions: ------------- [l overflow cesspool number: ----------�'- Fl innovmUv*/a|tornutivooysiem Type/name oftechnology: �-------- Comments(note condition ofsoil, signs ofhydraulic failure, level ofponding, damp soil, condition of vegetation, etc.): ' \ ��-� (cesspoolCesspools mustb d as part of\ cti ) (|ooateon site plan), Number and configuration - �--------- Oepth-tmp of liquid to inlet invert ---------- Depth of solids layer -' Oepthofanum|ayer - Dimensions ofcesspool - - ---------- Materlm|aofoonmhuoUon --------- Indication of groundwater in /OW Fl yes [l No t5ins.doc-fav,6116 Title"mo^°/inspection Form;Subsurface v"wao"Disposal orm"-rag",**,' Commonwealth of Massachusetts Title 5 Official Inspection Form X Subsurface Sewage Disposal System Form Not for Voluntary Assessments CV ------------- Property Address OwnerOwner's Name --------- -------- information is required for every ...... page, Cityrrown 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 soil, signs,of h 'raulic failure, level of ponding, condition of vegetation, etc.): 151ns.doc-rev.6116 'I'lue 5 Official Inspeclion Form:Subsurface Sewage Disposal Systern-Flage 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments PropeRy Addresy Owner Owner s Name information is required for every page, cityrrown 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: F4 hand-sketch in the area below drawing attached separately —------------ ffilns.doc-rev.6116 1 Ille 6 Official Inspection Form:Subsurfaco Sowago Disposal Syslon)•Page 16 Of 17 commmmx»mwealthof Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments PropeftyAddress Owner Owner's Name information is nmoimuxxe"ary —--------- | �� — Z�ixv�� uv�vInspection vunn� City/Town _ _________ � D. System Information (cont.) Site Exam: [] Check Slope El Surface water El Check cellar / El Shallow wells Estimated depth hohigh ground water: met Please indicate all methods used to determine the high ground water elevation: o/ Obtained from system design plans on record / If checked, date of plan reviewed: ---��- ' ' oom F1 Observed site (abutting prop erb/ubsematioo hole within 150 feet ofSAS) ' [l Checked with local Board ofHealth -explain: Fl Checked with local excavators, installers-(attach documentation) F� Accessed USGSdatabase-explain: You must describe how you established the high ground water elevation: / _ ____ | ^--^--^~��~ ----------- | ---------''----- ---' ---------- Bafmnmfiling this Inspection Report, please see Report Completeness Checklist oil next page, am�uoc'rev.one muoOfficial Inspection Form:Subsurface Sewage Disposal oyslem'Page,00fx Commonwealth of Massachusetts Title 5 Official In: Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ............... Property Address riW7 Owner s—Name information is required for every page. City/Town State Zip Code Date of Inspection Report Completeness Checklist [Vf Inspection Summary:A, B, C, D, or E checked Lv�Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.dDc-rev,6/16 Title 5 Official Inspection Form:Subsurface Sewage 01sposal Systain-Page 17 of 17