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HomeMy WebLinkAbout275 Hay Meadow Rd Title V Inspection - Title V Inspection Report - 275 HAY MEADOW ROAD 5/10/2019 * Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sys m IForm-Not for Voluntary Assessments Property Address n isf — { � X CA JM4 i Owner C9wr glees Na required tw every "" pager city/rown State zip� gate of tnsperation µ Inspection results most be submitted on this farm. Inspection forms may not be altered in any :way.Please see completeness checklist at the end of the form. rmpwa"Af"�`ean A Inspector Information filling out firings on the computer, use orkly t e tab 1 key to move your Name o I r cursor-dormt —� keythe return y Name key. �� � Address state Zip Code Telephone NLunber License Number B. Certification I certify that:I am a DEP approved system Inspector In full compliance with Section 15.340 of Title 5 (310 CMR'15.000);1 have personally inspected the gage disposal system at the property address listed above,the information reported below is true,accurate and complete as of the time of my inspection;and the inspection was performed on my training and experience in the proper function and maintenance of can-site sewage disposal sy�terxis.After conducting this inspection I have determined that the system: 1. Passes 2. Conditionally Passes 3. 0 Needs Further Evaluation by the Local Approving Authority 4, 0 Fails 1 s Signatu Date The system inspector shall L 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 has a design flow of 10,000 gpd or greater,the inspector and the system yawner shall submit the report to the appropriate regional office of the DER The original form should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Please note:This report only describes conditions at the time of inspection and cinder the conditions of wall at that time.This Inspection does not address how the system will perform in the future under the same or different conditions of use. 51nsp.c w revr.762b o I8 ra 5 C ram Ynqxaw Fom sWepe SystM.Pap ti of ae Commcnwealth of Massachusetts jai �S ctil n Form � Title 5r Office F 1 p posal System »hint for Voluntary Assessments Subsurface Sew99 lug Property AddreW Owner owners N Wo neation Zip Code Date of Inspection refit d(or esirery Page:. /rower C. inspection!Summary inspection Summary:Complete 1,2, 3,or 5 and all of 4 and 6. 1) 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.- /L_ 2) System Conditionally Passes: 0 One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The systems, upon completion of the replacement or repair, as approved by \drminedi'please Board of Health,win pass. he box for'yes","no"car"not determined-(Y, hl, ND)for the following statements. If"not explain. c tank is metal and over20 years old*or the septic tank(whether metal or not)is structurally unsound, ibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if existing tank is replaced with a complying septic tank as approved 6y the Boasn�of Health. *A metal septic tank veil s inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that th nk is less than 20 years old is available.. 0 Y H 0 ND( in below): Whzp.dec rev.7r 201a rsae 6 offidal Inspeamnn 1" read s�DISIMI li SWAM-Page 2 of 18 ���a� Al ComInonwealth of Massachusetts 'Title 5 Official Inspection Form Subsurface$swage Disposal System Form-Not for Voluntary Assessments kftmatlon is sari ream pa". QW~1 `°_sue- .ire a$ t ,. „ inspection Surll�I�rlary (coat.) j 2) Sy #arn!Conditionally Passes(cant): 1 0 p urn Chamber p psl'alarms not operationai.System will pass with Boats of Health approval if Purn larms are repaired. 0 Observation of sewag ckup or break out or high.static water level in the distribution box due to broken or obstructed pip or due to a broken,settled or uneven distribution box system will Pass inspection if(with appr ra Board of H'ealth): brokers pipe(s)are replaced [� Y ® N C1 ND(Explain below): 0 Obstruction is removed Y n N [] ND(Explain below): [ distribution box is leveled or replaced (3 Y N 0 ND(Explain Wow): i El The system required pumping more,than 4 times a year due to broken or obstructed pipe ),The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced El Y [I N n ND(Explain below): [] obstruction is removed ® Y ON 0 ND(Explain below): i 8) Further Evaluation Is Req by the Board of Health. Q Conditions exist which require her evaluation by the Board of Health in order to determine if the system is Wing to protect pu alth,safety or the environment_ a. System will pass unless Board of He h determines in accordance with 310 CMR. 15.303(l)(b)that the system Is not functionw In a manner which will protect public hearth, safety and the environment. t3Fraaap.doe•rev 72 r11s rift 6 Offidaa lnopKft Fam Subsurlaw spasq�Spay M 3 anti°ad + f. commonwealth of Massachusetts Title Official Inspection Farm Subsurface Sewage WIspcsai Sysftm Form Not for Voluntary Assessments Property ress farmatwon � ✓" -�' feq+lsred for every page. frcnva t State Zip Code Date of Inspection- . inspection summary (cant.) Cesspool or privy is within 50 feet of a surface water poi or;privy is within 50 feet of a bordering vegetated wetland or a salt marsh b, System " fall unless the Board of Health(and Public water Supplier,Ifany) determines the a system Is functioning In a manner that protects the public health, safety and environ rot: 0 The system has a se ` tank.and soil absorption system(SAS)and the SAS is within 100 fee#of a surface waters ly or tributary to a surface water supply. El The system has a septic taxi d SAS and the SAS is within a Zone 1 of a public water supply- 0 The system has a septic tank and, and the SAS is within 50 feet of a private water supply well, 0 The system has a septic tank and SAS an a SAS is less than 100 feet but 50 feet or more from a Private water supply swell*". Method used to determine distance: This system passes if the well water anaiysis, performed at a D certified laboratory,for fecal coliform bacteria indicates absent and fh+e wesence ol'ammonia nitro n and nitrate nitrogen its equal to or less than 5 ppm,,provided that no othrr failure criteria are triggered copy of the analysis must be attached to this form. c. Other:. a 4) System Failure Criteria Applicable to All Systems: You roust Indicate r`Yse"Or"Noy"to each of the following for all Inspections:. Yes No 0 Backup of sewage into facility or system component dine to overloaded or clogged SAS or cesspool E Discharge or ponding of effluent to the surface of the ground ar Surface waters due to an overloaded or clogged SAS or cesspool t5lnsp.doe W rep.7J25/,tri18 Tire 5 I Fap7Gc S-'W'riisp" !stentt•Pa¢ya 4 saP 119 COMMon'wealth Of MassachuseM r Title 5 ora-M al p strbsr,rfaCesewn Inspection Form ge Dis cowl stern Far, Not for Voluntary Assessments Pry Adftss tuned'�bran is for r page. r cX� ityrr c� . State Tip Cade E7 ate of lrmpec on f nsPectl ►rt SUMMary (cant.) 4) System Failure Criteria Applicable to All Systems:(cant.) Yes No 0 Static liquid level in the distribution box above outlet invert due to an overloaded or dogged,SAS or cesspool E] Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to dogged or Obstructed pipe(s). Number of times pumped:, n Any portion Of the SAS.Cesspool or privy is below high ground water elevation. I"9iAny pin of cesspool or privy is within 100 feet of a surface water supply or tributaoy to a surface water supply. Any portion of a.Cesspool or privy is within a Zone 1 of a public water supply 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 waler supply well with no acceptable water quality analysis. [This Systemm papa if the well water analYsfirs,performed at a DEP certified laboratory,fOr f6C,31 colIfarm bacteria indicates absent and the presence Of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no either failure criteria are triggered.A COPY Of the analysis and chain of custody must be attached to this form.1 E] The system is a cesspool serving a facility with a design,flow of 2000 gpd- ' 10,000 gpd. Ll The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CHAR 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. 5) Large Systems; To be considered a large system the System must serve a facility with a dent n flown of 10JO00 gpd tO 15,000 gpd. For la terns,you must indicate either"yes!or"no'to each of the following, in addition to the questions in ction CA. Yes No rl ❑ the sys s within 400 feet of a surface drinking water supply 0 11 the system is within feet of a tributary to a surface drinking water supply ® 11 the system is located in a ni n sensitive area(interim Wellhead Protection Area—IW°PA)Or a mapped.Zone public water supply well t&F <dac.r 7Aa�k tme 5 r oeasr -r~ sorie Commonwealth of Massachusetts Title 5 Offi imal Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f; erty Awditn per infOr"Wre don Page _ .. tyrrowr� State �Cade Date of 1n�n C. Inspecdon Summary (cant.) If you have answered'yes*to any question in Section C.5 the system is considered a significant threat,err answered*Yes'to any question in Section C.4 above the large system has failed.The owner or operator Of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department 6. You must Indicate"yes"or"race for each of the fallowing for all Inspections. Yes No E pumping information was provided by the owner,occupant;or Board of Health 0 Were any of the system components pumped out in the previous two weeks? 0 Has the system received normal flows in the previous two week period? © Have large volumes of water been introduced to the system recently or as part of this insp tjon? 0 Were as built plans of the system obtained and examined?(if they were not available note as A) VkEj Vfts the facs"lkty or dwelfing inspected for signs of sewage back up? Was the site inspected for signs of break out? 0 Were all system components,excluding the SAS,located on site? 11 Were the septic tank manholes uncovers opened,and the interior inspected for the condition of the baffles or left material of ►nstruci t the tank dimensions,depth of liquid, 9 d de th of sludge ud a . on, depth of scum? 0 Was the facility owner(end occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The 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. p Determined in the field(if any of the failure criteria related to Part dC is at issue appro)rimataon of distance is unacceptable)[310 CMR 15.302(5)1 cslnsp.dot-mv,MUM$ 7t 6 In -Tarn: a qV pa Syelom•pW B W 1a COMMOnw►ealth Of Massachusetts Title 5 OfficlaI Ins 'Subsurface Sewage System Form C�I�l�"i Form Disposal s _Not for Voluntary,assessments Proprerty Address Owmer informerTon is required for wry et — 4 --- — Page. �tyrro,��„ sake Zip Code [fake of irsPedion D. S' ,rstelm� trafarr'n�tc�n Residential Flow Conditions: Number of bedrooms(design): number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(far example: 110 gpd x#of bedrooms): -- Description: Number of current residents: Does residence have a garbage grinder? M Yes No Does residence have a water treatment unit? 0 Yes No If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection information in this report:) EJ Yes [ No Laundry system iced? 0, Yes No Seasonal use? " ❑ es ` . No Water meter readings,if available(last 2 years usage(gpd)): Detail: i Sump pump's � Yes No Last date of occupancy: " --U A\V Date t5in .dot rer�.aas as 100 s casaad inspedimrn Fmnnc Subsfaca S'e"ga Disposal •Pa9e 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal Systems Fo -Not far�J©luntaryssessrrtents Owner requwed for ewry Page. City-rr wn State Zip Code Goode Date of Inspection D. System Information (cent.) 2. Com mercia�lltndustdal Flow Conditions: Type oi,Establishmentr Design fl (based on 3110 CMR 15.203): Gallons per day(9td) Basis of flow(seatslpersonslsq.ft.,etc.)-. Crease trap pteesen E Yes ® No Water treatment unit prese 0 Yes ® No If yes,discharges to: Industrial waste holding tank present? Q Yeas Q No Non-sanitary waste discharged to the Title 5 system? Cl Yes ® No Water meter readings, if available: Last date of occupancy/use: late Other(describe below): 3. Pumping Records: Source of information:atron: Was system pumped as part of the inspection? p Yes LMA No If yes, volume pumped: gallom How was quantity pumped determined? `' Reason for pumping: tansp.doe•MV,I C 018 Me 5 Offidad in ecuoan rawrre B7esQaesl System, Page 8 06l8 1 COmmon+iwlealth Of Massachusetts Title 5 Official Inspection Farm Subsurface Sage Disposal System Fonn- of for Voluntary Assessments, Property Addy ass �C l Owner information is required for every t1. - Page. State Zip Cam Date of lnspection. S' S1 11t �rlf+lrmati©n (Cont.) 4. Type of System: Septic tank,distribution'box,soil absorption system 0 Single cesspool 13 Overflow cesspool Privy Shared system(yes no) it yes,attach previous inspection records,K any) ® InnovativelAlkernative 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 IIA system by system operator under contract Tight tank.Attach a copy of the Dpp approval. ® Other(describe): Approximate age of all components,dame in fled(if known)and source of infbirmatiorr 'lPhl"ere sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan); Depth below grade feet Material of construction: cast iron n 40 PVC ❑other(explain): Distance from private wager supply well or suction liner feet Comments(on condition of joints,venting,evidence of leakage,etc.):. tt lnep.doc-rav U2WM8 Tift a Official i woollon Po mr SL&Wface Swaw lisp •Page 0 or in P i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface,Sewage Disposal System Forme-Not for Voluntary Assessments ay Prope4 Address Owner information is ""red Pala, Cityl rown State Zip Code Date of InspeCti0ft @. System Information (colt.) 6. Septic'Tank(locate on site plan): ,L Depth below grade: feet Material of construction:rim concrete ❑metal fiberglass E]polyethylene 0 other(explain) If tank is metal,Est age. years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) C3 Ye-s El No Dimensions: [t Sludge depth: Distance from top of sludge to boWmr of outlet tee or baffle Scum thickness Distance from top of scam to top of outlet tee or baffle Distance from bottom of scam 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.): i + ' r"1 t5np.d0D-rew,712MOIS ''nft 6 Oft el CnVeOw Form SWmalaw SOMW 0WPMW SY •Pape 10 d IS , C0r"ln0nwealth Of Massech Title 5 Official Inspection posal System FOrm.Not for Voluntary Assessments PrOPerty Addrenj Amer v infcaraenatoon �],$team page.ed for every D. ysteM Information (cont.) 7• Cs%Seap(locate can site plan: dgrade: feet.. Material of scans cti n: ®concrete. 0 me 0 fiberglaw EJ Polyethylene Y other explain): Dimensions: Scum thickness Distance from trap 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: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural irate liquid)levels as related to outlet jnvc4tr a deuce of leakage, etc.): ' Tight Holding Tank(tank must be pumped at time of inspection)(locate can site plan): Depth beknnr g ale: Material of construction: 0 concrete ❑metal fiberglass 9 ® polyethylene ❑other(explain): Dimensions: Capacity. gallons Design Flow: gallons par aiay t6lrrep.dac•rev:71zkiY201e naa s OffidW kqockn Vim.&gWtftw se"ge of P aa a►ae Commionwealth of Massachusetts �VTitle 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wp-' — i�' pro Address 0Wftr w. inf0fMation is Mgwred for )c&t.J'—. page. civrom State Zip Code tote of lnspecWre D. System, Information (coat.) 8. Tig or Holding Tank(cunt.) Alarm p ntA ❑ yes ❑ No Alarm level: Alarm in working order: ® yes ❑ No Date of last pumping: Date Comments(condition of alarm and float s es„etc.): Attach COPY of current pumping contract(required).is copy attached? ❑ yes ❑ No 9. IDistrlbution 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;a evidence of leakage into or out of box.,etc.): ny let j 4t + Snsp,doc•Fear:7126=18 Me 5 0111 rl Inw,*Dn F.-sut,-ri— t7leposal by .P.01,12 of 18 11 In CC1MMOnwweam, of Massactlu"tts Title 5 Official Inspect-on Form Subsurface Sewage disposal Systems Form Not for Voluntary Assessments f`ropertty Adder + - Owner ddid infommlion is requ►rw for &L+`t,,, page" i� Citylf"own ' St Zip Code Date of Inspection �^ D- Syitiemt Information (cant.) 10. Pump Chamber(locate on sine plan): Pump$in working order:: �Yes No* Alarms in working order, XYes No* Comments(note condition of pump chamber,condition of pumps and appurtenances,etr-): *If,pumps or alarms are not in working order, system,is a conditional pass. 11. Soil Absorption System)(SAS)(locate can site plan,excavation not required): If SAS not located,explain why: Type: Q leaching pits number. El leaching chambers number leaching galleries number leaching trenches number, length: leaching fields number, dimensions: 0 overflow cesspool number: 0 innovative/alternative system Type/name of technology: MnV.dac mv.72MG18 To 5 Q15casi won Fcrm subnmxa Sewage dlap"M 5yatem-page 13 of 18 I u i y q q J,Q Commonwealth of Massachusetts 0 cial Inspection Form Subsurface Sewage Disposal System Fo Not � Propeify AddM83 dC� infOnnafion is required foreaeny state Zip Cade Date of inspect n page. City/Tom Q. System Information (cant.) 11. Sail Absorption System(SAS)(coat.) Comments(mate condition of soil,signs of hydrauk failure,level of ponding,damp soil,condition of vegetation,etc.): w h6 12. C''ess'porals(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration th—top of liquid to inlet invert Depth solids layer Depth of scu er Dimensions of cesspoo Materials of construction Indication of groundwater inflow Yes E] No Comments(note condition of soil,signs of hydraulic lure, level of ponding,condition of vegetation, etc.): tSiea p dac+rev.Tf2bf?Aia Title 5OffidW iw qy i=t W-BU sewepe 015PWW SWOM I raga 114 of AS C+nl MOnwealth of Massachusetts Title Official Inspection Form Subsurface Sewage Disposal System Form of for voluntary Assessments ir�a�x�iataon� �mz � � +� required for every page, o ;I Sattae` �� Clete of in ion U. SYStem Information (Cont) 13. Privy(locate on site plan): terals of construction; Lorne ons Depth of so Comments(note dotion of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.):. 15igAa#. tcei• .TJ '18 109 5 Cued lowac on Farms abwfam 4-g"MqpAW�•pagp 16 or 1a e, Commonwealth of Massachusetts lugTitle 5 Official Inspection Farm Subsurface Sewage Disposal Systern Form-Vot for Voluntary Assessments Property Aftem Owner Owners information is uired for eve )O C, page, -i'�'o�r State Zip Code Date of inspection D. System Information (cant.) 14. 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 El hand-sketch in the area below '" Q' drawing attached separately el I i LSinsp dtrc•rev. r to 766 5 OffidW ftpeckn Folm Sub wfaw pp 9� � Commonwealth of Massachusetlts Title 5 Onicial Inspection Form 'i Subsuriac*Sewerage Disposal System Form„ Not for Voluntary Assessments Proms Addnsss aes a infomsatbn is r" for Pam• 5t�ee zfl a D. System Information (cont.) 15. Site Exam: Check Slope Surface water k3b. 0 Check cellar'Do 40-t 0 Shallow wells Estimated depth to high ground water: fee 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: mass Observed site(abutting property/observation hole within 150 feet of SAS) Cl Checked with local Board of Health-explain- 0 Checked with load eI�r%lr tailers-(attach documentation) 0 Accessed USG S database m explain. You must describe how you ared the high grou wai � ��e rratiort. Vv"'.�-"� )'Klacc ,r 71 AA +c �, a Before filing this Inspection Report,please see Report Completsniass Checklist on next page.. wp1a4 ts r n C, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.Not for Voluntary Assessments p Pmpedy Address OWnerInformation is yy,,� ruiredfc�rtvery " ' page, wityrro" state Z'ep t.)ate o I E. Report Completeness (Checklist Complete all applicable sections of this foam Inclusive of'. A.Inspector Information:Complete all fields in this section.. S.Certification:Signed&Dated and 1,2,3,or 4 checked C. Inspection Summary- 4,2,3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed D.System Infonnation: For 6 TightlHolding Tank—Pumping contract attached For 14:Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15:Explanation of estimated depth to high groundwater included t6insp.doc-mv:7+26 018 'nse 6 frfWa9 Inspscl on Form:. r 9tw was swavp Mvosw S'ys%m•Page is of is