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Home My WebLink AboutPass - Title V Inspection Report - 360 WINTER STREET 8/17/2016 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address C-t d i'n A-S Owner Owners Na information is required for every page. 'City/Town ' State Zip Code Date of Inspection I 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. ` filling out forms / Important:When V A. General Information E' on the computer, ECE tlI� use only the tab 1. Ins ector: AUG 1 7 key to move your 201 cursor-do not C [°��e use the return Name of Ins ect r key. 469 C HEALTH DEPARTMENT C any Name 16 6X V6 Z p \Address Ci /Town State Zip Code 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 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation b he Local Approving Authority nspectors Sig to Date The system Inspectors ub t a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days 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 M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ` Owner Owner's Nark information is required for every page. Qity/Town ` State Zip Code Date of Inspection B: .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: (i �c1�`�� Q�v � C/h�i •Z B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be laced or repaired. The system, upon completion of the replacement or repair, as approved by the rd of Health, will pass. Check the box fo s", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined, please ex The septic tank is metal and over ears old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced wi complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structura sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years o 's available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 4 Commonwealth of Massachusetts L -- Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is Q j� �\ /� d � ,�5 � t re wired for every �U i �'I page. City/Town State Zip Code Date of Inspection B. Certification (coat.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) Conditionally Passes (cont.): ❑ Observation of s e backup or break out or high static water level in the distribution box due to broken or obstructe e(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with appro of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): El obstruction is removed ❑ El El ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced ❑ Y ❑ N El ND (Explain below): ❑ truction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of He ❑ Conditions exist which require further evaluation by the Board ealth in order to determine if the system is failing to protect public health, safety or the environme 1. System will pass unless Board of Health determines in accordance 'th 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will prot ublic health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form c �: Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Orw_('N . Lk) .✓V 7Y Property A Owner Owner's Nam information is � A required for every °r�� IL4 �. "- 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) determines 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 fe. f a surface water supply or tributary to a surface water supply. El The sys has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a se p ' ank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SA d the-SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a D ertifled laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitroge and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A opy 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 ❑ �Z 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 '/Z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Y Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments h Property Address Owner Owners N information is r �� 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: ❑ 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 to a surface water supply. ❑ [� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ V 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 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 Section D. No ❑ ❑ tem is within 400 feet of a surface drinking water supply ❑ ❑ the system is with) 0 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitr n sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone I public water supply well If you have answered "yes"to any question in Section E the syste is considered a significant threat, or answered"yes" in Section D above the large system has failed. Th caner or operator of any large system considered a significant threat under Section E or failed under Sec i D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contac a appro riate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System.•Page 5 of 17 j. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Na information is �y required for every page. Citylrown 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 k ❑ Pumping information was provided by tN owner, cupant, 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 this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) [ ` ❑ Was the facility or dwelling inspected for signs of sewage back up? [� ❑ Was the ste inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ❑ 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 4� 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. ❑ 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 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 - Commonwealth of Massachusetts L, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner O" a information required for is a � page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes 171 No Laundry system inspected? ❑ Yes W1 No Seasonal use? ❑ Yi No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: � •�' Date Commercial/industrial Flow Conditions: Type o Establishment: Design flow(base 10 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq. ., Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? s ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` Property Address ` J Owner Owner's information is A� G � �, ,\\�� --✓' required for every page. Cityfrown 'State Zip Code Date of Inspection D. System Information (cons.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: USMru� gy2v tC-� Gt. ��nt3-oiti: Source of information: Was system pumped as partof the inspection? Li Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page a of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address . bid Owner Owner's Na information is A 6U �y�� ,aQ3 YS 2 —�—/4 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 4 No Building Sewer(locate on site plan): � Depth below grade: feet 1 Material of construction: cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet CornmentS(on condition of joints, ventin evidence of leakage, etc.): 1ye) � Septic Tank(locate on site plan): Depth below grade: feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 9� Sludge depth: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address '- Owner �d Al Owners N _ information is required for every "6 y �� S.* page. Cityfrown 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 `s Scum thickness 4A Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13 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.): -Ai d�p, kt 6-4611.1, �dv Ll Grease Trap (locate on site plan): Depth below grade: feet Material construction: ❑ concrete metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 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: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 3 " ( _X) I zr&1_'_ lz��J_ Property Address Owner Owners Na information is j6j \, required for every J�— ""a jar�'"�`�v.'_ _ page. City/Town. State Zip Code Date of Inspection D. System Information (cont.) Com ents(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid le Is as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at ' e of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete L_J metal [I fiberglass ❑ polyethy e ❑ other(explain): Di nsions: Capacity: gallons Des' Flow: gallons per day Alarm presen : ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, Attach copy of current pumping contract(required). Is copy attached? ❑ Yes \❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syst m•Page 11 of 17 Commonwealth of Massachusetts -- - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner O s a information is required for every Owl 6 page. Citylrown 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.): Pump amber(locate on site plan): Pumps in workin der: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump mber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditiona ass. Soil Absorption System (SAS) (locate on site plan, excavation not requ ed): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 •• 'e Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address A- Owner Owner's information is 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: leachingfields `�"?�IX.S& number, dimension ❑ 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.): PV -*,, (A t2 Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and con uration Depth—top of liquid to in nvert layer Depth of solids la P y Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ `Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ccrr Owner Ow nets 10ne O` � . \ information is /'u� t/�. 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 soil, signs of hydraulic fail , level of ponding, condition of vegetation, etc.): ` t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner d75 information is Owner' Na e �[n� �� a required for every � D / T 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: hand-sketch in the area below drawing attached separately e _� } 1 4 L( _ LASS /dt, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste •Page 15 of 17 Commonwealth of Massachusetts " - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rl Property Address Owner J Own Na information is required for everynOaf yg page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope . Surface water Kra Check cellar Ajo a u� ❑ Shallow wells Estimated depth to high ground water: A — 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: cal Board of Health- xplain* ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed U,SGS database-explain: You must describe how you established the high ground water elevation: .VLLL -�U-�, t�- 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 C -a Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner Owner's N information is required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist [ Inspection Summary:A, B, C, D, or E checked [� 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 2 ho t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17