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HomeMy WebLinkAboutPass - Title V Inspection Report - 1000 JOHNSON STREET 10/17/2022 6'YU -r 400 Commonwealth of Massachusetts Title 5 Official Inspection. Form L w 1'J`L°'L1000k Subsurface Sewage Disposal System Form-Not for Voluntary Assessments RAN FN ENS Np RAM Property Address "• Owner O+wrte�s information is required for everyZ- page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. hnspect m forms may hat be after+ed In any way.Please see completeness checklist at the end of time form- rmpg out forms A.A. Inspector Information filling out forms on the computer, ( J use only the tab l �t�- -- - key to move your PbKq of Ins cursor-do not use the return key Comperry NarrM - -- — 6(1 Telepfane Number 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 personaby inspected the sewage disposal system at the property address listed above;the infformation reported below is true,accurate and complete as of the tithe of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After.conducting this inspection I have determined that the system: 1. Passes 2. /❑�Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails z '?--- 4e nsper.Ws -- Date The system inspector Lsu"ita y 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 owner shalt submit the report to the appropriate regional office of the DEP-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 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. t%WP AM•rev 7lIGM11 now 5 oMCW kwp"M FOM&AAWt"SurgM DMPoeal SYS*M•Pape 1 ar 1E Commonwealth of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-I of for Voluntary Ass ments Property Addrs Owner - owners Nam � � a�u err page. Cttyrrown State Zip Code Late of WApection C. Inspection Summary Inspection Summary.Complete 1,2,3,or 5 and all of 4 and 6. 1) System Passes: I , 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: 2) .System conditionally Pass: ❑ One or more system components as described in the"Conditional Pass"section need to be re repaired. The system, upon completion of the replacement or repair,as approved by the Boar of Health,will pass. Check the box fo " ',"no'or'not determined"(Y, N, ND)for the following statements. If*not determined,"please xptain. The septic tank is metal over 20 years old"or the septic tank(whether metal or not)is structurally unsound, exhibits substanti - filtration or exNtration or tank failure is imminent. System will pass inspection if the existing tank is ed with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if stnx:turaAy sound,not leaking and if a Certificate of Compliance indicating that the tank is less than years old is available. ❑ Y ❑ N ❑ ND (Explain below): L5ua AW•nw 7/laMU TMt 5 00"W k*patron Fans Subwxbm Sewage DbPosal Syawn.Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form-Not for Voluntaryy Assessments Property Address Owner N s q*M inre for ewrry page. City/Town Stale Zip Code Date of irapectiora C. Inspection Summary (cunt.) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/aJarms are repaired. ❑ ,Obsery sewage backup or break out or high static water level in the distribution box due to broken or obs ed pipe(s),or due to a broken,settled or uneven distribution box.System will pass inspection if(wi roval of Board of Health): ❑ broken pipe(s)are rep Q Y ❑i N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more thari 4 times a year due to broken or obstructed (s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of H ❑ Conditions exist i4hictt require further evaluation by the of Health in order to determine if the system is failing to protect public health,safety or the enviro nt. a. System will pass unless Board of Health determines in accordance with 310 CM 15.303(1)(b)that the system is not functioning In a manner which will protect public health, safety and the environment: L9rnp.doc•rw 72SMU Tile 5 Of dW Ywpedon Form.SLbKrfaoe Sawrgo DYpo"Sy&W"•Page 3 d 18 CommorTwealth of Massachusetts FTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Prop Address - � erty Owner Ownees information is 6�— k --- �/C�_ MAreqoir far every p� G (Town - — state Tjp Code Date of k motion C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetiand or a salt marsh b. S will fail unless the Board of Heafth(and Public Water Supplier,if any) determines t the system is functioning in a manner that protects the public health, safety and envir ent: ❑ The system has a sep' ank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water su or tributary to a surface water supply. ❑ The system has a septic tank a AS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS a the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the 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 DEP certifi tory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and ni a nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of anaWs must be attached to this form. c. Other: 4) System Failure Criteria Applicable to Ail Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or cogged SAS or cesspool . ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or cogged SAS or cesspool tskp doc•rw M 201 8 rife 5 OiRdy kmeckn Fame Subwjrh"sewage o+epoeW SYsb*•Page 4 or l 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface sewage Disposal System Form-Not for voluntary Assessments ern information is 11!Q y` � 6-V e 1.� l a / ?Z— required for every 1 _ — page. City/Town State Zip Code [)ate of Inspection C. Inspection Summary (coat) 4). System Failure Criteria Appyicable to All Systems: (cont) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded Dr clogged SAS or cesspoot 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Q Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ M 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 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 Tess 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 2000 gpd- 10,000 gpd. ' ❑ 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. 5) Large Systems: To be considered a large system the system must serve a facility with a desl of 10,000 gpd to lS,000 gpd. For large systems,you must indicate either"yes'or"no"to each of the following,in addition to the questions in CA. Yes No ❑ ❑ the system is wit 00 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen se area(Interim Wellhead Protection Area—rWPA)or a mapped Zone it of a • water supply well 6amp.aoc-rev MGM19 Tl/t 5 04Ck 1 Ywpecfon Fo &jb� Dkpo"system•Page 5 d 1 a Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments,- Prop"Address Owner Orrws Narne /�— p� / / information is SV� �/t'✓1 ��U— Q C!`1 ( v__(�'_2 Z-- required for every —— page, cayrrovM State Zip Code Date of inspection C. inspection Summary (cunt.) If you have answered"yes"to any question in Section C.5 ttie system is considered a significant threat, or answered"yes"to any question in Section CA 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"no"for each of the following for afl inspections: Yes No ,� ❑ Pumping information was provided by the owner,occ dpant,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 dweging inspected for signs of sewage back up? l Q Was the site inspected fof 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? may, ❑ Was the fecility o*mr(and,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. ❑ 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)] E&M.*X•rev.MMM18 TUe S 0MdM►dP"m ram Sjbw Sa#M"Drpood Sys*rn•P*pe 6 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments information a „� � a ems' requ+red for every -- -- p�- ciijiTown state zip code Data of fnspedign D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): - DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): Description: Number of current residents: — Does residence have a garbage grinder? Yes ❑ No Does residence have a water treatment unit? ❑ Yes Ukr No If yes,discharges to:Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes rVI No information in this report.) Laundry system inspected? ❑ Yes"' No Seasonal use? ❑ Y;es� No Water meter readings, if available(last 2 years usage(gpd)): Detail: s Sump pump? -- - -- -- -- �Yes ❑ No Last date of occupancy: ' `" 2�- Date rsnWeoc-rev.7I&Ml 8 ills 5 OfcW kapsrlm Form&Awaracs Somoo Disposal Sysbm-Paps 7 or 11 Commomvealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System corm-Not for Voluntary d l Assessments CSv �,, s-f-1 Property Address Owner - — — - — —— - -- informatm is requatd for every per. Qfy/Town State rip Code Date of knpedfon D. System Information (cont.) 2. ConrwnerciaUlndushial Flow Conditions: Type tablishment —- - - -— - Design flow 310 CMR 15.203): f�aaons t9vd) - - Basis of design flow(seatslpe /sq.ft., etc.): - — -— Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: - Industrial waste holding tank pr ent? ❑ Yes ❑ No Non-sanitary waste disc rged to the Title 5 system? ❑ No Water meter r gs, if available: --- Last dat occupancyluse: Date her(describe below): 3. Pumping Records: Source of information.- Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: How was quantity pumped determined? - — Reason for pumping: — - - 6WAp.doc.rev MGM$ re.5 04dW iapec-Fom Srbwx%b*Semp DWpo"SyvAm-Pape a of is • S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewat"Disposal Systorn Form-Not for Voluntary Assessments Property Address Owner oomez information is 2 2_ required for every A 6-"r —— ��`^ � (Q �'� _lb — Paw. Cityrrown State Zip Code 'Date of Inspection D. System Information (coat.) 4. Type of System: ASeptic tank,distribution box,soil absorption system Single cesspool ❑ Overflow cesspool ❑ Privy Shared system (yes 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of an components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): / Depth below grade: fee — Material of construction: Kcast iron ❑40 PVC ❑other(explain): — - Distance from private water supply well or suction line: feel Comments(on condition of joints,venting,evidence of leakage,etc.): 6WWdoc-rw rrxnone Too 5 ova Yrppaon F- S,�Sv*go•D"o" Page got 18 CommonweaFth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /L v PrOPerty Address Owner ownees mac_.) ` r!wired fort ��'t - �C� TJ lD -Y c, — page, Cltyffown state Zip Code Dale of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: - feet Material of constWion: Concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain) If tank is metal,list age: Y Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: �l Sludge depth: - — - � t � Distance from top of sludge to bottom of outlet tee or baffle - it Scum thickness - - — � t Distance from top of scum to top of outlet tee or baffle - Distance from bottom of scum to bottom of outlet tee or baffle - — ��` How were dimensions determined? — Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): ( mil L,(, ► _Q, c It t5W'W-ftc-nv M26mis n"5 OMdW rrpec*m Form subwiws Swrp•Dbposd SysW"•P+ge 10 or 18 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Q a Property Address - Owner required for every owner m � Q !\ information is l l"\ page- QwTown — -- state Zip �4Co& Dail of inspection D. em Information (cunt_) 7. Grea Trap(locate on site plan). Depth be rade: feet Material of cnnstru ' n: ❑concrete ❑me ❑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 Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structu integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 8. .Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below e: --- - Material of constru ' n: ❑concrete ❑me ❑fiherglass' ❑polyethylene ❑other(explain): Dimensions: Capacity: gas Design Flow: - - - — gaWns per dY t5hW Aoc-rev 7 26=1® TiM 5 ONCIM•npe[.11om Form:S'tbe I Ste^•Page 11 of 1 B Commonwealth of Massachusetts ' Title 5 official Inspection Form Subsurface Sewage Disposal System FaThm-Not for Voluntary Assessments ' Property�� ��.�1 ]�1 RR.... Owner Information is reWwad for ewxY page. aijr-Town Code Date of Inspection -state �+P D. System Information (cons.) 8. Tight or Holding Tank(cunt.) present.- Q Yes El No' Alarm level: - - Alarm in working order:' Q Yes Q No Date of last pumping: Date Cortimerrts(condition of aiartri and float switches, Attach copy of current pumping contrait(required). Is copy attached? Q Yes ❑ No 9. 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 Gut of box,etc.): -( _ t�._._ re V.e—I �— ---- tsnw4m-my Trawls TIN&5 001cki Mrpec6a Fans smwxt o.Swapa orpmW sye we•Papa 12 d 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ' - Subsurface SewaW Disposal System Fo�r-m}-Not for Voluntary Assessments Property Address Owner owr> - -- . information is wed for every ° pa"_ Cityliown State Zip code Date of Inspection D. System Information (coat.) 10. mp Chamber(locate on site plan): Pump ' working order. ❑ Yes ❑ No' Alarms in work order: ❑ Yes ❑ No` Comments(note condi i mp chamber, condition of,pumps and appurtenances,etc-): ` If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located,explain why: Type: ❑ leaching pits number. ❑ leaching chambers number. - ❑ leaching gageries number yo leaching trenches number,length: / ❑ leaching fields number,dimensions: - ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: --- - - -- -— - - 15arep doc•rw 7ns201 8 TMe 5 olfdal trnecim For[Srburlacn SwAnge Ohpooi Sydern•Page 13 of 13 Commonwealth of Massachusetts '~ Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner owns - mforrn for qu 2 �—- is reued for every _ page. (Aty(iown State Zip Code Date of hispection D. System Information (cunt.) L 11. Soil Absorption System(SAS)(cunt.) Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp sod,condition of vegetation,etc.): Ta 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): N mber and configuration — - - Depth- of liquid to inlet invert - Depth of solids la — Depth of scum layer Dimensions of cesspool - — Materials of construction --- —-- Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic fail level of ponding, condition of vegetation, etc.): 6*W,aoc•rev M&WIS rao 5 04CW►Weckn Form.Subwrtaoe SOWWO DW06 t sr34wn•Page 14 of I8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address - - : ��/�'s e I ra-inf _ bon is > for� —N11-- page. cityrrown state Zip code• Date of,rupection D. System Information (cant.) 13. Privy(locAte on site plan): Materials of ction: — - - - - Dimensions - - - - -- - — - - Depth of solids --- Comments(note condition of so , ns of hydraulic failure, level of ponding, condition of vegetation, etc.): t.%w-doc-mv.726=1• TMe 5 OIR W Nwprcbon Fans'&"AUce Se"Ve OMpod Spfem-Paw 15 of 1 b J t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1t s Property Addrew information is A— 6*"7/o -- 1_1 —fb —2 f Y pa". Ci (Town state Zp Gode Date of per, tY Msspection D. System Information (cost.) 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 bekrw ❑ hand-sketch in the area below ❑ drawing attached separately �o I t51nep.doc-rev 7Q6Mla r%e 5 OWW k-peclon Farm&—xfa-Sewer D"oay Symm•P"16 of 18 i Commonwealth of Massachusetts 1WTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address - - - - Owner Owner's informatm is regtHred for every — page- City/Town State Zip Code Date of Impeotion D. System Information (cons) 15. 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: pate ❑ 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: - __��-dam__ Before filing this Inspection Report,please see Report Completeness Checklist on next page. Imo.rev.726M18 lift 5 Oland Yep«im form SLtKri aor stooge owpoa System-Pape 17 0 18 a� s Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �Nsd-\AOwner - - -- S- infonnaLonis0✓1 required for every /fawn State Zip Code Date of Inspection —— Pa9e- CtTy E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information:Complete all fields in this section. B.Certification:Signed&Dated and 1,2,3,or 4 checked ( ) C. inspection Summary: 1,2, 3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed D.System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14:Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Expiarkition of estimated depth to high groundwater included t%W.dM•rM TrMo1 a TMa 5 0WdW knpedon Fans SUbWA "SwwQa DMP0"SYVAM•Pape 14 d 1 m