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Home My WebLink AboutPASS - Title V Inspection Report - 55 MARBLERIDGE ROAD 5/12/2025 Commonwealth of Massachusetts Title 5 Official Inspection Form =.mm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � t Property Address Owner Owner's N information is City/Town am to ZC �W r" required for every page. Y P ode Date 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:out forms A. inspector Information filling out fop s use oon nly he tab of Inspector e . keyto move our Name cursor-do not use the return key. Cornpa Name Corn an Address ri p city own State Zip Code Telephone Number License Number B. Certification I certify that: 1 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 sewage 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 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 rpVec�t�or's Sign ture Date The system inspector sha11 s b it 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 owner shall 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. 15insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ....... . Property Address Owner er's Name Information is required for every tv &2 page City/Towri- State Zip Code Date of Inspection 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: "A3 4 U 2) System Conditionally Passes: %reEl One or more system components as described in the"Conditional Pass"section need to be placed or repaired.The system, upon completion of the replacement or repair, as approved by e Board of Health,will pass. " ,� Check the,bpx for"yes","no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"plepse explain. The septic tank is me,tal,and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial,in"filtration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is'Ireplaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it tructurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than years old is available. EJ Y F-1 N 0 ND (Explain below):"""I'�'.."', ---------- ------------ 153nsp.doe•rev.712612010 Tide 5 offidal Inspection Form:Subsutfaoe Sewage Disposal System-Page 2 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ------------- Property Address Owner Ow er's Nam information is required for every page. City/I owl I State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): El p Chamber pumps/alarms not operational.System will pass with Board of Health approval if npus/alarms are repaired. El Observation of sewage"backup or break out or high static water level in the distribution box due to broken or obstructed pipe(g)-or=to a broken, settled or uneven distribution box.System will U pass inspection if(with approval )f ba of Health): ❑ Y ON ON' broken pipe(s)are replaced Y F-1 N F1 ND(Explain below): 0 n obstruction is removed El Y F1 ND(Explain below): 0 E El distribution box is leveled or replaced EEII Y El N D(Explain below): ---------------- ............. El 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 R Y n N Ej ND(Explain below): El obstruction is removed n Y E] N n ND(Explain below): 3) Further Evaluation Is Required by the Board of He"Ith;," F1 Conditions exist which require further evaluation by the,6cd of Health in order to determine if the system is failing to protect public health, safety or the env�irment. a. System will pass unless Board of Health determines In acco ance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which II protect public health, safety and the environment: t5lnsp.doc-rev.7/26/2018 Me 5 official Inspedon Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ---Pro>ert Address S o wner Owner's-Name fiiquired for every page. Cityrrown State .......... Zip Code Date of Inspection C. Inspection Summary (cont.) Cesspool esspool or privy is within 50 feet of a surface water Fj Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System wALfail unless the Board of Health(and Public Water Supplier, if any) determines that`th system is functioning In a manner that protects the public health, safety and environ 1 : ❑ The system has a septl"Ni nk and soil absorption system (SAS)and the SAS is within 100 feet of a surface water sulJoy,or tributary to a surface water supply. F1 The system has a septic tank aM�SAS and the SAS is within a Zone 1 of a public water supply. 11'1�n The system has a septic tank and SAS a"iml,the SAS is within 50 feet of a private water supply well. El 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�cerfifie boratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and ni to nitrogen is equal ,p to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of e analysis must be attached to this form. c. Other: ............ --------- ---------- 4) System Failure Criteria Applicable to All Systems: You Must Indicate"Yes" or"No"to each of the following for all Inspections: Yes No El Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t6insp.doe-rev.7/2612018 Tide 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 16 Commonwealth of Massachusetts Y= � Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f'raperty-Ad dress „M �..�� r (. Owner m information is wn -- State Zip Cad as required for every Ow ITo page. City/Town p e Date of Inspection C. Inspection Summary (cant.) 4) System Failure Criteria Applicable to All Systems: (coat.) Yes No ❑ 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 ❑ 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 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 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 its 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) LargeSystems: To be considered a large system the system must serve a facility with a design floirof,110,000 gpd to 16,000 gpd. For large systems`,'you,must indicate either"yes"or"no"to each of the following, in addition to the questions in Section C. ~� Yes No „. ❑ ❑ the system is within 400 fbe#of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tIT ry to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive ea (Interim Wellhead Protection Area—IWPA)or a mapped Zone ll of a public w r supply well t5insp.doo-rev.7/2&2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ------ Property Address i-vc---s Owner owner ame information is AIA- 11 1�( required for every J- -.- -\-- — page. cutynown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the 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 ail inspections: Yes No n Pumping information was provided by the owner, occupant,or Board of Health ❑ 14 Were any of the system components pumped out in the previous two weeks? E] 0 Has the system received normal flows in the previous two week period? E] [2N 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? El Was the site inspected for signs of break out? El Were all system components, excluding the SAS, located on site? El 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 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)1 15insp.doc-rev.712612018 Tide 5 Offidal inspection Fow Subsurface Sewage Disposal System-Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner 0 ers Nam,j information is required for every A11A page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310CMR 15.203(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 No If yes, discharges to: ---------------- Is laundry on a separate sewage system?(Include laundry system inspection F1 Yes 0' No information in this report.) N Laundry system inspected? r-1 Yes No Seasonal use? Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): Detail: LW ------- Sump pump? Yes Na �A Last date of occupancy: Date Wnsp.doc-rev.7f2612018 Title 6 official Inspection Form Subsurface Sewage Disposal System-Page 7 of 18 <ell Commonwealth of Massachusetts ... .............. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property-Address---___'__ Owner Owners Name infonriation Is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Comlnwlc lal/industrial Flow Conditions: -------- Type of Establishment: - - Design flow(based"on 34Q CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persont/sqjt., etc.): ---------- Grease trap present? El Yes n No Water treatment unit present? El Yes El No If yes,discharges to: El Yes FI No Industrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? LTAes 0 No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): .......---- 3. Pumping Records: Source of information: Was system pumped as part of the inspection? El Yes No If yes, volume pumped: gallons How was quantity pumped determined? ------- ------ Reason for pumping: t5insp,doc-rev.V26/2018 Tide 5 Offidal Inspection Form Substmfaoe Sewage Disposal Systern-Page 0 of 18 Commonwealth of Massachusetts ------------.... Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............... Property Addressa. Owner Owners Name N information is required for every _u± JA—$� page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system El Single cesspool El Overflow cesspool EJ Privy A, Shared system (yes o(00)) if yes, attach previous inspection records, if any) F1 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 El Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site? El Yes [J No 5. Building Sewer(locate on site plan): Depth below grade: ------ feet Material of construction: A � )RICast iron El 40 PVC El other(explain): Distance from private water supply well or suction line: ❑ Comments(on condition of joints, venting,evidence of leakage, etc.): ............ & ...........---.......................... 15insp.doc-rev.7/2612018 Tide 5 Offidal Inspection Form:Subsurface Sewage Disposal Syslem-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address ----------- ----------- Owner Owners Name information Is required for every bate of Inspection page. State Zip codia� D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: lqconcrete El metal F1 fiberglass 0 polyethylene E]other(explain) ---------- ----------- ----------- ----------- If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes El No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle ------------ Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): L"I 19 --- ------------- ------------ ---------- P14 --------------- ---------- Wnsp,dor•rev.7/26120f 8 Tide 5 official InsperAon Form:Subsudeoe Sewage Disposal System Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form . .... ..... Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address OwnerN,�ars am, ,,,, Z_S inforniation is required for every Aq.zi page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Greas Trap(locate on site plan): Depth Trap W grade: feet Material of construction: ❑ concrete b,,metal El fiberglass El polyethylene other(explain): Dimensions: Scum thickness ------- Distance from top of scum to top of outlet tee or ball Distance from bottom of scum to bottom of outlet tee or ba Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle ndition, structural 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 beloWg(pide.7 Material of construction:,,,, ❑ concrete n metal El fiberglass El polyethylene ❑other(explain): ------------ Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc rev.7126/2018 Tide 5 official Insp%fon Form:Subsurface Sewage D,spMsat System-Page 11 of 16 Commonwealth of Massachusetts - ----------- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c Property Address ---------- Owner Owner's NarnW information Is required for every page. City[Town State Zip Code Dateot�lns pection D. System Information (cont.) 8. Tigiii'"p1ding Tank(cont.) Alarm present: n Yes El No Alarm level: Alarm in working order: El Yes El No Date of last pumping: Comments(condition of alarm and float switches, etc.): ------------ ...................... ---------------------------------------------- Attach copy of current pumping contract(required). Is copy attached? El Yes El 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 out of box, etc.): (71�01, '-j \-k fZ-1— I6- t5insp.doc•rev.712612018 Tile 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments .................... ..................... Vroperty" Add-re-s"S' 7 Owner Owner's Name information is jAj (s required for every ------------ ------- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: Yes [j No* Alarms in working order: Yes El No* Comments (note condition of pump 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 galleries number: E] leaching trenches number, length: El leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t6insp.doo-rev,7126f2GI8 Tide 5 official kispection Fonm:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments C 4c' - ---------- Property Address 7 Owner o nees Na 7,-_ Information is required for every page 61tyffown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ------------------ ...... -------------------------- ---------- 12. Cesspools (cesspool must be pumped as pad of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert ------------- Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No "-b Comments (note condition of soil, signs of hydraulic failure, level of p ding, condition of vegetation, etc.): ----------- 15insp.doe•rev.7126/2018 Tide 5 Official Inspection Form Subsurfaoc Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts _YF � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owriers Nama� Information is LAI—,required for every 10i d page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials 6f,construction: —------------- Dimensions Depth of solids Comments(note condition of soil, signs hydraulic failure, level of ponding, condition of vegetation, etc.): ----------- t5insp.doe-rev.V2612018 Tide 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts ............ _= -- Title 5 Official Inspection Farm .. Subsurface Sewage disposal System Form -Not for Voluntary Assessments _. Property Address Owner Owner's Name _ information is State_ Zip Code gate .._. required for every page, City/Town p 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: ❑ hand-sketch in the area below ❑ drawing attached separately i" .. " `7 ,-- Tb t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42, ----------- Property Address Owner Owners Name—., Information Is ✓ 4 required for every page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: F1 Check Slope F1 Surface water El Check cellar n Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed. Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ------------------ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: ------------- You must describe how you established the high ground water elevation: ........... ----------------------------------------- -------------------- ........................................... —-------- Before filing this Inspection Report, please see Report Completeness Checklist on next page. Wnsp.doc-rev.7126r201 8 Tito 5 official Inspecilon Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -----------— Property Address <— Owner Ow r Name Information is c� 41(..n, req uIred for every .......... .......—, �) page. Cityrrown State Zip Code Date of Inspection 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: Explanation of estimated depth to high groundwater included t5insp.doc•rev.712612010 Tide 5 Official Inspecton Form:Subsurface Sewage Disposal System-Page 18 of 18