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HomeMy WebLinkAboutPass - Title V Inspection Report - 13 LACONIA CIRCLE 11/15/2025 c Commonwealth of Massachusetts . Title 5 Official Inspection ,For Subsurface sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner owner's Name information is �-�-- 9-e-1r uired for ev . ' r page, CitylTown State Zip Code Date of Inspection r 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. Imp1orUnt~When ►, Inspector Information filling out farms on the computer, t [ se only the tab L key to move your Name of Inspector r cursor-do not 4 use the return Company Name U " key. �... f46 A!) C/O lei .Co Address City/Town state Zip Code 4R- Telephone Number Vicense Number B. Certification l certify that:I am a DEP approved system inspector in full compliance with section 15.340 of Title 5 (310 CMR 15. ); l have personally inspected the sewage disposal system at the property address fisted 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 1 have determined that the system: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. El Fails ,r ram- \ - Inspectors Sign re Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board .of health or DEP)within 30 days of completing this inspection. if the systerh has a design flow of 101000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original form shogld be sent to the system owner and copies sent to the buyer, if applicable, and the approving 4uthdfity. Please note:This report only describes conditions at the tip. f,iris ction and under the S.Y4 i conditions of use at that time.This inspectlonf doe' s'not address•how the sifsten will perform in the future under the same or different conditions-of use. t5inspAoc-rev.7/26/2018 Title 5 Official bnspecdon Form:Subsurface Sewage•Disposal System•Page I of 18 Commonwealth of Massachusetts T otle 5 I Offic�al lnspection t. Subsurface Sewage Disposal system Form Not for Voluntary Assessments Property Address Owner lee a. 6/ information is r required for every � page. City/Town State Zip Code Date of inspection C. Inspection Summary Inspection Summary:Complete 1,2,3,or 5 and all of 4 and 5. 1) System Passes: I have not found any information which indicates that any of the failure cAteria 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 Fusses: El one oHQore system components as described in the"Conditional Pass"section need to be replaced repaired.The system, upon completion of the replacement or repair,as approved by the Board v ealth,will pass. Check the box for uy ","no"or"not determined"(Y, N,ND)for the following statements. If"not determined,,,please exp ' . The septic tank is metal and ov 0 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltra' or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replace ith a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is st urally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 ye old is available. El Y Ej N El ND(Explain below): t5insp.doc•rev.7/26/2018 Tile 5 Official fnspedon Farm:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Fors h Subsurface sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner ees Na information is � ��� �T required for every G page, CitylTown state Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ P p Chamber pumps/alarms not operational. System will pass with Board of Health approval if pump farms are repaired. 0 Observation of sewag ackup or break out or high static water level in the distribution box due to broken or obstructed pi s)or due to a broken,settled or uneven distribution box.System will pass.inspection if(with approv f Board of Health): Ej broken pipe(s)are replaced Y El N El ND(Explain below): ❑ obstruc.`on is removed Y ❑ N El ND(Explain below): El 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 pipes).The Sys will pass inspection if(with approval of the Board of Health): b en pipe(s)are replaced El Y El N ❑ ND(Explain below): ❑ obstructio removed El Y El N 0 ND(Explain below): 3) Further Evaluation is Required by the Board of Health: El Conditions exist which require further evaluation by the Board of alth in order to determine if the system is failing to protect public health, safety or the environme a. system will pass unless Board of Health determines in accordanc with 310 CMR 1i.303(1)(b)that the system is not functioning in a manner which will pr ect public health, safety and the environment: t t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 q T r Commonwealth of Massachusetts Title �c"Ials Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner owner's N information is required for every �itlYown peer y `—State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or prnry is within 50 feet of a surface water ❑ Ce od or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fai less the Board of Health(and Public water Supplier, if any) determines that the s ern is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank d soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or 'butary to a surface water supply. [:1 The system has a septic tank and S and the SAS is within a Zone 1 of a public water supply. [:1 The system has a septic tank and SAS an a SAS is within 50 feet of a private water supply well. [:] The system has a septic tank and SAS and the S is less than 100 feet but 50 feet or more from a private water supply welt'. Method used to determine distance: **This system passes if the well water analysis, performed at a CEP rtified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitroge nd Nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A py of the analysis must be attached to this form. c. Other: 43 System Failure Criteria Applicable to All Systems: You must Indicate"lies"or"No"to each of the following for all inspections: Yes No E, Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool gg p Discharge or ponding of effluent to the surface of the ground or surface waters ❑ SAS or cesspool due to an overloaded or clogged l p � t5insp,dac•rev.7/26/2018 Tide 5 Official fnspedon Form:Subsurface Sewage Disposal System.Page 4 of 18 F Commonwealth of Massachusetts Title 5 Official. Ins pect'ion For Subsurface Sewage Disposal System Form-Not for voluntary Assessments A Inv + Property Address ` Owner Owner's Name information is `�. &/Q7 required for every _ _......,,_..,� pager CityfTown State Zip Code Date of Inspection G, Inspection Summary (cent.) 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 TIK or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 0"below invert or available volume is less than da' ow /z y fl ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: E] 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 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.] E] The system is a cesspool serving a facility with a design flow of 2000 gpd- 10 00D gpd. The system fails.I have determined that one or more of the above failure ❑ criteria exist as described in 310 CNIR 15.303 therefore the system it r y em 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 design flow of 10,000 gpd to 16,000 gpd. For large s rns, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Sec r .4. Yes No El ❑ the system is within et of a surface drinking water supply 1:1 El the system is within 200 feet of a to ry to a-surface drinking water supply El 1:1 the system is located in a nitrogen sensitive a�knterim wellhead Protection Area--IwPA)or a mapped Zone 11 of a public w supply well 15insp-doe-rev.7126 28'l8 role 6 Official Inspection Form:Subsurface Smage Di l System-Page 5 of 18 s r Commonwealth of Massachusetts T'latle 5 Off'iocwial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments X Property Address Owner owner's Name% 3 information is6 -- �� required for every page. 1tyff0,M State Zip Code D of inspection C, Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a signifcant threat, or 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 C,4 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 roust indicate"yes"or"no"for each of the following for all inspections: Yes No rky El Pumping information was provided by the owner, occupant,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 NIP ❑ was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site 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 ❑ information on the maintenance of subsurface sewage disposal systems? proper The size and location of the soil Absorption system(SAS)on the site has been determined based on; E] Existing information.For example,a plan at the Board of Health. rx Determined in the field(if any of the failure criteria related to Part C is at issue ❑ approximation of distance is unacceptable)[310 C11 R 15.302(5)] t5insp.ddc•rev.7/2612018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Rage 6 uf 18 Y Commonwealth of Massachusetts b "l Tiotle Offiocimal Inspecti0on ors Subsurface sewage Disposal system Foirm Not for Voluntary Assessments Y Property Address Owner Owner's Name information is ol required for every //0 � page, Cffyffown state Zip Code Date of Inspection D. system information 1. Residential Flow Conditions: �. Number of bedrooms(design): Number of bedrooms(actual): '11 D d x of bedrooms): �- DES 1G111 flew based on 3'l 0 AMR 15.203(for example: gp f# } Descriptions.- Number of current residents: Does residence have a garbage gander? El Yes No Does residence have a water treatment unit? El Yes No If yes,discharges to: Is laundry on a separate sewage system?(include laundry system inspection Yes g No information in this report.) 1:1 Laundry system inspected? El Yes No Seasonal use? El Yes it No Water meter readings,if available(last 2 years usage(gpd)}: Ora Detail: r Sump pump? El Yes DqNo Last date of occupancy: C.kk Date t5insp.doc-rev.7126/20/8 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Officoial Form i/ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rN A_tj C_t:v4 c K r Property Address � Owner owners Nam information is "` --- / �'- required for every r --- page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow conditions: Type of tablishment: Design flow(ba d on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(s tslpersonslsq.ft.,etc.): Crease trap present? EI Yes El No Water treatment unit present? El Yes D No If yes,discharges to: Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes 0 No Water meter readings,if available: Last date of aecupancyluse: Date Other(describe below): r '] •`�`r'r`1 r1 3. Dumping Records: ;, - ► Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5fnsp.dac•rev.7/26/2018 Tree 5 Official Inspection Form:Subsurface Sewage disposal System•Page 8 of 18 Commonwealth of Massachusetts e; f itle Offi n ec. ion orm Subsurface sewage disposal System Form Not for Voluntary Assessments AL CLA I Property Address Owner owner's Name __..— information is r j required for every page. /tvown State dip Cade Date c#Inspection D. System Information (cont.) 4. Type of System: Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ overflow cesspool ❑ Privy Shared system(yes or t (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 YA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. El other(describe): Approximate age of all 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): c� Depth below grade: feet Material of construction: cast iron ❑40 PVC El other(explain): AJ/A-, Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): eA, - t5insp.doc-rev.7/26/2018 Me 6 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts yT'I*tle 5 Off Form ti 40 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V~ 1 Property Address Owner owner's Name _ l information is required for every page. dityfTown state Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): L� Depth below grade: feet Material of construction: concrete El metal El fiberglass ❑polyethylene El other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes Ej 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 SI-7 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.): �tYL C r t5insp.doc•rev.7/2612018 We s official fnspecdon Farm:Subsurface Sewage Disposal System•Wage 10 of 113 r Commonwealth of Massachusetts Tfttle 5 Offi*ci"alr 1� Subsurface sewage Disposal system Form Not for.Voluntary Assessments r Property Address Owner owners Name information is required for every page, CitylTown State Zip Code Date of Inspection D. S tem Information (cont.) 7. Grease p(locate on site plan): Depth below gr e: feet Material of construc n: D concrete El etal El fiberglass []polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee baffle Distance from bottom of scum to bottom of outlet to r baffle Date of last pumping: date Comments(on pumping recommendations, inlet and outlet to r baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 8. Tight or Holding'Tank(tank m be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: El concrete Elmetal El fiberglass El polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5inspAoc-rev.7/26/2018 Tile 5 Official Tnspedon Farr:Subsurface Sewage❑ispofal System•Pag 11 of 18 s Commonwealth of Massachusetts T MA a M ■ itie 5 Official Forrn w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ♦V 'tI(Ar 4 Property Address Owner owner's Na LY .11 a .� ..-� information is AV .,�, '"Z-0�) required for every ` pale. City/Town State Zip Code Dane of Inspection D. System Information (cant.) L. Tight or Holding Tank(cont.) Alarm presen : [_1 Yes El No Alarm level: Alarm in working order. El Yes [:1 No Date of last pumping: to Comments(condition of alarm and float switches,etc.): Attach copy of current pumping contract(required), is copy attached? ❑ Yes ❑ No g. Distribution Sox(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.):0 � ... - �. t t51nsp.doo-rev.7/26/2018 Tile 5 Official Inspec Uon Form:Subsurface Sewage Dispasaf system•Page 12 of 18 r ti Commonwealth of Massachusetts Tlotle Offimcmial Inspection .For � Subsurface Sewage Disposal System Fora-Not for Voluntary Assessments a yYy s y Property Address r - Owner owner's Ne information is `..' required for every page City/Town State Zip Code Date of inspecfion D. System Information (cant.) 10. Pump amber(locate on site plan): Pumps in wo `ng order: El Yes El Noy` Alarms in working or El Yes El No* Comments(note condition of p chamber,condition of pumps and appurtenances,etc.): *If pumps or alarms are not in working order, system is a conditional p = 11. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located, explain why: Type: El leaching pits number: El leaching chambers number: ❑ teaching galleries number: El leaching trenches number, length: leaching fields number,dimensions: ❑ overflow cesspool number: El inn ovativelalternative system Type/name of technology: Wnsp.doc-rev.7/26/2018 Title 6 official Inspection Form:Subsurface Sewage Disposal System*Page 13 of 18 4 Commonwealth of Massachusetts Title 5 Official Subsurface sewage Disposal System Form-Not for Voluntary Assessments w Property Address Owner Owner's N .. information is required for every page, Cityfrown State Zip Code Dante of inspection D. System Information (cont.) 11. Sail Absorption system(SAS)(coat.) Comments(note condition of soil,signs.of hydraulic failure,level of ponding, damp soil, condition of vegetation,etc.): R 12. Cessp .cesspool must be pumped as part of inspection)(locate on site plan): Number and c figuration Depth—top of liqui inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow El Yes [] No Comments(note condition of soil, signs of hydraulic failure,le I of ponding,condition of vegetation, etc.). Wnsp.doc•rev.7/26/2018 Tide 5 Official Inspedon Farm:Subsurface Sewage Disposal System•Page 14 of 18 ,I Commonwealth of Massachusetts TI'tle 5 Official -Fors Subsurface Sewage Disposal System Form Not for Voluntary Assessments Q1. ............ - yi V Property Address Owner owner's Na e information is ' -- required for every •- "4 -Ve �� - d page. CitylTown State Zip Code Date of Inspection D. System Information (cont,) 13. Fri (locate on site plan): Materials f construction: Dimensions Depth of solids Comments(note conditi of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Tide 5 official lnspedon Fora:Subsurface Sewage Disposal System•Page 15 of 18 T •� Commonwealth of Massachusetts A . TI"tle 5 Official ohm a Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Na information is ---- required for every page, ity/Town State Zip Code Date of Inspection D. System Information (cont.) 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; Ej hand-sketch in the area below ❑ drawing attached separately t5lnsp.dvc•rev.7/2612010 Tifle 5 Official Inspection Form:Subsurface Sewage disposal System•Page IS of 18 TP Commonwealth of Massachusetts Tiotle 5 Official Forb Subsurface sewage Disposal system Form Not for Voluntary Assessments Ai 1/4 ty Property Address Owner owner's Nam ..�- jnformaWn is required for every ' page. City[Town State Zip code Date of Inspection D. System Information (cont.) 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: Date El observed site(abutting pr9perty/observation hole within 150 feet of SAS) Checked with local oard of Health--explain: ❑ checked with local excavators, installers-(attach documentation) El Accessed USGS database-explain: You must describe how you established the nigh ja=nd water elevation: J Before filing this Inspection Report, please see Report completeness checklist on next page. t5insp.doc•rev.7/2612018 True 5 Official Inspection Farm:Subsurface Sewage Disposal System*Page 17 of 18 Commonwealth of Massachusetts MTitle 5 Official Forrn } Subsurfacie Sewage Disposal System Form Not for Voluntary Assessments Y ' Property Address Owner Ownees Name --� information is ��. _ r ���� �..�-'(,,�� Z� required for every — w -- - f page, Cityrrown State ZJp 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: 11 21 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 L t5lnsp.doo-rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage disposal System•Page I of'Ia f V m " d 16 14 IV 6 cz:> t � WOO U&-PIPS QUT QE HGE- 64 t) tj i- L or thilL Pipe IMM IrAskivw v7 'f ► GG u--ML C!: D i Lt f5s n ..� ..,aw_ � i ;,.