HomeMy WebLinkAboutPass - Title V Inspection Report - 330 CAMPBELL ROAD 11/15/2025 t
Commonwealth of Massachusetts
,lip Tl"tle !i 0 cl'al I For
_ r
5ubsurMce Sewage Disposal S stern Form-Not for Voluntary Assessments
Property Address
Owner owners Name
information is
_ `'`
required for every01
page, C !Town State Zip cede 'Date of Inspection
Inspection results must be submitted on this form.inspection f urns may not be altered in any
way.Please see completeness checklist at the end of the form.
importan#:When filling out forms A, Inspector In7
atton •
on the computer,
use only the tab a_t_j__7�0
key to move your Nam of or
cursor-do note
use the return Fan Namekey. �
Address
• '� /17
CitylTown State Zip Code
..... _W=1... . Telephone Number .� � � �`.
Lic&se•Number
B., Certification
i certify that:i am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 C R 15. ); 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 l have determined
that the system:
1. Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation 6y the local Approving Authority
4. El Falls
pectaes Slgnatu Date
The system inspector shall su mit a copy of this inspection report to the Approving Authority(Board
of Health or DIEP)within 30 days of completing this inspection. if the system has a design flaw of
10,1000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DER The original form shoq.ld 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 tjrfi6#itispe ion and under the
condirtlods of use at that time.This 11s 'on-dog mot bddtiess how the system will perform
1n the future under the same or ditrdnt conditions of use.
t5irsp,3dvc•rev.7/2612018 Tide 5 OHidal Inspedon Form:Surface Sewage'dispasal System•Page 1 of 18
Commonwealth of assachusetts
altle 5� Officia a ionFor
s
Subsurface Sewage[Disposal System Form-Not for Voluntary Assessments
4+y{ IV
rc,`3 �-wP
.
Property Address
Owner Owner's Na
information is 2V
/.
required for every �' "' OZ
page. Cityfrbwn Mate Zip Code Date of Inspection
C. Inspection Summary
lnspecbon Summary:Complete 1, 22 3,or 5 and all of 4 and 6.
1) system Pusses:
1 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:
V..., 40CLW .
2) System condlitionatly 'asses;
C] one or more system components as described in the"Conditional Vass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair,as approved by
the Board of Health,will pass.
Check the box for"yes","no"or"not determined"fY, N,ND)for the following statements.if"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exf ltration or tank failure is imminent.System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Cerbfcate of
Compliance indicating that the tank is less than 20 years old is available.
El Y ❑ N ❑ ND{Explain below}:
15insp.doc•rev.712612DI8 Tide 5 Official Mspec don Fow.Subsurface Se�Disposal System•Page 2 of 16
Commonwealth of Massachusetts
............. f ici n ctn ors
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44
* r .
?rr
Property Address
Cj
Owner Own Res Nam --� --
infomnaWn is l, ---" 2t�>
-
required for every Z-U
page, CityiTown State Zip Code Date of Insertion
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont,):
El Pu Chamber pumpslalarms not operational.System will pass with Board of Health approval if
PUMP s larms are repaired.
❑ Observation of se ge backup or break out or high static water level in the distribution box due
to broken or obstruct pipe(s)or due to a broken, settled or uneven distribution box.System will
pass,in"speCtion if(with roval of Board of Health):
El broken pipe(s)are re ced E] Y ❑ N E] ND(Explain below):
E] obstruction is removed E] Y El N ❑ ND(Explain below):
❑ distribution box is leveled or rep d E] Y E] N ❑ ND(Explain below):
E] The system required pumping more than 4 times a year due to broken obstructed pipes).The
system will pass inspection if(with approval of the Board of health):
❑ broken pipe(s)are replaced Ej Y F] N ❑ ND�EXpl '\bew):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explai
Nr
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is fail to protect public health,safety or the environment.
a* system will pass un Board of Health determines in accordance with 310 C R
15.303(7)(b)that the system i of functioning in a manner which will protect public health,
safety and the environment;
t5insp.doe-rev.7126/2018 Thle 5 offidal Inspection •Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Tl"tle 5 0 ci'al IFor
Subsurface Sewage Disposal System Form-Not for voluntary Assessments
36
r
{ ti
Property Address
Owner 0;r Al....'s Name
information is .4 �..,
required for every
page, b4ffown State Zip code Date of Inspection
C. Inspection Summary (wnt.)
El sspool or privy is within ao feet of a surface water
Ces ool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System wfll i unless the hoard of health(and Public water Supplier, if any)
determines that th stern is functioning in a manner that protects the public health,
safety and envlronme •
�] The system has a septic t and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply tributary to a surface water supply.
[] The system has a septic tank and S and the SAS is within a Zone I of a'public water
supply.
Q 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 SA 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 cert� boratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and n to nitrogen is equal
to or less than 5 ppm,provided that no other failure criteria are triggered.A copy o•the analysis must
be attached to this form.
c. Other:
4) System Failure criteria Applicable to All Systems:
4
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
o P Backup of sewage into facility or system component due to overloaded,or
clogged SAS or cesspool
P
El Discharge or paneling of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp,doc-rev.7/2612018 Tide 5 Offidaf Inspection Form:Sc trsurface sewage asposad Stem-Rage 4 of 18
Commonwealth of Massachusetts
Toltle 5 Offlacolal Inspection
Form-.
Subsurface Sewage Disposal System Form-Not for voluntary Assessments
Property Address
Owner Name
information is ((ff��-.V AMY �1(f
vr
V r
required for every ,
page. -CttyfTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) system Failure Criteria Applicable to All Systems: (cont.).
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 5"below invert or available volume is less
❑ than Y2 da flow
v
Required pumping more than 4 times in the last year NOT due to clogged or
Ej
obstructed i s . Number of times um ed:
ob P peg � A p
E] qR 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,
E] tjV 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 D EP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppnrr,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
AX The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000
The system fails.l have determined that one or more of the above failure
❑ - - 5.303 therefore the system fails.The
criteria exist as described�n 310 CMI�1 ys
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 15,E gpd.
For large systems,you t indicate either"yes"or"no"to each of the following, in addition to the
questions in.Section CA.
Yes No
El 1:1 the system is within 40 t of a surface drinking water supply
�] {� the system is within 200 feet of "butary to a surface drinking water supply
the system is located in a nitrogen sen -'ve area(interim wellhead Protection
El E] Area--hNPA)or a mapped Zone 11 of a p !'c water supply well
t5insp.dac•rev.7/26/2018 Tree 5 Offidai Inspection Form subsace a Disposal system•Page 5 of'Ia
K
Commonwealth of Massachusetts
fT 1Offi" ic' Inspection `
Subsurface Sewage Disposal System Forms-Not for Voluntary Assessments
•V
Property Address
owner owne?s Name
information is
a-
5 1
requlred for eery page, CltyffoWn 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 signif cant
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 must indicate"yes"or"no"for each of the following for all inspections:
Yes No
D 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?
El Has the system received normal#lows in the previous two weep 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 NIM
�] 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?
/12 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 sorption System J )on the site has
been determined based on:
E] .Existing information. For example,a plan at the Board of Health.
o Determined in the field(f any of the failure criteria related to Part D is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
t5insp.doc•rev,7/2612018 Tile 5 Official Inspec Uon Form:Subsurface Sewage Disposal System•Page 6 of 18
S
Commonwealth of Massachusetts
Taltle 5 Off1mcmial Inspection
For
" subsurface sewage Disposal system Farm Not for Voluntary Assessments
Property Address
.............
Owner Own Vs Name
information is 1A)
required for every �-
page. city/Town state Zip code Date of Inspection
M ystem Information
1. 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): r.
Description:
Number of current residents:
Does residence have a garbage grinder? 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 No
i i ❑
nformation n this report.)
Laundry system inspected? ❑ Yes No
seasonal use? El Yes No
Dater meter readings,if available Mast 2 years usage(gpd)):
Detail: _
Sump pump? El Yes No �--
Last date of occupancy; a&01--
D&e
t5insp.doc•rev.712512018 Tide 5 Official Inspection Form:Subsurfaoe Sewage Disposal System•page 7 of 18
Commonwealth of Massachusetts
1 i ion
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y
4
Syr
Property Address
Owner owner's Name
information is
�. .. evP(m _ 1
required for every �.
Rage. C4/Tolm State Zip Code Date of Inspection
D. System Information (cent.)
2. DommercialAndustriat Flow Conditions:
Type of Es ishment:
Design flow(base n 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(sea rsons/sq.ft.,etc.):
Crease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes,discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? Ej Yes ❑ No
Water meter readings,if available:
Last date of bccupancyluse: Date
Other(describe below):
3. Pumping Records.
Source of information:
Was system pumped as part of the inspection? Yes No
If yes, volume pumped:
gallons
How was quantity pumped determined? 1
q tY
Reason for pumping:
t6insp.doc•rev.7/26/2018 _ Tide 5 Official Inspection Fomr.Subsuftoe Sewage Disposal System-Page a of I
Commonwealth of Massachusetts
•
Ti
ot.le 5 Offin-cial Form
Subsurface Sewage Disposal system Form-Not for Voluntary Assessments
dqP.
Property Address `
Owner Owner's Name
infermatton is �.�,� ,, ,C �' --{
required for every � ��``"
Coffown State Zip Code Date of Inspection
page.
D. System Information (cant.)
4, Type of System:
Y
Septic tank,distribution box,soil absorption system
�] Single cesspool
❑ overflow cesspool
❑ Privy
Shared system (yes o PIN o yes,attach previous inspection records, if any)
❑ Innovative/A#ternative 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
El Tight tank.Attach a copy of the DIP approval.
[] other(describe):
Approximate age of all components,date installed(if known)and source of information:
P
Were sewage odors detected when arriving at the site? ❑ lies No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
cast iron ❑40 PVC ❑other(explain):
1 "(.)
Distance from private water supply well or suction line: feet
Comments(on condition of Joints, venting,evidence of leakage,etc.):
t5insp.doe-rev.7/26/2018 Title 5 official Inspection Fomk subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
o
f 1Official
Subsurface Sewage Disposal System Form-Riot for Voluntary Assessments
-3 y~` i.d•
Property Address C'
Owner owner's Narne
information is
required for every /0-0 A A�) � J�
page. CftylTown State Zip Code Date of Inspection
D. System Information (cont,)
bar Septic Tank(locate on Site plan): 6Z L > Cf%%-V
Depth below grade: feet
Material of construction:
0.,,C,oncrete 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 ❑ No
Dimensions:
�t
Sludge depth:
Distance from top of sludge to bottorrr of outlet tee or baffle
t'1
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 inert,evidence of leakage,etc.):
Se-
t5lnsp.doo•rev.7/26/2018 Tide 5 official Inspection Farm:suhsuftce Sewage Disposal system•Page to of is
i
Commonwealth of Massachusetts
T'Itle 5 Forr�
Subsurface sewage Disposal systems Form-Not for.Voluntary Assessments
F
Property Address 1
Owner CKVTpes Na •�
informativn is
rewired for suety
page. ftfrown state Zip Code Date of Inspection
Din s tern Information (coat.)
7. Grease Tra locate on site plan):
Depth below grade: feet
Material of construction:
El concrete El metal El fiberglass El polyethylene El 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,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
.j
8. Tight or H ing Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
El concrete ❑metal fiberglass ❑polyethylene. El other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doe•rev.7/26/2018 Tie 5 Offidal Inspedon Fomm Subsurface Sewage Disposal System*Page'I'I of 18
Commonwealth of Massachusetts
Tm Ad Mob. do ■ a
itie 5 unicial ,inspect0ion For
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address Y
)W C-
Owner owner's Name
information is
required for eery zi�V-� 1
Page. Citylrown State Zip Code DaW of Inspection
D. System Information (cont.)
8. Tig t or Holding Tank(cont.)
Alarm pr nt: El Yes D No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,et .
Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No
g. Distribution Sox(if present roust 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.):
tainsp.doc-rev.7/26/2018 Title 5 D€iiaal lnspedxon Fotm:Subsurface sewage Disposal System•Page 12 of 18
} 1 r
Commonwealth of Massachusetts
-T"tle 5 0 I colal ionFor
Subsurface Sewage disposal System Form-Not for Voluntary Assessments
4 t.
Property Address
r
Owner owner's Name
information is "' -
required for every '. �`' f i '
pages own State ��p Cade Qate a nspecfion
D. System Information (cont.)
10. ump Chamber(locate on site plan):
Pumps in order: El Yes [I Ne
Alarms in working order: El Yes ❑ No*
Comments(note condition of pump chamber,con ' ' of pumps and appurtenances,etc.):
*if pumps or alarms are not in working order,system is a conditional pass.
11. Solt Abb iorptlon System(SAS)(locate on site plan, excavation not required):
If SAS not located,explain why:
Type:
El leaching pits number:
1:1 leaching chambers number:
1:1 teaching galleries number:
❑ leaching trenches number,length: 001\
leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovativelatternative system
Type/name of technology:
15insp.doo•rev.712&2018 rrae 5 offida!Inspedon Farm:subsurface sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
� ' Inspecti6on
otle 5 0
Subsurface Sewage Disposal System orm-Not for Voluntary Assessments
jgcM14 r
Property Address
r
Owner Owners Name
information is /1).
- �
every �
w -.reired for v ry
page. QWTown State Zip Code Dante of Inspection
D, System Information (cant.)
11. Soil Absorption System(SAS)(cant.)
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of
vegetation,etc.):
0�'
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth— p of liquid to inlet invert
Depth of solids r
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow E] Yes ❑ No
Comments(note condition of soil,signs of hydraulic failure,level of riding,condition of vegetation,
etc.).
t5lnsp.doc■rev.7/26/2018 Tide 5 modal Inspedon Fonw.Subsurface Sewage Disposal System-Page M of 18
` t f l
Commonwealth of Massachusetts
Title 5 O -Form
Subsurface Sewage Disposal system Farm-Not for Voluntary Assessments
04- d,
'y -A
Property Address
Owner owwer's Name
information is
required for every X3
--
page, C /Town - State Zip Code Date of InspecUQn
M.System Information (cont,)
13. Privy cate on site plan):
Materials o construction:
Dimensions
Depth of solids
Comments(note condition o il,signs of hydraulic failure,level of ponding, condition of vegetation,
etc.):
f�
t5insp.doc•rev.7/2612018 Title 5 Official lnspedon Form Subsurface Sewage Disposal System•Page 15 of 18
A
Commonwealth of Massachusetts
T MA a
ive 5 .
M
icyInspect"ion Fs
y Subsurface sewage Disposal System Form-No for Voluntary Assessments
44
pnaperty Address
Owner Ownel's Names _
Information is
4
required for every
page, Crtyfrown State Zip Code Date of tnspechvn
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: -
hand-sketch in the area below
❑ drawing attached separately
r
r
17q
f
161nsp.doc-rev.7126/2018 We 5 Dffdal Inspection Fomx Subsurface Sewage Disposal System■Rage 16 of 18
Commonwealth of Massachusetts
Toltle
Offlocial Forr�
Subsurface Sewage Disposal System Fora Not for Voluntary Assessments
4 r
L.
Property Address
y
Owner owner's Marne
irrfamnation is
required for every •
page, Citylrown State Zip Code Date of lnspec#ion
D. System Information (cunt.)
15. Site Eam:
Q 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 wafer elevation:
❑ Obtained from system design plans on record
If checked.,date of design plan reviewed: Date
❑ -Observed site(abutting property/observation mole within 150 feet of SAS)
[� Checked with local 139ard f Health-explain:
- 0,--pz'I /2/,
El 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.
#5iW,doc•rev.7/2612018 Tt#lee 5 Official Inspedon Form:Subsurface Sewage Disposal system-Page 17 of 18
Commonwealth of Massachusetts
Offincia " � Forinn otle 5
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
73
Property Address
Owner Owner's Nam � __-�-
Information is 0
_---- "
l �- - 2-S
required for every ,Al �
t1
page. CityITown State tp bode Hate 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: ,
1,21 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
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