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Home My WebLink AboutTitle V Inspection Report - 109 RALEIGH TAVERN LANE 3/20/2012 *, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments —if rte , -- v� L -- Property,Address Owner Owner's Name information is � 0 ) ' required for every ---� �'�e State Zip Code Date of Inspection page City/Town 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:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key move your our cursor-do not t � �• ' use the return Name f Insp ctor key. Company Name Company ddr/e$-s y y� y / w( City/Town State Zip Code, Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 9 MR 15.000). The system: asses ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority L Inspector's Signature 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 system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions,at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future V :der the same or different conditions of use. 40") �to�,•x� ��,�.y t5ins-09/08 ✓`7 "' �,/! i'f Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 17 i Commonwealth of Massachusetts Title 5 ufficial Inspection Form 6� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t6> ki r J Property Address 1 Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out o high static water level in the distribution box due to broken or obstructed pipe(s) or due to a b oken, settled or uneven distribution box. System will pass inspection if(with approval of Board Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): 1 obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is levele or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system requir umping more than 4 times a year due to broken or obstructed pipe(s), The system will pass ' sp tion if(with approval of the Board of Health): ❑ broken ipe(s) e replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obst ction is rem ved ❑ Y ❑ N ❑ ND (Explain below): C) F rther Evaluation is Required by the oard of Health: ❑ Conditions exist which require further eval tion by the Board of Health in order to determine if the system is failing to protect public health, afety or the environment. 1. System will pass unless Board of Health et rmines in accordance with 310 CMR 15.303(1)(b)that the system is not functionin ' a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09108 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17 ^ ` ` Co00[5o'nVVealth of Massachusetts "�=°i�K�� .J��~��N K��°�� H*W1�� @ Q�@�� /� � K��H 0um��B��mw Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Name information is required for every L, IVA page, City/Town State Zip Code Date of Inspection B. Certification (cont.) � Yes No Required pumping more than 4timoo in the last year NOT due to clogged or � 0 �o obstructed pipebA. Number of times pumped: _____ Any portion of the SAS, cesspool ur privy is,below high ground water elevation. Any portion of cesspool or privy io within 1OO feet ofe surface water supply ur F~ '�l � �� tributary too surface water supply. El � Any portion nfa cesspool or privy is within a Zone 1ofa public well. ~v~ ` Any portion of a cesspool or privy is within 50 feet of a private water supply well. �l c�� Any porUonofa cesspool or privy iu less than 1OO feet but greater than 5Ofeet -- —� from a private water supply well with no acceptable water quality analysis. [This � eyotano passes if the well water ana|yois, performed at a DEP certified | laboratory,forfecal om|ifornn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppmn, � ' provided that no other failure criteria are triggered.A copy mf the analysis � and chain mf custody must be attached to this forrn.] El he system isa cesspool serving a facility with a design flow of2OOOgpd' O.0OOgpd. |� The system fails. \ have determined that one qr more of the above failure LJ criteria exist as described in 310 O[NR 15.303' therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary tn correct the failure. E/ Large Systems: To b e considered u |arge system the system must serve a facility with a design flow of10'O0O0pdto1S.DODgpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No Fl El the system is within 4OO feet ofa surface drinking water supply � 0 the system is within 2OO feet ofo tributary toa surface drinking water supply . the system is located in a nitrogen sensitive area (interim Wellhead Protection Area — |VVPA) ora mapped Zone || ofo public water supply well If you have answered "yes"to any question in Section Ethe system is considered a significant threat, or answered '`yes" in Section D above the large system has failed.The owner or operator ofany large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CIVIR 15.304, The system owner should contact the appropriate regional office of the Department. t5ms 09/08 Title n Official Inspection Form.Subsurface Sewage Disposal System'Page n"/^, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i Property Address I Owner Owner's Name information is b` � � �` �, 1?� v°��0 required for every Ly ((:: page. City/Town State Zip Code Date of Inspection D. System information Description: I I Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry n a'se crate sewage system? [if yes separate inspection required] ❑ Yes �No rY p g Laundry system inspected? ❑ Yes Seasonal use? ❑ Yes Water meter readings, if available last 2 years usage d G?69 S G Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection rr° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i - ter P v► Z v, Property Address Owner Owner's Name information is I"j e1 required for every 6)'r ® � - I Ca page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Approximate age of all components, date installed (if known) and source of information: q— -3 cD Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;I:ro El cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet ;teri construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) col If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: — Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection For Subsurface Sewage Disposal System Forme Not for Voluntary Assessments Property Address l Owner Owner's Name / information is �� ld o �� required for every 1 �� ! ��✓ '- — page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc,): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of Construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: -- Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc,): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins 09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ioe r°� J�ic�� °Tryvi~��, Z� n Property Address Owner Owner's Name information is l 1 -F- a.�aV-e r., required for every I �6,- page. City/Town State Zip Code Date of Inspection D. System information (cant.) Type: ❑ leaching pits number: ❑ leaching chambers number: i ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: q:rx 0 ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part 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 t5ins•09108 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title ffi i l Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments R Property Address V Owner Owner's Name information is required for every 7 oy- /A page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks, Locate all wells within 100 feet. Locate :�han'd_s blic water supply enters the building. Check one of the boxes below: ketch in the area below ❑ drawing attached separately co ver d,ii 5 VrwGd - II rood VAS ACA 0, vr�e- -% Lctti -e, t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 10 r- CA 1ei6 �� Ure Property Address i Owner Owner's Name information is `� / required for every J / o l Ire n kj CY to y e.r ate l�- page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist nspection Summary: A, B, C, D, or E checked 2-11nspection Summary D (System Failure Criteria Applicable to All Systems) completed Syste Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17