211 Title 5 Inspection Report 2002 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF
DEPARTMENT OF ENVIRONMENTAL PROTE
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: z/I i(/, f (,rt S /(b, NGL40*.1r4.4r A4b
Owner's Name:
KNTHY Ic Fi7F2
Owner's Address: 25 Np-FLIK p„E
eJcrftta.#a ln.:, mo
Date of Inspection: fg12,11 ea—
Name of Inspector:(please print) ALAN E WESS:ES.
Company Name: COLD SPRING ENMRONMEN T.AL INC_
Mailing Address: 350 OLD ENFIELD ROAD
BELCHERTOWN.MA 01007
Telephone Number: 413 323 5957
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system a'this address and that the information reported
below is sue,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 dun site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Tosses
Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 8/z'/oz
ALAN E WEISS.REGISTERED SANITARIAN
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.
Notes and Comments A/o _ o/ca .511 S/-rti.
Ncf 10 ,44.016.e, onfJ- tiof3o.1 J
Most rcoyA}b
*"**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.
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSILM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Z(( W..t»L.45 Rc4b
Owner: tefL
Date of Inspection: 41U Z
inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
-�.j��I have not found any information which indicates that any of the failure criteria described in 310 CMR
19.303 or in 310 CMR 15304 exist.Any failure criteria not evaluated are indicated below.
Comments:
R/e}f_ F-74-69- rq 6E
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"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.
Answer yes,no or not determined(Y,N,ND)in the
explain.
for the following statement.If'not determined'please
The septic tank is metal and over 20 years old. or the septic tank(whether metal or not)is suooturally
unsound,exhibits substantial infiltration or exnitration or tank failure u 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 Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or Yob static wider level in the distribution box due tobroken or
obstructed pipe(s)or due to a broken,settled or tmeven distributionbox.System will pass inspection if(with
approval of Board of Health):
ND explain:
broken pipe(s)arc replaced
obstruction is removed
distribution box is leveled or replaced
_ The system required pumping more than 4 rimes a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Heabh):
ND explain:
broken pipe(s)are replaced
obstruction is removed
Page 3 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: z(( Ai. gsc*t5
Owner:
Date of Inspection: 'lb o2
C. 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
s (ailing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in 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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or n ibutay to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS 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 certified laboratory,for col iform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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 must be attached to this form.
3, Other:
Page 4 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION.FORM
PART A
CERTIFICATION(cordial/0d)
Property Address: Z
Owner:
Date of Inspection: $,4pl 14�
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
%foBaokup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
(Air,Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
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 H day flow
Reeuired 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 aibutary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet Ma 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 Heil n ater analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to the form]
g (Yes/No)The system tails.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.
E. Large Systems:
To be considered a large system the system must serves facility wid,a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the atria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to i surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgfade the system in accordance with 310 CMR
15304.The system owner should contact the appropriate regional office of the Department.
rage 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Z II ,p(,TA-pnS
Owner: ie sr-et
Date of Inspection: $I2t IqZ
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Y _ Pumping information was provided by the owner,occupant,or Board of Health
4./ Were aiy of the system components pumped out in the previous two weeks?
rke-
_ Has the system received normal flows in the previous two week period? _Mo f- pc
I1
Have large volumes of water been introduced to the system recently or as part of this inspection?
_4/4
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?
Was the site inspected for sins of break.ow
Were all system components,excluding the SAS,located on site?
LePS_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of commotion,dimensions,depth of liquid,depth of siudse and depth of soma?
be, the facility owner(and occupants if different ikom 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:
Yes no
44 Existing information.For example,a plan at the Board of Health.
ye _ Determined in the Feld(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)1
. Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYS 1 EM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: ZI( /I) , cAeNS
Owner:
Date of Inspection:
8]2 01
RESIDENTIAL
Number of bedrooms(design): Z? Number of bedrooms(actual): z
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd xll of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no): P4,
Is laundry on a separate sewage system(yes or no):Wo [if yes separate inspection required]
Laundry system inspected(yes or no):---
Seasonal use:(yes or no):fit
Water meter readings, if available(last 2 years usage(gpd)):rel4
Sump pump(yes or no):Ho
Last date of occupancy:, tm p S,
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design Bow(based on 310 CMR 15203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Crease trap present(yes or no):
ladusnial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no).
Water meter readings,if available:
Last date of occupancy/use:
FLOW CONDITIONS
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: n N.111/—no„a
Was system pumped as part of the inspection( no):
If yes,volume pumped: /Occ gallons—How was quantity pumped determined?
Reason for pumping:� c,p ll
TYPE OF SYSTEM
✓Septic tank,distribution box,soil absorption system
Single cesspool
_Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology.Attach a copy of the arrest operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all corn� nents,date ins Iled(if known)and source of information:
1461 YO yTkrs 4-
W
Were sewage odors detected when arriving at the site(yes or no):1,6
. Page 7 of II
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: zit U. S"At..s ¢D.
Owner: f, ma_
Date of Inspection: -g(aioz_
BUILDING SEWER(locate on site plan)
Depth below grade: I&)
Materials of construction:_u3st iron _40 PVC other(explain):
Distance from private water supply well or suction line: Jo'
Comments(on condition of joints,venting, evidence of leakage,etc.):
SEPTIC TANK: YtS(locate on site plan)
11
Depth below evade: 20-2'(
Material of construction: vEoncrete_metal fiberglass polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(anach a copy of
certificate) r
Dimensions: S ,c y KY 1
Sludge depth: 2" U
Distance from lop of sludge to bonom of outlet tee or baffle: 3 .
Scum thickness: 2"
Disance from top of scum to top of outlet tee or baffle: Sa
Disance from bottom of scum to bottom of outlet tee or baffle: 4 if
How were dimensions determined: fltflS
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity liquid levels
as related to outlet in eIrt.evidence of leakage,etc.):
VC-. • (diA./e n&I 51.x40 LOA1 L, bakThs
GREASE TRAP:bifit(locate on site plan)
Depth below grade:
Material of construction: concrete metal_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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
. Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ZO A%, - Jer9
Owner:
Date of Inspection: K12I 10z
TIGHT or HOLDING TANK: Al 4(tank must be pumped at time of inspectionxlocate on site plan)
Depth below grade:_
Material of construction: concrete_metal_fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):_
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: FA(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.):
PUMP CHAMBER: NA- (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address
vi 'J.-aams RD
Owner: Fpe'7c
Date of Inspection: $
SOIL ABSORPTION SYSTEM(SAS): I1(5(locate on site plan,excavation not required)
If SAS not located explain why
leaching pits,number: L.1 ....ye S t 0 (t)/ M�"T'�,
leaching chambers,number: / J
leaching galleries,number:_
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of pouching,damp soil,condition of vegetation,
etc): t�,�
5i5t)S c4 $tin ',4 I top j Ild Lr14.4 ,u well
CESSPOOLS:d (cesspool must be pumped as pan of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth ofscum layer:
Dimensions of cesspool:
Materials of constmction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs ofhydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:
(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
FAR-dS-d1502 11:SH
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(watinued)
Property Address: N.F-4 $
Owner: ;T
Dale of Inspection: $ zf R>
P.01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal cyst to 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.
4a z zz'
8Ztzsr
C•2= 28`
"D .7- `If
Page l l of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ti) hI,fR 2r1 5
Owner:
Date of Inspection: sSjz/ /OZ-
SITE EXAM
1."-- Slope
Surface water
Check cellar
Shallow wells
/ t�
Estimated depth to Bound water (O feet
Please indicate(check)all methods used to determine the high ground water elevation:
_ 9btained from system design plans on record-If checked,date of design plan reviewed:
,/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:
7bOa1 v4.9 .) Dad wen L as PwnAp