Loading...
573 Septic Inspection 2016 Commonwealth of Massachusetts Title 5 Official Inspection Form a�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Owner information is required for every page. Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. C tSins•09/08 573 Westhampton Rd. Florence Ma. 01062 Property Address James& Cynthia Faulkner Owner's Name same City/Town Ma 01062 05/18/16 State Zip Code 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. A. General Information 1. Inspector: Ray Champagne Name of Inspector Whiteley Septic Service Company Name 21 Old County Rd. Company Address Southampton City/Town 413-527-0057 Telephone Number Ma. State 514118 License Number Ma. Zip Code 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 CMR 15.000).The system: Z Passes ❑ Conditionally Passes ❑ Fails ] Needs Further Evaluation by the Local Approving Authority nspector's Sig tore 05/18/16 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 under the same or different conditions of use. Tine 5 official Inspection Form.Subsunace Sewage Disposal System•Page 1 of 17 Owner information is required for every page. rsne.09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westhampton Rd. Florence Ma. 01062 Property Address James &Cynthia Faulkner Owner's Name same Ma 01062 05/16/16 Clly/Town State Zip Code Date of Inspection B. Certification (cont.) inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 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: This system consists of a 1500 gal 2 compartment septic tank with p astic tee baffles and a filter in outlet baffle. A d box leads into a 4 leg infiltrator field and besides heavy carry over in d box all levels are correct and no high water marks were observed. 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. Check the box for"yes", "no"or not determined" (Y, 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 exfiltration 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 Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Tie 5 official Inspeo on Form:Subsurface Sewage Disposal S)5Rn•Page 2 of 17 Owner information is required for every page. Sins'09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westhampton Rd. Florence Ma. 01062 Property Address James& Cynthia Faulkner Owner's Name same Ma 01062 05/18/16 City/Town State Zip Code Date of Inspection B. Certification (cont.) 13) System Conditionally Passes (cont.): Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed O Y D N E ND (Explain below): 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 is failing 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 Title s Official Inspection Form Sutsuaace Swage Disposal System•Page 3 of 17 )wner )formation is squired for very page. t5tns•09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westhampton Rd. Florence Ma. 01062 Property Address James&Cynthia Faulkner Owner's Name same Ma 01062 05/18/16 City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 tributary 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, perforated at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or 'j.ess than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 %day flow Title 5()Metal nspeceoo Form:Subsurface Sewage DRpoeaI Syst ff•Page 4 of 17 )wrier 'formation is equired for very page. thins•09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westhampton Rd. Florence Ma. 01062 Property Address James& Cynthia Faulkner Owner's Name same Ma 01062 05/18/16 City/ own State Zip Code Date of Inspection B. Certification (cant.) Yes No ❑ Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z 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 conform 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.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ Z 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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 ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a 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 upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspecton Form:Subsurface Sewage Disposal Systerc•Page 5 of 17 L\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westhampton Rd. Florence Ma. 01062 Property Address James& Cynthia Faulkner Owner's Name same Ma 01062 05/18/16 City/Town State Zip Code Date of Inspection wrier formation is quired for 'ery page. 15:ns•09108 C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ 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 N/A) 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 (arid 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)] D. System Information Residential Flow Conditions: 3 — Number of bedrooms (actual): Number of bedrooms (design): _ — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 330 Tito 501flciel lnspeaon Form:Subsurface Sewage Drsposal Syswr.Page 6 N 17 vner ormation is tuired for ery page. rsns•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westhampton Rd. Florence Ma. 01062 Property Address James &Cynthia Faulkner Owner's Name same Ma 01062 05/18/16 City/Town State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No cif wager 1657 Water meter readings, if available (last 2 years usage (gpd)): Detail: water meter reading 1857 - - - Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? industrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day(gpd) ❑ Yes ® No resently__ Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Title s Official Inspection Form:suosudace Sewage Disposal System.Page 7 of 17 at 'motion is sired for y page. Sins•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westhampon Rd. Ma. 01062_Property Address James &Cynthia Faulkner Owner's Name same Ma 01062 05/18/16_ Citym'own State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped. Iiow was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system 2012 owner gallons presently_ Date ❑ Yes ® No Single cesspool Overflow cesspool Privy Shared system (yes or no) Of 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 I/A system by system operator under contract 0 Tight tank.Attach a copy of the DEP approval. Other(describe): tine 5 Official Inspection Forn Subsurface Sewage Disposal System•Page a of n Commonwealth of Massachusetts R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 WesthamEton Rd. Florence Ma 01062 _— _- --.—_—.—— -- Property Address James& Cynthia Faulkner_ ---_.-_ --- -- Owner's Name A _ 01062 _—. 05/18/16 _—.— Came --' Stata e Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information. 5 yrs estimate —_—.--- --- - Were sewage odors detected when arriving al the site? Building Sewer(locate on site plan): Depth below grade: Material of construction: ❑ cast iron D 40 PVC ❑ other(explain): Distance from private water supply well or suction line. nation is red for I Page 151ns•0903 2.5 feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage observed,_ —.--_._.. —.----- -- Septic Tank(locate on site plan): Depth below grade: Material of construction: El concrete metal ❑ fiberglass ❑ polyethylene ❑ other (explain) ❑ 24" feet ❑ Yes ® No 4 tank is metal, list age'. is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 1500 years Dimensions: Sludge depth: 3 ❑ Yes ❑ No Title 5 Official Inspecnon Form subsurface Sewage Disposal Syste r'Page 9 of 17 Z. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ct-di 573 Westhampton Rd. Florence MaOt Property Address James 8 Cynthia Faulkner —.— ----- --- — -- — r owner's Name k112 01062 05/16/16 tattoo is same Ma — — - ed for ---— ---- — — — State Zip Code Date of Inspection page. City/Town D. system Information (cont.) Septic Tank(cont.) 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 tape 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.): Pumping recommendation of every 2 years depending on use and removal of garbage grinder„ also to clean filter annually 32 3" 10" Grease Trap (locate on site plan): Depth below grade: Material of construction. ❑ concrete [1 metal feet ❑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: 15ins•09108 Otte Ti e 5 INricxI mspec0oo Foam Subsurface Sege Disposal Sysem Page 10 at 17 :r nation is red for page. t5ins•09/00 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westhampton Rd_Florence Ma. 01 ---- Property Address James&Cynthia Fae ner Owner'sName Ma 01062 05118116_ Same ------- --- - --- - State Zip Code Date of Inspection Cttyl1"own D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or bole condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): all Nits appear to be sound and levels are correct,fairly heaves carryover observed In d bor:_ Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete [1 metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No —.. -- Alarm in working order. ❑ Yes ❑ No Alarm level: -- — Date of last pumping: bale — Comments (condition cf alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No me 5 Official Inspecbon For S surface Sewage Disposal System Page 11 of 17 ation is ed for Page. t5ins•03100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westhameton Rd. Florence Ma. 01062_ --. _ ---- --- - — Property Address James & Cynthia Faulkner— — ---------------- Owner's Name same _ Ma 01062 —.— --. _ -- -- _—'----- State Zip Code Date of Inspection City/town D. system Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0 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.): solids carry over noticed but level correct — — Pump Chamber(locate on site plan): ❑ Yes ❑ No Pumps in working order'. Yes ❑ No Alarms in working order. Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): •'f SAS not located, explain why: Title 5 Off icia1 Inspection Form.Subsu,lace Sewage Disposal System Page 12 or 17 L\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westhampton Rd. Florence Ma. 01062 .__.----- --- Properly Address James &C iaFaulkner ed for - -- ---.. -------- -- — — r ownrr's Name r)_nt Ma 01062 05/18/16 canon is same --- ----- - Mate Zip Code Date of Inspection page City/Town D. System Information (cont.) 'Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leachincl fields number, dimensions: overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of bonding,damp soil, condition of vegetation, etc.): No sins of Ilydraulic failure observed tSins-09/08 4 legs 13x24 field 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 ❑ Yes ❑ No indication of groundwater inflow Title 5 Official Inspection Form:Subsurface S w ge Dsposal System'Page 13 M 17 L. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 WeslhampionRd. Florence Ma. 01062 Property Address James&Cynthia Faul ner_ —_--.—.—.— —--- owner's Name same Ma 01062 06/18!16 _ _ _.—_-- --- -- -- City/town State Zip Code Date of Inspection D. 'System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.): sand soil atd box _ — --.-- -------- canon is ed for page. thins 09108 Privy (locate on site plan): Materials of construction. Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.): Ties Official LnspactOn Form Subsurface Sewage Deposal System'Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westham�n Rd. Florence Ma. 01062 Property Address James& Synthia Faulkner Owner's Name same CityiTown D. System Information (cant.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system. including ties to at least two permanent reference nce the landmarks Irks or Check one benchmarks. tLo boxes all below within 100 feet. Locate where public water supply Be E hand-sketch in the area below ❑ drawing attached separately • ation is ad for page. Ma 01062 05/18/16 Stele Zip Code Date of Inspection Tte e OM:a,':ospxt=7mm S.CS✓IZC sswea Dspuat ssreo•Pose a of 7 ler malion is sired for y page. b,ns•09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westhampton Rd. Florence Ma. 01062 Property Address James &Cynthia Faulkner Owner's Name Ma 01062 05/18/16 same City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: 121 Check Slope IEI Surface water Check cellar Shallow wells Estimated depth to high ground water: 5-6ft+ estimate 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: sandysoil at leach area no sump pump Before filing this Inspection Report, please see Report Completeness Checklist on next page. tee 5 Oltival Inspection Form:Subsurface Sewage Disposal System Page 16 0117 Commonwealth of Massachusetts 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 573 Westhampton Rd. Florence Ma. 01062 mer ,rmation is luired for ary page. nms•OS/00 Property Address James& Cynthia Faulkner Owner's Name same Ma 01062 05/18/16 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Z Inspection Summary:A, B, C, D, or E checked H Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Z System Information—Estimated depth to high groundwater 21 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Titles Olrival Inspection Form Subsurface Sewage Disposal SKtm,Page 17 of 17