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86 "Knoll Estates" Septic Inspection 2015 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Eta 0/%4 b&o E ,s7-727c5 Prpm Oij /0/9/9 SC/Y anon is tl for every CiryROxn State Zip Code Date of Inspection Inspection results must be submitted on this font.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. 'antes"e" A. General Information .ut forms computer. ly the tab move your -do not >return 1110 Inspector: /U/c-////r) T 5/6-72-617.77 /0E- Name of Insped3/£/2N P29 .CNG //v EdE, /A/ 7 Company Name /8 /i%e//or 12.04 J,a Company AddresL7I t •sr7 Ciry/ravn orate Zip Cade /3 S5/9 /8/7 Sr /OSC Telephone Number 7 1 ,`s / Lieanae 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 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Needs Furth g uation%he Lo,g I Approving Authority Date ❑ Fails The system inspector shall submit a copy of this inspection report to the Approving Author 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. Title 5 Oldel In 'on Fpm:Subsurface Sewaoe ppo. System Page 1 of 17 •Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments c? O%t ,&)O&t E SzZ .TJ Property Addressn' l l n/it St owner:,Hom /e479/4 mf/eT /1 l/ A ,9 0/060 6400/S C4/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: gl 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.My failure criteria not evaluated are indicated below. • , Comments: Aid P4.o.6L 4..*1 r ' lo,'4 y 5 n / 5 4,..)0/2A-/Ai 40/E-a 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): Tle 5 olftl Y.CNm rmrt subulve S.woo.C spo S SyM.m.P.o.za lr :ommrinwealth'of Massachusetts rift 5 Official Inspection'Form subsurface Sewage Disposal System Form-Not for Voluntary Assessments a& G//k. /6(10/L ST19 /—A" ',opedYAddresA i,� t 4,4 CA/ Jwnefs Namy/,U^0'/'/tn./ . i V Hi Ulg N Slate Zip Code Date of looped;Dirylrown B. Certification (Coot.) 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 ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or supply well. 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 fecal n is coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate r aelys s equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the 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 inspectionsf 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 dogged SAS or cesspool Liquid depth in cesspool Is less than 6'below invert or available volume is less than%day flow iW sGMJJ ri.d^^Rpm Subsurface Sewage Disposal System.Page 4 of >mmohwealth of Massachusetts The 5 Official Inspection Form ibsurface Sewage Disposal System Form—Not for Voluntary Assessments G/Ak_ kNott £st'1!"S ,perry °`° State Zip Code Date of Inspection Rowe Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of limes pumped: My 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. My portion of a cesspool or privy is within a Zone 1 of a public 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 collform 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. The system falls.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,system owner should contact the Board of Health to determine what wiill belie 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 ❑ ❑ Area-IWPA)located mapped Zone I of sensitive area well Protection 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 upgzede.OW system in accordance with 310 CMR 15.304.The system owner should contact the appropriAlp regional office of the Department. The 5 M Oi eY' =gym Fm,n sWMNW swaps Disposal s.Sm•Paco 5 of if rnonAreatth of Massachusetts le 5 Official Inspection Form Mace Sewage Disposal System Form-Not for Voluntary Assessments 84 6/1k 4/tioaL l 'r aName 0/2774- / _(/___@%l State Zip Coda Data of Impecs yMddro pan Thecklist :heck if the folio Yes No Xf ng have been done.You must Indicate"yes'or no as to each of the following: �f Pumping information was provided by the owner,occupant,or Board of Health frit cf/t-11 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? y Were as built plans of the system obtained and examined?(If they were not s o� 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 setic tank manholes uncovered,opened,and the interior of Inspected for the condition of the baffles or t es, material of construction, tank 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 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 15302(5)1 P. System Information Residential Flow Conditions: Number of bedrooms(design): — Number of bedrooms(actual): DESIGN flow based on 310 CMR 15203(for example:110 gpd x#of bedrooms): /50 % dim &s'q-v' /Pr SO /I /1JGS 0-__x Asb Z 9 90 es/on 0 yapNrm run[SuW as Seaga Clapond System'Poes6 of 17 mvieatth of Massachusetts 5 Official Inspection Form ace Sewage Disposal System Form•Not for Voluntary Assessments 6C 6.9 rf 'dress. ./LD4V P/145 Cf/ D6O lame ✓,t/ Stale Dp Code Date of stem Information ;cdption: ember of current residents: Yes ❑ No Des residence have a garbage grinder? laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes$ No X Yes ❑ No sundry system inspected? Yes No 0 ',easonal use? �No Vater meter readings,if available(last 2 years usage(gad)): )etail: - Sump pump? Last date of occupancy: Commerciaglndustrial Flow Conditions: .d Type of Establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seatslpersonslsq.ft.,etc.): No Grease trap present? Yes 0 Yes ❑0 No Industrial waste holding tank present? 0.Yes [a No Date Gallons per day(gpd) Yes.CX No Non-sanitary waste discharged to the Title 5 system? Water meter readings;if available: 70 5 OIAaO Inspection Rana suesu naw amass QISmW Slily".Riau I of 0 nonwealth.of Massachusetts le 5 Official Inspection Form Irface Sewage Disposal System Form•Not for Vdun�Assessments 96 619k 47(10 /r YAddre e/ti .4fi5A S c f/ mu" e Zip Code Date of Inspon ete ystem Information (cont.) ast date of occupancy/use: Other(describe below): Date General Information GU�rN f✓� Co ri'Z Dtorazz%G% ftAQstit r a,), COrn wf, /44 r5/ t6 0 Yes mh No Pumping Records: Source of information: Was system pumped as part of the inspection? If yes,volume pumped: How was quantity pumped determined? Reason for pumping: COLT/124C j gallons Nor A E IJ b o,u pu/vr L4 L - ,efray NO VCnate 56/Jt )z,c.cc TU £ Type of System: ,(J /C/0 t/ , 00/45— Septic tank,distribution box,soil absorption system /' O Single cesspool O Overflow cesspool O Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operati andst ❑ inspection of the VA system bysystemroperatotrunderncontract copy of O Tight tank. Attach a copy of the DEP approval. U Other(describe): TM 5 Official F W.on Font$UN'Ylaue Seal W.Disposal System•Fag.8 N IT ncinwealth.of Massachusetts le 5 Official Inspection Form rrface Sewage Disposal System G 6-�or Voluntary Assessments /0 Su' /o• M- o M,4 a State by Code Data y nda // ;/, pact on ��- iystem Information (coot.) fps q pproxiMate of all components,date installed(if known)and source 99 information: /✓/OCR i r Yes(No Were sewage odors detected when arriving at the site? Building Sewer(locate on site plan): Depth below grade: Material of construction: cast iron 1,E(40 PVC ❑other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, ^ of leakage,: D e evidence feet feet r • Zs/ • Septic Tank(locate on site plan): Depth below grade: Material of construction: ,concrete 2000 G lZL Z cona /912.r Jnaa_ j, Eft trig/2. UN/ r ❑metal O1 feet ❑fiberglass polyethylene ❑other(explain) ❑ If tank is metal,list age: Is age confirmed by a Certificate of Compliance? Dimensions: /0 i4. Y 5 'rCo Sludge depth: years (attach a copy of certificate) X Yes ❑ No 22 rrF on Emit suNURxa sewage Disposal strum.Pages W n tohwealth of Massachusetts e 5 Official Inspection Form dace gO)Sewage /9 sal System FooterVoIUeAssessments S ra a/U 4.9 S (7/ �U/s mXla/_�'A-A pit) MIL 0660 State Date of Inspection ;ystem Information (cont.) optic Tank(cont.) listance from top of sludge to bottom of outlet tee or baffle cum 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 6 2 ,. 2 el i ✓/YJSU/�-On 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.): NO ,012_6/g u?i f ,t>o7 Groan Trap(locate on site plan): �Ai eet Depth below grade: Material of construction: CI other(explain): metal ❑fiberglass ❑polyethylene ❑concrete ❑ �--- 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 TIM 5 CNel rt eubwMw swage Deposal System•Pope 10 Mn inwealth of Massachusetts 5'Official Inspection Form ice Sewage Disposal System Form-Not for Assessment 86 04 f /rti . 6 J kue d& 4 J ,D,A" J L/Y ame/IG��>N�f MD iacSt Ali r State Zip Code date of Inspection 9O/S" stem Information (cont.) structural integrity. invents (on pumping recommendations,inlet and outlet tee or baffle condition, d levels as related to outlet invert,evidence of leakage,etc.): )ht or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): ,0 /Q --- :plh below grade: aterial of construction: other(explain): ]concrete ❑ metal ❑fiberglass ❑polyethylene limensions: rapacity gallons '. )esign Flow: gallons per day ❑ Yes ❑ No Alarm present: 0 Yes ❑ No Alarm In working order. Alarm level: Date of last pumping: Data Comments(condition of alarm and float switches,etc.): 'Attach copy of current pumping contract(required) Is copy attached? ❑ Yes 0 No rmn awoor' s.•+go DIpgfll System'Pogo 11017 nonwealth of Massachusetts le 5 Official Inspection Form dace Sewage Disposal System Form-Not for Voluntary Assessments Sea em,k boots_ xcrnrrS rAn a� ti /AJ2 S MA)N n L PVC elate bp Code Data of Inspecton wn lystem Information (cont.) listribution Box(if present must be opened)(locate on sitan): )epth of liquid level above outlet invert evidence of solids carryover,any ;omments(note if box is level and distribution to outlets equal,any 3vidence of leakage into or out of box,etc.): Pump Chamber(locate on site plan): ,61A-U9 Yes ❑ No Pumps in working order: 0 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): If SAS not located,explain why: 5 CAWS Tyco Sewage Disposal System Psi°12 of 17 ionwealth Of Massachusetts e 5 Official Inspection Form dace Sewage Disposal System Form-Not for Voluntary Assessments 56, !J/1/ - 1&votL C ST7l YES Address,e0 i 11 1 ,149A 5CA j7M-72 /t Al 11-i41 /40 5 c/610 vn Zip Code ystem Information (cont.) ype: 0 0 leaching pits leaching chambers leaching galleries leaching trenches leaching fields ❑ overflow cesspool ❑ innovative/alternative system Typelname of technology: damp soil, condition of Comments(note condition of soil,signs of hydraulic failure,level of ponding, vegetation,etc.): Date ot Inspection number: number number: number, length: number,dimensions: number: /f� rite AiCJ-1E,5 zs xr X 3 it H F/z o rs S rz VA Cesspools(cesspool must be pumped as pall 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 1145 Wadi F ❑ yes ❑ No m Swage Disposal System•Pag.1301 v ionweaith of Massachusetts e 5 Official Inspection Form dace Sewage Disposal System t for Voluntary Assessments 94' cr4k K/ G 7-2i Address eNaNO/[-/ r / F-/Y /4'0 N A 0/0 60 / —'1 G/,.5-- M State Date of Inspection LP Code re � le ystem Information (cont.) omments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, tc4. Privy(locate on site plan): )0 NK Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): na soRaa M+Y�m, im¢sutun.•GMge DepW System•Par a of 17 nmonwealth of Massachusetts tie 5 Official Inspection Form surface Sewage Disposal System Form-Not for Voluntary Assessments a"dre20 ,v pA.9SL e .17/ Vp f-ot/ MM- 0/04.0 Zip Code Town State System Information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least where public supply sup y enters the building. all within 100 feet. Locate lding.Ch ck one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately Date of Inspection 7045— LmZ6.0 iDhoirt laes eaa9 laPectiOn Fom:Sutaueaca Saaaor cg•po SY^tam•.Page 15 0117 wealth of Massachusetts 5 Official Inspection Form e Sewage Disposal System�rm�for Volunt�Assessments air . &9 5-CA/ 'e algth LD%aJ 0/O40 State L ,es tem Information (cont.) Exam: heck Slope i lurface water ;heck cellar ;hallow wells Dated depth to high ground water. DatIn of spection feet .i—`�t ci/z/ Ise Indicate all methods used to determine the high ground. Obtained from system design plans on record atur /IiJ��- 11,G,5/6ti £ free-co S. 1p�j•�/j99 water elevation: 41-77e"^- If checked,date of design plan reviewed: Date kn6 d 99 Observed site(abutting properly/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: ou must describe how you established the hiigh�ground a�elevation: Before filing this Impaction Report,please see Report Completeness Checklist on next page. m.s Stead Lupedlon fOnt%Subsurface SMG.,Disposal Syaern•Pape 18 of n za 7 119 1 1 , C GU a _ % /1, �o,9! � t�'cJ 14) (19 4 ._. - a�___. ._. ___ T ') ' ZY /it* ' k; 5 4 ' 1 X ttx ,i 6 • 4' c� i D. ��� -� . r�`. 1 a .