324 Septic Permit & Inspection - A
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CHECK OR FILL IN WHERE APPLIC.
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet �n. Total leaching area_ sq. ft.
Other Distribution box ( ) Dosing tank ( ) -✓` /_f/c c •
Percolation Test Results Performed by Lf Date t-'� `� .. r
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water - J
Test Pit No. 2 minutes per inch Depth of Test Pit Deg[h to ground water
A. H
9U FfF rj it
if �Natr of epais•gr alteyations—Aswer wh , spli rs n a
Agreement: i
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by he.board� th.
si ., _l i s/Xl /�. ;"/.-
Description of Soil
Application Approved By _..%� ` `T/1"-)
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pam
Application Disapproved for the following reasons l/
by
Permit No
Date
Issued.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Qirertifirutr of ( umplianrr
THIS CE IF/YgT he I :v" al Sewage Disposal System constructed
at 3Y'✓..._ saner y'..Yf....4.....�LF -'�- .
has been installed in acco dance with the provisions of TITLE,. 5 o Tr�-e State Sanitary Code///s d in the
application for Disposal Works Construction Permit No / ' — i t dated 41 Or
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RANT THAT THE
SYSTEM WILL UNC ON SATISFAGCJORY. 'F] 'ny— �J `
DATE �..LL /9 0 ^ Inspector J�f=�-" �--- Tt^-' --
or Repaired
No.._/q"..1 C
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.1 .0F NQRTHAMPIJ\
fispusak
Permission is hereby granted
to Construct ( ) 05^R r (y)
at No
as shown on the application for Disposal
t J ! % ter
DATE -.�`L'
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urts fturnittilnrtiun tirrmit
Inds idu Sera e Dispo t®t
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Works Construction Permit Np;_/1"" Cj.//Dated CCIS
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FORM 1255 A. MYSULKIN, INC.. BOSTON
COMMONWEALTH OF MASSACHUSEI'I S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address. 324 Audubon Road, Northampton, MA
Owner's Name: John Parsons
Owner's Address: PO Box 534, Leeds, MA 01053
Date of Inspection: 8/12/04
Copy to: Board of Health, Northampton• Pat Goggins
Witness: Number: SSDS-922
Name of Inspector: Thomas S. Leue
Company Name: Homestead Inc.
Mailing Address: 1664 Cape St. . Williamsburg MA 01096
Telephone Number. (4131 628-4533
CERTIFICATION STATEMENT
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 septic system condition must be evaluated and classified into one of the following four conditions:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
The system condition: Passes
Inspector's Signature:
Date. August 12, 2004
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health
of DEP) within thirty(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 to the buyer,if
applicable and the approving authority.
Notes and Comments
****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 Inspection Form 6/1512000
page 1 of 9 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 324 Audubon Road, Northampton. MA
Owner: John Parsons
Date of Inspection: 8/12/04
Inspection Summary: Check A, B, C,D or E/ALWAYS complete all of Section D:
A. System Passes:
Y I have not found any information which indicates that any of the failure criteria as described in 310
CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments-
111 System Conditionally Passes:
N 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, or ND) in the for the following
statements. If"not determined"please explain.
(1) N 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. The system will
pass inspection if the existing septic 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:
(2) N 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 by the Board of Health). _ broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
ND explain'
(3) N The system required pumping more than four 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
obstruction is removed
ND explain:
(4) N Other: explain:_
C] Further Evaluation is Required by the Board of Health:
N Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the 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 5 Inspection Form 6/15/2000
page 2 of 9
Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
324 Audubon Road. Northampton. MA
John Parsons
8/12/04
2) System will fail unless 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 I 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 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 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 either "Yes" or"No" as to each of the following for all inspections:
YES (Y)or NO (N)
N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
N Liquid depth in cesspool is less than 6"below invert or available volume less than 1/2 day flow.
N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
N Any portion of the SAS, cesspool or privy is below high ground water elevation.
N Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
N Any portion of cesspool privy is within a Zone I of a public well.
N Any portion of cesspool or privy is within 50 feet of a private water supply well.
N Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply with no acceptable water quality analysis. [This system passes if the well water 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 5 ppm, provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
N The system fails. I have determined that one or more of the above failure criteria exist as defined in 310
CM 15.303,therefore the system fails. The system owner should contact the Board of Health should be
contacted to determine what will be necessary to correct the failure.
Title 5 Inspection Form 6/15/2000
page 3 of 9
Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
Property Address: 324 Audubon Road, Northampton, MA
Owner: John Parsons
Date of Inspection: 8/12/04
E] Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd.
You must indicate either"Yes" or "No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
YES (Y)or NO(N)
N the system is within 400 feet of a surface drinking water supply
N the system is within 200 feet of a tributary to a surface drinking water supply
N 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 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.
PART W CHECKLIST
Check if the following have been done. You must indicate "yes" or"no" as to each of the following;
YES (Y) or NO(N)
Y Pumping information was provided by the owner,occupant or Board of Health.
N Were any of the system components pumped out in the previous two weeks?
Y Has the system received normal flows in the previous two week period?
N Have large volumes of water been introduced to the system recently or as part of the inspection?
N/A Were"as-built"plans of the system obtained and examined? (If they are not available note as N/A)
Y Was the facility or dwelling was inspected for signs of sewage back up?
Y Was the site was inspected for signs of break out?
Y Were all system components,excluding the SAS,located on site?
Y Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of
the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum?
The size and location of the Soil Absorption System(SAS) on the site has been determined based on:
N a) Existing information. For example,a plan at the Board of Health.
Y b) Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [15.302(3)(b)].
Y The facility owner(and occupants,if different from owner)were provided with information on
proper maintenance of Subsurface Sewage Disposal Systems(SSDS).
RESOURCES:
Department of Environmental Protection,Western Regional Office,436 Dwight St., Springfield, MA
01103, (413)784-1100;Title 5 Hotline-(800) 266-1 122
Title 5 Inspection Form 6/15/2000
page 4 of 9 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C: SYSTEM INFORMATION
Property Address: 324 Audubon Road, Northampton. MA
Owner: John Parsons
Date of Inspection: 8/12/04
RESIDENTIAL
unknown
4
2
Y
Y
N
N
N/A
N
continuous
FLOW CONDITIONS
DESIGN flow based on 310 CMR 15.203 (gallons/day)
Number of bedrooms(design)
Number of bedrooms (actual)
Number of current residents
Is there a garbage grinder?(Y or N) _
Is there a Laundry Hookup? (Y or N)
Is the Laundry a separate system?(Y or N) (If yes, separate inspection required)_
Seasonal use(Y or N)
Water meter readings, if available (last two years usage) (gallons per day)
Sump Pump(Y or N)_
Date of last occupancy_
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft, etc.):
Grease trap present(Y or N):
Industrail waste holding tank present(Y or N):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):—
GENERAL INFORMATION
Pumping Records
Source of information: pu ped fall. 2001. says Owner
I Was system pumped as part of the inspection (Y or N)
If yes, volume pumped: 1500 gallons--How was quantity pumped determined? Pumper says
Reason for pumping: pre-sale agreement
Comment:
TYPE OF SYSTEM:
X Septic tank,distribution box, soil adsorption system.
Single cesspool
Overflow cesspool
Privy
N Shared system(Y or N)(if yes, attach previous inspection records,if any)
Innovative/Alternative technology. Attach copy of the current operation and maintenance contract(to
be obtained from system owner)
Tight tank(Attach a copy of the DEP approval)
Other(describe):
N Were sewage odors detected when arriving at the site(Y or N)
Title 5 Inspection Form 6/15/2000
page 5 of 9 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
Property Address: 324 Audubon Road Northampton, MA
Owner: John Parsons
Date of Inspection: 8/12/04
DISTRIBUTION BOX (located on site plan) ("D-box")
Y D-box part of septic system: (Y or N)
O Depth of liquid level above outlet invert
Comments: One d-box found, but only 1 pipe in and 1 pipe out
SOIL ADSORPTION SYSTEM (SAS): Technology Used (located on site plan by estimate):
leaching pits & number:
leaching chambers and number:
leaching galleries and number.
Y leaching trenches, number,length: one trench found at 50 ' long
leaching fields,number, dimensions:
overflow cesspool, number:
innovative/alternative system, Type:
Comments: (note soil conditions, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
No surface problems seen. System appears small for this house
but additional leaching area may be hidden.
If SAS not located
explain why:
'TIGHT OR HOLDING TANK (tank must be pumped at time of inspection)
N Tight tank part of system: (Y or N)
Depth below grade (inches) Measured
Tank width (inches) From Plan
Tank length (inches) From Plan
Tank height (inches) From Plan
Calculated gross volume (gallons (-alcu)ate
Materials of construction
Design flow: gallons/day
Pumps in working order: (Y or N)
Alarms in working order: (Y or N)
Date of last pumping
Comments: (conditions of inlet tees, condition of alarm and float switches, etc.)
PRIVY (locate on site plan, if any)
N Privy part of system: (Y or N.
Materials of construction:
Dimensions:
Depth of solids:
(soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation,et
Comments:
Tide 5 Inspection Form 6/15/2000
page 7 of 9
Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
Property Address: 324 Audubon Road, Northampton. MA
Owner: John Parsons
Date of Inspection: 8/12/04
CESSPOOLS (cesspool must be pumped as part of inspection)
N Cesspool part of system: (Y or N)
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(cesspool must be pumped as part of inspection)
Comments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation
GREASE TRAP (Usually present in certain commercial systems)
N Grease Trap part of system: (Y or N)
Materials of construction:
Depth below grade (inches) Measured
Dimensions:
Depth of solids layer
Depth of scum layer
Top of scum to top outlet calculated Inches
Date of last pumping
Bottom of scum to outlet. calculated Inrhe-
Scum thickness (inches) Average
Comments: (recommendation and conditions)
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
(Source of Information)
36 Estimated depth to ground water (inches)
Please indicate(check) all the methods used to determine high groundwater elevation:
Obtained from system design plan on record. Date of Plan:
Y Observed site(abutting property/observation hole within 150 feet of SAS)
Y Checked with local Board of Health-explain:
Information: Based on groundwater found in deep hole perc test on adjacent property.
Title 5 Inspection Form 6/15/2000
page 8 of 9 Homestead Inc.
distribution box •
North \ septic tank
4 leaching trench
a g3
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Garage Notes:
No known drinking water sources within 100' radius.
Additional leaching capacity was remembered by owner, but not located.
\ — .
COMMENTS:
Recommend pumoino on a 3 to 4 year schedule. Also, a copy of this plan posted in the
basement/utility area would keep this information accessible in future years for maintenance.
As-Built Drawing Date: Owner:
A HOMESTEAD INC.
Existing Septic System 8/12/04 John Parsons ` Thomas S. Leue R.S.
324 Audubon Road
Scale: 1 : 20' Revision Date: Leeds, MA 01053 / 1664 Cape St.
\ Williamsburg,MA 01096
Except as Noted yrv4s 14131628-4533
•
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
Property Address: 324 Audubon Road, Northampton, MA
Owner: John Parsons
Date of Inspection: 8/12/04
APPROXIMATE AGE All components, date installed,and source of information
Septic plan: 1977 system with new leaching facility about 10 years ago
Source of Information Owner
BUILDING SEWER (located on site plan)
18 Depth below grade (inches) Estimated Average
12 Distance in feet from private water supply well or suction line
PVC Materials of Construction
Comments:
SEPTIC TANK (located on site plan)
Concrete Materials of Construction
14 Depth below grade (inches)
0 Riser depth (inches)
59 Septic tank width (inches) Interior di monad nn@
120 Septic tank length (inches) Interior dimensions
58 Septic tank height (inches) Interior dimension
1,782 Calculated gross volume (gallons) calculated
9 Air space in tank (inches)
1,500 Net Volume (gallons) cal culated
22 Baffle depth (inches)
5 Sludge thickness (inches) Average
1 Scum thickness (inches) Average
31 Top Sludge : Bottom Baffle (inches) calcur aced
12 Bottom Scum : Bottom Baffle (inches) calculated
7 Top Scum : Top Baffle (inches) calculated
Comments:
Outlet baffle somewhat eroded. PCV tees should be installed in next few
years in case baffle starts to fail.
Recommendations:
PUMP CHAMBER
N Pump part of septic system: (Y or N)
Pumps in working order: (Y or N)
Alarms in working order: (Y or N)
Comments:
Title 5 Inspection Foim 6/15/2000
page 6 of 9 Homestead Inc.
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.
t ns.3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
324 Audubon Road
Property Address
Claudia Sperry
Owner's Name
Leeds
CM/rown
MA 01053 4/7/2014
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:
Thomas S. Leue
Name of Inspector
Homestead Engineering Inc.
Company Name
1664 Cape St.
Company Address
Williamsburg
City/Town
413-628-4533
Telephone Number
MA
State
SI-130
License Number
01096
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:
® Passes
❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
�trO.e.a-o S April 7, 2014
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 under
the same or different conditions of use.
Title S Official Inspection Form'.Subsurface Sewage Dsposa System.Page 1 of 17
Owner
information is
required for every
page.
(Sins 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
324 Audubon Road
Property Address
Claudia Sperry
Owner's Name
Leeds
Cityfown
MA 01053 4/7/2014
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:
® 1 have not found any information that 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:
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 tot 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):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval
if pumps/alarms are repaired.
idle 5Official Inspecton Form Subsurface Sewage Disposal System•Page 2 of 17
Owner
information is
required for every Leeds MA 01053 4/7/2014
page. City/Town State Zip Code Date of Inspection
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
324 Audubon Road
Property Address
Claudia Sperry
Owners Name
B. Certification (cant.)
B) System Conditionally Passes (cant.):
❑ 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 ❑ Y ❑ N ❑ 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
5ns•3/13 lltle 5 Official Insgdon Form Subsurface Sewage Disposal System•Page 3 of 17