41 Septic Inspection 2010 Commonwealth of Massachusetts
r; Title 5 Official Inspection F
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Not for Voluntary Assessments
Subsurface Sewage Disposal Sysiem Form
APR 2n
Inspection results must be submitted on this form. Inspection fo
way.
A. General Information
1. Property Information:
41 Dumphy Dr. Florence MA.
Property Address
Karen Klekotka
Owner's Name
same
Owners Address
City/Twm
Date of Inspection:
2. Inspector:
Ray Champagne
Name of Inspector
Whiteley Septic Service
Company Name
21 Old County Rd.__
Company Address
Southampton
City/Town
413-527-1835
Telephone Number
State
04/26/10
Date
Ma.
State
B. Certification
n,n re
Zip Code
01073
Zip Code
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. lam a DEP approved system inspector pursuant to Section 15.340 of
Title 6 (310 CMR 15.000).The system: •
❑ Passes
Needs Furthe
Inspect/ode Sig1,t
ure
[] Conditionally Passes
Evaluation by the Local Approving Authority
`rye 04/26/10
Date
4.0614*
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.
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Title 5 Official Inspection Form'.Subsurface Sewage Disposal System•
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cost.)
41 Dumphy Dr.
Property Address
Florence Ma.
City/Town State
Karen Klekotka 04/26/10
Owners Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
01062
Zip Code
❑ 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 1000 gal septic tank , and the tank is below effulent . The tank is 40"below
grade and effulent is 26" above tank in riser. There is no access to other parts of this system.
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 ❑ 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 extiltration 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.
ND Explain:
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Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cost.)
41 Dumphy Dr.
Properly Address
Florence
City/Town
Karen Klekotka
Owners Name
B) System Conditionally Passes (cont.):
Ma.
State
04/26/10
Date of Inspection
01062
Zip Code
❑ 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
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
❑ 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
❑ obstruction is removed
ND Explain:
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
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1":\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
41 Dumphy Dr.
Property Address
Florence
City/Town
Karen Klekotka
Owners Name
Ma.
Stale
04/26/10
Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
01062
Zip Code
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 we11 .
Method used to determine distance:
•• This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
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 must be
attached to this form.
3. Other:
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Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
41 Dumphy Dr.
Property Address
Florence
City/Town
Karen Klekotka
Owners Name
Ma. 01062
State ZipCode
04/26/10
__. _i _. ..
Date of Inspection
0)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 pending 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
Z ❑ Required pumping more than 4 times in the Dear NOT due to clogged or
obstructed pipe(s). Number of times pumpe-
❑ ® Any portion of the SAS, cesspool or privy is b=ow 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.
Any 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 coliform 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.
❑ ❑
Yes No
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.
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Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
41 Dum_phy Dr.
Property Address
Florence
City/Town
Karen Klekotka
Owner's Name
Ma.
State
04/26/10
Date of Inspection
01062
Zip Code
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 dunking 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.
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Commonwealth of Massachusetts
_ = Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. Checklist
41 Dumphy Dr.
Property Address
Florence Ma.
City/Town State
Karen Klekotka 04/26/10
Owner's Name Date of Inspection
01062
Zip Code
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?
❑ E 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(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 15.302(5)]
® ❑
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Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information
41 Dumphy Dr.
Property Address
Florence
City/Town
Karen Klekotka
Owners Name
Residential Flow Conditions:
Number of bedrooms (design):
Ma.
State
04/26/10
Date of Inspection
01062
Zip Code
Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15 203 (for example: 110 gpd x#of bedrooms). -
Number of current residents: 5
Does residence have a garbage grinder? IS Yes ❑ No
Is laundry on a separate sewage syslem? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): present meter
reatl 2-84506
Sump pump? ❑ Yes ® No
Last date of occupancy: presently
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: -. - -
Last date of occupancy/use: Date -
Other(describe):
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Title 5 Official Inspection Form'.Subsurface Sewage Disposal System•
Page 8 of 16
?\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dumphy DR.
Property Address
Florence
City/Town
Karen Klekotka
Ma. 01062
State Zip Code
04/26/10
Owner's Name
Date of Inspection
General Information
Pumping Records:
Source of information: pumper
Was system pumped as pan of the inspection?
If yes, volume pumped:
gallons - ---
How was quantity pumped determined?
Reason for pumping: -
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Yes ® No
❑ Shared system (yes or no) (if 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)
❑ Tight tank. Attach a copy of the DEP approval.
Other(describe):
unknown as effulent above septic tank
Approximate age of all components, date installed (if known) and source of information:
Approx 25yrs+/-
Were sewage odors detected when arriving at the site? ❑ Yes ® No
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Page 9 of 16
SL."‘ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dumphy Dr.
Property Address
Florence Ma.
City/Town State
Karen Klekotka 04/26/10
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade:
Material of construction:
❑ cast iron
40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
45"
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:
® concrete
40"
feet
01062
Zip Code
❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
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:
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
How were dimensions determined?
1000
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Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dumphy Dr.
Properly Address
Florence Ma. 01062
City/Town State Zip Code
Karen Klekotka 04/26/10
—__
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or bathe condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Recommend removal of garbage grinder
Grease Trap (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:
Date
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):
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Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dumphy Dr.
Property Address
Florence
City/Town
Karen Klekotka
Owner's Name
Ma. 01062
State Zip Code
04/26/10
Date of Inspection
Tight or Holding Tank (cont.)
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
Distribution Box Of present must be opened) (locate on site plan):
Depth of liquid level above outlet invert unknown
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(locate on site plan):
Pumps in working order:
Alarms in working order:
❑ Yes ❑ No
❑ Yes ❑ No
florence ladyslipper Novotny.doc•03/2006 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dumphy Dr.
Properly Address
Florence
City/Town
Karen Klekotka
Owner's Name
Ma.
State
04/26/10
Date of Inspection
01062
Zip Code
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:
effluent above septic tank--unable to access SAS
Type:
❑ leaching pits
❑ leaching chambers
❑ leaching galleries
❑ leaching trenches
❑ leaching fields
❑ overflow cesspool
❑ innovative/alternative system
Type/name of technology:
unknown
number:
number:
number:
number, length:
number, dimensions
number:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Hydraulic failure at tank
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?� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dumphy Dr.
Property Address
Florence
City/Town
Karen Klekotka
Owner's Name
Ma.
State
04/26/10
Date of Inspection
01062
Zip Code
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
Comments (note condition of soil, signs of hydraulic 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.):
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fbrence
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cost.)
41 Dumphy Dr
Property Address
Florence
City/Town
Karen Kiekotka
Ma. 01062
State Zip Cale
04/26/10
Owner's Name
Date of Inspection
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system 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.
o
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cunt.}
41 Dumphy Dr.
Property Address
Florence Ma.
City/Town State
Karen Klekotka _ 04/26/10
Owner's Name Date of Inspection
Site Exam:
Slope S/aht
Surface water ,vOZ1--
Check cellar e7/0-1"
Shallow wells ,'07t-e--
01062
Zip Code
Estimated depth to ground water: v'O
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 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:
You must describe how you established the high ground water elevation:
observed sight , no sump pump, sandy soil area, new design plan
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