Loading...
860 Septic Inspection 2015 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma. 01062 Property Address Sherri Kuchinskas Owner Owner's Name informations 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709115 everrequired for every page. City/Town 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. Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. A. General Information 1. Inspector: Ray Champagne Name of Inspector Whiteley Septic Service Company Name 21 Old County Rd, Company Address Southampton Ma. Ma. City/Town State Zip Code 413-527-0057 S14118 Telephone Number License 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 07/09/15 Inspector's Signal e P 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. thins•o,os Title 5 Officer InSpection Form.Subsurface Sewage Disposs System•Paget of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma. 01062 Property Address Sherri Kuchinskas Owner Owners Name information is requ ired for 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709/15 required every page. City/Town State Zip Code Date of Inspection tsns•09(08 B. Certification (coM.) 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 1500gal 2 compartment septic tank with plastic tee baffles and a d box with 4 inverts into a 20x 63 leach field. 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," lease 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): Me 5 Official Inspection Form:Subsurf ace Sewage Dispa yslem•Page2 of 17 Owner information is required for every page. thins•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma 01062 Property Address Sherri Kuchinskas Owner's Name 33 Birch Ln. Florence Ma 01062 Ma 01062 0709/15 cay/Town State Zip Code Date of Inspection B. Certification (coot.) B) 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 ❑ 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 Title s Official Inspection Form'.Subsurface Sewage Disposal System.Page 3 N 17 Owner information is required for every page. t5,ns•D9N8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma 01062 Property Address Sherri Kuchinskas Owners Name 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709115 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, 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: 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 Tele 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma 01062 Property Address Sherri Kuchinskas Owner's Name 33 Birch Ln. Florence Ma 01062 Ma 01062 0709/15 City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Z ❑ Z ❑ Z ❑ Z ❑ Z ❑ Z ❑ ❑ ❑ Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or 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. 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. Tees Orval mspecran ro,m:Subsurface sewage Dispos l Sys em•Pages or I? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma 01062 Property Address Sherri Kuchinskas Owner Owners Name required fn for 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709/15 everyevery page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ❑ ® ❑ ® ❑ Z ❑ ® ❑ Z ❑ Z ❑ Z ❑ ® ❑ Z ❑ 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(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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 sins.09108 Tine 5 Official Inspection For-Subsurface Swaps Dispose'System•Page 6 of 7 Owner information is required for every page. Mum•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma. 01062 Property Address Sherri Kuchinskas Owners Name 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709/15 City/Town State Zip Code Date of Inspection D. System Information Description: 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 Z No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes Z No Water meter readings, if available(last 2 years usage d present meter 9 ( y 9 (9p ]]� reading06122798 Detail: 6 Sump pump? ❑ Yes Z No Last date of occupancy: time presently part Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): canons 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: Title S Official Insperleg Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma. 01062 Property Address Sherri Kuchinskas Owner Owner's Name required fp is 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709/15 every for e. every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use. Other(describe below): presenter part time Date Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the 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 General Information 2013 owner gallons ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Tide 5 Official mspediion Form Subaurlaw Ssrey Dispossl System'Page Oct n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma. 01062 Property Address Sherri Kuchinskas Owner Owners Name information is 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709/15 every required p for e page. CiryROwn State Zip Code Date of Inspection Sins.09109 D. System Information (cont.) Approximate age of all components, date installed Of known)and source of information: 10-15 yrs estimate Were sewage odors detected when arriving at the site? 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: ❑ Yes ® No 1 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 ❑ metal .6 feet ❑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 1500 Dimensions: Sludge depth: The 5 Official Inspection From.Subwnam Sewage Disposal System•Page s of 17 Owner information is required for every page. thins•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma. 01062 Property Address Sherri Kuchinskas Owners Name 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709/15 City/Town State Zip Code Date of Inspection 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 How were dimensions determined? 2 compartment tank sludge judge 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 disposal or non use of same Grease Trap(locate on site plan): Depth below grade: Material of construction: feet ❑ 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 ml,5 Official Inspection Form:Subsurface Sewage Disposal synem.Page 10 of n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma. 01062 Property Address Sherri Kuchinskas Owner Owners Name information for is required 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709/15 ever every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): all parts appear to be sound and levels are correct 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): 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 15ins.03100 Title 5 Official Inspection Form.Subsurface Sewage Disposal System.Page 11 Of 17 Owner information is required for every page. 15ins•O9O8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma. 01062 Property Address Sherri Kuchinskas Owners Name 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709/15 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box Of present must be opened)(locate on site plan). Depth of liquid level above outlet invert 0 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.): levels are correct Pump Chamber(locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No 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: Title 5 olfidn Inspector Form'.sue ge Disposal System•Page 12 a117 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma. 01062 Property Address Sherri Kuchinskas Owners Name 33 Birch Ln. Florence Ma, 01062 City/Town Ma 01062 0709/15 State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 20x63 Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of hydraulic failure observed 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 isms•09/08 Tee 5 OMtiel Inspection Form.Subsurface Sewage Disposal System•Page 13 of IT Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 860 Florence Rd Florence Ma. 01062 Property Address Sherri Kuchinskas Owners Name 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709/15 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) sandy gravel soil at leach area 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.): t5ins 09/08 Title 5°foal Inspection Fora.Substaca Sewage Disposal System•Page 14 W 17 Coaanommalth of Massachusetts Title 5 Official inspection Form Not for Volusstary Assessments Subsurface Sewage Disposal Syste n Form D. System Information (cant) 850 Florence Rd. PrcpeayAddress Florence Ma. 01062 city/tow • sbte Zr Cole S%ta tat.i �((lch ivSkA� Owner's Nara nr.eorap.morm Sketch Of Sewage Disposal System:Provide a sketch of the sewage disposal system inducting tier to at least two permanent reference landmarks or benchmarla Locate all wells within 100 fed. Locate where mdlic water supply enters the beading. Becky Castro nwenceaea• T( Doi SI/itici H Ill P 1 1 The 5 MIS Form Si burb=Same Disposal SYslei Page 15 of*I 9 ISI P MN h � S _ / "r��Y�Nv 3lr d mfr -en -1 V— , vvww7 y .?J soot ( 61 ,(" W - s"1°t ip.,,b hi Papal a7U"1oi� o' _\.b ra s,,, Sb "^vi5�� f S v pe.�1 ---1j \ ii-td x.y of oy a,noi ,-179 lE I . ad wit\ �l„ �°�l £°1 x ,QZ „ 9.ZE 2- £1. „ 9,cZ z- V k'It"0 „-b,6S I -8 , IZ I-V 41‘" s +•}r7Q Wni CV 5santl t/kra-Z s»>y twit — 1 It ,61 ar -"PMahL ( e, ,��11j'{ ..+oei�eaa * 8 /1 J V � p, r q„11 iln v '1"5 °L VN '�'t"IS S?�� 3Y >cO t • "1.1A.V IPE Wr E‘REE =.4D 3 [FRp 12.4$ En Al F' LEACH FIELD CROSS SECTION DETAIL (NOT TO SCALE) w 4 fl CRoWrITO PCEVCNT Pb•DIN6 OF ILAM r' �iic 7��,L/ r, NWwJHK° _ L F MATER Y L �c-. MATERIAL g Dever��PW�(�suEvE "v.. e•© T ¢'➢y„SDe35 P©F.PIPEee•:' S' ... .••e 10-13"OF 3/4--IX'. 4S .IASNW SreNE :..°Ya: CERTIFIED TYtLE S FILL D -22" • EFFECTIVE SIZE OF LEACH FIELD.20'X 63'=1260 SO.FT. • MINIMUM 6"OF 1/4-1%"DOUBLE WASHED STONE UNDER PIPES • MINIMUM SLOPE OF 4"PERFORATED PIPE TO BE.005(1)2%) • BOTTOM OF LEACH FIELD TO BE LEVEL • REMOVE ALL TOPSOIL AND SUBSOIL(APPROX.22")FROM DIRECTLY BENEATH LEACH FIELD AND REPLACE WITH CERTIFIED TITLE 5 FILL MATERIAL LEACH FIELD PLAN VIEW DETAIL (NOT TO SCALE) 63' e4�i44-la',D+ugLE W/SMED$TON E. ' .: •-ro<pp"T 4°DIA,PEeFoom6.0 SDR 35� 4—ENDS OF P60.PIPE CINREC1ED IN 50LID 4'6DR35 . • CERTIFIED Tine S FILL T 5' E15TRIBET10N "SOX 4-"DIA.5D635 PIPE To SEPftc TAWI< • NUMBER OF DISTRIBUTION LINES:4 • DISTRIBUTION LINES TO BE SET4 FT.APART ON CENTER(4 FEET FROM EDGE OF FIELD) • ENDS OF DISTRIBUTION LINES TO BE CONNECTED USING SOLID 4"SDR 35 PIPE AND A 4" DIAMETER VENT PIPE IS TO EXTEND TO 3 FEET ABOVE FINISHED GRADE • BREAKOUT FILL TO EXTEND 15'IN ALL DIRECTIONS FROM EDGE OF STONE DE DE Sl -p40 IBM: 'faP of CtNCREfe-BOUND ASS LIMED L°LEVAfo1F1=IW DO' / 108 / lob SOMAS DAWSON-GREENE P.O. BOX 556 HESTERFIELD, MA 01012 (413) 296 - 4421 t'0 E Plan ?;,x J '__ _ C )— �o�`�he NoNorrtr.. ' of Health (ZPSubjeet to the following conditions: Design Engine.^r not _ and verify in writing ti the sewage dior•oyal syst: was installed in accor -'"'. ' :with these r±»,;ed r'. SCALE 1" - 30 SURVEY: act 3,zoos DRAWN: oct. lo, Zoos REVISED: Owner information is required for every page. sins•O9/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 860 Florence Rd Florence Ma. 01062 Property Address Sherri Kuchinskas Owners Name 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709/15 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water a Check cellar ® Shallow wells Estimated depth to high ground water. 4'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: original sketch Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title S Ofiaal Inspection Form Subsurface Sewage Disposal System.Page 16 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 860 Florence Rd Florence Ma. 01062 Property Address Sherri Kuchinskas Owner's Name 33 Birch Ln. Florence Ma, 01062 Ma 01062 0709/15 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Z Inspection Summary:A, B, C, D, or E checked Z Inspection Summary D (System Failure Criteria Applicable to All Systems)completed Z System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file tains•09/08 Title Si olnam Inspection Fo m:Subsurface Sewage Disposal System•Page 17 of 17