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123 Title 5 Reports 1999, 2015 r+ I, 1.. 1 ...,I 06/.6/6 pasTAa2 • Ms 41ip 'ya) 630/�/oM /OtOV ,v� -' 7 -.m a r ' fl"g f rra , 7')(et- 1- ,7f AS 7/pc ntcw S1N313W03 ONV 5310N AIIm11111a buIAmddu alp pug .Ig30lldde p 'I.Anq 510 at las sepia pus ammo tunas . N0.n tun N pino4.IsuIOpu.ql uupagoy 111uuulue4AU3 l0 IUUw11aJ.0 u411 Io 30910 LualB.l.I.pduldds s41 0l Poda.sql mans Wq•_ IWM.u1s1M..4$pa Am adsu!•41'magi lu pd!000•01 l0 man udp.p u 11111 14)u,.1sA•pinup 5• alas M0 p •uopasd.ul.NI eu1ndwoa 10.Asp los) ANNI uNIPNd3010 gasp to pWoml Apimpnv Bulnu.ddv 410 uI NwLII uu0asdw1 qg AJoa• 1lwgn.p.qs 1a.o.dsui w•ISAS•41 6 6/i rA wU :. gmdll6.,1010.•011 Agw,nn ul ad - v rvau 11 AB a n31 Ilnd.puN c.1..J Ap.uoppu03 •.nAll uql u1.A.plsodgp ammo.LagoAl to a.l.ldw•.55I Nsuwo. 'an II m.l•a P.POd la"00804"010160111 OHO Pkiu • ..•1030 •1w is .nw•As la audit'',.BUmu. ..11 P.la.dmll AII•Uau.d SAS41 nun Al1PI.I DEfilinValaniMME -r'etrp tsr y`,, 07 0 Toy par onto,do 7/f -» pv S.n 7r9iv9 Shay's' *4 N.1..110, J 111W:I 111 11 t, •1111 1•• wk... •,g .^.N' .1 amino,w d //u.u1.A.pa•. Y JJO•al 94, ntirw% /a,iariz *'r/r1 IugW...I W1aaWd64,,a.aN b6- i?sL _a's ewo0 a3 roe sr/ . w1^ 11u. .4p S �µ• l u." N 5.440 nrw 0-100/0-100/0e :.n4pv Alud.a rn � 'd71'S" Nl11IV:11J1111]:Idr/►?OO eves* .9 re/ V IUVJ Wa1J NU11JjJSNI flu I S A5 IVSf1145111 SUUMJ5 LIVJN11YwIS l4udi.9wvloD .ou.•AUu1 minas.a ONVO Limn is,'DULL 0411W hatSAaB 3YOO 100111. 1 09'i•J tine, it Iw U11140 VI. ❑ •112111 I 1311.1 u II1JLNIA1 d■u NOI.60'.L011.I 'IVJM:01N0111AN'1411 INAW1.11VJ80 �,� 6�6� SHIVJAV IVINaWWN(RIL N I At 111J11) ':IAII11J;IX'.I - 1 It SI.I:JSIIIf 1VUbv(V '111 II I ivamNUWWII',) 2I• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icadkendl Prplr4 Address: /_„3 /ZP/7/c' /h.A4/.41c Ce % ,3 sest_e� / Owns. tr. .5c. 41/ O FF F G.✓ .t_J Daft w;rtp..ti a J`/a//YES NBPECj1DM summer: Cheek A, B, C, or D: A. BY�TBI PASSES: i w: ' 1 have no found and Information Indlosl which Indicates that env of the failure conditions described In 310 CMR 16.80'rd,eflb4 ' anted*net sveWeted are Indicated below. L SYBT9S CONINTIONA&LY PASSES: (/ N4 One or mere system components es described In The "Conditional Poi esetion nod to be rearmed at rapaked,i:The earrpMdsn of the raplovement or repair.es approved by the fiend of Health. will pass. Indium/yes,no,at not determined IY. N.or ND). Describe bogie at detsrminedon In ell instances. If'net date The amnia tank Is metal,ualesa the owner or operator hes provided the system knpacter„wIN, CompIwe(attached)indicating that the took wee Installed within twenty 130)yens white the septic tank,whether in net metal.Is cracked.structurally unsound,shows.ubf sRIIS InNu Sum M Imminent. The system wet peso Inspection If the existing septie tank is r. N d,Yy1 h a operand by the Board of Health. Sewage backup or breakout or high static water level observed In the distribution box Is due to MS" or due toe broken,settled or uneven distribution box. The system wM pan Inspesdon If(with HSth). broken pipelel ace replaced obstruction Is removed distribution box le levelled or replaced The system requited plmpMBmon than fan times•year doe to broken or obttlu:t d pipelst. The•ypinlf Inepeotien If Iwltlt approval of the Bond of Haelthi: - -• broken*sliders replaced obstruction Is removed pad,9/a1 Pepe:er I t SUBSURFACE SEWAGE DISPOSAL SYSTEM NEPECTION FORM PART A CrATNCATNIN Icondnuedl SC /1/{ .es: /,(/ /GP 3 zen2 iyrPr/ ,p cav S7 5 99 C. FURTHER EVALUATION a EY THE BOARD OF HEALTH: ,j�' N ._ CMNIINN mat with rewire further evaluation by the Board of Health In order to determine ll the system LL BuESSDNITIOasety and the envIromnent. 1 $rYSTNS Will PASS MILERS BOARD Of HEALTH DETERMINES N ACCORDANCE WITH 710 Mt T '( NOT HEICIINAl10 N A MANIER WINCH WBL PRDTECT THE PUBLIC WALDO AND BAIUIY AND (� - Cesspool or privy I.within 50 feet of unlace wow Cesspool or privy is within 50 rer of•bordering vegetated wed.nd or•sell marsh. /7/0 J C • ' a•v4 :.SYSTW.1NRCI AL'iUMHS THE BOARD OF HEALTH LINO PUBLIC WATER SUPPLER.i ATM. sF UNCT �N A BM/NETI THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 1 IONBp..- -.. Thew/Lem her•'Roth:Wilt and soil shoorpEon system(SAS)and the SAS le whit 100 feel, t i •vlesewnu supply. et �tTh Jw�atmist teak;end PUP•bemption ty.um and the SAS N within a to lSE _a fpda tent NW sot Wempdoo!Ham and The SAWILBNMn SO t •841011usitssptsoll•bee1Pdon system and Ws,SAS It)aes WasA weB,u Isw•pN wake anSyshl for coflerm bw1Ma rid 0elutien from that fealty and the presence of emmonle Stumm' ° the ljppn. Method used to determine distance • Ippeolnrdrt not yid). OTHER vv. a.St;I 1110 19 alkl .`:,,u14:;.' Sa•Y n ry y .. _ . .. .,,.,..`�„( 9111YY'J OLC NW•eu•pwao•uj w.uM eyleptldn'I�.YIr., y� i �: .•_. '. ry'.� ....4,; ....Iy, ,.,wP.ee4•P.M M wilMUO ea ee0pw.usi.4.rn ..,,j . AJ .. AI4nJ'NMr'NIAuM►•wlxw.q Awln�p',Pml • �' 4 '+.. -r, r ' *pans uaM e:IIgWT manias•lO IOM OOY dpnp M " 1, fSV°r S. r x 4✓ $' ep..*ejjpw0,G4MOlp1 0411e JAW iei he ..... v y!, •Y ts'atlIle • rx IuuMf oamrl mews lO OO OOL e Mai(1KI*.10M, • 'k A w ,'I ne•q..IIMpo WI e1 uosw,.u1 ..Oa1I r.^ A SI :OUlMese1WWig M W.:. ge r,1 l/ I ' • n J A: '.NAN pus u• ONN rpewea vpwoeuwe•••• iO• 'oI.A n r .04°SWApu.u.WYWNMWIN ., y 1.1l_' LfA.: A• J 1.0109u.gl aM 010 1011 .. 001 un000•1. Mpi ogooe..A.' S t h �NM Apsm aI.M.1tslw A le Ie1 0s UNIIM 1I Mpe a paN..d• '" -, x •PM'Nod•la •uo=.uNiM l Ape M pedaedr , i"wri I:N� 1 , � ,•A .._.,. 1.;;4%illtiftlit JO Arlen IMAM.*•1ml•to I.•1 001 lMI•q AApe m poets.*.le " ' NSN WI M•1•q q Mpe w potlwo•wM•AS wpewW y ryes WI e "/ G:: J 'A''iA ,V ✓' kxSW posonneq• M I •eP RIN m•A I••1 an 1.•••uw•mop wow �AI +y l'7101 ' / �1�41•ts1 M•wfIOA.agpA•Io u.AUI MOpq -.u•y1•.M•I paetsts M AJf'I'4,_ r I • • ' so pap••••••w M•np u•AUI(Mule•AOg•••q wfngp•p WI ul NAM S y, 1 . t � � r f O .,. .0.K weM•• l••10 punols•4110.elm••y1 at Iuxyl•to sugwoe a ,1 {miff p•p•M•••us spat*ymweuao wMWa.1.Na..amq Sams . . -✓4n � r ; omit TTT �Y gl P.ielwo W PdW 4p•14 a Pagq WA 'MO•q v..l,ly'. :' $• IGlS a ep•.wfpwe°.mpq SUIMesel.gflo•ww w.Yt. ..}ti ...r .,L.S..Ae n, :BOIM•SO/•IS JO Wi.CI °N.je:04A• 1" s � ye .' ",2 c? t�ant/ Z/C/a7� « 'A ' ' -wrr•. IP•I•000al NOILV31111183 :.t;: ` ; v ♦i�{�� Y11We . 4' .. ac ..We NMLO3esd rF11lAS 1VIOJSO 3IVM3S 3OYAWISMs % ._ vaA•W!*Ara.':.. Wit 9 5E jj 9 1 � '? r evr n + wcrti .. r A�4 /WC • aFAx' ` 1 ,h v'AW +. r • qw tr y ggar •PpotnAalleow,eoq man,11 ndnMmoo' <` g� M / uaq •• b In of pme iVNPe unties oyl to Aw 111 PIW WR ,rt* f r^ ++44 w FYt F Y l� v 96 Gya, 1 ' oeeq nY Hlo Wluo°W" , —.--.- W.N1(df10♦11��dwp"P 10W ow p.lomodririe _ Thor, r 4'« wil rF $/ ! 'Sung woq pg4'woleA9 wPegegV 1NB 4131ge� xRv Y r i r f y fl �� ...r, .. ...w 'way*mum Mpnpui o Aw,nww•uw MM»«lod'Dog. "' A., •'rte. 'dn.eaoq oeexoe lull.1o/PolosJiy a•`eo.l►ao ?A101e�o4.y1 �t ti > 1 10N 400u olgoOOAs 100015 A•1010 ot0N lingua/1a Ow Pouplgo u••q MW weld 1011,11113,1',1' +wt.«w+.y. 1 Woq wu oAW Mlex�/o nwnW oeni 'pMbd IpNr § eY ..-M..ri-.w... ipogagileo/Yao/Viird uoolwww wMoiOwMw>1wpAi tll{ .r'n.Rq 1 §wr. k YO Si x- '4�1ow11 to O�Y m 7wOnaw•nuw,o 041 A9 WPHold amt_byxuie f i r^ Tf A9 f 4 t .e 1 �1i5 le you of wo 0N. to ,S'A.«WIN goepq Hnw mA nwy uaq s-i r �� :r ) n.,rr•.v/d tr /noay3Y/✓/9' d 4-;,it 180)133143 81YVJ J . Viiine utmost=MINAS 1V*OJ9a3DVM3833VJIN188n9 �ry L5 SUp14 C6 SEWAGE OISpOSAL ST PART C SYSTEM'FORMATION v. SCFH /e ,t7r,g /...) 42/93 /u r`2 /7t,p/70a[u S /' .. ., u,_&_v co Ai i2 .9 FLOW CONDITIONS /7o AI ,Number of bedrooms InurNL•_ • Ir II We;sepuMekr.Feoten.npdred two Ysr'e wogs MpdI: ri, r• /wr I Sod on 15.2031 GENERAL INFORMATION • ...- ....r.,...:: ...'�, as"obsession system �ljynt F�Ipg1IIFIFIDI 1npecdon records.1/.nyl, Y,�4 }?dEM*Petition is mSntmuroe COMM' . _ nhW'source eM1Wme 10N.elgi or nos_4(49 Psp f of O SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icamiarodl /%O /Le/% ,c /24-14 ic1 .i/� c_e ,at, N DMNbMew gM.:_8 y r.4 c a{aorgtmedent_cast lion_00 PVC_Wm.lexplelnl rI '- 2 f✓q/9S0rs /re in 4 //J o xrrpuedent ft onmau_mood Flbargas. _Polim hYI•n•_o h•rb.plant ;Bat spa_ issue aonlbmed by Certificate of Compliance_IYeo/Nol r..or S X . ' (on' /=L uw C/ 40 .to,bottom of outlet us or b.fam /0 I, /okra Ce 0� •�`., ,r, . • vs c✓..2.0 lop pl"PIM 10 lop of outlet ue or baffle: .0 r, suet,a I. hsawn to bottom of outlet .or baffle: /C 2$ 7 Z- azep .were Agwm d: /'''e4 S GitiQ /tau/ Go " water supply wM or suction AM N JfJ ti .C L. alpnts.venting,evidence of Inh.Sewto.1 4 -nnr /.v 9mod r '-g .o/ /p7e4/ s,; 01 l end outlet Ian Gebel/Bs,Copt of flquiff level In -00 C- smart._meta_Fiberglass _Polyethylene_othnlnplMnl condition of Inlet end outlet tees or baffles.depth of WNW level In relation to /4 8 Pam 7oftt SUBSURFACE SEWAGE DISPOSAL SYSTBS.NSRCIM si PART C SYSTEM INFORMATION(esnSrmnd) (7 Sc,v / dC/C /Ps /l- ' „rue Jn et/ 3"I� - 99 ass*must be pumped prior le, or at time el.Mupsetlen) A 4 ate metal Fiberglas Polyethylene other/explain) of Sant end goal switch...eta.) , of solids carryover,evidence el Aal(ape nto.or, SUBSURFACE BEWARE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM MFORMATNM leandrual gyE11T n_ 4'? /* .'Agooa r f/c ts .thins rem so J ♦�FE 91"17,7"." f- 3 — SYSTEM ISASI _ (Hest.M Nb p1w.It po..TM;excavation not required,beedon may be epprodmeled by non4nVUdve meUmd.J 1 lomat explain: L.6Se,? r Stan wI/.E is .•R:nnber:_mitrekos,numbs._ rle.!!NlMamsonea.amber.length: . �t/,vr// N glfal BNd. number,dim.n.lon •�/ : ey«bty ewp.ol number: 8 `(/I(J J'I/ / •. A ;l Nbra.0 Nseagoing echnology: de/ /OGd+ Gl.f/er� /. eeniYen of moll,signs of hydrwIe IWur..towel or pending. demo.on.condition or v.p.t.tlon.etch)I '-' 1Ioli .2 .7a∎.I7.alr. • rotrtente {t.k.wC«i. must be pumped as pen of In.p.ctlonl �ep�tT lyrl.of hydraulic ISw..levsi of pending.condition of.v.pebtlon,e1o.) of hydr.Wc Mum.lama of pending, condition of vegetation. ono./ eyiS ed 9/2/98 Pose t.ru SUBSURFACE SEWAGE 0WP0SAL s1107eq sIMUT10O F PAxrc SYSTEM NFORMATON Iemfnrod) er="zidc;err 0% Lhwi p..mrNM microns..landmarks or benchmarks 100'Mood*whom public wolar supply coma Into houm, to100-27 /072 1r✓r 'V IC72 '0 /G 1� /1-57' /1/z C)" fto SUBSURFACE SEWAGE DISPOSAL SYSTEM IMWEICFpIS.. PART C SYSTEM INFORMATION toomb.edl d Asia oo k/ Ff ic-t e1" news Sic.NiifEL/AJ S—�i— 99 Mod Nedve oar - viols- .tar Fast to r/ wad to daswMm High Groundw.wr Elevation: inner milord / t a spotty,observation hole.basement sump mte.l 719/,, &,. dons /f-d8 8at,r X-8o e•' 80 -rho et.;' of heath listeners Ow High Groundwaw El.vnlon. Iila;be oomph/ten) Pap II of II � m COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA II'21oe 10191 292.5500 ARCED PAUL CELLUCCI Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM S ' PnnTn CFRTIr1CAT ION JUN 4 1999 DAVID B.STNUHS Commissioner hi Property Address: . X77 /�U Ci rt/ J'7 Name of Owner ; ' ')Cella le/CC Cr/A/ r/0/t/ Al c iv% i% 7 Address of Owner: /0)ri alPAPODONS, sr Dote of hupection: /1-71V12/ v/ / '799 j P/ditJ JO I M Nene of Impostor:IPleese Feint) a//lc, / / /n / , /2 %/9 lr E P.1 am•DEP approved system Inspector pursuant to Section 15.340 of Tide S 1310 CMR 150001 Canpany Nome: _ 15//Y7ZL2 /79 F'71/C//c/ P!/>/7C/ Malang Address: _ S2-G 077/41/7a .Pd //e'<-y e' !moo A q/J Telephone Number: __ _ . . 9/3 :S7a A5-:},3- CERTIFICATION STATEMENT I certify that I have personally Inspected the sewage disposal eystarn nt this nddreee and that the Information repotted below Is true,saturate and complete as of the time of Inspection. The Inspection wee performed based on my (mining and experience In the proper function and maintenance of on site sewage disposal systems. The system' ✓Passes �vP/Q4nF i aitOXI It O. /C y Conditionally Passes /{• 'Coq..a d ,.-, t#I Needs Further Evaluation By the Local pprf plunge /� 4,� D Fails / F' Inspector•Slgn lyre: The System Inspector shall submit a copy of this I pection report to We Approving Authority(Board of Health or DEP)withln thirty t301 days of completing this Inspection. If the system Is a ehered system or has a design flow of 10,000 gpd or greeter,the Inspector end the system owner shell submit the report to the appropriate regional office of the Department of Envhonmental Protection. The original should be tent to9N system owner end copies sent to the buyer, it applicable. and the approving authority. NOTES AND COMMENTS QC/J4 /f YYP 6t/ s' .� Cre/v.t7/77Cit/ C), O/3i f='/tip J`7✓4../% 7-7rt-ce i-ec�i �6 cc, ie_en c /o•>I rc� ore//2 /o,:y p y✓, // _ 3 //te •C-5.1/ ...j s / // lP cl/ C7 2 r ZO revised 9/2/98 pxgr l ofll Ott-5' G /0/ 11: 17q! 1111:::124'. :ANw . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Iconlinoedl Property AI/dress: /%J end ADO c) sr a%.vm - eve N/1 Dwyer: T Se s/i g n,e c c/"/ Date of Inspectipn: r/.1/it 9 MISPEC OON SUMMARY: Check A, 6, C, or O: A. SYSTEM PASSES: VI have not found any information which Indicates that any of the failure conditions described in 310 CMS 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: Eye/:keys --road_ k /Pi Ape,lacog, ptrern r F/ CC B. /SYSTEM CONDITIONALLY PASSES: VOne or more system components as described In the "Cnndidmrsl Pass" section need to ho replaced or repaired. The system,upon completion of the replacement or repair.as approved by OM Board of 'MMonk, will peas. Indicate yes,no. or not determined(Y, N, or ND). Describe basis of detsnnlnetion in all Instances. II not determined",explain why not. The septic tank Is metal,unless the owner or operator has provided the system Inspector with•copy of a Certificate of Compliance(attached)Indicating that the tank was Installed within twenty 1201 years prior to the date of the Inspection:or the septic tank, whether or not metal, I.cracked, structurally unsound. shows substantial Infiltration or.Mteton,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. Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed pipe(*) or due to a broken, settled or uneven distribution box. The system will pass inspection if with approval of the Board of Health). broken pipets) era replaced obstruction is removed distribution box is levelled or replaced The system required pumping-more than four times a year due to broken or obstructed pipets). The system 11111 pen inspection If with approval of the Board of Health): broken pipets)are replaced obstruction is removed nett /5 eewc. o.c C /000 pa, c/tPo C n yI plus. /s 40 6 .e►C. .7 to #19,o 41.'4 /[t cO/r ante ap..e eta/ a revised 9/2/98 Par 2 of I I OProperty wner: Address: J. StN/EOtF.E LiN Date W Itrpee0arr: S/tfa,J,/4, C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF IIEALIII: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /%.l ALIN00W tjTnHocA lennai /C�O/L//VGI 0,14009 Conditions exist which require further eveluetian by the Board of Health In order so determine If the system Is falling to protect the public health,safety and the environment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES N ACCORDANCE WITH 31O CAR 15.303(1Nb)THAT THE SYSTEM IS NOT FUNCTIONING N A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENV®OTMIBIT Cesspool or privy I. within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or n salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS ran FUNCTIONING N A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - 31 OTHER The system has a septic tank and soil absorption system(SAS)and the SAS Is within 100 feet of e surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS Is within s Zone I of a public water supply well. The system has a septic tank and soli absorption system and the SAS Is within 50 feet of•private water supply well. The system has a septic tank end Noll absorption system end the SAS Is less than 100 feet but SO bet or more from• private water supply well.unless a well wear analysis for conform 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 Ien than 5 ppm. Method used to determine distance (approximation not valid). revised 9/2/98 Pete 1 el l I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ho M../Is.00act Sr ft/anii✓u "1I Addra.: y Cc/l/e roc C.�A./ • Property Ownw: /� Dem of Inspection: s,/>. /9 9 D. SYSTL3M FAILS: You must Indicate either "Yee" or No to each of the following: I have determined that one or more of the following failure conditions exist es described in 310 CMR 16.303. TM basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure yes / Backup W sewage into faelNMer sYStem component dorm an overloaded or-clogged SAS oressslssal. • 3i Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _ L/ Static liquid level In the distribution box above outlet invert due to no overloaded or clogged SAS or cesspool. _NA_ Liquid depth In cesspool is less than 6" below Invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the lest year NOT due to clogged or obstructed pipers'. Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ry� Any portion of a cesspool or privy is within a Zone I of a public well. _ ft Any portion of a cesspool or privy is within 50 feel of a private water supply well. _ I4J9 Any portion of a cesspool or privy Is less than 100 feet but greater than 50 feet from s private water supply well with no acceptable water quality analysis. If the well has been analysed to be acceptable, attach copy of well water antyels for -coliform bacteria,volatile organic-compounds, ammonia nitrogen end nitrate nitrogen. -. E. LARGE SYSTEM FAILS: t% 4 You must Indicate either "Yee" or "No" to each of the following: The following criteria apply to large systems In addition to the criteria above: The system serves a facility with a design flow of 10,000 god or greeter(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system-1e-within 200 feet of a trlbutery to•eurfeoaddnklog wow 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) The owner or operator of any such system shell upgrade the system In accordance with 310 CMR 15.30412). Please consult the local reglonN office of the Department for further Information. revised 9/2/98 P.Nr 4 or n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST /d1 /YI.EADOad ST i/oaeswu Ih_O or Addraaa: T. Ste al,e,c,c Lt/A-, Dote of Inspection: srA•'/9 9 Check 11 the foHowing have been done; You must Indicate either "Yes" o No No as to•scb of the following: Pumping Information was provided by the owner, occupant, or Board of Health. None of the system components).aaM.en plmnpadder at least two weeks and the system hnS ternseelM.Bwemel Blow rates during that period. large volumes of water have not been introduced Into the system recently or es part of this inspection. As built plans have been obtained and examined Nnte II they are not available with N/A. The facility or dwelling was Inspected for signs of sewage hack mp. The system does not receive non-sanitary or b,dnetdnl waste pow. The site was Inspected for signs of breakout, All system components, excluding the Soil Absorption System, have been located on the site, The septic tank manholes were uncovered, opened, and the interior of the septic tank was Inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid.depth of sludge,depth of scum. The size and location of the Soll Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined In the field III any of the failure criteria related to Pen C is at Issue,approximation of Sistente Is unacceptable/ 115.30213)1bli The facility owner land occupants,if different from.owner)were provided with lafom sdorson lh.aop.raaletooapoa-f Subsurface Disposal Systems. revised 9/2/98 Pear!or I I Property Address:Owner: CcN / -FF Cc/N Dad of Inspection: no.'is ei SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION /J►-/Apses/ jn'c_c, r F/o"-ei✓c.• flow CONDITIONS RESIDENTIAL:/,O Design flow: B.p.ddbedro Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow Number of current residents:_3 Garbage gdnder(yes or nol:S 0 Laundry(separate system) (yes or no). d If yes. eeperatelnspection required Laundry system Inspected (yes or no) 60.411,: Seasonal use(yes or noltd(O Water meter readings.If available(last two year's usage(good): Sump Pump(yes or no):_N 0 Lest date of occupancy: �r3 cOMMEROIAL/NDUSTRIAL: QI/T Type of establishment: Design flow: Bpd I Based on 15.203) B asle of design flow O reese trap :(yes or no) Industrial Waste Holding Tank present:(yes or no) Non-senitery waste discharged to the Title 6 system:l yes or no)__ Water meter readings,if available: Lest date of occupancy:_ OTHER:(Describe) - 4 Last date of occupancy: GENERAL INFORMATION PIMPING RECORDS and source of information: System pumped as pert of Ins action:(yes or no) 1/4'J if yes.volume pumped: gallons 7 Ramon for pumping: TYPE OF YSTBA Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (If yes, attach previous Inspection records.it any) IIA Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date Inetalled41 known)end source e 4 emladon: eve, Sewage odors detected when arriving at the site: (yes or nol_41Q revised 9/2/98 r.p.6 'F l) Property Property Address: /41 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) ~SY 00 ad Jr tele/LOA)CO, sterel .7 Sc WOE 6c,c£c,N -99 Dote of rNpetgon: BUILDING SEWER: (Locate on site plan, Depth below grade: /4 p / Materiel of construction: IEssl iron_40 PVC_ other leapleinl Distance from privet,water supply well or suction line a Diameter AO d Comments:(condition of Dints. venting,evidence of leekage,atc.l PiP i� er iti 9eecl Cew.47ineeci BEFOG TANA:_ k/ Hotels on site plan) Of Depth below grade: / V Materiel of construction: trionetele_metal Flberglaea Polyetbylane otbetl•apleln) If tank Is metal.list nee)la.age confirmed by Certificate of Compliance (Yes/No) Dimensions: 90 ee A' Vt a' d0'" F/•S4/ 0YO q.n c•,,o Sludge depth: /e of Distance from top of sludge to bottom of outlet tee or baffle: Set na AI/O/er Ue/ Scum tMCkness:_fL • Distance front top of scum to top of outlet tee or baffle: N eK. 4 _C$K Distance from bottom of stunt to bottom of outlet tee or baffle: — How dimensions were determined: f$L'$,d O Comment,: Neil r/ /I/f%dt. /4E C O/%%nt,/sivbi.fC40 (recommendation for pumping,condition of inlet endoullet tees or-bellles, depth of liquid level In relation to outlet Invert. etructural4ntegdty, evidence of leakage,etc.) v'te / �NK /f e ern ZtL1 d7 �ernnr y/1f eaV`.�iterm GREASE TRAP:N0_ Ae (locate on site plan) 'k..I Depth below grade:_ Material of construction: concrete_metal_Fiberglass Polyethylene__otherleapleinl Dimensions• Scum thickness:_ Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet lee or beffie: Date of last pumping: Comments: Irecommendedon for pumping, condition of Inlet end outlet lees or belllee, depth of liquid level In relation to outlet Invert. structural Integrity, evidence of leakage,etc.) revised 9/2/98 rae•t nr IF SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued/ Property Addwa:Ill /Sc if Dee, Sr f/offe /(/'C/ I'10 Owner: T SCNie .c,ccj.0 Dw.or Impacggn: 5/011/99 TIGHT OR HOLDING TANK: Clank must he pumped prior m. Or m time of. Inspection) (locate on site plan) 0A)4 Depth below grade:_ Mated/lief construction:_concrete_metal_Fiberglass Polyethylene_otherlexpleinl Dimensions: Capacity: gallons Design Tow: gallons/day Alarm present Alarm level: Alarm In working order, Yee No Dela of previous pumping: Comments: condition of Inlet tee, condition of alarm and goat switches.etc.I DIcate oT site BOX: ie 11 !locate on site plan) OS Depth of liquid level above outlet invert: Q Comments: Mote If level end dish' lion is equal,evidence of solid carryover, evidence of leakage into or out of box etc.) or gad pooa? PUMP CHAMBER:_ p i 4 r (locate on site plan) Pumps In working order:(Yes or No) Alarms M waking order(Yes or No Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.I revised 9/2/98 rsv erdu SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATI N Icordnuedl Pteperry Address:/r3 �n a Do roc) sr f o s t e w.c# "PI Owner: f $cH/ dic Dida of Inspection: 0 /9 9 SOIL ABSORPTION SYSTEM ISASI:_.. floosie on site plan.If possible:excavation not required,location may be approximated by non Intrusive methods) If not faceted, explain: E40 /S//4161 L4ScN "/•C LO Type: leaching pits.number:_ leaching chambers.number:_ leaching galleries,number:_ leaching trenches,number,length: • leaching fields,number, dimensions: gate /6 e4' 3/ C rise FT s overflow cesspool.number p Alternative ewer.): rte .. X. 7 e/ — 7 y e/L 6 its/ Name of Technology: 04.509 7 Comments: (net.eerMhdens lNl .ap yd failure, iS �ding. ..1 condition i y u ,_cs /as sK 4 t/ V..-L,/ di.t7T CESSPOOLS: (locate on site plan) AA#4 Number and configuration: Depth-top of liquid to Inlet invert: Depth of solids layer: Depth of scum layer: Dimensioi]of cesspool: Materiels of construction: Indication of groundwater: Inflow(cesspool must be pumped as pen of Inspection) Comments: (note condition of soil, signs of hydraulic failure,level of pending, condition of.vegetedon, etc.) PRIVY: !locate on site pen) Materiels of construction: Dimensions: Depth of solids_ Comments: (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.) revised 9/2/98 ruse 9 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C V . C /7-15 SYSIFM INFORMIITTON'centimeM�� P roperty Address: jd .i `'l 4"4/) c,c.ci y i 1k-toy Owner: U.te M moth low M/JI/ i / 722 S KETCH OF SEWAGE DISPOSAL SYSTEM: Include tin to.t loot two permonent reference landrnerks or benchmarks locate NI wells within 100' !Locate where public wetter nuppl revised 9/2/98 Put In nl II M yp PteCtd ?, Properly Address: ChM." sc.a,/terse �,.//t,/ Della of Irupaegera !/el //9 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /•23 tte/i oo et/ E SFr ATF/o/G.e *.'C! /11 MRCS USG, Report name_. Soil Type_ Typical depth to groundw.br DM.w.balte Milted Observation Well.checked Groundwater depth: Shallow B ITE EXAM Slop. 0 Surface water ^/Q Gam/ Check Ceder we Shallow well. NQ Ne E stimated Depth to Groundwater Fear ea d. Roue Macua all the methods us.d to deunNMI High Oroundwnt.r Flnv•don ObWm l bons Design Plans on record iFilb..rved.MK(Abutting property.ob..rvetiorr holt bosoms.° mono *lc I Modest. 1/Determined from local conditions Checked with local Board of health Ch.ck.d FEMA Maps Checked pumping record Checked local .Installers Used USGS D.t. Describe how you obblish.d the Nigh Groundwater Elevation. (Must he cmnpl.bdl revised 9/2/98 pme I t rd I I /2fr /fir setfr v.frr.CO (j -I 9 AO o/rtadr.lrl /9-28 ea.' stay >8- 80 c • IL A'S A do - /1a Lz ?re,/ rl o 9 80 " morn./df/�I go " /0 yet. r-e Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner's Name FLORENCE City/Town MA. State 01062 May 13, 2015 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 A. General Information filling out forms on the computer, use only the tab key to move your cursor-do not use the return key 4 0 t5ns 3113 1. Inspector: PHILIP J. PASIECNIK Name of Inspector GREG'S WASTE WATER REMOVAL Company Name 239 GREENFIELD ROAD Company Address SOUTH DEERFIELD City/Town 413-665-3989 Telephone Number B. Certification MA. State SI1526 License Number 01373 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. 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 &gee/ May 14, 2015 InsQectors Sion a$&e V 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. tills S Official l lnspaficn Form-S bswfa®Sewage pig Sy em.Page 1 N 17 Owner information is required for every page. Important:When filing out forms on the computer, use only the tab key to move your cursor-do not use the return key. a 151ns•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owners Name FLORENCE City/Town MA. 01062 May 13, 2015 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: PHILIP J. PASIECNIK Name of Inspector GREG'S WASTE WATER REMOVAL Company Name 239 GREENFIELD ROAD Company Address SOUTH DEERFIELD City/Town 413-665-3989 Telephone Number MA. State 511526 License Number 01373 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 Z Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspectors igna ■ May 14, 2015 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. Tnl 5 Official Inspect/an Form Subsurface Sewage Disposal System.Pays 1 Cl 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner Owner's Name information is FLORENCE MA. 01062 May 13, 2015 page. City/Town required for every page State Zip Code Date of Inspection page B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. thins•3113 Comments: MAIN HOUSE HAS BEEN VACANT SINCE ABOUT MARCH OF 2015 WITH NO NORMAL FLOW RATES TO THIS SYSTEM FROM THAT PART OF RESIDENCE. 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): Tile 5 ON,tlal Inspection Form:Subsurface Sewage Disposal System Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Ovmer Owners Name information is FLORENCE required for eve ry MA. 01062 May 13, 2015 page. City/Town State Zip Code Date of Inspection Sins•an3 B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): E broken pipe(s)are replaced E Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y E N ❑ ND(Explain below): E distribution box is leveled or replaced E Y ❑ N ❑ ND(Explain below): DISTRIBUTION BOX REPLACEMENT NEEDED DUE TO DETERIORATION OF THE EXISTING CONCRETE BOX. ALSO THE PIPE BETWEEN SEPTIC TANK AND DISTRIBUTION BOX NEEDS REPLACEMENT.ALL REPAIRS ARE TO BE DONE AS APPROVED BY THE BOARD OF HEALTH. THE SYSTEM, UPON COMPLETION OF THE REPLACEMENT OR REPAIR, AS APPROVED BY THE BOARD OF HEALTH, WILL PASS. ❑ 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 EN ❑ ND(Explain below): ❑ obstruction is removed ❑ Y EN ❑ 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 1$.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 ()ordering vegetated wetland or a salt marsh The 5 official Impaction Forts Synurs o Sewage owa System•Page 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 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner's Name FLORENCE City/Town MA. 01062 May 13 2015 State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): E 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): E broken pipe(s)are replaced E Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y E N ❑ ND (Explain below): E distribution box is leveled or replaced E Y ❑ N ❑ ND(Explain below): DISTRIBUTION BOX REPLACEMENT NEEDED DUE TO DETERIORATION OF THE EXISTING CONCRETE BOX. ALSO THE PIPE BETWEEN SEPTIC TANK AND DISTRIBUTION BOX NEEDS REPLACEMENT.ALL REPAIRS ARE TO BE DONE AS APPROVED BY THE BOARD OF HEALTH. THE SYSTEM, UPON COMPLETION OF THE REPLACEMENT OR REPAIR, AS APPROVED BY THE BOARD OF HEALTH, WILL PASS. ❑ 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 E N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y EN ❑ 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 t5ins•3/13 Title 501fioal hsp aion Form Subsurface Sewage Disposal System•Page 3 of 17 Owner information is required for every page. t5ins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner's Name FLORENCE City/Town B. Certification (cont.) D) MA. 01062 May 13, 2015 State Zip Code Date of Inspection 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 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 must be attached to this form. 3. Other: 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 '''h day flow Title 5 Official Tspedlon Form.Subsurface Sewage Disposal System.Page a at 17 Owner information is required for every page. 15ins•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner's Name FLORENCE MA. 01062 May 13, 2015 Cdy/TOwn State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: - ❑ M 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 ❑ Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal conform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no° to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department Title 5 Oltaal Inspection Form Subsurface Sewage Oisrysai System Page 5 N 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner Owner's Name information is red for every FLORENCE MA. 01062 May 13, 2015 page.page City/rawn State Zip Code Date of Inspection t5ins•3113 C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No N ❑ 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) Z ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ ❑ Was the site inspected for signs of break out? Z ❑ Were all system components, excluding the SAS, located on site? Z ❑ 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 Of any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)1 D. System Information Residential Flow Conditions: Number of bedrooms(design): N/A Number of bedrooms(actual). DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 6 660 gpd Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 6 0117 Owner information is required for every page. (5in5•3,13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner's Name FLORENCE MA. 01062 May 13, 2015 City/rown State Zip Code Date of Inspection D. System Information Description: Two Family/Main House& Inlaw Apartment Dwelling with 4 Bedrooms in Main House and 2 Bedrooms in Apartment=6 Bedrooms Total x 110 gpd per Bedroom =660 gpd. Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available(last 2 years usage(gpd)): Detail: Last 2 years usage- 29,900 cu.ft. =224,250 gallons/730 days= 307.19 gpd. ---More Than Household Usage at This Property 2 in Apt only house vacant ❑ Yes ® No ❑ Yes ® No ❑ Yes Z No ❑ Yes ® No 307 qpd Sump pump? ® Yes ❑ No Last date of occupancy: 3/2015--Main H. Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A Title 5 Offiaal Inspection Farm.Sub wrtam Sewn e D posal Sy em P g 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner Owner's Name information rs required for every FLORENCE MA. 01062 May 13, 2015 page. page. City/Town State Zip Code Date of Inspection tsins•3113 D. System Information (coot.) Last date of occupancy/use' Other(describe below): N/A N/A Date Pumping Records: Source of information: General Information LAST PUMPED ON 09/13/13 BY GREG'S Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: TANK MUST BE PUMPED AS PART OF REPAIRS gallons 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 ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Title 5&foal mspecuon Form:Subsurface Sewage Disposal System:Page a 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 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner's Name FLORENCE MA. 01062 May 13, 2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: SEPTIC TANK 15- 19 YEARS OLD" 1998" +/- / SAS& DB 40+YEARS OLD-- DATE UNKNOWN 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: 1.5 feet ❑ Yes ® No ABS TOWN WATER feet Comments (on condition of joints, venting, evidence of leakage, etc.): BUILDING SEWER APPEARED TO BE IN GOOD CONDITION. VENTING PIPES WERE VISIBLE ON THE ROOF OF DWELLING. NO VISIBLE LEAKAGE AT THIS TIME. Septic Tank(locate on site plan): Depth below grade: Material of construction: concrete 1 feet ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 10'6"Lx5'8"Wx5'6"D-(OUTSIDE ) 151ns-3/13 line 5 Official Inspection Fpm',Subsurface Sewage Dpsposal Syslem•Page 9 o117 Owner information is required for every page. (Stns.113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner's Name FLORENCE MA. 01062 May 13, 2015 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 27" Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK PUMPING IS RECOMMEDED AT LEAST EVERY TWO YEARS IF RESIDENCE AND APARTMENT IS FULLY OCCUPIED PVC INLET AND OUTLET TEES WERE IN PLACE AND APPEARED TO BE IN GOOD CONDITION. INLET TEE IS NOT STRAIGHT DOWN INTO TANK, BUT STILL FUNCTIONAL. LIQUID LEVEL WAS AT THE OUTLET INVERT. TANK APPEARED TO BE IN GOOD CONDITION. NO LEAKAGE WAS VISIBLE AT THIS TIME OR WHEN OTHER PUMPINGS WERE DONE ON PUMP REPORTS AT BOH. Grease Trap(locate on site plan): Depth below grade: Material of construction: ❑ concrete N/A LI metal N/A feet ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: N/A N/A N/A N/A N/A Date Tale s Official nspecton Form Subsurface Sewage Disposal System-Page 10 N 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 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner's Name FLORENCE MA. 01062 May 13, 2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ® Surface water Z Check cellar ❑ Shallow wells Estimated depth to high ground water: 4+ 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. OBSERVATION OF SITE AND ABUTTING PROPERTIES Before filing this Inspection Report, please see Report Completeness Checklist on next page. I51ns•3f13 Tile 5 Official Irtsped an Fwm.Subsurface Sewage Disposal System•Page 16 N 17 Owner information is FLORENCE required for every page. City/Town Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner's Name 1' MA. 01062 May 13, 2015 State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately SMem , OAtty=1[6 Sc, Le 6-f Porch a BEDRooM APAA MONT" 4tfil or fz33 �.t'Rc7fcce ~ Lay eat +'/- 35' #/— At-.1,r Y a4t a3IgU 11 A , - 2 ' 311 3 B: -Z , = 3af 2, -31 = 3713 " 8, _ ic- nle eer&K V' beep Zf - Cutre#CAVer' g,f utep E 0 3, Ptsk BoX 6g" bay (Sins 3113 Till 5 Official Inspaciian roan Subsurface Sewage Disposal System-Page 15 do Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner Owner's Name information is FLORENCE MA. 01062 May 13, 2015 required for every page 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.): N/A 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.): N/A N/A N/A N/A 151ne.3/13 Tlrle 5 Olfioal Inspection Form:Subsurface Sewage Disposal System.Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner Owner's Name information is FLORENCE MA. 01062 May 13, 2015 required for every Y o page. City/Town State Zip Code Date of Inspection ISine•3/13 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 1 -35 x 15+/- with 3 laterals Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE OR PONDING FROM CLOGGED SOIL CONDITIONS. SOIL OVER LEACHFIELD WASN'T DAMP AND VEGETATION APPEARED TO BE NORMAL IN GROWTH. NO GARBAGE DISPOSALS SHOULD BE USED IN DWELLINGS. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan). N/A 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 N/A N/A N/A N/A N/A ❑ Yes ❑ No Title 5 Dffoal Inspection Ferny Subsurface Sewage Dlsposel mien.Page 13 or 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 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owners Name FLORENCE MA. 01062 May 13, 2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box Of present must be opened) (locate on site plan): NOT ABOVE Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): EXISTING CONCRETE DISTRIBUTION BOX IS DETERIORATED WITH CRACKS IN COVER AND SIDE WALLS VISIBLE. REPLACEMENT IS NEEDED AS APPROVED BY THE BOARD OF HEALTH. SOME SOLIDS CARRYOVER WAS IN THE BOX. NO LEAKAGE WAS VISIBLE AT THIS TIME. ONE OUTLET PIPE WAS TAKING MOST OF THE FLOW. REPLACEMENT BOX WILL NEED TO BE RAISED IN ELEVATION. REPLACEMENT OF PIPE FROM SEPTIC TANK IS ALSO RECOMMENDED. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t Sns•3113 Tale 5 Official lnspetlw Form:Subsurface Sewage Disposal System•Page 12 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 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owner's Name FLORENCE MA. 01062 May 13, 2015 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.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete N/A El metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•3/13 Title 5 Official Inspection Fenn Subsurface Sewage Disposal System•Page 11 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 123 MEADOW STREET Property Address NOONIE HAMMARLUND Owners Name FLORENCE MA. 01062 May 13, 2015 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Z Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater • Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Oita al]ns petliOn Form Sub elate Sewage Disposal System Page 17 ol1] ,�' /n Commonwealth of ssachusetts ;,� / l P4 L City/Town of Septic System Installation Checklist B. Application Checklist(cont.) C; Distributor Box(31: CMR 1513_2; Approve 51,'A Problem All outlet pipes at same eievation Cnea by aoo/ng water 4/ Number of outets Uer ,YYrt .. - Number of laterals -- Per Plan,„ Inbt tee mm i'over outlet Vreua■ and w!tape = D box set on level base V.sue Top of D box 36• max depth V sua and w.'tape D box is water-tight Add water D box has a minimum of 2'thin wall and it undo dimension ,_- d) Pump Chamber(310 CMR 152311 Approved to Problem Tank is set eve Visual and w;level u Proper volume is provided Cnea plan and tank L. Float eievatons sat per peen Measure wmape ;_I ❑ ❑ Min 2'delivery line to D box Visual ❑ C Number of pumps. - ❑ l_, ❑ Specified pump provided or designers approval to equal poop Cafeci pump sequence ❑ 0 ❑ Covert eat to onside ❑ ❑ ❑ E$drnoel permit provided ❑ ❑ ❑ 5 of stone beneath chamber Visual n r ❑ Chamber is water-bgnt Test Min. 9'cover provided Visual ❑ Correct loading provided per plan Visual on tank ,., Notes iz N rt Peelle amber Ire sMen Pleats'1 1-0a ace•dee Farm NUM•eep 3 ell