535 Title 5 Inspection 1996, 2015, Construction Permit 2015 W011am F.Weld
Gowns
A g Paul C•Iluse'
NOV 19 1996 :L»
Comrrhon'(ealth of Massactjuse
Exec
Ddpar men b rraoldrinittifit
Environmental Protection
is
I Affairs
oN
Trudy Cox*
sweaty
David B.&ruin
raewtheawr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
S(h, CERTIFICATION
Property Addxtes S 3 S At 2TH F/f 2 n-iS /Lp 20 2.nrti i 97-0#
Date of Inspection//O/ 3 / / l/6 AddRss Owast
Marne of Inspectom a /{' 4 1,flit. 5 OIf different)
Company Name,Addren and Telephone Number. ,j�9.3-� / '3 g
Ct C > 52airs 5 /
o c Tm t
CERTIFICATION STATEMENT tc N 2 $ T. L--U Ia _ W
U
/ 0 IS-6
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is trw,accurate
and complete as of the time of inspection. The inspection was performed based on my training and ea id
maintenance of on.site sewage disposal systems. The system: , experience the proper function and
1. 5asses
_ Conditionally Passes'
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Sig,ture:
Data /0/3 / / 96
The System;r/phactor shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. the system L a shared system or by 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving
PPmoving authority.
INSPECTION SUMMARY:
Check
,,gqA,'B,C,or D:
A7 SYSjam PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as dammed in 310 CMR 15.309.
Any failure criteria not evaluated are indicated below.
87 SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replecement or repair,pauses
inspection. -..
Indicate yes,no,or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,cracked structurally unsound,shows substantial infiltration or a:BBration,or tank allure L
im nnoatthe Health.
system will pass inspection if the existing septic tank L replaced with a sonformtug septic tank as approved of
(revised 11/03/95)
1
Ong Winter Street • Boston,Massachusetts 02108 • FAX(617)5561049 • Telephone(617)292-6600
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontiaued)
Property Address SAS Ny. f-=n/2 r«5 ✓LO
Owner. 5 6ci / F T
Date of Inspection: /6/ 3 /
HI SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high aiic wat r level vel observed in the
H due to a broken,settled or ,1,�system distribution box is duo to broken or obstructed
or due t pest inspection H(with a he Pof
approval of the Board f
broken pipe(*)are replaced
obstruction is removed
distribution box it levelled or replaced
- The system inspection if(with ppproval of he Board of Hatith);a year due to broken or obstructed pipe(s). The system will pass
broken pipe(s)are replaced
obstruction is removed
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 is failing
public health,safety and the environment.
to Protect the
•
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DEFERMINrg THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT
Cesspool or privy is within 50 feet of•surface water
Cesspool or Privy is within 50 fest of a
bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
SAFETY T THE SYSTEM IS FUNCTIONING W 'ME MANNER THAT PROTECT B PUBLIC HEALTH AND THE ENVIEONMENT;
The system has a septic-tank and soil absorption system ands within 100 feet to•surface water supply or tributary to a
surface water supply.
septic- The system bas a tank and soil absorption system ands within•Zone I of•public water supply wet
- The system has a septic
- The system has a septic absorptoa system ands within 60 feet of•private water supply well.
P tank and soil absorption system and is lass
than
supply well,unless a well water analysis for mlifoem eolith*or test cut p0 test or more from a private water
ganic 3) OTHER from pollution from that facility and the presume of ammonia nitrogen and fete nitrogen compounds Is Indicates orrllesss theca 5 ppm.
(revised 11/03/95)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _
PARTA ..
CERTIFICATION(continued)
PropertyAddrose: 5. 3 5' N o 2 r k r' /9 'Lan 5 2 p.
Owner. 5w I F Y
Date of Inspection / O J 3 /
Dl SYSTEM FAILS:
_ I have determined that the system violates one or more of the following failure criteria as defined is 310 CMR 16.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the pound 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 overloadd or clogged.SAS or cesspool.
Liquid depth in cesspool L leas than G below invert or available volume is less than 1,2 day flow.
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 Soil Absorption System,=spool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 60 feet of•private water supply well.
Any portion of a cesspool or privy is lee than 100 feet but greater than 60 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves•facility with a design flow of 10,000 gpd or pester(Large System)and the qtr.is a signifies=threat to public
health and safety and the envmonmant because one or more of the following conditions=st:
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 seneWw area Onterim WeBLd Proration Area(IWPA)or•napped Zone II ot•public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compile=with the floodwater treatment program
requirements of 314 ChM 6.00 and 6.00. Please consult the local regional office of the Department for Hrthar.ioformation..
(revised 11103/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address 5- 3 5 4/ 07Z7w T/5? ✓h-S /2—/7.
owner. 5 C4—' / r 7'
Date of Inspection 0 / 3 / / 5 6
Check if the following have been done:
ping information was requested of the owner, occupant,and Board of Health.
(L1%ne of the system components have been pumped for at least two weeks and the system has been remelting normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.,
�Tbe facility or dwelling was inspected for signs of nap back-up.
✓
`The system does not receive non-sanitary or industrial waste flow
_L-411e site was inspected for signs of breakout. '
4,...,411 system components, excluding the Soil Absorption System have been located on the sit*.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was ivapectd for condition of baffles or
r' tees,material of construction,dimensions, depth of liguld,depth of Budge,depth of scum.
rC Tha size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
�Tha facility owner(and occupants,if different from owner)were provided with information on the proper maintansan of Sub-
Surface Disposal System.
(revised 11/03/95)
4
•
SUESDRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property.Address 5 3 s /V O ✓Z-%/f it I%- it /ass /9 ,
Owner. 5 (N I F i
Date of Inspection
/ 0 / 3 / / '9
4Q� �� FLOW CONDITIONS
Design De flow
Number of bedrooma:27
Number of current residenL:3_
Garbage grinder(yes or no):_f�S
Laundry connected to system or no):�i 5
Water meter readings, if available: t.V Pz..< `
aJ2
Last date of arvpancy: Z_vtSag NT
;OMMERCIAL NDDSTRIAL:
Ype of establishment-
mom I rona/day
'Tease trap present: (yea or no)
o $ Waste/folding Tank present: (yes or no)
'ate meter waste dmcharg.d to the Title 5 (ye.or no
mer readings,if available.
system: )
ut date of caepency:�
(EEM(Decorate)
n data of occupancy:_
MPING RECORDS and source of informs;•a:
System pumped rn part of inspection: (yes or no),ytj� 5 as If
Pumped: /LY9 d
Reason for pumping:
E 9PSYSTEM
c Septic tan r.0 'wriion box/soil abeorption
Single msspool system
Overflow cesspool
Privy
Shared
ther(Qpayslma)( es or no) (ifye. attach previous inspection
r.r«a.,if any)
IOXIMATE AGE of all component.,date installed(if la.own)and.ouma of information:
re odors detected when arriving at the site:(yes or no)Al if
ed 11/03/95)
6o P 2oAl. 1 tt ,*t—/(4-
GENERAL INFORMATION
5
-l9 � 7
!L/Lc orLUS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ea{ PART C
SYSTEM INFORMATION(continued)
Property Addles= 3 5- Nd2Tly F /9-72-01^-5 20 .
Owner. S u / F
Date of Inspection: ,/ d/ 3 / / �7 e
SEPTIC TANK_
(locate on sits plan)
Depth below grade: 2
Material of construction:✓concrete metal FRP other(explain)
Dimensions:_ /5"00 /GCCLr,r'F /Os� --+-r/ . YW ,5— ' Q
Sludge -
depth; . " —
Distance from top of sludge to bottom of outlet tee or baffe:3 Z
Scum thiclme s:_L_
Distance from top of scum to top of outlet taw or GO7e: /0 7/
Distance from bottom of scum to bottom of outlet taw or larle: / L
Comments:
(recommendation for pumping,condition of inlet and cutl:t tees or ba®ea,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) (1 tl-n P 3 /1 r,=L cc- S 6 (c I tC V C f_ o c
7`7R/Vkt O /6 17M 4 L r•c-i
GREASE TRAP._
(locate on site plan)
Depth below grade:_
Material of construction: connate metal FRP_other(a:plein)
Dimensions:
Scum thickness:
Distance from top of win to top of outlet tee or baffle:_
Distance from bottom of sam to bottom of outlet tee or barn.:_
Comments:
(recommendation for pumping condition of inlet and outlet tees or battles,depth of liquid level in relation to outlet invert,structural of leakage,etc.) mob,
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Pr°Perey Address: - JS A/o /LT F a-Ai 5 4Z/J .
owner. S w i F T
Dab of Inspection 3 / 4 6
TIGHT OR HOLDING TANK_
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_meta_FRP_other(explain)
Dimensions:
Capacity gallons
Design flow: venom/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX_
(locate on site plan)
Depth of liquid level above outlet invert: 5
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of boo,etc.)
/ /{ ✓ 2L /i / S TR I /; nT7rtt1. 0tJ /d-
A- 40 i3- 2/2K -e• ✓ K2 niD L&. ✓- ILLS
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order.(yes or no)_
Comments:
(note condition of pomp chamber,condition of pumps and appurtenances etc.)
(revised 11/03/95)
SUBSURFACE SEWAGE DISP C �
PART Y8 .INSPECTION FORM
Property SYSTEM INFORMATION(om4noed)
Date Address 0 2"771-1 / /3- /Z go" / OOner St, F
Inspection:
SOIL ABSORPTION SYSTEM(SAS):
If not on sit plan,
to be le;esavation not eequind,but may be apptvaimated by non>�usive methods)
present,sapient
Tope
leaching pita,number
leaching chambers,number
leaching pLaries,number: �)
inching launches.numbed � �v /
leaching Ely,number, ensions:
overflow cesspool,number�esios:Commenta: (note condition of soil, sips of hydraulic failure,level of ponding condition of w8etati
a
n4em.
•
ar • L L
CESSPOOLS:
(locate on site Plan)
Number
Depth-top ppf configuration.
oiilet
liquid r inlet invert
Depth of rosy lam
Depth of scum layer.
Dimevgos of cesspool:
Materials of construction:
Indication of groundwater
inflow I must be pumped as part of inspection)
:comments: (note condition of soil,sips of
hydraulic failure,)awl of goading, condition of
°e8etetio4 •tc.)
RIVY:
rah on site plea)
medals of loth of of solids construction:
mowav:(not.co ndn)on of sag signs o[IVdrsulie D+mensmr
failure,lewd ofPoadipg condition of v•gstatio4 etc.)
eised 71/03/95)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: S3 S No 21- 4 ✓c_kin 5 /. 4430
Owner 5 w
T
Date of In peotlon:
/O/ 31 196
SIOLTCH OF SEWAGE DISPOSAL SYSTEM:
include tie.to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater fest
method of determination or approximation: A O n. & A- T
/ 6
(revised 11/03/95)
9
Owner
intonation is
required for every
page.
Important:When
filling out forms
on the computer,
use only the tab
key to move your
cursor-do not
use the return
key.
15ins•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
535 North Farms Road
Property Address
Bobbe O'Brien
Owner's Name
Florence
Cityftown
MA
State
01062 9-9-15
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.
Rick Scott
Name of Inspector
RM Scott&Associates, LLC
Company Name
31 Shutesbury Road
Company Address
Pelham
CM/Town
413-256-0647
Telephone Number
MA 01002
State Zip Code
MA SI#1030. MA P.E. 31199.
Ucercee 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
Y /C7 T 0 7 9-9-15
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
rills 5 Official mspeoton Palm Subsurface Swage Disposal System.Page!of I]
Owner
information is
required for every
Page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
535 North Farms Road
Property Address
Bobbe O'Brien
Owner's Name
Florence MA 01062 9-9 15
City/Town —__... State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete an 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:
System passes Initial inspection on 8-20-15 was a"Conditional Pass'and revealed a need to
replace components.See Application for Disposal Works Permit dated 8-27-15. No failure criteria are
now present. See additional notes in report.
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 oid'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):
ions.3f13 Trite.5()Ural i1s:wt.:ton Go(m:Srhwrlae Sewage 016W60 Sye&'Page2 0117
Owner
information
required for
page.
tams atl5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
535 North Farms Road
r
Property Address
Bobbe O'Brien
Owners Name
Florence MA 01062 9-9-15
rY
City/Tows State Da Code Date of Inspection
B. Certification (cant)
❑ 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 distnbution 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 5 Ofiiaal FspetLmi Forte:Subsurface Sewage Oise sB Sy9em Page]N 1>
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
535 North Address
Road
Property Atltlress
Bobbe O'Brien
Owner Owners Name
intonation is Florence MA 01062 9 9-15
pagerequired for every Ci .._._ _ _ —_ _ . _...
Page, CMrrown State Zip Code Date of Inspection
B. Certification (coot.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
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 weir.
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. Omer:
v/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
ter .3/13 Tele 5 Vaal Inspeatien Form.Subsurface Sewage"PO System'Pays 4 of 14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
535 North Farms Road
Property Address
Bobbe O'Brien
Owner Omxr's Name
information 5 Florence MA 01062 9-9-15
required for even' State _. _... ._
pap Citylrawn St Zip Code Date of Inspection
B. Certification (comb.)
Yes No
❑ ® 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
❑ i/ 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. glitz
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-
gip 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.
,5tms,3/13 Mitt ofitiq Inspeddion corm Suhuafxe Serape 1)sposal System Pape san
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
535 North Farms Road
Property Address
Bobbe O'Brien
Owner _..... _.
Owners Name _.... __._ ._..
information¢ Florence MA 01062 9-9-15
required for every
Page- Cdy/rown State Zip Code Date of inspection
IC. Checklist
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
❑ t1 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?
1S
❑ 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?
N ❑ 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)]
✓ a System Information
Residential Flow Conditions:
Number of bedrooms(design)
3 3
Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
330
t5vs•3113 The 5Offiae1 Inspection Farm:9mwrfa a Sewage aifrcul System Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
535 North Farms Road
Property Address
Bobbe O'Brien
Owner Owners Name
information is Florence MA 01062 99-15
required for every ---_
page. City/Town State Zip Code Date of Inspection
tsm..asra
D. System Information
Description:
Gravity flow to a new(2015)1500 gallon septic tank. Gravity flow to a new(2015)3-outlet D-box and
3 trenches @ 70'long. Trenches are original to the house construction in 1985.
Number of current residents:
1
Does residence have a garbage grinder? Yes ❑ No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes No
Water meter readings, if available(last 2 years usage(gpd)): Not available.Private well
Detail:
Currently, a garbage grinder is installed. Use of a garbage grinder with this system is not
recommended.
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/personsisq.ft., etc):
Grease trap present?
Industrial waste holding tank present?
Non-sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day(gpd)
❑ Yes Z No
Currently
Occupied.
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
TNes DIfie1 Inspection Fom'.Subswface Semapg Dposi SKIam.Page 7 Mn
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
535 North Farms Road
Progeny Address
Bobbe O'Brien
Owner Owners Name
Intoanatbne Florence MA 9-9-15
required for every
Page. Celt/Town/Town State Zip Code Date of inspection
D. System Information (cont,)
Last date of occupancy/use-
Other(describe below):
Currently Occupied.
Date
General Information
/Pumping Records:
Per owner, previous pumping was> 5 years ago_
Source of information: Pump record at Health Dept is Oct 1996.
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
1500
gallons
From Tank Dimensions
VeraHeavy Solids Accumulation.
❑ 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):
his•3/13 The 5 Official hspettim Fenn Subsurface Sawa??Owosa SYstem•P geeat IT
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
535 North Farms Road ..
Property Address —_
Bobbe O'Brien
Owner Owners Name .....
informations Florence MA 01062 9-9-15
required for eve? -
page. Citylrown State Zip Code Date of inspedion
D. System Information (cont.)
Approximate age of all components, date installed Of known)and source of information
SAS installed in approx 1965. New Septic Tank and D-box installed in 2015.
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)-
2
feet
❑ Yes ® No
Approx 60 feet,well to sewer
Distance from private water supply well or suction line: from house.
Comments(on condition of joints, venting, evidence of leakage,etc.):
All exposed, in-house plumbing is in excellent condition. No evidence of any previous problem.
Vented to roof.
✓ Septic Tank(locate on site plan):
1.0
Depth below grade: tees
Material of construction:
®concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain)
150Qallon concrete with pipe tee inlet bafflepipe-tee outlet baffle with_g baffle.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
126"X66"X_5_4"effective depth.
Dimensions: _.
Sludge depth:
thins•3113 TNa 5 Official kspecbon Firm.Subw/ace Swage Disydl System•Page 90f 17
34" (in old tank)-
2'\A. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
535 North Farms Road
_ .... ._ _
Property Address
Bobbe O'Brien
Owner Owners Name
iformation S Florence MA 01062 9-9-15
required for every o --_ - - -_- - —__
Page GtyRown Slate Zip Cade Date of Inspection
t5ms•via
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
0"
20"
0"
Probed at inlet during inspection.
How were dimensions determined? Observed during pumping.
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc):
Very heavy solids accumulation. No significant separation between top of sludge and bottom of
scum. so very little retention time in the septic tank. Liquid levels are correct. Outlet end of the tank
showed significant deterioration, evidence of past leakage out of the tank and a damaged pipe from
tank to 0-box. The septic tank has now been replaced. Next maintenance pumping recommended in
2018, depending on rate of usage_
ti fA Grease Trap(locate on site plan):
Depth below grade: feet
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:
idle 5 Off 6MGecfim.ron Subsurface Snap Disposal System•Poe 10 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
535 North Farms Road _..
Property Address
Bobbe O'Brien
Owners Name
Florence MA 01062 9-9-15
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, stru
liquid levels as related to outlet invert, evidence of leakage,etc.):
ral integrity,
N/A 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:
galbm per day
Alarm present: ❑ Yes ❑ No
Alarm level: -------- Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Data"
Comments(condition of alarm and float switches, etc):
•Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
isms 3/13 itlg 5 OMOal Inspect=Fo'ni Subsurface Serrege Draposd Syetan•Par 11 of 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
535 North Farms Road
Properly Address
Bobbe O'Brien
Owner
Owners Name
required a Florence MA 01062
page. for even _ —
DaBe CMrrown State LP Code Date of Inspection
D./System Information (cont.)
✓ Distribution Box(if present must be opened) (locate on site plan):
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.):
Distribution box is buried 38". The D-box was originally observed as functioning but with significant
detedoratwn. D-box has now been replaced with new 3-outlet concrete D-box and PVC riser to-6"
below ground surface.
Pi/A 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.):
•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:
Documented SAS is three trenches @ 70 feet longSee sketch.
15me.3n] nie 5 Offiid!r oecuon FUm:Subsurface Sewn°
System•P 1 mn
Owner
information is
required for every
page.
tiro•3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
535 North Farms Road
Property Address
Bobbe O'Brien
Owners Name
Florence MA
City/town State
01062
Zip Code
9-9-15
Date of I
D. System Information (cont.)
Type:
leaching pits
leaching chambers
leaching galleries
leaching trenches
leaching fields
overflow cesspool
innovative/altemative system
number:
number
number:
number, length:
number, dimensions:
number:
!70 feet long
Type/name of technology: --- -- -� -
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
No sign of problems observed from ground surface.
NA Cesspools (cesspool must be pumped as part o
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
nspecfion)(locate on site plan):
TOM S Mod
❑ Yes ❑ No
Fo Dispose■System*Page 13¢v
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
535 North Farms Road
Property Address
Bobbe O'Brien
Owner Owners Name
trrfonnation is Florence MA 01062 9-9-15
required Wrevery Clyrrown State Zip Code _. Date of Inspection
Page.
15ms 3M3
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
HAI Privy(locate on site plan):
Materials of construction'.
Dimensions
Depth of solids —
Comments(note condition of soil, signs of hydraulic failure, level of p
etc.):
ding,condition of vegetation.
Tide 5(noel tr,9ectim Four Subsurface Sewage as W s9 System•Page 14 or n
s \ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Owner
information
required for every
page.
535 North Farms Road
_._. .
Property Address
Bobbe O'Brien
Owners Mama
Florence MA 01062 8-27-15
-_._.. __... .t.__.. co_
City/Town 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 an wells within 100 feet. Locate
where public water supply enters the building.Check one of the boxes below:
Z hand-sketch in the area below
❑ drawing attached separately
)vo a-n -FARMS SQ
I.
23*-e
-n-aox
\ 32'a
3-DuTCr D-isox ' "a'BO�
3ua.eo 39 1at)
3C' r2.sex._
fe—"1$- var..et\AktL
tv1s'
150p GRm.tot1SEPrlc1'AMk
8..q.rra 12"
thins 3113 The 5 ethoell Inspector Form.Subsurface Sewage Dspowd System•Page 15of 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
535 North Farms Road
Properly Address
Bobbe O'Brien
Owner's Name
Fbrence
City/Town
MA 01062 9-9-15
State Zip Code Date of Inspedion
D. System Information (cont.)
Site Exam:
Check Slope
Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water:
10
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: T-5 Insp Report l0-31-96
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Record at Health Department. T-5 inp Report 10-31-96
❑ Checked with focal excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Reviewed design plan on file at Health Department. The record information is consistent with ground-
surface observations.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
Title 5 onotl Inspeoban Force.Sirwmxe Sewage Disposal System.Page 16of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
535 North Farms Road
Property Address
Bobbe O'Brien
Owner Owners Name
Information is Florence MA 01062 9-9-15
Page
required for every
p CM1ylrovm State Zip Code Date of Inspection
YE. Report Completeness Checklist
® Inspection Summary:A, B,C, D,or E checked
El 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
,Sins-3n3 r,a 5 0Btld PwfA0.vn Farm.Sues,flaae SevapeD ooW System'Page IT at 17
IN Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
Important:
When filling
out forms on
the computer,
use only the
tab key to
move your
cursor-do
not use the
return key
non
161/511 3
Number ��I
Fee 17
DEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it.
A. Facility Information
Application is hereby made for a permit to:0 Construct a new on-site sewage disposal system
m Repair or replace an existing on-site sewage disposal system
Repair or replace an existing system component
1. Location of Facility:
535 NorthFarms Road
Address or Lot#
Florence
City/Town
2. Owner Information
Bobbe O'Brien
Name
MA
State
01062
bobbeo a._CAD 0-Lca-st.
Zip Code
e-mail address(optional)
Address(if different from above)
State
City/Town State
413-586-9538
Telephone Number
3. Installer Information
Steve Konieczny
Name
327 River Drive
Address
Zip Code
Karl's Excavating
Name of Company
kiactley MA
City/Town State
413-549-5396
Telephone Number
4. Designer Information
Rick Scott
Name
31 Shutesbury Road
Address
01035
Zip Code
RM Scott &Associates
Name of Company
Relbam MA
City/Town State
413-256-0647
Telephone Number
01002
Zip Code
9 cc
M t
Porn-
ovivvA
v t0.
Wet
v C
t5forml a.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
A. Facility Information (continued)
5. Type of Building:
• Dwelling
Other Type of
Building
❑ Showers
Specify other fixtures:
6. Design Flow.
Calculated Daily Flow:
7. Plan:
❑ Garbage Grinder(check if present)
Number of showers
Number of Sheets
Septic System Inspection Report
Title of Plan
8. Description of Soil:
❑ Cafeteria
Number of Persons Served
❑ Other fixtures
330 GPD
aatbeiji&Day
Gallons
Date of Original
Revision Date
9. Nature of Repairs or Alterations (if applicable):
Replace deterirated septic tank and 0-box at same locations and elevations as existing. SAS to
continue in service undisturbed.
10. Date last inspected:
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code
and not to place the system in operation until a Certificate of Compliance has been issued by this
Boa r• •f Health. 9/1 j;
8-20-15
Date
t5famml a.doc•06/03
Signature
sate
Application for Disposal System Construction Permit•Page 2 of 3
si
Application Approved B
Name
Application Disapproved for the following reasons:
Da 9#5
#920/1-13
NORTHAMPTON BOARD OF HEALTH
212 MAIN STREET
NORTHAMPTON, MA 01060
t5fonnla doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3