534 Title 5 Application/Permits 1968, Deep Soil Logs, Inspection 2012 Howard Laboratories
62 Main Street - Hatfield, MA 01038 Tel. (413) 247-5533 Fax (413) 247-9599
Client:
Matthew G. Martin
1169 Apple Valley Rd.
Ashfield MA 01330
WATER ANALYSIS REPORT
Invoice Number: 15957
Sample Location: 534 North Farms Rd. Florence
Date Sampled: 11-29-12
Date Received: 11-29-12
Parameter Sample Result
MA DEP/EPA Maximum
Contaminant Limit (MCL)
Comments
Total Coliform Bacteria
E. coe
Absent
Absent
Absent OK
Absent OK
§ Microbiology Certification #: M-00851 for Total Colifomn &E. coil (SM 92238-Colilert®)
Additional Water Quality Parameters
Parameter Sample Result MA DEP/EPA MCL Comments
Color 8 PtCo Color Units 15 PtCo Color Units OK
Iron 0.17 mg/L
0.3 mg/L OK
Manganese 2.85 mg/L 0.05 mg/L *
Nitrate 0.1 mg/L 10 mg/L OK
Nitrite 0.005 mg/L 1 mg/L OK
pH 6.60 pH Units 6.5 - 8.5 Ph Units OK
Sodium 3 mg/L 20 mg/L OK
Conductivity 0.63 mS/cm No Standard No Standard
Turbidity 2.92 NTU No Standard No Standard
Chloride 38.4 mg/L
250 mg/L OK
Hardness 174 mg/L No Standard c50 soft
>100 hard
Parameters marked with an asterisk are above acceptable MCL. Please refer to the
attached sheet for more information. Most of the parameters that are over the limit should
decline to below MCL after a few weeks as the water and materials floating in the well settle.
Analyst: EG Date: 12-3-12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt
Owner Owner's Name
information is
required for every Florence
page. City/Town
Important:When
filling out forms
on the computer,
use only the tab
key to move your
cursor-do not
use the return
key.
nine.11110
MA 01062 11/26/2012
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any way.
Please see completeness checklist at the end of the form.
A. General Information
1.
Inspector:
Thomas S. Leue
Name of Inspector
Homestead Engineering Inc.
Company Name
1664 Cape . St._
Company Address
Williamsburg
City/Town
413-628-4533
Telephone Number
MA
State
SI-130
License Number
01096
Zip Code
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title
5(310 CMR 15.000).The system:
® Passes
❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
t,/e 2Sizes' S A n
December 7 , 2012
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 shalt 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.
nne s Oncbl Inspecbon Form.Subsurface Sewage Dsposei System•Page 1 of 17
Owner
required for ie Florence _ MA 01062 11/26/2012
repaired for every _.__.. .
page. City/Town State Zip Code Date of Inspection
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt Martin
Owner's Name
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 that indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for'yes", "no" or 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):
bins•1910 Tree 5 Official Inspection Form'.Subsurface Sewage Disposal System•Page 2 of 17
Owner
information is
required for every
page.
thins•11/10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt Martin
Owners Name
Florence
City/Town
MA 01062 11/26/2012
State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑V ❑ 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 n 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
Title SORc®I Inspection Form.Subsurface Sewage Disposal System•Page 3 of Il
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt Martin
Owner's Name
Florence
City/Town
MA 01062 11/26/2012
State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
••This system passes if the well water analysis, performed at a DEP certified laboratory, for 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:
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 1/2 day flow
,Sins.11110 Title s Official Inspection Form'.Subsurface Sewage DspcsaI System Pegg a of 17
Owner
information is
required for every
page.
ens•HM
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt Martin
Owner._ . __...
OwneYS Name
Florence
MA 01062 11/26/2012
City/Town
State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Z
❑ Z
❑ Z
❑ Z
❑ Z
❑ Z
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: .
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a SAS, cesspool or privy is less than 100 feet but greater than 50
feet from a private water supply well with no acceptable water quality analysis.
[This system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence of
ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000 gpd-10,000
gpd.
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
❑ Z 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 Official Inspection Form'.SuMU,lace Sewage Deposal System.Page of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt Martin
Owner Owner's Name
information every is
required Florence MA 01062 11/26/2012
nage. fo
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ 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) N/A
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® [ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been
determined based on:
® ❑
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): unknown Number of bedrooms
(actual)'.
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of
bedrooms):
4
440+ gpd
51ns.11110 Tide 5 Official inspection Fenn..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
534 North Farms Road
Property Address
Matt Martin
Owners Name
Florence
City/Town
MA 01062 11/26/2012
State Zip Code Date of Inspection
D. System Information
Description:
1,000 gallon septic tank and long leaching trench.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection ❑ Yes ® No
required]
Laundry system inspected? ❑ Yes Z No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): Private well
Detail:
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/persons/sq.ft., etc.).
Grease trap present?
Industrial waste holding tank present?
Non-sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
❑ Yes ® No
unoccupied 30 days
Date
Gallons per day(gpd)
J Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
sins•11110 Title 5 0Rc®l Inspection Form SuMUkace Sewage Disposal System•Page 7 al 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
534 North Farms Road
Property Address
Matt Martin
Owners Name
Florence
City/Town
MA 01062 11/26/2012
State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below).
Pumping Records:
Source of information:
Date
General Information
Last pined summer 2010, says owner.
Was system pumped as part of the inspection?
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distributienbext soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
['Yes ® No
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the WA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
51ns•1100 Title 5 Olfichl Inspection Form.Subsurface Sewage Disposal System-Page 8 N 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt Martin
Owner Owners Name
information is Florence MA 01062 11/26/2012
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
Approximate age of all components, date installed Of known)and source of information:
septic plan: estimated as 1960's technology with a newer leaching trench at
the end, _probably an extension of an earlier trench.
Were sewage odors detected when arriving at the site? ❑Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3 average
feet
Material of construction:
®cast iron ®40 PVC ® other (explain): Orangeburg
Distance from private water supply well or suction line- Around 25 ft.
feet
Comments(on condition of joints, venting, evidence of leakage., etc.):
Iron out of house, Orangeburg pipe, then perforated Orangeburg, then
perforated PVC.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
®concrete
If tank is metal, list age:
2.5
feet
I metal ❑fiberglass E polyethylene C other(explain)
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes No
58" wide, 86•• long, 63"
height
3"
Dimensions:
Sludge depth.
ISins•11110 The 5 Official Inspection Form:Subsurface Sewage raspwal System.Page 9 ofta
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt Martin
Owner's Name
Florence
City/Town
MA 01062 11/26/2012
State Zip Code Date of Inspection
D. System Information (cons.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or
baffle
How were dimensions determined?
32"
1"
16"
calculated
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1,000 gallon tank in good structural condition. Removable baffle, 1960's
type. Outlet baffle reduced in height when clog removed- Water level above
height of outlet invert until clog removed. Current outlet could be
improved with PVC tee. A riser to the surface would improve access for
maintenance.
Grease Trap(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal
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:
Date
ins•nrlo Title 5 Ofnclal Inspection Form:Subsurface Sewage Dbposal System•Page 10 of IT
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt Martin
Owner Owners Name
information is
required for every Florence MA 01062 11/26/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan)
Depth below grade.
Material of construction:
❑concrete ❑ metal
❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions: - - -
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: - - -------------------
Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ] Yes ❑ No
LSTs•11A0 TAle 5 Official Inspection Form:Subsurface Sewage D System•Page 11 of V
Owner
information
equired fo is Florence MA 01062 11/26/2012
required for every
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt Martin
Owner's Name
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Distribution Box Of present must be opened) (locate on site plan).
None in system
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.):
Pump Chamber(locate on site plan):
Pumps in working order:
Alarms in working order:
❑ Yes ❑ No
❑ yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
thins•11/10 Tnk 5 Official Inspection Form.Subsurface Sewage Deposal System•Page 12 of 17
nx Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt Martin
Owner Owner's Name
information is
required for every Florence
page. City/Town
MA 01062 11/26/2012
Slate Zip Code
Date of Inspection
D. System Information (cunt.)
Type.
❑ leaching pits
❑ leaching chambers
❑ leaching galleries
❑ leaching trenches
❑ leaching fields
❑ overflow cesspool number: -----
innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
number:
number:
number.
number, length:
number,
dimensions:
1 trench,
approximately 100 ft.
No surface problems seen. Trench at multiple elevations. Bottom section
appears to have been built at a later date than upper section. Trench
absorbed significant flow from septic tank with no retained water or
surfacing.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool - -
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Ems.11110 Tile 5 Official Inspection Form Subsurface Sewage Disposal system.Page 13 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
534 North Farms Road
Property Address
Matt Martin
Owner's Name
Florence MA 01062 11/26/2012
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.):
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.):
61ns•11/10 DM s olficlal Inspection Form Subsurface Sewage Disposal System'Page 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
534 North Farms Road
Property Address
Matt Martin
Owner's Name
Florence MA 01062 11/26/2012
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 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
Z drawing attached separately
t5ms.11110 The 5 OIPtbl Ii pecbon FGrDV Subsurface Sewage Disposal system.Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt Martin
Owner Owner's Name
reformatifn is Florence MA 01062 11/26/2012
inf rma on every
page. City/Town Slate Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Z Check Slope
® Surface water
® Check cellar
I I Shallow wells
Estimated depth to high ground water:
3
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: pale
® 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:
At lowest extent of leaching area the soil is very sandy with many stones.
Nearby sinkhole demonstrates local water level. Stream surface about 50 ft.
distance also demonstrates local water level. Probably in flood plain, but
above mean high water.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ms•11/10 TM 5 ommcral In,p coon Form:Subsurface Sewage Disposal System•Page 16 of IT
14 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
534 North Farms Road
Property Address
Matt Martin
Owner Owner's Name
Ie fo Florence MA
reqquired uired for r every l M 01062 11/26/2012
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® 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
Isms•11)10 TAIe 5 Official Inspection Form.Subsurface Sewage Disposal System.Page 17 of 17
Well, reported location
NORTH
100'
Leaching trench
23 �_
156'
Mar
Partial House Outline Septic Tank 145,
•
Date: Owner: x HOMESTEAD INC.
As-Built Draw in 11/26/2012/26/2012 Matt Martin
Existing Septic System ;r- MOMS 8. Thomas S. Leue R.S.
534 North Farms Ro- • LEU�
Scale: 1 : 20' Revision Date: 12 - 1664 Cape St.
Florence, MA 01062 ,i 4.,py� Williamsburg, MA 01096
Except as Noted "��IIEO bta 14131 628-4533
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CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
1/TY or d /Lneint lc(e
1ppliratiun fur Binpuuat Ularkz Cllunntrurtinn lrrmit
Application is hereby made for a Permit to Construct, (Al or Repair ( ) an Individual Sewage Disposal
System at: i,eAuee
--YY LMa[ionAdtlStfs a ,/f'Ag1. ; Lot No.
vt � 1.;,Th1
Owner Address
Installer Address ('{G
Type of Building Size Lot ��A Sq. feet
Dwelling—No. of Bedrooms Expansion Attic (�(/ Garbage Grinder (yT(—S
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow Z5 gallons per person per ay. Total daily flow e«..Y gallons.
Septic TaTnks. laid capacity./.araeallons Length .f Width e%.. Diameter Depth/6.
Disposal { -No. A......... Width 4.9.0 Total Length VL' Total leaching area.t.CLQ_sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Percolation Test Results ,Other Distribution box (x) Dosing tatikl(g ) (f, leer _O D_ 7 '7
�Performed by ((�° �/ d7 Date /
Test Pit No. 1 `p J minutes per inch Depth of Test Pit e2Y Depth to ground water 2%
Test Pit No. 2 sr minutes per inch Depth of Test//Pit SO Depth to ground water 7
Description of Soil t Bette. / ('^L t]
' fr 4 E,
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
f( Signed
Application Approved By
Application Disapproved for the following reasons:
Date
Date
Date
Permit No Issued
CHECK OR FILL IN WHERE APPLICABLE
No Fax
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
1 ppR atinn for Binpxn at
rr
nrke Olunotrurtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair (4) an Individual Sewage Disposal
System at:
4..47
Location•Address
Owner
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No of persons Showers ( ) — Cafeteria ( )
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity, gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
Nature of Repairs or Alterations—Answer when a,pplicable
, , . r • r I
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The und signed further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the b*rd of Health. (.-
Signed
Application Approved By
Date
Date
Application Disapproved for the following reasons
Date
Permit No. Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ftrrtifirtttr of fQnmplittncr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No 1 dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No FEE
Binomial a into 0lnnstruction tirratit
Permission is hereby granted
to Construct ( ) or Repair (/5 an Individual Sewage Disposal System
at No - �
street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS