757 Florence Road Title 5 Inspection Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
757 Florence Road
Property Address
Owner Hafid Assab
Information is Owner's Name
required for Florence
every page.
City/Town
Important:
When filling
out forms on
the
computer,
use only the
tab key to
move your
curnOr not -do
tt use the
return key
,Sine.3(13
MA
State
01062
Zip Code
10/14/2015
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
Inspector:
Thomas S. Leue
Name of Inspector
Homestead Engineering Inc.
Company Name
1664 Cape St.
Company Address
Williamsburg
City/rown
413-628-4533
Telephone Number
MA 01096
State
SI-130
License Number
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
October 14, 2015
Inspector's S(gnature 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.
The 5 Official Inep.di 'Form:Su co 9cxage Disposal System.Plpe 1W 17
Owner
information is
required for
every page
Wns•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
757 Florence Road
Property Address
Hafid Assab
Owners Name
Florence MA 01062 10/14/2015
City/Town State Zip Cade Date of Inspection
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):
❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if
pumps/alarms are repaired.
TItle 5 Official Inepdso Form:Submiaw Sewn*Diq•a System•Page 2o117
1 Commonwealth of Massachusetts
LTitle 5 Official Inspection Form
:Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
757 Florence Road
Property Address
Owner Hafid Assab
information is Owners Name
required ery page Florence
every page
6he•3113
City/Town
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 ❑Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below):
MA 01062 10/14/2015
State Zip Code Date of Inspection
❑ 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
TMe S Official Imp:on Form:Su[w,fam Sewage Disposal System•Page 3 of 17
Owner
information is
required for
every page
ISins.3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
757 Florence Road
Property Address
Hafid Assab
Owner's Name
Florence
City/Town
B. Certification (cunt.)
MA 01062 10/14/2015
State Zip Code Date of Inspection
2. System will fail unless the Board of Health (and Public Water Supplier, if arty)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 colifonn
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than
5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this
form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all Inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or
cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than%day
❑ ® flow
Title 5 Official IMP tim Fwm:euMUrym Swye Disposal System.Page 4 M 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
757 Florence Road
Property Address
Owner Hafid Assab
intonnation is Owners Name
required for Florence
every page
MA 01062 10/14/2015
City/rown
State Zip Code Date of inspection
B. Certification (cont.)
Yes No
❑ Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s).Number of times pumped:
❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply.
❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well
❑ Z 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
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.]
❑ Z
The system is a cesspool serving a facility with a design flow of 2000 gpd-10,000 gpd.
❑ Z The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should
contact the Board of Health to determine what will be necessary to correct the failure.
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
❑ Z
❑ 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.
Tan Somsai Lno.don F.
•P"g5017
14 Commonwealth of Massachusetts
u7 5 Title 5 Official Inspection Form
ubsurface Sewage Disposal System Form •Not for Voluntary Assessments
7 Florence Road
Owner
information is
required for
every page
6415.113
Property Address
Hafid Assab
Owner's Name
Florence MA 01062 10/14/2015
City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes°or"na°as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner,occupant, or Board of Health
❑
01 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/AZ
[� ❑ 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?
®
El 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 4
(design):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of
bedrooms):
Number of bedrooms(actual):
4
440 gpd
MIS 5 pfitlal Newton Fwm:aubsu smaw anpo.ai Synpn Pose e d n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
757 Florence Road
Property Address
Owner Hafid Assab
information is Owners Name
required for
every page.
MM..vu
Florence
City/rmvn
MA 01062 10/14/2015
State Zip Code Date of Inspection
D. System Information
Description:
1000-gallon septic tank, pump tank and 4 leaching galleries.
Number of current residents:
3
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)): 95
Detail:
5/26/15 to 8/5/15 used 900 cu. ft.
Note: system not designed for a garbage grinder. Recommend it be removed.
Sump pump? ® Yes ❑ No
Last date of occupancy: Currently occupied.
Date
Commercialllndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons perday(gpd)
Basis of design flow(seatslpersons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Ti.5 ofoial Impaction Form'Subsurface Stage Disposal System•Pege 7 of 17
A , Commonwealth of Massachusetts
Title 5 Official Inspection Form
• 4ubsurface Sewage Disposal System Form-Not for Voluntary Assessments
757 Florence Road
Property Address
Owner Hafid Assab
information is Owner's Name
required for Florence MA 01062 10/14/2015
every page
City/Town State Zip Code Date of Inspection
LAns.Lls
D. System Information (cunt.)
Last date of occupancy/use:
Other(describe below):
Date
Pumping Records:
Source of information:
General Information
Last pumped 2 years ago, says Owner.
Was system pumped as part of the inspection? Oyes Z No
If yes,volume pumped:
How was quantity pumped
determined?
Reason for pumping:
Type of System:
gallons
Recommend pumping on 3 to 4 year basis.
❑ Septic tankr distsibation-bes, 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 ands lnpkOM Form:sutwwtaw sewage syWn•Paps a of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
757 Florence Road
Property Address
owner Hafid Assab
information is Owner's Name
required for
every page
tins.&fe
Florence
Ciyrfown
MA 01062 10/14/2015
State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components,date installed (if known)and source of information:
Septic plan: Leaching system built in July 1999. Septic tank and pump system
older.
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:
4 average
feet
15
Oyes ® No
feet
Comments(on condition of joints,venting,evidence of leakage, etc.):
No problems seen. Measurement is between water line and sewer line locations in
basement. Not much of basement pipes visible.
Septic Tank(locate on site plan):
3.5 average
Depth below grade:
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
Concrete septic tank, about 1000-gallons nominal capacity.
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
59" wide, 93" long, 57" height
Dimensions:
Sludge depth:
4"
litle 5Official Inspeticn Finn:Subsurface Sewage dycuu SyNam•Pa%9 Si?
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
757 Florence Road
Property Address
Owner Hafid Assab
information is Owner's Name
required for
every page
t5ins•3/13
Florence
CityRown
MA 01062 10/14/2015
State Zip Code Date of Inspection
D. System Information (cunt)
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
lido 5OmdaI InwNon Fwm:subw
e piaputl 5yelem.Page 11 of 17
gN Commonwealth of Massachusetts
Title 5 Official Inspection Form
■ Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
757 Florence Road
Property Address
Owner Hafid Assab
information is Owner's Name
required for Florence MA 01062 10/14/2015
every page.
Ctyown State Zip Code Date of Inspection
D. System Information (cunt.)
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?
25"
6"
22"
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.):
Tank structurally OK. Baffles intact. Large diameter riser over center cover to
within 6" of surface.
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:
Date
The 5 Official Impedon Form',subsuham swage Dispolal system.Page ra N n
lx Commonwealth of Massachusetts
Title 5 Official Inspection Form
Owner
information
required for
every page.
Sine•3113
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
757 Florence Road
Property Address
Hafid Assab
Owners Name
Florence MA 01062 10/14/2015
CltyRown State Zip Code Date of Inspection
D. System Information (cant.)
Distribution Box(if present must be opened)(locate on site plan):
None in system, plastic tee used instead
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: ❑ 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:
t.sofld'N Inge Lan Form:Subsurface sw.ip.Disposal system•Page 12 N 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
757 Florence Road
Property Address
Owner Hafid Assab
information is Owner's Name
required for
every page
ens•3/13
Florence MA 01062 10/14/2015
City/Town State Zip Code Date of Inspection
D. System Information (tont.)
Type:
❑ leaching pits
❑ leaching chambers
• leaching galleries
❑ leaching trenches
❑ leaching fields
❑ overflow cesspool
❑ innovative/alternative system
number
number:
number:
number, length:
number,dimensions:
number:
4
Type/name of
technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of
vegetation, etc.):
No surface problems seen. Center distribution system. One galley opened and
found no retained water or biosolids. Significantly mounded system.
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
TO sOfficial InWmm form'.Subsurface Sewage piepa&system•Page 13 W 17
Owner
information Is
required for
every page
[Sine•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
757 Florence Road
Property Address
Hafid Assab
Owners Name
Florence
City/Town
MA 01062 10/14/2015
State Zip Code Date of Inspection
D. System Information (cunt.)
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.):
The 5 official Inspection Form:Subsurface Swage d.pa.el System Page u of 17
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Owner
information is
required for
every page
5ru•3/13
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
757 Florence Road
Property Address
Hafid Assab
Owner's Name
Florence
City/Town
MA 01062 10/14/2015
State 2p 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
TNe 5Offida Inspe liar Fomt 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
757 Florence Road
Property Address
owner Hafid Assab
information is Owners Name
required for Florence
every page
City/rown
ISIne•3/13
MA 01062 10/14/2015
State Zip Code Date of Inspection
D. System Information (cont)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
5+ feet
Estimated depth to high ground water. 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:
Leaching area is built up several feet. Built to the current code.
The 6Ofdel Inspection Fenn:subsurface Swa a pipawl ByTern•Page 16 of 17
Owner
information is
required for
every page
Isms•wu
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
757 Florence Road
Property Address
Hafid Assab
Owner's Name
Florence
City/Town
MA 01062 10/14/2015
State Zip Code Date of Inspection
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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
Ttle 5 Official Inspeolion Form:Subw,hm Swage Disposal System•page rr of 17
Note:No known drinking water sources
North
Rs1ENTS:
1-
partial outline of house
septi tan
hin 100'radius.
leaching galleries
ump chamber
•.••.••• . yeas a co
y or tnis plan posted an the
anent/utility a ea would kee this information access
hie in future years for maintenance.
As-Built Drawing
isting Septic System
Date:
10/14/2015
Owner:
Hafid Assab
757 Florence Road
Florence, MA 01062
HOMESTEAD INC.
Thomas S.Leue R.S.
1664 Capest.
Williamsburg,MA 01096
[413162x-4533
Scale:1:10'
Except as Noted
Revision Date: