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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
107 Westhampton Rd -
Property Address
Stepnowski Family Trust
Owners Name
MWYglan -Florence Ma 01060 7/5/11
City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Dan A. Gray
Name of Inspector
Al-Enteprises
Company Name
72 Fox Hill Rd
Company Address
Bernardston
City/Town
413-648-9111
MA
State
01337
Zip Code
Telephone Number license Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes
❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspectors s
7/8/11
Date
The system inspector shall submit a c5py 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.
Tale 5 OMaa Inspection Fans.Subsurface Sewage Disposal System•Paw 1 W 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
107 Westhampton Rd -
Property Address
Stepnowski Family Trust
Owners Name
t alihallapan -Florence Ma 01060 7/5/11
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 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:
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):
m. 09108 Tm 5 ofi alI specio Fan" Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
107 Westhampton Rd -
Property Address
Stepnowski Family Trust
rer Owners Name
go r is
tirenation rt-Florence Ma 01060 7/5/11
sired
ry page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public hearth,
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
ins•09/08 Title S Official Inspection Fee SuModem Sewage Disposal System•Page 3 or 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
107 Westhampton Rd -
Property Address
Stepnowski Family Trust
Owner's Name
ffYrrrrOIM -Florence Ma 01060 7/5/11
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
••This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
s 09/138 Tale 5 Official Inspection Fain.Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
107 Westhampton Rd-
Property Address
Stepnowski Family Trust
er Owners Name
radon is
wed for _Florence Ma 01060 7/5/11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis- [this
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
• Z
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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
107 Westhampton Rd -
Property Address
Stepnowski Family Trust
Owner's Name
411111W_'!a-Florence Ma 01060 7/5/11
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)
® ❑ 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?
❑ E 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:
❑ Z Existing information. For example, a plan at the Board of Health.
E ❑ Determined in the field Of any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design):
No Design
Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
2
220
rbe s Official Inspection Form:Subsurface System.Page 60l n
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
107 WesthanlWn Rd
Property Address
Stepnowski Family Trust_—
Owners Name
Florence Ma 01060 7/5/11
�- — — State Zip Code Date of Inspection
Cily/Town
D. System Information
Description:
0
Number of current residents:
Does residence have a garbage grinder?
❑ Yes Z No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes E No
❑ Yes ❑ No
Laundry system inspected?
❑ Yes E No
Seasonal use Town Water
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commercialllndustrial 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:
Gallons per day(gpd)
E Yes E No
5/24 _ ___ _
Date
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
title 5 Offaal inspection Form:Subsurface Sewage Disposal System-Pa e 7 N 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
107 Westhampton Rd-
Property Address
Stepnowski Family Trust
Oxnefs Name
auon is KJ p m Florence Ma 01060 7/5/11
for State Zip Code Date of Inspection
page City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below):
Sins.osms
5/24
Date
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
9/93-4/00-7/1
❑ Yes ® No
gallons
Site Glass on Truck
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Tale 5 Official Inspection Form:Subsurface Sewage Disposal System.Page B 0117
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
107 Westhampton Rd -
Properly Address
Stepnowski Family Trust
Owners Name
t -Florence Ma 01060 7/5/11
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
30+Years
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:
5 1/2'
feet
❑ Yes ® No
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan).
Depth below grade:
Material of construction:
Z concrete ❑ metal
❑fiberglass
5/ 1/2' down but Riser to Grade on
Center Cover
❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate)
Dimensions:
Sludge depth:
❑ Yes ❑ No
Titles Official Inspection Fam:Subsurface Sw.see Disposal System.Page s o117
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,ns•ogm
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
107 Westhampton Rd -
Properly Address
Stepnowski Family Trust
Owners Name
!fie^ -Florence Ma 01060 _ 7/5/11
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or bathe
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?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Do to depth of tank unable to excavate inlet and outlet covers. Liquid level in tank 6"below top of
tank.
9 x5 x5
Un kown
Unkown
Unkown
Unkown
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
idle 5 anpedion Fnm.Subwrtxa Sewage Disposal System.Page 10 M17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
107 Westhampton Rd-
Property Address
Stepnowski Family Trust
Owners Name
Sbllrlr�llen- Florence Ma 01060 7/5/11
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
N/A
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
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.):
N/A
`Attach copy of current pumping contract(required) Is copy attached? ❑ Yes ❑ No
Tree 5(noel Inspeticn Form Subsurface Sewage Disposal system.Page 11 017
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
107 Westhampton Rd-
Property Address
Stepnowski Family Trust
Owners Name
/4811411=01111-Florence Ma 01060 7/5/11
City/rown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box Of present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
N/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.):
N/A
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Tate 5 Ofioal Inspection rum:Subsurface Serape Disposal System•Page 12 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
107 Westhampton Rd -
Property Address
Stepnowski Family Trust
Owners Name
Callemplon -Florence Ma 01060 7/5/11
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Drywell No. 1 6"liquid in bottom of tank, 10'from grade to bottom of tank. Drywell No. 2 8 .5' from
grade unable to excuavate due to depth. No evidence of breakout on side slope. Soils appear to be
dry.
2-Undetermined
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
rNe 5 OfficaI Inspedon Form.Subwrtam Sewage Disposal System•Page 13 al 17
Commonwealth of Massachusetts
JAW Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
107 Westhampton Rd -
Property Address
Stepnowski Family Trust
Owners Name
mow-Florence Ma 01060 715/11
City/Town State Zip Code Date of Inspection
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D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
107 Westhampton Rd-
Property Address
Stepnowski Family Trust
Owners Name
rA1111YNISOR-Florence
Cirylrown
Ma 01060 7/5/11
State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
107 Westhampton Rd-
Property Address
Stepnowski Family Trust
Owners Name
plyrwa}lan- Florence Ma _ 01060 7/5/11
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
Z Check cellar
❑ Shallow wells
Estimated depth to high ground water:
20' +
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:
House is elavated approx. 20'above westhampton rd no evidence of water sepage or ground water
at Westhampton Rd level. Which is approx. 10' below bottom of system.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
title 5 Oleaal lr sPeQmn Form.Subsurface Sewage Disposal System.Page 16 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
107 Westhampton Rd-
Properly Address
Stepnowski Family Trust
Owners Name
Sielellr4rrr-Florence Ma 01060 7/5/11
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, 0, 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
toe 5 Mani krspecan Form.Subsurface System•Page 17 or 17