27 Septic Inspection 2010 Owner
information is
required for
every page.
turns•09108
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 WEST FARMS ROAD
Properly Address
27 WEST FARMS ROAD CONDO ASSOCIATION ( PAUL C. MCCUTCHEON UNIT D )
Owners Name
FLORENCE
City/Town
MA. 01062
MAY 3, 2010
State Zip Code
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 16304 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):
Pe 5 Ortieai Inspection Form:Subsurface Sewage Oisresei System.Page 2 of 1,
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION ( PAUL C. MCCUTCHEON UNIT D )
Owner's Name
FLORENCE
Orly/Town
MA. 01062 MAY 3, 2010
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
PHILIP J. PASIECNIK
Name of Inspector
GREG'S WASTEWATER REMOVAL
Company Name
239 GREENFIELD ROAD
Company Address
SOUTH DEERFIELD
City/Town
413-665-3989
Telephone Number
MA.
State
S11526
License Number
01373
Zip Code
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
Z Passes
❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
MAY 7, 2010
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.
Tine 5 Official inspection Form:Subsurface Sewage Disposal System.gage 10f 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION ( PAUL C. MCCUTCHEON UNIT D)
Owner Owner's Name
information is FLORENCE
required for FLORENCE 01062 MAY 3, 2010
every page. CM)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:
of 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 day flow
inns.OWNS 1 ills 5 Official Inspection Form Subsurface sewage O,sWSel System•Page 4 of 17
'ner
xmation is
'aired for
f-re page.
ims•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION ( PAUL C. MCCUTCHEON UNIT D )
Owner's Name
FLORENCE MA. 01062 MAY 3, 2010
Cityfrown 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 ❑ 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
Tide 5 Official mspeG'm Form Subsurface Sewage Disposal System•Page 3 M 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION (PAUL C. MCCUTCHEON UNIT D
rner Owner's Name
ird
merlon n is
ae FLORENCE MA. 01062 MAY 3, 2010
,ry page.page. CirylTOwn State Zip Code Date of Inspection
>ns.09108
E. Report Completeness Checklist
Z Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
Z System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
floe 5()Nicol nspet,on Form Suesunem Sewage Disposal System.Page 17 of 17
Owner
information is
required for
every page.
15,n=.09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION ( PAUL C. MCCUTCHEON UNIT D )
Owner's Name
FLORENCE MA. 01062 MAY 3, 2010
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
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Loca
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
See A s i.1
I F / hLacA(
Dille 5 Official Inspection Form Sub CS Sewage DisposaI System•Page 15
tattoo is
ed for
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION ( PAUL C. MCCUTCHEON UNIT D)
Owners Name
FLORENCE
Cityfrown
MA. 01062 MAY 3, 2010
State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
N Check Slope
N Surface water
N Check cellar
❑ Shallow wells
Estimated depth to high ground water:
6+ ( Below Grade at Leaching Field)
feet
Please indicate all methods used to determine the high ground water elevation:
N Obtained from system design plans on record
If checked, date of design plan reviewed:
2003 From Newman Environmental Eng.
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:
Design Plan and Site Exam
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 Official Inspection Pomt Subsurface Sewage Disposal System.Page 16 of 17
Owner
information is
required for
every page.
ISins-09pe
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION ( PAUL C. MCCUTCHEON UNIT D
Owners Name
FLORENCE MA. 01062 MAY 3, 2010
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 I
vegetation, etc.):
Dimensions of Leaching Field 50ft. Long x 24ft. Wide are per Design Plan As
Built. Cut and Fill Area with Title Five Sand of 60ft. Long x 34ft. Wide are per Design Plan As Built
No clogging of the soil was evident at this time No signs of hydraulic failure or ponding to the
surface. The soil over the leaching field wasn't damp or spongy under foot at the surface. Vegetati
was mowed grass which was uniform in_growth over the area of the leaching field.
4 - Pipe L-FiE
50ft. L. x 24ft
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
N/A
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
❑ Yes ❑ No
Title 5O TUel Inspection Form Subsurface Sewage Disposal Syslem•Page 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 WEST FARMS ROAD
Properly Address
27 WEST FARMS ROAD CONDO ASSOCIATION ( PAUL C. MCCUTCHEON UNIT D )
r Owners Name
ration is gar FLORENCE MA. 01062 MAY 3, 2010
ed page City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy(locate on site plan):
Materials of construction:
Dimensions
N/A
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Title S Official Inspection Form'.Subsurface Sewage Disposal System•Page 14 W 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION ( PAUL C. MCCUTCHEON UNIT D)
Owner Owner's Name
information is FLORENCE MA. 01062 MAY 3, 2010
required for
every page. City/rown State Zip Code Date of Inspection
LSis•OF/D0
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integi
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):
N/A
Depth below grade:
Material of construction:
❑ concrete ❑ metal
❑ fiberglass ❑ polyethylene ❑ other(expli
Dimensions:
Capacity: gallons
Design Row: gallons per day
Alarm present ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ N
Date of last pumping ------ - ---- -- - ----- ---
Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached?
❑ Yes ❑ N
Title 5 Olfioal Inspectim Form Subsurface Sewage mswsai system.Page 11
nr
nation is
'eft for
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION ( PAUL C. MCCUTCHEON UNIT D )
Owners Name
FLORENCE
City/Town
MA. 01062 MAY 3, 2010
State Zip Cale
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 BDt Not Above
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 was level and flow was equal to all
four outlet pipes with the use of flow levelers put in at the time the system was installed. A little solids
carryover was in the box when opened for inspection. No leakage was evident into or out of the box
at this time. Distribution box cover was 40"deep below grade.
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.):
N/A
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Title 5 ort4a1 Inspection Fom,'.Subsurface Sewage Disposal System.Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION LPAUL C. MCCUTCHEON UNIT D )
Owner Owner's Name
information is FLORENCE MA. 01062 MAY 3, 2010
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:
7 Years Old / 4/30/2003 / As Built
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:
2.5
feet
❑ Yes ® No
PVC Entering Septic Tank
Town Water Supply
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints in the crawl space were in good condition. Joints from Unit D a
not visible due to being under a concrete slab.Venting pipes were visible outside the units on the
roofs. No visible leakage was evident at this time.
Septic Tank(locate on site plan).
Depth below grade:
Material of construction:
® concrete
2
feet
❑ metal ❑fiberglass ❑ polyethylene ❑ other(exph
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ h
12' Lx6'Wx6' D
Dimensions:
Sludge depth:
Eire.09108
None Detected
Tide 5 Official Inspection Pont sWsuM1xe Sewage Disposal system.Page 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION ( PAUL C. MCCUTCHEON UNIT D )
it Owner's Name
nation is
'ad for FLORENCE MA. 01062 MAY 3, 2010
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
N/A
None Visible
N/A
N/A
Measured Outside of Tank
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Recommendations for septic tank
pumping is every two years. PVC Inlet and outlet tees were in place and in good condition. Structural
integrity of the septic tank was visually good at this time. The liquid level was at the outlet invert when
the outlet cover of the septic tank was opened. No leakage was evident at this time. No outlet filter
was in place at the time of inspection as Design Plan shows. Risers were placed on all three
openings of the septic tank to make the covers within 8"of surface.
Grease Trap(locate on site plan):
Depth below grade:
Material of construction.
❑ concrete ❑ metal
N/A
feet
❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
.OSIOS Tile 5 Official Inspedim Form Sutsu facs Sewage Disposal System•Page 100117
Owner
information is
required for
every page.
i5w 09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION (PAUL C. MCCUTCHEON UNIT D )
Owner's Name
FLORENCE MA. 01062 MAY 3, 2010
Cfty/Town State Zip Code Date of Inspection
D. System Information
Description:
Designed for 5 Single Bedroom Apartments
Number of current residents:
Does residence have a garbage grinder?
4
❑ Yes
Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes El
Laundry system inspected? ❑ Yes
Seasonal use9 ❑ Yes El
Water meter readings, if available(last 2 years usage(gpd)): Unit D 81 gpi
Detail:
Last 2 Years Usage= 7900 Cu. Ft x 7.5 Gals. per Cu. Ft = 59,250 Gallons/730 Days= 81.16 gf
This usage is for Unit D only which is selling_
Sump pump? ❑ Yes
Currently
Last date of occupancy: Occupied
CommerciaUlndustrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑
Industrial waste holding tank present? ❑ Yes ❑
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑
Water meter readings, if available:
Tee 5 Official Inspection roan Subsurface Sewage Disposal Sys!em•Page 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION LPAUL C. MCCUTCHEON UNIT D)
'r Owners Name
ration is FLORENCE MA. 01062 MAY 3, 2010
pfor
page. Citylrown State Zip Code Date of Inspection
D. System Information (coat.)
Last date of occupancy/use:
Other(describe below):
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:
® 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
System septic tank was last pumped on 4/12/2010 by
Greg's per our records- 2000 Gallons was removed.
❑ Yes ® No
gallons
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe).
•09100 nne s[noel Inaped'o Form Subsurface Sewage Disposal System•Page Sof 17
Owner
information Is
required for
every page.
thins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION (PAUL C. MCCUTCHEON UNIT D)
Owner's Name
FLORENCE MA. 01062 MAY 3, 2010
City/Town 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:
❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevatic
❑ Z Any portion of cesspool or privy is within 100 feet of a surface water supply c
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 cesspool or privy is less than 100 feet but greater than 50 fe
from a private water supply well with no acceptable water quality analysis. [T
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the present
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppn
provided that no other failure criteria are triggered.A copy of the analy
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000g pd.
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. Th
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
❑ Z
❑ 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 Protectic
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 thre
or answered "yes" in Section D above the large system has failed. The owner or operator of any la
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 OVi al Ins ion Form bawl ace
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 WEST FARMS ROAD
Property Address
27 WEST FARMS ROAD CONDO ASSOCIATION ( PAUL C. MCCUTCHEON UNIT D)
it Owner's Name
cation is FLORENCE MA. 01062 MAY 3, 2010
pfor
page. City/Town State Zip Code Date of Inspection
•09108
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?
Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
Determined in the field Of any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)1
D. System Information
Residential Flow Conditions:
Number of bedrooms (design):
Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
4
550 GPD per
Design Plan
Title 501nael lnsoBGiac Form Subsurface Se aoeD pose By em Page 6 of
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SEPTIC TANKM£T: 10O,74 N WELL WEST FARMS PLACE, NORTHAMPTON,MA
SEPTIC TANS Oar:: 110.43 - --+ EXISTING CONTOUR(NEL.IOSIIE&MI
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