46 Septic Inspection 2015 &lap ✓ ems
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Whittier Street
Property Address
er Joe Ustaitis Jr.
madon is Owners Name
iced rgr Florence MA 01062 5/21/2015
y page.
Cityfrown State Zip Code Nte of Inspection
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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
MA
City/Town State
413-628-4533 SI-130
01096
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
May 21, 2015
Inspectors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of
Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a
design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the
appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use at
that time. This inspection does not address how the system will perform in the future under the
same or different conditions of use.
TS 5 Mad Inspection Form.Subsurface Sewage Disposal System..Page 1 of 17
Commonwealth of Massachusetts
iTitle 5 Official Inspection Form
eon is
d for
age.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
46 Whittier Street
Property Address
Joe Ustaitis Jr.
Owner's Name
Florence MA 01062 5/21/2015
City/Town 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 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.
3/13 Tide 5OMc'ial Inspection Form:Subsurface Sewage Usroeal System r Pape 2 M If
Corn monwealth of Massachusetts
Title 5 Official Inspection Form
;Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Whittier Street
Property Address
Joe Ustaitis Jr.
bon is Owner's Name
tfor Florence MA 01062 5/21/2015
age. Cityrrown State Zap Code Date of Inspection
•3/13
B. Certification (cunt.)
B) System Conditionally Passes (cord.):
❑ 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
Tm.s aria!Inspecbon Form:Subsurface Swag.Rarwal System.Page 3 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
sSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Whittier Street
Property Address
Joe Ustaitis Jr.
Owners Name
Florence
CiN Tom
NA 01062 5/21/2015
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
0 E1
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 61 below invert or available volume is less than%
day flow
Title 5 Official Inspection Porn 5KauMw Sewage OspaaaI SYbem-Page 4 417
on is
for
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•313
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
46 Whittier Street
Properly Address
Joe Ustaitis Jr.
Owner's Name
Florence
CityrTown
MA 01062 5/21/2015
State Zip Code Date of Inspection
B. Certification
Yes No
(cont.)
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.]
❑ 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
• the system is within 400 feet of a surface drinking water supply
Z 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.
Tie s Official 1mpc9nn Fwm:Subu,h®Sewage OisWfei system'Pape 5 at 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
"Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
46 Whittier Street
Property Address
Joe Ustaitis Jr.
on's Owner's Name
for Florence MA 01062 5/21/2015
9e city/Town State Zip Code Date of Inspection
3%3
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
❑ Z 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 bathes 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)1
D. System Information
Residential Flow Conditions:
Number of bedrooms 4 Number of bedrooms 4
(design): (actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of 662 qpd
bedrooms):
The 5 Official Inspection Form'.Subsurface aewase Deposal Syetxn-Page Got 17
\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Whittier Street
Property Address
Joe Ustaitis Jr.
3n is Owner's Name
for Florence MA 01062 5/21/2015
se. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1500-gallon septic tank, distribution box and a pipe and stone leachfield.
3
Number of current residents:
Dces residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system?(Include laundry system ❑ Yes ® No
inspection information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
98 gpd
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
6/16/14 to 4/6/15 used 4200 cu. ft.
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?
Continuous
Date
❑ Yes ® No
Gallons per day(gpd)
Water meter readings, if available:
•113
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
TAM5taco Inapet•On Fe,m'.SubsaSe Saw pa
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3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
,Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Whittier Street
Property Address
Joe Ustaitis Jr.
Owner's Name
Florence MA 01062 5/21/2015
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below):
Date
General Information
Pumping Records: -1
Pumped 2 years ago, says owner
Source of information:
Was system pumped as part of the inspection? ®Yes ❑ No
1,500
If yes, volume pumped:
How was quantity pumped
determined?
Reason for pumping:
Type of System:
C
gallons
Engineering plan
Recommend pumping every 3 to 5 years.
Septic tank, distribution box, soil absorption system
Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) Of 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):
rp%50fc®I In
Sutsurlea Sewage Geµsei Syslein•Page 8 of t]
Commonwealth of Massachusetts
F Title 5 Official spco Fom
ubsurface Sewage Disposal System In Form e-Not ti for Voluntary n Assessments
mIs
for
3e
•3/13
46 Whittier Street
Property Address
Joe Ustaitis Jr.
Owners Name
Florence MA 01062 ._ 5/21/2015
Cityrrown slate Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components date installed Of known)and source of information:
Septic plan: Plan dated 6/7/2004.
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): ABS plastic
Dees ® No
1 average
feet
Distance from private water supply well or suction line:
30
feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
No problems seen. Pipes are hidden in basement.
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
1.3 average
feet
®concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain)
Concrete septic tank, about 1500-gallons nominal capacity.
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
58" wide, 126" long, 59" height
2"
This a Official Inspection Form:Subsurface swage Disposal System.Page s of 17
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
.Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
96 Whittier Street
Property Address
Joe Ustaitis Jr.
n is Owners Name
'r Florence MA 01062 5/21/2015
e
City/Town State Zip Code Date of Inspection
113
D. System Information (cant.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or 28"
baffle
2"
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 21"
baffle
5"
calculated
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.):
Tank is mostly located under deck. Concrete looks to be in good condition.
Water level at outlet invert. A 16" riser over the center is located under a
panel in deck. A riser is over outlet. Inlet was inaccessible.
Recommend pumping on 3-5 year interval.
Grease Trap(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
feet
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
Title S Official Inspection Form.SuMUkce Sewage Disposal System•Pape 10 of 11
Ix Commonwealth of Massachusetts
Title 5 Official Inspection Form
.Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
46 Whittier Street
in is
for
3e
.3(13
property Address
Joe Ustaitis Jr.
Owner's Name
Florence NA 01062 5/21/2015
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:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
❑ Yes ❑ No
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
TIM 50111cS Inspection Foam:SuMwfeca Sewepo Disposal System•Page 11 7117
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
&Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Whittier Street
Property Address
Joe Ustaitis Jr.
is is Owner's Name
Florence MA 01062 5/21/2015
Cityrtown State Zip Code Date of Inspection
3/13
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
0"
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.):
D-box appears level and flow distributed 3 pipes out of box. No biosolids seen
in box.
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:
TS 5 Official bagel on Form'.Subsu
Q papoul SyM•m•Pape 12 a 17
n is
or
3e
3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
SSubsurface Sewage Disposal System Form-Not for Voluntary Assessments
46 Whittier Street
Property Address
Joe Ustaitis Jr.
Owners Name
Florence MA 01062 5/21/2015
Csy/rown Slate Zip Cade Dale of Inspection
D. System Information (coot.)
Type:
❑ leaching pits
❑ leaching chambers
❑ leaching galleries
❑ leaching trenches
• leaching fields
❑ overflow cesspool
❑ innovative/alternative system
number:
number:
number:
number, length:
number, dimensions:
number:
1 field, 15' x 60'
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. Raised leachfield area. System is vented at end.
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
Tme 5 Official Irmpdron Form Subs
wage
I system.Page 13417
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ubsurface Sewage Disposal System Form-Not for Voluntary Assessments
46 Whittier Street
Property Address
Joe Ustaitis Jr.
n in Owners Name
Of Florence MA 01062 5/21/2015
Ie.
3/13
Cityrrown
State lip 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.):
Tale 5Official Inspection Form'.Subsurface eawopet Disposal System•Page 14 M 17
▪ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Whittier Street
Property Address
Joe Ustaitis Jr.
n is Owners Name
or Florence
City/Town
113
MA 01062 5/21/2015
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
The 5°mcbl Irvpwann Form'.Subfulece Serge Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Whittier Street
Property Address
Joe Ustaitis Jr.
Owners Name
Florence
City?own
MA 01062
State Zip Code
5/21/2015
Date of Inspection
D. System Information (cont)
Site Exam:
Z Check Slope
❑ Surface water
M Check cellar
❑ Shallow wells
Estimated depth to high ground water:
5+
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 6/7/2004
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:
Built based on perc test data, raised leaching area and built to current code.
The 5 OMcm Inspection Form.Subs es swnpa Cuposal ahem.Po9.16 of n
113
a Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Whittier Street
Property Address
Joe Ustaitis Jr.
n is Owner's Name
'r Florence _ MA 01062 5/21/2015
e'
City/Town state Zip Code Date of Inspection
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
V13
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
TRW s Official Inspection Foim'.Su bwtM1rw Sewage Disposal sp4m.Page 17 of 17
181' i
____ _ 118'
1651
12,,.......,.....
Cleanout 165 -' Leachfield
m N
in
7
O
O
c a - Septic tank
p' '7 Note: access hatch
A built into deck.
E
a
Deck over
tank
NORTH
COMMENTS:
Recommend pumping on a 3 to 5 year schedule. Also, a copy of this plan posted in the
basement/utility area would keep this information accessible in future years for maintenance.
As-Built Drawing Date: Owner: HOMESTEAD INC.
Existing Septic System 6/7/2004 Joe Ustaitis Jr. Thomas S. Leue R.S.
Revision Date: 46 Whittier St. 664 Cape St.
Scale: Noted Florence, MA 01062 Williamsburg,MA 01096
14131628-4533
Except as Noted