113 Septic Inspection 2015 Commonwealth of Massachusetts
/tie 5 Official Inspection Form
surface Sewage Disposal System Form -Not for Voluntary Assessments
3 Whittier Street
Property Address
er Kim Goggins
maomn is Owner's Name
fired for Florence
page Ciy/Town
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on filling
forms on
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5ns 3113
MA 01062 4/15/2015
Stale Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any way.
Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Thomas S. Leue
Name of Inspector
Homestead Engineering Inc.
Company Name
1664 Cape St.
Company Address
Williamsburg MA
City/Town State
413-628-4533 SI-130
Telephone Number License Number
01096
Zip Code
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true, accurate and complete as of the time of the inspection. The inspection was performed
based on my training and experience in the proper function and maintenance of on site sewage disposal
systems. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CMR
15.000).The system:
® Passes
❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
� a April 15, 2015
Inspector's 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.
rpe 5Th'insp•mon Fam:Sunsu,leu Sewage Di spsna I Sudan.Page 1 m 17
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
=Subsurface Sewage Disposal System Form• Not for Voluntary Assessments
113 Whittier Street
Property Address
Kim Goggins
radon is Owner's Name
ea for Florence MA 01062 4/15/2015
City/Town
page 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. My 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
fins•113
n Fwm'.SuESUdace Sewage Dsposal System.Pape 2 of 17
ES Commonwealth of Massachusetts
>� -- Title 5 Official Inspection Form
.r -- -Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
113 Whittier Street
Property Address
Kim G ggins
ation is owners Name
!d for
Gib/flown MA 01062 4/15/2015
sage Florence - State Zip code Dare of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out
broken or obstructed pipe(s)or due to a broken,
pass inspection if(with approval of Board of
❑ broken pipe(s)are replaced
❑ obstruction is removed ❑Y
❑ distribution box is leveled or replaced ❑Y
or high static water level in the distribution box due to
settled or uneven distribution box. System will
Health):
❑Y
❑N ❑ND (Explain below):
❑ N ❑ ND (Explain below).
❑ 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
ma5°Meal Inspection Form:Subsurface Sewage Disposal s)sbm•Pe P .3 0117
iFS•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ubsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Whittier Street_ -
PropertyAddress _ —
Kim Goggins _owners Name
Florence MA 01062 4/15/2015
City!Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall 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:
ions
'for
rge.
Fs•3J13
•w This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform
r less
bacteria indicates absent and the presence of ammonia nitrogen and nitrate analysis en is equal to
coached to
than 5 ppm, provided that no other failure criteria are triggered. A copy the
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
• El
E El
❑
pV_
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
dogged SAS or cesspool
Liquid depth in cesspool is less than 6°below invert or available volume is less than'A
day flow
The 5 Official Inapectlen Form:Subsurface Sewage Disposal System•Pape 4 M 17
\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
"Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ion is
for
ige.
ns•119
113 Whittier Street
Property Address
Kim Goggins —_—_— —
Owners Name
Florence MA _ 01062
Clry(ran ---' State Zip Code Date of Inspection
B. Certification (cunt.)
Yes No
O El
❑ 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 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
❑ Z the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area–
IWPA)or a mapped Zone II of a public water supply
If you have answered"yes" to any question in Section E the system is considered a significant threat, or
answered"yes" in Section 0 above the large system has failed.The owner or operator of any large s Y stem
system considered a significant threat under Section E or failed under Section D shall upgrade
in accordance with 3W CMR 15.304.The system owner should contact the appropriate regional office of
the Department.
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.
My portion of cesspool or privy is within 100 feet of a surface water supply or tributary
to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a SAS, cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified laboratory,
for fecal coliform bacteria indicates absent and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no
other failure criteria are triggered.A copy of the analysis and chain of custody
must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000 gpd-10,000 gpd.
mN.SOfficial Inapt Form.sutuMce Sewage gsP091 System'Page 5 o 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ubsurface Sewage Disposal System Form•Not for Voluntary Assessments
113 Whittier Street
Property Address
Kim Goggins
m is Owner's Name
br
ns• J13
Florence
City/Town
MA _ 01062 4/15/2015
State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two-week period'?
❑ ® Have large volumes of water been introduced to the system recently or as part of this
inspection?
❑ ❑ Were as-built plans of the system obtained and examined?(If they were not available note
as N/A) N/A
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected
for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,
depth of sludge and depth of scum?
® ❑ Was the facility owner(and nrrupants 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: 4
Number of bedrooms 4 . Number of bedrooms _ --—.
(design)'. (actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of 660+ gpd
bedrooms).
Tab 50ficial Inspection Form'.Subsurface Sewage UsWeal sriNm.Page sa 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
51)S
ubsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Whittier Street
Property Address
Kim Goggins- - —_ - —. .
on is Owner's Name
for Florence MA 01062 4/15/2015
fo
City/Town State Zip Code Date of Inspection
D. System Information
Description:
1500-gallon septic tank, distribution box and a leachfield.
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? (Include laundry system
inspection information in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
9/5/14 to 12/16/14 @ 3900 CCF
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15 203).
Basis of design flow(seats/persons/sq.ft.,
etc.):
Grease trap present?
Industrial waste holding tank present's
Non-sanitary waste discharged to the Title 5 system?
Continuous
Date
Gallons per day(gpd)
Water meter readings, if available:
2
❑ Yes Z No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
286
❑ Yes ® No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
TO 5 Official Inspedi Form Submfaae Swage Disposal System•Pape 7 of 17
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For
7e.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
113 Whittier Street
Property Address
Kim Goggins --. _ -
Owner's Name
Florence _ MA 01062 4/15/2015
Cityrrawn State Zip Code Date of Inspection
n•YD
D. System Information (cunt)
Last date of occupancy/use'.
Other(describe below).
Date
General Information
Pumping Records:
Pumped about 3 years ago, says owner..
Source of information:
Was system pumped as part of the inspection? DYes ® No
If yes, volume pumped:
How was quantity pumped
determined?
Reason for pumping:
Type of System:
gallons
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):
This S Official Inspeoon Form.SuMwfeca Sewage OzWeol System•Page B or 1I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ubsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Whittier Street ----
Property Address
Kim Goggins
m is Owner's Name
for Florence MA 01062 4/15/2015
3e. Cart --- —'— State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
Septic plant Flan dated 7/11/1994.Were sewage odors detected when arriving at the site? ❑Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
Material of construction:
❑cast iron ❑40 PVC ®other(explain): ABS plastic
Distance from private water supply well or suction 25
feet
line.
Comments(on condition of joints, venting, evidence of leakage, etc.):
1.5 average
feet
No_roblems seen.
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
®concrete ❑metal
fiberglass
1.67 average
feet
❑ 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 ❑ Yes ❑ No
certificate) 58" Wide, 1121�i58" height
Dimensions:
Sludge depth:
is•3/13
3"
T*5 pfi[Yl Inapenon Form..auleaa Sewn.gsponi aim•Pens 9 o 17
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
113 Whittier Street —
Property Address —.
Kim Goggins
tn rm Owner's Name
'b` Florence MA 01062 4/15/2015
le. State Zip Code Date of Inspection
s•3113
City/Town
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or 28"
baffle 5„
Scum thickness
5"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee 14"
or baffle
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.):
Concrete looks to be in good condition. Tees in place. Riser to surface over
center cover.
Grease Trap(locate on site plan):
Depth below grade-
Material of construction:
❑concrete ❑ metal
Dimensions:
fiberglass
feet
❑ polyethylene ❑other(explain):
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 5 MOW Inspection Foam:subsuRere Se
.parietaott)
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
(Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
113 Whittier Street
Property Address
Kim Goggins
Owner's Name
Florence MA 01062 4/15/2015
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.):
on is
for
ge
•3/13
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ):
rglass ❑ polyethylene ❑other(explain):
fibe
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
T e 5 Mee!ImyMn Form:Su MUfcx Semetr Disposal System Pae 11 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
=Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
113 Whittier Street
Properly Address
Kim Goggins
Dn is Owners Name
Florence
for MA 01062 4/15/2015
ge
r•ru
—
City/TOWT Slate Zip Code Date of Inspection
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.):
Box has five pipes out. No significant biosolids in box. Box in good
condition.
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:
rib S Official inspection Form'.subsurface sewage Disposal system Pepe 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
113 Whittier Street
Property Address
Kiln Goggins
m is Owner's Name
for Florence MA 01062 4/15/2015
9a 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
30 ft. by 30 ft.
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- Conventional pipe and stone technology.
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
The 301fiIal Inspection Form:SchaWace Sewage nepomi system•Page 13 of n
3113
m5
br
3e.
•11J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
=Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
113 Whittier Street
Property Address
Kim Goggins _ - - - - - - - --
Owners Name
Florence MA 01062 4/15/2015
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Tnk s Official Irvpectlan Farm:Subsuhtte Sewage 0 System.Page II a117
Commonwealth of Massachusetts
rTitle 5 Official Inspection Form
.Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
113 Whittier Street
Property Address
Kim Goggins
,n in Owner's Name
Florence MA 01062 4/15/2015
le
•&13
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at
least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where
public water supply enters the building. Check one of the boxes below.
❑ hand-sketch in the area below
® drawing attached separately
TS 5 Official Inspection Form.Sub se
w
system.Page 15 of n
n is
or
le
3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
113 Whittier Street
Property Address
Kim Goggins
Owner's Name
Florence MA 01062 4/15/2015
CayrTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® 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 Plan of 7/11/1994
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:
Based on witnessed perc test conducted 5/4/1994. No water table to greater than
this depth.
The 5 Official Inspection Fom, Subswtace l System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
113 Whittier Street
Property Address
Kim Goggins
n is Owners Name
Florence MA 01062 4/15/2015
City/Ow state Zip Code Date of Inspection
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
it
le
113
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
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Title 5Offic'il Inspection Form Subsurface Sewage Disposal System•Gps 1]o!t]
thisVplanuposted in the basement/utility area would keep this
information accessible in future years for maintenance.
Leachfield, approximate layout
porch ...,.;. :''.:•
Y 113' ...: :.:; :;i::'':........
O yam- 1161/2. `. ..._::;i`:a;ii::i'..:; :: :;_;:;•
o
to
a Septic tank Distribution Box
Garage
Nearest pine tree
Note: No known drinking water sources within 100 foot radius.
Date:
Owner: a HOMESTEAD INC.
As-Built Drawing 4/15/2015 Kim Goggins ,I Thomas S. Leue R.S.
Existing Septic System
Revision Date: 113 Whittier Street / 664 Cape St.
Scale: 1 : 20' ,�s Williamsburg,MA 01�96
Except as Noted
Florence, MA 01062 \ �p�� total 628-4533