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97 Septic Inspection 2015 CITY of NORTHAMPTON PUBLIC HEALTH DEPARTMENT BOARD OF HEALTH MEMBERS: Donna Salloom, Chair Joanne Levin, MD-Suzanne Smith, MD STAFF-Merridith O'Leary.RS.Director—Daniel Wasiuk Inspector—Edmund Smith, Inspector—Lisa Steinhock RN Nurse r c� E gr" July 28, 2015 Estate of Angelina M.Pratt )7 Mountain Street 71orence,MA 01062 RE: Sewage Disposal System Inspection 97 Mountain Street )ear Homeowner: the Northampton Board of Health is in receipt of a report on the Subsurface Sewage Disposal System nspection conducted by Philip Pasiecnik at your property,97 Mountain Street on July 20, 2015.That nspection report indicates that your subsurface sewage disposal system fails to protect the public health and the environment as defined in Section 15.303 of CMR 15.000,State Environmental Code,Title 5. therefore,in accordance with the provisions of 310 CMR 15.000 of the State Environmental Code,Title 5, and under authority of Massachusetts General Laws,Chapter 21A,Section 13,you (or the subsequent )wner of the property) are hereby ordered to repair the subsurface sewage disposal system at 97 Mountain Street,within two years of the date of the original inspection,(July 20,2017). If further iegradation of the sewage disposal system occurs (e.g.sewage flowing to the surface of the ground),you nay be required to complete the repairs sooner. 111 work to repair/upgrade your subsurface sewage disposal system must be performed by a licensed sewage disposal system installer,in accordance with the requirements of 310 CMR 15.000,and with plans ipproved by the Northampton Board of Health. 'lease be advised that you are entitled to a hearing on this order to upgrade your subsurface sewage lisposal system,provided that you file a written petition requesting such a hearing in the Board of tealth office within seven (7)days of the receipt of this notice. 'lease feel free to contact the Board of Health office,at 587-1214 if you have any questions concerning his matter. thank you for your anticipated cooperation in this matter. sincerely, )aniel Wasiuk tealth Inspector TILE , 212 Main Street,Northampton,MA 01060 Ph (413)587-1214 Fax(413)587-1221 Owner information is required for every page. LSrns.WI/l 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 97 MOUNTAIN STREET Property Address ESTATE OF ANGELINA M. PRATT Owners Name —FLORENCE MA. 01062 July 20 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 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: HOUSE HAS BEEN VACANT SINCE LATE MARCH 2015 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 approvE 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 struc unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pa inspection if the existing tank is replaced with a complying septic tank as approved by the Board Health *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): Title 5 Official Inspection Form Subsurface Sewage Oisposar System•Page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 MOUNTAIN STREET Property Address ESTATE OF ANGELINA M. PRATT Owners Name FLORENCE s MA. 01062 July 20, 2015 every 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. Nhen ma cuter, tab your lot rn A. General Information 1. Inspector: PHILIP J. PASIECNIK Name of Inspector GREG'S WASTE WATER REMOVAL Company Name 239 GREENFIELD ROAD Company Address SOUTH DEERFIELD MA. 01373 City/Town State 413-665-3989 Sli 526 Telephone Number License Number Zip Code B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority ti Ins July 21, 2015 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. Title Si official Inspection Form Subsurface Sewage D's osaf System.Page 1 of 17 Owner information is required for every page. Dins.3n3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 MOUNTAIN STREET Properly Address ESTATE OF ANGELINA M. PRATT Owner's Name FLORENCE City/Town — — - MA. 01062 July 20, 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 heals 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 wat supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private wate 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 fe coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysi: 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 wa due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overlo or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is I than '/2 day flow ri,r 5 Official Inspection Form.Subsurface Sewage Disposal System.Page. ery Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 MOUNTAIN STREET.__ Property Address ESTATE OF ANGELINA M. PRATT Owners Name FLORENCE _ _ MA. 01062 July 20, 2015 State Zip Code Date of In ion City/Town B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 TS 5 Omoai Inspedlon Form.Subsurface Sass Disposal Sraem•Pay 3 of 17 Owner Owner's Name Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 MOUNTAIN STREET Property Address -- __ ESTATE OF ANGELINA M. PRATT Information is required for every FLORENCE page. City/Town 151ns-3/13 C. Checklist MA. 01062 Jujy20, 2015 State Zip Code Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the folk Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of t ❑ ® Were any of the system components pumped out in the previous two wet ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or a: this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were r available note as N/A) N ❑ 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 inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? N ❑ Was the facility owner(and occupants if different from owner) provided wit information on the proper maintenance of subsurface sewage disposal sys The size and location of the Soil Absorption System (SAS) on the site been determined based on: ❑ ® Existing information_ For example, a plan at the Board of Health. N Determined in the field (if any of the failure criteria related to Part C is at is! approximation of distance is unacceptable) [310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): N/A -- Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 4 440 GP Title 5 Official Inspection Form Subset!ce Swage Disposal System•Page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 MOUNTAIN STREET Property Address ESTATE OF ANGELINA M. PRATT —— — Owners Name FLORENCE MA_ 01062 July 20, 2015 :ry State Zip Code Date of Inspection Crty own B. Certification (cont.) Yes No D ® Required a in the last year NOT due to clogged or obstructed in Number times ❑ 4 Any portion of the SAS, cesspool or privy is below high ground water elevation. O E Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. O ® 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 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.] • E The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. E 0 The system fails. I have determined that one or more of the above failure exist criteria systemowner should contact the Board of Hea h therefore fails. to determine what will behe 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 the system is within 200 feet of a tributary to a surface drinking water supply • 0 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 a large the system considered a significant threat under Section E or failed under Section D shall upgrade system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Tub 5 olFoal Ins ion Fum:Subwnaw Sewage Disposal System Pi'e" 5 of 17 Owner information is required for every page. 15135.3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 97 MOUNTAIN STREET Properly Address -- ----- --- -- ---_ _ _ __ ESTATE OF ANGELINA M. PRATT Owner's Name ------- ----. __ _ _ __ FLORENCE City/Town MA. 01062 ---- ----- Jute20, 2015 State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other(describe below): N/A General Information N/A Date Pumping Records: Source of information: LAST PUMPED ABOUT 1987 PER OWNER;_ Was system pumped as part of the inspection? ❑ Yes N If yes, volume pumped: SEPTIC TANK WILL BE PUMPED WHEN SY IS UNDER REPAIR. How was quantity pumped determined? DNA_ Reason for pumping: Type of System: DNA ❑ 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): Ftle 5 Official Inspection Form Subsurface Sewage Disposal System•Page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 MOUNTAIN STREET Property Address ESTATE OF ANGELINA M. PRATT Owners Name MA 01062 _ July 20, 2015 FLORENCE State Zip Code Date of Inspection City/Town D. System Information Description: EXISTING 4 BEDROOM DWELLING NO GARBAGE DISPOSAL 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: LAST 2 YEARS USAGE= 8000 cu.ft. =60,000 GALLONS(730 DAYS= 8219 GPO 0 ❑ Yes Z No ❑ Yes Z No ❑ Yes ® No ❑ Yes ® No 82 GPD ❑ Yes ® No Sump pump? 03/15(2015__ Last date of occupancy: Date Commercial/Industrial Flow Conditions: NIA Type of Establishment: N/A -- Design flow(based on 310 CMR 15 203): Gallons per day(gpd) N/A Basis of design flow(seatslpersons/sq.ft.,etc.): ❑ Yes ❑ No Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No N/A — --- Water meter readings, if available: Title 5 Omod Inspection Form:Subsudaos Sewage Disposal System-Page 7 M 17 Owner Owners Name Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 MOUNTAIN STREET Property Address - --- -- --- -- ESTATE OF ANGELINA M. PRATT information is FLORENCE required for every page. City/rown ---------- --- MA. 01062 Jul 20, 2015 State Zip Code Y---- p Date of Inspection t5ins•3/13 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? NO OUTLET BAFFLE PI 15" +/_ NO OUTLET BAFFLE PF NO OUTLET BAFFLE PF ESTIMATED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK NORMALLY RECOMMENDED AT LEAST EVERY THREE YEARS. INLET BAFFLE WAS PUMPIN OUTLET BAFFLE WAS GONE WHEN OUTLET COVER WAS REMOVED. THE SCUM LAY BLOCKING LIQUID FLOW OUT THE TANK. LIQUID LEVEL WAS 3"OVER THE OUTLET It TANK REPLACEMENT IS NEEDED AS APPROVED BY THE LOCAL BOARD OF HEALTH. Grease Trap(locate on site plan): Depth below grade: Material of construction- ❑ concrete N/A ❑ metal ❑ fiberglass 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: N/A feet ❑ polyethylene ❑other(ex N/A N/A N/A N/A N/A Date -- --- ---_ Title 5 Omaal Inspecton Form Subsurface Sewage Disposal System.Page 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 MOUNTAIN STREET -- _—------- --— Property Address ESTATE OF ANGELINA M. PRATT — — Owners Name MA. 01062 July 20, 2015 FLORENCE State zip Code Date of Inspection City/Town D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information'. 48 YEARS OLD 1 1967 / INSTALLERS BILLING PAPERS FOR INSTALL 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 0 40 PVC 0 other(explain): — PUBLIC WATER SUPPLY Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,UILDING SEWER APPEARED TO BE IN GOOD CONDITION. VENTING PIPES WERE VISIBLE ON THE ROOF. NO VISIBLE LEAKAGE EVIDENT._ 2.5 feet Septic Tank(locate on site plan). Depth below grade: Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene 0 other(explain) 2 feet N/A If tank is metal, list age: years of certificate) 0 Yes 0 No Is age confirmed by a Certificate of Compliance. (attach a copy 8' Lx4.5'Wx5' D- 1000 GAL.+/-_ Dimensions: Sludge depth: 24" +l- Tlele S ORUSI Inspection Forth Subsurface Sewage Dispose.System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 MOUNTAIN STREET Properly Address --- - - --- - - --- - -- __ _ __ _ _ Owner ESTATE OF ANGELINA M. PRATT Owner's Name --------- information is —-------— —__ repaired for every FLORENCE page. City/Town--- ----------_ MA_ 01062 Jul 20, 2015 State Zip Code July Date of Inspection r5ins-3113 D. System Information (cost.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 3"_?BOVE WHEN COVER WAS OP! Comments(note if box is level and distribution to outlets equal, any evidence of solids carry evidence of leakage into or out of box, etc.): WAS FULL OF SCUM, LIQUID EFFLUENT. SLUDGE WAS VISIBLE INBTOHE OUTLET PIPES. WHEN SC ME LAYDE SEPTIC TANK WAS CLEARED FROM BLOCKING FLOW OUT THE TANK LIQUID FLOWF BOX AND FILLED BOX 8"OVER THE OUTLET INVERTS. PIPE FROM TANK TO BOX HA OF SOLIDS CARRYOVER. EVIDENCE OF SAS CLOGGING WAS VISIBLE AT THIS POIN Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Now Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A 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: Title 5 Official Inspection Form Subsurf ace Sewage Disposal System•Page 1: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 MOUNTAIN STREET Property Address —_----__-- ESTATE OF ANGELINA M. PRATT —_ -------- Owners Name MA. 01062 July 20,2015 FLORENCE state Zip Code Date of mspedion City/Town 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): N/A Depth below grade: Material of construction: ❑concrete N/A ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): N/A Dimensions: NIA Capacity: gallons N/A — Design Flow: gallons per day El ❑ No Alarm present: N/A Alarm in working order: El Yes ❑ No Alarm level: N/A 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 Tr Ile 5 Official Inspection Ferns Subsurf ace Sewage.Deposal System•Page 11 W 17 Owner information is required for every page. t5ins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 MOUNTAIN STREET Property Address --- -- --- -- - - - --_ _ ESTATE OF ANGELINA M. PRATT Owner's Name -- - --- - -- -- FLORENCE MA City/Town -------------- _ 01062 Jul 20, 2015 State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of ve etc.): N/A Privy(locate on site plan): Materials of construction: Dimensions Depth of solids N/A N/A N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of veg€ etc.): N/A Talk 5 Official Inspection Form.SubSurface Sewage Disposal System•page I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 MOUNTAIN STREET _ Property Address ESTATE OF ANGELINA M. PRATT --- owners Name Mq 01062 July 20 2015 it FLORENCE___ State Zip Co Date of Inspection CdylTown de D. System Information (cont.) Type: D leaching pits number: ❑ leaching chambers number: leaching galleries number: ❑ number, length: leaching trenches t -30'Lx20'W'1- ® leaching fields number,dimensions: With 3 Laterals O 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.): HYDRAULIC FAILURE WAS EVIDENT DUE TO SOIL CLOGGING IN THE SAS. NO PONDING VISIBLE AT THIS TIME SOIL VEGETATION WAS DARKER GREEN COLOR OVER SAS. WASN'T DAMP OVER SAS. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): tee 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 N/A N/A N/A N/A N/A ❑ Yes ❑ No Tile 5 Official Inspection Form:SubwOam Sewage Disposal System.Page 13 o117 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 MOUNTAIN STREET Property Address --.-- - - - -- - --- -_ _ _ _ ESTATE OF ANGELINA M. PRATT Owners Name FLORENCE MA City/Town -- -- ---- 01062 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: 6+ BELOW GRADE SA'. 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: OBSERVATION OF SITE FOR ESTIMATED HIGH GROUND WATER. ESTIMATED SEASON HIGH WATER TABLE WILL BE DETERMINED BY A LICENSED SOIL EVALUATOR FOR SY: REPAIR AT TIME OF PERC TEST. Before filing this Inspection Report, please see Report Completeness Checklist on next p ,Sine•3/13 Tale 5°Ninal Inspetlion Form Subsurface Sewage DennYrl System.Page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 MOUNTAIN STREET Property Address ESTATE OF ANGELINA M. PRATT_ —. --- Owner's Name FLORENCE — MA. 01062 July 20, 2015 ry Dry/Town State Zip Code Date of Inspedion D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at herre public permanent ater supply reference the build ng. Check one of thLocate oxes below:within 100 feet. Locate r I ® hand-sketch in the area below LI drawing attached separately t5'I Title 5 01(xial Inspection Form:Sub sunace se*OM Disposal System•Page 15 of 17 `�1 ery Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 MOUNTAIN STREET — -- Property Address ESTATE OF ANGELINA M. PRATT Owner's Name FLORENCE _ MA. 01062 July 20, 2015 State Zip Code Date of Inspection City/Town E. Report Completeness Checklist Z Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to AU Systems)completed ® System Information–Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Tine 5 Waal hsa+ion Porn Sue:ware sewage Disposal Sysem.Page 17 of 17