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
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t5'I Title 5 01(xial Inspection Form:Sub sunace se*OM Disposal System•Page 15 of 17
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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