669 Title 5 2017 Commonwealth of Massachusetts
=�zl Title 5 Official Inspection Form
A =�1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
669 Florence Road
Property Address
William Tobin
Owner
information is Owner's Name
required for Florence MA 01062 4/17/2017
every page. —
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.
Important: A. General Information
When filling out
forms on the
computer.use 1. Inspector:
only the tab key
to move your Thomas S. Leue
cursor do not Name of Inspector
use the return
key. Homestead Engineering Inc.
Company Name
1664 Cape St.
Company Address
Williamsburg MA 01096
rano
City/Town State Zip Code
413-628-4533 SI-130 _-
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
----77rryot40„, .S April 17, 2017
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.
Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 17
>riins•3+'13
Commonwealth of Massachusetts
aI! - Title 5 Official Inspection Form
; J , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
669 Florence Road
Property Address — —
William Tobin
Owner Owners Name
information is
required for Florence MA 01062 4/17/2017
every page. --- —
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):
fl Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
t5ins•113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,I 669 Florence Road
Property Address
William Tobin
Owner —- ----
information is Owner's Name
required for Florence MA 01062 4/17/2017
every page. --
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass
inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
n Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
t5ms•3l13
Commonwealth of Massachusetts
__: Title 5 Official Inspection Form
iSubsurface Sewage Disposal System Form - Not for Voluntary Assessments
!!tall.__ 669 Florence Road
Property Address
Owner William Tobin
information is Owner's Name
required for Florence MA 01062 4/17/2017
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines
that the system is functioning in a manner that protects the public health, safety and
environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.
Method used to determine distance:
** 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
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface
waters due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an
overloaded or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume
❑ Z is less than %day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Q� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
_
669 Florence Road
Property Address
Owner William Tobin - --
information is Owner's Name
required for Florence MA 01062 _ 4/17/2017
every page. City/Town - State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
® 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.
0 ® 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
® The system is a cesspool serving a facility with a design flow of
2000 gpd-10,000 gpd.
® 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
E) Large Systems: To be considered a large system the system must serve a facility
with a design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in
addition to the questions in Section D.
Yes No
® the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking
water supply
® the system is located in a nitrogen sensitive area (Interim
Wellhead Protection Area— IWPA) or a mapped Zone II of a
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.
t5ins•113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
►�_ ,, =_f Title 5 Official Inspection Form
= -
...%.
, ���- � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,=::_- -
669 Florence Road
Property Address
Owner William Tobin
information is Owner's Name
required for Florence MA 01062 4/17/2017
every page. City/Town 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)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the
tank inspected for the condition of the baffles or tees, material of
construction, dimensions, depth of liquid, depth of sludge and depth of
scum?
® ❑ Was the facility owner(and occupants if different from owner) provided
with information on the proper maintenance of subsurface sewage disposal
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:
Number of bedrooms 3 3
Number of bedrooms (actual):
(design):
382 gpd
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
t5ins•3113 Trtle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
- 669 669 Florence Road
Property Address
Owner William Tobin
information is Owner's Name
required for MA 01062 4/17/2017
Florence
every page. City/Town State Zip Code Date of Inspection -
D. System Information
Description:
1000-gallon septic tank, distribution box and 3 leaching galleries.
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes Zj No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
A request for this information has been made to the Water Department
Sump pump? ® Yes ❑ No
Continuous
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):) Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft.. etc.):
Grease trap present? ❑ Yes ❑ No
industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
•
•
Commonwealth of Massachusetts
t=*� — Title 5 Official Inspection Form
,, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` - —,� 669 Florence Road
Property Address
Owner William Tobin
information is Owner's Name
required for Florence MA 01062 4/17/2017
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: bate
Other (describe below):
General Information
Pumping Records:
Pumped last 7/30/2014
Source of information: .
Was system pumped as part of the inspection? ['Yes ® No
if yes, volume pumped: gallons
How was quantity pumped
determined?
Recommend on 3 to 4 year interval.
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance
contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by
system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•1'13 Trtle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
g_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
669 Florence Road
Property Address
Owner William Tobin
information is Owner's Name
required for Florence _ MA _ 01062 4/17/2017
every page.
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Septic leaching plan dated 9/15/2002. Septic tank is older.
Were sewage odors detected when arriving at the site? ❑Yes ® No
Building Sewer (locate on site plan):
Depth below rade: 1.5 average - _-
p g feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 18 ft. -
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
No problems seen.
Septic Tank (locate on site plan):
Depth belowgrade: 2.5 average
feet
Material of construction:
® concrete ❑ metal ❑fiberglass Li polyethylene ❑ other(explain)
Concrete about 1000 gallons.
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
59" wide, 86" long,
Dimensions: 57" tall
3"
Sludge depth:
t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
=_ =r Title 5 Official Inspection Form
"i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'TOW-
\--1_ -:.,,,-
669 Florence Road
Property Address
Owner William Tobin
information is Owner's Name
required for Florence MA 01062 4/17/2017
every page. —
—
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
25"
Distance from top of sludge to bottom of outlet tee or baffle
1"
Scum thickness - -
511
Distance from top of scum to top of outlet tee or baffle --
20"
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Calculated
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Cement tank, about 1000 gallons. Baffles intact. Recommend pumping on 3 to 4
year interval. Riser to 16" below surface over center cover.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete 10 metal ❑fiberglass ❑ polyethylene ❑other
(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5vms•3;13 Title 5 Official Inspection Fcnn.Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
** __.• Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
= 669 Florence Road
Property Address
Owner William Tobin
— —
information is Owner's Name
required for Florence MA 01062 4/17/2017
every page. Ci /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 11]polyethylene 111 other
(explain):
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
t5ins•3,13 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
1 Commonwealth of Massachusetts
•
-�� Title 5 Official Inspection Form
_ ,i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
' .�. 669 Florence Road
Property Address
owner William Tobin
information is owner's Name
required for Florence MA 01062 4/17/2017
every page. _
City/Town State 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 in good condition. No significant biosolids seen in box. 1 pipe out.
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:
is •113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
W 669 Florence Road
Property Address
Owner William Tobin
information is Owner's Name
required forFlorence MA 01062 4/17/2017
every page.
City/Town State Zip Code Date of Inspection
D. System Information (cont)
Type:
❑ leaching pits number: --
❑ leaching chambers number: --
3
leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
�I 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.):
No surface problems seen. Galleries were not opened.
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
tSris•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
669 Florence Road -
Property Address
owner William Tobin
information is Owner's Name
required for MA 01062 4/17/2017
every page. Florence
City/Town State ZipCode 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.):
trims•3'13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
=_',_= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
669 Florence Road
Property Address
Owner William Tobin
information is Owner's Name
required for MA 01062 4/17/2017
_
every page. Florence State Z Code Date of Inspection
City/Town P
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
15ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17
•
Commonwealth of Massachusetts
e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
-;;: / 669 Florence Road
Property Address
Owner William Tobin
information is Owner's Name
required for Florence MA 01062 4/17/2017
every page. _—
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
5 feet
Estimated depth to high ground water: 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 9/15/2002
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 perc test conducted 9/5/2002. Built to current code.
t5cn•113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
►.=__ __ I Title 5 Official Inspection Form
-i1-- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
" : 669 Florence Road
Property Address
Owner William Tobin
information is Owner's Name
required forFlorence MA 01062 4/17/2017
every page-
City/Town State Zip Code Date of Inspection
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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
t5ins.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 17 of 17
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Recommend pumping septic tank on a 3 to Z year schedule, depending on Q
use occupancy. :, .-' a
A copy of this document attached in the basement/utility area will keep this ci) . cn w
ormation available in future years for maintenance. X
System not sized for a garbage grinder. Do not connect one to this system. %. w