661 Title 5 2017 Commonwealth of Massachusetts
Title 5 Official Inspection Form
7,r,0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
661 Westhampton Road
Property Address
Owner Michael O'Brien
information is Owners Name
required for Florence MA 01062 8/25/2017
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
use the return Name of Inspector
key. Homestead Engineering Inc.
Company Name
ofht 1664 Cape St.
Company Address
Williamsburg MA 01096
City/Town State Zip Code
v 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:
Z Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Q August 25, 2017
inspector ss 5 natur 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.
t5ins•3,'73
cL \, Tue 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
*_ Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
661 Westhampton Road
Property Address
Owner Michael O'Brien
information is Owner's Name
required for Florence MA 01062 8/25/2017
every page. —City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E I always complete all of Section D
A) System Passes:
® I have not found any information that indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system; upon completion of the replacement or repair, as approved by the
Board of Health, will pass.
Check the box for`yes", "no" or"not determined" (Y; N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ® N ❑ ND (Explain below):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
t5ins•3/13 TNe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
4_#7T,=e• Title 5 Official Inspection Form
= �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11-0.1 661 Westhampton Road
Property Address
Owner Michael O'Brien
information is Owner's Name
required for MA 01062 8/25/2017
every page. Florence _
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 Z 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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
►�_ , Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
661 Westhampton Road
Property Address
owner Michael O'Brien
information is Owner's Name
required for Florence MA 01062 8/25/2017
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
C ® is less than 1/2 day flow
t5irs•313 Title 5 Oficial Inspection Form Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
-�' s, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
jT. 661 Westhampton Road
Property Address
Owner Michael O'Brien
information is Owner's Name
required for Florence MA 01062 8/25/2017
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.
❑ ® 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•3'13 Tte 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
g7-4 eTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
661 Westhampton Road
Property Address
Michael O'Brien
Owner
information is Owner's Name
required for Florence MA 01062 8/25/2017
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/At
® ❑ 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):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330+ gpd
t5ins•3113 Tee 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 or 17
Commonwealth of Massachusetts
e Title 5 Official Inspection Form
_= d Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
661 Westhampton Road
Property Address
owner Michael O'Brien _
information is Owner's Name
required for Florence MA 01062 8/25/2017
every page,
City/Town State Zip Code Date of Inspection
D. System Information
Description:
1000-gallon septic tank, distribution box, and a leachfield.
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 ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): 130
Detail:
2/10/17 to 5/10/17 used 1400 cu. ft.
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•113 Title 5Orficial Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
_ >_� Title 5 Official Inspection Form
I' =` = Id Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
• 661 Westhampton Road
Property Address
owner Michael O'Brien
information is Owner's Name
required for Florence MA 01062 8/25/2017
every page.
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other (describe below):
General Information
Pumping Records:
Pumped in 2014, says owner
Source of information:
Was system pumped as part of the inspection? ❑Yes ® No
If yes, volume pumped: --
gallons
How was quantity pumped
determined?
Reason for pumping: Recommend on 3 to 4 year interval
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):
tsins•3i13 Trtle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
IE=* = Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.94
1i==
661 Westhampton Road _
Property Address
owner Michael O'Brien
information is Owner's Name
required for Florence MA 01062 8/25/2017
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 plan for field dated 1998, septic tank from 1980.
Were sewage odors detected when arriving at the site? ❑Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5 average
feet
Material of construction:
ABS pipe
❑cast iron ®40 PVC ®other(explain):
Distance from private water supply well or suction line: 5 ft.
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
No problems seen. Measurement is between sewer outlet and water inlet in the
basement.
Septic Tank(locate on site plan):
1.3 average
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ 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, 90" long,
Dimensions: 58" tall
2"
Sludge depth:
!Sins•3/13 Title 5 Ofadel Inspection Form:Subsurface Sewage Disposal System•Page 9 at 17
Commonwealth of Massachusetts
*- - ft Title 5 Official Inspection Form
5 -Ilk_- Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
661 Westhampton Road
Property Address
owner Michael O'Brien
information is Owner's Name
required for Florence MA 01062 8/25/2017
every page.
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
26"
Distance from top of sludge to bottom of outlet tee or baffle
0"
Scum thickness —
6"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
24"
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. Concrete appears
structurally sound. Outlet cover has a crack, but structurally OK.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑metal Elfiberglass Elpolyethylene El 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
isms•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
►R=*
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
661 Westhampton Road
Property Address
owner Michael O'Brien
information is Owners Name
required for Florence MA 01062 8/25/2017
every page.
City/Town State Tap Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
o"
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.):
3 pipes out. About 18" below grade. Box appears level and flow
distributed. Moderate biosolids in box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
• If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t55ins•3113 Tele 5 Official Inspection Form:Subsurface Sewage Disposal System•Pepe 12 or 17
Commonwealth of Massachusetts
•_* — L Title 5 Official Inspection Form
of Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
661 Westhampton Road
Property Address
Owner Michael O'Brien
information is Owner's Name
required for Florence MA 01062 8/25/2017
every page —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:
15' x 20'
leaching fields number, dimensions:
❑ 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. Size is estimated based on grass conditions.
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
t5ms•3!13 Title 5 Cf`icial Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
!=_* , __ Title 5 Official Inspection Form
I —`y�- ai Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,, 661 Westhampton Road
zi
Property Address
Owner Michael O'Brien
information is Owner's Name
required for Florence MA 01062 8/25/2017
every page.
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.):
•
t5ns•3(13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of,?
Commonwealth of Massachusetts
R=* - Title 5 Official Inspection Form
` _- ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
661 Westhampton Road
Property Address
owner Michael O'Brien
information is Owner's Name
required for Florence MA 01062 8/25/2017
every page.
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
t5ins•3i13 Trtle 5 Official Inspection Form:Subsulace Sewage Disposal System•?age 15 of 17
Commonwealth of Massachusetts
_� Title 5 Official Inspection Form
T Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
661 Westhampton Road
Property Address
Owner Michael O'Brien
information is Owners Name
required for Florence MA 01062 8/25/2017
every page.
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
Z 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
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:
Very sandy soil. Basement is dry without a sump pump. Local perc tests usually
find water table deeper than this value.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
k _. Title 5 Official Inspection Form
=I1- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
__ 661 Westhampton Road
Property Address
Owner Michael O'Brien
-- —
information is Owner's Name
required for Florence MA 01062 8/25/2017
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
Z 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
t5ins•3'13 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
COMMENTS:
Recommend pumping on a 3 to 4 year schedule. Also, a copy of this plan posted in the
basement/utility area would keep this information accessible in future years for maintenance.
Partial House Plan
porch ii
ozi. s,
...
Y'v
0
(.11 NORTH
ie
Town water in *1R)-
nou
• Septic Tank
�.
Distribution Box
Leachfield, estimated layout
As-Built Drawing Date: Owner: HOMESTEAD INC.
I
xisting Septic System 8/25/2017 Michael O'Brien u►ss� Thomas S. Leue R.S.
A:
Scale: 1 : 20' Revision Date: 661 Westhampton R% - 1 , - 1664 Cape St.
Williamsburg,MA 01096
Except as Noted Florence MA 01062 \® � ��, 14131628-9533