1006 Title 5 2017 Commonwealth of Massachusetts
Title 5 Official Inspection Form
4*Now Iv, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1006 Florence Road
Property Address
owner Greg Marotta
information is Owner's Name
required for Florence MA 01062 8/10/2017
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, 1. Inspector:
use only the
tab key to Marcus Millett
move your
cursor-do not Name of Inspector
use the return Homestead Engineering Inc.
key. Company Name
1664 Cape St.
Company Address
Williamsburg MA 01096
X\ City/Town State Zip Code
413-628-4533 SI-13748
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:
[Si Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
August 10, 2017
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of
Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a
design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the
appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use at
that time. This inspection does not address how the system will perform in the future under the
same or different conditions of use.
t5ins•3'13 Title 5 Official lnspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
~ % 1006 Florence Road
Property Address
owner Greg Marotta
information is Owner's Name
required for Florence MA 01062 8/10/2017
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):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
t5ins•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
;L =�rTitle 5 Official Inspection Form
s. 7110.-_----_.rl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
=..•'' 1006 Florence Road
Property Address
Owner Greg Marotta
information is Owner's Name
required for Florence MA 01062 8/10/2017
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 L] 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
t5ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
*-z ,=- Title 5 Official Inspection Form
=at= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1006 Florence Road
Property Address
owner Greg Marotta _
information is
Owner's Name
required for Florence MA 01062 8/10/2017
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:
0) 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
❑ X 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 is less than '/
❑ ® day flow
t5ins•3"3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
►_I% Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1006 Florence Road
Property Address
owner Greg Marotta
information is
Owner's Name —. —
required for Florence MA 01062 8/10/2017
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 must be attached
to this form.]
❑ ® 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 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
❑ ® 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 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 Tile 5 Official Inspection Form:Subsurface Sewage disposal System•Page 5 of 17
, Commonwealth of Massachusetts
__- Title 5 Official Inspection Form
---11 .-'--) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
"7 1006 Florence Road
Property Address
owner Greg Marotta
information is Owner's Name
required for Florence MA 01062 8/10/2017
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/AZ
® ❑ 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?
Z ❑ 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?
X ❑ Was the facility owner(and occupants if different from owner) provided with information on
the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has been
determined based on:
Z ❑ Existing information. For example, a plan at the Board of Health.
❑ z 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 3 Number of bedrooms 3
bedrooms (design): (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of 330+ gpd
bedrooms): --
t5,ns•3'13 Idle 5 Official Inspection Form:Subsurface Sewage disposal System•Page 6 of 17
Commonwealth of Massachusetts
-=*-, ;__ _ Title 5 Official Inspection Form
k.a` '-7 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
• • —. 1006 Florence Road
-------------
Property Address
Owner Greg Marotta _
information is
Owner's Name
required for Florence MA 01062 8/10/2017
every page. —City/Town State Zip Code Date of Inspection
D. System Information
Description:
1500—gallon septic tank with outlet filter, pump tank, distribution box and
leachfield.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system ❑ Yes ® No
inspection information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
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
Water meter readings, if available:
tSns•3!13 Title 5 Official Inspection Form:Subsurface Sewage ge Dis poral System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
•
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1006 Florence Road
Property Address
owner Greg Marotta
information is Owner's Name
required for Florence MA 01062 8/10/2017
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:
Source of information: Not pumped since construction
Was system pumped as part of the inspection? plies ® No
If yes, volume pumped: gallons
g
How was quantity pumped
determined?
Reason for pumping: Recommend every 3 to 5 years at normal occupancy
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage asoosal System•Page 8 cf'7
•
Commonwealth of Massachusetts
- (Title 5 Official Inspection Form
w ="�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. 1006 Florence Road
Property Address
Greg Marotta
Owner
information is Owner's Name
required for Florence MA 01062 8/10/2017
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: said to be a 1974 system
Were sewage odors detected when arriving at the site? ❑Yes ® No
Building Sewer(locate on site plan):
1.Depth below grade: feeet average
et
Material of construction:
❑ cast iron ®40 PVC ®other(explain): ABS plastic
Distance from private water supply well or suction 28
line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
No problems seen. Measurement is between well inlet and sewer outlet in
basement.
Septic Tank(locate on site plan):
1.5 average
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Concrete septic tank. About 1500 gallons nominal.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of
certificate) L] Yes ❑ No
58" wide, 122" long, 60" height
Dimensions:
2"
Sludge depth:
15ins•3/13 title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� ,=. 10 0 6 Florence Road
Property Address
owner Greg Marotta
information is Owner's Name
required for Florence MA 01062 8/10/2017
every page.
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or 29"
baffle
1"
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 18"
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.):
Standard septic tank. Riser over center to the surface. Outlet filter found
and cleaned. Recommend riser to surface over outlet filter to help with
maintenance. Does not need pumping this year.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ 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
t5 ns'3113 The 5 Official Inspection Form:Subsurface Sewage Deposal System•Page 10 of 17
Commonwealth of Massachusetts
** _ITitle 5 Official Inspection Form
=- N1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•
• —�.•' 1006 Florence Road
Property Address
Owner Greg Marotta
information is Owner's Name
required for Florence MA 01062 8/10/2017
every page.
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquic
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 ❑ polyethylene ❑ 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 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
;i\ Commonwealth of Massachusetts
_== Title 5 Official Inspection Form
.1t- Vi Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.,y• ' ' 1006 Florence Road
Property Address
owner Greg Marotta -
information is Owner's Name
required for Florence MA 01062 8/10/2017
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.):
Five pipes out. No biosolids in box. No structural problems.
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.):
Appears to be operating properly. Recommend a riser over access port to the
surface in case there is a maintenance issue in winter when it would be hard
to dig.
• 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:
t5ins•3/13 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
-'fi
1006 Florence Road
Property Address
Owner Greg Marotta
information is Owner's Name
required for Florence MA 01062 8/10/2017
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:
leaching fields number, dimensions:
20' x 30'
❑ 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 issues seen. System is vented. Leaching area significantly built
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
t5ins•3/13 Title 5 Oficial 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
1006 Florence Road
Property Address
owner Greg Marotta
information is Owner's Name
required for Florence MA 01062 8/10/2017
every page.
Ci /Town State
City/Town 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.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
14 Commonwealth of Massachusetts
Ra*= — ' Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;,=,." 1006 Florence Road
Property Address
owner Greg Marotta
information is
Owner's Name
required for Florence MA 01062 8/10/2017
every page.
Ci /Town State City/Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
=_*Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1006 Florence Road
Property Address
owner Greg Marotta
information is Owner's Name
required for Florence MA 01062 8/10/2017
every page.
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
Z Check cellar
❑ Shallow wells
5+
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 7/21/2014
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:
Leaching system significantly built up. System built to current code
requirements.
t5ins•3113 Title 5 Official Iris
peclion Form Subsurface Sewage Disposal System Page 16 0(17
Commonwealth of Massachusetts
- _0,Title 5 Official Inspection Form
4,ll .-7---7--41__--- --
' ,--'-=','"
�— Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�� 1006 Florence Road
N
Property Address
owner Greg Marotta
information is
Owner's Name
required for Florence MA 01062 8/10/2017
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
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3'13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
COMMENTS:
Recommend pumping on a 3 to 5 year schedule. Also, a copy of this plan posted in the
basement/utility area would keep this information accessble in future years for maintenance.
House Outline
deck NORTH
ui
IILINIZ.7<,, ,
O c53 oT
Septic Tank with outlet filter
tJ
Leachfield, estimated layout Pump Tank
30'
Note: No known drinking water sources within 100 foot radius.
liiiI!IIItt111'ltttlttu! �'
Ven Distribution Box
Date: Owner: �► '
As-Built Drawing HOMESTEAD INC.
Existing Septic System 8/10/2017 Greg MarottaMums. Thomas S. Leue R.S.
1006 Florence Ro- : LauScale: 1 : 20' Revision Date: .- 1664 Cape St.
\ Williamsburg,MA 01096
RxrPnt ac NTntn..-1 Florence MA 01062 rd111 F.7SLdS1l
.0.,-A M:. CITY ofNORTHAMPTON pergeoti/—
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*"�=-�`f . PUBLIC HEALTH DEPARTMENT
I �� -
�� ;; _ Public Health Director-Merridith O'Leary t iN ( OQ ALS-
-17.,--,-...'z,
A S
,.--- Municipal Building—212 Main Street—Northampton,MA 01060 l/ yn��
Phone(413)587-1215--Fax(413)587-1221 /50f O�
hw
ttn://www,northamprona.evv/245/Health 00
Application for Witnessing Official Title 5 Inspections1
/�D d� d
Fee:$150.00(2 hour field);$75/hour thereafter i -r
4c /0/7
Date: / ( '3 i I Z(p l '4'
Site Address: ( ((( F LT ce )2 Parcel# 7->)
Property Owner: ( 736-ra !/
Property Owner Address: fek (r (cu-k-ce it-S. •
Telephone: 9 S - s'`.../.5.- ( 5<f) Cell:
Title 5 inspector
Name of Inspector -71,1 crrh c L QC( License#: Sr ( -so
Company Name - ' ..:c .J--
Mailing Address i c(0q C . S-
City/State/Tap Code IA*; , 1(,i cS,44t 5 b .�- PIA ()1Q< C
Telephone: ,:--
elephone: Office: -1(3 62 r-3 S Cell: y/ 3 6->F- ‘f S 773
Please answer the following:
/No: T5 Inspector tau,most recent plans for system to be inspected
f(;/No: T5 Inspector has pump-out records
e /No: T5 inspector tel location of private water supply wells(within 150 feet of system location)
Reason for Inspection:
I
Date requested for Inspection: gS /to ft 7 Time: cc
Return Application Ten Days Prior to Requested Inspection Date to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060
--------------
MAKE CHECKS PAYABLE TO THE CITY OF NORTHAMPTON ____
Application Fee is Non-Refundable