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997 Title 5 Inspection Report 5-21-2020Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 997 Westhampton Road Property Address I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposa systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Tned is Signature Date system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of corrpleting this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. tSinsp.dcc • rev. 7/2612018 Tills 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 18 Cassidy Bowman Owner Owners Name information is required for Florence MA 01062 5/21/2020 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. Inspector Information When filling out forms on the computer, use Brian J. Pranks only the tab key Name of Inspector to move your Brian Pranka Title 5 Inspections cursor - do not use the return Company Name key. PO Box 779 Company Address m Southwick MA 01077 Cityrrown 413-569-5226 State S14237 Zip Code renan Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposa systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Tned is Signature Date system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of corrpleting this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. tSinsp.dcc • rev. 7/2612018 Tills 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Insp a Subsurface Sewage Disposal System Fo •°'k 997 Westhampton Road C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: System in good working condition at time of inspection. Information in this report document the conditions observed today and today only. There is NO expressed or implied warranty or guarantee of the system and how it will perform in the future. A change in flow conditions may affect the septic system and the inspection results. Improper use can adversly impact the short and long term performance of the system. The inspector is not responsible for the seller withholding and/or misrepresenting information given to the inspector. 2) 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 substantia 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): t5insp.doc- rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 18 ection Form rm - Not for Voluntary Assessments Property Address Cassidy Bowman Owner Owners Name information is required for Florence MA 010625/21/2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: System in good working condition at time of inspection. Information in this report document the conditions observed today and today only. There is NO expressed or implied warranty or guarantee of the system and how it will perform in the future. A change in flow conditions may affect the septic system and the inspection results. Improper use can adversly impact the short and long term performance of the system. The inspector is not responsible for the seller withholding and/or misrepresenting information given to the inspector. 2) 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 substantia 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): t5insp.doc- rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments z 997 Westhampton Road Property Address Cassidy Bowman Owner Owners Name information is Florence required for MA 010625/21/2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not cperational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: 15insp.doo • rev, 7/26/2018 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 3 of 18 �'r\ Commonwealth of Massachusetts 9 Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w"i997 Westhampton Road property Address Cassidy Bowman Owner Owners Name information is Florence required for MA 01062 5/21/2020 every page. cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doo • rev. 7126/2818 Tile 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 18 c Commonwealth of Massachusetts a Title S .Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 997 Westhampton Road Property Address Cassidy Bowman Owner Owners Name information is required for every page. MA 01062 5/21/2020 State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® 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 water supply 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.] ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,300 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 CA. Yes No ❑ ❑ the system is with n 400 feet of a surface drinking water supply ❑ ❑ the system is with n 200 feet of a tributary to a surface drinking water supply El El Area system is located :-i a nitrogen sensitive area (Interim Wellhead Protection Area – IWPA) or a mapped Zone 11 of a public water supply well t5insedoc- rev. 7/26/2018 THIS 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 997 Westhampton Road Property Address Cassidy Bowman Owners Name Florence MA 01062 Cltyfrown Slate Zip Code C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system cons dered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional offce of the Department. 6. You must indicate `lyes" or "no" for each of the following for all inspections: 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 -he system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwell ng 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 tark 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? El ® 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: ❑ ® Existing informatior. 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)] t5insadoc -rev. 7/26/2018 Tilts OHiclal Inspection Form: Subsurface Sewage Disposal System • Page 6 of 18 Commonwealth of Massachusetts 11 Title 5 Official Insp V Subsurface Sewage Disposal System Fo 997 Westham System Information 1. Residential Flow Conditions: Number of bedrooms (design): ? Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (fcr example: 110 gpd x # of bedrooms): Description: System in good working condition at time of inspection. Information in this report document the conditions observed today and today only. There is NO expressed or implied warranty or guarantee of the system and how it will perform in the future. A change in flow conditions may affect the septic system and the inspection results. Improper use can adversly impact the short and long term performance of the system. The inspector is not responsiblefor the seller withholding and/or misrepresenting information given to the inspector. Number of current residents: Does residence have.a garbage grinder? ❑ ection Forret No rm - Not for Voluntary Assessments Yes pton Road No ® No Property Address ❑ Yes ❑ No Cassidy Bowman ❑ Yes ® Owner Owners Name Private information is Detail: required for Florence MA 010625/21/2020 every page. City/Town State Zip Code Date of Inspection System Information 1. Residential Flow Conditions: Number of bedrooms (design): ? Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (fcr example: 110 gpd x # of bedrooms): Description: System in good working condition at time of inspection. Information in this report document the conditions observed today and today only. There is NO expressed or implied warranty or guarantee of the system and how it will perform in the future. A change in flow conditions may affect the septic system and the inspection results. Improper use can adversly impact the short and long term performance of the system. The inspector is not responsiblefor the seller withholding and/or misrepresenting information given to the inspector. Number of current residents: Does residence have.a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd))� Private Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insedoc -rev. 7/26/2018 Tile 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 18 3. Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 2015 APO IN ON t5insp.doc • rev. 7/26/2018 Trio 5Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 18 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 997 Westhampton Road Properly Address Cassidy Bowman Owner information is Owners Name required for Florence MA 01062 5/21/2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other (describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 2015 APO IN ON t5insp.doc • rev. 7/26/2018 Trio 5Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 997 Westhampton Road Property Address Cassidy Bowman Owner Owners Name information is required for Florence MA 010625/21/2020 every page. City/Town State Zip code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: Home built 2001. System ori ional to home Were sewage odors detected when arriving at the site? 5. Building Sewer (locate on site plan): sinsp.doc • rev. 7/26/2018 Depth below grade: Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 33 inches ❑ Yes ® No Comments (on condition of joints, venting, evidence of leakage, etc.): Plumbing in good condition at time of inspection. No evidence of leakage. Joints and hangers in good condition. Venting normal. Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 18 commonwealth of Massachusetts Title 5 Official Inspection Form sl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments z 997 Westhampton Road Property Address Cassidy Bowman Owner Owners Name information is Florence required for MA 01062 5/21/2020 every page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 25 inches feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6x10x5 Sludge depth: <4" Distance from top of sludge to bottom of out et tee or baffle 22 Scum thickness <11. t5lnsp.doc • rev. 7/26/2018 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? Dip Tube Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level equal to outlet invert. Baffles in good working condition. No evidence of leakage in or out of tank. Septic tank in good condition at time of inspection. Outlet baffle contains a filter. This filter should be serviced every year to prevent backup into home. Riser installed over outlet baffle after inspection for filter maint. Tit,s 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo 997 Westhampton'Road D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ 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 feet ❑ polyethylene ❑ other (explain): Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 Dimensions: Capacity: Design Flow: gallons ❑ polyethylene ❑ other (explain): gallons per day ISlnsp.doc • rev. 7/26/2018 Tire 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 18 ection Form rm - Not for Voluntary Assessments Property Address Cassidy Bowman Owner Owners Name information is required for Florence MA 01062 5/21/2020 every page. City/Town State Zio Code date of Inanpnfinn D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ 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 feet ❑ polyethylene ❑ other (explain): Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 Dimensions: Capacity: Design Flow: gallons ❑ polyethylene ❑ other (explain): gallons per day ISlnsp.doc • rev. 7/26/2018 Tire 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo e 997 Westhampton Road u. system Intormation (cont.) 8. Tight or Holding Tank (cont.) Alarm present: Alarm level: Date of last pumping: ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 9' (Equal to) ❑ Yes ❑ No Comments (note if oox is level and distributon to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.) Liquid level equal to outlet inverts. No evidence of carryover. No scum or slime above static liquid level. Distribution box in poor condition at time of inspection. Box changed by Clean Septics with approval from BOH Agent. Per Marcus this Inspection report is changed from a conditional pass to a "Pass". tsmodoc • rev. 7/26/2018 Title 5 Offlclel Inspect on pone: Subsurface Sewage Disposal System - Page 12 of 18 ection Form rm - Not for Voluntary Assessments Property Address Cassidy Bowman Owner Owners Name information is required for Florence MA 01062 5/21/2020 every page. City/Town _ State Zip Code Date of incn2nfinn u. system Intormation (cont.) 8. Tight or Holding Tank (cont.) Alarm present: Alarm level: Date of last pumping: ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 9' (Equal to) ❑ Yes ❑ No Comments (note if oox is level and distributon to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.) Liquid level equal to outlet inverts. No evidence of carryover. No scum or slime above static liquid level. Distribution box in poor condition at time of inspection. Box changed by Clean Septics with approval from BOH Agent. Per Marcus this Inspection report is changed from a conditional pass to a "Pass". tsmodoc • rev. 7/26/2018 Title 5 Offlclel Inspect on pone: Subsurface Sewage Disposal System - Page 12 of 18 Commonwealth of Massachusetts - : Title 5 Official Ins ? _ Subsurface Sewage Disposal System Fo 997 Westhampton Road D. System (cont.) 10. 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.): ection Form rm - Not for Voluntary Assessments * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate or site plan, excavation not required): If SAS not located, explain why: Property Address number: number: number: number, length: number, dimensions: 1@15'x45' bed number: Cassidy Bowman Owner Owners Name information is required for Florence. MA 01062 5/21/2020 every page. Cily[Town State ZinCoria nafA„vinenon«;,.� D. System (cont.) 10. 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.): Type/name of technology: t5insp.doo • rev. 7/26/2018 Tile 5Offcial Inspection Form: Subsurface Sewage Disposal System • Page 13 of 18 * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate or site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system number: number: number: number, length: number, dimensions: 1@15'x45' bed number: Type/name of technology: t5insp.doo • rev. 7/26/2018 Tile 5Offcial Inspection Form: Subsurface Sewage Disposal System • Page 13 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form 7 Not for Voluntary Assessments 0 997 Westhampton Road Property Address Cassidy Bowman Owners Name Florence D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) MA 01062 State Zip Code Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of hydraulic failure. Soil clean and dry. Vegetation normal. No guarantee or warranty on how long the system will continue to operate properly in the future 12. Cesspools (cesspool must be pumped as cart 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,): 151nsodoc • rev. 7 /2 612 01 8 Tile 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Insp g — Subsurface Sewage Disposal System For 997 Westhampton Road u. system intormation (cont.) 13. 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.): t5lnsp.tloc • rev. 7/2 612 01 8 Title 5Official Inspection Form; Subsurface Sewage Disposal System • Page 15 of 18 ection Form m - Not for Voluntary Assessments Property Address Cassidy Bowman Owner Owners Name information is required for Florence MA 01062 5/21/2020 every page. Cityfrown State Zip Code Date of Inspection u. system intormation (cont.) 13. 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.): t5lnsp.tloc • rev. 7/2 612 01 8 Title 5Official Inspection Form; Subsurface Sewage Disposal System • Page 15 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 997 Westhampton Road Property Address Cassidy Bowman Owners Name Florence MA 01062 Cityrrown State Zip Code D. System Information (cont.) 14. 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 l5insp.tloc- reV. 7/2612010 Title 5 Official Inspection Fan: Subsurface Sewage Disposal System • Page 16 of 18 c Commonwealth of Massachusetts UTitle 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ice;; ° 997 Westhampton Road Property Address Cassidy Bowman Owner Owners Name information is Florence required for MA 01062 5/21/2020 every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells >4' 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 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: New system 2001. SAS elevated above origional grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insedoc • rev. 7/26/2018 Title 5 Officlal Inspection Form: Subsurface Sewage Disposal System • Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y. 997 Westhampton Road Property Address Cassidy Bowman Owner Owners Name information is required for Florence MA 01062 5/21/2020 every page. Clly[Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: E A. Inspector Information: Complete all fields in this section. E B. Certification: Signed & Dated and 1; 2, 3, or 4 checked E C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) corlpleted E D. System Information: For 8: Tight/Holding Tank — Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included tSInsedoc • rev. 726/2018 Tile 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 18 of 18 Drivoway 97' aam@on Road