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