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17 Septic Inspection Form 2012 Owner information is required for every page. Important:Wien filling out forms on the computer. use only the tab key to move your cursor-do not use the return key. vtrn vm Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owners Name Florence City/Town MA 01062 4/12/2012 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. A. General Information 1. Inspector: Thomas S. Leue Name of Inspector Homestead Engineering Inc. Company Name 1664 Cape St. Company Address Williamsburg MA City/Town State 413-628-4533 SI-130 Telephone Number License Number 01096 Zip Code B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Z Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Lispeotoie s' nelur�"� o April 12 , 2012 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 appropdate 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. Trtle 5 OF¢ml Inspection Form Subsurface Sewage Disposal System.Page 1 oft Owner information is required for every page mina 11)10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owner's Name Florence MA 01062 4/12/2012 Crty/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): artier 50Xiaal 1^spectioa mrm Se°cur ace Sewage Di powl System•Page 2 c1"7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owner Owners Name information i required for s Florence MA 01062 4/12/2012 every page. City/Town State Zip Code Date of Inspection Ems ^!1D B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y E N E 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 Tte 5 ORianl I!spe:'on Fam Subselace Sewage Disgasa System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owner owners Name mrormanon is Florence MA 01.062 4/12/2012 required for every page. City,7own State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or ' more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow airs•11/10 Tore 5 Sane¢,.nspeaon Form Saasurfae Sewage Disposal Systen•Pave 4 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owner Owner's Name inforinformation is required every Florence MA 01062 4/12/2012 m page. City/Town State Zip Code Date of Inspection 10 B. Certification (cant.) Yes No E Z E Z E Z 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 (Intenm Wellhead Protection Area—I W PA) or a mapped Zone I I 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. T tie s LN5d3unspa bon roan subsuaam Sewage Disposal System.Page 5 of 17 N Owner information is required for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owners Name Florence MA 01062 4/12/2012 CityiTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or no as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal Flows in the previous two-week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as-built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? Z ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened. and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field Of 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: 4 Number of bedrooms Number of bedrooms (design): (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 4 660 gpd 10 I ma 7 Official wue son corm Subsurface Sewage 0 sposal System.Page 6 of 17 Owner information is required for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owners Name Florence MA 01062 City/Town State Zip Code Date of Inspection D. System Information Description: Septic tank, distribution box and conventional leachfield. Number of current residents: 3 Does residence have a garbage grinder? Z Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection ❑ Yes ® No required] Laundry system inspected? ❑ Yes Z No Seasonal use? ❑ Yes ® No Water meter readings. if available (last 2 years usage (gpd)): Detail: 85 gallons per day from 12/6/11 to 3/5/12 Sump pump? ❑ Yes Z No COnti us 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: ins tam lure 5 oriael Inspectior Form Subsurface See20e Disposal System•Page 7 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hawthorn Terrace Properly Address Julie Rosten Owner Owner's Name Information is required for every Florence MA 01062 4/12/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont ) Last date of occupancy/use: Other (describe below): Date Pumping Records: Source of information: General Information Pumped November 2, 2011, says owner. Was system pumped as part of the inspection? If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: ❑Yes ® No 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): rAle 5 official 1soeNon°arm S!bsuraace Sewage Dlsocs I Sys @m.Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owners Name Florence MA 01062 4/12/2012 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: Plan not dated, perc test dated 4/28/89. Were sewage odors detected when arriving at the site? Building Sewer(locate on site plan): Depth below grade: Material of construction: ❑ cast iron ❑ 40 PVC N other (explain): Distance from private water supply well or suction line: 1 average feet Yes N No ASS Plastic 30 ft. feet Comments (on condition of joints,venting, evidence of leakage, etc.): No problems seen. Septic Tank (locate on site plan): Depth below grade: Material of construction: Z concrete 0.6 feet ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Standard septic tank of nominal 1,500 gallons capacity. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 57" tall, 122" long, 58" Dimensions (both tanks): wide Sludge depth: 1" me 5 CYpal msnecrio.Form Subsurface Sev+'age nisposa System.Page 9 of 17 C\ Commonwealth of Massachusetts Owner information is required for every page Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owner's Name Florence City/Town MA 01062 4/12/2012 State Zip Cade Date of Inspection D. System Information (cont ) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 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.): Tank structurally OK. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ 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 Title 50ffioal ospetlar Fos,. Subu4aue Sewage Disposa System Page 19 do Owner information rs required for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owner's Name Florence City/Town MA 01062 4/12/2012 State Zlp Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage. etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order LI Yes ❑ No Date Comments (condition of alarm and float switches, etc.): 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 6ms.,vm Tina 5 Official^spectOn corm sabmcace Sewd9e Disposal System-Page 11 or 17 Owner information is required for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owner's Name Florence city/Town MA 01062 4/12/2012 State Zip Code Date of Inspection D. System Information (cont.) Distribution Box Of present must be opened) (locate on site plan)• Depth of liquid level above outlet invert 0" 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.): Sox appears level and flow equally distributed. 5 pipes out. Significant biosolids in box. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located. explain why: Som.-11110 Tne 5 GFlwal Insr.a'tOn ro m Subsurface Sewage Disposal System•Puot 12 cf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owner Owner's Name information is Florence MA 01062 4/12/2012 required for every page. Cay/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: ❑ overflow cesspool number: ❑ innovative/alternative system About 30' x 36 Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc_): No surface problems seen. Pipe and stone technology in field. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to net invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Mile 5 09 oal Inspection Fern Surtax 4wage'Lsposal Sys em•Page 13of 17 y,„ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owner Owners Name information is Florence MA 01062 4/12/2012 required for every page City,Town State Zip Corte Date of Inspection D. System Information (cont.) Comments (note condition of sod.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.): Tate 5 gfical inspecilo..For m Subsueac Saogae uiseral Srmem.Page 14 Owner in formation is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owner's Name Florence MA 01062 4/12/2012 CityiTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately non.1110 I m¢s official m Owner information is required for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hawthorn Terrace Property Address Julie Rosten Owner's Name Florence MA 01062 4/12/2012 City/Town State Zip bode Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 5.3' feet Please indicate all methods used to determine the high ground water elevation: O Obtained from system design plans on record If checked, date of design plan reviewed. Perc date of 4/25/89 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: Original pert test found water table at this depth. Dry basement, sandy soil. Before filing this Inspection Report, please see Report Completeness Checklist on next page. rle 5 ctoeunspernon Form Subsurface Sewage Disposal System.Page 10 m17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hawthorn Terrace Propedy Address Julie Rosten Owners Name Florence City/Town MA State 01062 Zip Code 4/12/2012 Date of Inspection E. Report Completeness Checklist ® Inspection Summary. A, B, C, D. or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 10 Tale 5 cnioxnnsneotion Farm S bsu,face Sewage Jispoai sy m.Peg at NORTH 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 accessible in future years for maintenance. Note No known drinking water source within 100 foot radius. Septic Tank Distribution Box Leachfield 44 1/4' X7001/2 deck O 1 m n 1 0 To a X OF YAS As-Built Drawing Date: Owncr' ���y�e s�4s� HOMESTEAD INC. 4/12/2012 Julie Rosten o s Existing Septic System rh THONASSo a Thomas S Leue R.S. 17 Hawthorn Terrace ° LEU� Scale: 1 : 20' Revision Date: ,���,�.. 72 1 1004( ape Ht_ Florence, MA 01062 ���heFO snN`��� itiini.,�st 4=0; Om Except as Noted