100 Title 5 Application/Permits 1991, Title 5 Report 2015, Municipal Water Application 1991 Water Entry Fee Paid
RESIDENTIAL OR COMMERCIAL BUILDING WATER
To the City of NORTHAMPTON, MASSACHUSETTS:
The undersigned, being the
property located at
Owner
DEPT OF BUILDING INSPECTIONS
NORTHAMPTON MA 01060
Owner, Owner's Agent
100 Maple Ridge Road
(Number) (Street)
of the
, does
hereby request a permit to install and connect a 1" Water
(size)
Service to the Residence
(Residence, Commercial Bldg. , etc.)
at said location.
1. "Owner" shall mean the person holding title to the property
served or to be served by the water service.
2. The name and address of person or firm who will perform th
proposed work is Dave McCafferty
3. Plan/Sketch and specification for the proposed water service shall
be attached to permit.
In consideration of the granting of this permit, the under-
signed agrees:
1. The Water Department shall make all taps to the water main.
2. WATER ENTRY PERMIT fee is $200.00.
3. Additional work performed by City forces from the water main to
streetline shall be paid at the prevailing labor rates and cost
of materials
Water Meters 5/8" $100.00
3/4" $150.00
II II 1" $200.00
Water Meters 1}" and above shall be purchased by the owners - using city specs.
4. The Water Superintendent shall be notified for water line
inspection prior to backfill of trench
page 2
Water Entry Application
DATE:
June 17, 1991
$ 200.00
SIGNED:
(Applicant) (F.util (Kobylarz
31 Gregory Lane
entry fee paid.
(Address of Applicant)
Application approved and permit issued:
DATE: June 17, 1991
Water Meter Fee:
SIGNED:
(
Director of Pub Works)
ASS1tp'
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
v Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner Owner's Name
required atl is
r Florence MA 01062 6/26/2013
required for every
page. City/Town State Zip Code Date of Inspection
Important:When
filling out forms
on the computer,
use only the tab
key to move your
cursor-do not
use the return
key.
MVP
15ns•3113
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
city/Town
413-628-4533
Telephone Number
MA
State
SI-130
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:
® Passes
❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspectors Signature
June 26, 2013
Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use
The s O fical Inspec1on Form Subsurface Sewage Disposal System.Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Disposal Subsurface Sewa
g posal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner Owner's Name
informatlon is
required for every Florence MA 01062 6/26/2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cant.)
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 d the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval
if pumps/alarms are repaired.
Dins•3/13 Tree 5 Official loscecbon Form.SuGwrtace Seep Disposal System•Page 2 of 17
Owner
information is
required for every
page.
nuns•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owners Name
Florence MA 01062 6/26/2013
City/Town State Zip Code Date of Inspection
B. Certification (coot.)
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 ❑ V ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
LI distribution box is leveled or replaced ❑Y ❑ N ] ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below).
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
The s Official Inspection Fam:Subsurface sewage RsposaI System•Page 3 of 17
1 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner Owner's Name
r fn is
required Florence MA 01062 6/26/2013
page. for every
page. City/TOwn State Zip Code Date of Inspection
B. Certification (cunt.)
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
15ns•113 Title 5 official Inspection Form Subsurface Sewage Disposal System Page 4 N 17
Commonwealth of Massachusetts
or Title 5 Official Inspection Form
Owner
information is
required for every
Page,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner's Name
Florence
City/Town
MA 01062 6/26/2013
State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Z
❑ Z
❑ Z
❑ Z
❑ Z
❑ Z
❑ Z
C 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
❑ Z the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes" to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
fins.3'13 Ties Official Inspection Form'.subsu,h[e Sewage nsposal System•Page 5 of 17
Commonwealth of Massachusetts
e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner Owner's Name
information is Florence MA 01062 6/26/2013
required ror every
page. City/Town State Zip Code Cate of Inspection
C. Checklist
Check t the following have been done. You must indicate'yes" or"no"as to each of the following:
Yes No
® ❑
® ❑
Z ❑
® ❑
Z ❑
® ❑
® ll
® I
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?
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 systems?
The size and location of the Soil Absorption System (SAS)on the site has been
determined based on:
® ] Existing information. For example, a plan at the Board of Health.
® ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)(310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms
(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of
bedrooms):
Note: Design was made in error. Current code shows 100 In. ft.
required, only 60 In. ft. provided. Actual design flow
calculates at 264 gpd by today's code.
4
1,215 gpd
ens•3/13 Title 5 Official Inspection Fmm'.Subsurface Sewage Disposal system Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner Owner's Name
information is Florence MA 01062 6/26/2013
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1500 gallon septic tank, 3 leaching trenches.
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? (Include laundry system
inspection information in this report)
Laundry system inspected?
Seasonal use?
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
5/11/12 to 5/7/13 records. 1" quarter flow was higher, but lower with
lower occupancy.
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
220 gpd
Sump pump? ❑ Yes Z No
continuous.
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present, ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes E No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available.
thins.3)13 rim 5 Official inspection Form Subsurface Sewage Disposal System•Page 7 of 17
2 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Owner
information is
required for every
page.
tSins 3113
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner's Name
Florence MA 01062 6/26/2013
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 fall, 2012, says Owner
Was system pumped as part of the inspection? Eyes ® No
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
gallons
Does not need pumping this year.
❑ 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):
Ttle 5 Official Inspecton Form.Subsurface Sewage psposal System•Page B of 17
Owner
information is
required for every Florence MA 01062 6/26/2013
page. City/Town State Zip Code Date of Inspection
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owners Name
thins 3/13
D. System Information (cont.)
Approximate age of all components, date installed Of known)and source of information:
Septic plan: Plan 4/21/91.
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 ®other(explain):
Distance from private water supply well or suction line:
12" average
feet
ABS 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:
®concrete
.67
feet
Dyes Z No
❑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
58" wide, 126" long, 60"
Dimensions: height
Sludge depth:
The 5 Official Inspection Form.SUGUrbos Se vnpe[spo aI Splam•Page 90117
Commonwealth of Massachusetts
u gm. l-c� Title 5 Official Inspection Form
Ii=:
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner's Name
Florence MA 01062 6/26/2013
City/Town State Zip Code Date of Inspection
Owner
information is
required for every
page.
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 20"
baffle
Flow were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
36"
calculated
1,500 gallon septic tank in good structural condition. Liquid level at
height of outlet invert.
Grease Trap(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal
Dimensions:
Scum thickness
feet
❑fiberglass ❑ polyethylene ❑ other(explain):
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
bins•3113 Trtle 5 Official Inspection Ferm'.Subsurface Sewage Daposal System'Page I0 of 11
Owner
information is
required for every
Page,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owners Name
Florence
City/Town
MA 01062 6/26/2013
State Zip 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 ❑ polyethylene I other(explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes No
151ns•3tl3 Tile 5 Official I nspeNOn Form.subsurface Sewage Disposal System Page II of 17
1 Commonwealth of Massachusetts
Owner
information is
required for every
page.
tans.3/13
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner's Name
Florence MA 01062 6/26/2013
City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Distribution Box Of present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
3 Pipes out. Top was deteriorated and replaced with newer concrete cover.
Sidewalls appear structurally intact. Almost 3 ft. below grade.
Pump Chamber(locate on site plan):
Pumps in working order:
Alarms in working order:
❑ yes ❑ No
❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
• If pumps or alarms are not in working order, system is a conditional pass
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If MS not located, explain why:
The s Official Inspection Form:Subsurface Sewage OWseI System.Page 12m 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
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner's Name
Florence MA 01062 6/26/2013
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits
❑ leaching chambers
❑ leaching galleries
® leaching trenches
❑ leaching fields
❑ overflow cesspool
❑ innovative/alternative system
number:
number:
number:
number, length:
number.
dimensions:
number:
3 trenches, 20 ft. long
each
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.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan).
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
I5ins•3/13 Tile S Official I r pecton Fenn:Subsurface Sewage Dsposal System Page 13 of 17
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Owner
information is
required for every
page.
I'ms 113
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owners Name
Florence MA 01062 6/26/2013
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction'.
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Zak s Oficrel Irspecton Form:Subsumes Sewage Disposal System.Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner Owner's Name
information is Florence MA 01062 6/26/2013
pageed for every
page. City/Town State Zip Code Date of Inspection
t5ins•3/13
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
Z drawing attached separately
The 5 Official Inspection Form subsurface Sewage Deposal system.Page 15 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
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner's Name
Florence
City/Town
MA 01062 6/26/2013
State Zip Code Date of Inspection
D. System Information (cont)
Site Exam:
Z Check Slope
® Surface water
Z Check cellar
❑ Shallow wells
Estimated depth to high ground water:
6+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
9/19/91
If checked, date of design plan reviewed. Date
Observed site(abutting property/observation hole within 150 feet of SAS)
n Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
fT Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Perc test of 4/8/86 found no water to 103". On dry ridge of sandy soil.
Area perc test are generally this deep or deeper to water table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
sns•3/13 Tale 5 Official inspection Form'.subsurface Sewage Disposal SKtem.Page 16 of 17
Owner
information is
required for every Florence MA 01062 6/26/2013
page. City/Town State Zip Code Date of Inspection
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Maple Ridge Road
Property Address
Emil & Sandra Kobylarz
Owner's Name
thins•3/13
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
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Tile s Official inspection Form'.subsoil ace sewage Disposal System Page 17 of 17
Septic Tank
Distribution Box
Leaching trenches, approximate layout \1l
0 . 0
46 3/4'
o deck
A
Note: No known drinking water sources within a 100 foot radius.
Partial House Outline
�u"nl
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.
Date: Owner: aN 0 tom.,_
As-Built Drawing - Cr '�s� HOMESTEAD INC.
Existing Septic System 6/26/2013 Emil & Sandra Kobylarz TMpYUtas Thomas S. Leue R.S.
.11 100 Maple Ridge R. . . LE0�
Scale: 1 : 20' Revision Date: / • r2 ' - 1664 Cape St.
Except as Noted
Florence, MA 01062 ���"t�x[u �r.+�� wlh 14,3]62�d45 n 1
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
�t BOARDS/O�)F}}H{EpALTH /
C try OF WORT-MI rue
Oration fur flinpuittl iflurks Cltunstrurtiun Prrmit
SD Fait
Application is hereby made for a Permit to Construct ('1 or Repair ( ) an Individual Sewage Disposal
System at:
amt. 7
anmt E l-kgv Aida ov Coe \o.
� nv^ >�/3n/aCj Cr e �✓tP, Z 3/ C=FS. GOR LN Mltr7
Address
T of Building
Dwelling—No. of Bedrooms Expansion 4tic
Other—Type of Building _.SeU.�..FPtt�.. No. of persons C]I
Other fixtures
Size Lot , - q. feet
( ) Garbage Grinder (
( ) — Cafeteria ( )
Design Flow 5 V gallons per person per day. Total dail
pp
Septic Tank—Liquid capacity_/.S O%allons Length_LF(o Width 066
Disposal Trench-No. 3___. Width 3' Total Length 2.0'
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( Dosing tank ( p) �p
Percolation Test Results Performed by Pi R fl. J&
Test Pit No. I c2- minutes per inch Depth of Test Pit /O7
Test Pit No. 2 minutes per inch Depth of Test Pit
flow 62./0.0 gallons.
Diameter 62.il
Total leaching area sq. ft(S7)
Total leaching area sq. ft
Date if —8— 8 Cs
Depth to ground water—/_02
ii
Depth to ground water
Description of Soil 013 51 GC'�' S9N.Q Gu �j'i IP OF �'jt/�' Sau�J
FIRE _.5 P— mED CCAREE SjP - VEPX
A.,
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE S of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Application Approved By
Sign
6,_7 `(
Application Disapproved for the following reasons'
Permit No
Issued
by
a
has been installed in accordance with the prdomens oI -_ 5 of The State Sanitary Code s described in the
application for Disposal R orks Construction Permit No �-�--�i I dated �_ _7 c
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THA THE
SYSTEM WILL ,��yyyNC ION SA�SI CTORY.
DATE (] Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF A
rrtifiratr of faumptittttrr
Till TO C R " That e Individual Sewage Disposal System constructed (k) or Repaired ( )
to •
No l
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Disposal
Permission is hereby granted
to Construct (X) or .Repair ( ) an Individual Sewage Disposal System
at No
Pt
arks -euttsfr}u#lo x Drrai;
FEE -
/ street -
as shown on the application for Disposal \'forks Construction Permit No _.____- Dated
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Bmr I oV Hmlth
EALTH OF MASSACHUSETTS
RD OF HEALTH
NOPTHAMP1CN __._. ..
{ N P Tito Qlrniiiirurtion Permit
n yr f L
I`irn i.. - t - yv tiLS5i r' NPi6M Nk: r6r�.
tip
u ImNnr t e .t>> 'Mien fri DS�ro.al A� r . . ;d Srwt mike •
Be System
at No @B® ___. ..._. __.._ ... ...
I I ✓VV I Construction Pen ii Hq f2- I) .c1. f3" _l
r f 2 2.97. Uianl aP !(clh
OAT ..
Ft a� J z A. M ,ULKIr. INC. BOSTON
Fee
THIS I T
by
at .LA-F ?9p, 1
C. (TIFY
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrttfiratr of Iampttattrr
■
7
ndividual Sewage Disposal System constructed ( ) or Repaired ( )
L! _.....:_ i I f ( Koh feez
has been installed in accordan with the provisions of TIT tL 5 of The State Sahitary Cod yss dgscribed in the
application for Disposal Works Construction Permit No 'Oa- 1 dated / /(9/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL UNCTION SATISFACTORY.
DATE /6 /iii Inspector...
tab 01 L �`L "rr