372 Title 5 Report, 2012 (2) Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner Owners Name
information is
required for every Florence
page. City/Town State Zip Code
MA 01062 3/28/2012
Important:When
filling out forms
on the computer,
use only the tab
key to move your
cursor-do not
use the return
key.
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
City/Town
413-628-4533
Telephone Number
MA
State
S1-130
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
El Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
March 28, 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 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.
151115•11110 Title 5 official Inspection Form subsurface sewage Disposal System•Page 1«n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner Owner's Name
information is Florence MA 01062 3/28/2012
required for every
page. City/Town State Zip Code Date of Inspection
Gins•11110
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
(E1 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):
r ie 5 kcal Inspection Form:Subsur
ge Oisp058I Syslem Page 2 o11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner Owners Name
information is
required for every Florence MA 01062 3/28/2012
page. CM/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System
will pass inspection if(with approval of Board of Health):
E l broken pipe(s)are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
❑Y
❑ Y
El
❑ N El ND (Explain below):
❑ N El ND (Explain below):
E l N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipets).
The system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
E l obstruction is removed ❑ V ❑ 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
15ms.11/10 Tole S Official Inspectoon Form:Subsurface Sewage DiynwI System.Page 3 a»
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner Owners Name
information is
required for every Florence MA 01062 3/28/2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is
equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the
analysis must be attached to this form.
3. Other:
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
I5ins.nno idle 5 official nspecti Form Subsurface Sewage Disposal System•Page 0 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner Owner's Name
information for every rfn is
required Florence MA 01062 3/28/2012
page- City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El El
El E
0 El
El
0 El
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 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 conform 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_
Et 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
0 El
0 El
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.
'Sins-1 1/10 rill¢5 Official Inspection Form-Subsurface Sewage Disposal System•Page 5 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
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner's Name
Florence MA 01062 3/28/2012
City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑
El 0
❑ ❑
Z ❑
Z ❑
Z ❑
Z ❑
Z ❑
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) 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
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:
unknown Number of bedrooms
Number of bedrooms(design): (actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of
bedrooms):
3
330+
a Disposal System 5 Official spetSins•11/1O ion Form Subsunare Sewa � •Page 6 or IT
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owners Name
Florence MA 01062 3/28/2012
Ciy/Tawn
State Zip Code Date of Inspection
D. System Information
Description:
Conventional septic tank and leaching trench.
Number of current residents: 0
Does residence have a garbage grinder? N Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection ❑ Yes N No
required)
Laundry system inspected? ❑ Yes N No
Seasonal use? ❑ Yes N No
Water meter readings, if available(last 2 years usage (gpd)): 20031.63
Detail:
Town water
Sump pump? ❑ Yes N No
None
Last date of occupancy: Date since Dec. 2011
Commercialllndustrial 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:
(Sins.11/10 Tale 5 ORical Inspection Fain:Subsurface Sewage Disposal System.Page 7 of 17
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Owner
information is
required for every
page.
bins 11110
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owners Name
Florence MA 01062 3/28/2012
City/Town
State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below):
Date
Pumping Records:
General Information
Source of information: Last pumped about 10 years ago, says
Owner.
Was system pumped as part of the inspection?
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distributieabox, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) Of 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
Dees ® No
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Tllle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8ef 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner Owners Name
information is Florence MA 01062 3/28/2012
required for every
page. Cilyff own State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
No information, but said to be about 90 years old.
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:
Eyes ® No
2.0 average
feet
PVC to leaching trench
35 ft.
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Not visible in basement or crawlspace.
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
® concrete
2.1
feet
❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: y ears
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions(both tanks):
54"tall, 90" long, 58 wide
Sludge depth:
thins•11/10 rme 5 Onical InspeciiM£am.Subsunare Sewage Disposal System-Page 90117
Owner
information is
required for every Florence NA 01062 3/28/2012
page. Cityaown State Zip Code Date onmpedion
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owners Name
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?
No outlet baffle
q„
No outlet baffle
No outlet baffle
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural
integrity, liquid levels as related to outlet invert, evidence of leakage, eta):
Tank structurally OK. Standard septic tank of nominal 1,000 gallons
capacity. Outlet baffle was missing and replaced with PVC tee. Removable
inlet baffle OK. Recommend pumping soon.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
❑fiberglass
feet
❑ 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
IS,ns• v10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System.Page 10 Mn
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner Owners Name
information is
required Florence MA 01062 3/28/2012
Pfor every
pagee. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural
integrity, liquid levels as related to outlet invert, evidence of leakage, eta):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other
(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches, eta):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Lsirts.11rw Title 5 Olfnal Inspection Form Subsurface
ge Disposal system•Pape 11 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner Owners Name
information is
required for every Florence te]A _ 01062 3/28/2012
page C /town State Zip Code Date of Inspection
P9 M
D. System Information (cont.)
Distribution Box Of present must be opened)(locate on site plan):
None in system
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.):
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:
thins• I/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System Page 12 0117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner Owners Name
reguidfo is Florence MA 01062 3/28/2012
required for every
page. City/fown 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:
One, about 50
feet long
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. About 3' below grade
at deepest point.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•1110 Tile 5 0Ktlal Inspection Form:Subsurface Sewage Disposal System'Page
of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner Owners Name
information is
required for every Florence MA 01062 3/28/2012
page. 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.):
Sins.N10 Title 5 Official Inspection Form subsunacs Sewage Disposal System•Page 1aW 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
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner's Name
Florence
City/Town
MA 01062 3/28/2012
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
Title 5 Official nspMlm Fwa[Subwnare Sewage Disposal System.Page 15 W 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner Owners Name
mformacon is Florence MA 01062 3/28/2012
required for every
page. Ciy/rown State Zip Code Date of Inspection
15ins 11110
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water:
5+
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.
Open sandy soil, located about 8 to 10 feet above stream <100' distant
Basement is dry without obvious dewatering system.
Before filing this Inspection Report, please see Report Completeness Checklist on next
page.
Title 5 official InspecAon Form:Subsurface Sewage Psposal System•Page 16 of IT
c£� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Owner
information is
required for every
page
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
372 North Farms Road System 1
Property Address
Greg Lizotte
Owner's Name
Florence
City/Town
MA
State
01062 3/28/2012
Zip Code 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
L5ms.11/10 rnk 5 OflcAal Inspect on Form Saewnace Sw'e5e Disposal System.Page 7 ofn
/ .
50314,
System 2 septic tank
leachteld, approximate layout
3-
p/ 60
op
`t w Distribution Box
c
o_ /
Town Water In ► �,
partial House Plan
47, s
0 56, 44,
r
NORTH
lir
System 1 septic tank
leach trench
COMMENTS:
Recommend pumping on a 3 to 5year schedule. Also, a
copy of this plan posted in the basement/utility area.
would keep this information accessible in future years
for maintenance.
t)ate: Owner: SN OF pIS
As-Bull Drarrm<, ��`' '`��y HOMESTEAD INC.
Existing Septic Sy tear 3/28/2012 Greg Lizotte h� THOMAS S. `� Thomas S. Leuc R.S.
372 North Farms Road LEUE
Sc 1Ic. 1 : 2U Revision Date / ". �A, .. ;; 7g_ . r _ l�,<+r tint,sr
Florence, MA 01062 sF� 44 wJllai„str �1,� ouwo
Gxcept as Noted STEREO SO.44 I41 r 4911