167 Title 5 Reports 2010, 2012 Owner
information is
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
167 North Farms Road
Property Address
Don Warburton
Owner's Name
Florence
City/Town
MA 01062 September 26, 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:
Timothy E..Maginnis R.S.
Name of Inspector
Company Name
70 Montague Road
Company Address
Westhampton
City/Town
(413) 527-5291
Telephone Number
MA
State
SI 1039
License Number
01027
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 Furth-� tl•:!!ea`vl'. ocal Approving Authority
September 28, 2012
Date
The system inspe .)r/ opy of this inspection report to the Approving Authority(Board
of Health or DEP)wit - 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.
I5ins•rota Title 5 Official Form.Subsurface Sewage Disposal system•Page 1 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
167 North Farms Road
Property Address
Don Warburton
Owner Owners Name
information quirefor
is Florence MA 01062 September 26, 2012
every for P
every page. City/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 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:
With continued maintenance and proper operation, this system should provide trouble free service in
the years to come. Risers have been installed on the distribution box cover,the inlet cover, outlet
cover and pumpout man-hole of septic tank. Due to age of this system I recommend pumping every
year hereafter.
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):
N/A
15ins.11/10 Trim s Official Inspection Form Subsurface Sewage Disposal Syslem•Page 2 or 17
Owner
information s
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
167 North Farms Road
Property Address
Don Warburton
Owners Name
Florence MA 01062 September 26, 2012
City/Town State Zip Code Date of Inspection
B. Certification (cons.)
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):
N/A
❑ 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 ❑ V E N D ND(Explain below):
LI obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
N/A
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
tams•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System.Page 3 an
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
167 North Farms Road
Property Address
Don Warburton
Owner Owner's Name
information is Florence - MA 01062 September 26,2012
everrequired for P
every 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: N/A
"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:
N/A
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
151ns ntlo Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 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
167 North Farms Road
Property Address
Don Warburton
Owners Name
Florence
City/Town
MA 01062 September 26, 2012
State Zip Code Date of Inspection
B. Certification (cont.)
Yes N
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Z 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.
❑ Z 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.
❑ Z 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 colifarm 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 2000gpd-
10,000gpd.
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 (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.
thins•11/10 Tie 5 Official Inspection Fo,m.Subsurface Sewage Disposal System•Page Si U 17
Owner
information is
required for
every page.
isms•11110
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
167 North Farms Road
Property Address
Don Warburton
Owner's Name
Florence
City/Town
MA 01062 September 26, 2012
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
N ❑ 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?
N ❑ Has the system received normal flows in the previous two week period?
❑ N 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 ❑ Was the facility or dwelling inspected for signs of sewage back up?
N ❑ Was the site inspected for signs of break out?
N ❑ Were all system components, excluding the SAS, located on site?
N ❑ 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:
N ❑
N ❑ 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)]
N ❑
D. System Information
Residential Flow Conditions:
Number of bedrooms(design):
Unknown
Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
4
Unknown
Title s official.Inspection Form Subsurface Sewage D' lam•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
167 North Farms Road
Property Address
Don Warburton
Owners Name
Florence MA 01062 September 26, 2012
City/Town State Zip Code Date of Inspection
D. System-information
Description:
One leaching field @ (401 x 25W)approx.
Number of current residents:
Does residence have a garbage grinder? Z Yes ❑ No
Is laundry on a separate sewage system?fif yes separate inspection required] ❑ Yes ® No
Laundry system inspected? Z Yes ❑ No
Seasonal use? ❑ Yes ® No
5
Water meter readings, if available (last 2 years usage(gpd)):
Detail: -
PRESENT READING= 88657 cu. ft.
Sump pump? ❑ Yes ® No
Last date of occupancy: ocepy
occupied
Commercial/Industrial Flow Conditions:
N/A
Type of Establishment:
n flow(based on 310 CMR 15.203): N/A
Design ( % Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
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: N/A
(Sins•MAO TNe 5OXloal Inspection Form Subsurface Sewage Disposal System•Page 7 al 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
167 North Farms Road
Property Address
Don Warburton
Owner Owners Name
information is
required quired for Florence MA 01062 September 26, 2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below):
N/A
N/A
Date
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, 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
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
N/A
gallons
N/A
N/A
N/A
thins•tt no Title s amoral Inspection Form.Subsurface Sewage Disposal system.Pape a o117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
167 North Farms Road
Property Address
Don Warburton
Owner Owners Name -
required for is Florence MA 01062 September 26,2012
every fo
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components date installed Of known) and source of information:
45 years
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:
34"
❑ Yes Z No
feet
N/A
feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
The building sewer pipe is in sound condition. No leakage observed. Joints are in good condition,
venting is proper.
Septic Tank(locate on site plan).
Depth below grade:
Material of construction:
®concrete ❑ metal
2-(24")-Riser to within 6"
feet
❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
N/A
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
(8.511x 5'w x 4'd)
Dimensions:
Sludge depth:
t5ins•11110
None
Tale 5 olrioal Insped00 Form:Subsurtem Sewage Disposal System Page s 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
167 North Farms Road
Property Address
Don Warburton
Owners Name
Florence MA 01062 September 26, 2012
City/Town State Zip Code 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?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Structural integrity of this tank is good. It is in good operating condition. The inlet and outlet baffles
are poured concrete. operating properly and in sound condition. The liquid level at the outlet invert
was even with the invert. There was no evidence of infiltration or exfiltration.
48"
lip
1/2"
1/2"
Observed I measured
Grease Trap(locate on site plan):
Depth below grade:
Material of construction:
❑concrete
N/A
❑ metal
N/A
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:
N/A
N/A
N/A
N/A
N/A
Date
t5,ns•11/1D Title 5 Official Inspection Fon,, Subsurface sewage Disposal system.Pape 10 N 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
167 North Farms Road
Property Address
Don Warburton
Owners Name
Florence MA 01062 September 26, 2012
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, etc.):
N/A
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan).
N/A
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
N/A
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
N/A
N/A
N/A
gallons
N/A
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
N/A
Date
Comments(condition of alarm and float switches, etc.):
N/A
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15us•11/10 Title 5 Offinal Inspection Form'.Subsurface Sewage Disposal System•Page 11 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
167 North Farms Road
Property Address
Don Warburton
Owners Name
Florence MA 01062 September 26, 2012
City/Town 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 Liquid level at each (3)outlet invert was even
with the inverts.
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.):
With the approval of the Northampton Board of Health Office, the distribution box was replaced as a
result of this inspection. It is approximately 30" below grade. Plastic risers were installed to bring the
cover to within 12"of finish grade. The structural integrity of the new disribution box excellent. It is in
good operating condition. There was no evidence of infiltration or exflltration.
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.):
N/A
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
SAS was located on site. See attached as-built plan.
ems•11110 Titles Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17
Owner
information is
required for
every page.
tS'ns•11/10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
167 North Farms Roa
Property Address
Don Warburton
Owner's Name
Florence
C ty/rown
MA 01062 September 26, 2012
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
Type/name of technology:
N/A
N/A
N/A
N/A
N/A
140'L x 25W)
N/A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Vegetation in lawn grass. No signs of hydraulic failure above ground or below ground. No ponding
or damp soil.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
N/A
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
N/A
N/A
N/A
N/A
N/A
❑ Yes ❑ No
Title 5 dual ins]eclion Form.Subsurface Sewage Disposal system-Page 13 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
167 North Farms Road
Property Address
Don Warburton
Owners Name
Florence
MA 01062 September 26, 2012
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.):
N/A
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.):
N/A
N/A
N/A
N/A
Moo•11110 Title 5 Official Inspection form:Subsurface Sewage Disposal Syslem•Page 14 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
167 North Farms Road
Property Address
Don Warburton
Owners Name
Florence
City/Town
MA 01062 September 26, 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
Z drawing attached separately
gEC
N E)C PAGE.
thins•11110 TAIe 5 CfliTial Ins p lion Fann:SWwRa[ Sew a Disposal System•Page 15 of 17
Pond
lit
le
f Porch
,8,
la
le
�R
-
Driveway
'A
,,, , ,, ,,, ,,,,,,/
, Existing
/ Garage � 4 bedroom ,
i I house
/
/• /! S
Fence
'
Existing 4" sewer lir)$
/r,
O
Ir
'
a..
pump-out manhole ("C)
Existing
1.000 gallon septic tank)
Existing -�
distribution box-"D
(new 10/2012)
0
\\- Driveway-
a
oldewalk
91••••••Per
` ,', ` 'W,
N
'
pipe
IW
' pvc pert
1 40ft.
WWW
Existing 41 pvc solid pipe I
1-
W
Water
line
(ref.
only)
NORTH FARMS ROAD-FLORENCE, MASSACHUSETTS
AS-BUILT DIMENSIONS '
'B' to 'C' = 47'-0'
'B' to 'D' = 45'-6'
RISERS
1. Inlet of septic tank
2. Tank pumpout man-hole
3. Outet of septic tank
4. Distribution box
TITLE-5 INSPECTION PLAN
167 NORTH FARMS ROAD
FLORENCE, MA. 01062
September 26, 2012
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
167 North Farms Road
Properly Address
Don Warburton
Owner Owners Name
information is p
required for Florence MA 01062 September 26, 2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water:
4,
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:
September 26, 2012
Date
• Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
N/A
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
N/A
You must describe how you established the high ground water elevation:
-Reviewed previous Title-5 Inspection report.
-Inspected septic tank for signs in infiltration or exfiltration.
-Observed natural topography of site.
- Reviewed USDA Soil Survey Book of Hampshire County.
-Observed approximate elevation of nearby pond.
-Observed cellar for sump pumps and/or water marks on walls.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
tbos•11/10 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 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
167 North Farms Road
Property Address
Don Warburton
Owners Name
Florence
City/Town
MA 01062 September 26, 2012
State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
Z 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
6111a•Tina nuo 5 Official Inspection Form subsurface Sewage Disposal system.Page 17 0117
Owner
information is
required for
every page
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 167 North Farms Road
Owner'Name:
City/Town:
B. Certification (cont.)
Inspection Summary: Check A, B, C, D or E/ /wa s complete all of Section D
A. System Passes:
Don Warburton
Northampton Ma 010 fin
----�� Date of Inspection:
8 9 10
Y I have not found any information which indicates that any of the failure criteria as 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:
N 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.
Answer yes, no, or not determined (Y, N, or ND)for the following statements. If not determined', please explain.
N 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. The system will pass inspection if
the existing septic 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.
ND explain:
N 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 the Board of Health): broken pipe(s)are replaced
obstruction is removed PProval
distribution box is leveled or replaced
ND explain:
N 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
obstruction is removed
ND explain:
C. Further Evaluation is Required by the Board of Health:
N Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect the 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.
T5 Revised doc•09/09
Title 5 Official Inspection Form:Subsurface Disposal System•Paoe 2 of 9
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection rm
Subsurface Sewage Disposal System Form-Not for Voluntary A entP
11 1.
Property Address: 167 North Farms Road
Owner' Name: Don Warburton
Citylrown: Northampton, MA 01060 Date of Inspection:
pecnon results must ae suumined on mis torm. Inspection torms may not oe auerea in any way.
Owner Address: Po Box •0143 F or-n a MA 01r62
8/4/10
Copy to:
Witness: Owner
Board of Health. Northampton,
Homestead Inc.#' 5505-1436
A. General Information
1. Inspector:
Name of Inspector: Thomas S. Leue R. S.
Company Name: Homestead Inc .
Company Address: 1664 Cape St. . Williamsburg, MA 01096
Telephone Number: j4131 628-4533 License Number. SI130
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 septic system condition must be evaluated and classified into one of the following four
conditions:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
The system condition: Passes
Inspector's Signature:
i`Q,r. sue_ Date: 8/4/10
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
regional office greater, the
The original should system owner shall submit
to the system ownerfand copies tto the
appropriate g
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the condi
that time.This inspection does not address how the system will perform in the future
or different conditions of use.
T5 Revised.doc•09/09
Title 5 Official Inspection Form'.Subsurfrn DisnnsaI Svcrom•Pnnc I nr°
Commonwealth of Massachusetts
Title 5 Official Inspection Form
yi Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 167 North Farms Road
Owner Owner'Name: Don Warburton is �On
required for City/Town:
every page. Northampton MA (11060
^---� Date of Inspection: 8 9 1
B. Certification (cont.)
El Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 to
15,000 gpd. For large systems, you must indicate either YES (Y)or NO (N)as to each of the following, in addition to
the questions in Section D.
N 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
mapped Zone II of a public water supply we system is located in
N a etrogen sensitive area (Interim Wellhead Protection Area-IWpq)or a
well
the
If you 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.
C. Checklist
Check if the following have been done. You must indicate YES (Y)or NO(N)as to each of the following:
Y Pumping information was provided by the owner, occupant or Board of Health.
N Were any of the system components pumped out in the previous two weeks?
Y Has the system received normal flows in the previous two week period?
N Have large volumes of water been introduced to the system recently or as part of the inspection?
Y Were"as-built"plans of the system obtained and examined? (If not available note as N/A) _
Y Was the facility or dwelling was inspected for signs of sewage back up?
Y Was the site was inspected for signs of break out?
Y Were all system components, excluding the SAS, located on site?
Y Were the septic tank manholes uncovered, opened, and the interior of the septic tank inspected for the
condition off the bathes or tees, material of construction, dimensions, depth of liquid, depth of sludge and
scum?
Y 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:
Y Existing information. For example, a plan at the Board of Health.
N Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR15.302(5)].
T5 Revised doe•09/09
Title 5 Official Inspection Form:Subsurface Disposal System Page 4 of 9
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 167 North Farms Road
Owner' Name: DOD Warburton
City/Town: Northampton, MA 01060 Date of Inspection: 8/4/10
B. Certification (cont.)
2) System will fail unless 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 I 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 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 either YES (Y)or NO (N) as to each of the following for a inspections:
N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
N Liquid depth in cesspool is less than 6" below invert or available volume less than 1/2 day flow.
N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of
times pumped
N Any portion of the SAS, cesspool or privy is below high ground water elevation. —
N Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
supply.
N Any portion of cesspool privy is within a Zone I of a public well.
N Any portion of cesspool or privy is within 50 feet of a private water supply well.
N Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply
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 must be attached to this form.]
N The system is a cesspool serving a facility with a design flow of 2000 gpd-10,000 gpd.
N The system fails: I have determined that one or more of the above failure criteria exist as defined in 310 CM
15.303, therefore the system fails. The system owner should contact the Board of Health should be contacted
to determine what will be necessary to correct the failure.
COMMENT:
T5 Revised.doc•09/09 Title 5 Official Inspection Form:Subsurface Disposal System•Page 3 of 9
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
1:1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 1 7 North Farms Road
Owner'Name: Don Warburton
City/Town: North ton MA 01 60 Date of Inspection: S 4 10
Owner
information is
required for
every page.
D. System n ormatlon (cant.)
Approximate Age: All components, date installed (if known) and source of information:
!Septic plan: BoB_permit date 7/14/67
---!�----_Were sewage odors detected when arriving at the site (Y or N)
Building Sewer:
26
Cast iron
j-._ --18 - _
.Comments:
j Septic Tank:
19
_ -Concrete
(locate on site plan)
Depth below grade
(inches)
Material of Construction
Distance in feet from private water supply well or suction line
No problems seen.
Estimate dAvv
(locate on site plan)
Depth below grade
Materials of Construction
(inches)
—-- --_ _— If tank is metal, list age
t'- - -- -_.---Is age confirmed by a Certificate of Compliance?(attach a copy of certificate)
--- --� Riser depth (inches)
- 58 --- Septic tank width
I----88_ Septic tank length
57_ ___
r 1Septic tank height
,263 Calculated g
F---- -_- __ gross volume
--- 10-_--Air space in tank
f-- 1,000 Net Volume
----26- __- Baffle depth
--- __ Sludge thickness
--- _ 29 Top Sludge : Bottom Baffle
1 Scum thickness
I.
r___ 15 Bottom Scum • Bottom Baffle
_ 8 Top Scum • Top Baffle
Measured -How were dimensions determined?
I Comments:
�No operational or structural problems seen.
IRiser over center cover. Outlet baffle thin_ but functional.
I
(inches)
(inches)
(inches)
(gallons)
(inches)
(gallons)
(inches)
(inches)
(inches)
(inches)
(inches)
(inches)
Interior dimensions
Interior dimensions
interior dimensions
Cautd
Calculi
Average
Calculated
Average
alcula ed
alcula e
i--_- - --
Recommendations:
!Pump on 3 to 4 year interval.
7-5 Revised.doc•09/09
Title 5 Offidal Inspection Form:Subsurface Disposal System•Page 6 of 9
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 167 North Farms Road
Owner' Name: Don Warburton
City/Town: Northampton MA 01060 Date of Inspection: 8/4/10
D. System Information
Residential Flow Conditions:
3 Number of bedrooms (design)
3 Number of bedrooms (actual)
330+ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#bedrooms)
2 Number of current residents
Does residence have a garbage grinder?
N Is the Laundry a separate system? [If yes, separate inspection required]
N Laundry system inspected?—
N Seasonal use?
N/A I Water meter readings, if available(last 2 years usage (gpd))_
N Sump Pump? _
continuous Last date of occupancy
COMMERCIAL/INDUSTRIAL
Type of establishment: =
Design flow(based on 310 CMR 15.203): = gpd
Basis of design flow(seats/persons/sift, etc.): _
Grease trap present? _
Industrial waste holding tank present? _
Non-sanitary waste discharge to the Title 5 system? _
Water meter readings, if available: _
Last date of occupancy/use: _
OTHER (describe): _
General Information
Pumping Records: Source of information:dumped fall, 2009, says owner.
N Was system pumped as part of the inspection (Y or N)
If yes, volume pumped: _ gallons
How was quantity pumped determined?_
Reason for pumping:_
Comment: Pump on 3 to 4 year interval.
Type of System:
X Septic tank, distribution box, soil adsorption system
Single cesspool
Overflow cesspool
Privy
N Shared system (Y or N) Of yes, attach previous inspection records, if any) _
Innovative/Alternative technology. Attach copy of the current operation and maintenance contract(to be
obtained from system owner) =
Tight tank (Attach a copy of the DEP approval) =
Other(describe):
T5 Revised.doo•09/09 Title 5 Official Inspection Form'.Subsurface Disposal System•Panes of
Owner
information is
required for
every page.
• Alarms in working order: (Y or N)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
'Cesspools: (cesspool must be pumped as part of inspection)ry P ) (locate on site plan)
- --- - _ _.__ Cesspool part of system?
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
Comments: — (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 167 North Farms Road
Owner' Name: Don Warburton
City/Town:
Northam
ys em n orma ton (cant.)
'Distribution Box: (if present must be opened) ----------
- D-box part of septic system? (locate on site plan) ("D-box")
—-- B
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, and
out of D-box, etc.): Box level, 2 pipes out, but 3 on plans.
'Some concrete spelling, but structurally intact. Cover OK.
Pump Chamber: (locate on site plan)
Pump part of septic system?
Pumps in working order: (Y or N)
on NSA 01060 Date of Inspection: 8 4 10
'Privy: (locate on site plan)
Privy part of system?
---— —----__Materials of construction:
- ----__._--_Dimensions:
Depth of solids:
'Comments: (soil conditions, signs of hydraulic failure, level of
ponding, condition of vegetation, etc.)
Site Exam:
Check Slope
— — _ Surface water -— _ Official Perc Date
7/14/67 Official Plan Date
__Check Cellar — -- --
- Shallow wells — ---- — Other Official Source
--- - 72___ _ Estimated depth to ground water -- -Other Source
•Please indicate all the methods used to determine high groundwater elevations)
nche
•
• Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-explain:
L!:You must describe how you established the high ground water elevation:
Sandy soil found. Soil about 6 ft. above adjacent pond which is
!groundwater level. No sump pump in dry basement, etc. --
TS Revised doe•09/09
Title 5 Official Inspection Form:Subsurface Disposal System•Page 8 of 9
(Source of Information)
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address:
Owner' Name:
City/Town:
167 North Farms Road
Don Warburton
Northampton, MA 01060 Date of Inspection: 8/4/10
D. System
Grease Trap
N
Information (cont.)
lomments:
(Usually present in certain commercial systems)
Grease Trap part of system?
Depth below grade (inches) Measured
Materials of construction:
Dimensions:
Scum thickness (inches) Average
Top of scum to top of outlet tee calcul ated Inches
Bottom of scum to bottom of outlet tee Calculated Inches
Date of last pumping
(on pumping recommendation, inlet and outlet tee or baffle condition, etc.)
Tight or Holding Tank (tank must be pumped at time of inspection)
N Tight tank part of system?
Depth below grade (inches) Measured
Materials of construction
Tank width Tank length
Tank height Capacity
Design flow: gallons/day
Alarm Level (inches)
Alarms in working order?
Date of last pumping
Comments: (condition of alarm and float switches, etc.)
(inches)
(gallons)
Attach copy of current pumping contract(required). Is copy attached?
Soil Absorption System (SAS):
If SAS not located
explain why:
(locate on site plan, excavation not required):
leaching pits& number:
leaching chambers and number:
leaching galleries and number:
leaching trenches, number, length: _
Y leaching fields, number, dimensions: 23 ' wide by 41 ' long
overflow cesspool, number:
innovative/alternative system,Type:
Comments: (note soil condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
No surface problems seen. Sandy soil.
A sizable tree is located over field.
T5 Revised.doc•09/09 Title 5 Official Inspection Form:Subsurface Disposal System•Pam!7 win
PARTIAL House Outline
y.
0 1.. ‘ 42-1 I
rC'g .J- ,i to
2
town water in
Septic Tank r
' I I Leachfield, reported layout
Distribution Box --
NORTH Jr'
COMMENTS:
Recommend pumping on a 3 to 4 year schedule. Also, a copy of this plan posted in the
basement/utilit area would kee• this information accessible in future ears for maintenance.
tH UP W8 HOMESTEAD INC.
Date: ++ Thomas S. Leue R.S.
Owner: '� '
As-Built Drawing g/4/2010 Don Warburton TMapASE
Existing Septic System CI S LEUFr
167 North Farms Ro.• / .�0, 7ES v. ,
Williamsburg, notoe�
—Scale: 1 : 20' Revision Date: +,� �e 413 628-4e 3 OP
Florence, MA 01062 to, s�No
Except as Noted