545 Septic Inspection 2014 Owner
nformation is
'equired for every
rage.
Important:When
riling out forms
on the computer,
use only the tab
key to move your
cursor-do not
use the return
key.
rains'3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
545 Sylvester Road
Property Address
Estate of Timothy Zawlick
Owner's Name
Florence MA. 01062 Sept. 24, 2014
City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Timothy E. Maqinnis
Name of Inspector
Company Name
70 Montague Road
Company Address
Westhampton MA
City/Town State
(413) 527-5291 SI # 1039
Telephone Number 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 Further Evaluation by the Local Approving Authority
October 3, 2014
Inspectors Signature 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.
nue 5 Official Inspection Form Subsurf ace Sewage Disposal System•Page 1 or 17
Owner
nformation is
squired for every
'age.
usina.yia
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
545 Sylvester Road
Property Address
Estate of Timothy Zawlick
Owner's Name
Florence MA. 01062 Sept. 24, 2014
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.
N/A
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):
Title 5 Official Inspection Faun:Subsurface Sewage Disposal System.Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
fll Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
545 Sylvester Road
Properly Address
Estate of Timothy Zawlick
)wner Owner's Name
'formation is Florence MA. 01062 Sept. 24, 2014
equiretl for every
City/Town State Zip Code Date of Inspection
.age.
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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 pipets) 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
tsns 3117
❑ 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 E V E N S 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
rnie 5 Official nsgGmn Form Subsurface Sewage Disposal System•Page 3 of 17
)wner
ifonnation is
equired for every
■age
tsns•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
545 Sylvester Road
Property Address
Estate of Timothy Zawlick
Owner's Name
Florence MA. 01062 Sept. 24, 2014
Clty/rown 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
Title 5 Official Inspection Form Subsurface Sewage Disposal System.Page 4 of IT
Commonwealth of Massachusetts
0, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wner
formation Is
quired for every
39e
t5ins.3113
545 Sylvester Road
Property Address
Estate of Timothy Zawlick
Owner's Name
Florence MA. 01062 Sept. 24, 2014
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ E 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.
❑ E 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 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 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
❑ Z the system is within 400 feet of a surface drinking water supply
❑ Z the system is within 200 feet of a tributary to a surface drinking water supply
❑ E 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Pages of 17
vner
ormation is
1uired for every
ige.
thins 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
545 Sylvester Road
Property Address
Estate of Timothy Zawlick
Owners Name
Florence
City/Town
MA. 01062 Sept. 24, 2014
State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ 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:
❑ Z 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:
3 2
Number of bedrooms(design): - Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
110 qpd
Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Pages of 17
'ner
nmffiion is
luired for every
3e.
15ins•33/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
545 Sylvester Road
Property Address
Estate of Timothy Zawlick
Owner's Name
Florence MA. _ 01062 Sept. 24 2014
City/Town State Zip Code Date of Inspection
D. System Information
Description:
This is was installed by Robert Wade of Florence, MA in June 1999. No violations were noted. The
stystem is in good operating condition. However„ a swimming pool may be located on top of SAS
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:
N/A
Z Yes No
❑ Yes Z No
ZYes ❑ No
❑ Yes ® No
N/A
Sump pump? ❑ Yes Z No
March 2014
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
N/A
Type of Establishment:
N/A
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
N/A
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
N/A
Water meter readings, if available:
Title 5 Official Inspection Form subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
� 545 Sylvester Road
Property Address
Estate of Timothy Zawlick
Ter Owners Name
'"" lion is Florence MA. 01062 Sept. 24, 2014
uiretl for every
de City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use
Other(describe below):
Unknown
Date
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
N/A
N/A
gallons
N/A
N/A
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Yes ® No
❑ 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):
Inns.3/13
Titles omoal Inspection Form subsurface Sewage Disposal System•Page a o117
ner
■mation is
uired for every
le
15ins•3)13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
545 Sylvester Road
Property Address
Estate of Timothy Zawlick
Owner's Name
Florence MA. _ 01062 Sept. 24 2014
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
15 years
Were sewage odors detected when arriving at the site?
Building Sewer(locate on site plan)
Depth below grade:
Material of construction.
❑ cast iron
Z 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
19"
feet
> 75'
feet
❑ Yes Z No
Comments(on condition of joints, venting, evidence of leakage, etc.):
This system is in good working order. All joints are sealed properly, venting is ok, and there is no
evidence of leakage.
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
Z concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
g,
feet
N/A
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes Z No
1105Lx6.01Wx4'-42)
Dimensions:
Sludge depth:
None
Title s Official Inspection Form Subsurface Sewage Disposal System.Page e of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
=r
ration is
!red for every
t5ins 3113
545 WIvester Road
Property Address
Estate of Timothy Zawlick
Owners Name
Florence
C ty[Town
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
MA. 01062 Sept. 24, 2014
State Zip Code Date of Inspection
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.):
This tannk is very clean. No sludge or scum. There is an Inlet tee but no outlet tee in the tank. The
structural integrity is excellent. Liquid level at outlet was even with invert. There is no evidence of
failure.
N/A
N/A
N/A
N/A
N/A
Grease Trap (locate on site plan):
N/A _ _ — -
Depth below grade: feet
Material of construction.
❑ concrete ❑ metal ❑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
Title 5 Official nspeulon Form:Subsurface Sewage Disposal System'Page m of n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
545 SO/ester Road
- - -- - - - -- - - -- -- - - - - -
Property Address — —
Estate of Timothy Zawlick
Owners Name
Florence
alion is MA. 01062 Sept. 24, 2014
- - - - - - - -- - -
!tl for every — Slate Zip Code Dale of Inspection
City own
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 — — —
15ms 3113
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
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
N/A
❑fiberglass ❑ polyethylene ❑ other(explain).
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
Title 5 Official In ton Form Subsurface Sewage Disposal System•Page 11 of 17
Lion is
i for every
ems•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
545 S&ester Road ---- -- - --- ---------
Property Address
wner
ownee of TimothLZawlick - -_ _- - - --
O
's Name MA 01062— — Se t. 24, 2014
Florence MA State Zip Code Date of Inspection
City own
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan).
Liquid level is even with Iniverts.
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.):
The distribution box is 21" below grade. No evidence of carryover and no evidence of leakage into or
out of this box. It is in sound condition. -- _ _ ---- -
Pump Chamber(locate on site plan):
❑ Yes ❑ No*
Pumps in working order:
❑ Yes ❑ No'
Alarms in working order:
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
' 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 SAS not located, explain why:
See attached plan. The SAS's is a 50' x 15 leaching bed. It may be located partially under the
swimming_pool. It appears to be in_good working_order. ---- -- - - - -- ---
nne 5 0ifioal Inspection Form subsurface Sewage Disposal System•Page 12 NP
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
545 Sylvester Road _—_— -- ----
Property Address —
EstateofTimothyZawlick _—_ ___-----
owner's Name MA. 01062 Sept. 24, 2014
on is - --- —06 Sep . 4,Inspection 014
for every
Florence — — ——— — State Zip Code
City/Town
D. System Information (cont.)
Type:
leaching pits
number:
D leaching chambers
number:
C leaching galleries
number:
❑ number, length:
leaching trenches 1 col i0' x 1�
® leaching fields
number, dimensions:
O overflow cesspool
number:
D innovative/alternative system
Type/name of technology: ----
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
There are no signs of damp soil or ponding. The grass is normal for this time of year. There are no
signs of hydraulic failure.————— — --——----
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
,sins•3113
WIe 5 Official Ins
N/A
N/A
N/A
N/A
NIA
IC Yes ❑ No
mn Form subsurf ace Sewage Disposal System•Par t3 of n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
545 Sylvester Road—————--------------
Property Address
Estate of Timothy Zawlick -----------------
------ ---------
Owner's Name MA. 01062 Sept. 24, 2014
m is ---- — Hate of Inspection
/or every
Florence Zip Code
City/Town
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):
N/A
Materials of construction:
N/A
Dimensions
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
Depth of solids
etc),
N/A
Title 5 Official Inspection Foss Subsurface Sew age Disposal System•Page 14 of 17
15in5.3113
3 is
u every
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
545 Sylvester Road
Property Address
Estate of Timothy Zawlick
Owners Name
Florence
City/Town
D. System Information (cont.) including ties to
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, 9
at least two permanent reference e the marks g. Check one s the Locate
e all
be wells within 100 feet. Locate
where public water supply enters
❑ hand-sketch in the area below
drawing attached separately
Sins•3113
MA. 01062 Sept 24, 2014
State Zip Code Date
Title 500ical Inspection Form.Subsurface Sewage Disposal Syslem•Page 15 of 17
Commonwealth of Massachusetts
Official Inspection Form
I�
Title 5 Assessments
Subsurface Sewage Disposal System Form-Not for Voluntary
i
545 Sylvester Road
Property Address
--_---Set 24 2014
Estate of TlmolhtZawlick--------------------
Owner's Name MA. 01062 Sept.2 Date . 4,
is e Zip Code
Florence ------ state
every
City/Town
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water:
feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record Sit 24, 2014
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:
N/A
Checked Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
N/A
You must describe how you established the high ground water elevation:
-No water stains in basement.
-Review plan of record
-discussions with property owner
-no evidence of groundwater Infiltration in D box or septic tank_
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 omuannspection Farm subswace sewage osWsel system.Page 1s of 17
lira.3113
Commonwealth of Massachusetts
7rA Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary
545 Sylvester Road --------------prop---
Prop_
Property Address ----prop---
Estate of Timothy Zawlick _ 01062 Sept 24,?014
CirylrRown MA.
Owners Name —prop--- Date of Inspection
Flo State Code
Very own
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
Tine 5 DMUe1 Inspection Form Sulam/Mace Sewage Disposal System'Page 17 of 17
Miis.3113
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Nropeny Andress
Estate of Timothy_Zawiick
Owners Name
Florence
cityltown
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
MA. 01062.
State Zip code
Sept 24 2014
Date of Inspection
tins.3113
1. Inspector.
Timothy E. Ma i nis
n
Name of Inspector
Company Name
70 Montague Road
Company Address
Westham top n
City/Town
( 13)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
0 Conditionally Passes
Fails
uation by the Local Approving Authority
The
H
has a d
report to the a, if apps
and copies sent to the buyer,
October 3, 2014.____.
Date
mit a copy of this inspection report to the Approving Authority(Board
:ays of completing this inspection. If the system is a shared system or
tv r gpd or greater,the inspector and the system owner shall submit the
ate regional office of the DEP.The
original
should be sent to the system owner
-icable,and the approving
I
••"Thls report only describes conditions at the time of inspection and under the conditions of use
at that or This inspection does not address how the system will perform in the future under
the same a or different conditions of use.
la 5Maul Inspection Form Sub
ace Se+'a9�puW>a ey.wn y P&P't a II