53 Title 5 12-6-17 14 Commonwealth of Massachusetts
14 * -Title 5 Official Inspection Form
I; a - ubsurfacs Sewage Disposal System Form-Not for Voluntary Assessments
• _ 53 Maple Ridge Road
Pinnrty Amens
OweMary McGuire
kbinaaon I OwneYS Nems
required tor Florence MA 01062 12/6/2017
every Pea.
Ctyrrorm State ZIP Code On of Inspection
Inspection result 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.
t,,,,"'°„,' °bio A. General Information
out Mora on
the 1 Inspector
eonruM,
1p only t10 Thomas S. Leue
tab
mow your Name to
of Inspects
mina-do Homestead Engineering Inc.
not use the Company warn.
return key. 1664 Cape St.
Ill Company Aden
Williamsburg MA 01096
WA City/Ton SIb Zip Code
WA
413-628-4533 SI-130
Telephone Number Uoenee Number
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 16.340 of tide 5(310 CMR 15.000).
The system:
CO Passes ❑ Conditionally Passes 0 Fails
0 Needs Further Evaluation by the Local Approving Authority
----Las.. S I o— — _ December 8 r 2017
a—assure Date
The system inspector shah 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
diRarent conditions of use.
Beene nee aldYl
nprYa,Form:Subalpine Sorg Depose!91M,a•Ng,1 a 17
•
t. Commonwealth of Massachusetts
Title 5 Official Inspection Form
_/' 5bsurface Sewage Disposal System Form-Not for Voluntary Assessments
3 Maple Ridge Road
Property Address
04•118fMary McGuire
elbnlnesen w Oaners Name
reguFed ter Florence MA 01062 12/6/2017
INKY Page.
City/Town State
Zip Code bate of Impaction
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information that indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist,Any failure criteria not evaluated are indicated below.
Comments:
e) System Conditionally Passes:
O 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 ayes*, 'no'or snot 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 extltration 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 Making and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N ❑ND(Explain below):
O Pump Chamber pumps/alerns not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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. Commonwealth of Massachusetts
k .Title 5 Official Inspection Form
!!
11 ubsurface Sewage Disposal System Form-Not for Voluntary Assessments
- • !' .53 Maple Ridge Road
emeeemen
OwnerMary McGuire
information N Owner's Name
'nuked far Florence MA 01062 12/6/2017
mn r pew•
ayRown She tip Code omeotlmmigion
B. Certification (cont.)
B) System Conditionally Passes(cont.):
O 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 b 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 0 ND(Explain below):
❑ obstruction is removed ❑Y ❑N 0 ND(Explain below):
❑ distribution box is leveled or replaced ❑Y ❑N 0 ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system
will pass inspection If(with approval of the Board of Health):
❑ broken pip(*)are replaced ❑ Y ❑ N 0 ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Heat 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 Ina 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 esti marsh
Min•MS Tn,SOMAS limp:on FwwSubseboi Swap D o.s$3s. Ppna In
•
. 1. Commonwealth of Massachusetts
wl _Title 5 Official Inspection Form
bwrtsds Sewage Disposal System Form-Not for Voluntary Assessments
53 Maple Ridge Road
Property Address
Omer Mary McGuire
hbnnaton a owners Name
requiredkir Florence MA 01062 12/6/2017
every Paps.
'R"e n State as Code Date of Inspection
B. Certification (cont.)
2. System will NI unless the Board of Health(and Public Water Supplier, If any)determines that
the system Is functioning Ina manner that protects the nubile health,safety and environment:
O The system has a septic tank and soil absorption system (SAS)and the MS 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 MS is kiss than 100 feet but 50 feet or more from a
private water supply welt•.
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 we 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 MS or
cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SM or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or
dogged MS or cesspool
❑ ® flLiquid depth In cesspool is less then 6'below invert or available vokane is less Can IA day
Si •506
The 6 COM rt.p..um lin subewsw as..n dlrewe aya.e•ry.I a 17
. A, Commonwealth of Massachusetts
' k Title 5 Official Inspection Form
Ifdace Sewage Disposal System Foim-Not for Voluntary Assessments
._..r 53 Maple Ridge Road
PraperbrAdemn
Owner Mary McGuire
information is Owners Name
required for Florence MA 01062 12/6/2017
every page.
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped: .
❑ 0 My portion of the SM,cesspool or privy is below high grand water elevation.
❑ ® Any portion of surface water supply.cesspool or privy Is within 100 feet of a surface water supply or tributary to a
❑ ® My portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® My portion of a cesspool or privy is within 50 feet of a private water supply welt.
❑ ® My portion of a SAS,cesspool or privy is less than 100 feet but greater than 50 feet from
a private water supply well with no acceptable water quality analysis. [This system
passes If the well water analysis,performed at a DEP certified laboratory,for fecal
coliform bacteria Indicates absent and the presence of ammonia nitrogen and
nitrate nitrogen is equal to or less then S ppm,provided that no otter talkie's criteria
are triggered.A copy of the analysis and chain of custody must be attached to ids
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-10,000 gpd.
❑ ® The system taus.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system falls.The system owner should
contact the Boat 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
❑ 0 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 mewed 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 0 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 0 shall upgrade the system in
accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the
Department.
a..the 1w.SaatlwInspection Fan:aea.weSado on syM.n•Pigs 5arn
. Commonwealth of Massachusetts
>l .Title 5 Official Inspection Form
= bsurface Sewage Disposal System Form-Not for Voluntary Assessments
'53 Maple Ridge Road
Property Address
Durban Mary McGuire
Inknnotlon is Owners Nems
f°9' f°a kr Florence MA 01062 12/6/2017
every pis. Citrown slate
Lip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate ayes'or' o•as to each of the following:
Yes No
® 0 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 isoduoed b tie system recently a as part of this
inspection?
® ❑ Were
N1 as-budtt plans of the system obtained and examined?(If they were not available note as
Z 0 Was the facility or dwelling inspected for signs of sewage back up?
® 0 Was the site inspected for signs of break out?
® 0 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:
8 0 Existing information.For example, a plan at the Board of Health.
❑ ® n Determinedthe field(it any of the failure criteria related to Part C is at issue approximation
of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms 3 3
(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of 495 gpd
bedrooms):
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. Commonwealth of Massachusetts
• >w .Title 5 Official Inspection Form
!! : urface Sewage Disposal System Fonn-Not for Voluntary Assessments
- 53 Maple Ridge Road
Properly Address
Owner Mary McGuire
reerps jon ip Owner's Name
required kr Florence MA 01062 12/6/2017
every vada. Cayfrawn State 21p Code Date wswan
D. System Information
Description:
1500-gallon septic tank, distribution box and 3 leach trenches.
Number of current residents: 1
Does residence have a garbage winder? ® Yes 0 No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ® Yes ® No
Seasonal use? 0 Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 99
Detail:
8/12/15 to 11/3/15 was 1000 CF
Sump pump? 0 Yes ® No
Last date of occupancy: oiaeoes occapaecy
ate
Commerclalfndustrial Flow Conditions:
Type of Establishment
Design lbw(based on 390 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatslpersons/sq.ft,etc.):
Grease trap present? ❑ Yes 0 No
industrial waste holding tank assent? 0 Yes 0 No
Nan-sanitary waste discharged to the TS 5 system? ❑ Yes 0 No
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A. Commonwealth of Massachusetts •
17. •i1/4 . ;Title 5 Official Inspection Form
M Surface Sewage Disposal System Form-Not for Voluntary Assessments
, • ,, 53 Maple Ridge Road
Property Address
Omer Mary McGuire
Fform .ton a Ovelsle Name
ragiiraebf Florence MA 01062 12/6/2017
wary Pepe.
City/Tom State Zip Code Data of Inspection
D. System Information (cont.)
Last date of occupancy/me:
Deb
Other(describe below):
General Information
Pumping Records:
Souter of information: Pumped 2 or 3 years ago, from Owner
Was system pumped as part of the Inspection? ❑Yes ® No
If yes' volume per. esemm
How was quantity pumped
determined?
Reason for pumping: Recommend pumping on 3 to 5 year basis at full
P P g: occupancy. Does not need pumping now.
type of Sj,
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous inspection records, if any)
❑ ksrwaliva/Alternative technology. Attach a copy ofthe current operation and maintenance
contract(to be obtained from system owner)and a copy of latest inspection of the WA system by
system operator under contract
O Tight tank.Attach a copy of the DEP approval.
o Other(describe):
lea.me we sgelnapwlm mom eorma..sump o pmt syaw•rwa es11
• gtx Commonwealth of Massachusetts
• „i ,Title 5 Official Inspection Form
S = Surface Sewage Disposal System Form-Not for Voluntary Assessments
!i i
_ ,= 53 Maple Ridge Road
awwly address
ownw Mary McGuire
Mmmom b Owners Nem
reputedfor
w„ypaw, Florence MA 01062 12/6/2017
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:
Septic plans said to be built in fall, 1990.
Were sewage odors detected when arriving at tie silo? Oyes ® No
Building Sewer(locate on site plan):
Depth Sow grade: 4 average
reel
Material of cea5kefwiar
❑cast iron ®40 PVC ®other(explain): ABS pipe
Distance fromprivate water supply24
well or suction line: rot
Comments(on condition Of Mints,venting,evidence of Strap,etc
No problems seen. Measurement is between water line and sewer line locations in
basement. Mostly under floor slab. Sewer from former pool house added to
drawing.
Septic Tank(locate on site plan):
Depth below grade: 3.5 average
he
Material Of construction
®concrete ❑metal 0 fiberglass 0 polyethylene 0 oder(explain)
Concrete septic tank, about 1500-gallons nominal capacity.
If tank is metal, list age:
years
Is age confirmed bye Certificate of Compliance?(attach a copy of certificate) 0 Yes 0 No
Dimensions:
59^ wide, 126^ long, 57" tall
Sludge depth: 4-
ate•ale la,SUelllmpab,Fan.:sueP,ee bear pees!Wart•PRY 0ar17
• si4 Commonwealth of Massachusetts
• u, :Title 5 Official Inspection Form
r Surface Sewage Disposal System Form-Not for Voluntary Assessments
- 53 Maple Ridge Road
Property AddreU
OmerMary McGuire
Information is Owners Name
meg fO ind err Florence MA 01062 12/6/2017
City!rown state rip Code Dab of rnepwlbn
D. System Information (cont.)
Septic Tank(cant.)
Distance from top of sludge to bottom of outlet tee or baffle 26
Scum thickness it-
Distance from top of scum to top of outlet tee or baffle 6'
Distance from bottom of scum to bottom of outlet tee or baffle 21
How were dimensions determined? calculated
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid
levels as related to outlet invert, evidence of leakage, etc.):
Tank structurally Oa. Large riser over center cover to near surface. Inlet under
walkway and not opened. Recommend pumping on a 3 to 5 year interval.
Gnaws hap(locate on site obit.
Depth below grade:
feet
Material of construction:
°corncrete Omemv ®fiberglass Opntyaeylalb 0other(explain):
Dimensions:
Sari 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:
Dela
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Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
1\ !! :ubsurface Sewage Disposal System Form•Not for Voluntary Assessments
• .53 Maple Ridge Road
Property Address
Owner Mary McGuire
t rproggon is Owner's teems
regi4e°fot Florence MA 01062 12/6/2017
gnaw Wee. ckyrtorm date Zip Code Date of Inspedbn
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.):
light or Holding rank(tank east be pumped at this of irspedimt)(Wade one*pita):
Depth below grade:
Material of construction:
❑contra ❑ental ®atsogtess 0pages leve 0ober(esrpleb):
Dimensions:
Capacity: salons
Design Flow:
salons per day
Alarm present: 0 Yes 0 No
Alan tet. Alarm in working order. ❑ Yes❑ No
Date of last pumping:
Dote
Comments(condition of alar and float switches,etc.):
•Attach copy of current pumping contract(required). Is copy attached? 0 Yes 0 No
ens•afe %eotle Impdm Fon:&bda;wow 0Y00i6YMn•Pc 11 air
• ITS, Commonwealth of Massachusetts
i'c„
!!� =Title 5 Official Inspection Formi
bsurfeca Sewage Disposal System Fenn•Not for Voluntary Assessments
• 53 Maple Ridge Road
Property Address
bailer Mary McGuire
bMmevon is Ovmefl Nemo
required for Florence MA 01062 12/6/2017
ear row. Ceyrrown Stat
$Code Deer of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
on
Continents(note e box is Level and detb 4 on to outlets equet, any evidence of solids carryover,any
evidence of leakage into or out of box, etc.):
3 pipes out. Riser to 6' below surface. Box is clean and flow distributed.
PumpChorale(locale on ails plan):
Pumps in working order: ❑ Yes 0 No
Alarms in working order. 0 Yes ❑ No
Can rents(note sondem of pump Chamber,caMitim of pumps and appurtenances,etc):
• Spsmps or atones me not inwonting order,system is a conditions*pass.
Soil Absorption System(SM)(locate on site plan, excavation not required):
If SAS not located, explain why.
S.•ate 11.5 Of Mal x+n.von romi:ae.um.Svnp aror+System•sow 12 an
Commonwealth of Massachusetts
„i =Title 5 Official Inspection Form
w bsurface Sewage Disposal System Form-Not for Voluntary Assessments
•
_ 53 Maple Ridge Road
Property Address
Omer
Mary McGuire
bbnnetlon is Owner's Name
isgdre°far Florence MA 01062 12/6/2017
own ped
CIty/Town Sate np code Date of xep.awn
D. System Information (cont.)
Type:
❑ leaching pits number
fl teething chambers number-
❑ loathing galleries number.
® loathing trenches number, length: 3 @ 30• each
❑ teaching fields member,dbmenS.One:
❑ oveffi0w cesspool member:
❑ imavative/altemative system
sypebteatesd
technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
Wo surface problems sees. peactfield area is sigaificautIly bent sp.
Cesspools(cesspool must be pumped as pert of inspection)(locate on site plan):
Number and configuration
Depth-top of liquid to Inlet invert
Depth of solids layer
Depth of scam layer
Dimensions of cesspool
Mgadals of carstrucYna
Indication of groundwater inflow 0 Yes 0 No
n.•Silt rnscesie.e.+,,,Fenn:me.,.reSwap oyewEinem.F .130117
• ,, Commonwealth of Massachusetts
yi Title 5 Official Inspection Form
= beurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Maple Ridge Road
Property Address
Oa Mary McGuire
mformeson is Owners Name
required for Florence MA 01062 12/6/2017
every papa.
City/rown State Zip Coda Dab of Inepeedon
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
n.,peeassesssaepost
Materials of construction:
Dimensions
eeperoiseggs
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
ass•eye me OlmcW l
mpeglonram:&seeeosewgpyppaepye•P .14✓1>
•
• 1. Commonneafh of Massachusetts
'Siw __Title 5 Official Inspection Form
ibwrface Sewage Disposal System Form•Not for Voluntary Assessments 53 Maple Ridge Road
Property Address
Owner Mary McGuire
infommece is oxna's Name
required M
even,page.
Florence MA Stets Zip
12/6/2017
ClityLp Code Data 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:
Yteno ae'ch in the area 6Wow
drawing attached separately
•
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•
Commonwealth of Massachusetts
l _ - Title 5 Official Inspection Form
7t1111' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
e_
Commonwealth of Massachusetts
fs Title 5 Official Inspection Form
-r.—_ :Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Maple Ridge Road
y.
Property Address ---
Owner Mary McGuire
information is Owneds Name
required for
every page. CrtrwFlorence MAe 01062 . 12/6/2017
Zip Code Date of Inspection
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
N Inspection Summary D(System Failure Criteria Applicable to Ail Systems)completed
® System Information–Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5,s-
TM*5 OIId9Pnspa6oniTmo.9JWolisa Stooge Spam-Papp:760]
NORTH
m ® \
Co
_______
,,, Septic Tank Distribution Box
Partial outline of house. 491
r L n 11111111 /2
Note: No Known drinking water
sources within 100 foot radius.
M
Leach trenches, approximate layout. Viggo° ¢
COMMENTS:
Recommend pumping on a 3 to 5 year schedule. Also, a copy of this plan posted in the
basement/utility area would keep this information accessible in future years for maintenance.
As-Built Drawing Date: Owner: HOMESTEAD INC.
I
xisting Septic System l /5/207 7 Mary McGuire Thomas S. Leue R.S.
Scale: i 20' Revision Date: 53 Maple Ridge Road 166aCapest.
Williamsburg,MA 010%
Except as Noted Florence, MA 01062 14131628-4533