327 Title V Report 5-21-19Commonwealth of Massachusetts
Title 5 Official Inspection Form
W
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062
City/Town State Zip Code
Important: When
filling out forms on
the computer, use
only the tab key to
move your cursor -
do not use the
return key..
IeNn
5/21/2019
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. Inspector Information
Marcus Millett
Name of Inspector
Homestead Inc.
Company Name
1664 Cape St.
Company Address
Williamsburg
MA 01096
City/Town
State Zip Code
413-628-4533
SI -13748
Telephone Number
License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of
Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property
address listed above; the information reported below is true, accurate and complete as of the time of
my inspection; and the inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. After conducting this inspection I have
determined that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
24 May 2019
Inspector's 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 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 form should be sent to the system owner and
copies sent to the buyer, if applicable, and the approving authority.
Please Mote: 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.
t5insp.doc • rev. 7/26/2018 TMe 5Official Inspection Form: Subsurface Sewage Disposal System • Pagel of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property rens
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
City/Town state Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 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:
2) 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 oid* 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):
5insp.doc -rev, 712612018 Title 5 Official Inspection Form. Subsurtace Sevrege Disposal System • Page 2 of 18
Owner information
is required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Carol Bertrand
Owner's Name
Florence MA 01062
City/Town State Zip Code
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont):
21/2019
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval
if pumps/alarms are repaired.
❑ 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):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).
The system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) 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.
a. 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:
t5insp.doc • rev. D281201a Tdle 5Official Inspection Form. Subsurface Sewage Disposal System • Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
f
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health, safety
and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100
feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is
equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the
analysis must be attached to this form.
c. Other:
4) 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
❑
M
6l:N
Discharge or ponding of effluent to the surface of the ground or surface
waters due to an overloaded or clogged SAS or cesspool
t5insp. doe • rev. 7/26120/8 Title 5 Official Inspection Form'. Subsurface Sewage Disposal System • Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
City/Town State Zip code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ®
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'/ day flow
❑ ®
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: —
❑ ®
Any portion of the SAS, cesspool or privy is below high ground water
elevation.
❑ ®
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ®
Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ®
Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ®
Any portion of a cesspool or privy is less than 100 feet but greater than 50
feet
from a private water supply well with no acceptable water quality
analysis. [This system passes if the well water analysis, performed at a
DEP certified laboratory, for fecal coliform bacteria indicates absent and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A
copy of the analysis and chain of custody must be attached to this
form.)
❑ ®
The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ®
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) 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 C.4.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑J 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 – I WPA) or a mapped Zone II of a public water supply well
f5insp.doc • rev. 7/2&2018 Title 5Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/ 327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed, The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system
owner should contact the appropriate regional office of the Department.
6. You must indicate "yes" or "no" for each of the following for all inspections:
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:
®
❑
Existing information. For example, a plan at the Board of Health.
❑
®
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp, doe • rev. 7/28/2018 Tile 5 Official Inspection Form: Subsurface Smeage Disposal System • Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/ 327 North Farms Road
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
CitylTown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms 5
(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of 500+ gpd
bedrooms):
Description:
1500 -gallon septic tank, distribution box and a pipe -and -
stone leachfield. System not designed for a aarba e grinder.
Number of current residents:
Does residence have a garbage grinder?
Does residence have a water treatment unit?
If yes, discharges to:
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:
Current reading 42997379
Sump pump?
Last date of occupancy:
3
IFan �►C
❑ Yes ® No
❑ Yes ® No
11111RUM90 NE
❑ Yes ® No
continuous
Date
tsnsp.doc• rev. 7/2812018 Title 50Ricial lnspecton Form: Subsurface Sewage Disposal System • Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other (describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection?
Pumped last 9/7/2007.
❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Recommend pumping this year.
t5insp. coo • rev. 7/2612018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Owner information
is required for
every page.
Carol Bertrand
�ners Name
MA 01062 5/21/2019
State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® 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)
❑ 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):
Approximate age of all components, date installed (if known) and source of information:
System permit dated 11/17/1976.
Were sewage odors detected when arriving at the site? ❑ Yes ® NO
5. Building Sewer (locate on site plan):
Depth below grade: 1.8 average
feet
Material of construction
® cast iron 0 40 PVC ® other (explain): ABS plastic
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
No problems seen. Field is built with PVC.
6insp.doc • rev. 7/2812018 Title 5 Official Inspection Form. Subsurface Sewage Disposal System • Page 9 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
About 1500
If tank is metal, list age:
❑ fiberglass
Is age confirmed by a Certificate of Compliance? (attach a
copy of certificate)
Dimensions:
Sludge depth:
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
1.6 average
feet
polyethylene El other (explain)
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
years
❑ Yes ❑ No
58" wide, 122" long,
59" tall
5
23"
7"
4"
Calculated from
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural
integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):
1500 -gallon septic tank. water at appropriate level. Center
and outlet of the tank were excavated. Evidence of powdered
laundry detergent accumulating. Recommend pumping this year.
Baffles intact. Recommended installing riser to near surface
over center to facilitate maintenance.
l5insp.doc • rev, 7/2612018 Tftle 5 Official Inspection Form: Subsurface Sewage Disposal Sys em • Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Ow'ner's Name
every page. Florence MA 01062 5/21/2019
City/Town
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
State Zip Code Date of Inspection
feet
❑ fiberglass �lyethylene El other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural
integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):
& Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Capacity:
Design Flow:
❑ fiberglass � lyethylene [1 other (explain):
gallons
gallons per day
5insp.doc- rev. 7/262018 Tdle 5Officol Inspection Form', Subsurface Sewage Disposal System • Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present:
Alarm level:
Date of last pumping:
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached?
9. Distribution BOX (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
❑ Yes ❑ No
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.):
Box cover was deteriorated and collapsed. Box replaced with
new as agreed by Board of Health. 3 pipes out. Significant
biosolids seen in old box. Located 28" below grade. Outlets
appear to accept all flow.
i5inw.dcc • rev. 712&2018 Title 50fflcial Inspection Form: Subsurface Sewage Disposal System • Page 12 of 18
= Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
t5insedoc • rev. 9126/2018 TRIe 5 O ojal Inspection Form: Subsurface Sewage Disposal System • Page 13 of 18
* If pumps
or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not
located, explain why:
Type:
leaching pits
number:
leaching chambers
number:
El
leaching galleries
number:
leaching trenches
number, length:
®
leaching fields
number, 20 ft. x 30 ft.
dimensions:
[]
overflow cesspool
number:
F
innovative/alternative system
Type/name of technology:
t5insedoc • rev. 9126/2018 TRIe 5 O ojal Inspection Form: Subsurface Sewage Disposal System • Page 13 of 18
Cay Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No surface issues seen. Near drop—off of about 6 ft. Built in
exceptional soil with good drainage.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of
vegetation, etc.):
t5msp.doc• rev. 7/2&2018 Title 5 Official Inspection FormSubsurface Sewage Disposal System • Page 14 of 18
Owner information
is required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Carol Bertrand
uwner sluame
Florence
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
MA
State
01062
Zip Code
5/21/2019
Date of Inspection
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of
vegetation, etc.):
t5insp. doo • rev. 7128/2018 Title 5 Official Inspection Form. Subsurface Semage Disposal System • Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand -sketch in the area below
® drawing attached separately
t5insp.doc• rev. 712612018 Title 5 Official Inspection Form: Suosurace Sewage Disposal System • Page 16 of 18
Commonwealth of Massachusetts
— Title 5 Official Inspection Form
/p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
City/Town state Zip Code Date of Inspection
D. System Information (cont.)
15. 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:
/R
/1
./
Obtained from system design plans on record
If checked, date of design plan reviewed: 11/17/1976
Date
Observed site (abutting propertyfobservation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Perc test data
Checked with local excavators, installers - (attach documentation)
F� Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Dry sand soil Basement is dry without a sump pump. Near
drop—off that assures drainage. Depth to sand layers in perc
test.
Before filing this Inspection Report, please see Report Completeness Checklist on next
page.
t5insp.doc • rev. 7/26/2018 Tale 5Official Inspection Form'. Subsurface Sewage Disposal System, Page 17 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
327 North Farms Road
Property Address
Owner information Carol Bertrand
is required for Owner's Name
every page. Florence MA 01062 5/21/2019
City/Town State Zip Code pate of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank — Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp. doc - my 7/2812018 Trt e 5 Official Inspeotlon Form: Subsurface Sewage Disposal System • Page 18 of 18
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