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330 Septic Inspection 2007 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 330 Coles Meadow Road .:, _. _. Property Address Don McCool owner's Name Northampton MA 01060 11/29/2007 City/Town State Zip Code Date of Inspection owner information is required for every page. Important: When tilling out forms an the computer,use only the tab key to move your cursor do not key e the return key Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1 Inspector. Erik Kirchner Name cf Inspector Company Name 113 Hinsdale Rd Company Address Windsor MA CityTown State 413-584-3103 SI 4524 Telephone Number License Number B. Certification 01270 Zip Code 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 perionned 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: Li Passes Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/29/2007 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 cesign 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. Owner information is requ red for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 330 Coles Meadow Road Properly Address Don McCool Owner's Name Northampton City,'TOwn MA 01060 11/29/2007 State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check AB,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: B) System Conditionally Passes: ❑] One or more system components 'enlaced or repaired. The system, the Board of Health, will pass. Answer yes, no or not determined (Y. determined.- please explain. as described in the "Conditional Pass" section need to be upon completion of the replacement or repair, as approved by N, ND) in the ❑ for the following statements. If"not ❑ 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 exfltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as eprroved by the Board of Health. p 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. Distrioution box cracked and partially full of roots. ❑ 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 Hass inspection if(with approval of Board of Health): broken pipe(s) are replaced obstruction is removed owner information is requTed for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 330 Coles Meadow Road Property Address Don MCCOOI Owners Name Northampton City'Tovm MA 01060 11/29/2007 State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): distribution box is leveled or replaced ND Explain_ ❑ 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 1 obstruction is removed ND Explain. 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 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. iJ 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. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 330 Coles Meadow Road Property?.idress _.._ Don McOool Owner's Na^re Northampton MA 01060 11/29/2007 City.Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feel or reme 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 "Yes" or"No"to each of the following for all inspections: Yes No C 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 %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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Owner information is required for every page. 330 Coles Meadow Road Property address Don McCOUI Owners Name Northampton MA 01060 11/29/2007 Cityilown State Zip Code Date of Inspection B. Certification (core ) 0) System Failure Criteria Applicable to All Systems (cont.): Yes No J • 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. L- • 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- 10,000g pd. 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. Z 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 L Cl 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 '�L C 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. information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 330 Coles Meadow Road Property Address Don McCool Owner's Name Northampton MA 01060 11/29/2007 City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ I❑ 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? El L 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 tie 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 Of any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 330 Coles Meadow Road Properly Address Don Mecool Owner's Name Northampton City:Town D. Sy ;tern information Residential Flow Conditions: MA 01060 11/29/2007 State Zip Code Date of Inspection Number of bedrooms (design): unk Number of bedrooms (actual): 4 - - - DESIGN flow based on 310 CMR 15.203 (for example: 110 glad bedrooms).x#of bedrooms 440 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is !3undry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, If available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No September 2007 Las; :tat;. of occupancy. Date Commercial/Industrial Flow Conditions: Type of Establishment Des g 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 lade=trial 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). Owner information is required for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 330 Coles Meadow Road Property oatlress Don McCool Owners Name Northampton MA 01060 11/29/2007 City Town State Zip Code Date of Inspection D. System information (cont General Information Pumping Records: Source of!nformation_ Was system pumped as part of the inspection? If yes volume pumped: How:kids quantity pumped determined? Reason 'or pumping. Type of System: C owner gallons Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool ❑ Privy ❑ Yes ® No 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) Tight tank. Attach a copy of the DEP approval. Other(describe): Approximate age of all components, date installed Of known) and source of information: 197Cs per owner Were sewace odors detected when arriving at the site? ❑ Yes ® No Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 330 Coles Meadow Road _ Property Adoress Don Mecool Owner's Sam_ Northampton MA 01060 11/29/2007 Cay.Town State Zip Code Date of Inspection D. System Information cont.) 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: 2' feet N/A feet Comments (on condition of joints. venting, evidence of leakage. etc.): goof condition, vented through house. no evidence of leakage Septic Tank(locate on site plant'. Depth below grade: Malarial of construction. f,. c::ncrte 7" feet ❑ :netal ❑ fiberglass ❑ polyethylene ❑ other(explain) It tank is metal, list age: years Is ace confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 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 Distance from bottom of scum to bottom of outlet tee or baffle Form were dimensions determined? 8' x 5'x 4' 26" 10" stick and tape measure Owner information Is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 330 Co'es Meadow Road Property Andress Don McCool Owner s Name Northampton MA 01060 11/29/2007 City;Tow'. State Zip Code Date of Inspection D. System Information (cons; Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, ligr id levels as related to outlet invert. evidence of leakage, etc.): Lige'1 levels correct. some spawling present on baffle but still intact. Recommend replacing baffle with a tee. Grease Trap (locate on site plan): Depth below grade. Ma -rial of construction: ❑ concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions. -- Scu.a thickness - - - - - Distance from top of scum to top of outlet tee or baffle - -- - Disience from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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 cr Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Dept`. below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e. 330 Coles Meadow Road Property der,s; Don Mt C001 Owners Northampton MA 01060 11/29/2007 City;Town State Zip Code Date of Inspection Owner information is required for every page D. System information (cont.) Tight or Holding Tank (cont.) Dimenso,s. Cap2c:y. gallons Design Flow. gallons per day F farm pl esent. ❑ Yes ❑ No Alat i level'. Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date _. Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Ceram, nts (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evi lance of leakage into or out of box. etc.): Distribution box deteriorated and cracked with roots. Recommend replacing distribution box. No evidence of carryover. Liquid levels appropriate and equal. 0 Pump Chamber (locate on site plan). Pumps in working order. Alarms in working order. ❑ Yes ❑ No ❑ Yes ❑ No Owner Information is requir ed for even page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 330 Coles Meadow Road Property Address Don McCool Owners Name Northampton D. System Information (cont.; MA 01060 11/29/2007 State Zip Code Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS eoi located explain why: Type. [; leaching pits number: leaching chambers number: [ leaching galleries number ] leaching trenches number, length: leaching fields number dimensions: (J overflow cesspool number innovative/alternative system Type/name of technology: 3@ 20' Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation. etc.): Soil normal. no signs of failure or pending. Vegetation in good condition. Owner information is requ!red for ever'cage Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 330 Coles Meadow Road Property F ddress Don McCool Owners Lame Northampton MA 01060 11/29/2007 City Town Stale Zip Code Dale of Inspection D. System information (cont ) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Deptn—top of liquid to inlet invert Depth of solids layer - - - Dep-h of scum layer Dimonsians of cesspool Materiais of construction Ind cation of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation. etc.}. Privy (locate on site plan). Ma vials of construction: Dilrensicns Depth of solids Ccr;int is (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc) - D istyl 6v fi GAA bex 14-^cIN NI U 1IiI' L " h 3 - 2-eg i1veJ N I I 641(4 ritkAviiv if I • Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 330 Coles Meadow Road Properly Address Don McCool Owners Name Northampton MA 01060 11/29/2007 CrtyTowr State Zip Code Date of Inspection D. Sy:>tern Information (cont) Site Exam. El Cneck Slope © Surface water © Check cellar ❑ She low wells Est''dated depth to ground water_ >3' feet Please Indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, dale of design plan reviewed: Ci Date Observed site (abutting property/observation hole within 150 feet of SAS) Jhecked with local Board of Health -explain: [] Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Soil yraeelly and cry characteristic of outwash. Water table>3' JAMES P.KWIECINSKI r CYNTHIA L. KWIECINSKI 47H N TON U MA DRIVE PH 4135270010 17 0_ _ I �iiah1, ij Nr ./ 613 SAVINGS BANK seer P&vn,r 3`50 cok):11114, 1: 2 LL8709351: L 2010 70 4 34[.. 591093/2110 9 BRANCH 3 1(9- rr $ JCS �n,�,,,,., Se.tic System Re-Ins.ectian Fee PavmentgReccird Date: ohh51er Amount: S l/rot Cash Check# _ Property Owner^(✓'0 / •rr —Property Addres New Consnucnon Repair tlI JAMES P. KWIECINSKI CYNTHIA L. KWIECINSKI )I 47 HANNUMDROOK DRIVE PH 413-527-0010 it EASTHAMPTON,MA 0102 7-9 72 5 III '° oeoE:io C l --1 ji _Cra�' `" PION J/ E 7 SAVINGS BANK l, G } f 'I FOR / euti171 r 3 Jo Co Itifre tv 1: 2 L18709351: 1 20 10 1 70 29• _34 ')). S-.tic S stem Permit Pa ent Record// //��� Amount: $_ Date: p t% Cash____ __—Check# el 3 ` Property Owne Property Address New raw:mace 01570I JAMES P. KWIECINSKI ---------------- -------- - 577 —CYNTHIA&KWIECINSKI PH.413-527-0010 /-/ /� 53- 093/2118 47 HANNUMBROOK DRIVE / 9 BRANCH EASTHAMPTON,MA 01027-9725 PAY„THE rA OF Akeitriftin f-r Fry C_t1 jd DOLLARS ®. E/¢/S w EASTHAMPTON SAVINGS BANK 1: 2 1 18C7l +1 : 409 43 2 338o C 7ls / ✓ X 77 SU/ l c FOR