275 Septic Inspection 2011 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owner Owner's Name
information o r is
evert NORTHAMPTON MA. 01060 MAY 9, 2011
iced ed for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
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:
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 E N ❑ ND(Explain below):
than 11/10 rae 5°rids,Inspection Form:SuWUfxa Sewage DiSPOSHi System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owner Owners Name
information required for
is NORTHAMPTON
required for
every page. City/Town
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
MA. 01060 MAY 9, 2011
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
PHILIP J. PASIECNIK
Name of Inspector
GREG'S WASTE WATER REMOVAL
Company Name
239 GREENFIELD ROAD
Company Address
SOUTH DEERFIELD
Ciryrtown
413-665-3989
Telephone Number
MA.
State
$11526
License Number
01373
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
❑ .Needs Further Evaluation by the Local Approving Authority
❑ Fails
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 perfonn in the future under
the same or different conditions of use.
tees.11110 The 5 Mod inspection Form-.Subsurface Sewage Disposal System•Page 1 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments.
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owner's Name
NORTHAMPTON MA. 01060 MAY 9, 2011
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well °.
Method used to determine distance:
••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:
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
❑ N Liquid depth in cesspool is less than 6°below invert or available volume is less
than 'A day flow
thins.11110 ale 5 Official Inp.don ram:SuWlen Serape eieyxvl System.Page 4 a 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owners Name
NORTHAMPTON
City/Town
MA. 01060 MAY 9, 2011
State Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below):
❑ 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):
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)(D)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
thins•11/10 TMIe 5 Official Inspection F .Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owner Owner's Name
required is NORTHAMPTON MA. 01060 MAY 9,2011
evert'p for
ery page. Cdyrtown 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:
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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms(actual). 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
220 gpd
tins I1/10 T:e 5 OPOa V¢perthon Eons:Subsurface Sewage olpceM System Papas 0(17
Owner
information is
required for
every page.
urn•11110
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owners Name
NORTHAMPTON MA. 01060 MAY 9,2011
Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
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 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 well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ 0 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
❑ ® the system is within 400 feet of a surface drinking water supply
❑ 0 the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered°yes°to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Tele 50111cial NMttlion Form:Subsurface Smile Deposal Sy.te n•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owner Owners Name
in
irifn is
qued for NORTHAMPTON MA. 01060 MAY 9, 2011
every ev page. Ciy/TOwn State Zip Code Date of Inspect on
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below):
N/A
N/A
Date
Pumping Records:
Source of information:
Was system pumped as part of the inspection? (E Yes ❑ No
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) Of yes, attach previous inspection records, if any)
❑ Innovative/Altemative 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):
General Information
Pumped 2-3 years ago per owner.
1500
gallons
Tank Dimensions
Tank Inspection
1511s 11/10 me 5 cede Inspection Ram sWWxeSewage Disposal system.Pap BM 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owner's Name
NORTHAMPTON
City/Town
MA. 01080 MAY 9, 2011
State Zip Code Date of Inspection
D. System Information
Description
2 Bedroom hous with a 2 bedroom septic design.
3
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
219 gpd
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Last 2 years usage=21,300 cult x 7.5 gpcu.ft. = 159,750 gallons/730 days=218.83 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: o O n ccccupup ey
ied
Commercial/Industrial Flow Conditions:
Type of Establishment N/A
Design flow(based on 310 CMR 15.203): N/A
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
Grease trap present/ ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: N/A
15n•11110 Pile 5 Official euython Fum:SIDwnxe Sewpe Disposal System Pay 7•!17
Owner
information is
required for
every page.
am..11110
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owners Name
NORTHAMPTON
City/Imam
MA. 01060 MAY 9, 2011
State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
9 Years Old / 2002 / Design Plan Dated 09/18/02
Were sewage odors detected when arriving at the site?
Building Sewer(locate on site plan):
Depth below grade:
Material of construction:
E cast iron E 40 PVC ❑other(explain):
Distance from private water supply well or suction line:
❑ Yes E No
2.5
feet
Cast iron exiting house and PVC
entering septic tank.
Town Water
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
House built on a slab with no visible building sewer joints. Venting
pipes were visible outside the dwelling on the roof. No leakage was evident at this time.
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
E concrete ❑ metal
❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
N/A
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
10'6"Lx5'6'Wx5'4"D
Tuk 5 Official Impaction Form S
sye�em Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owner Ownees Name
information a NORTHAMPTON MA. 01060 MAY 9, 2011
everyrequired for
every page. City/Town State 21p Code Date of Inspection
ISim•11/10
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
27"
6"
11"
Measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Recommendation for septic tank
pumping is every three years. PVC Inlet and outlet tees were in place and appeared to be in good
condition. Structural integrity of the septic tank appeared to be good looking into covers after tank
was pumped. The liquid level was at the outlet invert when covers were opened. No substantial
infiltration or exfiltration was evident at this time. All 3 covers were at or near the surface on the tank.
Grease Trap(locate on site plan):
Depth below grade:
Material of construction:
❑concrete
N/A
❑ metal
N/A
feet
❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
N/A
N/A
N/A
N/A
N/A
Date
Title s ORrial Inspector Fum:Subsurface sewage Disposal system Page 10 of 11
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owner's Name
NORTHAMPTON
City/Town
MA. 01060 MAY 9, 2011
Slate Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 1" — NOT due to an overloaded or clogged
SAS
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.).
Distribution box has appeared to have settled
which is why the liquid level is 1"above the outlet inverts. Box appeared to be level and flow
appeared to be equal to all three outlet pipes at this time. Very little solids carryover was in the box
when opened for inspection. No leakage was evident into or out of the box at this time. Distribution
box cover was 30"deep below grade. Distribution box appeared to be in good condition and
replacement is NOT recommended at this time.
Pump Chamber(locate on site plan):
Pumps in working order:
Alarms in working order:
❑ Yes ❑ No
❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
thins•11/10 Title 5 Modal Inspection Fam-.SWwlace Sewer eisPOSal SysM1m•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owner Owners Name
information is
required for NORTHAMPTON MA. 01060 MAY 9, 2011
every page. City/Trrwn State Zip Code Date of Inspection
Sas•11/10
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
N/A
Depth below grade:
Material of construction:
❑concrete
N/A
❑ metal
❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
N/A
N/A
N/A
gallons
N/A
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
N/A
Date
Comments(condition of alarm and float switches, etc.):
N/A
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Tide 5 OMaal n Ton Fpm:Subsurface Sewage Disposal System.Page 11 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owners Name
NORTHAMPTON MA. 01060 MAY 9,2011
City/Town State Zip Code Date of Inspeotpn
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
N/A
N/A
N/A
rite 5 Official Inspection Form.Sutwlece Swops Disposal Syelem Page 14 m17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments
275 HATFIELD STREET
Propety Address
JOHN SULLIVAN
Owner's Name
NORTHAMPTON
City/Town
MA. 01060 MAY 9, 2011
State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits
❑ leaching chambers
❑ leaching galleries
❑ leaching trenches
leaching fields
❑ overflow cesspool
number:
number:
number:
number, length:
number, dimensions:
number:
3-Pipe L-Field
25ft. L x 15ft.W
❑ 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.):
Dimensions of leaching field is approximated by probing stone bed of leaching
field with a metal rod. Design Plan shows 3 different leaching field dimensions 12'x 20'on Page 1,
12'x 25'also on Page 1 815'x 25'on Page 2 Soil clogging wasn't evident from backup of liquid into
the distribution box from the leaching field. No signs of hydraulic failure or ponding was evident at this
time.The soil over the leaching field wasn't damp or spongy under foot.Vegetation over the leaching
field appeared to be normal in growth.
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
F4aterYls of construction
Indication of groundwater inflow
N/A
N/A
N/A
N/A
N/A
❑ Yes ❑ No
Ltim 11(10 The 5 offal hspechon Fwm:SAVala®Swap Disposal Synem•Paw 13 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owners Name
NORTHAMPTON MA. 01060 MAY 9, 2011
City/Town Slate Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
tEl Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water
4+
feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked, date of design plan reviewed:
09/18/02
Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked 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:
Design Plan and Site Exam
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
thins•1 1110 lite 6 Official Ir ecnon Farm Subsurface Sewage pgasel System Page 16 al 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments.
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owners Name
NORTHAMPTON
City/Town
MA. 01060 MAY 9, 2011
State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply entets the building. Check one of the boxes below:
l�SkekA M9* (9''giev.
® hand-sketch in the area below
❑ drawing attached separately)
D
1
a Rec reeu1
a9' y"
1p - R1 as'
,2/ , - /P,1 = 33 'y3 "
LI - c1 =ast / tl .
1 , - 1), =
21 - Df =
Lt0aleS FideCA
,c&o 69ml/en
a corup644-MPnT
A' Septic Teetk
Qf coo2Ns 10 sioecre.
a6""7 +or--
b.
at6t Fox
30" Deep
thins•11n0 MS 5 andel Insrxlpon Fomr Sutwsfae Sewage Disposal System Pape 15 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owner's Name
NORTHAMPTON MA. 01060 MAY 9, 2011
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
El Inspection Summary: A, B, C, D, or E checked
Z Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
terns•11110 Title 501Fa'M Inspection Form.Su0wlew Sewage Deposal System•Page 17 W 17
System Pumping Report
Greg's Wastewater Removal
239 A Greenfield Road
South Deerfield,MA 01373
Phone 413-665-3989 Fax 413-665-7358
****** This report will be sent to the BOARD OF HEALTH within 15 DAYS p******
Permit It_P_____ OS-MA License# Date of Pumping i-5-/ / / 1/
Property Owner JOHN SULLIVAN
Home Phone
Bus Phone
Cell Phone
Tank Size:
(413) 695-6606
1500 GAL 2 COMP
Concrete
Good
Tank Location CUSTOMER GETTING PLANS
Septic
Holding Tank
Address 275 HATFIELD STREET
Address 2
Address 3
City
State
NORTHAMPTON
MA Zip Code 01060
Total Volume: /i a0
Leach Tank Cesspool Grease Trap
Date of Previous Pumping, If Known:
Waste Received at Licensed Facility:
Licensed Facility Phone Number:
Town:
Misc Comments:
Driver:
wWTA
Y9,3 a Pd°
Created 5/10/2011 at 12:02'.22 PM
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