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Lot 88 Title 5 Report 2015 Owner information s required for every Page. Important:when filling out forms on the computer, use only the tab key to move your cursor-do not use the return key Sins•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Matuson Owners Name Northampton cityRwm MA 01082 4-15-15 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection foram may not be altered in any way.Please see completeness checklist at the end of the form. A. General Information 1. Inspector. Rick Scott Name of Inspector RM Scott&Associates, LLC Company Name 31 Shutesbury Road Company Address Pelham MA 01002 cltyrovm State Zip Code 413-256-0647 SI1030. MA P.E. 31199. Telephone Number License 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 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority / ite s Signature Date 4-15-15 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. fe"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. tie 5 ghd*.espxlip,Form:SSaulsa Swage Uspo.S Systan-Pope 1 of 17 Owner information is required for every page. Ltin•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Mattison Owner's Name Northampton City/Town MA 01060 4-15-15 State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: No failure criteria observed. System passes. See additional notes in report. B) System Conditionally Passes: ❑ One or more system components as described in the°Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): Tree 5 OP,aS Inspection Fpm:S Disposal Sy Wm•Page 2 of 17 Owner info motion is required for every page. t5ns•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Matuson Owners Name Northampton Cky/rown MA 01060 4-15-15 State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt.): ❑ 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced O r O N E r ❑ N O Y O N ❑ ND(Explain below): ❑ ND (Explain below): ❑ 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 Heal h): ❑ 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)(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 The 50156x1 Inspection Form:&tatwa Sewage orspys Sprain Page 3 or 17 Owner information is required for every page. tsirm-ata Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Matuson Owners Name Northampton Cay/rown MA 01060 4-15-15 State Zip Code Date of Inspection B. Certification (cunt.) 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 conform 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 N N N N 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 ritSS Official WPe[don Fenn Ssura2 Sewage Dismal System.Page q of 17 Owner information is required for every Page. t5in•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Properly Address Ron Matuson Owner's Name Northampton City/Town MA 01060 4-15-15 State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ E ❑ E ❑ E ❑ E 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 well. My 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 conform 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.] ❑ E 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 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 ❑ ❑ 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. Title S Official Yiyamwr Fern SWuea Sweep q$yy SnMin'Page S of t] Owner information is required for every page. Wrc•y13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Matuson Owner's Name Northampton City/Town MA 01060 4-15-15 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 E ❑ • ❑ E El El 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): 5 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 5 550 The 5 navel Inspection Fmt Subsurface Sewage Disposal System•Page 6 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 88 Maple Ridge Road Property Address Ron Matuson Owners Name Northampton MA 01060 4-15-15 CriYrtown State Zip Code Date of Inspection D. System Information Description: 1500 gallon septic tank. Gravity flow to Distribution box and Infiltrators in a six-line Leach Field. Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings Detail: available(last 2 years usage(gpd)): 2 ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. Commerclaglndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gust) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 1• •113 Tale S Moral l rmpe oo Form'.Subsurface Sewage nlagsel Sy&an•Pegs 7 of 17 Owner information is required for every page. L5,u•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Matuson Ownees Name Northampton City/Town MA 01060 4-15-15 State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other(describe below): Currently Occupied. Date General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes,volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: oe-e4;) — 1 2.18),x— Per owner, previous pumping was-November, 2014 ❑ Yes ® No gallons 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): two504WW aperpcn p,n up uTIg Sgydp oiwo, Sygam'Page8 N17 Owner information Is required for every page. 1Si¢•V13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Matuson Owners Name Northampton City/rovm MA 01060 4-15-15 State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed(if known)and source of information: System installed in 1998. System Design Plan and as-built documentation on file at Health Dept Were sewage odors detected when arriving at the site? Building Sewer(locate on site plan): Depth below grade: Material of construction: ❑ cast iron N 40 PVC Distance from private water supply well or suction line: ❑other(explain): ❑ Yes N 2 No feel N/A. Municipal supply-pressure line. Comments(on condition of joints, venting, evidence of leakage, etc.): All in-house plumbing is in excellent condition. No evidence of any previous problem. Vented to roof. Septic Tank(locate on site plan): Depth below grade: Material of construction: N concrete ❑ metal ❑fiberglass 1500 gallon concrete septic tank with cast-in baffles. 1.0 feet ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 126"X 66"X 54"effective depth. Dimensions: Sludge depth: One 5 Official k yecian Form:Subsurface Sewage DMus'Slam'Page W 1] Owner information is required for every page. ISim•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Matuson Owner's Name Northampton Cityrtowa MA 01060 4-15-15 State Zip Code Date of Inspeaion 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? —20" Probed during on-site inspection. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Minimal solids accumulation. Existing dimensions are sufficient to provide good retention time in the tank. Liquid levels are correct No evidence of past leakage out of the tank or high liquid levels above the outlet. Tank is in good condition. Cast-in inlet and outlet baffles are in good condition with some minor deterioration at outlet, consistent with age. Next maintenance pumping recommended in 2017, depending on rate of usage. Grease Trap(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal 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: Date roe S Official bsCeclion Form:Subsurface Sewage Disposal System•Page 10 of 17 Owner information is required for every page. I5w•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Matuson Owners Name Northampton City/town MA State 01060 Zip Code 4-15-15 Date of Inspection 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.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: gallons gallons per day ❑ Yes ❑ No Alarm in working order. ❑ Yes ❑ No Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Tie 501FOS bspec on Form:SYU"Ip 6ya�em•Page 11 0117 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Matuson Owner's Name Northampton MA 01060 4-15-15 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box Of present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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 is level and is distributing flow equally. Only minor solids carryover is observed. No evidence that solids have been carried out the distribution pipelines. Some deterioration of the box side walls, consistent with age but the D-box is structurally sound. No evidence of previous leakage out of the D-box or high liquid level above the outlets. 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.): •If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: D-Box found. Documented SAS is a six-line leach field with Infiltrators. See sketch. sins•aha The 5 017 ua wweo.'e+Form:Subsurface se na>Dew.System•Page 12 of 17 Owner information is required for every page. (Sins•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Matuson Owner's Name Northampton MA Cdy/Town State D. System Information (cunt.) 01060 415-15 Zip Code Date of Inspection Type: ❑ leaching pits ❑ leaching chambers 'leaching galleries leaching trenches leaching fields overflow cesspool 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.): No sign of problems observed from ground surface. Distribution box is buried approximately 20". A 20"oak tree is planted north of the D-box and tree roots are present at D-box, but roots have not invaded into the box or the distribution pipes. number number number number, length: number, dimensions: number: One Field. Approx 20'X 50'. 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 TNe 5 OKml I„eosdm Fcn x SAS,sso Sewage Desposal system•Pogo 13 U 17 Owner information is required for every page. elm-3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Properly Address Ron Matuson Owners Name Northampton Cay/Town MA 01060 4-15-15 State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of sod, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): TM S Masi Inspection Form.Subsurface Swpf Dlepiag Syslom•Page 14 of 17 Owner information is required for every page. Wins•ana Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Matuson Owners Name Northampton Clh'rtown 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: ® hand-sketch in the area below ❑ drawing attached separately MA 01060 4-15-15 State ap Code Date of Inspection MAe ■ APPRuk. Lm eon ioy 2o xSd LE C-11 Figs tort./ ) 2.7'6 S.T.Csa-- �n1lAYJ Sc.u Sit Our Dawcl.+wrf T SQ Ruef.Law .E.9.1 ST, G 5-'L3z. 1��sE Tide 5 grog Irtyycbon Form.SIDsurwa Swiye DiereW •Page 15 of 17 Owner information is required for every Page. LFns•313 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments 88 Maple Ridge Road Property Address Ron Matuson Owner's Name Northampton City/Town D. System Information (cont.) Site Exam: ❑ Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water MA 01060 415-15 State Zip Code Date of Irmpedbon 5 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: 11-16-98 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) • Checked with local Board of Health-explain: Record at Health Department 1998 Design Plan and as-built notes. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Reviewed design plan on file at Health Department. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Tie 5 Official Ygperdm Fdm:Sot 4ayf age Deposal SHen-Pape 16 of 17 Owner information is required for every page. !Sins.va Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Maple Ridge Road Properly Address Ron Matuson Owners Name Northampton MA 01060 4-15-15 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed El System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file The 5 Ofcal k spedon Form:Subsurface Sewage ninpo System•Pepe 17 ol 17