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223 Title 5 Application/Permits 1989, 2012, Reports 2012, 2015 Owner information is 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 isms.11/10 CArP / . L,a April 24,2015 Inspectors Signature Date The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this Inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owner's Name Northampton City/Town 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. MA 01062 April 24, 2015 State Zip Code Date of Inspection A. General Information 1. Inspector: Edward T. Berry Name of Inspector Edward IT Berry, P.L.S., Residential Development Consultant Company Name 113 Main Street Company Address Athol City/Town 978-249-8811 Telephone Number Ma State SI 778 License Number 01331 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority rue 5 Official Inspection Fonm subsurface Sewage Disposal system.Page 1 or 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 223 Maple Ridge Road Property Address Judith Steinberg Owner's Name Northampton MA 01062 April 24, 2015 City/Town 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: System is in good working order and no evidence of failing criteria was evident 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): tins•11/10 Ties°Moo,Inspection Form.Subsurf ace Sewage Disposal System•Page 2 or 17 Owner information is required for every page. tins.11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton MA 01062 April24, 2015 City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 E V E N S ND (Explain below): ❑ distribution box is leveled or replaced E Y E N E 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 ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 rue 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 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 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton MA 01062 April 24, 2015 City/Town State Zip Code Date of inspection B. Certification (cant.) 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ms.1 m0 Title 5 Official Inspection Form Subsurface Sewage Orsposat System.Page 4 or 17 Owner information is required for every page. usms•nnD Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 223 Maple Ridge Road Properly Address Judith Steinberg Owner's Name Northampton MA _ 01062 April24, 2015 City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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. ❑ ® 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. • Z • 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 ❑ ❑ 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 5°final Inspection Form subsurface Sewage Disposal System•Pages or n Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton MA 01062 April 24, 2015 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 ❑ ® 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? N/A ❑ 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 15ins•11%0 Title 5 Office:Inspection Form:SubsWace Sewage Disposal System•Page S 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 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton MA 01062 April 24, 2015 City/Town State Zip Code Date of Inspection D. System Information Description: The system consists of a 1500 gallon concrete septic tank, distribution box and 6-3 x 45'trenches with 6" of stone beneath. 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 Water meter readings, if available(last 2 years usage (gpd)): Approx. 80 gpd Detail: Last quarter meter reading was 1000 cuff. per Northampton Water Dept. obtained on 4/24/2015 2 Sump pump? ❑ Yes ® No currently Last date of occupancy: occupied Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15203): canons per day(gpd) Basis of design flow(seats/personsfsq.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: thins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 7 of 17 Owner information is required for every page. thins•11110 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton MA 01062 April24, 2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other(describe below): 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: last pumped 2 year ago, pumps every 2 years (owner) ❑ Yes ® No gallons 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/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): Title 5 Official mspecloo Form Subsurf Sewage Disposal System•Page 8 of n Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton MA 01062 April 24, 2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed Of known)and source of information 26 years, installed in 1989, Plans on record at Board of Health, Lot 21 Maple Ridge, Northampton Were sewage odors detected when arriving at the site? 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: ❑ Yes ® No 2.5 feet N/A-Town Water feet Comments(on condition of joints, venting, evidence of leakage, etc.): good condition Septic Tank(locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ fiberglass 2 to 2.5 feet ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Sludge depth: ❑ Yes 10.5'x 5.5' x 4' liquid depth No r51ns.N10 rme 5 Official nspedOn Form:Subsurface Sewage Disposal System•Page 9 0117 Owner information is required for every page. t5ins•11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owner's Name Northampton MA 01062 April 24, 2015 City/town State Zip Code Date of Inspection 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? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank in good structural condition, baffles in good condition. 27" measured 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 Title 5 Official Inspector Form:Sobsueace Sewage Disposal System.Page ID a n Owner information is required for every page. isms 11)10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton MA 01062 April 24, 2015 City/Town State Zip Code 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: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm 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 Toes°M6a.Inspection Earn:Subsurface Sewage Disposal System Page 11 of IT Owner information is required for every page. csms.1 ng Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton MA 01062 April 24, 2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0 Depth of liquid level above outlet invert 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.): The distibution box was uncovered (6" of cover over riser) and found to be level with no evidence of solids carry over. Pump Chamber(locate on site plan): Pumps in working order: Alarms in working order: Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ❑ Yes ❑ Yes ❑ No ❑ No Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: No hydraulic failure observed Title s Official inspection Form Subsurface sewage Disposal System•Page II of 17 Owner information is required for every page. rsIns.11110 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton MA 01062 April 24, 2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ 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 signs of hydraulic failure, ponding or excessive vegetation. System in area of lawn and was observed to be built above original grade through placement of fill as indicated on approved design plan dated 4/4/89 6-3' x45' 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 Title 5 olfidal Inspection For:Subsurface Sewage Disposal System•Page 13 of 17 Owner information is required for every page. tams.11110 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton City/Town MA 01062 April 24, 2015 State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, 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.): Title s Official Inspection Form subsurface Sewage pisposal system•Page 14 or n Owner information is required for every page. t5ins.nno Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton MA 01062 April24, 2015 City/Town 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 enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately Title 5 Official nspection Form Subsuna' Sewage Disposal System•Page Is of 17 Commonwealth of Massachusetts 0, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owner owners Name reformation is required for Northampton MA 01062 April 24, 2015 every page. City/Town State Zip Code Date of Inspection tSins.itlt0 D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 55-66" 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: 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: Obtained from approved plans on record at Board of Health Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Form Su sueace Sewage Disposal System•Page IS of 17 Owner information is required for every page. isms s 11110 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton MA 01062 April 24, 2015 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Z System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Paae IT of 17 TITLE 5 SEP77C INSPECTION SKETCH 223 MAPLE RIDGE ROAD, NORTHAMPTON PREPARED FOR JUDITH STEINBERG PREPARED BY EDWARD T BERRY, P.L.S TITLE 5 SYSTEM INSPECTOR #SI-778 APRIL 24, 2015 77E-OFFS A-7 = 20.0' A-2 = 23.5' A-3 = 277' C-4 = 85.0' B-7 = 28.0' B-2 = 26.8' B-3 = 26.0' 8-4 = 65.5' 45' 3 if�r 'Ilk R:t�l� \ 4 MI pp TI I I I i ��. t i 'k i i� d a� r; I Li'A r i' F,c � ,- jfi : 35'a i „ z 4 c.o.:. i.,,Y[ b .1, t 3 � p„.1111::ii �. 6 i � L` �� i � f , _ _ } ;ti�p�}} - 'g1" r p4'. -'`.,-,:e.: Y ,*A.C' 6 ;,. §j A I'M t)cytt �t u 1 3 �� P Y N i .4.?!:,..„...,:,.{z, �� t v S� - .. V q11 { t jk , i s ! 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Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. !sins.11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owners Name Northampton MA 01062 11/16/2012 City/Town 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: Edward T. Berry Name of Inspector Edward T. Berry, P.L.S., Residential Development Consultant Company Name 113 Main Street Company Address Athol Ma City/Town State 978-249-8811 SI 778 Telephone Number License Number 01331 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 Z Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority irimokki / Date J/— Z (7 -- Z Inspectors Signature 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 perform in the future under the same or different conditions of use Title 5 Office l Inspection Form subsurface ge Disposal system.Page 1 of 17 Owner information is required for every page. Mins 11110 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 223 Male Ridge Road Property Address Judith Steinberg Owner's Name Northampton MA 01062 11/16/2012 City/Town 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: B) System Conditionally Passes: Z 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," le s 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 Z N ❑ ND (Explain below): Title s ORiva In Mon Form Subsurface sewage Disposal system Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 223 Maple Ridge Road Property Address Judith Steinberg Owner Owners Name information is Northampton MA 01062 11/16/2012 every page. State Zip Code Date of Inspection every page. Cdyn'own ums.11/10 B. Certification (cont.) 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): Outlets were level and receiving equal distribution with no evidence of high static water level. No signs of solids carry over was evident, however, the distribution box, of concrete construction,was only in fair condition. The cover crumbled upon trying to open. This system will pass upon installation of a new distribution box. ❑ 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 accordarice 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 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 3 or 17 r Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. 4 Commonwealth of Massachusetts City/Town of Northampton Application for Disposal System Construction Permit Form lA 0047-/6 Number oo Fee DEP has provided this form for use by local Boards of Health if they choose to do so. Before using the form, check with your local Board of Health to make sure that they will accept it. A. Facility Information Application is hereby made for a permit to:❑ Construct a new on-site sewage disposal system ❑ Repair or replace an existing on-site sewage disposal system ® Repair or replace an existing system component 1. Location of Facility: 223 Maple Ridge Road Address or Lot# Northampton City/Town MA State 01062 Zip Code 2. Owner Information Judith Steinberg Name 223 Maple Ridge Road Address(if different from above) Northampton MA 01062 City/Town State Zip Code 413-320-2368 3. Installer Information Name Address City/Town Telephone Number \ stkjajt4 Name of ompany 4. Designer Information Edward T. Berry, P.L.S. System Inspector#778 Name 113 Main Street Address Athol City/Town t5forla.doc•06/03 (C ) 3ao - 936 8 State Zip Code Telephone Number Edward T. Berry, P.L.S., Residential Development Consultant MA State 978-249-8811 Telephone Number 01331 Zip Code Application for Disposal System Construction Permit•Page 1 of 3 N Commonwealth of Massachusetts �— City/Town of Northampton Application for Disposal System Construction Permit Form 1A a0/o?-//o $ Fee A. Facility Information (continued) 5. Type of Building: ® Dwelling Other: Type of Building ❑ Showers Specify other fixtures: 6. Design Flow: Calculated Daily Flow: 7 Plan: ❑ Garbage Grinder(check if present) Number of showers Number of Persons Served ❑ Cafeteria ❑ Other fixtures Gallons per Day Gallons Date of Original Number of Sheets Revision Date Title of Plan 8. Description of Soil: 9. Nature of Repairs or Alterations(if applicable): Replace existing Distribution Box as part of a conditonal pass for a Title 5 report, replace outlet cover on existing septic tank and install risers to finish grade over inlet and outlet covers of existing 1500 gallon septic tank(see accompanying Title 5 Report) 10. Date last inspected: November 16, 2012 Date t5formia.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3 r Commonwealth of Massachusetts City/Town of Northampton Application for Disposal System Construction Permit Form IA ,/ IOC 4-07 B. Agreement /`/ YYY/// The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal N aVa-�6 Number $ e/ Fee a rJ` Signature ion Approved By: 747 &Jet A Date m i4A-4/z,( i o Applicatii Disapproved for FILE CCPY t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3 Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. Commonwealth of Massachusetts City/Town of Northampton Certificate of Compliance Form 3 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. This is to Certify that the following work on an On-Site Sewage Disposal System ❑ Construction of a new system ❑ Repair or replacement of an existing system ® Repair or replacement of an existing system component Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP): DSCP Number DSCP Date Judith Steinberg Facility Owner 223 Maple Ridge Road Street Address or Lot e " Northampton MA City/Town State Designer Information: Edward T. Bery,P.L.S. & Paul O. Hadsel Edward T. Berry, P.L.S NNaa�1JQ Name of Company C. L l.Xm�'J5/ "77b /2 - 20- /2. Date Signature Installer Information: Karl's Excavating Name D eJ{, /f Signature Karl's Excavating Name of Company Date 10162 Zip Code Use of this system is conditioned on compliance with the provisions set forth below: Component repairs(manhole covers over inlet&outlet of septic tank and new D-Box)as recommended in Title 5 report have been completed by Karl's Excavating on 12/19/12. Attach this Certificate to the Title 5 Report for documentation that the system now passes the Title 5 Inspection dated 11/26/12 FILE COPT- • The issuance of this certificate shall not be construed as a guaraptee that the system will function as designed. K/ I w- ,[ &S / Date t5form3.doe.06/03 Certificate of Compliance•Page 1 of 1 17 b t tom,, f ty' i CHECK OR FILL IN WHERE APPLICABLE at: 223 Maple Ridge Lot #21 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY or NORTHAMPTON Fitz as ppliratinn fur 3inpannl 'H arks &Instrnition Permit Lion is hereby made for a Permit to Construct 009 or Repair ( ) an Individual Sewage Disposal Location-Address .....Isobar.L_.6...IUdY--Stt��iayhesg !.)..�{ C A CL/144 Installer or Lot No Address Type of Building Dwelling—No. of Bedrooms 4 Other—Type of Building Other fixtures Design Flow 55 gallons per person per day. Total daily flow 6fiD gallons. Septic Tank—Liquid capacit.45Q-D_gallons Length 1.0 ' Width 5 ' Diameter Depth Disposal Trench-- No. 5 Width....0 r Total Length...275 ' Total leaching area_1.3.7.5 sq. ft Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft. Other Distribution box (X]§ Dosing tank ( ) Percolation Test Results Performed by J . Graciai PE #29701 Date 3-1-89 Test Pit No. 1 16 minutes per inch Depth of Test Pit 90" Depth to ground water 55" Test Pit No. 2 minutes per inch Depth of Test Pit 106" Depth to ground water 66" Address Size Lot__2_.9.8E ACSa tteet Expansion Attic ( ) Garbage Grinder ( x$ No. of persons Showers ( ) — Cafeteria ( ) Description of Soil Silty Sand & Gravel Nature of Repairs or Alterations—Answer when applicable Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by e board of health. Application Approved By Application Disapproved for the fallowing reason Permit No Data Issued. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H A TH OF Tertifirttte of t nm na THIS IS TO CERT Y-, Tl t e Individual Sewage Disposal System constructed (�`) or Repaired ( ) by �ia JJ at -P ,-/ _.. ., has been installed in accordance with the p visions of TITI6 5 & he State Sanitary Code as described in the application for Disposal Works Construction Permit No 1/f dated el ac/ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS GUARANTEE THTTHE SYSTEM WILLI FU/[ICTIOt TISFACTORY. DATE C%L—f.E./ 7°9: Inspector 7 No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7 OF . ........ . ... ..•_ . . . . .... . '::: . �in#►nntt! prkn ftnnntrurtinn .Permit Permission is hereby granted to Construct ( 1) or Repair ( ), an Individual Sewage Disposal System at No Street as shown on the application for Disposal Works Construction Permit No Dated FEE Board of Health DATE F011 1255 BOSTON