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373 Title 5 Application/Permits, 1976, Reports 1999, 2005 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02198(617)292-5500 ARGEO PAUL CELLUCI TRUDY COXE SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION DEC Property Address: Owner's Name: Owner's Address: Copy to: Witness: Name of Inspector: Company Address: 373 North Farms Road, Northampton, MA Dateof Inspection: 12/7/99 Glenn Cardinal 373 N. Farms Rd. , Northampton, MA 01060 Hoard of Health, Northampton; Pat Goggins, Goggins Realty Owner Number: SSDS-393 Thomas S. Leue Company Name: Homestead Inc. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) 1664 Cape St., Williamsburg, MA 01096 Telephone: (413) 628-4533 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the Information reported 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 do not represent or warrant the operation or proper function of this system for any period of time. The septic system condition must be evaluated and classified into one of the following four conditions: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails The system condition: Passes �\^ Inspector's Signature: 177,174-0-0 J L-12-4--51----_ Date' pecember 7 . 1999 The System Inspector shall submit a copy of this Inspection report to the Approving Authority within thirty(30)days of completing this Inspection. It the system Is a shared system or has a design flow of 10,000 gpd or greater,tthhee Inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies to the buyer,if applicable and the approving authority. INSPECTION SUMMARY:Check A, B, C,or0: A] SYSTEM PASSES: X I have not found any information which indicates that any of the failure criteria as described in 310 CMR 15.303 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. Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances.(If not determined,explain why not) The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial Infiltration or extiltration,or tank failure is imminent. The system will pass Inspection if the septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass Inspection if(with approval by the Board of Health). Describe observations: broken pipe(s)are replaced _ obstruction is removed100 distribution box is levelled or replaced (revised 9/2/98 Page 1 of 7 Homestead Inc SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 373 North Farms Road, Northampton, MA Owner's Name: Glenn Cardinal Date of inspection: 12/7/9 9 The system required pumping more than four 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 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 it the system is failing to protect the public health,safety and the environment: 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1Xb)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and is within 100 feet to a surface water supply or a tributary to a surface water supply. The system has a septic tank and a SAS and the SAS is within a Zone I of a public water supply well. The system has a septic tank and a SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and a SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER Dj SYSTEM FAILS: Must indicate either*Yes"(Y)or"No"(N)as to each of the following: I have determined that one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. YES or NO N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. N Discharge or ponding of effluent to surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N Liquid depth in cesspool less than 6"below invert,or available volume less than 1/2 day of calculated daily flow.(Part 7) N Required pumping 4 times or more in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped N Any portion of the Soil Absorption System,cesspool or privy below high groundwater elevation. N Any portion of a cesspool or privy is within 100 feet of a surface water supply or a tributary to a surface water supply. N Any portion of a cesspool,privy or any portion of the Soil Absorption System is within a Zone I of a public well. N Any portion of a cesspool or privy is within 50 feet of a private water supply. N Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coltorm bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system a significant threat to public health and safety and the environment because one or more of the following conditions exist: N the system is within 400 feet of a surface drinking water supply N the system is within 200 feet of a tributary to a surface drinking water supply N 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) The owner or operator of any such system shall upgrade the system in accordance with 314 CMR 15.304(2). Please consult the local regional office of the Department for further information. (revised 9/2/98 Page 2 of 7 Homestead Inc Properly Address: Owner's Name: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B-CHECKLIST 373 North Farms Road, Northampton, MA Glenn Cardinal 12/7/99 CHECK IF THE FOLLOWING HAVE BEEN DONE: YES or NO Y Pumping information was provided by the owner,occupant or Board of Health. Y None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this Inspection. LYA As built plans have been obtained and examined. Note it they are not available with N/A. Y The facility or dwelling was inspected for signs of sewage back-up. Y The system does not receive non-sanitary or industrial waste flow. Y The site was inspected for signs of breakout. Y All system components,excluding the Soil Absorption System,have been located on site. Y The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on site has been determined based on: pj a) Existing information on file with the Board of Health. Y b) Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)]. Y The facility owner(and occupants,if different from owner)were provided with information on proper maintenance of Subsurface Sewage Disposal Systems(SSDS). RESIDENTIAL: unknown unknown 3 2 Y Y 144 N continuous FLOW CONDITIONS Design Flow gallons/day/bedroom for SAS Number of bedrooms(design) Number of bedrooms(actual) Total DESIGN flow gpd Number of current residents Is there a Garbage grinder?(Y or N) Is there a Laundry Hookup?(Y or N) Is the Laundry a separate system?(Y or N) (II yes,Inspection required) Seasonal use(Y or N) Water meter readings, if available(last two years usage)(gallons per day) Sump Pump(Y or N) Date of last occupancy PUMPING RECORDS and source of information: pumped October. 1997 from Owner's information. J7 System pumped as part of inspection(Y or N) If yes,volume pumped: gallons Reason for pumping: Comments: Not needing Dumping this year. Sewage odors detected when arriving at the site: $ APPROXIMATE AGE of all components,date installed Of known)and source of information: 1976 system per OwneI's information (revised 9/2/98 Page 3 of 7 Homestead Inc SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C-SYSTEM INFORMATION Property Address: 373 North Farms Road, Northampton, MA Owner's Name: Glenn Cardinal Date of Inspection: 12/7/99 GENERAL INFORMATION TYPE OF SYSTEM: Z Septic tank/distribution box/soil adsorption system. Single cesspool Overflow cesspool _ Privy Shared system(Y or N),If yes,attach previous inspection records,if any. I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Other(explain) BUILDING SEWER: y (located on site plan) 24" Average depth below grade Material of construction: X cast iron _Sch.40 PVC _other(explain)_ 26• Distance from private water supply well or suction line 4" Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) No problems seen. SEPTIC TANK: g (located on site plan) 18" Average depth below grade Material of construction: % concrete_metal_FRP_polyethylene_other(explain) If tank is metal, list age_Is age confirmed by Certificate of Compliance(Y or N) 58 96 Septic tank width(inches) Septic tank length(inches) Septic tank height(inches) Calculated gross volume(gallons) Air space in tank(inches) Net Volume(gallons) Baffle depth(inches)_ Sludge Thickness IAveracel Scum thickness(inches) (Average l Top of sludge layer to bottom of outlet tee or baffle(inches) Bottom of scum layer to bottom of outlet tee or baffle(inches) Top of scum layer to top of outlet tee or battle(inches) How dimensions were determined: pleasured. Comments: (recommendation for pumping,conditions of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) Tank structurally OR. Baffles in place.. (revised 9/2/98 Page 4 of 7 Homestead Inc. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C-SYSTEM INFORMATION(continued) Property Address: 373 North Farms Road, Northampton, MA Owner's Name: Glenn Cardinal Date of Inspection: 12/7/99 GREASE TRAP: ILA (Usually present in certain commercial systems) Depth below grade: _ Material of construction:_concrete_metal_FRP polyethylene_other(explain) Dimensions: _ (A) scum thickness (8) top of scum layer to top of outlet tee or baffle (C) bottom of scum layer to bottom of outlet tee or baffle (D) date of last pumping Comments: (recommendation for pumping,conditions of inlet and outlet tees or baffles,depth of liquid level in relation to outlet Invert, structural integrity,evidence of leakage etc.) DISTRIBUTION BOX: $ (locate on site pan)("D-box") Depth of liquid level above outlet invert: 0" Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendations for repairs,etc.)s pox not level. speed levellers installed to balance flow SOIL ADSORPTION SYSTEM(SAS); Y Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods. If not located,explain: Type: a. leaching pits 8 number: b. leaching chambers and number: c. leaching galleries and number: d. leaching trenches,number,length: e. leaching fields, number,dimensions: field about 20' x 3Q, f. overflow cesspool,number: O. Alternative system, name technology: h. Comments: (note soil conditions,signs of hydraulic failure, level of ponding,condition of vegetation, recommendations for maintenance or repairs,etc.) po problems seen on surface CESSPOOLS: N/A (locate on site plan, if any) Note: Cesspools must be pumped as pan of the inspection. 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(cesspool must be pumped as part of inspection) Comments: (note soil conditions,signs of hydraulic failure,level of ponding,cendalon of vegetation,etc.) PRIVY: VA (locate on site plan,if any) Materials of construction' Dimensions: Depth of solids: Comments: (note soil conditions,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 9/2/98 Page 5 of 7 Homestead Inc SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C-SYSTEM INFORMATION(continued) Property Address: 373 North Farms Road, Northampton, MA Owner's Name: Glenn Cardinal Date of Inspection: 12/7/99 PUMP CHAMBER: J/A (part of pump-up systems only) Pumps in working order:(Y or N) Alarms in working order:(Y or N) _ Comments:(note condition of pump chamber,condition of pumps and appurtenances,etc.) TIGHT OR HOLDING TANK: itla (Special circumstances only) Depth below grade: _ Material of const ruction:_concrete_metal_FRP_polyethylene other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order Yes No Comments: (conditions of inlet tees,condition of alarm and float switches,etc.) ESTIMATED DEPTH TO GROUNDWATER: greater than 48 inches NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM Slope Surface water Check Cellar Shallow wells Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plan on record Observation of Site(Abutting property,observation hole,basement sump,etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers _ Use USGS Date Describe how you established the High Groundwater Elevation.(Mug be completed) po groundwater seen in basement death relatively near leachfield. Actual depth to groundwater probably starlificantly greater. COMMENTS: RESOURCES: Department of Environmental Protection,Western Regional Office,436 Dwight St.,Springfield, MA 01103, (413)784-1100; Title 5 Hotline-(800)266-1122 (revised 9/2/98 Page 6 of 7 Homestead Inc. / Partial House Plan ( , • '• , N Deck Called North \ I Ip Septic tank / Zg Garage Na. II D-bo ON MIS Leachfield No known groundwater drinking sources within 100' radius. As-built Drawing of Scale: 1 : 150 Owner: Glenn Cardinal HOMESTEAD INC. Existing Septic System Note: 373 North Farms Rd. 1664 cape st. Page 7 of 7 Some Dimensions Approximated Northampton, MA 01060 Williamsburg,MA 01096 4131 62S-493:3 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 373 North Farms Road, Northampton, MA Owner's Name: Jeff Sharp O(O 2- Owner's Address: 373 N. Farms Rd. . W�n. MA 0 €E Date of Inspection: 6/9/05 Copy to: Board of Health, Northampton: Witness: er Number: SSDS-984 Name oilnapector: Thomas S. Leue Company Name: Homestead Inc. Mailing Address: 1664 Cape St. , Williamsburg, MA 01096 Telephone Number. (4131 628-4533 CERTIFICATION STATEMENT 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 septic system condition must be evaluated and classified into one of the following four conditions: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails The system condition: Passes Inspector's Signature: / ms, S `"" - Date• Whine 9. 7005 The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health of DEP) within thirty(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 to the buyer, if applicable and the approving authority. Notes and Comments ****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 S Inspection Form 6/15/2000 page 1 of 9 Homestead Inc. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 373 North Farms Road Northatgpton MA Owner: Jeff Sharp Date of Inspection: 6/9/05 Inspection Summary: Check A,B, C, D or E/ALWAYS complete all of Section D: A. System Passes: Y I have not found any information which indicates that any of the failure criteria as 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: N 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. Answer yes,no,or not determined (Y, N, or ND) in the for the following statements. If"not determined"please explain. (I) N 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. The system will pass inspection if the existing septic 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. ND explain: (2) N 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 by the Board of Health). broken pipe(s) are replaced obstruction is removed _ _ distribution box is levelled or replaced ND explain: (3) N The system required pumping more than four 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 ND explain: (4) N Other: explain: _ C] Further Evaluation is Required by the Board of Health: N Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety or the environment: I) 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. Title 5 Inspection Form 6/15/2000 page 2 of 9 Homestead Inc. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (continued) Property Address: 373 North Farms Road. Northampton, MA Owner: Jeff Sharp Date of Inspection: 6/9/05 2) System will fail unless 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 I 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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 either"Yes" or"No" as to each of the following for all inspections: YES (Y) or NO(N) N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. N Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. N 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 less than 1/2 day flow. N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped N Any portion of the SAS, cesspool or privy is below high ground water elevation. N Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N Any portion of cesspool privy is within a Zone I of a public well. N Any portion of cesspool or privy is within 50 feet of a private water supply well. N Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] N The system fails. I have determined that one or more of the above failure criteria exist as defined in 310 CM 15303,therefore the system fails. The system owner should contact the Board of Health should be contacted to determine what will be necessary to correct the failure. Title 5 Inspection Form 6/15/2000 page 3 of 9 Homestead Inc. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (continued) Property Address: 373 North Farms Road, Northampton, MA Owner: Jeff Sharp Date of Inspection: 6/9/05 E] Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd. You mast indicate either"Yes" or"No"as to each of the following. The following criteria apply to large systems in addition to the criteria above: YES (Y) or NO (N) N 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 N 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 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. PART B: CHECKLIST Check if the following have been done. You must indicate "yes"or"no"as to each of the following: YES (Y) or NO(N) Y Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the previous two weeks? Y Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of the inspection? Y Were"as-built"plans of the system obtained and examined? (If they are not available note as N/A) Y Was the facility or dwelling was inspected for signs of sewage back up? Y Was the site was inspected for signs of break out? Y Were all system components,excluding the SAS,located on site? Y Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y a) Existing information. For example, a plan at the Board of Health. lY b) Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [15.302(3)(b)]. Y The facility owner(and occupants,if different from owner) were provided with information on proper maintenance of Subsurface Sewage Disposal Systems (551)5). RESOURCES: Department of Environmental Protection,Western Regional Office,436 Dwight St., Springfield, MA 01103, (413) 784-1100;Title 5 Hotline-(800) 266-1122 Title 5 Inspection Fonn 6/15/2000 page 4 of 9 Homestead Inc. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C: SYSTEM INFORMATION Property Address: 373 North Farms Road, Northampton MA Owner: Jeff Sharp Date of Inspection: 6/9/05 RESIDENTIAL unknown 3 3 Y Y N N N/A N continuous FLOW CONDITIONS DESIGN flow based on 310 CMR 15.203 (gallons/day) Number of bedrooms (design) Number of bedrooms (actual) Number of current residents Is there a garbage grinder? (Y or N) _ Is there a Laundry Hookup?(Y or N) Is the Laundry a separate system?(Y or N) (If yes, separate inspection required) Seasonal use (Y or N) Water meter readings,if available (last two years usage)(gallons per day) Sump Pump(Y or N)_ Date of last occupancy_ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft, etc.): Grease trap present(Y or N): Industrail waste holding tank present(Y or N): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: pumped 9/17/04 as per receipt N Was system pumped as part of the inspection(Y or N) If yes, volume pumped: gallons --How was quantity pumped determined? Reason for pumping: Comment: does not need pumping this year TYPE OF SYSTEM: X Septic tank, distribution box, soil adsorption system. Single cesspool Overflow cesspool Privy N Shared system(Y or N) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach 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): ly_ Were sewage odors detected when arriving at the site(Y or N) Title 5 Inspection Folm 6/15/2000 page 5 of 9 Homestead Inc. OFFICIAL INSPECTION FORM • NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C: SYSTEM INFORMATION(continued) Property Address: 373 North Farms Road, Northampton, MA Owner: Jeff Sharp Date of Inspection: 6/9/05 APPROXIMATE AGE All components, date installed, and source of informatior Septic plan: said to be 1976 system Source of Information Earlier Owner BUILDING SEWER 24 35 east iron Comments: (located on site plan) Depth below grade (inches) per i mated Average Distance in feet from private water supply well or suction line Materials of Construction All visable pipes appear to be connected to sewer. SEPTIC TANK Concrete Materials of Construction 12 Depth below grade 0 Riser depth 58 Septic tank width 96 Septic tank length 60 Septic tank height 1,450 Calculated gross volume 9 Air space in tank 1,200 Net Volume 24 Baffle depth 2 Sludge thickness 1 Scum thickness 34 Top Sludge : Bottom Baffle 14 Bottom Scum : Bottom Baffle 7 Top Scum : Top Baffle Comments: Tank structurally intact, Baffles (located on site plan) (inches) (inches) (inches) (inches) (inches) (gallons) (inches) (gallons) (inches) (inches) (inches) (inches) (inches) (inches) in place. rntprior dimensions Interior dimensions Interior dimensions Calculated Calculated Average Average Calculated Calculated 5lalcut ated Recommendations: Pump on 3 to 4 year interval. PUMP CHAMBER N Pump part of septic system: (Y or N) Pumps in working order: (Y or N) Alarms in working order: (Y or N) Comments: Title 5 Inspection Form 6/15/2000 page 6 of 9 Homestead Inc. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C: SYSTEM INFORMATION(continued) Property Address: 373 North Farms Road, Northampton, MA Owner: Jeff Sharp Date of Inspection: 6/9/05 DISTRIBUTION BOX (located on site plan) ("D-box") D-box part of septic system: (Y or N) O Depth of liquid level above outlet invert Comments: Box levellred with speed levellers. SOIL ADSORPTION SYSTEM (SAS): Technology Used (located on site plan by estimate): leaching pits&number: leaching chambers and number: leaching galleries and number: leaching trenches, number, length: Y leaching fields,number, dimensions: about zo rt. by 30 ft. overflow cesspool, number: innovative/altemative system,Type: Comments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) No problems seen on surface. If SAS not located explain why: TIGHT OR HOLDING TANK (tank must be pumped at time of inspection) N Tight tank part of system: (Y or N) Depth below grade (inches) Measured Tank width (inches) From PLan Tank length (inches) From Plan Tank height (inches) From P1 a¢ Calculated gross volume (gallons Calmat ate Materials of construction Design flow: gallons/day Pumps in working order: (Y or N) Alarms in working order: (Y or N) Date of last pumping Comments: (conditions of inlet tees, condition of alarm and float switches,etc.) PRIVY (locate on site plan, if any) N Privy part of system: (Y or N Materials of construction: Dimensions: Depth of solids: Comments: (soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation,et Title 5 Inspection Form 6/15/2000 page 7 of 9 Homestead Inc. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C: SYSTEM INFORMATION(continued) Property Address: 373 North Farms Road, Northampton, MA Owner: Jeff Sharp Date of Inspection: 6/9/05 CESSPOOLS (cesspool must be pumped as part of inspection) N Cesspool part of system: (Y or N) 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(cesspool must be pumped as part of inspection) Comments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, GREASE TRAP (Usually present in certain commercial systems) N Grease Trap part of system: (Y or N) Materials of construction: Depth below grade (inches) Measured Dimensions: Depth of solids layer Depth of scum layer Top of scum to top outlet calculated Inchee Date of last pumping Bottom of scum to outlet. Calculated Inches Scum thickness (inches) Average Comments: (recommendation and conditions) SITE EXAM (Source of Information) Y Slope Official Perc Date Y Surface water Official Plan Date Y Check Cellar Other Official Source N Shallow wells Other Source >48 Estimated depth to ground water (inches) Please indicate(check) all the methods used to determine high groundwater elevation: Y Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: ;Information: No groundater seen in basement, relatively close to leachfield. Actual depth to groundwater usually deeper in neighborhood. Title 5 Inspection Fonn 6115/2000 page 8 of 9 Homestead Inc. �,'x{, Partial House Pla S — Deck Called North ICI Septic tank 28'61 c Garage D-box "2.9 314 Outline of Patio —.y Leach field No known groundwater drinking sources within 100'radius. COMMENTS: Recommend pumping on a 3 to 5 year schedule. Also, a copy of this plan posted in the basement/utility area would keep this information accessible in future years for maintenance. Date: Owner: As-Built Drawing HOMESTEAD INC. Existing Septic System 6/9/05 Jeff Sharp ) Thomas S. Leue R.S. 373 North Farms Roa• Scale: 1 : 20' Revision Date: Florence, MA 01062 / 1664 Cape St. Williamsburg,MA 01096 Except as Noted [4131 6284533 • I CHECK OR FILL IN WHERE APPLICABLE No...7C..V Fin _5 va THE COMMONWEALTH OF MASSACHUSETTS A OARDOF� HEALTH OF Applirtttiun-fur flinpnnttl Marko @luuntrurtintt Prrttrit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an lndi\idual Sewage Disposal System at: 3�7��3� ttt..a. )-9e, T" 'Iacanon ladvess or Int Na 8 2d nw ?iuIQl) Address Installer Amass Type of Building Size Lot Sq. feet Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building .. No. of persons Showers ( ) — Cafeteria ( ) Other fixtures .__ _...__..._........_._.._...___._... Design Flow gallons per person per day. Total daily flow gallons. Septic Dank—Liquid capacity g:lions Length Width Diameter Depth Disposal Trench—No. Width Total Length Total leaching area sq. ft Seepage Pit No Diameter Depth below inlet - Total leaching area se. it Other Distribution box ( ) • Dosing tank ( ) Percolation Test Results Performed by Date Test Pit No. 1 minutes per inch Depth of Test I'it Depth to ground water Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water Description of Soil Nacre of P 7' o Alt• ati s—Answer whe applicgbl _: andereari Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NS of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the b arc of health. Siignee dal .�y// t » ez T. L . ���� PPP s // Application Approved By t-t.�c+.. ._LFj�-4!Disct./f.�F JI UUU UU Derc Application Disapproved for the following reasons' Permit No.--1 0 y Dae Issued ``"�)�,' 6 L..9 7 b ERE APPLICABLE CHECK OR FILL IN No THE COMMONWEALTH OF MASSACHUSETTS OARD OF HEALTH OF ) ppliratiun for Qispnsttl Thurks Qianstrurtiuu Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ' wt Inditidual Sewage Disposal System at' ?7 7 7) Location•Address Owner Installer or Lot No. Address Type of Building Dwelling—No. of Bedrooms Expansion Attic ( Other—Type of Building No. of person Other fixtures Design Flow Septic Tank—Liquid capacity Disposal Trench—No. Seepage Pit No Other Distribution box ( Percolation Test Results Test Pit No. 1 Test Pit No. 2 Address Size Lot Sq. feet Garbage Grinder ( ) Showers ( ) — Cafeteria ( ) gallons per pet-son per day. Total daily flow gallons. gallons Length Width Diameter Depth Width Total Length Total leaching area sq. ft. Diameter Depth below inlet Total leaching art t sq- ft. ) Dosing tank ( ) Performed by Date nil—lutes per inch Depth of Test Pit Depth to ground water minutes per inch Depth of Test Pit Depth to ground water Description of Soil �3 fr Nature of Rea 's or Alt at s— nswer whe applicable w ' %lio1 at ?_ t Agreement: The undersigned agrees to install the aforcdescrihed Individual Sewage Disposal System in accordance with the provisions of Article AI 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,Ithe board,of health. Signed Application Approved By Date Application Disapproved for the following reasons' rr :7 Permit No Date i Issued Date by THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Cnrrtifiratr of tIInntplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ) Installer at has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF FEE Dispns91 finrks f nustryrtinn drrwit granted is hereby anted to Construct ( ) or Repair ((") an individual Sewage Disposal System at No . sr e as shown on the application for Disposal Works Construction Perigit No '' Dated aaartl of Health DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS