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671 Title 5 Application/Permits, Certificates of COmpliance, Inspections, 2011 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins rner Owner's Name ,nnation is lured for every Florence MA 01062 5/16/2011 3e. City/Town State Zip Code Date of Inspection portant:When ng out forms the computer, r.only the tab r to move your sor-do not r.the return 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: Thomas S. Leue Name of Inspector Homestead Engineering Inc. Company Name 1664 Cape St. Company Address Williamsburg MA City/Town State 413-628-4533 SI-130 Telephone Number License Number 01096 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: Z Passes ❑ Conditionally Passes ❑ Needs Further Evaluation by the Local Approving Authority 5 ❑ Fails May 16, 2011 Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a 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. ns-11710 Tile 5 Official Inspection Form Suosurtace Sewage Disposal System'Page 1 of 17 mer >rmation is Iuired for every 3e. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence MA 01062 5/16/2011 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 that indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): ne•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Par 2 of 17 mer xmation is ;aired for every 3e. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence MA 01062 5/16/2011 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (corn.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y D N S 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 ns.IMO Title 5 onmiei Inspection Form:Subsurf ace Sewage Disposal System.Page 3 of 17 mar ormation is wired for every ge. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owners Name Florence MA 01062 5/16/2011 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 0) 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 dogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow Title 5 Official Inspection Fort.Subsurface Sewage Disposal System.Page a of 17 finer u red fo r every is lured Florence MA 01062 5/16/2011 for 1e. City/Town State Zip Code Date of Inspection Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owners Name n: 11110 B. Certification (cant.) Yes No ❑ Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ___ ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z 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 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 ❑ Z 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 ❑ Z 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 official nspeulon Fmm.Subsurf ace age Disposal System.Page 5 of v ner lrmation is uired for every je. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence MA 01062 5/16/2011 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? Were as built plans of the system obtained and examined? (If they were not available note as N/A) 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 The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field Of any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 4 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660+ ins 11/10 Title 5 Official nspeulon Form.Subsurface Sewage Disposal System.Page 6 Mn ner ■mation is uired for every fie. ins.11110 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence MA 01062 5/16/2011 City/rown State Zip Code Date of Inspection D. System Information Description. Conventional septic tank, to a distribution box and leachfield. 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)): 2 Detail. Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day(gpd) ❑ Yes ® No Continuous Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Title 5 00dal Inspection Farm Subsurface Sewage Disposal System•Page 7 of 17 'Der ration is Dived for every re. ins•11110 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence MA 01062 5/16/2011 City/Town State Zip Code Date of Inspection D. System Information (cont) Last date of occupancy/use: Other(describe below): Date Pumping Records: Source of information: General Information Pumped fall 2010, says owner. Was system pumped as part of the inspection? ❑ Yes Z No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system gallons ❑ 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 Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 ner ired to is every .a Florence MA 01062 5/16/2011 ]eked to fe. City/Town State Zip Code Date of Inspection Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name D. System Information (cont.) Approximate age of all components, date installed Of known) and source of information: System plan dated 5/10/1978 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 Z other(explain). Distance from private water supply well or suction line: 2 average feet ABS pipe ❑ Yes Z No 6 ft. feet Comments (on condition of joints, venting, evidence of leakage, etc.): problems seen. Mostly below floor slab. Septic Tank (locate on site plan): Depth below grade: Material of construction: 2.3 feet ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Standard septic tank, about 1500 gallons nominal. Riser to within 3" of surface over center cover. Outlet cover inaccessible below an ornamental stone wall, so outlet baffle could not be evaluated. If lank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions. Sludge depth: ❑ Yes ❑ 56"tall, 126' long,60"wide No ins 11/10 rifle 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 al 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Fner Owner's Name ouired fn is aire Florence MA 01062 5/16/2011 d for every te. City/Town State Zip Code Date of Inspection ins•11 110 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 lee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 35" 0" 24" measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank structurally OK. Water level at height of outlet pipe invert. Recommend pumping on 3 to 5 year interval. 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 Inspection Form.Subsurface Sewage Disposal System'Page ID of IT Tier al-nation is wired for every re. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence MA 01062 5/16/2011 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 Tnle 5 Official Inspection Form subsurface sewage Disposal System•Page 11 of 17 per irmation Is uired for every Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owners Name Florence MA 01062 5/16/2011 City/imp 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 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 seems level and flow equal. Three pipes out. Pump Chamber(locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes El No ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: P15•11 no Title 5 official Inspection Form.Subsurface Sewage Disposal System•Pena 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Properly Address Patrick Goggins ner Owner's Name fo r every wred is Florence MA 01062 5/16/2011 ulred b fie. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches leaching fields ❑ overflow cesspool ❑ innovative/alternative system number. number: number: number, length: number, dimensions. number: 60' x20' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No surface problems seen. About 3 feet below grade to base. Media exposed and found to not be heavily contaminated. 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 n:•11/10 Title 5 Officio!Inspection Form.Subsurface Sewage Disposal System•Page IS of 17 mer smarm is uired for every )e. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence MA 01062 5/16/2011 City/Town 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.): ns•11110 Ttlie 5 Official Inspection Form:Subsurface Sewage DSposai System•Page 14 of 17 ner ormation is aired for every te. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence City/Town MA 01062 5/16/2011 State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below Z drawing attached separately its•11/10 Title 5 official ospecnon Form Subsurface Sewage Otsposai System Page 15 of 17 Tier ormation is oired for every re. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence MA 01062 5/16/2011 City/Town State Zip Code Date of Inspection D. System Information (cont) Site Exam: Z Check Slope ® Surface water Z Check cellar ❑ Shallow wells Estimated depth to high ground water: >4 feet Please indicate all methods used to determine the high ground water elevation. ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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. Leachfield in a typically dry area. Perc test done at depth of field. Before filing this Inspection Report, please see Report Completeness Checklist on next page. os.11110 Titles Official mspeclion Form Subsurface Sewage Disposal System•Page 16 of 17 ner lrmatian is uired for every le Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence City/Town MA 01062 5/16/2011 State Zip Code Date of Inspection E. Report Completeness Checklist El Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information -Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ns 11110 Title S Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17 , t , >.: schedule. , Also, a copy of this plan Partial House Plan • '- - posted in the basement/utility area would keep this information accessible •_ in future years for maintenance. Well le deck .f / 40' P f •-• 400 / Septic Tank to leachfield, approximately 300 feet / NORTH MECo pole 75-2 Distribution Box �♦ s mo from House N Leachfield, approximate layout p 401/2 I P Driveway 7+I 20" diameter pine with orange reflector As-Built Drawing Date: Owner: / �� HOMESTEAD INC. Existing Septic System 5/16/2001 Patrick Goggins TMoWS� `° Thomas S. Leue R.S. 671 Nort h Farms Ro. e s �0� Scale: l :20' Revision Date: 72 1664 Cape St. Florence, MA 01062 �f e` Williamsburg, MA 01096 Except as Noted ��>Frteo a�,t�� [4131628-4533 21 Commonwealth of Massachusetts Title 5 Official Inspection Form wner formation is squired for every age. nportant:When ling out forms 1 the computer, ae only the tab y to move your irsor-do not se the return MR Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence MA 01062 4/10/2014 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. Thomas S. Leue Name of Inspector Homestead Engineering Inc. Company Name 1664 Cape St. Company Address Williamsburg City/Town 413-628-4533 Telephone Number MA State SI-130 License Number 01096 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 � yfa� .S April 10 , 2014 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a 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. TWa 5 Official Inapecton Four:Su05urla a Sewage Dispose' Fogel of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Properly Address Patrick Goggins weer Owner's Name formation is Florence MA 01062 4/10/2014 fled for every 1ge. avroVm State Zip Code Date of Inspecfion 5'ms 3/13 B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information that 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 condition except for a slow leak in septic tank. 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 tot 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. ❑ N ❑ ND (Explain below): (— Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. Title 5 Official InspecOon Form:SubsuRece sewage fXSpcsaI System•Page 2 of 17 weer formation is quired for every Florence MA 01062 4/10/2014 ige. CiTyRovm State Zip Code Date of Inspection Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name ISlns.3113 B. Certification (cant.) 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 ❑ obstruction is removed [ distribution box is leveled or replaced ❑ N ❑ ND (Explain below): ❑ N ❑ ND (Explain below): ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(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 U Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh TNe 5 O1Official Inapecbon Form'.Subsurface Sewage Disposal System•Page 3 of 17 Mier formation is quired for every 313 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence MA 01062 City/Town State Zip Code 4/10/2014 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: Ye 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 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or pending 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 'A day flow Tide 5gfichl Inspec&on Form.Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Amer Owners Name formation is quiretl for every Florence MA 01062 4/10/2014 Ig¢. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 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. ❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ N Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ N Any portion of a SAS, 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 2000 gpd- 10,000 gpd. 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. ❑ N ❑ N 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 ❑ N ❑ 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 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. 5ins•3/13 The S Official Inspection Form.Subsurface Sewage Dsposal System•Page 50119 j aver ormation is Florence MA 01062 4/10/2014 quired for every Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owners Name ge. City/Town State Zip Code Date of Inspection C. Checklist Check rf the following have been done. You must indicate"yes" or no as to each of the following: Yes No N ❑ ❑ N ❑ ❑ N N ❑ N ❑ N ❑ N ❑ N ❑ 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/AZ 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? • I 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: N ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field Of any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 4 660 gpd ins.11i Tie 5 Official Inspection roan.Subsurface sewage r]iposel srnam.Pages of 17 Commonwealth of Massachusetts or Title 5 Official Inspection Form `- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L wrier formation is quired for every Age. Sins 3/13 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence city/Town MA 01062 4/10/2014 State Zip Code Date of Inspection D. System Information Description: Nominal 1500-gallon septic tank, a distribution box and pipe s stone leachfield. 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, if available(last 2 years usage(gpd)): Detail: Private well 0 ® Yes ❑ No ❑ Yes ® No ❑ Yes Z No ❑ Yes ® No N/A Sump pump? ❑ Yes ® No Last date of occupancy: Date Unoccupied about a month. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Tte 5 Official Inspection Fonn.Sutsurrace Sewage Disposal System•Page 7 tl 1] yner ormation is wired for every ge. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owners Name Florence City/Town MA 01062 4/10/2014 State 7}p Code Date of Inspection D. System Information (cont.) Last date of occupancy/use. Other(describe below): Date Pumping Records: Source of information: General Information Pumped in fall 2010, says owner. Was system pumped as part of the inspection? ❑Yes ® No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: gallons Does not need pumping in the next year or so. ® Septic tank, distribution box soil absorption system ❑ Single cesspool El Overflow cesspool ❑ Privy [ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): ■ns•3/13 Ttle 5 Official Inspection Fdm'.Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road poop Property Address Patrick Goggins tuner Owner's Name formation is Florence MA 01062 4/10/2014 quired for every rge. Oity/Tovm State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed Of known)and source of information: Septic plan: 5/10/1977 design date. Were sewage odors detected when arriving at the site? Dyes Z No Building Sewer (locate on site plan). Depth below grade: 2.5 average _. feet Material of construction: ❑cast iron ❑40 PVC ®other(explain): ABS pipe Distance from private water supply well or suction line. 6 ft. feet Comments(on condition of joints, venting, evidence of leakage, etc.): No problems seen. Mostly below floor slab. Septic Tank(locate on site plan): Depth below grade: Material of construction: ®concrete ❑ metal 2 .2 feet ❑fiberglass ❑ polyethylene ❑ other(explain) Standard concrete septic tank, about 1500-gallons nominal. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 60" wide, 128" long, 56" Dimensions: height 2" Sludge depth: Sins.3113 Tee S Officiei Inspecton From subsurface sewage Disposal System•Page 9 of 17 £� Commonwealth of Massachusetts Title 5 Official Inspection Form formation is quired for every Igo. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence City/Town MA 01062 4/10/2014 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? 30" n/a n/a" calculated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.). 1500-gallon septic tank in OR structural condition. Liquid level at height of side seam, indicating a caulking leak, which can often be repaired. Does not need pumping this year. Baffles in good condition. A riser to close to the surface located over center cleanout. Grease Trap(locate on site plan): Depth below grade: Material of construction: feet [ concrete ❑ metal ❑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 5'ns•3I13 Tie 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins ^mer Owner's Name formation is Florence MA 01062 4/10/2014 quired for every ige. 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: ❑fiberglass ❑ polyethylene ❑ other(explain): 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 s s.3/13 Tale s Official Inspection Form.Subsurface Sewage Disposal System.Par 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins mow Owner's Name forma quiredoo is Florence MA 01062 4/10/2014 me. for every tge. OiryRown State Zip Code Date of Inspection D. System Information (cant.) Distribution Box(if present must be opened) (locate on site plan). Depth of liquid level above outlet invert D 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 in fair condition. 3 pipes out. Box cover was extensively cracked and replaced with new. 3 speed levelers installed. One pipe appears to be accepting less flow than other two pipes. D-box inspected 12/5/13, but inspection process not completed until spring 2014. 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: Stns.3113 Hie 5 Official Inspection Form,Subseace Sewage Disposal System•Page 12 of 17 caner formation is wired for every Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owner's Name Florence cityrrown MA 01062 4/10/2014 State Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: innovative/alternative system 60' x 20' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No surface problems seen. 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 Lens•3'13 Tile 5 Official Inspection Form-.Subsurface Sewage Disposal System•Page 13 of 17 veer armatron is aired for every ge. .ns v1a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins Owners Name Florence City/Town MA 01062 4/10/2014 State Zip Code Date of Inspection D. System Information (cant.) 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.): TIM 5 official Inspection Fomi:subsurface Sewage Disposal system•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins tuner Owner's Name fn is quired Florence MA 01062 4/10/2014 toe. City/Town State Zip Code Date of Inspection Sins 3113 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 'Me 5 Official Inspe ton Form.Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Property Address Patrick Goggins vner Owner's Name omits is Florence MA 01062 4/10/2014 auired for every State Zip Code Date of Inspection ge. City[town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >4 feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed. Date 5/10/1978 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: Perc test data, dry gravelly soils, shallow leaching system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Sins.3113 rite 5 official Inspeclon Form.Subsurface Sewage DRWSaI System.Page 15 o117 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 671 North Farms Road Properly Address Patrick Goggins vner Owner's Name Ruired for every fn is Florence MA 01062 4/10/2014 ge. . City/Town State Zip Code Date of Inspection 5'S•Y13 E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file The 5 Official Inspeccon Form Subsurface Sewage nepasal System•Page IT of 17 \-_> schedule.uAlso,laycopy�of this plan Partial House Plan ., posted in the basement/utility area would keep this information accessible in future years for maintenance. Well -. .deck J -- _-_ ao' 1, it \ao Septic Tank to leachfield, approximately 300 feet , NORTH MECo pole 75-2 Distribution Box .............. °o from House ". \ Leachfield, approximate layout t 401/2' Driveway 20" diameter ne with orange a reflector 9 As-Built Drawing Date: Owner: � � .� HOMESTEAD INC. Existing Septic System 4/10/2014 Patrick Goggins ;_ TMpy�g� Thomas S. Leue R.S. 671 North Farms Ro• : mut- e Scale: 1 : 20' Revision Date: l 1664 Cape St. Florence, MA 01062 CEO �r° wale ,h°g' Ma otu9e Except as Noted unto tR - laid e28a533 Commonweal kfT ofJsjasssa tts City/Town of b �� System Pumping Record Form 4 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 your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Importan 1 S When on o out System Location: filling Y forms to,u computer,b ke to only move tab key Address twmor- d n Ur rsor-tl not City/Town State Zip Code use there urn key. 2. S Stem Owner: ./ CT C-C?" s (? Address(if different l Cl from location) 17:1 ",ma�,yS/J1 (�)"��'' CitylTown ott T hone N b2r B. Pumping Record C� 1. Date of Pumping Date �� 2. Quantity Pumped: �(,yllene 3. Type of system: Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? [i Yes 5. Condition p[System: Gle CA 6. System d By. Name If yes,was it cleaned?/C Fes !] No Company 7. Loc @tion where contents were disposed: t5form4.doc 03/06 Vehicle License Number Signature of Hauler Date Signature of Receiving Facility Date System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts .?0/ -// City/Town of Northampton Number Application for Disposal System $ /0 Construction Permit Fee FORM 3A - CERTIFICATE OF COMPLIANCE No. Fee C09414o7(w!AL?t(oF' ?1d71SSACn&USnTYS Board of Health, Northampton, MA CERTIFICATE OF COMPLIANCE Description of Work: ( ) Complete System ( X ) Individual Components The undersigned hereby certify that the Sewage Disposal System. Repair by: Richard Jaescke at: 671 North Farms Road, Northampton has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as built plans relating to application No. dated 7/24/14 . Approved Design Flow 660 (gpd). Installer: Designer: Inspector: Date: Date: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. tsformsl a tloc•06/03 Application for Disposal System Construction Permit•Page 4 of 4 ■o. Commonwealth of Massachusetts /0//1-if City/Town of Northampton Number Application for Disposal System s /0 Construction Permit Fee FORM 3A - CERTIFICATE OF COMPLIANCE Fee ti. .._ coa�ta�.aN�at��CoTm�ssAcI1usET'��_--�-��. � �, f �Ci Board of Health, Northampton, MA 'ij,l - t? 1 NI 1 7 2014 ( X ) Individual Compor'enta The undersigned hereby certify that the Sewage Disposal System: Re `e?_!t__ . -— by: Richard Jaescke at: 671 North Farms Road Northampton has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as built plans relating to application No. dated 7/24/14 . Approved Design Flow 660 (gpd). CERTIFICATE OF COMPLIANCE Description of Work: ( ) Complete System Installer: g,ha,r,( ( t__ an c Date: /a//6//vf Designer: Thomas S. Leue, Homestead Inc. Date: Inspector: . r� k� Cr .�. � Date: /0-7 - 20 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. t5fornsl a cloc•06/03 Application for Disposal System Construction Permit•Page 4 of 4 Commonwealth of Massachusetts City/Town of Northampton Application for Disposal System Construction Permit Farm 1A Number 00 Fee dad #4795 EP has provided this form for use by local Boards of Health if they choose to do so. Before using the form, check with )ur local Board of Health to make sure that they will accept it t. Facility Information pplication is hereby made for a permit to: Repair On-site Sewage Disposal System. Location of Facility: Address. 671 North Farms Road City/Town: Northampton MA 01062 Owner Information Name: Address: City/Town: Telephone: Patrick Goggins 8 Main St. Florence, MA 01062 413 586-7000 x 102 Installer Information Name: Richard Jaescke Address' City/Town: Telephone: Designer Information Name: Name of Company: Address- City/Town: Telephone: Thomas S. Leue R.S. Homestead Engineering Inc. 1664 Cape Street Williamsburg. MA 01096 413 628-9533 Type of Building: Garbage Grinder(check if present) X Other: Type of Building Dwelling Number of Persons Served Showers Number of showers Cafeteria Other fixtures Specify other fixtures: \. Facility Information (continued) formsla doc•06/03 Application for Disposal System Construction Permit•Pagel of 4 Commonwealth of Massachusetts pr�/V City/Town of Northampton Number Application for Disposal System $ 40 °° Construction Permit Fee Design Flow: 660 Gallons per Day Calculated Daily Flow: 660 Gallons Plan: 7/24/14 Date of Original Number of Sheets 2 Revision Date Title of Plan: Plan to Repair Septic System Description of Soil: loamy sand Nature of Repairs or Alterations (if applicable): New septic tank in a new location 0. Date last inspected: 4/10/14 3. Agreement 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 tt>isBoard of Health. gnature m Application Approved By: Date Date Application Disapproved for the following reasons APPIREI formal ooc•06/03 Application for Disposal System Construction Permit•Page 2 of 4 0. Commonwealth of Massachusetts City/Town of Northampton Application for Disposal System Construction Permit Fee FORM 2A - DSCP MG/y Number $ /2°° Feep Co9ytgvto,14WIALT I0'F 144?1SSAC4FUSfT''rs Board of Health, Northampton, MA DISPOSAL SYSTEM CONSTRUCTION PERMIT armission is hereby granted to: Repair an individual sewage disposal system at 71 North Farms Road Northampton as described in the application for Disposal System Construction armit No.,Pia dated 7/yfr madded: Construction shall be completed within three years of the date of this permit. All local conditions must be met. ate SA Board of Healt formsla doc-06103 Application for Disposal System Construction Permit•Page 3 of 4 o. Commonwealth of Massachusetts 20/l/-i7 City/Town of Northampton Number Application for Disposal System $ /0 Construction Permit Fee FORM 3A - CERTIFICATE OF COMPLIANCE COMMOT'W291.catCOF W SS9c9j?uSETYS Board of Health, Northampton, MA CERTIFICATE OF COMPLIANCE escription of Work: ( ) Complete System ( X ) Individual Components he undersigned hereby certify that the Sewage Disposal System: Repair V: Richard Jaescke 671 North Farms Road, Northampton as been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved °sign plans/as built plans relating to application No. sted 7/24/14 Approved Design Flow 660 (gpd). istaller: esigner: ispector: Thomas S. Leue, Homestead Inc. Date: Date: Date: /0.7 71 he issuance of this permit shall not be construed as a guarantee that the system will function s designed. formsla doc•06/03 Application for Disposal System Construction Permit•Page 4 of 4 NORTH Partial House Plan /Well deck �,, Existing Septic Tank: pump,cut channel through top, xj �40' attach inlet pipe to outlet with Schedule 40 pipe, till with �� �clean sand and backfill. a / \ ' Install 1500 gallon Title 5 from House septic tank with outlet filter. to leacchtl/eld, approximately ately 300 feet 9% slope / '\ �O \r MECo pole 75-2___.---7 \ 04.-13 NORTH Distribution Box v "o a Leachtield, approximate layout Driveway 40 1/2' J A \ N N 20" diameter pine with orange reflector t 60' Date: Owner: tN Plan to Repair QP �co HOMESTEAD INC. Septic System 7/24/2014 Patrick Goggins P Y� r �rxoungs, Thomas S. Leuc R.S. Revision Date: 671 North Farms Road' Scale: 1 : 20' Florence, MA 01062 ��0��� � Williamsburg,pn1A 01096 Except as Noted ��fnoo tow- 14131 628-4533 CONSTRUCTION SPECIFICATIONS 671 North Farms Road, Northampton Title 5 Septic System Plan Number 642 I. General a No work on this system construction shall take place until a permit for the approved system plan has been received from the local Board of Health. A copy of the Disposal Works Construction Permit should be on site for inspection during the time of construction. Additional specifications may be included elsewhere in this design. b. Loading requirements are specified for the septic tank are designated H-10. c. Alternatives to these specifications should be discussed with the System Designer in advance at 800 285-4533. Septic Tank a The septic tank selected by the contractor shall conform with 310 CMR 15 223 The septic tank shall be a minimum effective liquid capacity of 1,500 gallons below the outlet invert, rectangular,and with a minimum length to width ration of 1.5:1. Liquid depth to be 48". Compartmentalized tanks are not to be used unless required as stated on the plan drawing. b. Septic tank shall be installed on a minimum of 6"of crushed stone, leveled to grade and thoroughly compacted. Septic tanks shall have a minimum cover of 9". No structures shall be located directly upon or above the septic tank access locations which interfere with performance, access, inspection, pumping, or repair. c. All three access covers to the septic tank shall have risers at least 20"diameter, if round,tightly fitted to the tank to resist water infiltration and terminated with a tight fitting cover no more than 6" below ground surface. If, with the agreement of the Owner, one or more of the risers are terminated flush with ground, these shall be secured against unauthorized entry with stainless steel hardware. d. Inlet and outlet tees shall be of Schedule 40 PVC and shall extend a minimum of 6"above the flow line of the septic tank and be on the center line of the septic tank located directly under the clean-out manhole. All fittings to be glued and secured against any movement due to horizontal or vertical impacts. Cross-sectional flow baffles shall not be used as substitutes for inlet or outlet tees. The inlet pipe elevation shall be no less than 2"nor more than 3"above the invert elevation of the outlet pipe. Inlet tee minimum of 10"length below water surface. The outlet shall be provided with a tee extending below the flow line 14"and be equipped with a gas baffle. There shall be an air space of at least 3"between the tops of the tees and the inside of the tank cover. Inlet tees may be modified or a 6"riser on inlet cover may achieve this spacing. The tops of the tees shall be left open to provide ventilation or separate ventilation shall be prof ided. Final Grading a. At conclusion of work, loam and seed all disturbed areas to perennial grass mixture. Added loam may be required for adequate grass growth. Mulch slopes with hay,burlap or netting to minimize erosion. b. Systems built late in the year,where the grass cover does not have a chance to establish itself, requires the contractor is to return after spring thaw and resurface final grades and add grass seed cover as required to equalize and stabilize all disturbed areas lomestead Inc. Page 1 7/24/14, NORTH Partial House Plan g, f — Well deck ■ , NMI Existing Septic Tank: pump, cut channel through top, 40' attach inlet pipe to outlet with Schedule 40 pipe, till with i 0a clean sand and backfill. o Install 1500 gallon Title 5 from House septic tank with outlet filter. to leachfield, approximately 300 Met 9% slope 1 per MECo pole 75-2 NORTH Distribution Box ♦ I `o N Leachtield, approximate layout Driveway - 7______ 40 „2 r 7-- \ N 20” diameter pine with orange reflector - \ 60' Plan to Repair Date: Owner: �e ' p re-. HOMESTEAD INC. Septic System 7/24/2014 Patrick Goggins / p y� ire TMmW � Thomas S. Leue R.S. 671 North Farms Roa 2 ;l ° z Scale: 1 : 20' Revision Date: / r 1664 Cape St. Except as Noted Florence, MA 01062 *.gyp,. �a� Williamsburg, MA 01096 P rrarn ear 14131628-45.33 CONSTRUCTION SPECIFICATIONS 671 North Farms Road, Northampton Title 5 Septic System Plan Number 642 I. General a No work on this system construction shall take place until a permit for the approved system plan has been received from the local Board of Health. A copy of the Disposal Works Constriction Permit should be on site for inspection during the time of construction. Additional specifications may be included elsewhere in this design. b. Loading requirements are specified for the septic tank are designated H-10. c. Alternatives to these specifications should be discussed with the System Designer in advance at 800 285-4533. Septic Tank a The septic tank selected by the contractor shall conform with 310 CMR 15.223. The septic tank shall be a minimum effective liquid capacity of 1,500 gallons below the outlet invert, rectangular, and with a minimum length to width ration of 1.5:1. Liquid depth to be 48". Compartmentalized tanks are not to be used unless required as stated on the plan drawing. b. Septic tank shall be installed on a minimum of 6" of crushed stone, leveled to grade and thoroughly compacted. Septic tanks shall have a minimum cover of 9".No structures shall be located directly upon or above the septic tank access locations which interfere with performance, access, inspection, pumping, or repair. c. All three access covers to the septic tank shall have risers at least 20"diameter, if round,tightly fitted to the tank to resist water infiltration, and terminated with a tight fitting cover no more than 6" below ground surface. If, with the agreement of the Owner, one or more of the risers are terminated flush with ground, these shall be secured against unauthorized entry with stainless steel hardware. d. Inlet and outlet tees shall be of Schedule 40 PVC and shall extend a minimum of 6"above the flow line of the septic tank and be on the center line of the septic tank located directly under the clean-out manhole. All fittings to be glued and secured against any movement due to horizontal or vertical impacts. Cross-sectional flow baffles shall not be used as substitutes for inlet or outlet tees. The inlet pipe elevation shall be no less than 2" nor more than 3"above the invert elevation of the outlet pipe. Inlet tee minimum of 10"length below water surface. The outlet shall be provided with a tee extending below the flow line 14"and be equipped with a gas baffle. There shall be an air space of at least 3"between the tops of the tees and the inside of the tank cover. Inlet tees may be modified or a 6" riser on inlet cover may achieve this spacing. The tops of the tees shall be left open to provide ventilation or separate ventilation shall be provided Final Gradinz a At conclusion of work, loam and seed all disturbed areas to perennial grass mixture. Added loam may be required for adequate grass growth. Mulch slopes with hay, burlap or netting to minimize erosion. r. Systems built late in the year, where the grass cover does not have a chance to establish itself,requires the contractor is to return after spring thaw-and resurface final grades and add grass seed cover as required to equalize and stabilize all disturbed areas. 'omestead Inc. Page 1 7/24/14, NORTH Partial House Plan I tiis Mr deck deck , NMI Existing Septic Tank: pump, cut channel through top, ei q0 attach inlet pipe to outlet with Schedule 40 pipe, till with /' A��, clean sand and backfill. /^/ from Install 1500 gallon Title 5 m House septic tank with outlet filter. to Ieachfield, approximately 300 feet 9% slope 6 ,, \ ..„ X `r —MECo pole 75-2 O 'er -10' NORTH Distribution Box ■' `€ N Leachfield. approximate layout Driveway 401/2' /17)__________ I b 20" diameter pine with orange reflector 'IL Date: Owner: tNO 9 Plan to Repair �lT '`+ Thomas'I. Leue INC. Septic System 7/24/2014 Patrick Goggins moors. Thomas S. Leue R.S. 671 North Farms Road ;1 ° Jc- Scale: 1 : 20' Revision Date: ,. 72 , • 1664 Cape Sr. Except as Noted Florence, MA 01062 V�e%Oe Ttke Williamsburg,428 4{A(11(196 CONSTRUCTION SPECIFICATIONS 671 North Farms Road, Northampton Title 5 Septic System Plan Number 642 1. General a. No work on this system construction shall take place until a permit for the approved system plan has been received from the local Board of Health. A copy of the Disposal Works Construction Permit should be on site for inspection during the time of construction. Additional specifications may be included elsewhere in this design. b. Loading requirements are specified for the septic tank are designated H-10. c. Alternatives to these specifications should be discussed with the System Designer in advance at 800 285-4533. !. Septic Tank a. The septic tank selected by the contractor shall conform with 310 CMR 15.223. The septic tank shall be a minimum effective liquid capacity of 1,500 gallons below the outlet invert, rectangular,and with a minimum length to width ration of 1.5:1. Liquid depth to be 48". Compartmentalized tanks are not to be used unless required as stated on the plan drawing. b. Septic tank shall be installed on a minimum of 6"of crushed stone, leveled to grade and thoroughly compacted. Septic tanks shall have a minimum cover of 9". No structures shall be located directly upon or above the septic tank access locations which interfere with performance, access, inspection, pumping, or repair. c. All three access covers to the septic tank shall have risers at least 20"diameter, if round,tightly fitted to the tank to resist water infiltration,and terminated with a tight fitting cover no more than 6" below ground surface. If, with the agreement of the Owner, one or more of the risers are terminated flush with ground, these shall be secured against unauthorized entry with stainless steel hardware. d. Inlet and outlet tees shall be of Schedule 40 PVC and shall extend a minimum of 6"above the flow line of the septic tank and be on the center line of the septic tank located directly under the clean-out manhole. Al] fittings to be glued and secured against any movement due to horizontal or vertical impacts. Cross-sectional flow baffles shall not be used as substitutes for inlet or outlet tees. The inlet pipe elevation shall be no less than 2"nor more than 3"above the invert elevation of the outlet pipe. Inlet tee minimum of 10"length below water surface. The outlet shall be provided with a tee extending below the flow line 14"and be equipped with a gas baffle. There shall be an air space of at least 3" between the tops of the tees and the inside of the tank cover. Inlet tees may be modified or a 6"riser on inlet cover may achieve this spacing. The tops of the tees shall be left open to provide ventilation or separate ventilation shall be provided. Final Gradin e a. At conclusion of work, loam and seed all disturbed areas to perennial grass mixture. Added loam may be required for adequate grass growth. Mulch slopes with hay,burlap or netting to minimize erosion. ). Systems built late in the year, where the grass cover does not have a chance to establish itself, requires the contractor is to return after spring thaw and resurface final grades and add grass seed cover as required to equalize and stabilize all disturbed areas. 'omestead Inc. Page 1 7/24/14,