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668 Title 5 Application/Permits, Inspections 2009, 2011 er information is fired for every page. ortarrt:When filling arms on the outer,use only the <ey to move your or-do not use the rn key Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 668 North Farms Road Property Address Sillerman Residential Properties, LP. Owner's Name Northampton MA 01060 6/5/2012 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Thomas S. Leue Name of Inspector Homestead Engineering Inc. Company Name 1664 Cape St. Company Address Williamsburg MA 01096 City/Town State Zip Code 413-628-4533 SI-130 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority hmpeotol s sn‘n itt- 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. S lc„ June 5, 2012 hate ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 OrfioaL Inspection=omm subsurface&wage ovsocrel system.Pagel of IT information is i for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 668 North Farms Road Properly Address Sillerman Residential Properties, LP. Owner's Name 2 201 Northampton MA 01060 6 6/5/2012 of State Zip Code City/Town 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: Distribution box was not located and opened. 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): iNe S Ofliceunspetldn Form Sposortage Sewage Disposal System•P ge 2 m IT Tformation is I for every page Sins ,tlD Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 668 North Farms Road Property Address Sillerman Residential Properties , LP. Owners Name Northampton MA 01060 6 6/5/2012/5/2012 State Zip Code of Inspection City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ ND (Explain below): ❑ ND (Explain below): ❑ ND (Explain below): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ❑ Y ❑Y ON ❑Y ON ❑ The system required pumping more pipe(s). The system will pass inspection ❑ broken pipe(s)are replaced ❑ obstruction is removed 0 than 4 times a year due to broken or obstructed if(with approval of the Board of Health). ❑ Y ❑ N ❑ ND(Explain below): ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(6)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 TRIe 5 Official Inspection Form Subsurface Sewage Disposal System'Page 3 or P nformation is I for every page. 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 668 North Farms Road — Property Address Sillerman Residential Properties, LP. owners Name 2012 Northampton MA 01060 6 6/5//5/2012on State Zip code Ciryftown 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 within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine — distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow The 5 ORicia■mspectmn 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 668 North Farms Road Property Address Rifleman Residential Properties, LP. nformation is Owner's Name Northampton 6/5/2012 l for every page. MA 01060 ns.11110 City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: • 0 ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. 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 DEP analysis.r[fied system t Pa for fecal coliform bacteria yindi indicates absent tand the certified laboratory, 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.] O ® 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or"no"to each of the following, in addition to the questions in Section D. Yes No • ® the system is within 400 feet of a surface drinking water supply • ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. TIe 50Rical Inspection Fo,m.Subsurface Sewage Disposal System.Pages of 17 ntormation Is I for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 668 North Farms Road Property Address Sillerman Residential Properties, LP. Owner's Name Northampton MA 01060 6/5/2012 6 /t2 State Zip Code City/Town 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) As-built plans for leachfield unavailable ® ❑ 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 (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)1 Z ❑ ® ❑ D. System Information Residential Flow Conditions: Number of bedrooms 4 Number of bedrooms (design): (actual): DESIGN flow based on 310 CMR 15.203 (for example. 110 gpd x#of bedrooms): 4 668 gpd Tries Official In for Farm Svorvo-ece Sewage Disposal system.Par 6 of 17 nformation is I for every page. pins nnO Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 668 North Farms Road _Property Address Sillerman Residential Properties , LP. Owner's Name 6/5/2012 Northampton MA 01060 State Zip Code Date of Inspection City/Town D. System Information Description. Standard concrete septic tank, pump chamber, distribution box and leachfield. Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Private well. Sump pump? Cantinnoua Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment. Design flow (based on 310 CMR 15.203): Gallons per day(gpd) 3 ❑ Yes Z No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No N/A ❑ Yes Z No Basis of design flow (seats/persons/sq.ft., etc.): ❑ Yes ❑ No Grease trap present? Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes 0 No The 5 Inspection Form Subsurface Sewage Dsposa,.System.Page]of 17 nformation iS i for every page. ens•1100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 668 North Farms Road Property Address Sillerman Residential Properties , LP. Owners Name 6/5/2012 Northampton State 01060 Code Date of Inspection City Town Water meter readings, if available: D. System Information (cont.) Last date of occupancy/use'. Other(describe below): Pumping Records: Source of information. Was system pumped as part If yes,volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date General Information Pumped in 2005, per previous Title V Report of the inspection? gallons ❑Yes ® No rote s orr�o�ai • Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy • Shared system (yes or no) Of yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to nspection of the I/A syst be from by system operator owner) and a copy of latest under contract ❑ Tight tank. Attach a copy of the DEP approval. Other(describe): ■ specton Form.Subsanaae Singe Disposal System•Pace 8 or is information is i for every page. a,es.11110 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 668 North Farms Road Property Address sillerman Residential Properties, LP. Owners Name 6/5/2012 Northampton _ MA 01060 Date of Inspection State Zip Code City/Town D. System Information (cont) Approximate age of all components, date installed (if known) and source of information. Plan for leachfield replacement dated 8/16/04, replaced in 2005. Were sewage odors detected when arriving at the site? Oyes ® No Building Sewer(locate on site plan): Depth below grade: Material of construction. ❑ cast iron ❑ 40 PVC ® other(explain): Distance from private water supply well or suction line: 2.16 feet ABS plastic 26 ft. feet Comments (on condition of joints,venting, evidence of leakage, etc.): Located under cement floor. No problems seen. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 4 average feet If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) 60" tall, 126" long, 58" Dimensions: wide _ Tile 5 Off al I aspetlwa Form sunsmraze Sewage Disposal system.Page 9 of17 information is d for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 668 North Farms Road Property Address Sillerman Residential Properties LP. Owner's Name MA _ 01060 6/5/2012 Northampton State Zip Code Date of Inspection City/Town wn 6" Sludge depth: D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or 29 " 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 25" baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank structur ally okay. Inlet tee had fallen off and was observed floatin g in tank. N -b'odearadable materials (towels bserved in tank. Four inch riser over inlet cover. 24" riser over outlet. Outlet filter removed, rinsed, and re•laced. Tank is a roachin• need for pumping. Grease Trap (locate on site plan): Depth below grade: Material of construction: other ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene (explain): 3" calculated feet 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 Ties Off ml I spec oo Form Subsurface Sew2QC Disposal System•Page to of 17 information is d for every page mna.nno Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 668 North Farms Road Property Address Sillerman Residential Properties, LP. Owners Name Northampton City/Town MA 01060 6/5/2012 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: other El❑ polyethylene (explain). ❑ concrete ❑ metal ❑fiberglass Dimensions: Capacity: gallons Design Flow: gallons per day D Yes El No Alarm present Alarm in working order. ❑ Yes El No Alarm level: — 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 Talks Official I nspecllon Forth SubmRace Sewage Disysal%stem•Page non l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 668 North Farms Road Property Address Sillerman Residential Properties, LP. for every page. Northam ton MA formation is Owners Name 01060 6/5/2012 State Zip Code Date of Inspection thins 11110 City/Town 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, etbut unable to determine Distribution box indicated on site plan_ exact location. Distribution boxes and leach£ields for all three houses in subdivision are ad acent to one another. No Location information available throu gh Northampton Board of Health, owner, or desi ngineer. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ® Yes ® Yes ❑ No ❑ No Li•uid level in •um• chamber a ears ••r o• Alarm function verified. Pump op ration could not be initiated manually for unknown reasons. a fate. Dual • u • s in tank_ Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: House is •2 a three-house subdivision. This s stem is d signated as Par rcel 2.. Leachfields for all three houses are adac ent to one another. to distribution box available. Risk of of of dama•e too ch d No eat to ties warrant excavation. mis 5 OPiaxi Inspection roam Sbburace Se wage D.spaml System•Page 12 on9 formation is for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 668 North Farms Road Property Address Sillerman Residential Properties LP. Owner's Name 01060 6/5/2012 Northam ton State Zip Code Date of Inspection City/Town D. System Information (cont.) Type: ❑ leaching pits number. ❑ leaching chambers number • leaching galleries number: ❑ number, length: leaching trenches number, 42'x 30' ® leaching fields dimensions: ❑ number: overflow cesspool ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No surface problems seen in three-home leachfield area System vented. Due and construction materials, no uroble likely. System >so over i n flow. 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 1Ne 5ORinai Inspection Form Subsurface Sewage Disposal System.Par 13 of 7 iformation is for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 668 North Farms Road Property Address Sillerman Residential Properties, LP. Owner's Name Northampton MA 01060 6/5/2012 City/Town State Zip Code Date of Inspection Indication of groundwater inflow ❑ Yes ❑ No D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)'. Title s ORael Inspection Form Suownace Sewage Disposal System.Page 14 of 1/ formation Is forever)?page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 668 North Farms Road Property Address Sillerman Residential Properties, LP. Owner's Name Northampton MA 01060 6/5/2012 City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately Title s Official Inspection Fo,m Subsurface Sewage Disposal System•cage 15 of n formation is for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 668 North Farms Road Property Address Sillerman Residential Properties, LP. Owner's Name /2012 Northampton MA 01060 6 6/5/5 Inspection 012 City/Town State Zip Code D. System Information (cont) Site Exam: Z Check Slope Z Surface water ❑ Check cellar ❑ Shallow wells 6+ ft Estimated depth to high ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record April 15, 2004 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: Built to current code. Tie 5 Official Inspection Fount Subsurface Sewage Disposal System.Gage 16 of 17 formation Is for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 668 North Farms Road Property Address Sillerman Residential Properties, LP. Owner's Name Northampton MA 01060 6 6/5/5/ 012 Inspection City/Town State Zip Code Before filing this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist Z Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed El System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official inspection Fair^Subs, ace ge Disposal System•Page^/of 4 House Outline B COMMENTS: A" e Recommend pumping on a 3 to 5 Distances 66 ft. 86 ft. year schedule . Also, a copy of an this plan posted in the 66 ft. 90 86 ft ft. basement/utility area would keep "D 872ft ft 1/ f this information accessible in A future years for maintenance. porch Sp Well Septic Tank C p Pump Tank To leachtield, E distance unknown` Y 1N OFYAS�c LIONIESI r INC. Date: Owner: �'J' HG a� ng Septic S st 6/5/2012 Sillerman Properties, LP. r� TMoan�s "a Thomas S Leuc R.S. Cxist,ng Sep IL .3.S cn, (o LEU� 668 North Farms Road% Revision Dater y < S T� 11511ion L,r�,r kl/t. O9b Scale 1 : 20' Florence, MA 01062 Seisrreeo s*�a� 14131 6284511 MA( Except as Noted e ct Sw'w C !17 i SYSTEM FOR PARCEL 3 SYSTEM FOR PARCEL VENT PIPE I VENT PIPE PARCEL 1 SYSTEM FOR PARCEL 1 • VENT PIPE SYSTEM TIES LOCATION OF SEPTIC TANK : A-C=57.5" : B-C=54.5" LOCATION OF PUMP TANK A-D=46.0" : B-D=48.5' LOCATION OF "D-BOX" E-G=76.5" : F-G=96.0" SCALE: F — A18621.39 Il,,es� v�s reef' Vc' LA--1X- C / s ) Z 650 NORTH FARMS ROAD AS-BUILT PLAN OF SEWAGE DISPOSAL SYSTEM IN NORTHAMPTON, MASSACHUSETTS SURVEYED FOR SWEET MEADOW PROPERTIES, LLC PUMP TANK stA SEPTIC TANK 921.65 1� = 30' DATE: APRIL 15, 2004 JOB 9 HERITAGE SURVEYS, INC. REGISTERED CO EGEP HIGHWAY &PROFESSIONAL LAND STREET POST OFFICE BOX I SOUTHAMPTON, M S A000SETTS (413) 4467-010404 DWG tl 4467WR02 MAP 4467- 0415 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 668 North Farms Road Owner' Name: Alexander Janke City/Town: Northampton, MA 01060 Date of Inspection: 11/2/09 B. Certification (cont.) 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. 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: 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 leveled or replaced ND explain: N The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND 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: 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. T5 Revised dog• 12/07 Title 5 Official Inspection Form:Subsurface Disposal System•Page 2 of 9 ter motion is sired for y page inspection restms must oe suominea on tnis form. inspection forms may not oe anerea in any way. Owner Address: 668 N. Farms Rd. Florence MA 01062 Copy to: Board of Health Northampton. Goggins Real Estate Witness: Homestead Inc.#: ssos-1374 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 668 North Farms Road Owner' Name: Alexander Janko City/Town: Northampton MA 01060 Date of Inspection: 11/2/09 A. General Information 1 Inspector'. Name of Inspector: Thomas S. Leue R.S. Company Name: Homestead Inc. Company Address: 1664 Cape St. , Williamsburg MA 01096 Telephone Number: ( 413) 628-4533 License Number. SI130 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 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: Date: 11/2/09 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 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. svised.doc•12/07 Title 5 Official Inspection Form:Subsurface Disposal System•Page 1 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 668 North Farms Road Owner Owner' Name: Alexander Janko information is required for City/Town: Northampton every page. P MA 01060 Date of Inspection: 11 2 9 B. Certification (cont.) 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. For large systems, you must indicate either YES (Y)or NO(N) as to each of the following, in addition to the questions in Section D. 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 ll 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. C. Checklist Check if the following have been done. You must indicate YES (Y)or NO (N)as to each of the following: 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? N/A Were "as-built" plans of the system obtained and examined? (If 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 scum? Y 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: Y Existing information. For example, a plan at the Board of Health. N Determined in the field Of any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR15.302(5)]. T5 Revised.doc• 12/07 Title 5 Official Inspection Form:Subsurface Disposal System•Page 4 of 9 ner rmation is sired for ry page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 668 North Farms Road Owner' Name: Alexander Janko City/Town: Northampton, MA 01060 Date of Inspection: 11/2/09 Certification (cont.) System will fail unless Board of Health (and Public Water Supplier, if any)determines that the system unctioning 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 :er 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 ter supply well"Method used to determine distance This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria licates absent and the presence of ammonia nitrogen tr n ed r to nitrogen n this form. is equal less than 5 ppm, provided of the analysis no other failure criteria are triggered. A copy Y Other: System Failure Criteria Applicable to All Systems: �u tasA indicate either YES (Y) or NO (N) as to each of the following for all inspections: 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 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 fecal coliform bacteria indicates aent an at the other fcelufeammo ammonia are of nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided triggered.A copy of the analysis must be attached to this form.] N The system is a cesspool serving a facility with a design flow of 2000 gpd-10,000 gpd. N The system fails: I have determined that one or more of the above failure criteria exist as defined in 310 CM 15.303, 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. COMMENT .vised.doc•12/07 Title 5 Official Inspection Form:Subsurface Disposal System•Page 3 of 9 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address 668 North Farms Road Owner Name: Alexander Janko City/Town: Northampton, MA 01060 Date of Inspection: 11/2S9 D. System Information (cont.) Approximate Age: All components, date installed, and source of info. ISSeptic plan: plan dated 8/16/04, built spring 2005 - -N - Were sewage odors detected when arriving at the site (Y or N) ,Building Sewer: 26 I _ABS—plastic 26 Comments: I Septic Tank: 40+ Concrete (locate on site plan) Depth below grade (inches) Material of Construction Distance in feet from private water supply well or suction line No problems seen. Under floor. (locate on site plan) Depth below grade (inches) Materials f C Estimated Average 0 onstruction - - -. - - - If tank is metal, list age • 44 Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) Riser depth 1-- _ - - - -- (inches) I- - - 5 _ - - _Septic tank width _ 126 Septic tank length 60 _ -Septic tank height I 1,903 Calculated gross volume I 5 - I- - - Air space in tank L 1,700 _Net Volume - -_ _26 - _ Baffle depth I 5 - Sludge thickness r 29 Top Sludge : Bottom Baffle r I - - 2 Scum thickness L 20 Bottom Scum : Bottom Baffle 2 Top Scum : Top Baffle I Measured i - _How were dimensions determined? Comments: Comments: (inches) (inches) (inches) (gallons) (inches) (gallons) (inches) (inches) (inches) (inches) (inches) (inches) Interior dimensions Interior dimensions Interior dimensions al ul to Calculated Average Calculated Average Calculated Calculated '[Outlet filter was clogged so extra liquid in tank. Cleaned. Some non-biodegradable_materials (towels) should not be disposed in tar (Risers to suface over outlet. Inlet too deep to dig (over 60" depth) . 'Recommendations: - - - --- -- - - 'Pump on 3 to 4 year interval. Pump soon. 15 Revised doe• 12/07 Title 5 Official Inspection Form:Subsurface Disposal System•Page 6 of 9 wner formation is quired for iery page. ystem n ormation iidential Flow Conditions: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 668 North Farms Road Owner' Name: Alexander Janko City/Town: Northampton MA 01060 Date of Inspection: 11/2/09 4 _ _ Number of bedrooms (design) 4 _ Number of bedrooms(actual) 668 _ _ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#bedrooms) 3 I Number of current residents _ N i Does residence have a garbage grinder? N _ Is the Laundry a separate system? [If yes, separate inspection required] N Laundry system inspected? N Seasonal use? N/A ! Water meter readings, if available(last 2 years usage) (gallons per day) N ! Sump Pump? _ continuous Last date of occupancy= )MMERCIALIIN D USTRIAL 'pe of establishment: :sign flow(based on 310 CMR 15.203): = gpd asis of design flow(seats/persons/sift, etc.): rease trap present? _ dustrial waste holding tank present? _ on-sanitary waste discharge to the Title 5 system? _ later meter readings, if available: _ ast date of occupancy/use: _ ITHER (describe): — General Information 'umping Records: Source of information. Not pre viousl o 1, says owner 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: Purrs on to 4 ear interval. Type of System: X_ Septic tank, distribution box, soil adsorption system Single cesspool _ Overflow cesspool Privy pJ 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): = Title 5 Official Inspection Form:Subsurface Disposal System•Page 5 of 9 T5 Revised doc• 12/07 Commonwealth of Massachusetts b Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 668 North Farms Road Owner Information is required for every page. Owner' Name: City/Town: ys em n orma on (cont.) Distribution Box: Of present must be opened) - -- - -- - - -- (locate on site plan)D-box part of septic system? ("D-box') Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence o evidence carryover, and out of D-box, etc. D-box not located. Alexander Northam ton 1 D p Date of Inspection: 11/1[03 Pump Chamber: (locate on site plan) Pump part of septic system? Y 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.): 'Dual_ pump system in lead-lag configuration. Pumps exercised. Cesspools: (cesspool must be pumped as part of inspection) (locate on site plan) Cesspool part of system? 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 Comments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy: (locate on site plan) Privy part of system? Materials of construction: Dimensions: Depth of solids: .Comments: (soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Site Exam: y ((Source of Information) Check Slope - --- - Surface water Official Perc Date _ 8/16/04 Official Plan Date Check Cellar _----- Shallow wells - - - -- - - Other Official Source 60+_ _ Estimated depth to ground water -- Other Source Please indicate all the methods used to determine high groundwater elevations) nche • Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of f Health-explain: Y------_ _ _ Checked with local excavators, installers-explain: ou must describe how you established the high ground water elevation: 'Area built up to conform to current code reguirements._ As-built drawings not available either from the Owner or Board of healt T5 Revised.doc• 12/07 Title 5 Official Inspection Form.Subsurface Disposal System•Page 8 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: °North Farms Road er Owner' Name: Alexander erJanko motion is Northampton MA 01060 Date of Inspection: 11 2 09 I'nation City/Town: y page. ystem n ormation (cont.) rease Trap: (Usually present in certain commercial systems) Grease Trap part of system? Depth below grade (inches) Materials of construction: _ Dimensions: A race Scum thickness (inches) _ _—. - - - -- C bated Inches — -Top of scum to lop outlet tee 1 1 t d Inches Bottom of scum to bottom of outlet tee W red Date of last pumping iomments condition Tight or Holding Tank: (tank must be pumped at time of inspection) N _ Tight tank part of system? Maur d - _Depth below grade (inches) Materials of construction ___ _Tank length (inches) Tank width Capacity (gallons) _ _ Tank height - - - - Design flow: gallons/day I __ Alarm Level (inches) L L—.— — _Alarms in working order? ___ Date of last pumping /!Comments: (condition of alarm and float switches, etc.) L Mach copy of current pumping contract(required). Is copy attached? Soil Absorption System (SAS): (locate on site plan, excavation not required): If SAS not located 'explain why: -- - ---_. - .--- _. _. leaching pits& number: -- -- - -- ---leaching chambers and number: _ __-- ------ -- -- - - leaching galleries and number: _ _ - - ---- - ----- - - - - - _ leaching trenches, number, length: Y leaching fields, number, dimensions: 18 ' x 50 '_ oveoW cesspool number: --- - ----- -- -- _ innovative/alternative system,Type: 'Comments: (note soil condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc) !Field area clean and dry. No breakout or other problems. No as-built drawing makes location of d-box very drf ficult - _ -. !System vented, but d-box not located. Due to age and ''construction details, no problems are likely. Title 5 Official Inspection Forth:Subsurface Disposal System•Page 7 of 9 T5 Revised doe• 12/07 4 1 I 0 1 r 1 1 House Outline 1 1 131 COMMENTS: I g Recommend pumping on a 3 to of Distances _ _ °A��. - year schedule. Also, a copy o£ I-- _ - _66 ft. 1 _ 86 ft. bass entn tility an the_ 72 ft. 1 901/2 ft - D _ basement/utility area would keep_ 11 I — -. - i _-. - _ _ Al I 1 - -- E 84 1/2 ft. 100 ft. 1 this information accessible in 1L _ -- _ _ -- - - , 84 1/2 future ears for maintenance. 1 - porch Well Septic Tank or oD Pump Tank E Date: Owner: e40 Cr w8 <y HOMESTEAD INC. As-Built ng Drawing System 1112109 Alexander Janko ,i TMoNnes, : Thomas S. Leue R.S. [,Existing Septic System id S LEUEy 668 North Farms Ro �� z 1664 Cape St. Revision Date: y fre. e`er Williamsburg,1664 Ca MA W096 Except i :Noted S Florence, MA 01062 f��h'RFO 5��\`! 14131 628-4533 Except as Noted ' D LO c)',,.:pii,1*, PA) T Cc G6 (dis r 71 O.Err, DES r'j %i T li� ' oiS i c a / 5 • o,t,. I 1 GROvno V14-c6 4 ! .tiCA', /p ' GP,;.,, t , , 4 .. ' • IL �Nu ica . SA�D9 ii.. G2w,;> e; A TEC /b'cc 1 No._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF �HEAL�TH /// CITY OF L lefd/\ M4)11, ATI Application for linpnsul Marko Cnnnotrnr#inn Fermi# Application is hereby made fty Permit to Construct Cie) or Repair ( ) an Individual Sewage Disposal System at fell/ in/2/7 f ---'fr,Q1c cowe .6.441..1 e 130 sL / 12 Location Installer Type of Building Dwelling—No. of Bedrooms Other—Type of Building No. of persons Other Ttufes Design Flow L.J.J gad' Septic Tan qwd capacir O(all Disposal �No. � Wilt or A No.. v/2j4 J ess Address L /0/98 2645 �//Size Lot... q Expansion Attic ( go Garbage Grinder Showers ( ) — Cafeteria o s per person pe day. Total daily flow � ..-7-.Q gals. ength Lh Wid p .o Total Length Seepage Pit No Diameter Depth ow in Other Distribution box (,<) Dosing Percolation Test Result; y Performed by o! Test Pit No. I ..minutes per inch Depth of Test Pit afnutes per inch Depth of Test Pit Diameter Depth_._. Doe.... Total leaching area 4iReei q. ftftl' ' Total leaching area sq. ft.et , xM 4'26% ,l� ' ?r° eq y Date r ,r6:16.. Depth t6 ground water_oet eff2x-'_A-T Depth to ground water 2/4 / Test Pit No. 2 Description of Soil.&44tt-.%/..G.:G.- - 41,0-8 "s e44-C At/a- t, 4Rr 24tria . Nature of Repairs or Alterations—Answer when applicable Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLD 5 of the State Sa de—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has keen i sued b tie b ?Signed. Application Approved By rd of health. d Application Disapproved for the following reasons. IS- 7E Permit No Date Date Date Issued_ Daze D/-30 /t-y 0 75 ' OFF..t COMMONWEALTH OF MASSACAUSETTS a - � Board of Health, ALI- DISPOSAL SYSIEM CON RUCIION PERMIT emission is hereby granted to; ConstruciA RR pair( )/ Upgrra-dee(( ) Abandon( ) an individual sewage disposal system 'D f ta NO2`� �I-441A /C I #�(//0) as described in the application for sposal System Construction Permit No. Q7 30.dated fa' ovided: Construction shall be completed witlei i three mars of the date of the- it. 1 I cal con to must he met. 71255 Rev 5/96 AM Swam Co Boston MA Date 7)-' — 0 oard of Health