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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owners Name
Mt Prospect II. 60056 4/9-13/09
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.
farm: A. General Information
filling out
on the
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le tab key
re your
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1. Inspector
Tom Martin
Name of Inspector
Turkey Hill Field Services
Company Name
140 Easthampton Rd.
Company
Westhampton
pton ton
Ma
City/Town State
413-527-5311 514199
Telephone Number License Number
01027
Zip Code
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
InspedorsS'gnie
Date
913%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 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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owners Name
Mt Prospect II. 60056 4/9-13/09
City/roam State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) System Passes:
• I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.My failure criteria not evaluated are
indicated below.
Comments:
Pump both sides of dual compartment tank every 3 years at minimum
8) 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 folbwing 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):
Title 5 Offlaal hspecton Fenn Raw Was sewage DIpo. syebn•Pape 2 do
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Properly Address
American Escrow and Closing Company
Owner's Name
1699 Wall St. Suite 700
d for P fn is Mt Prospect II. 60056 4/9-13/09
page. Cdymown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y O N O 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 ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning In a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
The 5 Official bmpxA0n Form'.Sb+lew Swag Disposal System•Page 3 N 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owners Name
Mt Prospect II. 60056 4/9-13/09
Cdy/rown 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 welP•.
Method used to determine distance:
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliiform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
Tess 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
❑ Z Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Z Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ Z Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Z Liquid depth in cesspool is less than 6° below invert or available volume is less
than %day flow
0309 Tale 5 Waal hgSm Form:&DVdae Snips Disposal System•Pape 41117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owner's Name
bon Mt Prospect II. 60056 4/9-13109
age. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ E Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: .
❑ E Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ E
tributary portion to a surface cesspool or
sum is within 100 feet of a surface water supply or
supply.
❑ E Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ E My portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal conform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
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
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 drtnking 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 11 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.
BOB
The 5 Official Inspection Fan.SiZ4wI Sewage DiWOSS System Page 5 al 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fonn -Not for Voluntary Assessments
310 Old Wilson Rd, Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owners Name
Mt Prospect II. 60056 4/9-13/09
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)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design):
not
available
Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
4
not available
4O9 Title 5()Mad mgrlion Form'.Subsurface Sevier'Dbpvd Syfldn•Page 60117
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owner's Name
Mt Prospect II. 60056 4/9-13/09
City/Town State Zip Code Date of Inspection
D. System Information
Description:
Gravity feed system with dual compartment 1500 gal tank feeding to a distribution box with five lines
leading out of distribution box. Stone and pipe leaching bed Please note that the system on file at the
Northampton Board of Health for this address does not correspond to this property. No plan for this
property was available for reference.
Number of current residents: not occupied
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)):
Detail:
Town Water
not available
Sump pump?
Last date of occupancy:
Commerciaillndustrial Flow Conditions:
Type of Establishment
Design flow(based on 310 CMR 15203):
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:
❑ Yes Z No
october 2008
Date
Gallons per day(gpd)
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
-Me Mad Ikon Form:Subsurface Sewage Disposal System•Pne 7 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owners Name
Mt Prospect II. 60056 4/9-13/09
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below):
Date
General Information
❑
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes,volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Owner: pumped once in 2007(No evidence of both
sides of tank being pumped)
1300 gal+/-
goons
size conversion
® Yes ❑ No
5 inch scum layer with potential to block flow to
second compartment of the tank
Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)Of yes,attach previous inspection records, if any)
❑
Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
rho 5 official insoedice ram:&t5&fa a Suer olvemS sytsn•Pape 8 417
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age.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owners Name
Mt Prospect ll. 60056 4/9-13/09
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
installed in 2004/2005
Were sewage odors detected when arriving at the site?
Building Sewer(locate on site plan):
Depth below grade:
Material of construction:
❑cast iron
®40 PVC ❑other(explain):
Distance from private water supply well or suction line:
❑ Yes ® No
5-6'
feet
11'from suction line(town water)
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
no evidence of leakage
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
concrete ❑ metal
4'(risers on inlet and outlet sides)
feet
❑fiberglass ❑ polyethylene ❑other(explain)
2'riser on inlet side of tank.4'riser on the outlet side of tank. Please note that when pumping this
tank one should insist on pumping troth sides of the tank. (Some carryovers present upon inspection)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
10'x 5'x 5'
Dimensions:
Sludge depth:
3 inches inlet side, 1 inch oulet
side
The 5 Official Inspection rorn Subsurface Sewer DisPOSP31 System.Page 9 a117
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owners Name
Mt Prospect II. 60056 4/9-13/09
City/Town State Zip Code Date of Inspedion
D. System Information (cunt.)
Septic Tank(cont)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid levels appropriate. No signs of leadage or infiltration. Structural integrity fine.Inlet and Outlet
tee showed signs of either poor installation or settling resulting in no gap between top of tees and
tank covers. Tees modified in order to insure proper air venting. Tank was pumped as part of this
inspection because of a thick layer of scum in the primary settling side of this dual compartment
tank.Pumping will insure free flow of liquids between the compartment Owner should insist on
pumping both sides of this tank when pumping. Pump at least every three years. More often with
heavy use.
38"
5-6 inches
2 inches(system pumped)
3-4 inches(system pumped)
measured
Grease Trap(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
feet
❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
TAM 5 Official Fpm Font S . lyp Sewage Dual System Page 10 11
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owners Name
Mt Prospect II. 60056 4/9-13/09
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
nee 5 gfcal IssFyclim Form:Subsurface Steeps Disposal syaWn•Page 11 N 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owners Name
Mt Prospect II. 60056 4/9-13/09
City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 1/8" above bottom of owlet invert.Appropriate.
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 level. Box 3.5' below grade. No evidence of carryover. No evidence of leakage into or out of box.
Cover of box sitting flush against the top of the inlet tee. Inlet tee modified to vent air into the box and
the leaching field.
Pump Chamber(locate on site plan):
Pumps in working order:
Alarms in working order
❑ Yes ❑ 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:
N)e Ti tla 5 o1Fos hgatim Fpm Subsurface Swage Dispel System•Papa 12 of 17
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I for
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owner's Name
Mt Prospect II. 60056 4/9-13/09
Cdy/rown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number
❑ leaching chambers number:
❑ leaching galleries number
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No sign of hydraulic failure. No ponding or damp soil. Condition of vegetation normal.
5 lines. 50'x 30'
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
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age.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owner's Name
Mt Prospect II. 60056 4/9-13/09
City/Town Stale 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.):
no rre 5 Orr Form:Subsurface
Sewage uwa System Par uan
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owner's Name
Mt Prospect II. 60056 4/9-13/09
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage deposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate of wells within 100 feet Locate
where public water supply enters the building. Check one of the boxes below:
13 hand-sketch in the area below
drawing attached separately
Title 5 Of ficiaJ hspecton Form:&JUMe Sewage Disposal Sysisn•PCy 15 of 17
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page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owners Name
Mt Prospect II. 60056 4/9-13/09
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Z Check Slope
® Surface water
O Check cellar
❑ Shallow wells
Estimated depth to high ground water
3.8 feet.
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 ktcal Board of Health-explain:
system across the street with deep hole data places ESHGW at 69"M. Macko 12/16/04
❑ Checked with local excavators,installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Deep observation hole dug 40' from the leach field along the same gradient as the leach field. This is
a raised bed leach field. Deep Hole log revealed 20"of fill,a stripped A horizon, 18"of course sand
as a Bw horizon. Parent material also a course sand with Estimated Seasonal Ground Water at 40•
below grade at this location. Please note that this elevation is approximated 4-5 below the bottom of
the this raised bed leach field
Before Ming this Inspection Report,please see Report Completeness Checklist on next page.
O9 raft 5 OII'el hwx8 Foam SubMq
Sewer OigcaY System-Par 16 0117
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nation is
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page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
310 Old Wilson Rd. Northampton, Ma.
Property Address
American Escrow and Closing Company 1699 Wall St. Suite 700
Owner's-Name
Mt Prospect II. 60056 4/9-13/09
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary:A, 13, C, D,or E checked
Z Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
E System Information—Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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