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112 Septic Inspection 2016 mer =alien is luired for every 3e- portant:When ng out forms the computer, r only the tab f to move your sor-do not the return Ina.3)13 02/6 Wok: j D Commonwealth of Massachusetts rep kc ec Title 5 Official Inspection Form g6Y6 Ve/41 #> Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vk.• �0 112 Chesterfield Road / Property Address Bob Shrader Owner's Name Northampton (Leeds) City/Town MA 01053 7/21/2016 8 08.12.2016 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: Alan Weiss Name of Inspector Cold Spring Environmental Consultants, Inc. Company Name 350 Old Enfield Road Company Address Beichertown MA 01007 City/Town State Zip Code 413-323-5957 Telephone Numbe Registered Sanitarian #933 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 7/21/2016 8 8/12/2016 Inspector. ignature 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. title 5 Official Inspection Form.Subsurface sewage Disposal System•Page 1 of 17 er mation is 'red for every Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 112 Chesterfield Road Property Address Bob Shrader Owner's Name Northampton (Leeds) MA 01053 7/21/2016& 08.12.2016 City/rown 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: E I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system consisted of a 1,000 gallon concrete septic tank, a distibution box and three leach lines serving a 4 bedroom dwelling. Liquid levels in the septic tank were below the outlet invert indicating leakage, and a hole was noted in the tank sidewall. The septic tank was repaced with a new 1,500 gallon concrete tank. The distribution box was level and in good condition with equal flow to the outlets. The system passes following tank replacement. 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): The tank has been replaced as discussed with the Health Department and a permit has been attached. ins 3tl3 Title 5 orcival Inspection Form Subsurface Sewage Disposal System Pe9e 2 et 17 nation is red for every ms'vl3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 112 Chesterfield Road Property Address Bob Shrader Owners Name Northampton (Leeds) MA 01053 7/21/2016 8 08.12.2016 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 E Y E I N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y E N D 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 [' YEN ❑ 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 Title 5 Onioal Inspection Form Subsurface Sewage Disposal System.Page 3 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 112 Chesterfield Road Property Address Bob Shrader Owners Name ation is Northampton (Leeds) MA 01053 7/21/2016 &08.12.2016 td far every City/Town State Zip Code Date of Inspection ins.3113 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: 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 MS 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 Title 5 Official Inspection Form subsunace Sewage Disposal System•Page 4 of v L\ Commonwealth of Massachusetts 1 FmTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 112 Chesterfield Road Property Address Bob Shrader Owner's Name di is fo Northampton (Leeds) MA 01053 7/21/2016 &08.12.2016 tl for every CilylTOwn State Zip Code Date of Inspection B. Certification (cont.) 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. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis- [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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. ❑ Z ❑ Z Title 5 Official Inspector'Form Subsurf ace Sewage Disposal System•Page 5 of IT ins 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Chesterfield Road Property Address Bob Shrader _— ------ Owner'sName --_-- Mq 01053 7/2112016806_12.2016__ rery Northampton Leeds) __------ StAe 01 Code Date/2016ecti0 Cy/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 Were as built plans of the system obtained and examined? (If they were not inspection? 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 dimensions, depth of liquid, depth obaffles udge and depth of scum?construction, Was the facility owner (and occupants if different from owner)provided with ® ❑ information on the proper maintenance of subsurface sewage disposal ssystems? The size and location of the Soil Absorption System(SAS)on the been determined based on'. plan at the Board of Health. ® ❑ Existing information. For example, a p Determined in the field (if any of the failure criteria MR 15.3o Part C is at issue ® ❑ approximation of distance is unacceptable) [ D. System Information Residential Flow Conditions: Number of bedrooms (actual). Unknown Number of bedrooms (design). DESIGN flow based on 310 CMR 15.203(for example. 110 gpd x#of bedrooms). 4 Unknown Title 5 OKmial Inspection Form:Subsurface Sewage Disposal SrMMem•Pages of 17 Commonwealth of Massachusetts Official Inspection Form Title 5 Assessments Subsurface Sewage Disposal System Form -Not for Voluntary 112 Chesterfield Road ___----- -__ Property Address --- Bob Shrader ------ 712112016&06.12.2016 Owner's Name MA 01053 01 01053 7/2112 16ecti0n Northampton deeds -- State ary City/Town D. System Information Description. The septic system consists of one 1,000 gallon septic tank, a distribution box and a three line leachfield_The tank has been replaced with a new 1,500 gallon tan .____------ 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: ----- Laundry_was connected to main system ----- 2 ---- Yes E No p Yes E No 0 Yes ❑ No Yes E No ❑ Yes E No Sump pump? Current_ Last date of occupancy: bate Commercial/Industrial Flow Conditions: Type of Establishment -- Design flow(based on 310 CMR 15.203). Gallons per day(god) Basis of design flow(seatslpersonslsg H., etc.). Yes ❑ No Grease trap present? L Yes ❑ No Industrial waste holding tank present? 0 Yes ❑ No Non-sanitary waste discharged to the Title 5 system? Water meter readings, if available, C;q,Form.subsurf ace Sewage Disposal system'Page 7 of fl Title 5 Official mzpe m•3113 Commonwealth of Massachusetts Official Inspection Form Title 5 Assessments Subsurface Sewage Disposal System Form -Not for Voluntary 112 Chesterfield Road--—------------ - Property Address Bob Shrader ------ _ 01053 712112016&08.12201 Owner's Name MA —- Inspection ---- Date of Nodhampton Leedsl ----------- state Zip Code y GityROwn D. System Information (cont.) --------------- Date Last date of occupancyluse: Other(describe below): General Information Pumping Records: Pumped severalyearsa_go__ ----------- Source of information: ® Yes ❑ No Was system pumped as part of the inspection? 1,000 —— If gallons es, volume pumped: ------ y Measured____ _----------- How was quantity pumped determined? -- InsQection -------- Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool O Privy previous inspection records, if any) ❑ Shared system (yes or no) (if yes, attach p Attach a copy of the current operation of latest ❑ maintenance Innovative/Alternative contract(to be obtained ai esyst system ow owner) and inspection of the 11A system by system rop sysem der contract r) trac a copy Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): .3113 Tale S Official aspetllen Form.subsurf ace Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts on Form Title 5 Official Inspection Subsurface Sewage Disposal System Form - 112 Chesterfield Road _____—--- - - - Property Address hrader ---- 712112016&08.12.201__ Bob Shrader —-------- _ MA __ 01053 — N�hs Name -nate of Inspection ampton[Leeds) ----- State Zip Code city/Town D. System Information (cont.) e of all components, date installed(if known) and source of information. Approximate age The septic system is more than 30 years old.___ _—--- Were sewage odors detected when arriving at the site? Yes � No Building Sewer(locate on site plan). is'3113 2 feet Depth below grade: Material of construction: 40 PVC ❑other(explain) ❑cast iron 10' !_ I well or suction line'. feet Distance from private water supply Comments (on condition of joints,venting, evidence of leakage, etc.): The building sewer was in_good condition with no evidence of leakage, Septic Tank(locate on site plan): Depth below grade: Material of construction: other(explain) metal fiberglass ❑ polyethylene ®concrete place.The The 1,000 gallon concrete tank was in poor condition and leaking. Liquid levels were below the outlet invert with no evidence of high staining tngsaindtno co rrosion noted. Concrete outlet baffles in p new 1500 gallon tank had new_p 1.5 feet years If tank is metal, list age: Yes ❑ No Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 85 x4.5'x 42'__—------ Dimensions: 24„----- -- Sludge depth: TAM 5 Of¢ial Insp9Glon Form Subsurface Sewage Disposal System.Page 9 of O Commonwealth of Massachusetts Form Title 5 Official Inspection Noor luntary Assessments Subsurface Sewage Disposal System Form- 112 Chesterfield Road Property Address ------ Bob Shrader___ __----- 01 Owners Name ------ Date of Inspection ton(Leeds)_ - State Zip Code Northamp_ _ _--- 053 712112016 &08.12. MA - cavRewn D. System Information (cont.) Septic Tank(cant.) 12^_ ______------ Distance from top of sludge to bottom of outlet tee or baffle Scum thickness of scum to top of outlet tee or bathe Distance from top 8"_____------------ Distance from bottom of scum to bottom of outlet tee or baffle Measured Comments were dimensions p determined?com structural integrity, recommendations, inlet and outlet tee baffle condition, Commeves(on pumping liquid levels as related in to p outlet invert,with evidence of leakage, leakage below the outlet invert with no evidence of h staining_____----------_ The septic tank was in poor condition with evidence of leakage and some corrosion. Liquid levels (locate on ). Grease Trap ( site plan _ ------- Depth below grade'. feel Material of construction: (explain): ❑ metal ❑fiberglass ❑ polyethylene ❑ ❑ concrete 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 TTe 5 OPooat.nspeGioo For Subsorleo Sewage DISPOS System Page 10 ofn ;ommonwealth of Massachusetts ectlo Form title 5 Official Inspm tiorn Voluntary Assessments e Disposal System subsurface Sewage 112 Chesterfield Roa Property Address ____ _—--------- 01053 712112016&08_14,2016—— No hampt Shrader_ edsi ---- _ Date of Inspection MA _ Owner's Name - State Zip Code Northampton¢eedsZ _--------- c�ivrrow" cont.) System Information ( structural integrity, D. Co inlet and outlet tee or bathe condition, d recommendations,invert, evidence of leakage, etc.): Comments (on pumping liquid levels as related to outlet invert, —----------- locate on site plan): at time of inspection) (locate - - Tank(tank must be pumped - - - —_ Tight or Holding _ Depth below grade: 0 Material o re of metal construction: 0 fiberglass ❑ polyethylene other(explain). concrete --------- Dimensions: __ ____—---------- gallons Capacity: gallons per day Design Flow: Yes ❑ No Alarm present: Yes ❑ No Alarm in working order. Alarm level. Date Date of last pumping. Comments(condition of alarm and float switches, etc.): attached? ❑ Yes ❑ No Attach copy of current pumping contract(required). Is copy TS s OXlual Inspection Form suosunace sewage Disposal system'Page 1t of 17 is 3113 ommonwealth of Massachusetts eCtO Form title 5 Official Insp Not Voluntary Assessments e Disposal System Form- subsurface Sewage __—---------- 112 Chesterfield_Road _ Property Address _-------___ Bob Sg Owner's Name Nodham o n (Leeds)--- ------ MA — 01053_ 712112016&08 _12201 City/Town State Zip code Date of nspOCtiCfl ——-of D. System Information (cont.) (if present must be opened)(locate on site plan). Distribution Box( P Outlet Inverts____ —----------- Depth of liq(note level above outlet invert distribution evidence of solids carryover, any Comments(note if box is level and disc to outlets equal, any no high stainin The box was found to be level and d evidence of leakage into or out of box, P Distribution box was re laced in 199__—__-- - - - Pump Chamber(locate on site plan): ❑ Yes No' Pumps in working order. Q Yes ❑ No. order. appurtenances, etc.):in working condition of pumps and app pump chamber, Comments(note condition of p - - 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 wbY: reties°meal InspectLon Gam.subsurface Sewage puposal System•Page 12 of 17 mmonwealth of Massachusetts Inspection form Insp r itie 5 Official System For bsurface Sewage Disposal Sy m-Not for Voluntary Assessments 2 Chesterfield Road _------------- -- —----- - —_---____ .122016 712112016 &OB_ —-- �, System Information (cont.) sporty Address MA 01053 ----Inspection DI)Shradar___—----—— — Date of wnels Name ate Zip Code lodhamgton �Leeds)_----------- state '.ityROwn t. Type ❑ leaching pits ❑ leaching chambers leaching galleries ❑ leaching trenches leaching fields ❑ overflow cesspool Innovativelalternative system Typelname of technology. Comments (note condition of soil,signs of by No high staining, p etc. soil or impacted vegetation were observed. vegetation, ) onding, damp hydraulic failure was note ,__—------ number. number: number. number, length. number, dimensions number. 31ine 18 x35'!(- draulic failure, level of ponding, damp soil, condition of No evidence of pumped as part of inspection) (locate on site plan): Cesspools (cesspool must be pump Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of w nstruction Yes ❑ No 0 Indication of groundwater inflow ttje S altC I Inspection ionForm.subsorlaCe Sewage nlsWSaS System•P8ge 13 e117 •3113 itie 5aOff Massachusetts ection Form Itie Disposal System Form-Not for Voluntary Assessments bsurface Sewa9 -- 2 Chesterfield Road ------ opertY Address OB 12 2016 hrader 01053 _ ZL?h?01 — = o 8 ——— MA -Cate of inspection '0)TO Name ate- Zip Code ton Leeds - State amp � � -------- -- °"'" (cont.) vegetation, System Information ( suet of ponding, condition of veg ). Co signs of hydraulic failure, Comments (note condition of soil, 9 —_—---- etc.): ---------------- Privy (locate on site plan): Materials of construction: Dimensions ———----------—-- ----�--_-�vegetation, sins of hydraulic failure, level of ponding, condition o Depth of solids Comments (note condition of soil, 9 etc.): -------------- Title s ORiaaunspecnon Farr:subsurface$a+'age Disposal system'Page 14 a 17 •3M 3 nmonwealth of Massachusetts Itle 5 Official Inspection Form orVolunrtaryAssessments e Disposal System _-- 'surface Sewage __--------- 2 Chesterfield_Road _——- ----- ipedyAddress 01053 — 712112016 &08122016___ o hampt r ———-------- _ Date/2016 &Inspection of MA ryriownl e State Zip Code orthampton{_Leeds) —------—— ;tyrtown stem, including ties to ). System Information (Cont.) e disposal system,Sketch least Of o permanent a Disposal ence landmarks provide a view of mar sewage Locate least two P I enters the building. Check one of the boxes below. eage Dist reference landmarks or benchmarks. Locate all wells within , in feet. ties where public water supply 0 hand-sketch in the area bellow ® drawing attached separat .3113 Title 50Riaal Inspection Form.SuGSUnace Sewage Disposal System'Pads 15 of 9 nmonwealth of Massachusetts Inspection Form tsurface Sewage Disposal SY ue 5 Offispa stem Form-Not for Voluntary Assessments Chesterfield Road_ perry Address - -- —— g 0812.2016 01053 _ 712112016 _ ----- b Shrader ——---- —— MA Date of Inspection Tiers yITo Name — State Zip Code ----- _ton jLeedsl —------- tYlTdwn ). System Information (cont.) Site Exam. Check Slope ❑ Surface water Check cellar ❑ Shallow wells 5+- eet 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 ❑ 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: - - Previous 1997 Title V Report. ____—------- Checked with local excavators, installers- (attach documentation) 0❑ Accessed USGS database-explain: You must describe how you established the high ground water M1 elevation: g groundwater in area Work in area,toporaphY.BOH records and no evidence of hl-------- -______----- ection Report,please see Report Completeness Checklist on next pa Before filing this Insp ge. Gam.Subsunace Sewage olspoes system'Page 16 0117 rnla s Off ineveao� 3113• Imonwealth of Massachusetts Inspection Form tle 5 Official Inspecti for Voluntary Assessments e Disposal System surface Sewag Chesterfield Road _------ --- -- _-_- tertY Address —---MA - &08.12,2_016______ 01053 _ _ 712112016 _-- Shreds( —_---- -- ————— Date 2 msP&of ner's Name State Zip Code rtthampton (Leeds' _-------- ,.. yllosin Report Checklist . Repot Come ® Inspection Summary: 6 C, D, or E checked stems) completed ® Inspection Summary D (System Failure Criteria App licable to All Sy Estimated depth to high groundwater ® System Sketch offse anon- 15 or attached in separate file ® Sketch of Sewage Disposal System either drawn on page Title s Official Inspection Form.Sumueace Sewage Disposal System•Par v d 17 •311] THE COMMONVVEALTH OF MASSACHUSETTS F HEALTH OARD onstrurtion et? OF zr Ningtratiuti -fur Dispo5al U �ttt CO on is hereby made fin Construct • ••.... . ........... Oda—. ......... ............ .... Locati011, Ada .. . :tartest . ..................................................... .....----........ ilditlE S1EC t,stalky aurrzsz ng—No. of Bedroornv. ........ . ............ ........Expansion Attic ( ) Garbage Grinder ( ) —Type of Building .. ....... ............. No. oi venom__........ ... Showchz ( ) — Cafeteria ( ) Other natures ••.. .. ........ . ........_.......L._ . . .......... . .. ........ ...................... ....... ow........................................_gallons per person per dai. Total daily dew.............. .. .... .... pato" nk—Lignid opacity_____.....gallons Length..... \V idth .... .... 1 Rinieter.. ...... . ..Demi. .... trench- No __. ... . .Width„........... Total Length_................. 'fetal leaching arM.•... ... .. --art. it. PitNo. ............. Diameter ...._....... Depth below inlet.... ..............Total leziching arezz.... . ..... .sq. it on Test Results Performed by • .... ................. ....__..... .... _.... stribution box ( ) Dosing tank ( ) Date t Pn Nu. 1..... _minutes per inch Depth of Teri Pit............. Depth to ground wider........... • \ lIttS per inch Depth ............. .................. ......____ ........ ....... . Depth to ground water_ .................... ,t Pit No. 2 ........ .... .... .... ....... .. ... .. . .........._ . _ ... ._ Repair (Kin Luctividurd Sewage Disposal ..... ........... .. ....... Let NO• non of Soil .... ................ ........................... ............................ ) tit Repirirs or AkekW:ars.—AUSWe when app.1 ..... .. ... • . Sewage Disposal S loith-- - -- .....----- - ystem in :I CCOT&flee it1.1 laCe the system ill the undersigued agrees to install the afotedeseribed Individual rotisions of Article NI cir the State Sanitary Code—The u ersigned further z tees not to p .... . .. anent: Whin until a Certificate of Compliance has issued by the U lication Approv Sinnott Disapproved for the following reasons ...... ........... .. ...... ................................. ted Ily. ..... ..... ...... .......... . .... .......... .......... .... . . . ..... t 7A Date ......... ... C Permit No laste ...............•••........... .................EALTH OF ..... THE COMM ' MASSACHUSETTS BOARD OF HEALTH OF . by... ...... .. . .. .. .... ...... . . Ba Issued..... .... ..... .....- Date ...................... ....................................... THIS IS TO CEPTIEV, 'that the Individual Sewage Disposal System constructed ( or Reizaired ( ) Oztrittitate 01 Clutpliante iii M .. .. ..... .....-..... .. .. .... ......... .. ... ........... .. .. lees been nrstallerl in nccot dance with the proviriens, or Article NI of The State Sanitary Code as deseiiberl in the application for Disposal Works Construclioll Permit No— .......... ....... (1.M . . ..... .. .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT CONSTRUED AS A GUARANIES THAT THE E ..... ..... ......................_............... Inspector. ....... ......... .. SYSTEM WILL FUNCTION SATISFACTORY. .IVER. MassGIS's Online Mapping Tool a > ® 0 in it Op OLIVER U dates Please use the red PUS Zoom to a town om 8'g2016 9'56 AM ILNER. MassGIS's Online Mapping Tool C. � 0 It on.' maps masse s OLIVER Updates Please use the red pus zoom to a town 0 8'8/2016 9156 AM Commonwealth of Massachusetts City/Town of Compliance Certificate of Comp Forma but the DEP has provided this form for use by local Boards of Health. Other forms ma y be used, in a rmati ion must be eeubh to antelly tieeam form they that provided here. Before using this form, check with This is to Certify that the following work on an On-Site Sewage Disposal System ❑ Construction of a new system Repair or replacement of an existing system ❑ Repair or replacement of an existing system comp onent Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP)- ---/ DSCP Date DSCP Number ( �F - Sc.),S Facie( �C.t ein Facility Owner cf r e- ddree Lot# Street sor LOt# _-_L'II1r' ____---- Zip Code G�T(` �( �,� n� - ------- State CitylTOwn it Designer Information'. Alan E Weiss, RS Name signature Instal Information. >y _ltd (f Name Date sign rovisions set forth below. Use of this system is conditioned on compliance with the p Recommendpump tank every two-three Years. ColdSPring Environmental Consultants, Inc. Name of Company Date % \ Name of Company he issuance of this certificate shall not be construed as a guarantee that the system will function as gned. rm3 doc•06/03 Date Certificate of Compliance•Page 1 of 1