36 Septic Inspection 2015 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1 36 Sovereign Way
:" Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner
information is
required for every
page
Important:When
filling out forms
on the computer,
use only the tab
key to move your
cursor-do not
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t5lns.3/13
Owners Name
Northampton MA 01062 9/01/2015
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:
Alan Weiss
Name of Inspector
Cold Spring Environmental Consultants, Inc.
Company Name
350 Old Enfield Road
Company Address
Belchertown MA 01007
City/I-own State Zip Code
413-323-5957 Registered Sanitarian#933
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
9/01/2015
Inspectors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this Inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner Owners Name
information is MA 01062 9/01/2015
required Northampton for every City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information 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.
t5ins•3n3
Comments:
The septic system at a single family dwelling was inspected. Liquid levels in the septic tank and
distribution box were at the outlet invert. The system has not been used for the last several months
(since June). A two line leach field system was installed approximately 17 years ago. The 1,500
gallon septic tank should be cleaned & pumped every two years. The alarm and pump in the 1,000
gallon pump chamber were functional. The distribution box was in good condition. Discharge of
condensate tubing from the furnace to the septic system is not recommended.
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
Board of
inspection if the existing tank is replaced with a complying septic tank as approved by the Bop
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 Official nspe:tiion Form:Subsurface sewage D,sposall System•Page 2 of n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner Owners Name
information is
page. Northampton MA 01062 9/01/2015
for every City/Town State Zip Code Date of Inspection
page.
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.):
❑ obboken or obstructed pipe(s) or due to aubroken settled orrt uneven l distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y E N E 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
Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 3 or 17
t5ns 3/t3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Sovereign Way
Properly Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner Owners Name
information is Northampton MA 01062 9!01/2015
page. for every State Zip Code Date of Inspection
page. City/Town
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 MS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance.
tsoa.3113
** 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 %day flow
Title 5°Waal Inspection Form Suosurface Sewage Disposal System.Page 4 of n
IS,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner Owner's Name
information is Northampton _ MA 01062 9/01/2015
required for every State Zip Code Date of Inspection page. City/Town
B. Certification (cont.)
Mine f 3113
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® 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 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.
El 0
Title 5 Official Inspection Form.SubsuTece Sewage Disposal System.Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner Owners Name
information is
page Northampton MA 01062 9/01/2015
required for every State Zip Code Date of Inspection
page. City/Town
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
thins.3/ia
Yes No
® El
® ❑
Z ❑
® ❑
® ❑
® ❑
® ❑
® ❑
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 Of any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)1
D. System Information
Residential Flow Conditions:
=
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
3
330+
Title s Official Inspection Fomi Subsurf ace Sewage Disposal System.Page o of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner Owners Name
information is Northampton MA 01062 9/01/2015_
required for every City/Town State Zip Code Date of Inspection
page.
D. System Information
Description'.
The system consists of a 1,500 gallon septic tank, a 1,000 gallon pump chamber, a distribution box
and a two line leachiftg_fleld (14W x 45'L).
19ns'303
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:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non-sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day(gpd)
0
❑ Yes E No
❑ Yes E No
❑ Yes ❑ No
❑ Yes E No
❑ Yes E No
June 2015
Date
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Title 5 OKioal Inspection Form Subsurface Sewage Disposal System•Page T at 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Sovereign Way
Properly Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner Owner's Name
information is Northampton MA 01062
page. 9/01/2015
required for every Stale Zip Code Date of Inspection
pagee. City/Town
D. System Information (cont.)
Last date of occupancy/use.
Other(describe below):
Pumping Records:
Source of information:
Was system pumped as part of the inspection? IN Yes ❑ No
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if 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.
Date
General Information
Owner: Not Pumped
1,500
gallons
Measured
Tank was pumped for inspection.
❑ Other(describe):
trs•0A3
Title 5 OKitlal Inspector Form.Subsurface Sewage olsMSel System.Page a of 17
Owner
information is
required for every
page.
t5ms•3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fonn- Not for Voluntary Assessments
36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner's Name MA 01062 9/01/2015
Northampton
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
17 Years
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:
1.5
feet
❑ Yes ® No
Over 10' from water line.
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
The sewer was in good condition with intact joints and no evidence of leakage.
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
feet
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
The 1,500 gallon septic tank is in good condition with intact inlet and outlet PVC tees. Midchamber
tees were missies and had to be installed.
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
10.5'x 5.5' x 4.2'
Dimensions:
Sludge depth:
30"
Tide 5 Official Inspection Form Subwwace Sewage Disposal System•Page 9 of P
Owner
information is
required for every
page.
Sins 3)13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner's Name
Northampton MA 01062 9/01/2015
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The two chamber septic tank was structurally sound with no evidence of leakage or corrosion. Liquid
levels were at the outlet invert, and no high staining was observed. The septic tank should be
pumped every two to three years. PVC inlet and outlet tees were intact. Midchamber tees were
missing and were installed.
10"
Measured
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Titles Official nspection Form Subsurf ace Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner Owner's Name
information Is Northampton MA 01062 9/01/2015
required for every
page. 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.):
15ins•3113
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
Title 5 Official Inspection For.Subsurf ace Sewage Disposal System'Page 11 of 17
Aer
Owner
information is
required for every
page
Sins 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner's Name
Northampton MA 01062 9/01/2015
City/Town State Zip Code Date of Inspection
D. System Information (Dont.)
Distribution Box Of present must be opened) (locate on site plan):
@ Outlet Invert
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The distribution box was located, inspected and found to be level with equal distribution to the outlets.
Liquid levels were at the outlet invert with no high staining observed. The cover of the box is located
3" belo grade. No solids carryover was noted.
Pump Chamber(locate on site plan):
Pumps in working order: Z Yes ❑ No
Alarms in working order: ® Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
The pump, the alarm and all floats were tested and found to be in working order. The pump chamber
was in good condition with no evidence of corrosion or leakage.
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Title 5 Orcidal Inspection Form Subsudre sewage Disposal System.Page 12 of 17
owner
nfotmation is
'equired for every
sage.
thins•113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner's Name
Northampton MA 01062 9/01/2015
City/Town 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: 45L
❑ overflow cesspool number:
❑ 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.):
Soils were dry at the time of inspection with no signs of ponding or wetness indicative of hydraulic
failure. Vegetation was normal.
2 Lines: 14'W x
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
honer
formation is
squired for every
age.
rsns.3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner's Name
Northampton MA 01062 9/01/2015
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction.
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Title 5 Official mspealon Form Subsurface Sewage Disposal System.Page 14 or 11
Commonwealth of Massachusetts
uTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Teter
nformation
squired for every
rage.
151M-3413
36 Soven Way
Property Address
Shelley Lake C/O Cathy Hunter,Goggins Real Estate
Owners Name
Northampton MA 01062 9/01/2015
___._ _._...
City/Town State Zip Code Dale 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
P 1 E
The 5°noel Inspecbon Form Subsurface Sewage Saws&system•P4ge 130
/wrier
formation is
squired for every
age
Sins 3f13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
Owner's Name
Northampton MA 01062 9/01/2015
City/rown State Zip Code Date of Inspection
D. System Information (cant.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water:
4'+ System Raised
feel
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
Attached: 1998
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:
Records attached from 1998 from BOH.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Records
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 Official■ Inspection Form Subsurface Sewage Disposal System.Page 16 o19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
36 Sovereign Way
Property Address
Shelley Lake: C/O Cathy Hunter, Goggins Real Estate
honer Owner's Name
,formation is Northampton MA 01062 9/01/2015
squired for every
iaBe_ City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
thins.3n3
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
• Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17