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74 Septic Inspection 2011 Owner information required every page. Important. When filling out forms on the mputer, only the tab key to move your cursor-do not use the return key Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 74 sovereign Way Property Address Uzi)Okoroanv amyu Owner's Name Nouthampton City/Town MA 01160 5/5/11 Stale 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: Karl M. Kuelmer Name of Inspector Kuehnefs Inspection Services Company Name 168 County Road _... Company Address Southampton City/Town 413 533-3031 Telephone Number MA State - - SI 124 License Number 01073 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 5/5/II 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 InspMon Foe Subsurr 5 eva Se nry¢sal System Page 1of required for page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 sovereign Way Address Um Okoroanvanwu Name Northampton MA 01060 5/5/II Slate 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 15.303 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B)System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes" , "no" , or"not determined" (Y, N, ND<) for the following statements. It "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 pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. N ❑ ND(Explain below). the 5 official Inspection worm:Subsudaw Sewage oil IT Owner information Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 74 sovereign Was Properly Address Um Okoroanvanwu Name Northampton City/Town B. Certification (coot.) MA 01060 5/5/11 Stale Zip Code Care or Inspection 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 '(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NO (Explain belowp. ❑ obstruction 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(I)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: n Cesspool or privy is within 50 feet of a surface water ❑ Cesspool privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 Official Inspection Form Subwnace Sewage Disposal System-Page 3 N 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 74 sovereign Way Properly Address Uzo Okoroanyanwu Owner Owner's Name information is for Northampton MA 01060 5/5/11 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 1 00 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 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 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 CI CI [81 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 Title S Official Inspection Form SMsulace Sewage Disposal Sgstem-Page 4 of IT required every Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 74 sovcrcign Wat Property Address Uzo Okoroanvanwu Owners Name Northampton City/Town B. Certification (cont.) MA 01060 5/5/11 state Zip code Date of Ipso ection 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. ❑ ® 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. ❑ ® portion of a cesspool or privy is less than 1 00 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 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 yh3in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Cermet Inspects.,Fain Disposal System-Page5 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 74 sovereign Way Properly Address Uio Okoroanyamcu Owner's Name Northampton MA 01060 56/11 City/Town Stale Zip Code Dale of Inspection C. Checklist Check if the following have been done. You must indicatd Sid4 dr nb'as to each of the following'. Yes No O EA ® ❑ O El O 1Z Z ❑ ® ❑ ® ❑ ® ❑ ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design) Number of bedrooms (actual). ; DESIGN flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms)'. 440 gpd <^N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 74 sovereign Way Properly Address UL0 Okoroarn ann u Owner owners Name information is Northampton required for every page. City/Town 1609-99105 MA 01060 5G/11 State Zip Code Date of Inspection D. SYSTEM INFORMATION Number of current residents'. Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes I No Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage(gpd))_ 4 residents IN Yes No Detail Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 31 0 C MR 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: ❑ Yes ® No ❑ Yes ® No not available n Yes 1/ No present Date Gallons per day(gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Title 5 014aad inspect Form subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts ▪ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 sovereign Way Property Address Uzo Okoroanvanwu Owner's Name Northampton City/Town D. System Information (cont.) Last date of occupancy/use: Other(describe below): MA 01060 5/5/11 State Zip Code Date of Inspection April 2011 Date General Information Pumping Records: Source of information'. _ -- .-. system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: gallons measured at time of pumping How was quantity pumped determined? to allow for inspection of tank 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. ❑ Other(describe). Title marl Inspection Fo bsurrace Sewage Dispo -Page B Of Commonwealth of Massachusetts s: ft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 74 sovereign Way Owner information is required for every page. Property Address Uzo Okoroanyanwu Owner's Name Northampton MA 01060 515111 City/Town slate Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed Of known) and source of information: 15 years old information from reallor 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. 24 inches feet ❑ Yes ® No feet Comments(on condition of joints, venting, evidence of leakage, etc.)- Septic Tank(locate on site plan): Depth below grade: Material of construction: ®concrete ❑metal If tank is metal, list age: 16 inches feet ❑fiberglass ❑ polyethylene ❑other(explain) years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 126 X 68 X 64 inches Dimensions: Sludge depth'. 5 inches Lne 5 Official Inwedlm For Subsurface Sewage Dspo®L Sys!em-Page of 17 nlormaron is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 74 sovereign Wad Properly Address Uzo Okoroanvanw u Owner's Name Northampton MA 01060 5/II/1l City/Town slate 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.)-. 22" 3" 5" 18" measured at time of pumping Grease Trap (locate on site plan): Depth below grade: Material of construction. feet n 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: Dale Tide 5 Official Inspection Form Subsurface Sewage P Wmal System-Page 10 of 17 Owner intormannn is required for every page- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 sovercign Way Properly Address Uzo Okoroanyanwu Owner's Name Northampton MA 01060 5/5/11 GN/Town Sale Tin rode not of In Hun 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. in concrete ❑metal ❑fiberglass ❑polyethylene in 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 Tide 501Laal Inspection Fono Subsurface Sewage Psposal System—Page I I of If [weer ,mm,auon ES squired for a,er/page. tb+ns E 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 sovereign Way Property Address Uzo Okoroanvanwu Owners Name Northampton MA 01060 5/5/11 City/Town State Zip Code Dare of Inspection D. System Information (cont.) Distribution Box Of present must be opened) (locate on site plan): even flow in all legs Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.). box is level no indication of problems Pump Chamber(locate on site plan)'. Pumps in working order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Tide 5 Official Inspection Fuel:Subsunace Sewage r spozal smmt-Page 12 of 17 Miner 'formation is enured for very page. 03/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 71 sovereign Was Property Address Uzo Okoroanyanw'u Owners Name Northampton City/Town D. System Information (cont.) Type' MA 01060 5/5/ti Slate Zip Code Date of Inspection leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system number: number number number, length: number, dimensions: number: Unknown Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of bonding, damp soil, condition of vegetation, etc.)'. 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 g1Udi Inspection Form.SIDVrte®Sev a9eL sposal System-Page 13 of n C (Saner informatio IS myni¢d for Pa page t5u,s-Q9Ma Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 sovereign Way Properly Address Unknown panels Nine Northampton MA 01060 5/5/11 Stale Zip Code Dale of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, ete-)_ 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.): Tire 5 Official Inspection rmn Subsurface Sewage Disposal system-Page la of Z"_ Commonwealth of Massachusetts Title 5 Official Inspection Form t is; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 sovereign Way Property Address Unknown looner Owner's Name dorrnaron is MA 01060 >/5/I I venirea for Northampton very page. CitYlTOwn Stale 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 1 00 feet. Locate where public water supply enters the building. Check one of the boxes below: n hand-sketch in the area below ® drawing attached separately SEE ATTACHMENT'. Tie s Official Inspection Form Subsg ff ace Sewage Disposal System-Page 15 of 17 t5ios-09108 ler formation is equlred for very page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Net for Voluntary Assessments 74 sovereign Wat Properly Address Uzo Okoroanvanwu Owner's Name Northampton MA 01000 5/11/1I Cdvllown State Zip code Date of Inspection D. System Information (cont.) Site Exam ® Check Slope flat in area of system then sloping off to mad ® Surface water None IZ Check cellar do 0 Shallow wells None Estimated depth to high ground water >8 feet veer 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- no information on file at BON ❑ Checked with local excavators, installers-(attach documentation) • Accessed USGS database -explain: You must describe how you established the high ground water elevation. Vie;'ed site. Knowledge of the area Before tiling this Inspection Report, please see Report Completeness Checklist on next page. Tie 5 Official Inspection Form.Subsimce Sewage Llwoml System-Page 16 of 17 Toner ntormation is 'equired for .very page. Inns-09700 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 sovereign Way Property Address Uzo Okoroamamcu Owners Name Northampton MA 01060 5/5/Il Oiryrtown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed IN System Information -Estimated depth to high groundwater • Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Offinal mspecIon Fom Sobsinace Sewage Disposal?stem-Page 17 of 17 Ito!inctuis!CI 411•11 ••••• ••- - • - ' - - • 4 1-1 ; - .• .• ' •t• i4 • '•• ' ‘• • • 1500 gallon septic tank i6' below grade distribution box 16' below grade garage LEGEND AC=21.5' BC=505' AD=39.5' BD=62' 74 SOVEREIGN WAY SOUTHAMPTON ENVIRONMENTAL SERVICES INC. INSPECTOR: Karl M. Kuehner NO SCALE: Map Output Page 1 of 1 help//maps.massgis.srate.mam s/senlei/comesdesrimap.Esrimnp?ScniceName=matotcns&ClicntVcrsion=l0&_ 5/2/2011 USGS 3D Topographic Ma p „t. httpalntaps massgis.statcma.us/servleNcon.esn estimap.EsrimapScn iceNamr—matowns&ClientVersion=4 0&_. 5/2/2011 Kuehner's Inspection Services 168 County Road Southampton, MA 01073 Phone (413) 533-3031 TITLE 5 INSPECTION At the request of Mr. Okoroanyanwu Uzodinma, an inspection of the septic system located at 74 Sovereign Way, Northampton, MA. was performed on May 5, 2011. The septic system was in normal operation at the time of the inspection. The inlet and outlet baffles were in place and functional. The septic tank was pumped to allow for inspection. The distribution box was located and inspected. Flow was equal in all legs of the system_ It is my opinion based on information available that this septic system meets the passing requirements of Title 5 (310 CMR 15.00) at this time. Problem Areas: I_ None'. Recommendations: I. A regular maintenance schedule should be established. This report is based on conditions existing at the time of the inspection, and is not intended to project, guarantee, or warranty the future operation of the septic system. For further information please refer to the attached inspection report Inspector: Karl M. Kuehner Supervisor