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83 Septic Inspction 2013 Ito t Owner information's required for every page. Important When filling out fors on the computer. use only the tab key to move your cursor-do not use the return key. tSns•11110 Commonwealth of Massachusetts ,mot+ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 Sylvester Rd., Northampton Property Address Nancy Rustic;and Michelle Sauve 83 Sylvester Rd. Owners Name Northampton Citylrown Ma 01060 5/13/2013 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. Torn Martin Name of Inspector Turkey Hill Field Services Company Name 140 Easthampton Rd. Company Address Westhampton City/Town 413-527-5311 Telephone Number Ma 01027 • State Zip Code SI 4199 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. 1 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 " . VV\W't1\ 5/13/13 Inspector's 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. The 5 Official Inspect=Form Subsurface Sewage Disposal System•Page 1 of 17 Owner intonation Is required for every page. 15'ro•II/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 83 Sylvester Rd., Northampton Property Address Nancy Ruscio and Michelle Sauve Owner's Name Northampton City/Town 83 Sylvester Rd. Ma 01060 5/13/2013 State Zip Code Date of Inspection B. Certification (cord.) Inspection Summary:Check A,B,C,D or E I 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. 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, NO)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): Observed a hole in the septic tank in the area of the outlet filter.A tree root had completely penetrated the tank. The 5 morel YWKedan Form:Subsurface Sewage niapos System•Page 2 of 17 Infoer rmations Northampton Ma 01060 5/13/2013 p g far every City/Town State Zip Code Dale of Inspection page e. B. Certification (cont.) Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 Sylvester Rd., Northampton Pro perty Address Nancy Ruscio and Michelle Sauve 83 Sylvester Rd. Owners Name 6u¢•11110 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 ❑ N ❑ ND(Explain below): ❑ obstruction is removed O V O N O 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 Tale S Otdal Inspection Font&Aswa s Sewage Disposai System.Page 3 of 17 Owner information is required for every page. ism.11110 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 Sylvester Rd., Northampton Property Address Nancy Ruscio and Michelle Sauve owners Name Northampton City/Town B. Certification (cont.) 2. System will fall 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 (3 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. ❑ from has septic tank nk and SAS and the SAS is less than 100 feet but 50 feet or more N private Method used to determine distance: 83 Sylvester Rd. Ma State 01060 5/13/2013 Zip Code Date of Inspection D) **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal cofrforn bacteria indicates absent and the presence of ammonia nitrogen and nitratendroge analysis equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy Y be attached to this form. 3. Other: 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 Y day flow Title s official Ircspeclion Fpm:Wass-face Sewage Disposal System.Pa.R<an Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 S Wester Rd. Northam on Property Address Nancy Ruscio and Michelle Sauve 83 Sylvester Rd. vier Owners Name 'ormations Northam on (wired for evo7 City/Town lgo. B. Certification (coot.) t5in•11110 Ma 01000 State Zip Code 5/13/1013 Date of Inspection 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 ❑ )4 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. ❑ 0 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 equ A Goes of the ppm,or provided that no other failure criteria are triggered. 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. ❑ 0 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 system considered a significant threat tunde Section E or fai led eunderr Section D shall uopgrade these system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. T06 5 Official Inspection FF^^.Subsurface Sewage Disposal System•Page 5 al 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 S Ivester Rd., Northam on Property Address Nanc Ruscio and Michelle Sauve 83 S vester Rd. mer Owner's Name i w Ma 01060 rdf1p re even, Northam on t fared fore State Zip City/rown Code C. Checklist Check if the following have been done.You must indicate"yes'or"no" as to each of the following: ISVn•11110 5/13/2013 Date of Inspection Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ E6 Were any of the system components pumped out in the previous two weeks? O ❑ 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? O ❑ 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 on oiny owner(and a nif of subsurface sewage disposal systems? information on the proper 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 CMR related Part C is at issue approximation of distance is unacceptable)[310 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): 4 TS 5 Cadet spsCt°i Form'.s barfem Sewage Disposal System*Page 6 N 17 mer snnation is wired for every ge. i5lm•11/0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 S Ivester Rd., Northam ton Property Address Nancy Ruscio and Michelle Sauve °,ales Name Northam rton City/Town D. System Information Description: 83 S Ivester Rd. Ma 01060 5/13/2013 State Zip Code Date of Inspection 2 Number of current residents: ® Yes ❑ No Does residence have a garbage grinder? Is laundry on a separate sewage system?[U yes separate inspection required] ❑ Yes ® No ® Yes ❑ No Laundry system inspected? ❑ Yes ® No Seasonal use? Yes 40 Water meter readings, if available(last 2 years usage(gpd)): Detail: water readine s from last two • arter ear bills examined Sump pump? Last date of occupancy: CommerciaWlndustrial Flow Conditions: Type of Establishment ❑ Yes ® No currently Date Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/Persons/set etc.): El ❑ No Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? Water meter readings,if available: The 5 Official Inspection Forts Subsurface Sewage Disposal Sham•Page]of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 S Ivester Rd., Northam ton Property Address Nan Ruscio and Michelle Sauve ner Owners Name minion N Northam Eton aired for eve? city/Town D. System Information (coot.) Last date of occupancy/use: Other(describe below): thins•+vfO 83 Sylvester Rd Ma 01060 State Zip Code General Information Date 5/13/2013 Dale of Inspection Pumping Records: um int 2007 and 2002 Source of information: Was system pumped as part of the inspection? If yes,volume pumped: gallons pumped was quantity p fwd determined? Reason for pumping: Type of System: ❑ Septic tank,distribution box,soil absorption system ❑ Yes ❑ No ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system(yes or no) Of yes,attach previous inspection records,if any) ❑ Innovative/Altemative 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. o Other(describe): 1500 cal se he tank with 750 gal leachin alle TS 50fitlal Inwecbon ram'.Subsurface Savage Disposal System.Page a an er mation is aired for every Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 S Ivester Rd., Northam on Property Adder Nan Ruscio and Michelle Sauve owners flame Northam ton CryR� D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 26 ears old 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: Comments(on condition of joints,venting,evidence of leakage, etc.): thins•nno 83 S vester Rd. Ma 01060 State Zip Code 511312013 Date of Inspection 2 feet feet ❑ Yes 0 No Septic Tank(locate on site plan): 1.8 Depth below grade: feet Material of construction: ex ®concrete CI metal ❑fiberglass ❑ polyethylene CI other(explain) ) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of 10 6caz 5 ' Dimensions: Sludge depth: 6-8" ❑ Yes ❑ No again page 9 of 17 The SOlrw-ea breathes rmn'.Subsurface San6+p�5W� Commonwealth of Massachusetts J Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 S Ivester Rd., Northam• on Property Addre ss Nancy Ruscio and Michelle Sauve 83 Sylvester Rd. or ONnerS Name f is Northam ton fired red for oven City/Town 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 bathe 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, Upon inspection ecreated of outlet thero,tt S rmdei�hing at this point tho gh the hone had been somewhat seal d b bsan ard o by the Some b sand and o �anice. Some effluent also •-ssin• throw h outlet i Mins•11/10 Ma 01080 State Zip Code 5/13/2013 Date of inspection 24 2 inches scum 4 inches — 14 Grease Trap(locate on site plan): Depth below grade: teat Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or bathe Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Ties s OIPwiYOU Form.sultstrtaoe Sewage Disposal Systen•Pageta an Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 83 S Ivester Rd., Northam ton Property Address Nan Ruscio and Michelle Sauve 83 S Ivester Rd. or Owner's Name Ma 01060 511312013 nation s Northam• on Dare of Inspection .ea for even stare Zip code 3. City/Town D. System Information (font.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): thins•11110 Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: other(explain): ❑concrete ❑� metal ❑fiberglass ❑polyethylene ❑ ( P ): Dimensions: Capacity: gallons Design Flow: gallons per day ❑ Yes ❑ No Alarm present -- Alarm in working order: ❑ Yes ❑ No Alarm level: Date of last pumping: Dare Comments(condition of alarm and float switches,etc): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes No wee s&Lida Inspecbon Fan:Subsurface Sewage Disposal System•Pape 11 W 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 S Ivester Rd., Northam on Property Address Nancy Ruscio and Michelle Sauve ner Owners Name '"nation is Northam aired for every City/town Ie. D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): 28 inches below rade.3 lines from box. Cover broken and needs re rlacement 83 Sylvester Rd. Ma State 01060 Zip Code 5113/2013 Date of Inspection Pump Chamber(locate on site plan): Yes ❑ No Pumps in working order: Yes ❑ No Alarms in working order 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: 6vn•11/10 rie sgfica Inspect/on Fan:Subsurface Sverige Disgsd sYS/e"•0W/12 0117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 S Ivester Rd., Northam ton Property Address Nan c Ruscio and Michelle Sauve 83 Sylvester Rd. met Owlets Name orelation is Northam ton wired for every CiNROwn 9e. D. System Information (coot.) tens•11/10 Type: ❑ leaching pits Ma 01080 State Zip Code number leaching chambers number. leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of pending, damp soil,condition of Leaching gallery opened and found dry. Some water run through the system to observe that it etc.): was still receivin• flow des•ite hole in tank 5/1312013 Date of Inspection 1,750 allon 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 ❑ Yes ❑ No Indication of groundwater inflow Title s Meal 'wr« Subsurface Sewage DIsposal System Page 13 a 17•