Loading...
111 Septic Inspection 2015 CITY of NORTHAMPTON PUBLIC HEALTH DEPARTMENT BOARD OF HEALTH MEMBERS: Donna Salloom, Chair Joanne Levin, MD—Suzanne Smith, MD STAFF .Merridith O'Leary.RS Director—Daniel Wasiuk, Inspector—Edmund Smith, Inspector—Lisa Sleinbock, RN,Nurse October 13,2015 Patrick and Jillian Niedzwiecki 111 Old Ferry Road Northampton, MA 01060 Dear Homeowner: FILE COPY RE: Sewage Disposal System Inspection 111 Old Ferry Road The Northampton Board of Health is in receipt of a report on the Subsurface Sewage Disposal System Inspection conducted by Ray Champagne at your property,401 Kennedy Road,on October 9, 2015.That inspection report indicates that your subsurface sewage disposal system fails to protect the public health and the environment as defined in Section 15.303 of CMR 15.000,State Environmental Code,Title 5. Therefore,in accordance with the provisions of 310 CMR 15.000 of the State Environmental Code,Title 5, and under authority of Massachusetts General Laws,Chapter 21A,Section 13,you (or the subsequent owner of the property)are hereby ordered to repair the subsurface sewage disposal system at 111 Old Ferry Road,within two years of the date of the original inspection, (October 9,2017). If further degradation of the sewage disposal system occurs (e.g. increased sewage flowing to the surface of the ground),you maybe required to complete the repairs sooner. All work to repair/upgrade your subsurface sewage disposal system must be performed by a licensed sewage disposal system installer,in accordance with the requirements of 310 CMR 15.000,and with plans approved by the Northampton Board of Health. Please be advised that you are entitled to a hearing on this order to upgrade your subsurface sewage disposal system,provided that you file a written petition requesting such a hearing in the Board of health office within seven (7) days of the receipt of this notice. Please feel free to contact the Board of Health office,at 587-1214 if you have any questions concerning this matter. Thank you for your anticipated cooperation in this matter. Sincerely, Daniel Wasiuk Health Inspector 212 Main Street,Northampton,MA 01060 Ph(413)587-1214 Fax(413)587-1221 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki wner Owner's Name formation is same Ma. 01060 10/09/15 'erypage.go r age. CitY/TOwn State Zip Code Date of Inspection rery P 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. nportan A. General Information Men filling out suns on the omputer,use 1 Inspector: my the tab key r move your Ray Champagne ursor-do not Name of Inspector se the return Whiteley Septic Service Company Name 4m \ 21 Old County Rd. Company Address Southampton Ma. Ma. City/Town State Zip Code 413-527-0057 S14118 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 0/09/15 Inspector's Sigma re / 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. isms•09,08 Title 5 Official dim Form Subsurface Sewage Disposal System•Page I of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form• Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki ner Owner's Name rmation a same Ma. 01060 10/09/15 ■wired for ■ry page. City/Town State Zip Code Date of Inspection 15me•0909 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. Comments: This system consists of a 1000gal septic tank with concrete baffles and a d box with 2 inverts. The Top of tank has broken at the inlet end (near driveway)and the d box has deterioated to leaking and the 2 inverts were saturated to about 2" above bottom of invert.Ther appears to be no health hazard as the system is 36" below grade. 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): We 501Dual Inspection Fonn subsurface sewage Disposal System•Page 2 of 17 ter rotation is sired for ry page. tins•09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 _ Property Address Patrick&Jillian Niedzwiecki Owners Name same Ma 01060 10109/15 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ 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 ❑ N ❑ ND (Explain below): ❑ obstruction is removed O V E N S 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)(6)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 Tie 5 Official Inspection Form Subsurf ace Sewage Disposal System•Pages of A ler mation is sired for Y Page. (Sins-08'08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki Owners Name same City/Town State Zip Code Date of Inspection Ma. 01060 10/09/15 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: sa 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 ❑ E 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 Tills 5 Official Inspection Fwm:Subsurface Sewage Disposal System•Page 4 of 17 ier rnmation u sired for FY page. t5ins•0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki -- - Owners Name same Ma. 01060 10/09/15 City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. ❑ Z 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 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.] ❑ Z The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ Z 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 ❑ Z the system is within 400 feet of a surface drinking water supply ❑ Z 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. Tble 5 Official Inspection Fans Subsunace San'sos Disposal System.Page 5 of 17 rer rmation is sired for ry page. 51ns•09100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki Owners Name same Ma. 01060 10/09/15 City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No E ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ E Were any of the system components pumped out in the previous two weeks? E ❑ Has the system received normal flows in the previous two week period? ❑ E Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ E Were as built plans of the system obtained and examined?(If they were not available note as N/A) E ❑ 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? ❑ E 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. E ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): unknown Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 unknown Title 5 Official Inspection Form Subsurface sewage oagwai System.Page¢a 17 3tlon s d for >age. (Pins•09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Old Fee Rd. Northampton MA. 01060 Properly Address Patrick&Jillian Niedzwiecki ——Owners Name Ma 01060 10109/15 same State Zip Code Date of Inspection City/Town D. System Information Description: 4 Number of current residents: � Yes El No Does residence have a garbage grinder? Is laundry on a separate sewage system?[if yes separate inspection required) ❑ Yes Z No ❑ Yes 1:1 No Laundry system inspected? ❑ Yes ® No Seasonal use? city water Water meter readings, if available(last 2 years usage(gpd)): readin 210610 Detail: --- ® Yes ❑ No Sump pump? presently — Last date of occupancy: Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personslsq.ft., etc.): —" ❑ Yes ❑ No Grease trap present? ❑ Yes DI Industrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: rltle 5 Official Inspection'Corm: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 111 Old Fer Rd. Northampton MA. 01060 Property Address Patrick 8 Jillia n Niedzwiecki Owner's Name 10/09/15 tionis Ma. 01060 - 1 same State Zip Code Date of Inspection agge.e. City/Town D. System Information (cont.) Last date of occupancy/use: Other(describe below). thins•03'09 General Information p esemly Date Pumping Records: 2014 owner —— Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons 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) 0 Innovative/Alternative technology. Attach a copy of the current operation and maintenance inspection of the I/A system y by system roperator under contacts copy of Tight tank.Attach a copy of the DEP approval. 0 Other(describe): Title 5 o&goal Insydlon Form Subsurface Sewage Disposal System.Par 8 M 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki Owner's Name ation is p same Ma. 01060 10/09/15 g City/Town State Zip Code Date of Inspection pagee.. D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 40±Yrs estimate_. - - t5ins•08/08 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: 28" feet city water feet Comments(on condition of joints, venting, evidence of leakage, etc.): no evidence of leakage observed Septic Tank(locate on site plan): Depth below grade: Material of construction: ®concrete ❑ metal If tank is metal, list age: 24" feet ❑ Yes ® No ❑fiberglass ❑ polyethylene ❑ other(explain) years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1000 Dimensions: Sludge depth: 2" Tide 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki er Owner's Name merlon is same Ma. 01060 10/09/15 fired State Zip Code Date of Inspection Y page.. City/Town D. System Information (cont.) 151ns•09108 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.): several indications of hydraulic failure observed, Replacement of system recommended 32" 12" tape rule Grease Trap(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date The 5 moral Inspection Form Subsurface Sewage Disposal System•Page 10 al IT ler mation is aired for y page. sns•0&0e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki Owner's Name same Ma. 01060 10/09/15 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.): structural integrity compromised with broken tank and leaking d box also the outlet inverts are saturated to 2"above bottom of ppe 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 The s Steal Inspector'Form Subsurface sewage Disposal System•Page 11 of n ner 'rotation is uired for try page. buns•09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki Owners Name same Ma. 01060 10/09/15 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box Of 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.): box has deterioated and leaking 7" Pump Chamber(locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soli Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 91' nation is fired for page. 51 •Wlre Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki Owners Name same Ma. 01060 10/09/15 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 ❑ 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.): no surface signs of hydraulic failure observed 2 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 501fitiel Inspetlion Form.Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki —_ —. -- - --Owner's Name ation is p same Ma. 01060 10/09115 g State Zip Code Date of Inspection pagee.. City/rown D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): lawn area no signs of vegitation growth and system is 36"bg 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.)'. Sins.44Gs Title 5 Official Inspection Form Subsurface sewage Oispos system•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki Owners Name Ilion is Ma 01060 10/09/15 C for same rage. CirylTOwn State 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 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 pins•oa0s y6 iss V 1 ' The 5 Ofnael hsPadian Form Suoarrace Se+:%B niwosal Syssm•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick&Jillian Niedzwiecki Owners Name atron is NI page. City/Town same Ma. 01060 10/09/15 g State Zip Code Date of Inspection me•0968 D. System Information (cont.) Site Exam: ® Check Slope ® Surface water Check cellar ® Shallow wells Estimated depth to high ground water: tbd at new design but suggest 4-5 ft. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: sump pump and neighbors yard Before filing this Inspection Report, please see Report Completeness Checklist on next page. title 5Official Inspection Form.Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,'= 111 Old Ferry Rd. Northampton MA. 01060 Property Address Patrick& Jillian Niedzwiecki Owners Name same Ma. 01060 10/09/15 City/Town State Zip Code Date of Inspection ation s d for ,age. ns•OW08 E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed El System Information-Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5Official Inspection Form.Subsurface DEspoeal System•Fade 11 of n