560 Septic Inspection 2012 CITY of NORTHAMPTON
PUBLIC HEALTH DEPARTMENT
BOARD OF HEALTH MEMBERS:Donna Salloom, Chair—Joanne Levin, MD—Susanne Smith, MD
STAFF Merridith O'Leary, RS, Director—Daniel Wastuk Inspector—Edmund Smith,Inspector—Jennifer Brown, RN.Nurse
:tober 22, 2012
Mate of Irene Rivard-Attn: Susan Rivard
iO Sylvester Road
arthampton,MA 01062
:: Septic System Inspection at 560 Sylvester Road,Northampton MA 01060
Whom It May Concern:
le Northampton Board of Health is in receipt of a report on the Subsurface Sewage Disposal System Inspection
inducted by Philip Pasiecnik of Greg's Waste Water Removal "Title 5 Inspections at 560 Sylvester Road,
orthampton,on October 1,2012".That inspection report indicates that the subsurface sewage disposal system at
at address Needs Further Evaluation by the Local Approving Authority as defined in Section 15.340 of CMR
3.000,State Environmental Code,Title 5.
ierefore,in accordance with the provisions of 310 CMR 15.000 of the State Environmental Code,Title 5,and under
ithority of Massachusetts General Laws,Chapter 21A, Section 13,the septic system design information has been
'viewed by me to ensure compliance and evaluated because of the Title 5 Official Inspection conducted by Phillip
3siecnik.
ae review has identified the septic system constructed approximately 50 years ago,prior to a 1988 repair(1500
Ilion replacement septic tank),present house 2 Bedrooms,with a garbage grinder,and approximately 2 x 10'of
aching trench. The system failed Title 5 inspection because of a system backup due to SAS failure.
herefore,in accordance with the provisions of 310 CMR 15.000 of the State Environmental Code,Title 5,and under
ithority of Massachusetts General Laws, Chapter 21A,Section 13,you (or the subsequent owners of the property)
-e hereby ordered to upgrade the subsurface sewage disposal system at 411 Westhampton Road,within two (21
ears of the date of the inspection,(by October 1.20141.If any degradation of the sewage disposal system occurs
'.g.sewage flowing to the surface of the ground),you may be required to complete the upgrade sooner. As the house
currently unoccupied,it will remain uninhabited until the system passes Title V regulations.
11 work to repair/upgrade the subsurface sewage disposal system must be performed by a licensed sewage disposal
(stem installer,in accordance with the requirements of 310 CMR 15.000,and with plans prepared by a Registered
unitarian or Registered Professional Engineer and approved by the Northampton Board of Health.
lease be advised that you are entitled to a hearing on this order to upgrade your subsurface sewage disposal system,
rovided that you file a written petition requesting such a hearing in the Board of health office within seven(7)
ays of the receipt of this notice.
lease feel free to contact the Board of Health office,at 587-1214,if you have any questions concerning this notice.
212 Main Street,Northampton,MA 01060
Ph(413)587-1214 Fax(413)587-1221
�t Ct-r-y
/ CE7n i=. e-i >rnn.SEti
k you for your anticipated cooperation in this matter.
rely,
and Smith
th Inspector,Northampton Health Department
212 Main Street, Northampton,MA 01060
Ph(413) 587-1214 Fax(413)587-1221
Commonwealth of Massachusetts
liTitle 5 Official Inspection F Orm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
560 SYLVESTER ROAD
Property Address ----- --- -
ESTATE OF IRENE RIVARD— -----
Owner Owner's Name --- SUSAN GODARD DAUGHTER
information is
required for
NORTHAMPTON
every page. City/rows -- ----- ___ MA. 0_1062
State -- OCTOBER 1, 2012
Zip Code
Date of Inspection
tsw•ivio
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:
NO NORMAL FLOW RATES GOING TO SYSTEM AT THE TIME OF INSPECTION.
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 I
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):
Title 5 Official,hspectiea Fpm $
uMUrtas 0 l SYalan.Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments — —
560 SYLVESTER ROAD ——------
ESTATE OF IRENE RIVARD— SUSAN GODARD DAUGHTER
Property Address
s NORTHAMPTON OCTOBER 112
Owners Name MA. 01062 __
State Zip Code Date of Inspection
—
, 20
City/Town
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
g out
to
use
b key
our
)not
turn
Sins.11110
1. Inspector: _-----
PHILIP J. PASIECNIK ——--
Name of Inspector __----
GREG'S WASTE WATER REMOVAL____--------
Company
Name
239 GREENFIELD ROAD_,__------
-- 01373 ._
Company Address MA. ZIP Code
SOUTH DEERFIEL -------
—
City/Town 511526 __ _---------�
T1le
-665-3989 —_ ------ License Number
Telephone phone Number er
B. Certification
1 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
roved system inspector pursuant to Section 15.340 of
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal Title 5(310 CMR 15.000).The system:
❑ Passes
❑ Needs Further Evaluation by the Local Approving Authority
• 1 �
❑ Conditionally Passes
® Fails
Date
ard
The system inspector shall submit a copy of this inspection report l tto o the Appro i shAuthority(Boar system
of Health or DEP)within 30 days of completing this inspection.
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 retort time.This describes conditions at the time of inspection and under the conditions of use
at that or different conditions inspection
f use.td�how the system will perform in the future under
Title 5 Missal Insertion Form:Swwnaw Sewage p'sPose Sys.f•Paget el 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
560 SYLVESTER ROAD
Property Address ------
E STATE OF IRENE RIVARD—SUSAN GODARD DAUGHTER
___
Owners Name
NORTHAMPTON ------------
CM/Town ----------------- MA. 01062 OCTOBER 1, 2012
State Zip Code
(cont.) Date of
B. Certification
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 heaht
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is witt
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 w
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private wa
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 col fo m bacteria aindicateshabselnt andrthe presence of ammonia Dnitrogen certified
and laboratory,nira nitrate for fecal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysi rr
be attached to this form nitrogen is e
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
❑ ® 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
�•Brio
than %day Flow
Tit 5 Official Inspection Form Sbw,race Sewage Disposal System.Pare. 4 orn
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - - -
560 SYLVESTER ROAD ___—--------
Property Address
ESTATE OF IRENE RIVARD-SUSAN GODARD DAUGHTER — ----- 2012_
Owner's Name MA. 01062 OCTOBER 1 ---
NORTHAMPTON --
MAe 01 Code pate M OCTOBER Inspection
City/Town
B. Certification (cont.)
B) System Conditionally Passes (cons):
❑ to broken of sewage backup or dueato a broken, settled water uneven distribution box. due or
pass ss inspection or ion obstructed
(with pipe(s)approval of Board of Health):
pass inspection if(with app ❑ Y � N 0 NO(Explain below):
O broken pipe(s)are replaced
Y 0 N ❑ ND(Explain below):
• obstruction is removed lain below):
O distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Exp
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):
Y ONO ND (Explain below).
� broken pipe(s) are replaced
Y N ❑ ND(Explain below).
• obstruction is removed - —
C) Further Evaluation is Required by the Board of Health:
❑ he system exist which require
failing to protect public rheath,evaluation
afety or the the environment in order to determine if of
1. System will pass unless Board of Health
determines
15.303(1)(b)that the system is not functioning In manner which will protect public health,
safety and t he
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°Fos inspection Form:Subsurface Sewage Discos&Sysrem•Page 3 at 17
ins•11110
t5pns•mia
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
560 SYLVESTER ROAD
Property Address ----------------------
ESTATE OF IRENE RIVARD- -_---
SUSAN D DAUGHTER
Owners Name--------------___-- ER
NORTHAMPTON ----------------------__.__
NORTn
--------- MA 01062 OCTOBER 1, 2012
C. Checklist state zip Code pate of nspeohon
Check if the following have been done. You must indicate"yes"or"no"as to each of the follov
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of HE
❑ ® Were any of the system components pumped out in the previous two week
❑ • Has the system received normal flows in the previous two week period?
❑ o Have large volumes of water been introduced to the system recently or as f
this inspection?
W
❑ ®
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?
® ❑ inspected for the ondibonhofthe baffesoror tees, materialtof construction,
tar
dimensions, depth of liquid, depth of sludge and depth scum.
epth of ?
® ❑
Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systen
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® ❑ ermined 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):
N/A umber
flow based on 310 CMR 15.203(for example:110 gpdfx bedrooms of bedrooms):) 2
TOW 5 Official In
220 gpd
Fpm Subsurface sewage Di
sWSel Sygan.Pape 6pf]
Commonwealth of Massachusetts
Official Inspection Form
Title 5 Not for Voluntary Assessments
Subsurface Sewage Disposal System Pone-
560 SYLVESTER ROAD__ --------
Property Address
ESTATE OF IRENE RIVARD-SUSAN GODARD DAUGHTER OCTOBER 1,2012
owners Name MA_ _01062---
Zip Code Date or OCTOBER
lion
NORTHAMPTON — - State P
Clty(rown
B. Certification (cont.)
Yes No dogged or
Required pumping more than 4 times in the last year NOT due to ogg
❑ ® obstructed pipe(s). Number of times pumped:
Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of f surface water privy is within 100 feet of a surface water supply or
❑ ® tributary to
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 ion a cesspool
but
feet
50
from a private water supply well no acceptable water qualty analysis. [
Thi
s
stem passes a the well water analysis, Pe rformed at a DEP certified
laboratory,for fecal na it bacteria indicates presence
of am nitrogen and nitrate nitrogen to or less than ppm,
provided that no other lur copy of the analysis
and cai n of custody musbe 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 the
® CI system owner shouldlcontact the Board of Health t therefore determineswhatfwilll behe
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 ennitrogen II lsef a publtrwa(Interim Wy well head Protection
❑ ❑ Area-IWPA)or a mapp
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section 0 above the large system has failed.The owner or operator ate 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.
vns 11110
TNe 5 Oflical InspOJ'LC Fan".S�ai'DacS 5 Dish&System Page 5 of 17
Owner
information is
required for
every page.
rsms•11//0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
560 SYLVESTER ROAD
Property Address --
ESTATE OF IRENE RIVARD— _----------
Owners Name----------SUSAN GODARD DAUGHTER
NORTHAMPTON -----
City/Town MA. 01062
State Zi OCTOBER 1, 2012
D. System Information (cont.) Zip Code
C Date of Inspection
Last date of occupancy/use:
Other(describe below):
Pumping Records:
Source of information:
FamilYhas no record of lastpumping._
Was system pumped as part of the inspection?
If yes, volume pumped:If ® No
gallons ----------__
General Information
Date
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 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. Mach a copy of the DEP approval
® Other(describe):
Septic tank, soil absorption system
Title 5 OrkiaInspection Form Subsurface wage Disposer System.Page 8 of/7
Commonwealth of Massachusetts
Official Inspection Form
Title 5 Not for Voluntary Assessments
Subsurface Sewage Disposal System Form- – --
560 SYLVESTER ROAD _ _-----------
Property Address
ESTATE OF IRENE RIVARD=SUSAN GODARD DAUGHTER OCTOBER 1,201?__ —
Owners Name MA Date of Iaspe,dio^
NORTHAMPTON --- -State Zip code
City/Town
D. System Information
Description. d r bedroom=22:0 er 310 CMR 15.203
2Bedroom house z 110 g p�e e
—---
–
0
Number of current residents: ® Yes ❑ No
Does residence have a garbage grinder? Yes ❑ No
Is laundry on a separate sewage system?(if yes separate inspection required)
[] Yes ® No
Laundry system inspected? 0 Yes ® No
Seasonal use? NIA o
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Private Well Not Metered
----__------ Yes ® No
Sump Pump? 8115112±1 No
Date
Last date of
occupancy
.Last
Flow Conditions:
NIA __—_---___—
Type of Establishment _——
Design flow(based on 310 CMR 15.203): Gallons per day(god)
Basis of design flow(seats/personslsq.ft., etc.):
0 Yes ❑ 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:
,ms•11110
tie 5 Official Inspection F0m1 SubwnauSewage olswsaL System Page 7 0111
Owner
information is
required for
every page.
(Sins•Ilia
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Volunta A
560 SYLVESTERROAD
Property Address
ESTATE OF IRENE RIVARD—SUSAN GODARD
Owners Name
ry ssessments
NORTHAMPTON
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 baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural into
liquid levels as related to outlet invert. evidence of leakage, etc.):
pumped at least every three years. Cast concrete inlet baffle appeared Septic tank is recommended
concrete outlet baffle had some scaling evident, but still functional. Tank appeared to be in good
condition with scaling of the concrete at the outlet end above the lquid levell.Liqu Liquid level was at ti
outlet invert after being unoccupied for 6 weeks. No leakage was evident at this time.
DAUGHTER
MA. 01062
State __ OCTOBER 1, 2012
Zip Code Date of Inspection
25"
14"
Grease Trap(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal
N/A
feet
❑fiberglass ❑polyethylene
❑other(explaii
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
Ties 5 Official Inspcton Fain.Subsurface
Sewage Disposal System f Page 10 p(1]
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form-
560 SYLVESTER ROAD __ ----- --
Property Address — — — --
ESTATE OF IRENE RIVARD–SUSAN GODARD DAUGHTER__— OCTOBER?,2012
Owners Name MA. 01�? c[ion
NORTHAMPTON_ ------ State
Zip 62 Date of Inspe
CdYnown
D. System Information (cont.)
Approximate age of all components,date installed(if known)and source of information:
Tank 25+/-Years Old-SAS 50+Years Old / Estimated from ssystem components found.
0 Yes ® No
Were sewage odors detected when arriving at the site?
Building Sewer(locate on site plan).
Depth below grade:
Material of construction:
®40 PVC ❑other(explain).
® cast iron
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage,etc.):
Building sewer appeared to be in good condition.Venting was visible
outside the dwelling. No leaka�t a was v isible at this time.__ —---- — –
1
feet
Cast Iron Exits House
PVC Enters Septic Tank
30—_—
feet
Septic Tank(locate on site plan):
Depth below grade:
Material of construction.
®concrete
metal
fiberglass
.5 or 6"
feet
0 polyethylene ❑other(explain)
NIA
years
If tank is metal, list age: No
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes
10'6"Lx5'6"Wx5'4"D I Outside_)_
Dimensions.
Sludge depth:
5iins.11110
Tele 5 OIrial inspect on Fam:Subsurface Sewage Disposal system•Page s of 17
Owner
information is
required for
every page_
oms.mio
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
560 SYLVESTER ROAD
Propeny Address
ESTATE OF IRENE RIVARD— ---------
Owners Name -------- SUSAN GODARD DAUGHTER
NORTHAMPTON
City/Town------------ MA. 01062 OCTOBER 1, 2012
D. System Information (cont.) State Zip Code
Date of Inspection
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryove
evidence of leakage into or out of box, etc.):
N/A
Pump Chamber(locate on site plan):
Pumps in working order
Alarms in working order: Yes ❑ No
0 Yes ❑ No
Comments(note condition of pump p chamber, condition of pumps and appurtenances, etc):
N/A
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
TO?5 Official L¢OMim Form:subsurcace Sewage Disposal sy&pn•Pave rzan
Commonwealth of Massachusetts
Title 5
Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
560 SYLVESTER ROAD ___----------- _ __
Property Address
ESTATE OFD RIVARD—SUSAN GODARD DAUGHTER
O
NORT Z—— OCTOBER 1,20'I2__
Name MA_ Date of Inspection
NORTHAMPTON ——— -state Zip code
ciyrrowT
D. System Information (cont.) st uc ural integrity.
Comments(on pumping recommendations, inlet and outlet e or bathe condition,
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).
NIA_—
Depth below grade:
Material of construction. other(explain).
❑concrete 0 metal
❑Fiberglass ❑ polyethylene ❑
Dimensions:
gallons
Capacity: ----------
gallons per day
Design Flow:
Alarm present: ❑ Yes ❑ No
Yes ❑ No
Alarm in working order:
Alarm level:
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Yes ❑ No
'Attach copy of current pumping contract(required). Is copy attached? ❑
Title 5 OKr o Inspection Form:Subsurface Sewage Disposal System•Pape 11 of 17
ans.11110
Owner
information is
required for
every Page.
tsins•11/10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
560 SYLVESTER ROAD
Property dress --__-------
ESTATE OFIR_ENERIVARD— _ —
Owner's Name _--
___SUSAN GODARD DAUGHTER_
NORTHAMPTON
City/Town --_----------_ MA. 01062 OCTOBER 1, 2012
State Zip Code
D. System Information (cont.)
Date of Inspection
s
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vege
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 vegetati
etc.):
N/A
Tme 5 Olrrai Iry4RcAion Fpm'SuMU/ex Sewag Dl System.Page 14 d1
Commonwealth of Massachusetts
Official Inspection Form
Title 5 Assessments
Subsurface Sewage Disposal System Form-Not for Voluntary
560 SYLVESTER ROAD__—_------ --
Property Address
——--
ESTATE OF IRENE RIVARD=SUSAN GODARD DAUGHTER OCTOBER 1, 2012 __--
Owners Name 01062__
MA_ Date of Inspection
NORTHAMPTON State Zip code
CiryROwn
D. System Information (cont.)
Type.
0
number
leaching pits
leaching chambers
number:
El
number:
leaching galleries 2_t0 L+I-
number, length:
® leaching trenches
number,dimensions:
0 leaching fields
0
number:
overflow cesspool
0 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.):
Pipe exits septic tank for app rox. 12'to a tee. From this tee a snake ran only
Orangeburg pipes running to and from tee
were more feet and stopped due to sludge buildup pie Oryn 9
were in poor condition and very brittle. No sewage backup was evident at this time due to dwelling
bein unoccu led, Sludge buildup in pipes is evidence of a clogged SAS.———------
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan).
NIA
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 r Subsurface Sewage Deposal Syneo.raga 13 as
Title Official Inspection °^a
ins'11110
Owner
information is
required for
every page.
151ns.11(10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
560 SYLVESTER ROAD
Property Address------ ----------_
ESTATE OF IRENE RIVARD—SUSAN GODARD DAUGHTER
Owner's Name
NORTHAMPTON
CiryiTowrl ---------_ MA. 01062 OCTOBER 1, 2012
D. System Information (coot.) State zip Code Date of Inspection
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 3+
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:
Daughter states no records on file at B.O.H. office.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Observation of Site and Abutting Properties. No Sump in Basement of Dwelling.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
Tr/le 5 Official Inspection fpm
Subsurface Sewage nispnsal5Ya2m•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
560 SYLVESTER ROAD
__-----
Property Address
ESTATE OF IRENE RIVARD–SUSAN GODARD DAUGHTER
Owners Name
NORTHAMPTON —
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D. System Information (cont.) ties to
Sketch Of Sewage at least two permanent eferencelandmarkseor view
benchmarks. Locate all elllls system,
ithin 100 feet.including Locate
where public water supply enters the building. Check one of the boxes below.
01062 OCTOBER 1, 2012—
MA.
State Zip Code Date of inspection
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
560 SYLVESTER ROAD. ----.—.
Property Address
ESTATE OF IRENE RIVARD-SUSAN GODARD DAUGHTER_--- — ---
Owner's Name MA 01062 OCTOBER 1, 2012
NORTHAMPTON _—_— —.--- State Zip Code Date of Inspection
City/Town
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
• Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
Z System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
title 5 nlfidal In oil Form:Sub
System Page 17 M 17