275 Septic Inspection 2011 (2) Sonar
formation is
puirtd for
cry Page
Commonwealth of Massachusetts
Title 5 Official 'Inspection Form
Subsurface Sewage Disposal System Fonn Not for Voluntary Assessments
275 HATFIELD STREET
Properly Moms
JOHN SULLIVAN
Oeneh Na,,.
NORTHAMPTON MA. 01080
C9yfown MAY 9,2011
Stab Zip Cods Data of tropenion
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E l always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure cites described
in 310 CMR 18303 or in 310 CMR 15.304 exist Any failure Lynette 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 die replacement or repair, as approved by
the Board of Health,will pass.
Check the box for'yes', 'no or"riot determined'(Y, N, ND)for the following statements. If"not
determined,'please explain.
The septic tank is metal and over 20 years 01d•or the septic tank(whether metal or not)is
structurally unsound,exhibits substantial infiltration or exNtration 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 ifs is structurally sound, not leaking and N a Certificate of
Compliance Indlcating that the tank Is less than 20 years old Is available.
❑ Y Z N ❑ ND(Explain below):
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Commonwealth of Massachusetts
Q Title 5 Official Inspection Form
rgy Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
`i9' 275 HATFIELD STREET
Property Aden,
JOHN SULLIVAN
a, Owners Name
; la
na
raa me
NORTHAMPTON MA 01060 MAY9,2011
Y Page. CeyRawn Stale Zlp Code Data A eepeceiun
B. Certification (cunt.)
2. System will fall unless the Board of Health(and Public Water Supplier,N 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 MS 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 weir.
Method used to determine distance:
This system passes if the well water analysis,performed at a DEP certified laboratory, for fecal
colifonn 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 mit Indicate"Yes"or"No"to each of the following for pJl inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
E Oiecharge or cording of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ E Static liquid level In the distribution box above outlet invert due to an overloaded
or dogged MS or cesspool
❑ E liquid depth in cesspool is less than 6'below invert or available volume is less
than %day flow
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
275 HATFIELD STREET
properly Address
JOHN SULLIVAN
Owner's Name
NORTHAMPTON MA. 01060 MAY g,2011
Cey?pwn Stab bp Code Dab 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
® ❑ Pumping information was provided by the owner,occupant,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
5 ❑ 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)
5 ❑ Was the facility or dwelling Inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
5 ❑ 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?
slay and location of the Soli Absorption System(SAS)on the site has
been determined based cm
Existing information. For example,a plan at the Board of Health.
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):
2
Number of bedrooms(actual).
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms).
2
220 gpd
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Commonwealth of Massachusetts
ea Title 5 Official Inspection Form
ISubsurface Sewage Disposal System Forrn-Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Ownefa flame
NORTHAMPTON MA.
State
ten is
for
We
City/Town
01060
Lp Cade
MAY 9. 2011
Cate of Inspection
D. System Information (cont)
Last date of occupancy/use:
Other(describe below):
NIA
N/A
Sate
General Infomwtlon
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Pumped 2-3 years ago per owner.
1500
® Yes ❑ No
—n
Tank Dimensions
Tank Inspection
Type of System:
Septic tank, distribution box. soil absorption system
Single cesspool
0 Overflow cesspool
Privy
[] Shared system (yes or no)Of yes,attach previous inspection records, if any)
InnovatNe/Alternative technology. Attach a copy of the current operation and
inspection of the contract
system by system operator under contracts copy of latest system owner)and
Tight tank. Attach a copy of the DEP approval.
Other(describe):
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page
Commonwealth of Massachusetts
Title 5 Official Inspection uForm Assessments
Subsurface Sewage Disposal System Form-Not tor
275 HATFIELD STREET
Property Address
JOHN SU LL IV AN
Ownela name
NORTHAMPTON._-
CM/Town
D. System Information (cont.)
Approximate age of all components,date installed (if known)and source of information.
9 Years Old / 2002 I Des•n Plan Dated 09/18/02
Were sewage odors detected when arriving at the site?
Building Sewer(locate on site plan)-.
Depth below grade:
Material of construction
®cast iron tEl 40 PVC ❑other(explain)'.
Distance from private water supply well or suction line:
MA 01060 MAY 9, 2011
Saw Zia Code Date of It-sp.:bon
❑ Yes ® No
2.5
feet
Cast iron Sting house and PVC
entering septic tank. _
Town Water
bet
Comments(on condition of joints,venting, evidence of leakage, etc.):
Rouse built on a slab with no visible building sewer joints. Venting
pipes were visible outside the dwelling on the root. No leakage was evident at this time.
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑metal
❑fiberglass ❑polyethylene ❑other(explain)
WA
If tank is metal, list age. years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
10'6"Lx56'Wx514"D
Dimensions:
Sludge depth:
6"
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Commonwealth of Massachusetts
Title 5 Official Inspection uFFo �n�
Subsurface Sewage Disposal System Form-Not for
275 HATFIELD STREET
Property Address
JOHN SULLNAN
Owns Name MA. 01080 MAY 9 2011 _
'"`� NORTHAMPTON State Zip Coe, Date d Inge n
or GMrto«n
D. System Information (cont.)
Distribution Sox(if present must be opened)(locate on site )NOndue to an overloaded or clogged
Depth of liquid level above outlet invert SAS
Comments(note if box is level and distribution to outlets equal, any evidence of soles carryover,any
evidence of leakage Into or out of box,etc): Distribution box has appeared to have settled
which is why the liquid level is 1"above the outlet inverts. Box appeared to be level and flow
appeared to be equal to as three outlet pipes at this time.Very little solids carryover was in the box
when opened for inspection. No leakage was evident into or out to of the be box at s time iistributan
box• acement is NOT recommended at this peon box appeared
s. o
Pump Chamber(locate on site plan):
Pumps in working order
Alarms in working order:
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
D Yes
• Yes
No
❑ No
N/A
Soil Absorption System(SAS)(locate on site plan.excavation not required).
If SAS not located,explain why:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
275 HATFIELD STREET
homeroom/ow
JOHN SULLIVAN
Oane/s Name
is NORTHAMPTON MA 01060 MAY 9,2011
CMRam Stste Zip Code DW of knpamn
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation.
etc.):
N/A
Privy(locate on site plan):
Materials of construction:
Dimensions
N/A
N/A
N/A
Depth of solids
Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
N/A
•Iwo
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
275 HATFIELD ELD STREET
Properly Addma
JOHN SULLIVAN
a` wee MA. 01060 MAY 9 2011
NORTHAMPTON stem coo• tune of Inspection
CkyROwn
D. System Information (cons.)
She Exam:
El Check Slope
EJ Surface water
❑ Check cellar
❑ Shallow wells
44
Esbmated depth to high ground water het
Please indicate all methods used to determine the nigh ground water elevation:
Obtained from system design plans on record
09/18/02
If checked,date of design plan reviewed: one
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked whh 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.
De n Plan and Site Exam
Before filing His Inspection Rapor4 pleas
see Report Completeness Checklist on next page.
no.s omaa•aKa'rmn ac..ri sw.ri a.w.+soon.r,r,16 a 17
Commonwealth of Massachusetts
lyTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
275 HATFIELD STREET
Property Address
JOHN SULLIVAN
Owners Name MA 01050 MAY 9 2D11
eon° NORTHAMPTON Date d mweaa^
f M Mate Lp Code
ago Cityrrvwn
E. Report Completeness Checklist
® Inspection Summery' A. B,C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
� System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either dram on page 15 or attached in separate file
in•11110
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FORM 3A • CERTIFICATE Of C0Mfl.W C -
Nan-0-L
COMMONWEALTH OF MASSACHUSETTS
toad of Health, MATH k girti i • MA.
CERTIFICATE OF COMPLIANCE
Decription of Work: 0 Individual Component(s) %tomplete Sy stern
The undersigned hereby certify that Re Sewage Disposal System,
Consln+aed I ). Repaired lA Uppaded I Abandoned ( 1
Or' CLeritV Sffr1ttC.
Ili i 5 14 ATTI LjI rt.
has been ms:alled in accordance with the provisions of 310 CMR 15.00 (Title 51 and the
approved design planslas-Wh plans rebung to appiication No.
dated
IrualttF. . •\\ °\ a.
Designer: Adf
Date 9-2 Pet
�
Wie/Oa Approved Design Covina (gpol
(CIA) inspector
The isswnce of this permit shill not be construed as a guarantee that the system will
function as designed.
.s-w se i- SO Q cs4( a ,,
0110 amore roe.LM
THE COMMONWEALTH OF MASSACHUSETTS
—l/aRreter rm MASSACHUSETTS
pplira ion for pisposttl *stem Construction Permit
Application is hereby made for a Permit to Construct( ) or
(v-)an On-site Sewage Disposal System at
Fit 7Ldre
Locauun Address or Lot No.
a^.S 1faTFia-0 577
A/04 T ,n-mpTOW M/}
Installers Name,Add.ess,and TeI.N0
/(Harts 5/cevP-rdit.
Type of Building:
Dwelling No. of Bedrooms 3 /
Other Type of Buildin¢ Garbage Grinder(i.
Other Fixtures _ MCI No.per Persons _ Showers
/IOBCzT A'✓Tr9 SEAL 440,71-
295 ilyrrnao 67:
Designer;NNamme.Address and Tel No.
I J!
Design Flow
Plan Date ___
Title
Description of Soil
gallons per day.
Calculated daily flow
Number of sheets Revision Date
Cafeteria(
gallons.
Nature of Repairs or Alterations(Answer when applicable)BEpifY
To.SaG + L11caQ TAA K Tn L - 0 oa • S�� r iiltih aAlL�l
aL
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Till 5 of the Environmental Code and not to place thesystem in operation until a
Certificate of Compliance has been it ed by t is Board of Health_
Signed- -ru....a
Application Approved by
Application Disapproved for the following reasons
Permit No.
33 -VG
Date Issued
Date
/0 --43-96
Date
THE COMMONWEALTH OF MASSACHUSETTS
,MASSACHUSETTS
Certificate of Compliance
or re aired;repVaeed(�on
i �
THIS IS TO CERTIFY,Y,that the On-site Sewage Disposal System installed( _ P has been constructed in
i.:r. ,.:. ,.
t_ - -` - I"" by j._ 9l�.— dated
i >>
• Use of this system is conditioned on compliance with the provisions set forth below:
accordance with the provisions of Title 5 and the For D�spa of System Construction permit No.
tiara sYS/ff'will function °"s g^id�This
The issuance of this certificate shall not be construed as a g
Certificate expires on
DATE
> >- y�
Nu. '
Inspecto
THE COMMON WE LTH OF MASSACHUSETTS
,MASSACHUSETTS
p pnsttl
$ - , >ystent Construction Permit
� T
ror /l /y
C
Permission is hereby grante to
to construct( )o repair( an System located at
r - /1-1 e
Application for Disposal System Construction Permit The applicant recognizes ha;her
and as described in the above APP �,, �-
duty to comply with Title 5 and the following local provisions or special conditions
DATE construction must 6e atnpkted within then Tears of the date abelow. ✓
.e �
DATE
FOAM 1255 Per P'-5 aM.illlxiN CO-BCSr]x.MA
i
FORM 3A - CERTIFICATE OP CONITLIANg
ti
COMMONWEALTH OF MASSACHUSETTS
Board of Health, NORTH duiriViziti , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Components) 13'famplete System
The undersigned hereby certify that the Sewage Disposal System,
Constructed 1 ). Repaired I/Upgraded I I, Abandoned (
by CLeriN V.- Ti.et'-
al. 275 lei Art'IPL-13 S4,
has been installed in accordance with the provisions of 310 CMR 13.00 (Title 5) and the
approved deessign ptans/as-built plans relating to app■ication No
dated 7//8/0Q Approved Design Flow.alaa igpol
Irsialte;.. `-y,��'. .s.t��li o. dStl
Designer: '%n CIA Inspector
Date Q-25.0L
The issuance os this permit shall not be construed as a guarantee that the system will
function as designed.
Sgje4 t -L 4_4 4 Altau. a,,s -`-7
011 anIQrt0 rod 1311
THE COMMONWEALTH CF MASSACHUSETTS
NORTHAMPTON
MASSACHUSETTS
FEE o
Application fur Disposal §ystem (ianstrurtion hermit
Application is hereby made for a Permit to Construct( )or Repair( X)an On-site Sewage Disposal System at:
Dawn Add,tI$ to'No- ounces Nn.AJJ V S.and 7c1.N.
BOB KUTA
275 HATFIELD STREET
584-7409
a Name.AMam.did Mb.
CLEAN SEPTIC,INC.
paypia'S fart.M&rn ml Tel No
[CEA]Civil Engineering Associates
10 Crane Avenue
East Longmeadow,MA 01028 Tel:(413)525-2874
Type of Building:
Dwelling No.of Bedrooms 2 Garbage Grinder( )
Other Type of Building No.per Persons Showers( ) Cafeteria(
Other Fixtures
Design Flow
Plan Date
Title
Description of Sal See Attached Soil Profile
222
gallons per day.
Calculated daily flow
220
09/18/02 Number of sheets 4 Revision Date
Proposed Sewage Disposal System Prepared For: 275 HATFIELD STREET NORTHAMPTON
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected'
Agreement:
The undersigned agrees to ensure the construction and maintenance or the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by this Board of Health.
�;ied Date
Application Approval by Date
Application Disapproved for the following reasons
gallons.
Permit No 23-0 ")-- Date Issued
THE MMONWEALL .OF MASSACHUSE I I
, MASSACHUSETTS
dertifira r of (lomplianrr
T I CERTIFY, ..t the On-si ewafl Disposal System installed(„)otreu6lre44 pled("4on
6 by for fSO L1 j�tr-x+.+
II 11i S has been constructed in
at - O -- dated
accordance�ithf a nwajgions of Tit Sand the for Disposal System Construction Permit No. -� -
1 Gr . Use of this system is conditioned on compliance with the previsions set forth below:
/5 arno
The Issuance of this ccrtificj h loot onstrtred as a guarantee that the system wiB�tion as Miguel, This
Certificate expires on /
DATE e a-- Inspector , f f ,�r, •