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315 Title 5 10-25-14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1/47 ., 315 Sylvester Rd., Northampton_Property Address Marissa and Alexander Grevior 315 Sylvester Rd. Owner Owners Name requireaio0n is sa Northampton Ma 01060 10/25/14 page. City/Town 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. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector. key to move your cursor-do not Torn Martin use the return - - --- ------- -- - - key. Name of Inspector Turkey an Field Services w Company Name 140 Easthampton Rd Company Address Westhampton Ma 01027 City/Town State Zip Code 413-923-8684 4199 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 she 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 Evaluationlu�by the Local Approving Authority C7/r"/1Gr*/W/I 1025/14 ____--�VV7 Inspectors 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 perforin in the future under the same or different conditions of use. thins•NIS ale 5&fdel rspe..oa,t roan subsurface Sewage Disposal System.Page 1 of IT Commonwealth of Massachusetts ahr _(/ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .de 315 Sylvester Rd., Northampton Property Address Marissa and Alexander Grevior 315 Sylvester Rd. Owner Owner's Name information's required for eveevery Northampton _ _ Ma 01060 10/25/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: Pump every other year under normal use. 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): isms•3/13 Title s Official 1 gnuwn Form Subsurface Sewage Disposal System•Gem 2 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • 315 Sylvester Rd., Northampton Property Address Marissa and Alexander Grevior 315 Sylvester Rd. OwnerO wrleYs Name _ _ information is every Northampton pages:d for eve _P Ma Z10 ed Dateof 10/25/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 El Y ❑ N El 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 t rm•3113 rill 5 offos Magadan Form:Subsurface Sewage Disposal System.Page 3 Mn Commonwealth of Massachusetts Title 5 Official Inspection Form r—,_EN _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pt -- ')r,��,�' 315 Sylvester Rd., Northampton Property Address Marissa and Alexander Grevior 315 Sylvester Rd. Owner Owner's Name. _ is information r 7 Northampton _ Ma 01060 10/25/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 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: **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 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 ❑ ® 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 %day flow 5ns.3/13 Title 5 Official Inspection Conn:Subsurface Sewage Dispose,System Page epaamir Commonwealth of Massachusetts rr - €/, Title 5 Official Inspection Form T• _`-�- i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments }_L= S •Ny„ , 315 Sylvester Rd., Northampton Property Address Marissa and Alexander Grevior 315 Sylvester Rd. Owner Owners Name —. information qure.for is Northampton Ma 01060 10/25/14 n page. City/Town State Zip Code Dale 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: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z My portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0 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.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area–IWPA)or a mapped Zone 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. Gns•3/i3 Tine 5 Official Inspection Finn:Subsurface Sewage p¢posei Sy tsm-Page 5 M 17 Commonwealth of Massachusetts Commonwealth of Massachusetts if Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rr , 315 Sylvester Rt, Northampton Properly Address Marissa and Alexander Grevior 315 Sylvester Rd. Owner Owner's Name information a required for every Northampton - - _ Ma 01060 10/25/14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: ?. Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): private well Detail: Sump pump? 9 Yes ® No Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): talions per day(gpd) - -- — Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: -- - -- Eons•w13 This 5Offioa Inspection Fano Subwrlace Sense Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form F: _'i- 0 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments IP,-„--atc. 315 Sylvester Rd., Northampton Property Address Marissa and Alexander Grevior 315 Sylvester Rd. _ Owner Owner's Name information is Northampton required every _ Ma 01060 10/25/14 page. City/Town - State Zip Cale Date of Inspection D. System Information (cont.) Last date of occupancy/use: -- - -- Date Other(describe below): General Information Pumping Records: Source of information: pumped 2013 and every other year previously Was system pumped as part of the inspection? ❑ Yes �'2 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. Other(describe): Septic Tank with Leaching galleries 15e¢.3113 rile 5 omdal Inspection Form.Subsurface Sewage Disposal System.Page sof 17 Commonwealth of Massachusetts Title 5 Official Inspection Form If0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 1 %,se 315 Sylvester Rd., Northampton Property Address Marissa and Alexander Grevior 315 Sylvester Rd. Owner owners Name -'- - information is reouiredrorevety Northampton _ Ma 01060 10/25/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 13 years old Were sewage odors detected when arriving at the site? El Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): -- --. Distance from private water supply well or suction line: 40 - -- feet Comments(on condition of joints, venting, evidence of leakage, etc.): ok Septic Tank(locate on site plan): Depth below grade: 1.75(risers at inlet and outlet feet Material of construction: ® concrete ❑ metal El fiberglass El polyethylene El other(explain) 1500 gal Twin Compartment Tank. Strongly advise informing pumpers of Twin Compartment Tank and that both ends of the tank are pumped. • If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes ❑ No Dimensions: 10'x 6'x 5' Sludge depth: 1 inch ,sins•3n3 nue spndN Inspection Form''&Pylae Sesame Disposal System'Page 9 of 17 Commonwealth of Massachusetts r _ �r Title 5 Official Inspection Form __r�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / i_ cL49 315 Sylvester Rd., Northampton Property Address Marissa and Alexander Grevior 315 Sylvester Rd. Owner Owners Name - - -information is required for every, Nnrthoampton Ma 01060 Date of 10/25/14 pagwn State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge or scum at outlet Scum thickness twin compartment 3"at inlet 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.): recommend pumping this tank at the end of 2015 and every other year subsequently. Please inform pumping company that you have a twin compartment tank and have them pump both ends of the tank. Grease Trap(locate on site plan): Depth below grade: - feel Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: . _ Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle — - - - - - Date of last pumping: Date 5ms•3/13 Me 5gfida 1nspeticn Fens:Subsurface Sewage Dlsrasal Symem-Page ID al IT Commonwealth of Massachusetts Title 5 Official Inspection Form ___r_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 315 Sylvester Rd., Northampton Property Address - Marissa and Alexander Grevior 315 Sylvester Rd. Owner Owners Name information is required for every Northampton Ma 01060 10/25/14 page- 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.): 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 y Li other(explain): Dimensions: Capacity: galbns - - - 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 (Sins•3113 Title 5 Offidal Inspedron Form:Subsurface Sewage Disp s System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form "rSubsurface Sewage Disposal System Form -Not for Voluntary Assessments WNW • „ � 315 Sylvester Rd., Northampton Property Address Marissa and Alexander Grevior 315 Sylvester Rd. Owner - -.__- —__ Owner's Name information for isreqUirNorthampton Ma 01060 10/25/14 Page, for every P __. page. Clryrtown State Zip Code Date of Inspection 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ Not Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): ' If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: ts'ns.3/13 llR 5 Official Inspechan fpm:Subulae Sewage Disposal System Page 12 of 17 Commonwealth of Massachusetts ktt --n Title 5 Official Inspection Form 94 T;F!i 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I�_ 315 Sylvester Rd., Northampton Property Address Marissa and Alexander Grevior 315 Sylvester Rd. Owner Owner's Name - - - - - - information is required for every Northampton Ma 01060 10/25/14 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: -- --- - ❑ leaching chambers number: ❑ leaching galleries number. 3- ❑ 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 signs of hydraulic failure. Ran 150 gallons through system and no backup at outlet. Excavated to the sides of the leaching gallery into stone. Stone dry . No water or evidence of flooding. 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 0 Yes ❑ No LSiris•3/13 Title 501Rpal Nspegron Form'.Subsurface Sewage Disposal System•Page 13 N 17 Commonwealth of Massachusetts it s Title 5 Official Inspection Form _ --,._'_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • :,., 315 Sylvester Rd., Northampton -Property Address _- -- Marissa and Alexander Grevior 315 Sylvester Rd. Owner Owner's Name - -— inform required 5 Northampton _ Ma 01060 10/25/14 _ page. for every __. P _- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, 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 vegetation, etc.): Mins•3/13 Tate5 Ofival L;elicit Farm:Subsurface Sewage Disposal System•Page 1C of 17 Commonwealth of Massachusetts P = -€/ Title 5 Official Inspection Form mem- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •\C� 315 Sylvester Rd., Northampton Property Address Marissa and Alexander Grevior 315 Sylvester Rd. Owner Owners Name information is required for every Northampton Ma 01060 10/25/14 page. City/Town State Zip Code Dale 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 Ndi To SCALE __ -- 0 LOCH tAlb . 1 _� d L — ® zsv AsP"1A A t GAL t ,,ES J tuTu 13' duT /Soo ri h,-,,, L — — ! iauk ( My C l' A to D 26,0 i3-to C its! �` z7 te D 19 I I — S1(L.vin4\) r (\. 15L,s-3.13 Tale 5Ofica Inspectun Fame-.Subsurface Sewage Deposal System-Page IS of 17 Commonwealth of Massachusetts itzsift Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a .S' 315 Sylvester Rd., Northampton Property Address Marissa and Alexander Grevior 315 Sylvester Rd. Owner Owners Name information is required ror every Northampton _ Ma 01060 10/25/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 6 -. feel 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: included 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: see copy of system plan provided by owner. Before filing this Inspection Report, please see Report Completeness Checklist on next page. ttins•3/13 Bile 501fio&Insi:Ton Fpm:Subsurface Savage Disposal System'Page 16 d 17 Commonwealth of Massachusetts =__ � Title 5 Official Inspection Form E `_aw i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •�, ,:: 315 Sylvester Rd., Northampton Property Address Marissa and Alexander Grevior 315 Sylvester Rd. Owner Owners Name _ information is required for every Northampton Ma 01060 10/25/14 page. City/Town — Zip State Zip Code Date of Inspection E. Report Completeness Checklist O Inspection Summary: 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 drawn on page 15 or attached in separate file I5'ms•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal SySta'n Fade 17 Of 17