88 Title 5 2017 (2) RM Scott&Associates
31 Shutesbury Road
Pelham, MA 01002
Office: (413)256-0647
Mobile: 413-658-4921
Email: rsscottpe(n),comcast.net
April 11, 2017
Edmund Smith
Health Department
212 Main Street
Northampton,MA 01060
Subject: Septic System at 88 Maple Ridge Road (Property of Ron Matuson )
Title 5 Inspection on 4-15-15, and Re-inspection on 4-10-17.
The previous inspection, on April 15,2015,has exceeded its 2-year validity so 1 have
completed a re-inspection of the system in accordance with 310 CMR 15.000 (Title 5)
requirements,and telephone instructions from Christopher Bishop of your office on 3-23-
17. Per the owner,the house has been largely unoccupied for the last two years. My
inspection yesterday is consistent with this lack of use—there is no solids accumulation
Despite lack of use the liquid levels are correct, indicating no leakage from any system
components.
This system is certified as,"Passed" by the criteria in the regulation. A copy of the
updated report with additional comments is enclosed for your use and files.
If you have questions on any aspect of the inspection or the report please contact me at
the address,email or telephone contacts above.
Sincerely,
Richard Scott.P.E.
cc: Ron Matuson,Owner
Julie Held, Realtor,Maple and Main
Buyer do Julie Held
Commonwealth of Massachusetts
Title 5 Official Inspection Form
wie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
- 88 Maple Ridge Road
Property Address
Ron Matuson (Ref: Prior Inspection 4-15-15)_ _
Owner
Owners Name - -- - - -
information is
requiredNorthampton MA 01060 410-17
Page,
for every _- - - -__- - _... . . _
pCity/Town
y/rown 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 Rick Scott
use the return
key
Name of Inspector
RM Scott 8 Associates, LLCVIr
m Company Name
Jct 31 Shutesbury Road
Company Address
tae X Pelham MA 01002
•
City/Town State Zip Code
413-256-0647 SI1030. MA P.E. 31199.
Telephone Number License Number
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
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
4-10-17
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 perform in the future under
the same or different conditions of use.
15Ms•3113 Title 5 ORmal Inspection Farm Subsurface Sewage Disposal System'Page 1 of ll
?'\ Commonwealth of Massachusetts
y Title 5 Official Inspection Form
' mi �s� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 Maple Ridge Road
b _
Property Address
Ron MatusonWRet. Prior Inspection 4-15-15.)
Owner
Owners Name
Inbnnanon is
Northampton MA 01060 440-17
page.ed for every P _—_.. _._ —_
page. Cilyrrown State Zip Code Dare of Inspection
B. Certification (cont.)
/ Inspection Summary: Check A,B,C,D or E 1 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 failure criteria observed. System passes. See additional notes in report
ili A 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" (V, 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
e 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 0 N 0 ND(Explain below):
ISns i 3na Tule 5°Baal lnsneNon Form Subsurface Sewage nupaeal System•Page i o1 17
Commonwealth of Massachusetts
vs Title 5 Official Inspection Form
�_ I 6 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Maple Ridge Road.
Property Address ----
Ron Matusorl Ref: Prior Ins_p ctlon 4-15-15.)
Owner Owner's Name - _-
requiresfarevery Northampton MA 01060 410-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
El 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 ❑ V ❑ N ❑ ND (Explain below):
El obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
5 distribution box is leveled or replaced El 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 IDNION ❑ ND(Explain below):
❑ obstruction is removed OVONO ND(Explain below):
IVIA 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:
El 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
,5,„.v1., Tile 5 offpal Inspection Form sumurtaos sews a Di
g srysel syabmPage>Wt)
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
iil I« Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�. m, 88 Maple Ridge Road_ _
Property Address
Ron Matuson(Ref Prior Ins _
pection 4-15-15.)
Owner O -
owners Name
information is Northampton MA 01060 4-10-17
rage. for every P __.
page. ClryRown State Zip Code Nate 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:
E 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.
9 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
9 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:
\./ 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 'A day flow _
Isms.3113 tines Mined Nsp%Ibn Foma Subsurface Sewage Disposal System•Fog.4 01 17
Commonwealth of Massachusetts
li Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Maple Ridge Road
Properly Address
Ron Matuson (Ref Prior inspection 4-15-15.)
Owner Owner's Name --- - -- -'
information is
required for very Northampton __. _ MA 01060 4-10-17
page. Cay/TownState 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:
❑ ® 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.
❑ 0 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.
❑ ® 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.
/°/A E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 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.
isms.Jns Tam 5 Official Inspection Form:Subsurface sswane Disposal System•Page s o11?
.... ...._.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
CL._ • e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
il
88 Maple Ridge Road
L
Property Address
Ron Matuson (Ret Prior Inspection 4-15-15.)
Owner -- '-
Owner'sName
information is
recta-ad for every Northampton __. . MA 01060 _ 4-10-17
page. 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
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Z Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
c4 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?
z ❑ 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:
Z ❑ 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)]
/13. System Information
J Residential Flow Conditions:
Number of bedrooms(design): 5-- -- Number of bedrooms (actual): 5--- -
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550
sins.3113 Tale 5 ornoal Inspection Fenn s,dsunare Sewage Disposal System.Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V`ti
ti 88 Maple Ridge Road
a
Property Address
Ron Matuson (Ref Prior Inspection 4-15-1U
Owner _ - - _.--
Owners Name -- ---
Information is every
Northampton required for eve P _... .__ _- MA 01 410o17
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1500 gallon septic tank with cast-in inlet and outlet baffles. Gravity flow to Distribution Box and
Infiltrators in a six-line Leach Field.
Number of current residents: —_
Does residence have a garbage grinder? ❑ Yes 0 No
Is laundry on a separate sewage system?(Include laundry system inspection
D Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes 0 No
Water meter readings, if available(last 2 years usage (gpd)): -Detail:
See prior inspection report dated 4-15-15. Per owner, the house has been for sale and largely
unoccupied the last two years. Inside-the-house inspections were not repeated as part of today's
inspection.All outside-the-house inspections are completed to update this process for a sale toclose
approx.4-29-17.
Sump pump? ❑ Yes ® No
Last date of occupancy: April, 2015.
Date
/y/A CommemiaUlndustrial Flow Conditions:
Type of Establishment
Design flow(based on 310 CMR 15.203): --- --- ---- ------ -___- _
Gallons 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
"',,,'3/la rule 5 Official Inspection Form-Subsurface Sewage DispOSal System.Page 7 of 17
Commonwealth of Massachusetts
4 4..) Title 5 Official Inspection Form
i- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
-/
4 n"7, 88 Maple Ridge Road
L
Properly Address
Ron Matuson (Ref: Prior In pection 4-15-15.)
Owner
Owner's Name
mro required
for
Is Northampton MA 01060 4-10-17
page- ror a.ery P _._
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: - - ---------
Date
Other(describe below):
/ General Information
✓ Pumping Records:
Source of information: Per owner, previous pumping was -November, 2014
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)
❑ 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):
i&ns•3113 Tare 5 omoell Inspection Fenn Subeurlacs Sewage Disposal System.Pegs sof 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form Not for Voluntary Assessments
-f 88 Maple Ridge Road
-nal,. d
Property Address
Ron Matuson (Ref: Prior Inspection 4-15-15.)
Owner Owners Name -'
information a Northam ton
required for every P MA 01060 4-10-17
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.
Sgtem installed in 1998. System Design Plan and as-built documentation on file at Health Dept. _
Were sewage odors detected when arriving at the site? ❑ 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: N/A. Municipal supply- pressure
line.
Comments(on condition of joints, venting, evidence of leakage, etc.):
All in-house plumbing is in excellent condition No evidence of any previous problem. Vented to roof.
Septic Tank(locate on site plan):
Depth below grade: 1.0
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene 5 other(explain)
1500 gallon concrete septic tank with cast-in baffles.
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 126"X 66"X 54"effective depth.
Sludge depth: 1.,
thins-3/13
rifle 5 Olrpal Inspen 41 Fmn Subewlam Sewage D'posal Sysiem.Page 9o11'
.._.._....
: Commonwealth of Massachusetts
aa Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
e
is
,- 88 Maple Ridge Road
Property Address
Ron Matuson1Ref Prior Inspection 4-15-15.)
ower _-
Owners Name
Information is Northampton_._ MA 01060 4-10-17
required for every P __._. . _ ... .
page. City/TownSta[a Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle -34 --
Scum thickness
Distance from top of scum to top of outlet tee or baffle _5
Distance from bottom of scum to bottom of outlet tee or baffle -- ---- - -- --
How were dimensions determined? Probed during on-site inspection.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
4-15-15 Report: --Minimal solids accumulation. Existing dimensions are sufficient to provide good
retention time in the tank. Liquid levels are correct. No evidence of past leakage out of the tank or
high liquid levels above the outlet. Tank is in good condition. Cast-in inlet and outlet baffles are in
good condition with some minor deterioration at outlet, consistent with age. Next maintenance
pumping recommended in 2017, depending on rate of usage.
4-10-17 Update Report: —All outside-the-house components have been re-excavated and re-
inspected.The house has been unoccupied so, as expected, there is no appreciable solids
accumulation. Despite lack of use, the liquid levels in the septic tank and D-box are correct, indicating
no leakage from the system
WW/A Grease Trap(locate on site plan):
Depth below grade: reef
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
6.n..3113 Title 5 Waal Inspection Farm soosunaca sewage Disposal sv.a^•Paae 10 a117
Commonwealth of Massachusetts LT'
Vi(� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s 88 Maple Ridge Road
Property Address
Ron Matuson(Ref: Prior Inspection 4-15-15.)
Owner owners Name -- -- -
information is Northampton required for every pt MA 01060 4-10-17
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.):
a/A Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
9 concrete 9 metal ❑fiberglass ❑ polyethylene
9 other(explain).
Dimensions:
Capacity: _
gallons
Design Flow: _
gallons per day —
Alarm present: ❑ Yes ❑ No
Alarm level: -- - - - — Alarm in working order: ❑ Yes 9 No
Date of last pumping
Date ate
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes 9 No
iSins•3/13
Trts 5 onla&mfwton Form:Subsurface Sewage Disposal system.Page 11 01 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
..,/ 88 Maple Ridge Road _
Property Address
Ron Matuson(Ref Prior Inspection 4-15-15.)
Owner Ow Name
-'
Owner'sName
information is Northam
required for every Northampton MA 01060 4-10-17
page. CiryRown 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.):
4-15-15 Report: --Box is level and is distributing flow equally. Only minor solids carryover is
observed. No evidence that solids have been carried out the distribution pipelines. Some
deterioration of the box side walls, consistent with age but the D-box is structurally sound. No
evidence of previous leakage out of the D-box or high liquid level above the outlets.
4-10-17 Update Report: --No change in condition of the D-box. Liquid is at the pipe inverts and
dividing flow evenly. Minor deterioration of the box and cover is observed but structurally sound.
Minor root intrusion is noted from a nearby tree.
AYA Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No'
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:
D-Box found. Documented SAS is a six-line leach field with Infiltrators. See sketch.
i5rns.113 nue 5 Official Inaov'"ion Form Subwlaca Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
; LI-1077 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
i 88 Maple Ridge Road
Property Address ----
Ron Matuson(Ref: Prior Inspection 4-15-15.)
Owner Owners Name - - ---information is
Northampton MA 01060 4-10-17
required for everyP
page. 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: One Field.
Approx 20'X 50'.
❑ 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 sign of problems observed from ground surface. Distribution box is buried approximately 22". A
20"oak tree is planted north of the D-box and tree roots are present at 0-box, but roots have not
invaded into the box or the distribution pipes. _.
iif/p 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
1Sins-3n3 rale 5 Official Inspection Farm Subsurface Sewage Disposal System.Page 13 orf]
Commonwealth of Massachusetts
d !j =r- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
_is
88 Maple Ridg_eRoad
Property Address
Ron Matuson (Ref: Prior Inspection 4-15-15�
Owner Owner's Name
miis
reqquireduiredffor every Northampton
MA 01060 4-10-17
o -_
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.):
NIA 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•3/13 11e 5 OfficialInspection Form.Subsurface Sewage Disposal System Page 1.4 Mn
Commonwealth of Massachusetts
a - ,o , Title 5 Official Inspection Form
k..,----9'i l .9 0 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
¢' 88 Maple Ridge Road
Properly Address
Ron Matuson(pet Prior Inspection 4-15_15 __ ___
Owner Owners Name
ren is
quiredifre Northam ton MA 01060 4-10-17
page. for every ._ _p
page. City/Town 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
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Isw•3aa Tim 5 Official mspecten Fpm-.stsunece Swage DtsPosal System-Page 15 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
yi -,,. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
trig. -YY
! 88 Maple Ridge Road
Property Address
Ron Matuson(Ref: Prior Inspection 4-15-15.)
Owner
Owner's Name
information is
Northampton MA 01060 4-10-17
required for every i P —_— _ _ - —
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: 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: 11-16-98
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Record at Health Department. 1998 Design Plan and as-built notes.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Reviewed design plan on file at Health Department
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
rsins.3/13 Title 5 Official Inspeaim Form Subsurface Sewage Disposal System•Page 111 of I?
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_y
la • Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
V-014
i.
. , 88 Maple Ridge Road
Property Address
Ron MatusonjRef{Prior Inspection 4-15-15.)
Owner
Ownais Name
reto Is
requiredr even Northampton MA 01060 4-10-17
page. tor - —_. - ---
City/Town State Zip Code Dale of Inspection
E. Report Completeness Checklist
Z 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
50e•3/13 TrIle 50Rtlal Inspection Form'Subsurface sway.Disposal Syciwn•Page 17 cr 17