88 Title 5 2015 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
Owner Owers Nana
information Northampton MA 01062. 4-15-15
required for every CayRoen Stale 2lp Code oats of rmpetbn
par
Inspection results must be submitted on this form.Inspection forms may not be akered In any
way.Please see completeness checklist at the end of the form.
"Penal*:when A. General Information
filling out roma
on the computer,
use only the tabab
1. Inspector.
key 10 mow your
cursor-do not Rick Stott
use the return
Name or Inspector
key_
RM Scott&Associates,LLC
CaeMm'Narte
31 Shutesbury Road
Company Address
Pelham MA 01002
City/Tow State IN Code
413-256-0647 SI1030. MA P.E. 31199.
Telephone Number license Number
B. Certification
I certify that I have personally Inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of
Title 51310 GAR 15.000).The system:
0 Passes 0 Conditionally Passes 0 Fails
❑ Needs Further Evaluation by the the Local Approving Authority 4-aei5-15
sorsa Date
The system Inspector shall submit a copy of this Inspection report to the Approving Authority(Board
of Health or DEP)wthln 30 days of completing this inspection. If the system is a shared system or
has a deign 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 et the time of Inspection and under the conditions of use
at that time.This Inspection doss not address how the system will perform In the future under
the same or different conditions of use.
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Commonwealth of Massachusetts
a n Title 5 Official Inspection Form
r ;; Subsurface Sewage Disposal System Ferro-Not for Voluntary Assessments
„re 88 Maple Ridge Road
•1/4
Properly Address
Ron Matuson
Owner
Infmnatbnin Orale Nene
required for awry Northampton MA
Me- Cdprown 01060 4-15-15
Saes Zip Code Dab of lmpegbn
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 failure criteria observed. System panes. See additional notes in report.
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 b
the Board of Health, will pass. Y
Check the box forges','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 exfltration or tank failure is imminent System will pass
rlieal existing nspection if the sting tank is replaced with a complying septic tank as approved by the Board of
•A metal septic tank will pass inspection If it is structurally sound, not leaking and if a Certificate of
Compience indicating that the tank is less than 20 years oil is available.
❑ Y ❑ N 0 ND(Explain below):
a5.•3/15
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• Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Maple Ridge Read
Pmpenr Mame
Ron Matuson
Owner One's Name
information
a Northampton MA 01080 4-15-15
page. abEvery
Pepe. Gwyn Slav Zip Cass Dale of inspection
B. Certification (cont.)
❑ Pump Chamber pumpshaamre 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 dlsbibubon 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 pipes)are replaced ❑ Y ❑ N 0 ND(Explain below):
❑ obstruction is removed ❑ V ON 0 ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed plpe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ V ONO ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N 0 ND(Explain bekow):
C) Further Evaluation is Required by t e Board of Health:
❑ Conditions exist which require fuller evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safely or the environment
1. System will pass unless Board of Health determines In accordance with 310 CMR
15.303(1gb)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
ISne.3/13 rte 5 Cbual aWSm Form.Subsurface Emcee Ottpcal Sys m•Papa ar 17
t Commonwealth of Massachusetts
», Title 5 Official Inspection Form
�..o „ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Maple Ridge Road
property Address
awrr Ron Matuson _
Ovines n b Owlets Name
Nbrrequired forevery Northampton MA 01060 4-15-16
Page. CAyflOwn Siete Zip Code Date dincps:bon
B. Certification (cont.)
2. System will fall unless the Board of Health(and Public Water Suppler,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(SM)and the SM is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SM and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and MS and the SAS is within 50 feet of a private water
supply well.
0 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:
Fs This system passes tithe well water analysis, performed ata 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 thuds are triggered.A copy of the analysis must
be attached to this form.
3. Other:
0) System Failure Criteria Applicable to All Systems:
You gag Wiest*"Yes"or"No"to each of the following for if inspections:
Yes No
D ® Backup of sewage into facility or system component due to overloaded or
dogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or dogged SAS or cesspool
❑ ® Static liquid level In the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ n Liquid depth In cesspool is less than 8"below invert or available volume is less
than%day flow
G".st]
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
a - = Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1_1 _
88 Maple Ridge Road
Property Adages,
Ron Matuson
Owner Owner's None
information Northampton MA 01080 4-15-15
is
mewed fwaw;ry
cow City/Teem state Zip mp
Code Date of lemon
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 groes 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
tnlutary to a surface water supply.
❑ ® My portion of a cesspool or privy is within a Zone 1 of a public well.
El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well,
El My 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 DEP certified
laboratory,for fecal conform bacteria Indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 8 ppm,
provided that no other failure criteria an 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 fi .l have determined that one or more of the above failure
cdterla 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 he considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 Bpd.
For large systems,you must indicate either"yes"orno"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 contatt the appropriate
regional office of the Department.
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Commonwealth of Massachusetts
0Title 5 Official Inspection Form
,�
w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Maple Ridge Road
Property Address
Ron Matuson
Owner
information k Donors Name
requs.d for men, Northampton MA 01080 4-15-15
Pegs Cityrrp.n Stets Zip Code note 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
® D 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?
® ❑ Has the system received norma 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?
® 0 Were all system components,excluding the SAS, boated on site?
® 0 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?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® El Existing information.For example,a plan at the Board of Health.
® ❑ Determined in the field(8 any of the fakirs 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): 5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 0 of bedrooms): 550
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Commonwealth of Massachusetts
I! '_,� r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Maple Ridge Road
Propaey Address
Ron Matuson
Owner O,me.s Name
intormMon
required for awry Northampton MA 01080 4-15-15
page. CAVorroxn State Zip Code OM of Ireperlbn
D. System Information
Description:
1500 gallon septic tank. Gravity flow to Distribution box and Infiltrators in a sic-line Leads Field.
Number of current residents: 2
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? 0 Yes 0 No
Seasonal use? ❑ Yes ® No
Water meter readings, If available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Currently
Occupied.
Comnerciainndustrfsl Flow Conditions:
Type of Establishment
Design flow(based on 310 CMR 15.203): (eae„a per this(gpd)
Basis of design flow(seatslpersonsfsq.R,etc.):
Grease trap present? 0 Yes 0 No
Industrial waste holding tank present? ❑ Yes 0 No
Non-sanitary waste discharged to the Tele 5 system? ❑ Yes 0 No
Water meter readings, If available:
,SF.•113 US 5O S Irspaien Fmn'Wtorleos Wy Napo*'WWI•Pae 7,f 17
Commonwealth of Massachusetts
`v Title 5 Official Inspection Form
( Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Maple Ridge Road
Pmpeny Addese
0 Ron Matuson
OwletOa
Woman is nars Name —
required for every Northampton MA 01060 4-15-15
pap. Cityrreae State Zip Code Dab ortrapatlbn
D. System Information (cont.)
Last date of occupancy/use: Currently Occupied.
Pete
Other(describe below):
Gsnerallnfonnation 62e4;') iz�l5�la�
Pumping Records:
Source of information: Per owner, previous pumping was^November,2014
Was system pumped as part of the inspection? 0 Yes 0 No
If yes,volume pumped:
pions
How was quantity pumped determined?
Reason for pumping:
Type of System:
O Septic tank,distribution box,soil absorption system
❑ Single cesspool
O Overflow cesspool
❑ Privy
O 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):
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Commonwealth of Massachusetts
kiTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Maple Ridge Road
Property Address
Ron Matuson
Owner Owners Name
Inhumation a MA 01060 415-15
Page. (Drewry Nty/Tam do State Zip Code Dae at mapectloa
Page. City/Tam
D. System Information (cont.)
Approximate age of all components,date Stalled(6 known)and source of information:
System 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 S No
Building Sower(locale on site plan):
2
Depth below grade: feet
Material of construction:
❑cast iron S 40 PVC 0 other(explain):
NIA Municipal guppy-pressure
Distance from private water supply well or suction lint line.
Comments(on condition of joints,venting, evidence of leakage,etc.):
NI in-house pkunbing is in excellent condition. No evidence of any previous problem. Vented to roof.
Septic Tank(locate on site plan):
1.0
Depth below grade: tact
Material of consanlcbon:
S concrete ❑metal El fiberglass ❑polyethylene 0 other(explain)
1500 gallon concrete septic tank with cast4n baffles.
If tank is metal, list age: yens
Is age confined by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes 0 No
126"X 66"X54"effective depth.
Dimensions:
10
Sludge depth:
lire•113 Trsoeurl Special Form Samba SMOG Dame wem'Paw 4a 17
`� Commonwealth of Massachusetts
Title 5 Official Inspection Form
(� ; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 88 Maple Ridge Road
Properly Address __
Ron Matuson
Owner
Mronnalion s Owners Name
reqused brewery Northampton MA 01060 4-15-15
page. CilyfTwn Stale
Zip Cede ori of Inspection
D. System Information (corn.)
Septic Tank(com.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 0'
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or befit `20'
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.):
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.
Grease Trap(locate on site plan):
Depth below grade:
fen
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:
Dale
c -Ill
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Commonwealth of Massachusetts 0�, -F1 Title 5 Official Inspection Form
- IR y; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
86 Maple Ridge Road
Pmpedy AGNaas
Ron Matuson
Owner oenera Nene
Indentations NrdhataMetredre,eery op
MA 01060 475-15
pope. Cly/test state yap code este 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 ❑other(explain):
Dimensions: —
Capacity: galore
Design Flow; galena per day
Alarm present 0 Yes 0 No
Alarm level: Air in working order 0 Yes 0 No
Date of last pumping: Dare
Comments(condition of alarm and float switches, etc.):
•Attach copy of current pumping contract(required).Is copy attached? 0 Yes ❑ No
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Commonwealth of Massachusetts
1 " Title 5 Official Inspection Form
_ . 1 Subsurface Sewage Disposal System Form-Not for Vduntery Assessments
c. ,i..•
"--.,,,T,1 88 Maple Ridge Road
Pmpedy Address
Ron Matuson
Owner owners Name
infonnation is
remind for every Northampton MA 01060 4-15-15
Pena. Cxyfroan
sate 4 Code Data of Impaction
D. System Information (cont)
Diseibutlon Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet Invert Q
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any
evidence of leakage into or out of box,etc.):
Box is level and Is dishibuting flow equally. Only minor solids carryover is observed No evidence
that solids have been carried out the distribution pipeines. 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.
Pump Chamber(locate on site plan):
Pumps in working order:
0 Yes 0 No`
Alarms in working order. 0 Yes D 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 soc-line leach field with Infiltrators. See sketch.
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Qa Commonwealth of Massachusetts
VTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Maple Ridge Road
n1waM Address
Ron Matuson
Owner Owele Name
Irdemmallen
required for every Northampton MA 01060 4-15-15
papa. CeylT wa State Zip Cade Dag cf 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'X50'.
O overflow cesspool number
❑ innovativelaltemattve system
Type/name of technology:
Comments(note condition of soil,signs of hydraufc failure, level of ponding, damp soil,condition of
vegetation,etc.):
No sign of problems observed from ground surface. Distribution box is buried approximately 20'. A
20"oak tree Is planted north of the D-box and tree roots are present at D-box, but roots have not
Invaded into the box or the distribution pipes.
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
Materiels of conshucbon
Indication of groundwater inflow 0 Yes 0 No
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A Commonwealth of Massachusetts
' s ! Title 5 Official Inspection Form
_. __. is Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�. 88 Maple Ridge Road
Property Adder"
Ron Matuson
Owner Owners Nane
infoonalion b
required for every Northampton
Paas. Cxl!Town MA 01080 D ofIn
Slab Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of sod, signs of hydraumc failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of consbuclbn:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
eta):
o...m
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t Commonwealth of Massachusetts
v Title 5 Official Inspection Form
• • i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
I_r
88 Maple Ridge Road
Property Addams
Ron Matuson
Owner Owners Nam
information a
repel sol bravery Northampton MA 01080 4-15-15
Page. Clyfrown Stab al Code Date of Inspection
D. System Information (cord.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,Including tes 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
ti hand-sketch in the area below
❑ drawing attached separately
h4 clearia.
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Commonwealth of Massachusetts
`At - Title 5 Official Inspection Form
if-:
Subsurface Sewage Disposal System Fenn-Not for Voluntary Assessments
88 Maple Ridge Road
Property Address
Ron Matuson
mrorer aeanis Ownefa Neme
required for awry NoRhampton MA 01080
Page. Cay/rown 4-15-15
D. System Information (cont.) State mfewh�oe
Site Exam:
❑ Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depthto high ground water 5
feel
Please Indicate all methods used to determine the high ground water elevation:
n Obtained from system design pians on record
If checked,date of design plan reviewed: 11-1&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.
MS 5 Mali U Fent Samba a..le.MwaeI alien'PN Ie an
Commonwealth of Massachusetts
0ux Title 5 Official Inspection Form
I f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Maple Ridge Road
Properly Address
Ron Matuson
Owner Caesfs Name -
wifmmauon b
required soy every Northampton MA 01080 4-15-15
Pegs. City/Teem Stale Zip Code Dale al Impedaon
E. Report Completeness Checklist
® Inspection Summary:A,S, C, D.or E checked
El Inspection Summary D(System Fadure 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
Sine•Via TY 5 Odd Yepejon Far.&4ulo
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