249 Title 5 2018 t\- Commonwealth of Massachusetts
1 —ITitle 5 Official Inspection Form
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Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
valig
- Al 249 Sylvester Road
Property Address
Jay Fisher& Brian May _
Owner Owner's Name
information isrequirNorthampton MA 01007 10/17/2018
page. for every
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. Inspector Information
filling out fors
on the computer, Alan Weiss
use only the tab
key to move your Name of Inspector
cursor-do not Cold Spring Environmental Consultants, Inc.
use the return Company Name
key.
350 Old Enfield Road _
Company Address
' Belchertown MA 01007 _
X1:1
o City/Town State Zip Code
faun`/�- 413-323-5957 _ Title V System Inspector#738
' Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); I have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
AA' 10/17/2018
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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
5inspdoo•rev.712612019 rine 5 Oficial nspeclion Form.Subsurface Sewage Disposal System Page 1 of IS
S.:\ Commonwealth of Massachusetts
e Title 5 Official Inspection Form
._R! Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i `ilii=6::
249 Sylvester Road
Properly Address
J1Fisher& Brian May _
Owner Owners Name
information is
required for every P Nortamhton MA 01007 10/17/2018
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system at a single family residence was inspected and no evidence of failure was found.
System consists of one 1,500 gallon septic tank connected to a distribution box and a multiple leach
tank/galley system. The liquid level in the septic tank was at the outlet invert, and the leaching galley
was dry with clean stone at the bottom. The system is 1.5 years old, and was being used by 2
persons at the time of inspection. Septic tank should be pumped and cleaned every two years.
Furnace condensate tubing should be disconnected from the septic.
2) 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.
❑ V ❑ N 5 ND (Explain below):
tainsp doc.rev.7/26/2018 nee 5 OIbtlal Inspection Form Subsurface Sewage Disposal System•Page 2 of
Commonwealth of Massachusetts
(: -e Title 5 Official Inspection Form
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Commonwealth of Massachusetts
-kti
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FTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.i-c„..0 249 Sylvester Road
Property Address -- - - ---
Jay Fisher& Brian May
Owner Owners Name
information is
pNorthampton MA 01007 10/17/2018
page. for every City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
5 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
5 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.
c. Other: .
4) 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
1517150 doc•rev.7126/2018 rile 5 official Inspection Form.Subsurface sewage Disposal System-Page 4 one
L"\-- Commonwealth of Massachusetts
��_,_i-e Title 5 OfficialInspection Form
i4 _ — M Subsurface Sewage Disposal System Form-Not for Voluntary Assessments k,/✓ 249 Sylvester Road _
Property Address
Jay Fisher 8 Brian May
Owner Owners Name
requir d for
is Northampton MA 01007 10/17/2018
required for every P _ . .
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ Z Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Z Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
❑ Z Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Z 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.]
❑ Z The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ Z 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.
5) 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 C.4.
Yes No
❑ 5 the system is within 400 feet of a surface drinking water supply
5 5 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—IW PA) or a mapped Zone II of a public water supply well
A51nsp.doc.rev.7/2612018 Title 5 Oficial inspection Form.Subsunace Sewage Oisposal System.Page 5 0118
c Commonwealth of Massachusetts
1 :1e Title 5 Official Inspection Form
1 l.— iti Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
—49
ra=tr
[ 249 Sylvester Road
Properly Address
Jay Fisher&Brian May
Owner Owners Name
information for
is Northampton MA 01007 10/17/2018
required for every P page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section C.4 above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
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?
® ❑ 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?
® ❑ 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?
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)]
t5nsp doc•rev.7/2612018 Title 50fficlal Inspeebon Form.subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
itc_ —_i3 Title 5 Official Inspection Form
1. i M Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
lip
249 Sylvester Road
Property Address
Jay Fisher& Brian May
Owner Owner's Name
Information s Northampton MA 01007 10/17/2018
gfor every P —
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440+ _--
Description:
System consists of a concrete, 1,500 gallon septic tank, a distribution box and a 34'x 8'x 2' leaching
galley area. _
Number of current residents: 2.
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes Z No
Last date of occupancy: Current
Date
15lnsp.doc.rev.7/26/2018 Tile 5 Official Inspection Form'subswace Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
k'�r_0 Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
X49 249 Sylvester Road
Property Address
Jay Fisher& Brian May _
Owner Owners Name
information is Northampton __. MA 01007 10/17/2018
required for every P
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: -
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner: Not pumped since 2017.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: g galllonsi;s
How was quantity pumped determined? Measured _.
Reason for pumping: Inspection
t5insp doc•rev.712612018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 80116
Commonwealth of Massachusetts
q Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
IP
249 Sylvester Road
Property Address
Jay Fisher& Brian May
Owner Owner's Name
information is P
required for every Northampton MA 01007 10/17/2018
Paye, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known)and source of information:
System is approximately 1.5 years old based on Certificate of Compliance.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
[' cast iron ® 40 PVC ❑ other(explain): — ---
Distance from private water supply well or suction line: 10'+
feet
Comments (on condition of joints, venting,evidence of leakage, etc.):
Building sewer was in very good condition with no evidence of leakage. _
t5insp,doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 or t8
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.-FLWIliF Title 5 Official Inspection F:41=rsi2i
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4.i, 249 Sylvester Road
Property Address
Jay Fisher 8 Brian May
Owner Owner's Name
information is Northampton MA 01007 10/17/2018
ed for every
_. ..
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
1
Depth below grade: feet -
Material of construction:
Z concrete ❑ metal ❑ fiberglass 5 polyethylene 5 other(explain)
If tank is metal, list age: --
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 5 Yes ❑ No
Dimensions: 10.5'x 5.5'x 42
Sludge depth: 12 --
Distance from top of sludge to bottom of outlet tee or baffle 24 -.
Scum thickness 6'
Distance from top of scum to top of outlet tee or baffle 6"
Distance from bottom of scum to bottom of outlet tee or baffle 6"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Concrete, 1,500 gallon septic tank was structurally sound and in very good condition with no evidence
of leakage. PVC inlet and outlet tees were in place. Liquid level was at the outlet invert with no
evidence of high staining.
Dinsp doc•rev.7/28'2018 Title 5 Otfidal Inspection Form:subsurface Sewage Disposal System•Page 100na
<h\ Commonwealth of Massachusetts
d---_ 0 Title 5 Official Inspection Form
1 'i_ it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
" 249 Sylvester Road -
Property Address
Jay Fisher 8 Brian May
Owner Owner's Name
reformation is Northampton MA 01007 10/17/2018
required for every P
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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: gallons
Design Flow: gallons per day
15lnsp.doc.rev.7/28/2019 Title 5 Official Inspection Form'.subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
---e Title 5 Official Inspection Form
I•
- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,,,,,,,_-71 249 Sylvester Road
Property Address
Jay Fisher& Brian May
Owner Owner's Name
inquired for
is Northampton MA 01007 10/17/2018
page. for every P
Paye, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: -- -- Alarm in working order: ❑ Yes ❑ No
Date of last pumping: bate
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Outlet Inverts
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.):
Distribution box was level and in good condition with equal flow to the outlets after resetting the flow
levellers. No evidence of leakage or solids carryover.
t5lnsp.doc•rsc 7126/2018 Title S Official Inspection Foinc Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
-_ Title 5 Official Inspection Form
4 = N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4, 1 249 Sylvester Road
Property Address
Jay Fisher& Brian May
Owner Owner's Name
information is
requiredNorthampton MA 01007 10/17/2018
page.
for every City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number: --
❑ leaching galleries number: 1: 34'x 8'x 2'
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
r5insp.4oc•rev.7126/2018 Title S officio!Inspection Form:Subsurface Sewage Disposal System Page 13 of 18
.,<::::\ Commonwealth of Massachusetts
,i: 0 Title 5 Official Inspection Form
s� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
g>v 249 Sylvester Road
Property Address
Jay Fisher& Brian May
Owner Owner's Name
information is
Northampton MA 01007 10/17/2018
required for every P - -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No evidence of hydraulic failure, ponding or damp soil conditions was observed. System was
functioning as designed.
12. 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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
tSinsp4oc•rev 7128/2018 Title 5 official Inspection Form subsurface Sewage Disposal System.Page 14 of 18
C� Commonwealth of Massachusetts
F Title 5 Official Inspection Form
lRSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
g249 Sylvester Road
Property Address
Jay Fisher&Brian May _
Owner Owners Name
information is
Northampton MA 01007 10/17/2018
required for every P - --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
lslnsp doc•rev7126r2018 Title 5 Dlfidal Inspection Form:Subsurface Sewage Disposal system•Page 15 or 18
?"\ Commonwealth of Massachusetts
9 Title 5 Official Inspection Form
1P
- Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
249 Sylvester Road _
Property Address
Jay Fisher& Brian May
Owner Owner's Name
information is Northampton MA 01007 10/17/2018
requiredfor every P —
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
t5insp.doc•rev.712512010 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 =4 H Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
meley.,6ti
u 249 Sylvester Road
Property Address
Jay Fisher&Brian May
Owner Owners Name
information is
requiredNorthampton MA 01007 10/17/2018
far every p - ._ -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
❑ Surface water
Z Check cellar
❑ Shallow wells
4'+
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: DaDate to 2017
e
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Records Attached. _
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Based on topography, observed setting and records.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Ptle 5 Olftlal Inspection Form:Subsurface Sewage Disposal System.Page 17 o118
vCommonwealth249SylvesterRoad of Massachusetts
Title 5 Official Inspection Form
1 "i Subsurface Sewage Disposal System Form -Not for Voluntary9 Assessments
n�
Properly Address
Jay Fisher& Brian May - -
Owner Owners Name
information is
Northampton MA 01007 10/17/2018
required for every p _. — -
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t55'nsp.doc•rev.712612018 Title 5 Oficial Inspection Form subsurface Sewage Disposal System•Page 18 one
Distribution box ("C") Existing septic tank (ref. only)
Inspection port (D"
SAS (ref.only) o v OS. fl Pumpout man—hole ("E")
(6 concrete chambers)
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AS—BUILT DIMENSIONS Instnller As-built pram
Ken Bousquet Lot 5 - Sylvestyer Rd.
'A' to 'C' = 49' 'B' to 'C' = 82' 305 Miller St. Florence, MA
'A' to 'D' = 85' 'B' to 'D' = 112' Ludlow, MA. February 23, 2017
'A' to 'E' = 11.5' 'F' to 'r = 33' Celli <413) 237-5523 Owner.
Fax (413) 547-6514 Davlo and Hathway Dev.
Southampton, MA.
Feb 231703.35p Ken Bouaquet Excavating (413)547-6514 p.1
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Septic Tank Outlet Tee
249 Sylvester Road
Northampton Ma
10.17.2018
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Northampton Ma
10.17.2018
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Distribution Box
249 Sylvester Road
Northampton Ma
10.17.2018