Loading...
414 Title 5 2017 • Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - 1 - 9 P y Not for Voluntary Assessments N.ITZ4.0 414 Cole Meadows Rd Northampton, MA. 01060 Property Address - --- -- -- ----.- Mark 8 David Rejniak Owner Owner's Name - - -- -' --- --- information is _ required for every 414 Cole Meadows Rd Northampton __ MA 01060 5.26.2017 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 Charles J Kaniecki use the return key./. � Name of Inspectorete - - — - - Company Name - -- —'-- — - - - 146 Valley Rd Company Address reafn X Southampton MA 0 CitylTown State Zipp Cage 413 695 0593 cell __ SI 119 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 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority PSC / IL.Q — "id - 27 ...] . e ) Inspector's 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 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. i5insdoc•rev.6/16 Tills 5°Pinel Inspection Form Subsurface Sewage Disposal System•Page 1 o111 Commonwealth of Massachusetts faaay Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ti- -- 414 Cole Meadows Rd Northampton_MA. 01060 Property Address Mark& David Rejniak Owner Owner's Name information is required for every 414 Cole Meadows Rd Northampton_ _ MA 01060 5.26.2017 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 ❑ 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 ❑ 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 151maoc•rev.5115 Tits 5 Ofca]Inspection Form Subsurface Sewage Disposal System.Pape 3 or 17 Commonwealth of Massachusetts fi ' Commonwealth of Massachusetts - Title 5 Official Inspection Form c- _! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e "1/4-----0, 414 Cole Meadows Rd Northampton, MA. 01060 Property Address Mark& David Rejniak Owner Owner's Name _ -- information is required for every 414 Cole Meadows Rd Northampton MA 01060 5.26.2017 page. City/Town State - 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. ❑ ❑ 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. 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. thins to rev.6116 Title S Michel Inspeuian Form:Subsurface Sewage Disposal System•Page 5 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form • 1111 _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e `lr0 414 Cole Meadows Rd Northampton, MA. 01060 Property Address Mark 8 David Rejniak --- Owner Owner's Name information is required for every 414 Cole Meadows Rd Northampton MA 01060 5.26.2017 page CitYrrown — _ State Zip Code Date of Inspection page C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ 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? y ❑ 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: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): unknow Number of bedrooms(actual): 3- -- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 r5'ns me•rev 6'19 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Pape s of 1] • Commonwealth of Massachusetts WO Title 5 Official Inspection Form --_ri— Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4€11-17j. * - 414 Cole Meadows Rd Northampton, MA. 0106.0 Property Address --- -'— Mark&David Rejniak _ Owner Owners Name - - -- --'- -' information is required for every 414 Cole Meadows Rd Northampton MA 01060 5.26.2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: The owner advised us that the system was constructed in about 1956 with a 750 gallon septic tank. it was connected to a leaching pit which is covered by a fake well house. The sas pit is flooded to the surface and the tank also is flooded. Given the age we were concern with collapse and did not uncover the inlet out let baffles. Number of current residents: 2 —. Does residence have a garbage grinder? ❑ Yes Z 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 Z No Water meter readings, if available (last 2 years usage (gpd)): City water no data Detail: The basement landry discharges to the surface of the land. They are installing a new landry on the firs floor and plan to connect it to the new septic system when installed. Then removing the basement landry and shower. Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: -- -- -.-- Design flow(based on 310 CMR 15.203): canons per day(gpd) - Basis of design flow(seats/persons/Wt., 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: ----- tSHis Toe•rev.6,16 Title 5 Official Inspection Form.subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts • r _, Title 5 Official Inspection Form wt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °e t` ° 414 Cole Meadows Rd Northampton, MA. 01060 Property Address Mark &David Rejniak Owner —... Owner's Name information is 414 Cole Meadows Rd Northampton MA 01060 5.262017 required for every page. — - - -t— - City/Town State Zip Code Date of Inspection D. System Information (cant.) Last date of occupancy/use: current Date Other(describe below): General Information Pumping Records: Source of information: 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): Septic tank to a leaching pit both flooded t51ns doc•revon a Tale 5 Offi a,Inspecllon FamSubsurface Sewage Disposal System•Page 8 of17 Commonwealth of Massachusetts !r -= / Title 5 Official Inspection Form c771K —74� - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 414 Cole Meadows Rd Northampton, MA. 01060 Property Address - -'— -- -- --- Mark& David Rejniak Owner Owner's Name - - - - - - - ind on Is 414 Cole Meadows Rd Northampton MA 01060 _ 5.26.2017 required for every 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: 1956.= 61,years Were sewage odors detected when arriving at the site? ® Yes ❑ No Building Sewer(locate on site plan): Depth below grade: fe feet Material of construction: Z cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: 20 feet feet Comments(on condition of joints, venting, evidence of leakage, etc.): All appear good Septic Tank(locate on site plan): Depth below grade: 2 feet feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: est 750 gallons Sludge depth: flooded Sins tloc•rev 6/16 title 5 Official Inspection Form:Subsurface Sewage Dispose/System•Page 9 d 17 Commonwealth of Massachusetts Ind Title 5 Official Inspection Form 'F Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments 414 Cole Meadows Rd Northampton, MA. 01060 Property Address Mark& David Rejniak Owner Owner's Name required information for is 414 Cole Meadows Rd Northampton MA 01060 5.26.2017 required for every -- - — - - - page. City/Town 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 flooded 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 -- — -- How were dimensions determined? visual Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Unable to uncover entire tank for fear of it collapsing_,_ 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 tSinsdos•rev.6/16 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 414 Cole Meadows Rd Northampton, MA. 01060 Property Address Mark& David Rejniak Owner Owner's Name -- —' --- -' -- information is required for every 414 Cole Meadows Rd Northampton MA _ 01060 5.26.2017 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 ❑other(explain): Dimensions: Capacity: gallons 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 dcc rev.6116Tlw 5 official Form subsurface Sewage Disposal system•Pape 11 or 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form rl _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Cole Meadows Rd Northampton, MA. 01060 Property Address Mark& David Rejpiak Owner Owner's Name reformation Isrequi414 Cole Meadows Rd Northampton MA 01060 5.26.2017 page .ed for every Northampton page. City/Town 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.): No D-Box 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: 15ms doer rev.6/16 mm 5 OMoal mspecron Form.Subsurface Sewage Disposal System•Pape 12 of 17 Commonwealth of Massachusetts ) ` =Gr Title 5 Official Inspection Form ;:fit ; Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1f_ ': 414 Cole Meadows Rd Northampton, MA. 01060 Property Address — -- —' --- ------ Mark& David Rejniak Owner Owner's Name --_ -information is required for every 414 Cole Meadows Rd Northampton MA 01060 5.26.2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 1 ❑ leaching chambers number: -- - --- ❑ leaching galleries number: -- — ❑ 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.): Leaching pit is flooded. Signs of over flow 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 15NSJm•rev 6tl6 Tllle 5 official Inspection Form Subamlace Sewage Disposal System•Page 130117 Commonwealth of Massachusetts , Title 5 Official Inspection Form ■1= "s. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 414 Cole Meadows Rd Northampton, MA. 01060 Properly Address Mark& David Rejniak Owner Owner's Name information is 414 Cole Meadows Rd Northampton MA 01060 5.26.2017 required for every - -- — ------ - 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.): t51ns do;•rev.6116 Title 5 Official Inspwlion Form.Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form 1{ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ."®e e, ,o®" 414 Cole Meadows Rd Northampton, MA. 01060 Property Address Mark& David Rejniak Owner O --- -- . - Owner's Name information is 414 Cole Meadows Rd Northam Q ton MA 01060 _ 5.26.2017 required for every 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 Mine dec•rev.6116 Tee 5()Nicol Form subsurface Sewage Disposal System.Page IS of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form _-��— Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54:e.ry a' 414 Cole Meadows Rd Northampton, MA. 01060 __ — _ -- Property Address Mark& David Rejniak Owner Owner's Name information Is 414 Cole Meadows Rd Northampton MA 01060_ 5.26.2017 — — required for every P __ __ page. City/Town State Zip Code Date of Inspedion D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 3 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: 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: Based on observations the system is flooded. The ground water level appears to be near the surface give the slope from the basements dry cellar and the septic sas area. BE AWARE that there is an out flow from the City's water line to a pond in the back of the property. The owner advises that there is a 2 inch pipe that is connected to the city's water line that is buried on the property. This was installed by the owner. Before filing this Inspection Report, please see Report Completeness Checklist on next page. !Sine clot.rev.6116 Title 5°moral lni pan:orr Form Subsurface Sewage Disposal System Page 16 of IT Commonwealth of Massachusetts Title 5 Official Inspection Form __ _-. 0 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 . 414 Cole Meadows Rd Northamptoy MA. 01060 Property Address Mark & David Relniak Owner Owners Name information m required414 Cole MeadowsRd Northampton MA 01060 5.26.2017 p —_ — —._. _ am page. for everyP City/rown State Zip Code Date of Inspection E. Report Completeness Checklist Z Inspection Summary: A, B, C, D, or E checked Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ns dc.rev 6/16 Till.)5 OWc al Inspection Form.Subsurface Sewage Disposal System•Papa 17 of 17 414 Coles Meadow Rd Northampton MA. Locations: Tank is C to A= 27' B = 26' Yellow line indicates approx. Location of a water line SAS is D to A= 68' B = 81' not for drinking water Surface discharge of laundry is 62' from house wall Blue oval locates the SAS Red Box indicates septic tank Orange line is Laundry surface discharge • ,.. , • • i i 1 c.2016 Google Google Earth Imagery Date:5J/0/2014 42°22'01.51'N 72°38'49.79"W eiev 255 ft eye alt 731 ft 0 Northampton 414 Coles Meadows Rd. May 26, 2017 , .. ., ., 4 ..... .... , „.. ... , ' A - ..• i• r' '+ . ••• • • •'`',, .'IS-A .''''`.,*-• ,• '• t•' 4 Or" - r•f• yr-,),,,+ •,,,,., .,. •''I:4/ -s.) i •1•, s'''' ' ••• 4' '''' •"-;•:•,'.,/. , Ns „...,, ''' ' *-%1 4 `k• f7,_• • ' -''\ "ik „ . a.: •;*; I . ."-. .......,.,-, r 4 ...,, Aii -•-'.._...-.--'-'..> ip __----_,--- ... , -----„..----,..------ _-------........------ •••' , . .if 'N N-N,X/Its,,. '1%,....'- '''.. 'AS' ' tot ••1& 4 4 4 4- .•.a.1,.. 'lb.''s.....s:L...' .4141 ,,,rilte .4.. ..... 4f,.,. .r 4„„. ...... • .• ,..• • -, I , 1 eliew . .., _ , . 0, -1, a , 1,. . , 4.. .1i- 46..- , , .- IIC i i I , ; 4 • ' ..._ .. ..., 0 , A -..aiblIMIIIMW .. • • • ' r- • .x yam . ` y „ • 17 'I t �R, ..1. ' •? r Tgi dire/ • :f • (I! K fS 1 A • ' 171411481L ' y-. fi gr • s�J 1Do J l/l� C /a _� . 3 M+RR S. k T 4' ! ) ^ Z •l _ rf t,-- lorr 5 . A'..� {.� c 1 O '4liS`. F i . • i CUJ6-1 - -r° SA $