710 Title 5 11-16-17 Commonwealth.of Massachusetts 17
Title 5 Official Inspection Form
Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments
710 NORTH FARMS ROAD
Property address
ROBERT&LORRAINE BATES
Owner Owner's Name
information is
required for every NO.f2THAMPTON _ MA 01060 NOVEMBER 16 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
filling out-forms A. General Information
on the computer,
use only the tab 1. Inspector
key to move your
cursor-do not MARK T.THOMPSON _
use the return Name of inspecto
key.
r I
HILLTOWN ENVIRONMENTAL CONSULTING
;xy Company Name
P. O: BOX 314,
Company Address
CHESTERFIELD MA 01012
Cityfrown IState Zip Code
(413)296-4499 S13688
Telephone Numbeir License Number
B. Certification
1 certify that 1 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
Tltle 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspect is Signature Date
i
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 adesign flow of
10,000 gpd or greater,the.inspector and the system owner shall submit the report_to'fte appropriate
regional office of the DEP.The original should be sent to the system&ner and copies sent to the
buyer, if applicable, and the approving authority.
""*This report only describes conditions at the time of inspection anis 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 fuse.
[Sinsdoc•rev.8/16 Title 5 Official Inspection Forret Subsurface Sewage Disposal System i Page 1 of 17
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Commonwealth of Massachuseft °
Title 5 Official Inspection Farm
Subsurface Sewag�Disposal System Form-`Not for Voluntary Assessments
710 NORTH FARMS ROAD___._..
Property Address
ROBERT&LORRAINE BATES
Owner Owner's Name
information isrequiNORTHAMPTON MA 01060 NOVEMBER 16,2017
page. C�yred for every /town State Zip Code Date of inspection
page
B. Certificati(in (cont.)
Inspection Sum ary: Check A,B,C,D or E/always complete all of Section D
A) System Passe:
IN I have not fund 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:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair,as approved by
the Board of Health,will pass.
Check the box for°yes","no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,'exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ms.doc•rev.6116 Title 5 official Inspectlon Form.Subsurface Sewage Disposal System•Page 2 of 17
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Commonwealth of Massachusetts fN
Title 5 Official Inspection Form
Subsurface:Sewage Disposal System Form-Not for Voluntary Assessments
r 710 NORTH FARMS ROAD
Property Address
ROBERT&LORRAINE BATES
Owner Owner's Name ,. ff
information is NORTHAMPTON MA 01060 NOVEMBER 16 2017
required for every _�._.._
page. citylrovm- .. State Zip Code Date of Inspection
B. Certificatibn (cont.)
❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if
pumps/afari ns 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.
I. 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
El Ce,1 spool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6116 Titre 5 Official Inspection Form:Subsurface Sewage Disposal system•page a of 17
Commonwealth of Massachusetts
Title 5 Off cia-I LnspecUon Form
Subsurface'sewage, Disposal System Form Not for Voluntary.Assessments
710 NORTH FARMS ROAD
Property Address
ROBERT&LORRAINE BATES
Owner Owners Name
information is
required for every NORTHAMPTON I MA 01060 NOVEMBER 16,2017
••-•----
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,If any)
determines{that the system Is functioning in a manner that protects the public health,
safe y'and en( vironment:
F1 The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a.Zone 1 of a public water
supply.
❑ The sys em 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 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:
I
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all.inspections:
Yes No
ElBackup 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 V.day flow
t5fhs.dod•rev.6116
Title 6 Official Inspection Form Subsurface Sewage Disposal System•page 4 of-17
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Commonwealth�of Massachusetts
Title 5. Official Inspection Form
Subsurface Sewag'Disposal System Form-'Not for Voluntary Assessments
710 NORTH FARMS ROAD
Property Address
ROBERT&LORRAI,NE BATES
Owner Owners Name
Information is SIA 01060 NOVEMBER 16,2017
required for every NORTHAMPTON
page. cityrrown 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.
❑ ED 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 toor 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 Secltion D.
Yes No
❑ ❑ JJ 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)ora 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.upgmde the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
Mns doc•rev.6116 Tike 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 5 of 17
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Commonwealth bf Massachusetts
Title 5 Offida.l Inspecotion Form►
-- 6 Subsurface Sewage Disposal System Form-Not>for Voluntary Assessments
710 NORTH.FARMS!ROAD
Property Address
ROBERT&LORRAINE BATES
Owner Owner's Name
information is
required for everyNORTHAMPTON MA 01060 NOVEMBER 16,2017
page. CitylTown 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 bythe 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'
ED ❑ Were as built plans of the system obtained and examined?(if they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
0 ❑ Was the site inspected for signs of break out?
0 ❑ Were all system components, excluding the SAS, located 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?
❑ 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:
® ❑ 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 b4dl oms(design): 3 --_. Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms)_ 330
isms doc•rev,8118 Tide 5 Official Inspection Fond:Subsurface Sewage Disposal System•Page a of 17
Commonwealth'of 9Via5
sachusetts 7 / 7
Title 5 4ffrc'a - Ins lection Form
Subsurface Sewage Disposal System Foam:-Not for Voluntary Assessments
I
710 NORTH FARMS ROAD _
Property Address
ROBERT&LORRAINE BATES
Owner Owner's Name 1
information is
required for every NORTHAMPTON MA 01060 NOVEMBER 16,2017
---
page. l ityffowrl State Zip Code Date of inspection
D. System Information
Description:
SINGLE FAMILY DWELLING
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes 0 No
Is laundry on a separate sewage system?(Include laundry system Inspection
information in this report.) Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage PRIVATE WELL
9 � ( Y 9 (gpd}):
Detail:
I
Sump pump? ❑ Yes ® No
Last date of occupancy: CURRENT
Date
Commercialfindustrial 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 tap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary wIaste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:
t5ins.dod•rev.8118 TWO 5 OBiclal Inspection Form!Subsurface Sewage Disposal System•Page 7 of 17
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Commonwealth of Massachusetts C�
Title 5 Offidat Inspection Form
Subsurface Sewage Disposal System Form=Not for Voluntary Assessments
I
710 NORTH FARMS ROAD
Property Address
I
ROBERT&LORRAINE BATES
Owner Owner's Blame _ ._...._...
information is
required for every NORTHAMPTON MA 01060 NOVEMBER 16,2017
._—�. --
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
formLAST PUMPED IN 20112 PER OWNER
Source of ination:
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
I
❑ 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):
t5lns.doo•rev.6116 i Titie 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage e Wisposal Systefir Form-Not for voluntary Assessments
I
710 NORTH f-AKMi KVAU
Property Address
ROBERT&LORRAINE BATES
Owner Owner's Name
information is
required for every -NORTHAMPTON ...... MA 01060 NOVEMBER 16 2017
page. cityrrowrt I . state Zip Code Date of inspection
D. System ln�ormatlon (cont.)
Approximate ag e of all components, date installed (if known)and source of information:
SYSTEM INSTALLED IN 1998 PER OWNER
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
El cast iron [__1 40 PVC Z other(explain): ABS
private Distance from water supply well or suction line, fee6t+
Comments(on I condition of joints,venting, evidence of leakage,etc.):
PLUMBING IN.,_ERY GOOD SHAPE. NO EVIDENCE OF LEAKS.THERE IS A BATHROOM WITH
AN EJECTOR PUMP LOCATED IN BASEMENT.VENT PIPE VISIBLE ON ROOF.
Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
0 concrete El metal El fiberglass ❑polyethylene ❑other(explain)
If tank is metal, list age. years
Is age confirmerd by a Certificate of Compliance?(attach a copy of certificate) El Yes [I No
Dimensions: 126 1"L x 69"W x 68"D
Sludge depth: 2-3"
t5rmdoc rev.6146 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth'of Massachusetts
i Title 5 official. Inspection Form
s Subsurface Sewagl Disposal'System Form Not for Voluntary Assessments
710 NORTH FARMS ROAD
Property Address � � --
ROBERT&LORRAINE BATES _
Owner Owner's Name
information is NORTHAMPTON I MA 01060 NOVEMBER 16,2017
required for every
page. Cityrrown 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 20'
Scum thickness 0-1"
Distance from tl p of scum to top of outlet tee or baffle 3011-
8-1
0"8N
Distance from bottom of scum to bottom of outlet tee or baffle
PROBED AND MEASURED
How were dimensions determined? —
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
TANK AND TEES ARE IN VERY GOOD SHAPE AND APPEAR STRUCTURALLY SOUND.OUTLET
COVER WAS CRACKED AND REPLACED AS PART OF INSPECTION. SOME MINOR
CORROSION OF CONCRETE ABOVE FLOW LINE NEAR OUTLET PIPE WAS OBSERVED
WHICH IS COMMON FOR TANKS OF THIS AGE.THE LIQUID LEVEL IS EVEN WITH OUTLET
INVERT AND THERE IS NO EVIDENCE OF LEAKAGE OR BACKUPS OCCURRING.THE SEPTIC
TANK SHOULD BE PUMPED EVERY 3 TO 5 YEARS. AVOID USING POWDER DETERGENTS
AND FLUSHING LATEX PAINT INTO SYSTEM.
i
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Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
D concrete D metal D fiberglass D,polyethylene D other(explain):
1
I
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from 1bottom of scum to bottom of outlet tee or baffle
Date of last pimping: Date _
l5ins.doo-rev.6/16 I Title 5Official Inspection Form;Subsurface Sewage Disposal System•Page 10 or 17
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Commonwealth)of Massach e
us tts
9�� V
Title 5 official Inspection Form
Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments
I
-- 710 NORTH FARMS ROAD
Property Address
ROBERT&LORRAINE BATES
Owner Owner's Name
reqirredfo
uireve y NORTHAMPTON MA 01060 NOVEMBER 16,2017
page. C-dyrrown 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:
Elconcrete I ❑metal ❑fiberglass g El polyethylene ❑other(explain):
Dimensions:
Capacity: i —
gallons
Design Flow: gallons per day
Alarm present:) ❑ Yes ❑ No
Alarm level: — Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(co ndition of alarm and float switches, etc.):
I
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5inuAdc•re4 6116 Title 5 Official Inspection Form:Subsurface Sewage oisposal System•page 11 of 17
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I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments
710 NORTH FARMS ROAD
Property Address
ROBERT&LORRAINE BATES
Owner Owner's Name
information is
required for every NORTHAMPTON MA 01060 NOVEMBER 16,2017
page. CltyMwn 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
0'•
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.):
D-BOX IS 30"BELOW GRADE AND IS IN O.K. SHAPE.THERE IS SOME CORROSION OF THE
CONCRETE PRESENT ABOVE THE FLOW LINE AND ON THE BOTTOM OF THE COVER WHICH
IS COMMON IN SYSTEMS OF THIS AGE. SOME MINOR SOLIDS CARRYOVER WAS OBSERVED
BUT THERE IS NO EVIDENCE OF BACKUPS OCCURRING. LIQUID LEVEL WAS EVEN WITH
THE INSTALLED FLOW LEVELERS.THERE ARE ONLY 2 OUTLET PIPES PRESENT AS
OPPOSED TOITHE 3 SHOWN ON THE APPROVED DESIGN PROVIDED BY THE CITY.
i
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 Absorpti n System(SAS)(locate on site plan, excavation not required):
If SAS not located,explain why:
1
IS ris.doc•rev.6116 Title.5 Official Inspection Form:Subsurface Sewago Disposal System•Page 12 of 17
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Commonwealth of Massachusetts
Title 5- Official- Inspection. Form
t Subsurfape.Sewag Disposal System Forint-Not for Voluntary Assessments
740 NORTH FARMS ROAD
Property Address
ROBERT&LORRAINE BATES
Owner Owner's Name
information is
reguiiredforeVdry NORTHAMPTON MA 44464 NOVEMBER 46 2447
page. City/Town state Zip Code Date ofdnspecSon
D. System Information (cont.)
Type:
❑ I) aching pits number:
❑ leaching chambers number:
Q leaching galleries number:
® leaching trenches number,length: TWO:3'W x 2'D
x 55'+1-L
❑ Leaching fields number,dimensions: - --
❑ overflow cesspool number:
❑ innovative/alternative system
11 ypeiname of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of
vegetation,etc;):
SOIL IN AREA OF TRENCHES SHOWED NO SIGNS OF HYDRAULIC FAILURE. VEGETATION IS
MOWED LAWN AND APPEARS NORMAL.THE ORIGINAL DESIGN CALLED FOR 3 TRENCHES,
BUTONLY . ARE PRESENT. IT APPEARS THAT THE LENGTH OF THE TRENCHES MAY
HAVE BEEN INCREASED FROM 44'TO 55' BASED ON PRESENCE AND LOCATION OF VENT
PIPE AT FAR 'ND OF SYSTEM.
a
Cesspools (cess I must be pumped as part of inspection)(locate on site plan):
Number and con i uration
Depth—top of liquid to inlet invert
Depth of solidsi layer
Depth of scum layer
Dimensions ofcesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5lns.doo rev.6/1B Title 5 Official Inspection Form:subsurface Sewage Disposal System-P.pge 13 of 17
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Commonwealth of Massachusetts
Tale 5 Official Inspection Form
Subsurface Sewage Disposal-System Foram-Not for Voluntary Assessments
710 NORTH FARMS ROAD
Property Address
ROBERT&LORRAINE BATES
Owner Owner's Name
information is
required for every NORTHAMPTON MA 01060 NOVEMBER 16,2017
page, cityrrown State Zip Code Date of Inspection
D. System Information (cant.)
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.):
I
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1.5ins.doc-rev.6116 Tice 5 Official Inspection Form:$ubsurrace Sewage Disposal System•Page 14 of 17
Commonwealth of N9assachusetts 15
,.�
Title 5 Official Inspection Form 1
17
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
710 NORTH FARMS ROAD
Property Address I
ROBERT&LORRAINE BATES
Owner Owner's Name
information is NORTHAMPTON i MA 01060 NOVEMBER 16,2017
required for every
page. Cityf'rown j 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 w l ter supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
-17
ern{'ape-
K Z-Du44e4-Cover
(5100 6aS�p4,!c--FA.-,k
IA( -j3`b r rr
..._ ........._.___........._.._,.__......
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iJ �V ote�
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t5lns.doc•rev.efl 6 Title 5 Official inspection Form:Subsurface Sewage Disposal System•page 15 of 17'
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Commonwealthof Massachusetts
_ Tithe 5 official Inspection Form
Subsurface Sewag,l Disposal System Form-'Not for Voluntary Assessments
710 NORTH FARMS ROAD
Property Address I —
ROBERT&LORRAINE BATES
Owner Owners Name.
information is.required for eNORTHAMPTON f MA 01060 NOVEMBER 16,2017
very cityrrown
page. ; State Zlp Cade Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
® Check celiar
❑ Shallow wills
Estimated depth to high ground water: > 120'
feet
Please indicate all methods used to determine the high ground water elevation:
0 Obtained from system design plans on record
If checked, date of design plan reviewed: D0 /�25197
❑ 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 de Icribe how you established the high ground water elevation:
HIGH.GROUNDWATER ELEVATION WAS ESTABLISHED DURING A WITNESSED PERC TEST
PERFORMED BY TIM MAGINNIS ON JUNE 12, 1997
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Before filing this inspection Report, please see Deport Completeness Checklist on next page.
isins.doe•rev.06 Tdle 5 Official inspection Form;,Subsurface Sewage Oispoeal System•Page 16 of 17
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Commonwealth,of Massachusetts
-- Title 5 Official Inspecti®n Farm
— s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
710 NORTH FARMS ROAD
Property Address
ROBERT&LORRAINE BATES
Owner Owner's Name
information is NORTHAMPTON _
required for every MA 01060 NOVEMBER 16,2017
page. City(rown I State Zip Code Date of Inspection
E. Report Coinpleteness Checklist
® Inspection Summary:A, B, C,D,or E checked
Inspecti=mated
ystem Failure Criteria Applicable to All Systems)completed
® System depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 19 or attached in separate file
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151ns.doc•rev.6116 I Tito 5 Official Inspection Form Subsurface Sewage Dispossl System•page 17 of 17
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