468 Title 5 8-29-19 Commonwealt i of Massachusetts
Title 5 Official Inspection Form
Subsurface Se age Disposal System Form - Not for Voluntary Assessments
ulv� 468 Coles Mgadow Road
Property Address
Owner Coles Meado Property LLC
information is Owner's Name
required for Northampton MA 01060 8/29/2019
every page. City/Town l 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 A. Inspector Information
forms on the
computer,use Marcus Millett
only the tab key Name of Inspecto
to move your Homestead Inc.
cursor-do not
use the return Company Name
key. 1664 Cape St.
Company Address
Williamsburg MA 01096
Cityrrown State Zip Code
413-628-4533 SI-13748
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); 1 have personally inspected the sewage disposal system at the property address
listed above;the ir}formation 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 th system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ® Fails
29 August 2019
Inspector's Signa ure Date
The system in pector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or D P)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 aI plicable, 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 d'fferent conditions of use.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealt i of Massachusetts
VTitle 5 Official Inspection Form
Subsurface Sei vage Disposal System Form - Not for Voluntary Assessments
w.; 468 Coles Meadow Road
Property Address
Owner Coles Meado Property LLC
information is owner's Name
required for Northampton MA 01060 8/29/2019
every page. Cityrrown State Zip Code Date of Inspection
C. Inspectio Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ 1 have not found any information that indicates that any of the failure criteria described in 310
CMR 15.303 o in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
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," lease 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 Hea h.
*A metal sept}c tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance inldicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc•rev.7/26=18 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Se age Disposal System Form - Not for Voluntary Assessments
468 Coles M allow Road
Property Address
Owner Coles Meadow Property LLC
information is Owner's Name
required for Northampton IMA 01060 8/29/2019
every page. CityRbwn I state Zip Code Date of Inspection
C. Inspectio Summary (cont.)
2) System Cor ditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑
Observation of sewage backup or breakout 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 pip (s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstructio is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The systet i required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system wil 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):
3) Further Evaluation is Required by the Board of Health,:
❑ Condition exist which require further evaluation by the Boardl of Health in order to determine if
the syster>i is failing to protect public health,safety or the environment.
a. Syste 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:
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Forrrc Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Se Nage Disposal System Form - Not for Voluntary Assessments
� 468 Coles M adow Road-
Property
oadProperty Address
Owner Coles Meadow Property LLC
information is Owner's Name
required for Northam ton MA 01060 8/29/2019
every page. Citylrown State Zip Code Date of Inspection
C. Inspectio 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 sy tem has a septic tank and soil absorption system (SAS)and the SAS is within 100
feet of a surfac a 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 sy tem has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The sy tem 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 bacte is 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 i dicate "Yes" or "No" to each of the following for all inspections:
Yes NQ
Backup of sewage into facility or system component due to overloaded or
® clogged SAS or cesspool
101 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
t �
Commonwealth of Massachusetts
Title 5 fficial Inspection Form
Subsurface Se age Disposal System Form - Not for Voluntary Assessments
468 Coles M adow Road-
Property
oadProperty Address
Owner Coles Mead o Property LLC
information is Owner's Name
required for Northampton MA 01060 8/29/2019
every page. Cityrrown State Zip Code Date of Inspection
C. Inspectio Summary (cont.)
4) System Fai ure Criteria Applicable to All Systems: (cont.)
Yes N
❑ 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 %day flow
❑ 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 water supply
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 2000 gpd-
10,000 gpd.
® 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 wiRt I 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 CA.
Yes N .
❑ f711 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
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Se Nage Disposal System Form - Not for Voluntary Assessments
468 Coles M adow Road
Property Address
Owner Coles Meado Property LLC
Information is Owner's Name
required for Northampton MA 01060 8/29/2019
every page. Cityrrown 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 ans red"yes"to any question in Section CA above the large system has failed. The
owner or oper for of any large system considered a significant threat under Section C.5 or failed
under Section 14 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 i dicate "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:
® ❑ Existing information. For example,a plan at the Board of Health.
❑ ® Determined in the field (f any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 fficial Inspection Form
Subsurface Se age Disposal System Form - Not for Voluntary Assessments
468 Coles Meadow Road
Property Address
Owner Coles Meadow Property LLC
information is Owner's Name
required for Northampton MA 01060 8/29/2019
every page. Cityfrown State Zip Code Date of Inspection
D. System In ormation
1. Residential Flow Conditions:
Number of bed ooms(design): unknown Number of bedrooms 7
(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of 770+ gpd
bedrooms):
Description:
Two 1500-gallon septic tanks, distribution box and an
infiltrat r leachfield. Serves three dwellings.
Number of cun ent residents: 1
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 ❑ Yes ® NO
inspection information in this report.)
Laundry systern inspected? ❑ Yes ® NO
Seasonaluseil ❑ Yes ® No
Water meter radings, if available (last 2 years usage (gpd)):
Detail:
Unmet red water consumption.
Sump pump? ❑ Yes ® No
Last date of occupancy:cupancy: Continuous
Date
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
c Commonwealt of Massachusetts
Title 5 fficial Inspection Form
Subsurface Se age Disposal System Form - Not for Voluntary Assessments
468 Coles Meadow Road
Property Address
Owner Coles Meado Property LLC
information is Owner's Name
required for Northampton MA 01060 8/29/2019
every page. Cityrrown 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 aste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter r adings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping ecords:
Source of infoi mation: No records on previous pumping.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped:
gallons
How was quanta pumped determined?
Reason for p mping: Pump as part of a repair.
15insp.doe•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
f
c Commonwealth of Massachusetts
Q vi
Title 5 Official Inspection Form
lid
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
468 Coles M adow Road
Property Address
Owner Coles Meadow Property LLC
information is Owner's Name
required for Northampton MA 01060 8/29/2019
every page. 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 (f known) and source of information:
Said to be built around millennium.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building S wer (locate on site plan):
Depth below grade: 1 average
feet
Material of construction:
❑ cast iron ®40 PVC ® other(explain): ABS plastic
Distance from private water supply well or suction line:
feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
No problems seen. Not much visible.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t� Subsurface Swage Disposal System Form - Not for Voluntary Assessments
468 Coles Meadow Road
Property Address
Owner Coles Meadow Property LLC
information is Owner's Name
required for Northampton MA 01060 8/29/2019
every page. Citylrown State Zip Code Date of Inspection
D. System I formation (cont.)
6. Septic Tan c (locate on site plan):
Depth below rade: 1.0 average
feet
Material of co struction:
® concrete ❑ metal ❑fiberglass polyethylene El other(explain)
Both tans about 1500 gallons each. House 1 tank appears
better maintained, and no problems seen. Other tank overdue
for pump#q, serious structural deterioration seen on outlet
end.
If tank ism tal, list age: years
Is age confi ed by a Certificate of Compliance? (attach a copy ❑ Yes ❑ No
of certificate)
Dimensions: 58" wide, 59" tall,
126 lona
Sludge depth Tank 1: 8", Tank 2: 13"
Distance from top of sludge to bottom of outlet tee or baffle Tank 1: 23", Tank 2: 18"
Scum thickne s Tank 1: 1", Tank 2: 3"
Distance frorT top of scum to top of outlet tee or baffle Tank 1: 6", Tank 2: 6"
Distance froff bottom of scum to bottom of outlettee or baffle Tank 1: 17", Tank 2: 15"
How were di ensions determined? Calculated and
estimated
Comments(c n pumping recommendations, inlet and outlet tee or baffle condition,structural
integrity, liqui I levels as related to outlet invert, evidence of leakage,etc.):
1500—gallon septic tanks. Tank 2 needs replacement.
t5insp.doc•rev.728/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
4
Commonwealt i of Massachusetts
Title 5 Official Inspection Form
Subsurface S wage Disposal System Form - Not for Voluntary Assessments
468 Coles M adow Road
Property Address
Owner Coles Meadow Property LLC
information is Owner's Name
required for Northam ton MA 01060 8/29/2019
every page. City/Town state Zip Code Date of Inspection
D. System I formation (cont.)
7. Grease Trap (locate on site plan):
Depth belovif grade: feet
Material ofconstruction:
❑ concrete ❑ metal ❑fiberglass ❑ ❑ other(explain):
polyethylene
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 p mping:
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 H� din nk (tank must be pumped at time of inspection) (locate on site plan):
Depth below rade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑polyethylene [Iother(explain):
Dimensions:
Capacity:
gallons
Design Flo
gallons per day
t5insp.doc•rev.7/2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonweal h of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
468 Coles Meadow Road
Property Address
Owner Coles Meado1w Property LLC
information is owner's Name
required for Northampton MA 01060 8/29/2019
every page. Citylrown 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: Date
Comments condition of alarm and float switches, etc.):
•Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distributio i Box (if present must be opened) (locate on site plan):
Depth of liqui level above outlet invert
Comments(nte 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 no� found. Went directly to leachfield.
f5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
cam, Commonwealt i of Massachusetts
? Title 5 Official Inspection Form
fI
SubsurfaceS wage Disposal System Form - Not for Voluntary Assessments
468 Coles M$adow Road
Property Address
Owner Coles Meado Property LLC
information is owner's Name
required for Northampton MA 01060 8/29/2019
every page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
10.Pump Char nber (locate on site plan):
Pumps in wor ing order: ❑ Yes ❑ No*
Alarms in worling order: ❑ Yes ❑ No*
Comments(n to condition of pump chamber,condition of pumps and appurtenances, etc.):
* If pumps or larms 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 to ted, explain why:
Type:
❑ leaching pits number:
leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 3 @ 401 ea.
❑ leaching fields number,
dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
L ?
Commonweal�h of Massachusetts
Title 5 fficial Inspection Form
Subsurface S wage Disposal System Form - Not for Voluntary Assessments
468 Coles M adow Road
Property Address
Owner Coles Meadow Property LLC
information is Owner's Name
required for Northam ton MA 01060 8/29/2019
every page. Cityrrown State Zip Code Date of Inspection
D. System Information formation (cont.)
11.Soil Absor tion System (SAS) (cont.)
Comments(n to condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, et .):
No break ut problems seen. Infiltrator technology. Dug in
field an , found retained water to within about 1" of top of
chambers, indicating probably groundwater. Leaching area
built in apparent wetland. Size of trenches is estimated.
12.Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and onfiguration
Depth—top o liquid to inlet invert
Depth of solid layer
Depth of scun i layer
Dimensions of cesspool
Materials of cI nstruction
Indication of roundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealt i of Massachusetts
Title 5 Official Inspection Form
Subsurface S wage Disposal System Form - Not for Voluntary Assessments
468 Coles M' adow Road
Property Address
Owner Coles Meadow Property LLC
information is Owner's Name
required for Northampton MA 01060 8/29/2019
every page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
13.Privy (locat on site plan):
Materials of cc nstruction:
Dimensions
Depth of solid
Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/282018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
cam, Commonweal�'hA�1`
sachusetts
Title 5 al Inspection Form
Subsurface S wage Disposal System Form - Not for Voluntary Assessments
v468 Coles M adow Road
Property Address
Owner Coles Meadow Property LLC
information is Owner's Name
required for Northam tone MA 01060 8/29/2019
every page. City/Town state Zip Code Date of Inspection
D. System Ir formation (cont.)
14.Sketch Of Sewage Disposal System:
Provide a vie of the sewage disposal system, including ties to at least two permanent reference
landmarks or enchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sk tch in the area below
® drawing attached separately
t5insp.doc-rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
J—) ,Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Swage Disposal System Form - Not for Voluntary Assessments
4_68 Coles Meadow Road
Property Address
Owner Coles Meadow Property LLC
information is Owner's Name
required for Northampton MA 01060 8/29/2019
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15.Site Exam:
® Check Slope
® Surface water
❑ Check cellar
® Shallow wells
"
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Cbtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting properly/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ hecked with local excavators, installers- (attach documentation)
❑ ccessed USGS database-explain:
You must describe how you established the high ground water elevation:
Leachingjarea is wet. Obligate wetland plants throughout.
Standing water in pond about 100 feet distant. Actual depth
to groundwater to be determined during a perc test for a
repair.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
It r
Commonwealt of Massachusetts
Title 5 Official Inspection Form
Subsurface Swage Disposal System Form - Not for Voluntary Assessments
468 Coles M adow Road
Property Address
Owner Coles Meadoiq Property LLC
information is Owner's Name
required for Northampton MA 01060 8/29/2019
every page. Cityrrown IState Zip Code Date of Inspection
E. Report C mpleteness Checklist
Complete all pplicable sections of this form inclusive of:
® A. Inspe for Information: Complete all fields in this section.
® B. Certif cation: Signed & Dated and 1, 2, 3, or 4 checked
® C. Insp ction Summary.;
1, 2, 3, r 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
D. Syst m Information:
For 8: T ght/Holding Tank—Pumping contract attached
For 14: 30ketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
1 100
1 House 2
NORTH House 1
\ deck
\ House 3 �� 00��
Q /
�--� Septic Tank
Septic Tank
M
T
Ndte: actual connection point unknow u'
Leach trenches, approximate layoL
Distribution Box
rr
Date: Owner: cF wss
As-Built Drawing �� ' s�yG HOMESTEAD INC.
Existing Septic stem 8/29/2019 Coles Meadow Property LLC Thomas S. Leue R.S.
g p Y THOMAS su
468 Coles Meadow Road IILE"
Scale: 1 . 30' Revision Date: / 72 msb Cape St.
Northampton MA 01060 9�c�8 `�P�e Williamsburg,MA 01096
Except as Noted P TfR�D SPS [413]628-4533
CITY of NORTHAMPTON
PUBLIC HEALTH DEPARTMENT '
Public Health Director-Merridith O'Leary
'A
Mur,icipal Building-212 Main Street-Northampton,MA 01060
Phone(413)587-1215-Fax(413)587-1221
http://www.northamptonma.gov/245/Health
CERTIFYING TITLE V INSPECTION
Date of Inspection: Al Time:
Property Owner:
Location of Title V Inspectio y �° g' CdS '' 6'�d
Title 5 Inspector:
License#:
L --
Phone#:
COMPON NTS IDENTIFIED: I `47'G n /tel Gam' �i(-t�f •- it d
Gtli df. G
Tools
BUILDING SEWER:
SEPTIC TANK: Z `fz Jr,iif
Yes No Liquid l velbelow.the outlet/invert
Yes No Eviden�e of:backup
Yes No Sludge depth and thick ss (Within 12,inches of outlet tee-_pumping recommended)
D-BOX: rrl' oG A4.1
Yes No Static water level is at or higher.than invert of outlet pipe
Yes Broken box,obstructed pipe,or box is uneven or settled
Yes Nl D-box is level and flow is equal
Yes-4 No Eviden a of solids carryover
SAS:
Yes-2LNo Leaching system located
Yes No_X Portion f the.SAS exposed to determine condition
YesX_ No tvidenCE of breakout,ponding,or sewage backup
Yes No Leaching,pit/Cesspool
PUMP CHAMBER:
Yes No Alarms and plui qps functioning correctly
Yes No Does system include a siphon
CESSPOOL/PRIVY:
NOTE: CESSPOOL TO BE PUMPED:A PART OF INSPECTION
INA
GREASE TRAP/TIGHT TANK
NOTE:TANK MUST BE PUMPIi�D AS T`OF INSPECTION
GROUNDWATER DETERMINATION-
Methods of estimati g HIGH groundwater el ation:
Yes No Location of bottom'of leaching facility compared to the HIGH.groundwater elevation
completed?
WA ,5 - a n . 1
J
Sign a of Ward of'H alth Agent DAte
• , CITY of NORTHAMPTON
PUBLIC HEALTH DEPARTMENT
Public Health Director—Merridith O'Leary
p Mu icipal Building—212 Main Street—Northampton,MA 01060 /
Phone(413)587-1215—Fax(413)587-1221
http://wwiv.northamplonma.Qov/245/Health
Application for Witnessing Official Title 5 Inspections
Fee: 150.0012-hour f eld);$75/hour thereafter_,
Date:
Site Address: `e s /!�QQ�oW VO Lj :'Parcel # 3
Property Owner: SGtr to �2 wUhM �c� �,e -.. .:uljhLf ►�
Property Owner Address: -2 War /-v`e-
Telephone: ...... Cell: ' 3, 7 7�8
Title 5 Inspector �.
Name of Inspector T6vyl, License M
Company Name �Vx� �2a�.k L Lt C
Mailing Address I Lo G I)I D 13 30
City/State/Zip Code
Telephone: Office: fro �, � 3-3 Cell:
Please answer the following
e / No: T5 Inspector has most recent plans for system to be inspected
Yes/(No. T5 Inspector.has pump-out-records
CYe .No: T5 Inspector has location of private-water supply wells-(withim150-feet of system location)
.
Reasonfor Inspection:
Pp
rl ESQ- Is b �YlaiV
Date u
re ested for Inspection: a 6* �.d
q_ p � Time:
Return Application Ten Days Prior to Requested Inspection Date to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060
MAKE. CHECKS PAYABLE TO THE CITY OF NORTHAMPTON
Application Fee is Non-Refundable