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219 Septic Inspection 2005 COMMONWEALTH OF MASSACHUSEI I S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 219 Audubon Road, Northampton, MA Owner's Name: James & Cynthia Faulkner Owner's Address: 219 Audubon Rd. Leeds, MA 01053 Date of Inspection: 6/3/05 Copyto: Board of Health, Northampton; Jones—Hutchins Realty Witness: Jeff Hutchins Number: SSDS-980 Name of Inspector: Thomas S. Leue Company Name: Homestead Inc. Mailing Address: 1664 Cape St. . Williamsburg, MA 01096 Telephone Number. (413) 628-4533 CERTIFICATION STATEMENT 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 septic system condition must be evaluated and classified into one of the following four conditions: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails The system condition: Passes Inspector's Signature: Date: ,Tune 3. 200% The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health of DEP) within thirty (30) days of completing this inspection. If the system is a shared system or 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 to the buyer, if applicable and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 of 9 Homestead Inc. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owner Owner's Name information is required for Leeds every page. City/Town Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. 15185•gs08 MA 01053 January 29, 2013 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. A. General Information 1. Inspector: Timothy E. Maginnis R.S. Name of Inspector Company Name 70 Montague Road Company Address Westhampton City/Town Home: (413)527-5291 Telephone Number Cell:(413) 575-8523 MA State SI-1039 License Number 01027 Zip Code 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 :a" . .,•t �\ al Approving Authority 6w0 Inspector' January 29, 2013 Date V The system inspecto _/ py of this inspection report to the Approving Authority(Board of Health or DEP)within'. ... . 'a completing this inspection. If the system is a shared system or 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. Title 5 Official Inspection Form Subsurface Sewage Disposal system•Page 1 Of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owners Name Leeds MA 01053 January 29, 2013 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 0 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The septic tank at this site was pumped on November 30, 2012 and was not full for this inspection. Not enough water was used to fill this tank prior to the inspection. There were no signs of leakage in or around this tank. Water was poured into the distribution box to confirm proper flow to the SAS. No failure noted. 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): N/A t5ins•03185 Title 501fioal Inspection Form Subsurface Sewage Dspo I Sy lea Pans 2 of 17 Owner information is required for every page. ttins•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owners Name Leeds MA 01053 January29, 2013 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cunt.): ❑ 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 E N E ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): N/A ❑ 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): N/A 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 Title 5 Official Inspection Form Subsurface sew'a a Disposal System.Page 30117 Owner information is required for every page. pare•179/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owner's Name Leeds City/Town 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, 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. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ 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: N/A MA 01053 January 29, 2013 State Zip Code Date of Inspection "This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: N/A D) 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 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 Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 0 of 17 Owner information is required for every page. thins•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owner's Name Leeds MA 01053 January 29, 2013 City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ N Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ E Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ N Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ E Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ N 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.] ❑ E The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ E 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 ❑ N the system is within 400 feet of a surface drinking water supply ❑ N the system is within 200 feet of a tributary to a surface drinking water supply ❑ E 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. Title S Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 17 Owner information is required for every page. tOins•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owner's Name Leeds City/Town C. Checklist MA 01053 January 29, 2013 State Zip Code Date of Inspection Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No N ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ N Were any of the system components pumped out in the previous two weeks? N ❑ Has the system received normal flows in the previous two week period? ❑ N Have large volumes of water been introduced to the system recently or as part of this inspection? N ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) N ❑ Was the facility or dwelling inspected for signs of sewage back up? N ❑ Was the site inspected for signs of break out? N ❑ Were all system components, excluding the SAS, located on site? N ❑ 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: N ❑ N ❑ N ❑ 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): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 496.80 gpd Tale 5 Off Tsai Inspection Form.subsWace sewage Disposal System•Page 9 of 17 Owner information is required for every page. (Sins.09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Ownees Name Leeds MA 01053 January 29, 2013 City/rown State Zip Code Date of Inspection D. System Information Description: Existing 1,000 gallon septic tank, distribution box an Infiltrator leaching trench system installed in August 1986. SAS and distribution box installed in 1996. Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 1 year average: 126,274cu. ft. Detail: Nov. 7, 2011 = 124,200 cu. ft. and Nov. 5, 2012 = 128,348 cu. ft.. Sump pump? ❑ Yes ® No Last date of occupancy: Currently occupied Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A Tilla S Olgcol Inspection Fcm Suaweace Sewage Disposal System•Page 70117 Owner information is required for every page. thins•09/09 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owners Name Leeds MA 01053 January 29, 2013 City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other(describe below): N/A N/A Date General Information Pumping Records: Source of information: Hadley, MA. -Source of info. =Sue Etzel Was system pumped as part of the inspection? ❑ Yes ® No Pumped on Nov. 30, 2012 by Karl's Excavating of If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: 1,000 gallons on Nov. 30, 2012 gallons receipt from pumper Maintenance ❑ 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): Tiles Official Inspealm form Subsurface Sewage Disposal System•Page 8 or 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owner's Name Leeds MA 01053 January 29, 2013 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: 1,500 gallon septic tank= unknown. Distribution box and an Infiltrator leaching trench system. Installed in August 1996. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC - ❑other(explain): Distance from private water supply well or suction line: 2' feet 4" pvc solid pipe N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4" pvc solid pipe from house to tank is in good working order. Pipe from tank to distribution box is also in good working order. No eveidence of leakage and all joints are sound. Venting is proper Septic Tank(locate on site plan). Depth below grade: Material of construction: 18"to top of pumpout manhole. - 3 covers on this tank ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) This is a 1,500 gallon concrete septic tank. Outlet tee is 4" pvc pipe and is operating properly. There is also a concrete outlet baffel on this tank. The tank shows no signs of leakage, in or out. It is in good working order. Inlet cover is under sidewalk and not inspected. Risers have been installed on pump out man-hole and outlet cover. If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Sludge depth: ❑ Yes ❑ (9.33'L x 5'W x 5'D) No 0 Sins 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 Owner information is required for every page. t5lns•OBtla Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 219 Audubon Road Properly Address Susan Etzel Ownefs Name Leeds MA 01053 January 29, City/Town State Zip p Code Code Oafe of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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? 0 0 0 0 measured and observed Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At the time of this inspection, the septic tank was not full because it had been pumped in November 2012. There was about 6"of wastewater in the bottom. There were no signs of leakage Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ID 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: N/A N/A N/A N/A N/A Date Title 5()final lupus-lion Form:Subsurface Sewage Disposal System•Page 10 N 17 Owner information is required for every page. Sins•oaoe Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owners Name Leeds MA 01053 January 29, 2013 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.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete N/A [' metal N/A ['fiberglass ❑ polyethylene ❑other(explain): Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Title 5 Official Inspection Form subsurface sewage Disposal system.Page 11 of IT Owner information is required for every page. ISins.PJNW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel owners Name Leeds Cityfrown MA 01053 January 29, 2013 State Zip Code Date of Inspection D. System Information (cont.) Distribution Box of present must be opened) (locate on site plan): Depth of liquid level above outlet invert Distribution box installed in 1996. 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 in good working order. There are 3 speed levelers on the outlet pipes of this box. Water was poured into distribution box to verify its working condition. So evidence of carryover or leakage Water at outlet pipes was even with each invert and flowed properly. Pump Chamber(locate on site plan): Pumps in working order. Alarms in working order: ❑ Yes ❑ Yes ❑ No ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances etc). N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: SAS is a 3 trench Infiltrator system. Each trench is(54'L x 3W)with 9'in between each trench. Each Infiltrator has an effective length of 6 feet. There are 9 Infiltrators per trench Title 5 Official Ins ion Form Subsurface Serge Deposal System•Page 12 of 17 Owner information is required for every page. llns•09/02 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owners Name Leeds MA 01053 January 29, 2013 City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 3 @ 54'L each Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): This is an Infiltrator leaching trench system and it is not in failure. The SAS is 13 years old and is in good working order. There is no evidence of ponding or damp soil. The vegetation is normal grass. No signs of hydraulic failure. Each trench is(54'L x 3W)with 9' in between each trench. Each Infiltrator has an effective length of 6 feet. There are 9 Infiltrators per trench 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 N/A N/A N/A N/A N/A N/A ❑ Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 W 17 Owner information is required for every page. tans.osroe Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 219 Audubon Road Property Address Susan Eel Owner's Name Leeds MA 01053 January 29, 2013 City/Town State Zip Cade Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: Dimensions Depth of solids N/A N/A N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Tales Off icial Ins Form.Su ace Ssw o Disposal Sysiam•Page 14 at 17 Owner information is required for every page. inns• MOS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owner's Name Leeds City/Town 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 MA 01053 January 29, 2013 State Zip Code Date of Inspection E G M EMLA aC w Hie 5 Official Inspection rwm'.Subsurface Sewage Disposal System•Pape 15 of 17 AUDUBON ROAD — LEEDS MASSACHUSETTS Lamp po Driveway t A Existing water supply line Underground electric line to lamp post Q' Existing 05 Solar panel 07 „ (iii' It's] xisting Septic tank Pump out man—hole ("C') pvc solid pipe 0 0 0 Existing � Q 3 bedroom z/, h 0 ouse .�J i ix ii I S garage Existing Infiltrator leaching trench system 3 Trenches with 9 Infiltrators per trench (Effective length of Infiltrator = 6ft.) AS—BUILT DIMENSIONS 4ft Reserve area t Reserve area -Existing distribution box �4" pvc solid pipe Site Address: 219 Audubon Road Leeds, Massachusetts 01053 Current owner: Susan E. M. Etzel Telephone: Cell: (413) 584-2073 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owner Owners Name information is Leeds required for MA 01053 January 29, 2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) (Sins.09/03 Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: This system was designed to be 4' above groundwater. 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: January 12, 2013 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: 1. This inspector conducted original test pits in 1996 and designed the system to be 4 feet above groundwater.. 2. Observed no infiltration in distribution box. 2. There are no sump pumps in this dry cellar. 3. Review of previous Title-5 Inspection report. 4. Review USDA Soil Survey of Hampshire County. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 official InspecllM Form.Subsurface Sewage Disposal System•Page 16 of 17 Owner information is required for every page. (Sire.09308 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 219 Audubon Road Property Address Susan Etzel Owner's Name Leeds City//own MA 01053 January 29, 2013 State Zip Code Date of Inspection E. Report Completeness Checklist Z Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official inspection Form'.Subsurface Sewage Disposal System•Page 17 of 17 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (continued) Property Address: 219 Audubon Road, Northampton, MA Owner: James Si Cynthia Faulkner Date of Inspection: 6/3/05 2) System will fail unless 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. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: D] System Failure Criteria applicable to all systems: You must indicate either"Yes" or "No" as to each of the following for all inspections: YES (Y) or NO (N) N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N Liquid depth in cesspool is less than 6" below invert or available volume less than 1/2 day flow. N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped_ N Any portion of the SAS, cesspool or privy is below high ground water elevation. N Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N Any portion of cesspool privy is within a Zone I of a public well. N Any portion of cesspool or privy is within 50 feet of a private water supply well. N Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] N The system fails. I have determined that one or more of the above failure criteria exist as defined in 310 CM 15.303,therefore the system fails. The system owner should contact the Board of Health should be contacted to determine what will be necessary to correct the failure. Title 5 Inspection Form 6/I5/2000 page 3 of 9 Homestead Inc. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (continued) Property Address: 219 Audubon Road, Northampton, MA Owner: James S Cynthia Faulkner Date of Inspection: 6/3/05 El Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd. You must indicate either"Yes" or "No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: YES (Y) or NO(N) N the system is within 400 feet of a surface drinking water supply N the system is within 200 feet of a tributary to a surface drinking water supply N 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 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. PART B: CHECKLIST Check if the following have been done You mast indicate "yes"or"no"as to each of the following:, YES (Y) or NO (N) Y Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the previous two weeks? Y Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of the inspection? N/A Were"as-built"plans of the system obtained and examined? (If they are not available note as N/A) Y Was the facility or dwelling was inspected for signs of sewage back up? Y Was the site was inspected for signs of break out? Y Were all system components,excluding the SAS,located on site? Y Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y a) Existing information. For example, a plan at the Board of Health. N b) Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [15.302(3)(b)]. • The facility owner(and occupants,if different from owner) were provided with information on proper maintenance of Subsurface Sewage Disposal Systems(SSDS). RESOURCES: Department of Environmental Protection,Western Regional Office,436 Dwight St., Springfield,MA 01103, (413) 784-1100;Title 5 Hotline -(800)266-1122 Title 5 Inspection Form 6/15/2000 page 4 of 9 Homestead Inc. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C: SYSTEM INFORMATION Property Address: 219 Audubon Road Northampton MA Owner: James & Cynthia Faulkner Date of Inspection: 6/3/05 RESIDENTIAL 497 3 4 2 Y Y N N N/A N continuous FLOW CONDITIONS DESIGN flow based on 310 CMR 15.203 (gallons/day) Number of bedrooms(design) Number of bedrooms(actual) Number of current residents Is there a garbage grinder?(Y or N) _ Is there a Laundry Hookup?(Y or N) Is the Laundry a separate system?(Y or N) (If yes, separate inspection required)_ Seasonal use(Y or N) Water meter readings, if available(last two years usage) (gallons per day) Sump Pump(Y or N)_ Date of last occupancy_ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (Y or N): Industrail waste holding tank present(Y or N): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: pumped "about 3 years ago", says Owner A Was system pumped as part of the inspection(Y or N) If yes,volume pumped: gallons --How was quantity pumped determined? Reason for pumping: Comment: does not need pumping this year TYPE OF SYSTEM: X Septic tank, distribution box, soil adsorption system. Single cesspool Overflow cesspool _ Privy N Shared system(Y or N) (if yes,attach previous inspection records,if any) Innovative/Altemative technology. Attach copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank(Attach a copy of the DEP approval) Other(describe): 1a_ Were sewage odors detected when arriving at the site (Y or N) Title 5 Inspection Form 6/15/2000 page 5 of 9 Homestead Inc. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C: SYSTEM INFORMATION(continued) Property Address: 219 Audubon Road. Northampton. MA Owner: James & Cynthia Faulkner Date of Inspection: 6/3/05 APPROXIMATE AGE All components, date installed, and source of informatior Septic plan: dated 8-25-96, septic tank from 1977 Source of Information Owner BUILDING SEWER 24 4 ABS Comments: (located on site plan) Depth below grade (inches) Estimated Averagg Distance in feet from private water supply well or suction line Materials of Construction Hole in sidewalk over inlet. SEPTIC TANK Concrete Materials of Construction 18 Depth below grade 0 Riser depth 60 Septic tank width 112 Septic tank length 61 Septic tank height 1,779 Calculated gross volume 8 Air space in tank 1,500 Net Volume 22 Baffle depth 4 Sludge thickness 4 Scum thickness 35 Top Sludge : Bottom Baffle 11 Bottom Scum : Bottom Baffle 5 Top Scum : Top Baffle (located on site plan) (inches) (inches) (inches) (inches) (inches) (gallons) (inches) (gallons) (inches) (inches) (inches) (inches) (inches) (inches) Interior dimensiong Interior di manni nuns Interior dimensions Calculated Calculated Average Average Calculated Calculated Calculated Comments: Partly under sidewalk.Tank appears to be installed backwards, not a serio problem. Outlet tee is PVC and functional. Recommendations: A riser, 12 to 16" high would facilitate maintenance. PUMP CHAMBER N Pump part of septic system: (Y or N) Pumps in working order: (Y or N) Alarms in working order: (Y or N) Comments: Title 5 Inspection Form 6/15/2000 page 6 of 9 Homestead Inc. S OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C: SYSTEM INFORMATION(continued) Property Address: 219 Audubon Road Northampton, MA Owner: James & Cynthia Faulkner Date of Inspection: 6/3/05 DISTRIBUTION BOX (located on site plan) ("D-box") Y D-box part of septic system: (Y or N) O Depth of liquid level above outlet invert Comments: Box sloping to end outlet, so 3 speed levellers installed tiro balance flow. Box relatively clean for age. SOIL ADSORPTION SYSTEM (SAS): Technology Used (located on site plan by estimate): leaching pits &number: leaching chambers and number: leaching galleries and number: Y leaching trenches, number, length: 3 trenches, each 54 ' leaching fields, number, dimensions: overflow cesspool,number: innovative/alternative system,Type: Comments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Infiltrator trenches. No breakout or surface problems seen. f SAS not located explain why: TIGHT OR HOLDING TANK (tank must be pumped at time of inspection) N Tight tank part of system: (Y or N) Depth below grade (inches) Measured Tank width (inches) from Plan Tank length (inches) from F)an Tank height (inches) From Plan Calculated gross volume (gallons calculated Materials of construction Design flow: gallons/day Pumps in working order: (Y or N) Alarms in working order: (Y or N) Date of last pumping Comments: (conditions of inlet tees, condition of alarm and float switches, etc.) PRIVY (locate on site plan, if any) N Privy part of system: (Y or N Materials of construction: Dimensions: Depth of solids: Comments: (soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, et Title 5 Inspection Form 6/15/2000 page 7 of 9 Homestead Inc. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C: SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: 219 Audubon Road Northampton MA James & Cynthia Faulkner 6/3/05 CESSPOOLS N Comments: (cesspool must be pumped as part of inspection) Cesspool part of system: (Y or N) 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(cesspool must be pumped as part of inspection) (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, GREASE TRAP (Usually present in certain commercial systems) N Grease Trap part of system: (Y or N) Materials of construction: Comments: Depth below grade Dimensions: Depth of solids layer Depth of scum layer Top of scum to top outlet Date of last pumping Bottom of scum to outlet. Scum thickness (recommendation and condi (inches) (inches) ons) Measured Calculated Inches calculated Inches Average SITE EXAM (Source of Information) Y Slope Official Perc Date Y Surface water 8/25/96 Official Plan Date Y Check Cellar Other Official Source N Shallow wells Other Source 58 Estimated depth to ground water (inches) Please indicate(check) all the methods used to determine high groundwater elevation: Y Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Depth to groundwater before large amounts of fill added for new system. System rebalanced to better distribute the flow. Information: Title 5 Inspection Form 6/15/2000 page 8 of 9 Homestead Inc. Note: No known drinking water sources within a 100 foot radius. , Infiltrators tar NORTH bt :' Infiltrators j Leaching Trenches Distribution Box 62 I MMO. COMMENTS: ' ■ Recommend pumping on a 3 to 5 year ■ schedule. Also, a copy of this plan Outline of House posted in the basement/utility area wou1,1 Jcyep this information accessible in future years f or maintenance. 34 f/Z SFr Septic Tank As-Built Drawing Date: Owner: HOMESTEAD INC. • Existing Septic System 6/3/05 James & Cynthia Faulkner , - ) Thomas S. Leue R.S. 219 Audubon Road Revision Date: 1664 Cape St. Scale: l : 20' Leeds, MA 01053 j Wituamsburg,MA 01096 Except as Noted 14131628-4533 • OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 219 Audubon Road, Northampton, MA Owner: James 6 Cynthia Faulkner Date of Inspection: 6/3/05 Inspection Summary: Check A,B, C, D or E/ALWAYS complete all of Section D: A. System Passes: Y I have not found any information which indicates that any of the failure criteria as 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: N 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. Answer yes, no, or not determined(Y, N,or ND) in the for the following statements. If"not determined"please explain. (1) N 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. The system will pass inspection if the existing septic 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. ND explain. (2) N 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 by the Board of Health). _ broken pipe(s) are replaced obstruction is removed _ _ distribution box is levelled or replaced ND explain: (3) N The system required pumping more than four 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 obstruction is removed ND explain: (4) N Other: explain: _ C] Further Evaluation is Required by the Board of Health: N Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the 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. Title5 Inspection Form 6/15/2000 page 2 of 9 Homestead Inc.