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856 Septic Inspection 2009 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Owner Owner's Name reformation is required rmat on for NORTHAMPTON MA JUNE 12, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B.C.D or E/always complete all of Section D A) System Passes: ® 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: B) System Conditionally Passes: ❑ One or more system components as deserted 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, ND) in the ❑ 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. ND Explain: ❑ 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 ❑ obstruction is remover.: tsinsp2c.o3IW ,fiofilmal In lam Form Subsunaa Sewage Disposal System.Page 2 o Owner information is required for every page Important: When filling out forms on the computer.use only the tab key to move your cursor-do not use the return key. a _ei yep doc.03/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Ownees Name NORTHAMPTON MA. 01062 JUNE 12, 2009 City/Town Sate Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector. PHILIP J. PASIECNIK Name of Inspector GREG'S WASTE WATER REMOVAL Company Name 239 GREENFIELD ROAD Company Address SOUTH DEERFIELD Cay/rown 413-665-3989 Telephone Number B. Certification MA. State S11526 License Number 01373 Zip Code 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. l am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 95.000).The system: ® Passes ❑ Condwonally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority JUNE 12, 2009 Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. Form:Subsurface Sewage O,sposei System.Pao of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 656 BURTS PIT ROAD Property Address MICHAEL BAUR Owner Owner's Name reformation is required for NORTHAMPTON MA. 01062 JUNE 12, 2009 every every page. City/Town ;rate Zip Code Date of Inspection fsirendoe•name B. Certification (cord.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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: 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 dogged SAS or cesspool ❑ ® Static liquid level m the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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. We 5 Offius1 inspection Form-Subsurface sewage Disposal system•Page offs Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Owner's Name NORTHAMPTON RSA. 01062 JUNE 12, 2009 City/Town B. Certification (cont.) Zip Code Date of Inspection B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: 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)(6)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 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. ;Soso doe.03/D8 ,le;eal it rpccnan Fenn Subsurface Sewage Deposal sraem.Page s offs Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Owner Owner's Name information fn is quire NORTHAMPTON MA. 01062 JUNE 12, 2009 every page. City/Town 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 by the owner, occupant, or Board of Health ❑ N 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:welling 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 inforiation For example, a plan at the Board of Health. ❑ ® Determined :n 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)] 15insp doc.0'908 :ele 5 Official Iris min Form:suosw(a a Soo age Disposal system.Pap 6 of Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Owner Owners Name information is NORTHAMPTON required for every page. City/Town ,InsPV°c-03108 01062 JUNE 12, 2009 Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. )This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. O EN E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either`yes,or-no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located iii 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 faded 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. I II,,h oou,el In.,.euion Form Subsurface Sawaoe DISoosaI system.Pane 5 of IS Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Flom - Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Owner's Name NORTHAMPTON MA. 01062 JUNE 12, 2009 City/Town Slate Zip Code Date of Inspection D. System Information (co General Information Pumping Records: Source of information. Septic tank was pumped by Greg's on 11/10/04 for Title 5 Inspection. Was system pumped as part of nspection? ® Yes ❑ No If yes, volume pumped' 1500 gallons How was quantity pumped determined^ Tank Dimensions Reason for pumping. Tank Inspection and Removal of Solids Type of System: ❑ Septic tank distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or rich) Of 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 :!A system by system operator under contract Tight tank. Attach a copy of the DEP approval. Other(describes Approximate age of all components, date installed Of known)and source of information_ 25 Years Old +or- / 1980's / Esimaied Were sewage odors detected when arnvmg at the site? ❑ Yes ® No Sinspdoc•03:08 Tme 5 Official Inspection roan:Subsurface Sewage Disposal SYs:em.Rage a of Owner Informations required for every page. Uin p dcc'0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Owner's Name NORTHAMPTON 01062 JUNE 12, 2009 City/Town Sra1e Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): N/A Number of bedrooms(actual). DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x it of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[it yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes Z No Water meter readings, if available(last 2 years usage (gpd)): = 14850 Gallons = 148 gpd Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied Commercialllndustrial Flow Conditions: Type of Establishment: N/A 4 440 gpd 2 Design flow(based on 310 CMR 15.203). — ------------- ---- --- Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft_ etc 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: Last date of occupancy/use: Other(describe): Date face Sewage Disposal System Page 7 of Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Owner's Name NORTHAMPTON Cty/rown MA. 01062 JUNE 12, 2009 State Zip Code Date of Inspection D. System Information (cart.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert. evidence of leakage, etc.): The septic tank should be pumped every two years. Cast in place concrete inlet and outlet baffles were functional and extend 15"and 17" below the flow line. Structural integrity of the septic tank was good. The liquid level was at the outlet invert. No leakage was evident at this time. Grease Trap(locate on site plan). Depth below grade: Material of construction: ❑ concrete ❑ metal N/A feet ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet fee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity. liquid levels as related to outlet invert. evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade N/A Material of construction. ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): RinW.doc•03/08 I i..a tl OriaaI Imspe4lm Pomm Sub age Disposal System•Fa9e TO of IS Owner information is required for every page. 03108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 856 BURTS PIT ROAD Properly Address MICHAEL BAUR Owner's Name NORTHAMPTON MA. 01062 JUNE 12, 2009 City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 Town Water feet Comments(on condition of joints, venting. evidence of leakage, etc.): All visible joints in the lower level of the dwelling were in good condition. Venting was visible outside the dwelling on the roof. No leakage was evident at this time. Septic Tank(locate on site plan). Depth below grade Material of construction: ® concrete ❑ metal If tank is metal, list age: ❑ fiberglass 1.5 feet ❑ polyethylene ❑ other(explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet lee al baffle Distance from bottom of scum to bottom of o1 Net tee or baffle How were dimensions determined? 10'6"Lx5'6"Wx5'4"D 8" 23" 11" Measured um Form Subsurface Sewage Disposal Syslem•Page 9 of 15 Owner information is required for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Owner's Name NORTHAMPTON MA. 01062 JUNE 12, 2009 City/Town State Zip Code Date of Inspection D. System Information (cent) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) i iccate on site plan, excavation not required): If SAS not located, explain why. Type: ❑ teaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alte]natise system Type/name of technology (1) 3-Pipe L-Field 28' L x 25'W Comments (note condition of soli signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No clogging of the soil was evident from backup of liquid into the distribution box. No signs of hydraulic failure or ponding to the surface. The soil over the leachfield wasn't damp or spongy. Vegetation was mowed grass and uniform in growth throughout the area of the leachfield. 6tnsp doe'03)08 If Si Official Inspection Form.Subsurface Sewage Disposal System•Page 12 of 1.5 Owner information is required for even'page, CftyITown Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Owner's Name NORTHAMPTON iS •ry WO-03X18 MA. 01062 JUNE 12, 2009 State Zip Code Date of Inspection D. System Information (cons) Tight or Holding Tank(cont.) N/A Dimensions: Capacity: gallons Design Flow: gaunns per day Alarm present ❑ Yes ❑ No Alarm level: --- --- - Alarm in working order: ❑ Yes ❑ No Date of as pumping: Date Comments (condition of alarm and float switches. Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert But Not Above Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.) Distribution box was level and flow equal to three outlet pipes. Little solids carryover was in the box when opened for inspection. No leakage was evident into or out of the box. Distribution box cover was 18"deep below grade. Pump Chamber(locate on site plan): Pumps in working order: Alarms in working order: FO ❑ yes ❑ No ❑ Yes ❑ No e Sew ge 1:W0681 System•Page 11 S%5 Owner information is required for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Owners Name NORTHAMPTON MA. 01062 JUNE 12, 2009 City/rown State Zip Code Date of Inspection D. System Information (cant Sketch Of Sewage Disposal System Provide a sketch 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 er.ters the building. 56-e_ Ex 44kachec Ismsp doe•03108 efts Official Insp¢oucn Form Subsurface Sewage Disposal System.Page 14 ot I Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Owners Name NORTHAMPTON MA 01062 JUNE 12, 2009 City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 N/A Indication of groundwater inflow ❑ Yes ❑ No 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.): 191sp doe.03/08 i..p. .tuff peWm Form Subsurface Sewage Disposal ayslem•Pace 13 of Owner information is required for every page. awn doc•flame Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 856 BURTS PIT ROAD Property Address MICHAEL BAUR Owners Name NORTHAMPTON MA. 01062 JUNE 12, 2009 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 4+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed-. Date • Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -expla n.. You must describe how you established the nigh ground water elevation: Site Exam I tlen Form subs dace Sewage DsposaI System Page 15 of 15 EXHIBIT "A" Four Bedroom Dwelling Driveway Garage 43' 3 Porch 34'5" Ill Deck 1500 Gallon SepticTank ��—Distribution Box Sewage Disposal System at 856 Burt Pit Road Northampton, Ma. 01062 Area of Leachfield 28ft. Long x 25ft.Wide(Approx.) Diagram Not To Scale