41 Certificate of Compliance & Inspection Forms Title V Checklist
Date Received:
Owner: ' aItFN kltv_o yN Address: yl D nPH A c-
Engineer: lie , fc rt Installer: LJL 14 1.1
Make sure 4 copies of the plan are submitted (do not accept permit
application until we have 4 copies of the plan)
I /Give the permit a number (use computer based log)
orioin.Is in
copies of all documentation including checklist
Send Copies to Dave with two of the original design plans and put
ee's Box
that
plan
Dave Approve Plan. Send letter to BOH noting approval or corrections
eed to b- ade. Also send a copy of the checklist.
Once letter from Dave is received AP or BW will sign permit and stamp
Before we issue construction permit staff must make sure installers
e is on the appf ation AND that that installer has a permit with us. DO NOT
EPT MO OR PERMIT IF INSTALLER DOES NOT HAVE PERMIT.
Contact home owner or installer that plans have been approved.
er mail them or have them come pick plans and permit up.
AP will schedule Final Inspection and contact Dave
Final inspection is passed and "as built" received.
Cert of compliance Issued.
CLOSED
HERITAGE SURVEYS, INC.
Professional Surveyors and Engineers
241 College Highway & Clark Street
Post Office Box 1
Southampton, Massachusetts 01073-0001
Bruce A Coombs, President
Professional Surveyor, MA, CT& VT
E-mail: bruce@heritagesurveys.com
Telephone(413)527-3600
Facsimile (413) 527-8280
Website: heritagesurveys.corn
Title V Certificate of Compliance
DESIGNER & INSTALLER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental code: Title V, Minimum Requirements for
the Subsurface Disposal of Sanitary Sewage, Section 15.021 (3), the Designer and Installer of a
system are required to sign this form as a condition for issuance of a Board of Health Certificate of
Compliance for the onsite septic system.
This is to certify that the onsite sewage disposal system that Heritage Surveys, Inc. designed as:
new construction
X repair/upgrade (existing system)
SITE: 41 Dunphy Drive, Northampton,MA
FINAL INSPECTION DATE: August 6, 2010
DWCP #:
OWNER: Karen Klekotka
has been constructed in compliance with 310 CMR 15.00, and all local requirements. Any changes
to the original approved plans have been reflected on an as-built plan that has been submitted to the
Board of Health.
DESIGNER
Heritage Surveys, Inc.
241 College Highway & Clark Street
P.O. Box 1
Southampton,MA 01073
(413) 527-3600
✓ Si /0c
Date
INSTALLER
Whiteley Excavating
52 Maple Street
Southampton,MA 01073
(413)527-2321
NOTE: This certificate represents no warranty, expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system.Rather, the plan and installation are in compliance with all applicable rules and regulations as
are in effect at the time of plan submittal.
/C
DATE: S—
JOB#:5133-6S 1 I6'1
LOCATION:.4t bot3P
SYSTEM TIES
A—C=15.83'
B—C=36'
A—D=29.67'
B—D=39.67'
A—L P.#1=38.6 7'
B—I.P.#1=24.83'
A—!.P.#2=46'
B—I.P.#2=37.5'
A—END TRENCH#1=53.5'
B—END TRENCH#1=28.83'
A—END TRENCH#2=62.67'
B—END TRENCH#2=40.33'
NOT TO SCALE
241 College Highway&Clark Street
P.O. Box 1
Southampton,MA 01073
(413) 527-3600
!eribige $inegs, IIIc.
RESTRICTION
U� NIn INI
B : 28Pg: 14 Pa e: o
Pee d d: 07/08/2010 1 36 AM
uu
I, Karen J Klekotka,owner of the real estate and designated as 41 Dunphy Drive in Florence, Hampshire
County, Massachusetts by virtue of a deed dated August 6, 1993 and recorded with the Hampshire County
Registry of Deeds in book 4269,page 283, hereby impose the following restriction upon said premises.
This property will not be allowed to have a garbage disposal in accordance with the Board of Health for ne
septic system placement.
Karen J Klekotka
Witness my hand and seal this 3 rot day of
�vvv\B G. Co
r-• :}o'FV L-p'a m y
*- , p1�Oi L® *�
• /"i• ll l g lY 0t Commonwealth of Massachusetts
n/4 070/0
Notary of the Public
The above named Karen J Klekotka personally appeared before me and acknowledged the forgoing to be
her free act and deed.
ATTEST. HAMM:IRE,✓ 1444m74 ,REQJfTER
MARIANNE L. DONOHUE
BOARD OF HEALTH
MEMBERS
SUZANNE SMITH,M.D.
DONNA C.SALLOOM
JOANNE LEVIN,M.D.
STAFF
Benjamin Wood,MPH
Director of Public Health
Patricia Abbott,R.N.,Public Health Nurse
Aimee Petrosky,Health Inspector
Heather Mcbride,Clerk
June 7, 2010
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
Heritage Surveys, Inc
College Highway and Clark Street P.O. Box 1
Southampton Ma
212 MAIN STREET
NORTHAMPTON,MA 01060
Re: Plan Review 41 Dunphy Drive
To whom it may concern,
The septic design plan for 41 Dunphy Drive has not been approved for the following reasons.
1) The plan does not show the required manholes. 15.228 (2)
The an does under the septic tank. 15.228 (1)
3) The dimensions of the tank are not indicated. These are necessary
so I
• A • r • • • a III
sufficient
4) Gas baffles are not indicated. 15.227 (4)
5) All system components should be marked with magnetic tape. 15.221(12)
6) Please provide an invert grade of outlet from tank.
7) Please provide invert grades of incoming and outgoing for D box.
8) Please provide grades of top and bottom of SAS.
9) Please provide invert dimensions at beginning and end of trench pipe.
Please resubmit the plan with these corrections. Also as a note because the new system design
is over old septic components I will need a receipt submitted for to where the system components
have been transported to ensure that they have been discarded in accordance with DEP standards.
If you have any questions please don't hesitate to contact me directly at the office, 413-587-1217.
Thanks,
Aimee Petrosky
HERITAGE SURVEYS, INC.
Professional Surveyors and Engineers
241 College Hwy&Clark St, P O Box I
Southampton, Massachusetts 01073-0001
Bruce A. Coombs, President
Professional Surveyor, MA, CT& VT
E-mail:bruce@heritagesurveys.com
Telephone(413)527-3600
Facsimile(413)527-8280
Websire:heritagesurveys.com
LETTER OF TRANSMITTAL
TO: Northampton Board of Health
Attn: Aimee Petrosky
212 Main Street
Northampton, MA 01060
DATE: June 21, 2010
JOB #: 5733-051109
SUBJECT: 41 Dunphy Drive
Revised Septic System Upgrade Plan
WE ARE SENDING YOU:
COPIES
DATE
PLAN #
DESCRIPTION
2
05/02/06
Revised
06/21/10
5733-
100621
Plan of Proposed Sewage Disposal System
Upgrade, 41 Dunphy Drive in
Northampton, Massachusetts Prepared
for Karen Klekotka
The enclosed sewage disposal system upgrade plan has been revised to address
all of your concerns within your June 7, 2010 letter. Please contact this office
if you should have any questions or comments.
Sincerely,
44,/e P l Gt
Mark P. Reeddag
BOARD OF HEALTH
MEMBERS
SUZANNE SMITH,M.D.
DONNA C.SALLOOM
JOANNE LEVIN,M.D.
STAFF
Benjamin Wood,MPH
Directorof Public Health
Patricia Abbott,R.N.,Public Health Nurse
Aimee Petrosky,Health Inspector
Heather Mcbride,Clerk
May 19, 2010
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
RE: Local Upgrade Approval 41 Dunphy Drive.
Dear Board Members,
212 MAIN STREET
NORTHAMPTON,MA 01060
There has been a request for a Local Upgrade Approval at 41 Dunphy Drive. On December 8,
2005 Peter McErlain performed a soil suitability test for 41 Dunphy Drive. The request is for a
reduction in setback requirements from 10 feet to 4 feet. Based on 310 CMR15.410 I recommend to
the board that we approve the variance request.
Thank
1 ,LL✓
imee Petrosky
Health Inspector
Northampton Health Department
212 Main Street
Northampton ma 01060
E3
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
Vao
RIM
Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Wastewater Management Program
Form 9A - Application for Local Upgrade Approval
Required by 310 CMR 15.403(1)
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming
septic system with a design flow of less than 10,000 gpd,where full compliance, as defined in 310 CMR
5.404(1), is not feasible.
System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full
compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410
through 15417
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of
a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved
capacity of a septic system constructed in accordance with either the 1978 Code or 310 CMR 15.000.
A. Facility Information
Facility Name and Address
Karen Klekotka
Name
41 Dunphy Drive
Street Address
Northampton
City
2. Owner Name and Address-
Karen Klekotka
MA
State
01060
41 Dunphy Drive
Zip Code
Name
Northampton
City
01060
Street Address
MA
State
(413)586-6794
Zip
3. Type of Facility(check all that apply):
® Residential ❑ Institutional
4. Describe Facility:
4 bedroom home
Telephone Number
❑ Commercial ❑ School
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
® Conventional ❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
leach field
5733fonn9a.doc•rev.5/02
Application for Local Upgrade Approval* Page 1 of 1
Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Wastewater Management Program
Form 9A - Application for Local Upgrade Approval
Required by 310 CMR 15.403(1)
A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
Design flow of existing system:
Design flow of proposed upgraded system
Design flow of facility
unknown
gpd
440
gpd
446
gpd
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
Z Voluntary ❑ Required by order, letter, etc. (attach copy)
❑ Required following inspection pursuant to 310 CMR 15.301:
2. Describe the proposed upgrade to the system:
Proposed system includes a 1500 gallon septic tank, distribution box and 2-3'x 45'leaching
trenches
date of inspection
3. Local Upgrade Approval is requested for:
❑ Reduction in setback(s)—describe reductions:
Reduction in setback between property line and proposed leaching trench-4 foot separation
proposed.
❑ Percolation rate for 30 to 60 min./inch:
❑ Reduction in SAS area of up to 25%:
min./inch
SAS size,sq.ft. %reduction
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction n
Percolation rate min./inch
Depth to groundwater
❑ Relocation of water supply well (explain):
5733fonn9a.doc•rev.5/02 Application for Local Upgrade Approval* Page 2 of 2
Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Wastewater Management Program
Form 9A - Application for Local Upgrade Approval
Required by 310 CMR 15.403(1)
❑ Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the
Code:
A waiver is being requested to eliminate the Northampton Board of Health requirement to size the
system 1.5 times larger. (The system has been sized for a four bedroom house with no garbage
disposal.)
If the proposed upgrade involves a reduction in the required separation between the bottom of the soil
absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the
high groundwater elevation pursuant to 310 CMR 15.405(1)(i)(1). The soil evaluator must be a member
or agent of the local approving authority.
High groundwater evaluation determined by:
Evaluator's Name(type or print)
Signature Date of evaluation
C. Explanation
Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be
completed)
1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible:
An upgraded system in full compliance with 310 CMR 15.000 is not feasible due to the existing sites
restraints. The proposed system maintains public health and safety to the maximum extent feasible.
2. An alternative system approved pursuant to 310 CMR 15283 to 15.288 is not feasible:
Some alternative systems are not economically feasible to require. Other systems require the same
area and depth. The proposed system maintains public health and salty to the maximum extent feasible.
3. A shared system is not feasible:
There is no system large enough or in close proximity to the site.
4. Connection to a public sewer is not feasible:
Public sewer is not available
5733form9a.doc•rev.5/02
Application for Local Upgrade Approval* Page 3 of 3
Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Wastewater Management Program
Form 9A - Application for Local Upgrade Approval
Required by 310 CMR 15.403(1)
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
® Application for Disposal System Construction Permit
® Complete plans and specifications
® Site evaluation forms
❑ A list of abutters affected by reduced setbacks to private water supply wells or properly lines.
Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2).
❑ Other(List):
D. Certification
"I,the facility owner, certify under penalty of law that this document and all attachments,to the best of my
knowledge and belief, are true, accurate, and complete. I am aware that there may be significant
consequences for submitting false information, including, but not limited to, penalties or fine and/or
imprisonment for deliberate violations."
eell 2-0/e)Fadli y nets Si g nature
Date
Karen Klekotka
Print Name
Heritage Surveys, Inc.
Name of Preparer
Date
College Highway&Clark Street- P.O. Box 1 Southampton
Preparers address City/Town
MA/01073
State/ZIP
(413) 527-3600
Telephone
NOTE: 310 CMR 15.403(4) requires the system owner to provide a copy of the local upgrade
approval to the appropriate Regional Office of the Department of Environmental Protection, Bureau of
Resource Protection, Division of Watershed Management, upon issuance by the local approving
authority and before commencement of construction.
5733form9a.doc•rev.5/02 Application for Local Upgrade Approval Page 4 of 4
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key_
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.
A. General Information
1. Property Information:
41 Dumphy Dr. Florence MA.
Property Address
Karen Klekotka
Owner's Name
same
Ownefs Address
City/Town
Date of Inspection:
State
04/26/10
Date
Zip Code
2. Inspector:
Ray Champagne
Name of Inspector
Whiteley Septic Service
Company Name
21 Old County Rd.
Company Address
Southampton Ma. 01073
City/Town State Zip Code
413-527-1835
Telephone Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. l am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes
❑ Needs Further Evaluation by the Local Approving Authority
04/26/10
® Fails
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
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Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
41 Dumphy Dr.
Property Address
Florence Ma.
01062
Cily/Town State
Karen Klekotka 04/26/10
Zip Code
Owner's Name Date of Inspection
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 16303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
This system consists of a 1000 gal septic tank, and the tank is below effulent .The tank is 40" below
grade and effulent is 28" above tank in riser. There is no access to other parts of this system.
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
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:
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Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
41 Dumphy Dr.
Properly Address
Florence Ma. 01062
City/Town State Zip Code
Karen Klekotka
04/26/10
Owners Name
B) System Conditionally Passes(cont.):
Date of Inspection
❑ 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 removed
❑ 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)(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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
41 Dumphy Dr.
Property Address
Florence Ma.
CM/Town state
Karen Klekotka 04/26/10
Owner's Name Date of Inspection
01062
Zip Code
C) Further Evaluation is Required by the Board of Health (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.
••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:
Florence ladyapper Novotny.doc•03'2006
The 5 Official Inspection Form:Subsurface Selvage Disposal System•
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cunt.)
41 Dumphy Dr.
Property Address
Florence Ma.
City/Town State
Karen Klekotka 04/26/10
Owner's Name Date of Inspection
01082
Zipeode
DI 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 8°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: 3.
❑ ® 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.
El ® 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.
❑ ❑
Yes No
® ❑
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.
florence tadyslipper Novotny.doc•032006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cunt.)
41 Dumphy Dr.
Properly Address
Florence
City/Town
Karen Klekotka
Owners Name
Ma.
State
04/26/10
Dale of Inspection
01062
Zip Code
E) Large Systems: To be considered a large system the system must serve a facility with a
design Flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either°yes'or°no'to each of the following, in addition to the
questions in Section D.
YES NO
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered°yes°to any question in Section E the system is considered a significant threat,
or answered°yes°in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
florence ladyslipper Novotny loc•03/20116 Tile 5 Official Inspection Fonn:Subsurface Sewage Disposal System•
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. Checklist
41 DumphLDr.
Property Address
Florence Ma. 01062
City/Town State Zip Code
Karen Klekotka 04/26/10
Ownees Name Date of Inspection
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
❑ E Were any of the system components pumped out in the previous two weeks?
E ❑ 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?
❑ E Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
E ❑ Was the facility or dwelling inspected for signs of sewage back up?
E ❑ Was the site inspected for signs of break out?
❑ E Were all system components, excluding the SAS, located on site?
❑ E 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?
E ❑
The size and location of the Soil Absorption System (SAS)on the site has
been determined based ow
❑ ❑ Existing information. For example, a plan at the Board of Health.
Determined in the field Of any of the failure cdteda related to Part C is at issue
approximation of distance is unacceptable)1310 CMR 15.302(5)1
E ❑
florence ladyslipper Novotny.doc•0312006
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Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information
41 Dumphy Dr.
Property Address
Florence Ma.
City/Town State
Karen Klekotka 04/20/10
Owners Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms(design):
01062
Zip Code
Number of bedrooms(actual). 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: 5
Does residence have a garbage grinder? E Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes E No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes E No
Water meter readings, if available (last 2 years usage(gpd)): present meter
read 2-84506
Sump pump? ❑ Yes E No
Last date of occupancy: presently
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
florence bdystipper Nwotny.doc•03/2006 The 5 Official Inspection Form:Subsurface Sewage Disposal System•
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dumphy DR.
Pmparty Address
Florence Ma.
Cilyffown state
Karen Klekotka 04/26/10
Owner's Name Date of Inspection
Pumping Records:
Source of information:
General Information
pumper
01062
Zip Code
Was system pumped as part of the inspection?
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Yes ® No
❑ Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) 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)
❑ Tight tank.Attach a copy of the DEP approval.
Other(describe):
unknown as effulent above septic tank
Approximate age of all components,date installed Of known) and source of information:
Approx 25yrs+/-
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Florence ladysliipper Novotny.dee•032006 Title 5 Official Inspection Form.Subsurface Sewage Dispsal System•
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dumphy Dr.
Property Address
Florence Ma.
City/Town State
Karen Klekotka 04/26/10
Owner's Name Date of Inspection
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:
01062
Zip Code
45"
feet
feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
No evidence of leakage observed,
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
® concrete
❑ metal ❑ fiberglass
40"
feet
❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of
certificate)
❑ Yes ❑ No
Dimensions:
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 tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
1000
Florence ladyslipper Novotny.doc•03/2006 The 5 Official Inspection Form:Subsurface Savage Disposal System•
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dumphy Dr.
Property Address
Florence Ma. 01062
City/Town State Zip Code
Karen Klekotka 04/26/10
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Recommend removal of garbage grinder
Grease Trap(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
❑ fiberglass ❑polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
❑fiberglass ❑polyethylene ❑ other(explain):
Potence bdyslipper Nov ny.doc•03/2006 The S Official Inspection Form.Subsurface Sewage Disposal System•
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dumphy Dr.
Property Address
Florence Ma. 01062
City/form State Zip Code
Karen Klekotka 04/26/10
Owners Name Date of Inspection
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
unknown
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order.
Alarms in working order:
Florence ladyslipper Novotny.doc•03/2006
❑ Yes ❑ No
❑ Yes ❑ No
Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•
Page 12 of 16
Commonwealth of Massachusetts
gi Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dumphy Dr.
Property Address
Florence Ma. 01062
City/Town State Zip Code
Karen Klekotka 04/26/10
Owners Name Date of Inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
effluent above septic tank—unable to access SAS
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number
❑ innovative/altemative system
Type/name of technology: unknown
Comments (note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
Hydraulic failure at tank
florence ladyslipper Novoty doc•03/2006
The 5 Official Inspection Form:Subsurface Sewage Disposal System•
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (coot.)
41 Dumpily Dr
Property Address
Florence
cay/Town
Karen Klekotka
Owners Name
Ma.
Slate
04/26/10
Date at Inspection
01062
Tip Code
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 enters the building.
horence lad/slipper Nomhry-doc•03/2005
4 Jr�
Cjfr
Title S Official Inspeciton Form.Subsurface Sewage Disposal Ste.
Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dumphy Dr.
Property Address
Florence
City/Town
Karen Klekotka
Owner's Name
Ma. 01062
State Zip Code
04/26/10
Date of Inspection
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 El 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.):
fiorence ladyslipper Novotnydoc•032006 The S Oficial Inspection Forme Subsurface Sewage Disposal System•
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
41 Dunphy Dr.
Property Address
Florence Ma.
City/Town State
Karen Klekotka 04/26/10
Owner's Name Date of Inspection
01062
Zip Code
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
Please indicate all methods used to determine the high ground water elevation:
• Obtained from system design plans on record
If checked,date of design plan reviewed. Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
observed sight , no sump pump, sandy soil area, new design plan
florence Iadyslipper Novotny.doc•031005 Tale 5 Official Inspection Form:Subsurface.Ces.ag.Disposal System•
Page 16 of 16
HERITAGE SURVEYS, INC.
Professional Surveyors and Engineers
College Highway & Clark Street
Post Office Box 1
Southampton, Massachusetts 01073
Brace A. Coombs, President
Professional Surveyor, MA, CT& VT
E-mail: bruce(deritagesurveys.corn
Telephone(413) 527-3600
Facsimile(413)527-8280
Website: heritagesurveys.com
LETTER OF TRANSMITTAL
TO: Karen Klekotka
41 Dunphy Drive
Northampton, MA 01062
DATE: May 2, 2006
JOB #: 5733-051109
SUBJECT: Septic Upgrade, 41 Dunphy Drive
Northampton, MA
•
COPIES
DATE
PLAN #
DESCRIPTION
5
05/02/06
5733-
060502
Plan of Proposed Sewage Disposal System
Upgrade at 41 Dunphy Drive, Nothampton, MA.
Prepared Karen Klekotka
1
Original Application for Disposal System
Construction Permit
1
Original Form 9A - Application for Local
Upgrade Approval
The following should be submitted to the City of Northampton Board of Health:
• Three copies of the plan
• The original Application for Disposal System Construction Permit
(which needs to be signed and installer information added)
• Form 9A Application for Local Upgrade Approval (which needs to be signed)
• Site Suitability for On-Site Sewage Disposal T.P. 1-1
• Check for $50.00 made out to the City of Northampton
Please contact this office if you should have any questions or comments
relative to the above.
Sincerely,
Mark P. Reed
On-Site Review
Deep Hole Number: 1-1 Date: 12-8-05 Time: . Weather:Cold/Clear
Location(identify on site plan):
Land UseNegetation: Lawn/Grass Slope(%): Surface Stones:
Landfomt:
Position of Landscape:
Distance from.
Open Water Body
Possible Wet Area
Drinking Water Well 100'+
Feet
Feet
Feet
Drainageway
Property Line 10'+
Other
T.P.
Feet
Feet
Feet
DEEP OBSERVATION HOLE LOG
Depth from
Surface
(Inches)
Soil
Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other(Structure,Stones,Boulders,
Consistency, %Gravel)
0— 12"
12"—26"
26"—30"
30"—37"
37"—112"
A
Fill
old A
B
C
Sandy Loam
Sand
Sandy Loam
Sandy Loam
Fine-Med.
Sand
10 YR 3/3
Fill
10 YR 3/3
10 YR 4/4
10 YR 5/4
None
Massive, Friable, Few roots
Sand Fill
Massive,Friable
Massive, Friable, stones & cobbles
Loose single grain, few small
stones
Parent Material(geologic) Outwa h
Depth to Groundwater: Standing Water in the Hole: None
Estimated Seasonal High Ground Water. >112"
Depth to Bedrock: 112"
Weeping from Pit Face: None
Certification
I certify that in November 1994, I passed the soil evaluator examination approved by the Department of
Environmental Protection and that the above analysis was performed by me consistent with the required
training, expertise . experience desc:b-. in 310 CMR 15.017.
-
Signature: ,E di r 44 Date: 12-8-05
Peter J. cErlain
HERITAGE SURVEYS, INC.
Note: Due to limited space only one test pit was required, so as to not to disturb the existing system. Per Health Inspector.
HERITAGE SURVEYS, INC.
COLLEGE HIGHWAY 4 CLARK STREET—P.O.BOX 1
SOUTHAMPTON,MASSACHUSETTS 01073
TELEPHONE(413) 527-3600 FAX(413) 527-8280
Site Suitability, for On-Site Sewage Disposal
Project Number: 5733-051109
Performed by: Peter McErlain
Health Inspector:Richard Bombadier
Site Address
Klekotka/Dunphy Drive
41 Dunphy Drive
Northampton, MA 01062
New Construction
T.P.# 1-1
Date: 12-8-05
Equipment Operator: Marion Excavating Corp.
Client Name&Address
Karen Klekotka
41 Dunphy Drive
Northampton,MA 01062
Repair ❑
Office Review
Published Soil Survey Available: No ❑
Year Published Publication Scale
Surficial Geologic Report Available: No ❑
Year Published Publication Scale
Flood Insurance Rate Map:
Above 500 year flood boundary❑
Wetland Area:
National Wetland Invetory Map(Map Unit)
Current Water Resource Conditions(USGS):
Range: Above Normal ❑
Other References Reviewed:
Yes ❑
Soil Map Unit
Yes 0
Geologic Material(Map Unit) Landform
Drainage Class Soil Limitations
Within 500 year flood boundary ❑ Within 100 year flood boundary
Month
Normal ❑
Wetlands Conservacy Program Map(Map Unit)
Below Normal ❑
Perc
Time
Measurement
Time
Measurement
Begin Saturation
2:49
18 Gals.in
Begin Saturation
End Saturation
3:04
@20"
End Saturation
9"depth
Measurement
3:07
@17"
9"depth
Measurement
6"depth
Measurement
3:10
@14"
6"depth
Measurement
Elapsed Time
9"to 6"
3Min
Elapsed Time
9"to 6"
Percolation Rate: <2min/in
Bottom of Percolation Test Hole:48"
Percolation Rate:
Bottom of Percolation Test Hole:
Determination for Seasonal High Water Table
Method Used
D Depth observed standing on observation hole 112 inches
Depth to soil mottles N/A inches
Depth weeping from side of observation hole N/A inches
Ground water adjustment N/A inches.
Index Well Number Reading Date
Adjusted ground water level
Adjustment factor
Index well level
Depth of Naturally Occuring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil
absorption system? Yes
If yes,what is the depth of naturally occurring pervious material? 37"—112".
If not,what is the depth of naturally occurring pervious material?
Pero Test Wimess Payment Record {{
Date: a/a/n� Amount: s Sga)
Property Owner
Property Address A sad/A (
New Construction Repair
KAREN J KLEKOTKA
41 DUNPHY DRIVE
FLORENCE,MA 01062
Pay to the
. Order of
Dalefi Z LOOo
E SAVINGS BANK
549
53-7168/2118
SQi ` )
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