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17 Septic Inspection 2009 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. vtL 151,u•MOO Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Owners Name Northampton City/Town MA 01060 August 11 2009 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 (413)527-5291 Telephone Number MA State S11039 License Number 01027 Zip Code B. Certification 1 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 E Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspectord Sign August 11, 2009 Date The system inspector 3Ylall 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. Title 5 Official Inspection Form.Su4wlez Sewage Disposal System•Page 1 or t Owner information is required for every page. Isins•09,,e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Owners Name Northampton MA 01060 August 11, 2009 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: ❑ 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 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): There is a discharge of gray water from the laundry and shower to the City catch basin. It must be connected to the existing septic tank. The pipe from the septic tank to the distribution box is plugged and must be replaced. The distribution box is damaged and must be replaced. The 5 Official Inspection Form'.Subsurface Sewage Disposal System Page 2 of Owner information is required for every page. Mins•0908 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Owner's Name Northampton MA 01060 August 11, 2009 City/Town State Zip Code Date of Inspection B. Certification (cons.) B) System Conditionally Passes(cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced Z Y ❑ N ❑ ND (Explain below): ® obstruction is removed ® Y ❑ N ❑ ND(Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below): 4 pvc pipe from septic tank to distribution box is clogged and broken and must be replaced. Distribution box is damaged and must be replaced. ❑ 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 See above ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 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 Imo 5 Official Inspection Fern:Subsurface Sewage Disposal System.Page 3 of 3 Owner information is required for every page. rains.owm Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Owners Name Northampton MA 01060 August 11, 2009 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, 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 **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-City water 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 5Official Inspection Form.Subsurface Sewage Disposal System.Page 4 N4 gee Owner information is required for every page. ,Sms.MOB Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Owners Name Northampton MA 01060 August 11, 2009 City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ C1 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. 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal Symnn.Page 5 of 5 Owner information is required for every page. thins•08/66 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Ownefs Name Northampton MA 01060 August 11, 2009 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 ® ❑ ® ❑ • ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ Z ❑ Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field Of 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): 4 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 4 440 Title 5 Official Inspection Form.Subsurface Sewage Disposal System Page 6 of 6 Owner information is required for every page. tins•osma Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Owners Name Northampton MA 01060 August 11, 2009 City/Town State Zip Code Date of Inspection D. System Information Description: 1500 gallon septic tank, distribution box and two-500 gallon leaching galleys Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system?[if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage(gpd)): (000121410/ Detail: There is a discharge of gray water from the shower and laundry that is connected to a City catch basin. This discharge must be connected to the existing septic tank before approval of this system is granted. 4 ❑ Yes ® No ® Yes ❑ No Z Yes No ❑ Yes ® No Sump pump? Last date of occupancy: Commerciaglndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? Water meter readings, if available: ® Yes ❑ No currently occupied N/A N/A Gallons per day(gpd) N/A ❑ Yes ® No ❑ Yes Z No ❑ Yes ® No N/A Tale 5 Official Inspection Form:Subsurface 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 17 Fair Street Property Address Paul Yeskie Owner's Name Northampton MA 01060 August 11, 2009 City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other(describe below): N/A Currently occupied Date General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract Paul Yeskie-owner ❑ Yes ® No N/A gallons N/A To be pumped at time of repair ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): 151ns.09/09 TWe s Official Inspection con,Subsurface Sewage oiepoeal System Page 8 of 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 17 Fair Street Property Address Paul Yeskie Owner's Name Northampton MA 01060 August 11,2009 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: Septic tank= 1997(12 yrs old) leaching galleys= 1989 (20 yrs old) Were sewage odors detected when arriving at the site? 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: ❑ Yes ® No 30" feet N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe from house to tank is in good condition. Pipe from septic tank to distribution box appears to be plugged and is to be replaced. Septic Tank(locate on site plan). Depth below grade: Material of construction: ®concrete 1500 gallons 1.5' feet ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age' yea Witt Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No (115(6'x4") Dimensions: Sludge depth: Thiel 5 official Inspection Pelee Subsurface Sewage Disposal System•Page 9 of 9 Owner information is required for every page. thins•09/GB Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Owner's Name Northampton MA 01060 August 11, 2009 Cityftown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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? 42" 1"t above outlet tee 2"+ 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.): The pipe from the septic tank to the distribution box appears to be plugged and is to be replaced. The liquid level was above the outlet tee. The septic tank tees are in place but will be replaced when sewer line is replaced. The tank is in sound condition and there is no sign on leakage. Due to the age of the existing leaching system, I recommend annual pumping. 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 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 50fficel Inspection Form Subsurface Sewage Disposal System•Page 10 of 10 Owner information is required for every page. Ism•09)08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Ownees Name Northampton MA 01060 August 11, 2009 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/A Depth below grade: Material of construction: ❑ concrete N/A ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No N/A 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 Tick 5 nampal Inspection Foirn subewsa®Sewage Disposal System•Page 11 of 11 Owner information is required for every page. Sins•09105 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Owner's Name Northampton MA 01060 August 11,2009 City/Town State Zip Code Date of Inspection D. System Information (cant.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 2 t. 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 is in damaged and must be replaced. There is evidence of carryover and the 4" sewer pipe leading to it is plugged. Pump Chamber(locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ 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: There are two-500 gallon leaching galleys on site. They were installed in 1989. They were located and the top covers removed. Because of their age and slower percolation rate, there was standing water in each of them. This was not groundwater. T is 5 moat Inspection Form Subsurtae Sewage Disposal System•Page 12 of 12 Owner information is required for every page. thins•03/00 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Owners Name Northampton MA 01060 August 11, 2009 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: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There was no sign of hydraulic failure above ground. No damp soil or ponding. Vegetation was lawn grass. The top covers of the galleys were removed and effluent was observed. Due to the age of this system, it is believed that the percolation rate has slowed but is not currently in failure, thus the presence of sewage. The leaching galleys continue to drain but at a slower rate. 2-500 gallons each Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A 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 ❑ Yes ❑ No Title S olrwlal InspMiM Form.Subsurface Sewage Disposal System•Page 13 of 13 Owner information is required for every page. t81ns 09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Owners Name Northampton MA 01060 August 11, 2009 City/Town State Zip Code 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A N/A N/A N/A Title 5 Official Inspection Form.Sub BOB Sewage DlaposaI System•Page 14 of 14 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 17 Fair Street Property Address Paul Yeskie Owners Name Northampton City/Town MA 01060 August 11, 2009 State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below drawing attached separately t5ins•09/09 Tito 5Official Inspedlm Form:Subsurface Sewage Disposal System•Page 15 of 15 1 gao septic tank raffiPtir (installed n 1997) Pumpout man-hole ('C' 'pvc solid pipe I- I— W 0 D 4'pvc solid pipe "6" V/ / / {'""`} { _ (to be replaced • / / / / / i / / '/ // O A" / Q 0 7 / Existing / (n -500 gallon leaching pits .C.. ji% 4 bedroom / Cr) / house / / / / / ' / / / / / / / / / U Z E.. / 0 V, / / Existing discharge I- ro 6/ / / / laundry/shower) 0_ u: _ N•• (to be removed) Q F„ Distribution box ('D') (to be replaced ../ Driveway EC rn • O —"c" - - I Z I lean-to Existing garage I Catch basin I I shed I- L __ J w F- I— As—built plan AS-BUILT DIMENSIONS EC SUBSURFACE SEWAGE DISPOSAL SYSTEM — A' to 'C' = 22'-6' 'B' <a 'C• = 29'-9' 17 Fair Street ll w• to •n• = ea•-o• •c• <o •o• = ze•-s• Northampton, Massachusetts •x• <o •e = 9e'-o• 'c• to •E' = ac•-s• Owner: Paul Yeskie Address: 17 Fair Street Northampton, MA 01060 August 11, 2009 Page 1 of 2 Section A — A ' Existing ground 500 gallon leaching pits 2 ' 3/4' - 1 1/2' stone Jr • ti 6.5' • . . .5 ' _ . . 5' Groundwater @ 6.5' . _ _ 17 Fair Street Northampton, Massachusetts Owner: Paul Yeskie Address: 17 Fair Street Northampton, MA 01060 August 11, 2009 Page 2 of 2