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43 Septic Inspection 2015 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. svC a reins.3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owners Name Northampton City/Town MA 01060 12/01/2015 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: Alan Weiss Name of Inspector Cold Spring Environmental Consultants, Inc. Company Name 350 Old Enfield Road Company Address Belchertown Cityrrown 413-323-5957 Telephone Number MA 01007 State Zip Cade Registered Sanitarian#933 License 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. I 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 12/01/2015 Inspectors Signature Date ❑ Fails 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 nu e 5 Official In speou on For:suexwam 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 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owners Name Northampton City/Town MA 01060 12/01/2015 State Zip Code Date of Inspection B. Certification (cant.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 1 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 system consists of a two chamber(1,500 gallon)septic tank, a distribution box and a leachfield (25 W x 25'L). Liquid levels were at the outlet inverts of the septic tank and distribution box with no evidence of high staining. The septic tank should be pumped every 2 to 3 years. 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): Title 5 official Inspection rum:Subsurface Sewage Disposal System.Page 2 of 17 Commonwealth of Massachusetts =TTitle 5 Official Inspection Form Owner information is required for every page. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owner's Name Northampton MA 01060 12/01/2015 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ V ❑ N ❑ ND (Explain below): ❑ 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 ❑ NO (Explain below): ❑ obstruction is removed E V E 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)(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 t5ms.3113 idle 5 onioxl mspeceon Form:Subsurface Sewage Disposal System.Page 3 of 17 Commonwealth of Massachusetts 9 Title 5 Official Inspection Form Owner information is required for every page. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owners Name Northampton MA 01060 12/01/2015 City/Town State Zip Code Date of Inspection B. Certification (cant.) 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 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 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 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 1/2 day flow 51ns•3113 T■tle 5 OXIdall Inspection Form Subsurf ace Sewage disposal System•Page 4 o117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a-" 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owner's Name Northampton MA 01060 City/Town State Zip Code Owner information is required far every page. 12/01/2015 Date of Inspection B. Certification (cent.) 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. ❑ 0 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. ❑ El 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 15304.The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form Subsoil ace Sewage Diaposal System•Page b of 17 Commonwealth of Massachusetts 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 43 Fair Street Properly Address Marissa Elkins and Tara Futrell Owners Name Northampton MA 01060 12/01/2015 Owner information is required for every page. Lain•3113 Gity/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"n& as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal Flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Z ❑ 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: ® ❑ Z ❑ 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 now based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 330+ Title 5 Officio'Inspection Form Sdhswlace Sewage Disposal System•Page 6 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 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owners Name Northampton MA 01060 12/01/2015 City/Town State Zip Code Date of Inspection D. System Information Description: System consists of one double chamber, 1,500 gallon septic tank, a distribution box and a leachfield (25 Long x 25 Wide). Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpdf: Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): 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: 3 ❑ Yes ® No ❑ Yes El No ❑ Yes ❑ No ❑ Yes ® No Gallons per day(gpd) ❑ Yes ❑ No Current Date ❑ Yes ❑ ❑ Yes ❑ ❑ Yes ❑ No No No gins.113 Tae 5 Official Inspection Form'.SubsurSce sewage Disposal System.Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i= 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owner's Name Northampton MA 01060 City/Town Stale Zip Cade Owner information is required for every page. 12/01/2015 Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other(describe below)'. 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 Date Pumped 2 years ago. 1,500 gallons Measured ® Yes ❑ No Tank pumped after inspection. ❑ 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)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): 151 os.ana Tie 5 Official Inspection Form subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts r6e Title 5 Official Inspection Form Owner information is required for every page. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owners Name Northampton MA 01060 12/01/2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed Of known) and source of information: The system is 11 years 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): 2 feet Distance from private water supply well or suction line: 10'+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Building sewer was in g condition with no evidence of leakage. ❑ Yes ® No Septic Tank(locate on site plan): Depth below grade: Material of construction: 1.0 feet Z concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Concrete double chamber 1,500 gallon septic tank has tees in place with no high staining observed. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 10.5'x 4.5'x 42' Dimensions: Sludge depth: 18" thins•3113 trifle 5 Official Inspection Fomc Subsurface Sewage Disposal System•Page 9 01 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owner Owner's Name information is Northam ton MA 01060 12/01)2015 required for every P page. City/Town 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? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank was structurally sound with no evidence of leakage or corrosion. Liquid levels were at the outlet invert with no high staining observed. PVC tees were in place and in fair condition. 18" Measured Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal 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: Date rsn s.9n3 Ti e 5 Official Inspection Form Subsurface Sewage Disposal System.Face 10 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form F" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Owner information is required for every page 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owners Name Northampton MA 01060 12/01/2015 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): Depth below grade Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Dare Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t51ns.3113 TiIle3 Othual Inspection Form Subsurface Sewage Lesbos cm•Page 11 o117 Commonwealth of Massachusetts z Title 5 Official Inspection Form Owner information is required for every page. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owners Name Northampton City/Town MA 01060 State Zip Code 12/01/2015 Date of Inspection D. System Information (cant.) Distribution Box(if present must be opened) (locate on site plan): @ Outlet Invert 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.): The distribution box was located, inspected and found to be level with equal flow to the outlets. Liquid level was at the outlet invert with no evidence of high staining. Cover was 20" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ Not Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 'If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I5ins JI13 title 5 Oflio al Inspect on Form:Subsurface Sewage Disposal System•Page 12 el 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owner Owners Name information is required for every Northampton MA 01060 12/01/2015 page. City/Town State Zip Code Date of Inspection Mains 9113 D. System Information (cant.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 25W x 25L Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of ponding, wetness,damp soils or impacted vegetation indicative hydraulic of failure. 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 ❑ Yes ❑ No Tim 5 ommi Inspection Form:Subsurf ace Sewage Proposal System•Page 13 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 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owners Name Northampton City/Town MA 01060 State Zip Code 12/01/2015 Date of inspection D. System Information (cont.) 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.): thins•3113 Tii Official Inspection Form:Subsun. ge Disposal System•Page 14 or 17 Owner information is required for every page. 61m.3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owners Name Northampton MA 01060 12/01/2015 City/Town 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 rice 5 Official Inspection Form r Subsurface Sewage Disposal System r Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owner Owner's Name information is Northam tan MA 01060 12/01/2015 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water Z Check cellar ❑ Shallow wells Estimated depth to high ground water: 5' 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: 2004 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: Work in area,topography and record on file showing 60" depth of ESHWT. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Irtspecuon Form Su bsWa ce Sewage Disposal System Page 16 o117 Owner Information iS required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 43 Fair Street Property Address Marissa Elkins and Tara Futrell Owner's Name Northampton MA 01060 12/01/2015 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist • 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 151ns-3/13 title 5 cal Inspection Form Subsurface Sewage Dlaposal System Fag 7 of 17 mcty Oj ltosth4 tmuce ?%tcuoauia4 tt4 212 9JCae4 Shat ?tsvMtaorow, 2t4 01060 7d. 413-587-1214 ?az 413-587-l22! Title V Certification of Compliance TO BE FILLED OUT BY THE SYSTEM DESIGNER PESWGNER SIGN-4£F Pmaaat to 3:0 COM 15 90 of Me Sae Fanatoxattt Code'. :,tc V,Monona Requaemems for the Subdurtice Daiwa!of Santry Saar,Seaton 15 021(3�,ve Designer of a system s,cyuirad to ago Otis Ars as a ceaditan fn u.unxt of a Bwd of$tat Cmacttt of Compliance to the onto apde system ract u to comfy that the anwa DGNt!tonal awn Res I . Id a Y3 F omerer as ',halal ynew c n n1Cmt /,,rant(tasting system) DWCP. a 9O� Yz 1 ha bee agolflont to coaaaLance not 310 GIIt 1500, and all local ecgt ntsnenn.Any changes m ebe angina appealed pats ha'e two ratted on an as-built plat that hen b.m sutntincd to M Saud of Arnt R, F, H[°`��fAu Assoc .. r .1A.n, a�iiha.T� /Y6 7AyLor 17Ff1 Ue•.a �9ou6S' seA vOTy;i ltd&aetiieaaan represent to tarn ,raamM mds9td u oast hnmonitor totipary oi W ante mania dpi astern Paw tio fiW one meta&tm ec in cxr5d,m+n aitls sA WOW*links and"pistons as re in taint sae Sete atria natant. I 1 1 1 i Scldi vN.7 -"nab, 77fYF7 77V b4 ti N�'n; �„yL >1 �� 1 rnrla+nrwJr 711,ts I ors 1 a,yj 1 9 ilFir 4 ■ N y2Uw ad % hdw 7Jb� gi it .1, r> a% 1 ho ip/ rrcuJ>drrit Ivry'?ff fr k/ (v Q.%d '9H22rJr/ 2 ?Ft...•r 3,r_a F/, Imponsnt. WMn Nlea out forms an tre computer. ,,u only 1M tab kir m move'Ih' Cone 4o non vwthe nrvm ser It 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for jse by focal Boards of Health Other forms may oe used, but the inlormabon must be substantially the same as that provided here Before using this tam, crock air you' local Board of Heath to determine the form they use The System Pumping Record must be sad mired !c the loot Board at Health or other approving authority within 14 days from the pufnpmg date in accordance wen 310 CMR 15 351 A. Facility Information 2 System location A Addreei City/Sown System Owner N .f . 'e_' NON Cnyrtown bcaoni B. Pumping Record Dale al Pumping 3 Type of system. ❑ Cesspool(sl n Other (describe) 4 Effluent Tee Filter present? ❑ Yes 5 Condittn of System. Sato Stets . by oat. y Telophone Numf f t51am4 mc•OYOE tams Supsnor Septic Services Company here Contents were dis 2 Quantity Pumped 5"G < . Gerons Septic Tank L TV(Tank 0i Grease Trap i1 yes, was it deaneu2 ( r j ri Vehwe Lkerw Number no redid, Sytem Purnp■no Rowe .nege o. Septic Tank Inlet Tee 43 Fair Street Northampton, MA 12.01.2015 • tfS• (ir�I l- ..V� Mi • if r ,?j • :31 343 r' <' '.a11'• Mid chamber teelbaffle 43 Fair St Northampton, MA 12.01.2015 Septic Tank Outlet Tee 43 Fair Street Northampton, MA 12.01.2015 Distribution Box 43 Fair Street Northampton, MA 12.01.2015