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141 Septic Inspection 2014 11, Commonwealth of WINO WWII Title 5 Official inspection Form Subsurface Sewage Disposal System Farm•Not for Voluntary Assessments 141 Fait Street Extension Prxerty Address Nettie Russel ottdier eall Nana 10011191130n (equal fix wry Northampton Itage MITaln 01060 91412014 DA eale Me of Inked= bapection results must be submitted on Ma form.Inspection tonne may not be altered In any ww.Please use completeness checklist el the end of the form. ImPals""n" A. General Information ennwofffis • on the ortAile, use one:tem 1. 11111M40r. kflbmfrayol r Cum-do not Nen Weiss useltio relUM mr•at insWID: key Cold Spree Snub:emerge,Consultants,Inc. Cavan Nara 350 Old Enfield Road Damn ACtrose Seichenoen MA 01027 Cliyeroon Salto M coa 413-323-5957 Moldered Sanitarian 0953 Tolophone Nunn Lin mires B. Certification I certify NM I have permeate/WNW the seems dimosal gram al Ube address and that the Information retorted below Is Ins,secure,and compile as of the tine of dm ispeclien.The irtmeolion wee performed bead on my MINN and experience in Cie proper function end maintenance of on Me wee disposal systems. I an•DEP appeared system Inspeceor pursuant to Section 15.140 of Tim 5(510 CUR 15.000).The system: 0 Panes 0 Conditemally Passes 0 Faits 'ITPI' 1 Further Evaluation by the Local ApprovIn;Authorib 91512014 The system Inspector Mal submk a copy of Ms inspection report to the Amusing Authority(Board of Huth or DEP)weir 30 dais of comp:Doe th4 insmcbon.N Ow syslern I a Oared system or has a design Sow of 10,000 gpd Or greater,the inspector and the system prof she submit the report to the appropriate wend orb=of the DEP.The original shouN be sent to the stem ismer and copies sent to the blew,If apple.and Me approving aulhorly. ""fhla report only desalbse conditions at the time of InepectIon and under The condlows of use it that IMO TIM Inepetelisi doss not address how the eyelem well perform hi the We under the same or rtifbreM riondtdone of um. sonn I* MS Swain flans Sasebo.loniva.•■••S OPMPA'P•P 1°117 Commonwealth of Massachusetts _.ice._ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Properly Address Marcia Russell lamer Owners Name regupena d we iore ven Northampton MA 01060 9/4/2014 ' cdynom State npcme Date mInspection 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 Corm. 'mp°mant Wien A. General Information filling cut tams ommemnpSer, use only me lab 1. Inspector: key to move your ^or-do not Alan Weiss use the fawn Name of Irsplor key. Cold Spring Environmental Consultants,Inc. Company Nare 350 Old Enfeld Road Company Address Belohertown MA 01007 City/Town State Lp Code 413-323.5957 Registered Sanitarian it933 Telephone Number 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 ❑ Fails ® Needs Further Evaluation by the Local Approving Authority 9(5/2014 Inspectors 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. brc•MI Tam 5 6rai MgRen Fora Subsace Setup awe eprem•Pope 1 M 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Property Address Marcia Russell Owner penes None information is Northampton page, ter every City/Teem y/rpwn papfia.. MA 01060 9/4/2014 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: C I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15304 exist.Any failure criteria not evaluated are indicated below. Comments: System consists of one 1500 gallon septic tank and one brick built leaching pit. The septic tank was installed in 1988 and stone was added to the leaching pit at the same time. Water levels were appropriate with no high staining noted. Permit from 1988 Septic Tank installation mentions house has 2 bedroom system House not actually has 3 bedrooms. B) System Conditionally Passes: C 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 exfltration 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 i(it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. C Y ❑ N C ND(Explain below): rn:s OFea i,.p.men Fe nn.awns..s...a o.P®a System.Pi a zel Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Properly Address Marcia Russell Owner Owners Name information is Northampton pase re]Iw every Gay/roam Page Mamma MA 01060 9/4/2014 State lip Cade Date art 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 ❑ V ❑ N ❑ ND(Explain below). ❑ obstruction is removed ❑ Y ❑ N ❑ ND(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 pipes)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ V ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: Z 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 me 5 osea Impr:s F m,sm.t.snipe Disposal system•six 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Property Address Marcia Russell Owner Owners Name rtemlatron Is required fore Northampton p30e. Crty/ro*n MA 01060 9/4/2014 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 welt. Method used to determine distance: This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliomr 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. System design flow was 220 gallons per day(two bedrooms)on the 1988 permit. One bedroom was added to the residence,making a total of three bedrooms at this time. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No 0 El 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 On•viq n1.5 011ei Inspectec Porn]:aw,r.m Po..w a.w+».t., Pope 4SI? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Properly Address Marcia Russell Owner Owners Name information for every Northampton requirs Page. City?oath MA 01060 9142014 Slate Lp code pate N Inspection B. Certification (cont.) Yes No ❑ Z 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. My portion of cesspool or privy its within 100 feet of a surface water supply or tributary to a surface water supply. 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,pertoened at a DEP certified laboratory,for fecal conform 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. Tile 5 oeaamn Fes:seu.es swage arose A'+a^•Per 5 or17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Property Address Marcia Russell Owner pants Name required information Northampton MA 01060 9/4/2014 aaae, every City/Town State Zip Code Date of Inspection 61rIs 3113 C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® 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 facilay 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 sde has been determined based on: ® ❑ 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)1 D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 GPD lg.5(Mal sue....sna.D.sas sm...Pope of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Property Address Marcia Russell Owner owners Name Intamnano Northampton MA 01060 9/62016 px¢tl MexaY cdynawn� Stare ➢p code Dare of inspection 15ms-1'13 D. System Information Description: One 1,500 gallon septic tank with one older brick leaching pit. 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(gpd)): Detail: City Water 1 ❑ Yes ® No ❑ Yes Z No ❑ Yes ❑ No ❑ Yes Z No NA Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seatslpersonslsq.n,etc.): Grease trap present? Industrial waste holding tank present? Non-sanitary waste discharged to the?file 5 system? Water meter readings,if available: ❑ Yes Z No Current Date Galena per day Wed) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Me 5 ones weeon row suadw..s.w.a Disposal»+..m.P,a,?of Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Property Address Marcia Russell Orme' Owners Name information° Northampton MA 01060 9/4/2014 pagrequired. to emy page. City/Town State Op Code Date at Inspection D. System Information (cunt.) Last date of occupancy/use: Other(describe below): Dale Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No 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)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): Septic tank with one brick leaching pit. General Information Owner-Pumped in 2006 1,500 gallons Measured Inspection 51...113 The 5 on.an.pto.r.m.sb..nasaar o.wa seem.a.w S&17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Properly Address Marcia Russell Una Owners Name required mrevey Northampton MA 01060 9/4/2014 page. cMrrown State Lc Code Date Of Inspection D. System Information (cant.) Approximate age of all components,date installed(if known)and source of information: Septic tank was installed in 1988 and is 28 years old. The leaching pit h older 8 functioning. Were sewage odors detected when arriving at the site? Building Sewer(locate on site plane. Depth below grade: Material of construction: C cast iron ®40 PVC C other(explain) C Yes ® No 2' >10' Distance from private water supply well or suction line: fret Comments(on condition of joints,venting,evidence of leakage,etc.): Building sewer and joints were in good condition with no evidence of leakage. Septic Tank(locate on site plan): Depth below grade: Material of construcon: 12 Inches feet ®concrete C metal 0 fiberglass ❑polyethylene C other(explain) Septic tank(1,500 gallon tank)with concrete baffles. Septic tank and baffles were intact and in good condition. Levels were appropriate and no exfiltration or infiltration were noted. If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) C Yes C No 10'x5'x 4.5' Dimensions: Sludge depth: 2.5' ryet s ones m.oe.ma rem:sonars serape Dispose aflm.awn n+T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Property Address Marcia Russell Owner Owners Name impmladpn is Northampton MA 01060. 9/4/2014 required for every pace, Ctyrtwm State Lp code Date N Inspection D. System Information (cont.) Septic Tank(cunt.) 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.): Concrete inlet and outlet baffles in good condition. Tank was structurally sound with no evidence of exflaretion or infiltration. Liquid levels were at the outlet invert. Tank should be pumped every two years. Measured Grease Trap(locate an 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 a...an -am.(HMO i.w.aon Fes.Sumac&w.a.Dspasa ar..m•Page 10.I17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Property Address Marcia Russell Owner owners Name information n required woven, Northampton MA 01060 9/4/2014 required State ap Code Date of Inspectc page. Cayrrovm D. System Information (cunt.) 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: C concrete ❑metal ❑fiberglass C polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes C No Alarm level: Alarm in working order C Yes ❑ No Date of last pumping: ome Comments(condition of alarm and float switches,etc.): •Attach copy of current pumping contract(required). Is copy attached? ❑ Yes C No Tale 5 Dead Sparta Fes:Subsurface Se..o.D.pead System.age II a17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Property Address Marcia Russell Owner omers Name required information is Northampton MA 01060 9/4/2014 Page- env/Town State Tip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan)'. NA 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. C Yes C No. Alarms in working order: C Yes C No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.) It 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. Located on site plan. rk a0110.Emp.mmFen,:aba,ma Sewage Deposal stem.Pas 1101 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Property Adds Marcia Russell owner owners Name information Northampton MA 01060 9/4/2014 page. for every State lip code Date of lnspxdon Page. Gly/fCwll 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/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): Soils were dry at the time of inspection. No signs of hydraulic failure. No liquid was present in the leaching pit. Vegetation was not impacted,and no high staining was noted. Top of leaching pit was T below grade,and the bottom was 7 feet below grade. 500+/-Gallon Cesspools(cesspool must be pumped as pan 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 tins-383 Tne 5 OflaallmpectIonFonn a.e.ammSnap DSpmvsr.em•Page 13 as 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Properly Address Marcia Russell Owner Owners Name rnwmnwns Northampton MA 01060 9/4/2014 pa red fa every cave. cnyrtwm State lip Code Date aInspection 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 sanding,condition of vegetation, etc.): w.. 3413 nee Somas mamma Fem.s,wmo Sewage o-,6.System.Page 144117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Property Address Marcia Russell Onna Owners Nane remea Northampton MA 01060 9/4/2014 required for everY cayrtosn State Zip Code Date Of Inspection Daps. 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 m.•vn rile 5 amm mweamrwm.suwn.ceSa pm Orsppsal swm.Page 15.117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Properly Address Marcia Russell Owner owners Name information Northampton MA 01060 9/4/2014 Page-gem for tar every pe. CMrtwm State Zip Code pale cif Inspection D. System Information (cant.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >7 Feet Mn 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: pate ❑ 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: No groundwater infiltration or staining from groundwater infiltration was noted in the bottom of the leaching pit. Before filing this Inspection Report,please see Report Completeness Checklist on next page. w.•3/13 Tees oars Newton swmsws' Benno:wps snem.aa,a GA 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Fair Street Extension Property Address Marcia Russell Owner owners Name regt*nloreery Northampton MA 01060 9/4/2014 Daps, Clry?own State lip code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A,B,C,0,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater El Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file rye 5 OII SIr p.fan Fenn-sw.Y4x.Sewage Onward swm.gg•17 0117