1156 Septic Inspection April 2011 Timothy E. Maginnis R.S.
Registered Sanitarian
70 Montague Road
Westhampton, MA 01027
Ms. Susan Cook
1156 Westhampton Road
Northampton, MA. 01069
Re: Title-5 inspection
April 14, 2011
Dear Ms. Cook;
On April 12, 2011, I conducted an inspection of the subsurface sewage disposal system at
your residence at 1156 Westhampton Road,Northampton, MA. I have enclosed a copy
of the Title-5 Inspection report for your records.
At the time of my inspection I did not find any violations of Title-5 and the system was
operating properly. It is my opinion that with proper operation and maintenance this
system should provide trouble free service now and in the future. I recommend annual
pumping and proper disposal of all sanitary sewage.
If you have any questions or would like any additional information,please contact me.
Very truly yours;
f�E.. I
Timoth E. aginm . .
,7 c.c. Northampton Board of Health
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1156 Westhampton Road - (Rt. 66)
Tel: (413)626 -0218
Property Address
Susan Cook
Owners Name
Northampton MA 01060 April 12, 2011
City/Town 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.
Title-5 System Inspector# 1039
Name of Inspector
Company Name
70 Montague Road
Company Address
Westhampton MA 01027
City/Town State Zip Code
(413) 527-5291 S11039
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 IP onditionally Passes ❑ Fails
❑ Needs Further Evalu.57c. ;�NeF .. ,�,�; oving Authority
April 13, 2011
Date
The system inspector s 1all sr' fC!1Gil ,/this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days o' 6mpleting 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.
ins.o9m9 Tine 5 Ofboal Inspection Form Subsurface Sewage Disposal System•Pagel of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1156 Westhampton Road - (Rt. 66)
Property Address
Susan Cook Tel: (413)626-0218
Owners Name
nation is
red for Northampton MA 01060 April 12, 2011
page. 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:
bit 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:
Recommend annual pumping.
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):
N/A
Title 50Reial Inspection Form Subsurface Sewage Disposal System•Page 2 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1156 Westhampton Road - (Rt.66)
Property Address
Susan Cook Tel: (413)626-0218
Owners Name
teflon d for Northampton MA 01060 April 12, 2011
page. City/Town State Zip Code Date of inspection
u.09/08
B. Certification (cont.)
B) System Conditionally Passes (cant.):
❑ 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 ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y O N O ND (Explain below):
N/A
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
N/A
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
Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1156 Westhampton Road- (Rt. 66)
Property Address
Susan Cook Tel: (413)626-0218
Owners Name
ration is Northampton MA 01060 April 12, 2011
ed for
page. 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
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 'A day flow
ss,09/08 Tale 5 Official Inspection Form.Subsurface Sewage olspasai System.Page 4 0117
Idllfn is
eel for
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1156 Westhampton Road- (Rt. 66)
Property Address
Susan Cook Tel: (413)626-0218
Ownefs Name
Northampton MA 01060 April 12, 2011
CitylTown 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.
❑ ® 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.
❑ 0 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.
ns•03109 TOW 5 Official Ins ion Farm.subsurface Sewage Disposal System•Page 5 of IT
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1156 Westhampton Road - (Rt. 66)
Property Address
Susan Cook Tel: (413)626-0218
r Owners Name
;aeon a fore Northampton MA 01060 April 12, 2011
page. City/Town State Zip Code Date of Inspection
:•09108
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 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 with GB Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
734.08 GPD
Title 5 Official Inspecnm Form:Subsurf ace Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1156 Westhampton Road- (Rt. 66)
Property Address
Susan Cook Tel: (413)626-0218
Owners Name
anon
:d for Northampton MA 01060 April 12, 2011
page, City/Town State Zip Code Date of Inspection
D. System Information
Description:
Septic tank, distribution box, and 4 leaching trenches @(40'L x 2'W x 2'N) each
3
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ® Yes ❑ No
currently
Last date of occupancy: occupied
Commercial/Industrial Flow Conditions:
N/A
Type of Establishment:
N/A
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
N/A
Grease trap present? ❑ Yes ® No
Industrial waste holding tank present? ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
N/A
Water meter readings, if available:
„ oona Title 5 Omani Inspection Forth.Subsurface Sewage Disposal System.Page l el 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1156 Westhampton Road- (Rt. 66)
Property Address
Susan Cook Tel: (413)626-0218
Owners Name
anon is ton MA 01060 NJ for Northampton April 12, 2011
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below):
NIA
Currentllyoccupied
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:
Susan Cook-owner
❑ Yes ® No
To be pumped on April 18, 2011, by T.R.A.K. of
Williamsburg, MA.
Real estate transfer
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):
Tine S&Xival Inspection Form Subsurface Sewage Disposal System•Page a of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1156 Westhampton Road- (Rt. 66)
Tel: (413)626- 0218
Property Address
Susan Cook
Owner's Name
anon is Northampton MA 01060 April 12, 2011
:a for P
page. 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:
16 years-System designed and installed in 1995. Source of information was Plan on file and
designer knowledge.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
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:
18"
feet
N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Building sewer pipes are solid and in good working order. No leakage noted. Joints are sound.
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
1 foot (12")
feet
❑ fiberglass ❑ polyethylene
❑ other(explain)
Top of tank is 12"to finish grade. The inlet and outlet bathe are poured concrete and are sound in
good working order. Liquid level at inlet is approx. 1.5" below inlet invert.
If tank is metal, list age:
N/A
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
(122"L x 64"W x 48"D)-outside
Dimensions:
Sludge depth:
Title 5 Official Inspection Form Subswlace Sewage Disposal Syslem•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1156 Westhampton Road - (Rt. 66)
Property Address
Susan Cook Tel: (413)626-0218
Owners Name
Won is
d for Northampton MA 01060 April 12, 2011
cage. 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.):
The septic tank is approximately 16 years old and has poured in place concrete baffles. The tank is
structually sound and not leaking. The liquid level at the outlet baffle is even with the invert. I
recommend annual pumping.
44"
1"
measured and observed
Grease Trap (locate on site plan):
N/A
Depth below grade: feet
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:
N/A
N/A
N/A
N/A
N/A
Date
t,096171 Title 501ficial In on Form'.Subsurface Sewage Disposal System•Page 10 of IT
L\ Commonwealth of Massachusetts
Mon is
d for
1age.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1156 Westhampton Road - (Rt. 66)
Tel: (413)626-0218
Property Address
Susan Cook
Owners Name
Northampton MA 01060 April 12, 2011
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.):
N/A
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:
N/A
Capacity: gallons
N/A
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
N/A
N/A
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
N/A
•Attach copy of current pumping contract(required) Is copy attached? ❑ Yes ❑ No
„09/08 Title 5 Official Inspection Form'.Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1156 Westhampton Road- (Rt.66)
Property Address
Susan Cook Tel: (413)626 -0218
Owners Name
don is Northampton MA 01060 April 12, 2011
rigor P P
rage. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
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.):
There are 4 outlet pipes in the distribution box. Effluent was even with outlet inverts. The distribution
box is level and in good working order. No evidence of carry over and no evidence of leakage into or
out of the distribution box. Its dimensions are (21"L x16"W). It is approximately 16"below grade.
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:
The location and size of SAS is based on the existing plan on file with the Board of Health and this
designer's knowledge of the system. No evidence of failure was observed. This system is in good
working order.
Title 5 Official Inspection Fenn:Subsurface Sewage Disposal System•Page 12 of 17
lion is
d for
age.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1156 Westhampton Road- (Rt. 66)
Properly Address
Susan Cook Tel: (4 3)626-0218
Owners Name
Northampton MA 01060 April 12, 2011
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:
@
(401 x 2'H x 2W)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
There were no signs of hydraulic failure above or below ground. No damp soil or ponding.
Vegetation was grass and normal for this time of year.
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
Tiff s 5 Official Ins
N/A
N/A
N/A
N/A
N/A
❑ Yes ❑ No
Ian rent subsurf ace Sewage Disposal system-Page 13 of 17
lion is
I for
age.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1156 Westhampton Road- (Rt. 66)
Property Address
Susan Cook Tel: (413)626-0218
Owner's Name
Northampton MA 01060 April 12, 2011
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.):
There were no signs of hydraulic failure above or below ground. No damp soil or ponding.
Vegetation was grass and normal (dry)for this time of year.
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 50Bidal Inspection Form.Subsurface Sewage Disposal System•Page 14 N IT
lion is
I for
age.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1156 Westhampton Road- (Rt. 66)
Property Address
Susan Cook Tel: (413)626 -0218
Owners Name
Northampton
City/Town
MA 01060 April 12, 2011
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
SEE A ■AC tIEO
Title 5 Offinal Inspection Form:Subsurface Sewage Disposal System•Page 15 d 17
✓ESTHAM'TON ROAD (Rt, 66) - NORTHAMPTON, MASSACHUSETTS
erhead utilities
.
Fence
4' pvc solid pipe t
Pump-out manhole ('C')
00 Gallon septic tank
Distribution box ('D'
Amp pump discharge
\Sand box (top of tank)
4' pvc solid pipe
Of
4' pvc solid pipe •vc •err .I•e
-
•-- - pvc
.-p-er-.-pipe
-%----j
cog
4-
2
1
a
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a
c)
As—built dimensions
April 12 , 2011
ca
c3\ 0 4
TITLE-5 IN ECT
As—built plan
Owner: Susan Cook
Address: 1156 Westhampton Road
Northampton, MA 01062
Telephone: (413) 626 — 0218
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1156 Westhampton Road- (Rt. 66)
Property Address
Susan Cook Tel: (413)626-0218
Owners Name
ion is for Northampton
MA 01060 April 12, 2011
,pe. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water:
> 3'
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:
April 12, 2011
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:
Oserved no water stains on cellar wall
Inspected septic tank for signs of infiltration/exfiltration
Reviewed USGS soil Survey logs.
Noted local topography(upland wooded lot)
Original test pit data at SAS by this designer
No water observed
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 Official nspenlw Form'.Subudare Sewage Deposal System•Page Is of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1156 Westhampton Road- (Rt. 66)
Tel: (413)626-0218
Property Address
Susan Cook
Owners Name
ion is
for Northampton MA 01060 April 12, 2011
19e, City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
El Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
El System Information—Estimated depth to high groundwater
El Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Title S lcal Ins Lon Fom'.Sob ace swap Disposal System•Page 17 of IT