1075 Septic Inspection 2012 Timothy E. Maginnis R.S.
Registered Sanitarian
70 Montague Road
Westhampton, MA 01027
Mr. Blake Simmons
1075 Westhampton Road
Florence, MA. 01062
March 30, 2012
Re: Title-5 Inspection - 1075 Westhampton Road
Dear Mr. Simmons
Enclosed please find a copy of a Title-5 Inspection Report for the subsurface sewage
disposal system at 1075 Westhampton Road in Florence, MA.
On March 27,2012,I conducted a Title-5 inspection at this site. As a result of the initial
inspection, I determined that a Conditional Pass was appropriate because the distribution
box was deteriorated and need to be replaced.
After installation of the new distribution box on March 29th and March 30th, I conducted
follow-up inspections to determine whether or not the disposal system was functioning
properly. As a result of this inspection 1 concluded that a new distribution box had been
installed and that the system is not in failure. It is operating in a manner that protects
public health, safety, welfare and the environment.
Please be aware that this inspection report only describes conditions at the time of the
inspections and under the conditions of use at that time. It does not address how the
system will perform in the future under the same or different conditions. No warranties,
expressed or implied.
Due to its age, I recommend the septic tank be pumped this year and every year hereafter.
Please review the attached report and if you have any questions or would like any
additional information,please contact me at the above address.
Very truly yours;
■
I_- =
Timo'.ii..,Magi R. .
c.c.Northatnpton Board of Health
ter
rmabon is Florence MA 01062 March 27, 2012
ay p for. Ciryrrown State Zip Code Date of Inspection
ry page
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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1075 Westhampton Road
Property Address
Blake&Lyn Simmons
Owner's Name
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A. General Information
1
Inspector:
Timothy E. Maginnis R.S.
Name of Inspector
Company Name
70 Montague Road
Company Address
Westhampton MA
City/Town State
Home: (413) 527-5291 Cell:(413) 575-8523 SI-1039
License Number
Telephone Number
01027
Zip Code
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:
❑ Conditionally Passes
the Local Approving Authority
❑ Fails
I
IAA,- Z, % f March 30, 2012
Inspectors '' 1e!l7til Date
�.
The system in - -I 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.
Hue 5 Official Inspection Farrte Subsurface Sewage Disposal System.Pape 1 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
-7�1a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1075 Westhampton Road
Properly Address
er
nation is
red for
r page.
ortant:
:n filling out
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Blake 8 Lyn Simmons _owners Name
Florence MA 01062 March 27, 2012
Cityrf own 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 MA
City/Town State
Home: (413) 527-5291 Cell: 413)575-8523 SI-1039 Number
Telephone Number
01027
Zip Code
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
❑ N
® Conditionally Passes ❑ Fails
on by the Local Approving Authority
Insp
;l ISTEA _ of this inspection report to the Approving Authority(Board
The H s - submit copy P
'—' n 30 da s of completing this inspection. If the system is a shared system or
of Health Y P 9 P
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.
March 30, 2012
Date
Tale 5 Offioei Inspection Font' Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1075 Westhampton Road
Property Address
Blake& Lyn Simmons
:r Owners Name
nation is Florence _ MA 01062 March 27, 2012
red for - State Zip Code Date of Inspection
page. City/Town
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.
t5rns.09108
Comments:
N/A
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. Syste
will pass inspection if the existing tank is replaced with a complying septic tank as app inent. by
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 5 Official Inspection Foam:subsurf ace Sewage Disposal System.Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1075 Westhampton Road — - —
Property Address
Blake 8 Lyn Simmons — -
Owners Name
ad for Is MA 01062 March 27, 2012_ —
p ge. Florence _ State Zip Code Date of Inspection
page. City/Town
B. Certification (cont.)
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 ❑ ND (Explain below):
® distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below):
Distribution box is old and in disrepair. It should be replaced. End of SAS pipes to be capped.
Risers to be installed on tank and"D" box
king•09408
❑ 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):
NIA
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
Toe 5 Official Inspection Fone.Subsurface Sewage Disposal System•Page 3 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1075 Westhampton Road
—
Property Address
Blake&Lyn Simmons
Owners Name MA 01062 March 27, 2012
Fit/ State Zip Code Date of Inspection
City/Town own
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 1/2 day flow
Tine 5 Official Inspection Fdm:Subsudaca Sewage Disposal System.Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1075 WesthamQon Road —
Property Address
Blake&Lyn Simmons
for Owner's Name
ld Is Florence _ MA 01062 _ March 27, 2012
d gar State Zip Code Date of Inspection
a9e. OW/Town
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.
❑ ® 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
❑ 0 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
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.
t5,ns•09109
True 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 5 N 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1075 Westhampton Road
Property Address
Blake 8 Lyn Simmons
Owners Name
lion is Florence MA 01062 March 27, 2012
Igor City/Town — — State Zip Code Date of Inspection
age.
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?
® p 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
Ill ® 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?
t5ins•09/08
❑ 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)]
11 System Information
Residential Flow Conditions:
unk Number of bedrooms (actual).
Number of bedrooms(design):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
5
unknown
Tea 5 official Inspection Pow:Subsurf ace Sewage Disposal System•Page 6 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1075 Westhampton Road
Property Address
Blake 8 Lyn Simmons --- — -
-----
Owner's Name
Florence
MA 01062 March 27, 2012
— --
—-- State Zip Code Date of Inspection
City/Town
D. System Information
Description:
1,200 gallon septic tank, distribution box and an SAS with 3 lines exiting the distribution box. The
type and size of the SAS was determined by review of existing septic system design by Huntley
Associates and by measuremet in the field -----
Number of current residents'.
® Yes ❑ No
Does residence have a garbage grinder?
Is laundry on a separate sewage system? [if yes separate inspection required] ❑
Yes ® No
® Yes ❑ No
Laundry system inspected?
❑ Yes ® No
Seasonal use9 94766 cu. ft. _
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Garbage disposal to be removed -- ---
❑ Yes ® No
Sump pump? Currently
Last date of occupancy: occuQed—_
Commercial/Industrial Flow Conditions:
NIA_____ ---
Type of Establishment.
N/A
Design flow(based on 310 CMR 15.203). Gallons per day(gpd)
N/A
Basis of design flow(seatslpersons/sq.ft., etc.): --
❑ Yes ❑ No
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present?
Non-sanitary waste discharged to the Title 5 system?
❑ Yes ❑ No
N/A
Water meter readings, if available:
Tale 5 Maa&In$pedion Form Subsurface Sewage Disposal System.F r r of tT
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1075 Westhampton Road
— — --
Property Address
Blake 8 Lyn Simmons_ — — —
Owners Name 2012
on is Florence MA 01062 March
State Zip Cade Date of Inspection
me City/Town
D. System Information (cont.)
Last date of occupancy/use'
Other(describe below):
NIA
General Information
N/A
Date
Pumping Records:
Blake Simmons Source of information:
Was system pumped as part of the inspection?
❑ Yes ® No
To be pumped
If yes, volume pumped: gallons
NIA
How was quantity pumped determined?
N/A
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
atdst
maintenance contract(to inspection of the I/A system by obtained system operator eunder contracts copy of
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe).
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Tale 5 Official Inspection Form Subsurface Sewage Disposal System•Page 0 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
_ — -
1075 Westhampton Road -- -- —
Property Address
_ --
Blake 8 Lyn Simmons — —
Owner's Name MA 01062 March 27, 2012 — —
on is
---
for Florence State Zip 01062
Code Date of Inspection
ige. City/Town
D. System Information (cont.)
Approximate age of all components date installed Of known)and source of information:
System is approximately 33 years old. Source of information is plan by Huntley and Associates dated
May 17, 1979 --- - --
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 0 40 PVC ❑other (explain):
Distance from private water supply well or suction line:
2.5'to 1.5'
feet
4•wc solid pipe
N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
4•' pvc solid pipe from house to tank is in good working order.l Pipe from tank to distribution box is
also mood working order No eveidence of leaks a an doll joints are sound. Venting is proper
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
This is a 33 year old single compartment 1,200 gallon concrete septic tank. Baffles are poured in
place concrete and are operating properly. The tank shows no signs of leakage, in or out. It is in
good working order. Inlet cover is 24 below grade. Outlet cover is 14" below grade. All 3 covers to
have risers installed. ---- — ----
16"to top of pumpout manhole.
3 covers will be installed
N/A
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑
Yes ❑ No
1101x5'-W x41J)— —-
Dimensions.
Sludge depth:
Sins•09109
Tae 5 Official Inspector Form Subsurface Sewage Disposal System•Pare 9 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1075 Westhampton Road — — — ---
Properly Address
Blake&Lyn Simmons — --
Owner's Name
fo r is Florence MA 01062 March 27, 2012
for — State Zip Code Date of Inspection
age_ City/Town
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
measured and observed
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.):
Due to the age of this system I recommend that the septic tank be pumped now and every year
hereafter. The tank is in good condition. At the time of this inspection,there were no signs of
leakage. The inlet and outlet baffles are showing signs of age but are working properly__
sins•0908
44"
< 1„
3"
1"
Grease Trap(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
NIA
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
Date
Tide 5 Official Inspection Form.Subsurface Sewage Disposal System•Pepe 100117
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1075 Westhampton Road
Address
Blake&Lyn Simmons
Owners Name MA 01062 27, 2012
City/Town - State Zip Code Date of Inspection
Citylrown
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.):
NIA
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):
N/A
Dimensions:
Capacity: gallons
N/A
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level.
Alarm in working order: ❑ Yes ❑ No
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
rue 5 OKidal Inspector Form Subsurface Sewage Disposal System•Page 11 of v
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1075 Westhampton Road
Property Address
Blake&Lyn Simmons
Owner's Name
Florence MA 01062 March 27, 2012
State Zip Code Date of Inspection
City/Town
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan).
Liquid level was even with outlet inverts.
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.):
Distribution box is 18" below grade and should be replaced. The interior has corroded and there
were a few surface cracks on top. There are 3 outlet pipes Liquid level was even with the outlet
inverts. There was little evidence of carryover but no leakage On or out)at the time of this inspection.
A plastic riser will be installed to briny the cover up to within 12"of finlshgrade. . —.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
❑ Yes ❑ No
Alarms in working order:
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 top of the SAS is approximately 18"-24" below grade. It consists of 3 lines of -4" pvc pert. pipe
and stone, 30' long and 20'wide. It is not in failure at this time.
Title s orctial Inspedgn Fpm:SubsunacS Sewage Disposal System.Page 12 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1075 Westhampton Road — — — —
Properly Address
Blake&Lyn Simmons
Owner's Name
Florence --._ MA _ 01062 March 27, 2012
State Zip Code Date of Inspection
Gin/flown
D. System Information (cont.)
Type:
O leaching pits number:
❑ leaching chambers number:
0 leaching galleries number:
O leaching trenches number, length:
1 A(30'Ix20'w)
® 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.):
This system is not in failure. It is 33 years old and is in good working order. There is no evidence of
po g or damp soil The vegetation is normal grass No signs of hydraulic failure
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
Tllle 5 Official Inspection Form:Subsurf ace Sewage DiSpoSel Syslen•Page 13 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form• Not for Voluntary Assessments
1075 Westhampton Road
P roperty Address
Blake&Lyn Simmons--------
O wners Name MA _ 01062 March 27, 2012
Florfo — State Zip Code Date of Inspection
City/rawn own
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):
N/A
Materials of construction: -
N/A
Dimensions
N/A _
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Title 5 ONtial Inspeahon Form:Subsurface Sewage DLSPOSal System•Page 14 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1075 Westhampton Road — — --
Property Address
Blake&Lyn Simmons — — —
Owners Name MA 01062 March 27, 2012
Florence — State Zip Code Date of Inspection
City/Tawn
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
f ce the building. Check onarks the Locate
ea all wells within 100 feet Locate
where public water supply enters
❑ hand-sketch in the area below
® drawing attached separately
C.E wet \ f�i°c6„E
Title 5 Onlual Inspection Fenn Subsurface Sewage Disposal System•Page 15 of 17
E(T
E/\
E/T _, oovesrnuna utlunee
so1PE pipe\/1*
E/T
1,200 gallon \
septic tank
E/T
E/
Creeping
Juniper
REFERENCE POINTS
'A' = Corner of house
'B' = Pole N 160-2
'C' = Inlet man-hole
'D' = Pumpout man-hole
'E' = Outlet man-hole
'F' = Distribution box
ID'
T-6' of 4' pvc-
solid pip
3af of 4' pvc
perf pipe
er line (ref. only)
2
B. x
X
X
Fri x—x-
AS-BUILT DIMENSIONS
'A' to 'C' = 42'-7'.
'A' to 'D' = 47'-0'
'A' to 'E' = 51'-5'
'A' to 'F' = 60'-0'
'B' to 'C' = 53'-0'
'B' to '0' = 51'-0'
'B' to 'F' = 511-0'
Municipal
Water tine (ref, only
W w —
Westhampton Road — Northampton, MA.
Title-5 As—built plan
Subsurface sewage disposal system
1 Leachfield 0 (30'1 x 20'w)
1075 Westhampton Road
Northampton, Massachusetts
Owner: Blake Simmons
Address: 1075 Westhampton Road
Northampton, MA 01062
Tel: (413) 537-2150
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1075 Westhampton Road — .
Property Address
Blake& Lyn Simmons.
Owners Name
on is MA 01062_ March 27, 2012
for Florence State Zip Code Date of Inspection
9e Cdyrrown
D. System Information (cont.)
Site Exam:
• Check Slope
® Surface water
® Check cellar
❑ Shallow wells
5'from top of ground —_
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
• Obtained from system design plans on record
March 27, 2012
If checked, date of design plan reviewed: Date
• Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
ns•0906
® Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
1. Groundwater was determined to be>4' as shown on test pit data of record. Plan of record shows
GW to be 5', 6', &7'. A Soil Evaluation was not conducted at the time of this inspection.
2. No evidence of groundwater seepage into septic tank or distribution box.
3. Observed site for wetlands and or other plant indicators of wet soil.
4. Inspected cellar for signs of water stains in basement.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 Ottmiat inspection Form aubsunace Sewage olsposai System•Page 160117
on Is
for
ge.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1075 Westhampton Road _ —
Property Address
Blake& Lyn Simmons
Owners Name MA 01062 March 27, 2012
Florence State Zip Code Date of Inspection
CityR own Own
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
Title 5 Official In on Form:Subsurf ace Sewage Disposal System'Page 17 of 17
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OBSERVATION PITS
REQUESTED BY: Robert NUTTLEMAN --
I,CCAaON: _ 1095 WESTHAMPTON ROAD
HAMPTON, MA
MAILING P.DDRESS: Same
DATE: 5-15-79 OBSERVER: Denni&_tabin--
6 ' 0"
#1 1
OTS
Sandy Silt
3' 0"
Hard Till
oxides
Gravel
Groundwater 5 ' 0"
Perc Rats_
6' 6'
OTS
#3
Silt
Coarse sand
Gravel
1' 0"
1 ' 0"
1' 0"
OTS
Silt
Coarse Sand
Gravel
6' 6"
it
Groundwater 6 ' 0"
Perc Rate
8 ' 0"
OTS
#4
1 ' 0"
1 ' 6"
1' 0"
Silt 1 ' 0"
Coarse Sand
Gravel
Groundwater 7 ' 0__
Groundwater 6 ' 0"
Perc Rate _6 min/in
Perc Rate
+ Oven:ig'nt Test
ALMER NUN'TLEY, JR., B ASSOCIATES. 1•C
SURVEYORS ENGINEERS - PLANNERS
NOTE: Secon '.
pert waived ,-
to soil coed
tions.
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