1431 Septic Inspection 2016 F/j£ C4py
RM Scott&Associates
31 Shutesbury Road
Pelham, MA 01002
Office: (413)256-0647
Mobile: 413-658-4921
Email: rscottpe<dcomcast.net
April 27, 2016
Dan Wasiuk
Northampton Health Department
212 Main Street
Northampton, MA 01060
Subject: Title 5 Septic System Inspection at 1431 Westhampton Road, Florence
(Property of Richard Ciach)
On April 7, April 17 and April 23, 2016, 1 completed on-site inspection activities for the
septic system at the subject property in accordance with 310 CMR 15.000 (Title 5)
requirements. This original system was installed in 1998, per the owner.
Inspection activities before and after the pumping on April 20 show that the system is
"Passed"per the Title 5 criteria. All components are found to be in good condition and no
failure criteria are observed. A copy of the inspection report is enclosed for your use and
files. Additional comments are included in the report.
If you have questions on any aspect of the inspection or the report please contact me at
the address, email or telephone contacts above.
Sincerely,
Richard Scott. P.E.
cc: Richard Ciach, Owner
Julie Held, Realtor
Buyer do Julie Held
;ion is
I for every
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach, 154 Cooke Avenue, Northampton, 01060
Owner's Name
Northampton MA 01062 4-23-16
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.
rM:when A. General Information
it forms
:impute/
y the tab 1. Inspector:
nove your
•do not Rick Scott
return Name of Inspector
RM Scott&Associates, LLC
Company Name
31 Shutesbury Road
Company Address
Pelham MA 01002
City/Town State Zip Code
413-256-0647 MA SI#1030. MA P.E. 31199.
License Number
a
•3/13
Telephone 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
4-23-16
Inspector's 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.
Tithe 5 Olraal Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
ion is
I for every
•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System passes. Inspection activities on April 7, April 17 and April 23, 2016. Pumping was completed
on April 20, 2016. No failure criteria are present See additional notes in report.
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 exiltration 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):
Tine 5 Official Inspection Form'.Subsurface Sewage Disposal System Page 2 of 17
ion is
for every
3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
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 ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ 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 ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
/t//p 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 &twe face Sewage Disposal System.Page 3 of n
ion is
for every
3n3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
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:
"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 '%day flow
tee 5 Official Inspecton Fong.Subsurface Sewage Disposal System•Page 4 of,t
ion is
for every
3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Properly Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® 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 0
El IF]
NL E) Large Systems: To be considered a large system the system must serve a facility with a
�M 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.
Tele 5 Olfioal Insperdon Form Subsurface Sewage Disposal System•Page 5 at 17
on is
for every
3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1431 Westhampton Road(Route 66)
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Z 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?-11(If they were not
available note as N/A) Zoo' T-S Tose.REe02i. rv�p t- J, t zotA t°I 8 '
® ❑ 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?
Z ❑ 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. T-t tate.Rerawt
• ❑ 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)] Cow isrEJr iJ/
aNlf,TC O0.3egy IJJ4.
/D. System Information
Residential Flow Conditions:
Number of bedrooms (design):
3
Number of bedrooms (actual).
DESIGN flow based on 310 CMR 15 203 (for example: 110 gpd x#of bedrooms):
3
330
True s Official Inspection Form-.Subsurface Serb Disposal System•Page 6 of 17
ion is
for every
VIZ
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
City/Town State Zip Code Date of Inspection
D. System Information
Description:
Gravity flow to a two-compartment 1500 gallon septic tank. Gravity flow to a 3-outlet D-box and
estimated three trenches each 40 feet long. System is original to the house construction in 1998.
Iv�
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:
Currently, a garbage grinder is installed. Use of a garbage grinder with this system is not
recommended.
3
Z Yes ❑ No
❑ Yes ® No
❑ Yes ❑ No
❑ Yes ® No
Not available.
Private well.
Sump pump? ❑ Yes ® No
Currently
Last date of occupancy: Occupied.
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatslpersonslsq.ft., etc.):
Grease trap present' ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Title 5 Official Inspection Fam:Subsurfae Sewage Disposal System.Pape]of n
ion is
for every
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below):
/Pumping Records:
Date
General Information
Source of information: Per owner, previous pumping was 2 years ago. No
pump record at Health Dept except May, 2009.
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
1500
gallons
From Pumper
Very Heavy Solids Accumulation.
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe)
3/13 Title 5 Ofreal Inspection Form:Subsurface Sewage Disposal System•Page B of 17
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for every
311
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components date installed (if known)and source of information:
System installed in approx. 1998 with construction of the house.
/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).
1.0
feet
❑ Yes ® No
Distance from private water supply well or suction line: fro fro m m h 70 feet, well to sewer exit
house.
Comments(on condition of joints, venting, evidence of leakage, etc.):
AU exposed, in-house plumbing is in excellent condition. No evidence of any previous problem.
Vented to roof.
'Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
1.0
feet
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500 gallon concrete with pipe tee inlet baffle pipe-tee outlet baffle with filter.
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
126"X 68"X 54"effective depth.
Dimensions:
Sludge depth:
12"
title s Office!Inspecton Form'.subsurf ace Sewage Disposal system.Page 9 of n
ion is
for every
3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
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
22"
30"
How were dimensions determined? Probed at inlet during inspection.
Scum &Sludge are at inlet end.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Very heavy solids accumulation. No significant separation between bottom of scum and inlet pipe
tee. Effective tank volume was significantly reduced by scum and sludge buildup, so there is very little
retention time in the septic tank, and some solids have been carried out of tank to D-box. Liquid
levels are correct. No indication of recent high liquid level or leakage into or out of tank. Conditions of
the concrete tank and pipe tees are good. Next maintenance pumping recommended in 2018,
depending on rate of usage.
NA 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
Tore 5 Ofnal Inspatllm Gann:Subsurface Sewage Disposal System Page 10 of 17
ion is
for every
3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owner's Name
Northampton MA 01062 4-23-16
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.):
HA 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: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes LI No
Ti11e s OProal Ins
ion Form:subsurface sewage Disposal System.Page 11 N n
ion is
for every
3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
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 0
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.):
Three-outlet distribution box is buried 18". Some solids carry-over resulted in 2"scum in D-box. Box
was cleaned as part of pumping activity. Liquid depth in D-box is now correct. No significant
deterioration of the D-box. No indication of leakage into or out of box.
A//A 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.):
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:
Documented SAS is three trenches @.40 feet long. See sketch.
Title s ORioal Inspection Form Subsurface Sewage Disposal system•Page 12 of IT
ion is
for every
3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owner's Name
Northampton MA 01062 4-23-16
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: 3@40 feet long
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Al/A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No sign of problems observed from ground surface.
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
Tithe S Official Inspegim Form:Subsurface Sewage Disposal System.Page 13 of 17
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for every
!13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1431 Westhampton Road (Route 66J
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Fans.Subsurface ssre9e Disposal syst
Page 14 N 17
Fir
on is
for every
Y13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
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
55-1•SLCr
58'-fd' C¢.,n2
60'-4„oucLS-
S4rr.YIW<NN*
4e-
r-
/ •a,Lieo Woo..sea'iav
i
•1 "' PaeveaTrj.
Ar'lo OF a c'JYYO taAw
40 of $AS
Tim Ytv�Toa-i3ov.Tr\PSI
624.4
3-8R
t-Iousc
1 OPEw 9aacry
yo-1*
�L —
25-9"SN
2't•-etre
28-5 For
2■
3-owv r
-So‘
aftcoSo 115'
Dil 5&Wel hsperuon Farm
Disposal SY&Bm•Pege 15 a117
ion is
for every
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
Z Surface water
Z Check cellar
❑ Shallow wells
Estimated depth to high ground water:
6
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: T-5 Insp Report 5-13-2009
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
• Checked with local Board of Health -explain:
Record at Health Department. T-5 Insp Report 5-13-2009
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Reviewed previous inspection report on file at Health Department. The record information is
consistent with ground-surface observations. Cellar is dry. Ground surface slopes consistently away
from the house and SAS to both north and south.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 16 N 17
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for every
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1431 Westhampton Road (Route 66)
Property Address
Richard Ciach
Owners Name
Northampton MA 01062 4-23-16
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Z Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
Z System Information—Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Tale 5 Official Inspection Form.Subsunace Sewage Disposal System.Page 17 of 17