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64 Septic Inspection 2016 ce\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments er nation is red for page. wtant: n filling out s on the Cuter,use the tab key aye your -do not he return A 64 West farms Rd florence Ma. 01062 Property Address Michel Ryan &Alan Kuusisto Owner's Name same City/Town Ma 01062 10/19/16 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: Ray Champagne Name of Inspector Whiteley Septic Service Company Name 21 Old Count_Rd. Company Address Southampton City/Town 413-527-0057 Telephone Number Ma. Ma. State Zip Code 514118 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 Inspector's Sign 10/19/16 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. ;.08/08 Title 5 Official Inspecbon Form 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 64 West farms Rd florence Ma. 01062 Properly Address Michel Ryan &Alan Kuusisto Owner's Name :ion is same Ma 01062 10/19/16 for State Zip Code Date of Inspection age. 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. Comments: This system consists of a 1000 gal septic tank with concrete baffles and a 500 gal leach pit.The leach pit is 26"deep with 25" standing effluent. This pit is 60" below grade.The baffles at tank is showing concreterading and should be replaced or repaired. 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 exflltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Title 5 Off mxl Inspection Form Suaoma ye Disposal System'Page of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn -Not for Voluntary Assessments 64 West farms Rd Florence Ma. 01062 Property Address Michel Ryan &Alan Kuusisto Owner's Name ion is same Ma 01062 10/19/16 for State Zip Code Date of Inspection age, 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 El ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): El distribution box is leveled or replaced ❑ Y O N E 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 O N E ND (Explain below): El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(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 El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 Official mspecbon Form Subsurface Sewage Disposal system.Page S or 17 n is or •0910¢ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 West farms Rd florence Ma. 01062 Property Address Michel Ryan &Alan Kuusisto_ Owner's Name Ma 01062 10/19/16 same _ _ _ -- - City/Town State Zip Code Oate 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 colifonn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow Title 60ROiai mspecton Form:Subsurface Sewage Disposal System.Page 4 of 17 Commonwealth of Massachusetts 7 Title 5 Official Inspection Form �'s1l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 West farms Rd florence Ma. 01062 Property Address Michel Ryan &Alan Kuusiso—_.__—_—.— --.-.- -- -- Owner's Name same _ Ma 01062 10/19/16 - - - - -- -- -- - —_ "—" - State Zip Code Date of Inspection City/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 colifonn 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 15303,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 (Interim Area-IWPA) or a mapped Zone II of apubl c water supply Protection 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. •09)08 Tie 5 Official Inapecton Fo,m:Subeumce Sewage Dlsrts l System•Page s of 17 •OeIOB Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Property A dress Rdflorence Ma. 0106 Property Address Michel Ryan &Alan Kuusisto--._—.—.._-- ----- -- Owners Name Ma 01062 10/19116 same C ity/T — State Zip Code Date of Inspection lr own C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No 0 El ® ❑ • Z • ❑ Z ❑ ® ❑ ® ❑ El El 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 (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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 unknown Title s Official mspecton Form.Subsurface eeNage DspovlSys em.Page B 0117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 West farms Rd florence Ma. 01062 _._ ------- ---- Property Address -- rebelrcamel Ran &Alan Kuusisto__.__ --- - Name Ma 01062 10119116 ----- _-- State Zip Code Date of Inspection ciiyrtow� D. System Information Description: of This sytem consists of a 1000 gal.degrading , a 500 pl. leach pit which hats 25'_of standing watear. es he pit Is 26"de p annd 5' BG concrete 5 Number of current residents: ❑ Yes ® No 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? water meter Water meter readings, if available (last 2 years usage (gpd)): reading 1420.2 Detail: ❑ Yes Z No Sump pump? presently _. Date Last date of occupancy: 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.): ❑ Yes ❑ No Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes [3 No Non-sanitary waste discharged to the Title 5 system? -- Water meter readings, if available: •DBIDS Title 5 Official Inspector Form:SOosnriaee Swage Disposal System•Page 7 of n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 West fauns Rd florence Ma. 01062____Property Address ---- Michel Ryan &Alan Kuusisto______.------- tgry 9lt6. _-- Owner's Name Ma 01062 __ ------ 0/1 of Inspection Same - State Zip Code CltylTOwn D. System Information (cont.) presently Date Last date of occupancy/use: Other(describe below)'. General Information Pumping Records: unknown Source of Information: a Yes ® No Was system pumped as pan of the inspection? If yes,volume pumped: gallons Haw 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 of latest ❑ inspection of the I/A�system by system roper for nder owner) a copy(t be obtained contract Tight tank.Attach a copy of the DEP approval. Other(describe): tank directly to leach pit .09/00 Tae 5 Official Inspection Poffn Sutsudace Sewage Disposal system•Page B el] Commonwealth of Massachusetts Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 West farms Rd florenceMa. 01062 Property Address Michel Ryan &Alan Kuusisto same City/Town City/Town Date of Inspection Title 5 Official Inspection Form Ma state Owner's Name 01062 Zip Code 10/19/16 D. •09100 System Information (cont.) Approximate age of all components, date installed Of known) and source of information: 30-40yrs+/-estimate ______—.------- ---- 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 Distance from Ovate water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage observed, ----- ❑ other(explain): 3 feet feet Septic Tank(locate on site plan): Depth below grade: Material of construction: 0 metal ® concrete 2.5 feet 0 fiberglass ❑ polyethylene Yes ® No ❑ other(explain) ears If tank is metal, list age: s ❑ No Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes Dimensions: Sludge depth: Disposal System'Page 9 of 17 Title S Official Inspection Farm:Subsurface Sewage Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 West farms Rd florence Ma. 01062__ -- Properly e Address Michel Ryan &Alan Kuusisto ___ _--------- 10119116 Owner's -_. 's Name Ma 01062 -bate of Inspection Same . State Zip Code City/Town D. System Information (cont.) Septic Tank (cont.) 35" Distance from top of sludge to bottom of outlet tee or baffle - 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 12 _ - - - Distance from bottom of scum to bottom of outlet tee or baffle sludge judge 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.): Pumping recommendation of every 1-2 years depending on use ----- Grease Trap (locate on site plan): eet Depth below grade: Material of construdion: other(explain): ❑metal ❑ fiberglass ❑ polyethylene ❑ ❑ concrete --- 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 Date of last pumping: Page'°0'9 Title 5 Official inspection Form Subsurface 9awa9e Disposal System' 9e •09106 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - -64 West farms Rd florence Ma. 01062 __-.--.—-- Properly Address ----- Michel Ryan &Alan Kuuss o__ 10119116 __—_ ---- Owner's Name Ma 01062 0i1 01062 0/1ofInspection same state cnrrrown--------- cont. 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, c): - _ - leach Qlt saturated and glogg_ed____. . _-- Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: other(explain) ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ Dimensions: gallons Capacity: _ -- gallons per day --- --- �-- — Design Flow: ❑ Yes ❑ No Alarm present: ❑ Yes ❑ No Alarm in working order'. Alarm level: - -- Date of last pumping: Date Comments(condition of alarm and float switches, etc.): attached? ❑ Yes ❑ No Attach copy of current pumping contract (required). Is copy Title 5 Official Inspection Fomm Subsurface Sewage Disposal System.Page 11 of 17 09/09 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 West farms Rd florence Ma. 01062_____—-------_---- ProPedYAddress ---- Michel Ryan &Alan Kuuss o______–. . 10119116 __ ---- Owner's Name Ma 01062 Inspection same ---- ale Zip Code Date of Insp CiIY/TOwn st D. System Information (cont.) Distribution Box Of present must be opened) (locate on nachpH no d box ____.___-------- Depth of liquid level above outlet invert evidence of solids carryover, any Comments (note if box is level and distribution to outlets equal, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): ❑ No Pumps in working order: 0 Yes Yes ❑ No Alarms in working order. Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: me 5 gpaal Inspatlon Form:SuESWace Sewage Disposal SysMO'Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 West fauns Rd florence Ma_0106 Property Address — -- MichelRyan &Alan Kuusisto____—--------- 10119116_ Owner's Name Ma 01062 State Zip Code Date of Inspection CNYrfown D. System Information (cont.) Type: 0 0 number. leaching pits number: leaching chambers number: leaching galleries number, length. leaching trenches number, dimensions. leaching fields number. overflow cesspool innovative/alternative system 1-500g_ Type/name of technology'. _-- soil, condition of Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp vegetation, etc.): no surface signs of hydraulic failure observed- sandy soil with g_rav-____—----- 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 ❑ Yes ❑ No Title Indication of groundwater inflow 5n iCi nz%cton Form Subshate Sewage Disposal System•Page 13 b» commonwealth of Massachusetts Subsurface 5 Official Inspection Form Not for Voluntary Assessments Subsurtace Sewage Disposal System 64 West farms Rd florence Ma.010____—----- -- Michel Address _ ---- Ma I Ryan &Alan Kuussto___—-- t Oryg/16 rope Owners Name 01062 _— -- --- Zip Code Date of Inspection same —_------- ---- State c cont. D.. System Information (cont.) condition of vegetation, Comments(note condition of soil, signs of hydraulic failure, level of pending, — — etc.): sand soil with stone Privy (locate on site plan): Materials of construction: Dimensions _____-------__-- Depth of solids of ponding,condition of vegetation, Comments(note condition of soil, signs of hydraulic failure, etc.): ----------- Title 5 Off Cai Inspecton FOCm'.suMUtlso Servage Disposal system•Page 14 of 17 a9■95 ommonwealth of Massachusetts itle 5 Official Insp action Form ubsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West farms Rd florence Ma.01062 Property Address __. ----- riche- Ryan &Alan Kuusisto 01082 10�ig�16 ___---- owner's Name Ma Date of meee„°" same__-- ,w<— stare zip tole ciHRam, tort.) D. System Information ( Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system.Including ties to at least two permanent reference rs the ing or one benchmarks.the boxes bells within 100 feet. Locate where public water supply ® hand-sketch in the area below 0 drawing attached ice ail / \V 05 nr Kl � I � a l' , on FOA .su'sa,aceS oe -flea.'Kn cla',rn Syslev.Pa Se,Shci :ommonwealth of Massachusetts Inspection Form Title 5 Official lnsp ctifor Voluntary Assessments Form -Not Subsurface Sewage Disposal _ - 64 West farms Rd Florence Ma. 01062 — _------ Prom's'Address Miche I Ryan &Alan Kuusisto___ _—--------------- — ----- 10119116_ same Name Ma 01062 --- Zip Code Date of Inspection same — --- - State City/Town D. System Information (cont.) Site Exam: ® Check Slope Surface water Check cellar ® Shallow wells 8-10'estimate 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 ❑ 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: a 0 Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how You established the high ground water elevation: sandyRravel soil sight elevated_____--------- Before filing this Inspection Report, please see Report Completeness Checklist on next page. ;me 5 011maunspemor,Form Subsurface Sewage Orsposal Shy•Page 16 of n 09106 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 West farms Rd florence Ma. 01062 _---- Property Address --_—_.__—_--------_ Michel Ryan &Alan Kuuslsto —_ ------ Owner's Nate same Ma 01062 10/19116 OCity/Town State P ZI Code Date of Inspection __ E. Report Completeness Checklist E Inspection Summary:A, B, C, D, or E checked • Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information–Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Of iCal Inspection Form SUESChace Sewage Disposal System'Page 17 oI17 09108• 64 WEST FARMS ROAD NORTHAMPTON.MASS. 01060 Lot size: 0.884 acre total Drawing scale:As-Built(NTS) Owner Michel Ryan Alan Kuusisto 64 West Farms Road Northampton, MA, 01060 Phone:(413)320-9601 No wells were within. 100 feet f proposed soil absorption system. 96.0 A SY /A/ /ED 57/0- RAM P CR04W /ooT/N � A4 n T/C -TANK 98A FINAL AS-BUILT DISTANCES Septic tank in: Septic tank ctr Septic tank on D-box: Obs'n port: A-C=38' B-C-27' A-D-42' 6" B-D=24 9" A-E-44'2" B-E=24' A-F=64' 9" B-F=32' T" A-G=69'9" B-G=41'4" *1=0 I o p 1185 FILE CO Y NA/a fia /6-pp 6 L Zpl/e rem =/00.0 98.0 STEP�' /00.0 /02.Oi' E , 4Y674IENT WEST" Fi9R'/ns ROAD: A r'US /C ;0":'S