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710 Title 5 2017 Commonwealth of Massachusetts iat Title 5 Official Inspection Form '; ! Subsurface Sewage Disposal System Form- Not for Voluntary Assessments k cO 710 NORTH FARMS ROAD Property Address ROBERT& LORRAINE BATES Owner Owner's Name mquiredfo is NORTHAMPTON MA 01060 NOVEMBER 16, 2017 required for every _- -..... .. . - _ _ page. City/TownState 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. Important:When A. General Information filling out forms or the computer. use only the tab 1 Inspector key to move your cursor-do not MARK T. THOMPSON use the return key. Name of Inspector SC HILLTOWN ENVIRONMENTAL CONSULTING Company Name P. O. BOX 314 o X Company Address CHESTERFIELD MA 01012 Cty/rown State Zip Code (413)296-4499 SI 3588 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation Evaluation by the Local Approving Authority �` ^ar _ -. . Inspect is 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 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. thin ax•rev SII6 nue 5 Official Inspection Foim Su Wax Sewage Disposal Svnan.Page I of I Commonwealth of Massachusetts ,6 , Title 5 Official Inspection Form =' I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1,710-77 710 NORTH FARMS ROAD -- Property Address ROBERT&LORRAINE BATES __- - --- Owner Owner's Name information is NORTHAMPTON MA 01060 NOVEMBER 16. 2017 page required far every - - - -- State -- Page Gay/Town atZip 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. 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): Llln 5 OMuaI Impe<Lon Form Subsurface Sewage Dispose,System•nape 2 0.1' isms dist'rev 600 , A:\ Commonwealth of Massachusetts Fie r Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ro ' // 710 NORTH FARMS ROADProperty Address Atltlress ROBERT& LORRAINE BATES Owner Owner's Name information is NORTHAMPTON MA 01060 NOVEMBER 16, 2017 required for every -_ page. 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). 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 s„ss d,x•rev elle Tin.5 Officanns{wuiw rum Subsurface Sewem Disposal System.Patio a D.I.' I:x Commonwealth of Massachusetts 1� rTitle 5 Official Inspection Form Id d -- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C. '�.y 710 NORTH FARMS ROAD_ Property Address ROBERT & LORRAINE BATES Owner Owner's Name information Is required for every NORTHAMPTON MA 01060 NOVEMBER 16,-2017 - _- - 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 O 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 Y day flow T,le5 ONual Inspection Form Subsurface Sewage Disposal System•Page 4 of It Commonwealth of Massachusetts yitier Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i ar7,1 710 NORTH FARMS ROAD Properly Address ROBERT 8 LORRAINE BATES Owner - Owner's Name mimmation is NORTHAMPTON MA 01060 NOVEMBER 16 2017 page- required for every - — - - page. ClCity/TownSlatete 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 falls. 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. ,ens due•rev 6n6 Mtn 5 Official nsRoinn torn SJwnace sewanx plsoo al sysiem.Far s or 17 ; \ Commonwealth of Massachusetts r1R= Title 5 Official Inspection Form ',via: Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ‘7,.,( ,---.:(1/ ,- 710 NORTH FARMS ROAD Property Address ROBERT& LORRAINE Owner --. ___... Owners Name mtormation is NORTHAMPTON MA 01060 NOVEMBER 16,2017 required for every page. 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 O ❑ Pumping information was provided by the owner, occupant, or Board of Health O 0 Were any of the system components pumped out in the previous two weeks? O ❑ Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? O ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) O 0 Was the facility or dwelling inspected for signs of sewage back up? O ❑ Was the site inspected for signs of break out? O ❑ Were all system components, excluding the SAS. located on site? O 0 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: O ❑ Existing information. For example, a plan at the Board of Health. ❑ 0 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)] D. System Information Residential Flow Conditions: 3Number of bedrooms(actual). 4 Number of bedrooms(design): - 330 DESIGN flow based on 310 CMR 15.203(for example. 110 gpd x#of bedrooms): - him mc.me 66/16 Title 5 GOaa Inspector Form Subaunaw Sewage D.sposai System•Page 5 a•17 Commonwealth of Massachusetts i-71417--.41p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 710 NORTH FARMS ROAD Property Address ROBERT 8 LORRAINE BATES _. _. ___. . .. . _... Owner Owner's Name inforrnarion is NORTHAMPTON MA 01060 NOVEMBER 16.2017 reamred for every -- --- ----- -- page. City/Town State Zip code Date of Inspection D. System Information Description: SINGLE FAMILY DWELLING _ _.. _... 3 Number of current residents- Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report) Laundry system inspected? 0 Yes ❑ No Seasonal use? ❑ Yes 0 No PRIVATE WELL Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? _ _. ___ __ __. - __ ❑..Yes No CURRENT Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment. Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/Wt., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? 0 Yes In No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - ;Sine cot rev 916 1de 6001081 Insuerdon Pam Subsurface Sewage Disposal Syslem•Page 7ale ,,,f-\ Commonwealth of Massachusetts _ 5 F Title 5 Official Inspection Form II Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..�,. 710 NORTH FARMS ROAD Property Address ROBERT & LORRAINE BATES Owner Owner's Name anon is required NORTHAMPTON MA 01060 NOVEMBER 16. 2017 page. for every City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: LAST PUMPED IN 2012 PER OWNER Was system pumped as part of the inspection? ❑ Yes Z No If yes,volume pumped: gallons - - -- 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) (if 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). urs ooc•Fey ef,6 mm 5 Official mfeecien rmm SuhSOaDn Sewage Diswsei SyOam'Page fin'17 i Commonwealth of Massachusetts ia` (� Title 5 Official Inspection Form 3� " - U Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 710 NORTH FARMS ROAD Property Address ROBERT & LORRAINE BATES Owner Owners Name information quired for is NORTHAMPTON MA 01060 NOVEMBER 16, 2017 page for every - _. _. State --_- page City/Town ZipCode Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: SYSTEM INSTALLED IN 1998 PER OWNER Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): 1.5'+/- Depth below grade: Mei _.. . _... Material of construction. ABS ❑ cast iron 9 40 PVC ® other(explain)'. - - -------- 16'+(- Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): PLUMBING IN VERY GOOD SHAPE. NO EVIDENCE OF LEAKS. THERE IS A BATHROOM WITH AN EJECTOR PUMP LOCATED IN BASEMENT.VENT PIPE VISIBLE ON ROOF. Septic Tank (locate on site plan): 1' Depth below grade: Met Material of construction. concrete ❑ metal ❑fiberglass 9 polyethylene ❑ other(explain) If tank is metal, list age: veers Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) in Yes ❑ No 126" Lx69"Wx68"D Dimensions: 2-3.. Sludge depth' 6ne ex.rev 3116 Tines(tarsi Inscecuon Form Subsurface Sewage PSMsa,System.Page 9 or Commonwealth of Massachusetts il-twoo Title 5 Official Inspection Form ® - 11) Subsurface Sewage Disposal System Form-Not for Voluntary Assessments YT 710 NORTH FARMS ROAD Property Address ROBERT& LORRAINE BATES Owner Owners Name - information is NORTHAMPTON MA 01060 NOVEMBER 16, 2017 required for every - _ _ page 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 20 -- 0 Scum thickness _ Distance from top of scum to top of outlet tee or baffle 30" Distance from bottom of scum to bottom of outlet tee or baffle --- - - PROBED AND MEASURED 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.). TANK AND TEES ARE IN VERY GOOD SHAPE AND APPEAR STRUCTURALLY SOUND. OUTLET COVER WAS CRACKED AND REPLACED AS PART OF INSPECTION. SOME MINOR CORROSION OF CONCRETE ABOVE FLOW LINE NEAR OUTLET PIPE WAS OBSERVED WHICH IS COMMON FOR TANKS OF THIS AGE. THE LIQUID LEVEL IS EVEN WITH OUTLET INVERT AND THERE IS NO EVIDENCE OF LEAKAGE OR BACKUPS OCCURRING. THE SEPTIC TANK SHOULD BE PUMPED EVERY 3 TO 5 YEARS. AVOID USING POWDER DETERGENTS AND FLUSHING LATEX PAINT INTO SYSTEM. Grease Trap(locate on site plan): 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: Date 15i00 mc.rer 6)16 Tule 5 Mel Inspection Form SUosieace Savage Disposal System.Page 10 011: Commonwealth of Massachusetts fp Title 5 Official Inspection Form Vl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments (,�y 710 NORTH FARMS ROAD.....Property Address ROBERT& LORRAINE BATES Owner Owner's Name require nfo is NORTHAMPTON MA 01060 NOVEMBER 16 2017 required for every i -- - IPC - - --- page. Crly/rown 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.): 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 D polyethylene ❑ other(explain): Dimensions: Capacity-. gaiwns Design Flow: 9 gallons per day Alarm present. ❑ Yes ❑ No Alarm level: ------- Alarm in working order: ❑ Yes 0 No Date of last pumping. Dare Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No trims doc rev 6n6 Title 5 OfIoal m2ecvm Fogs Subsurface savage Disposal Svsrem.Sage n or v Commonwealth of Massachusetts iTirg-airi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments IC 4 / 710 NORTH FARMS ROAD Property Address - -- _- ROBERT& LORRAINE BATES Owner Owners Name information is NORTHAMPTON MA 01060 NOVEMBER 16. 2017 required for every -.__. — -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0" 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.): D-BOX IS 30"BELOW GRADE AND IS IN O.K. SHAPE. THERE IS SOME CORROSION OF THE CONCRETE PRESENT ABOVE THE FLOW LINE AND ON THE BOTTOM OF THE COVER WHICH IS COMMON IN SYSTEMS OF THIS AGE. SOME MINOR SOLIDS CARRYOVER WAS OBSERVED BUT THERE IS NO EVIDENCE OF BACKUPS OCCURRING, LIQUID LEVEL WAS EVEN WITH THE INSTALLED FLOW LEVELERS. THERE ARE ONLY 2 OUTLET PIPES PRESENT AS OPPOSED TO THE 3 SHOWN ON THE APPROVED DESIGN PROVIDED BY THE CITY. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ 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: =ere dm.rev File Tire 5 ofrioai Inspection=arm Subsurface Sewage Disposal System•Pape 12 of r Commonwealth of Massachusetts 1. (e Title 5 Official Inspection Form NAi Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;11-07710 NORTH FARMS ROAD — _- .- Property Address ROBERT& LORRAINE BATES - Owner Owner's Name - - --- - - ---- - ---- rformationis NORTHAMPTON required for every MA 01060 NOVEMBER 16, 2017 - - - -- - - --- - Page City/town State Zip Code Date of Inspection D. System Information (cont.) Type'. ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ---- 2'D ® leaching trenches number, length: TWO: 3W xx 55+/-L ❑ leaching fields number, dimensions: ❑ overflow cesspool number: O innovative/alternative system Type/name of technology- Comments echnologyComments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOIL IN AREA OF TRENCHES SHOWED NO SIGNS OF HYDRAULIC FAILURE. VEGETATION IS MOWED LAWN AND APPEARS NORMAL.THE ORIGINAL DESIGN CALLED FOR 3 TRENCHES. BUT ONLY TWO ARE PRESENT. IT APPEARS THAT THE LENGTH OF THE TRENCHES MAY HAVE BEEN INCREASED FROM 40'TO 55 BASED ON PRESENCE AND LOCATION OF VENT PIPE AT FAR END OF SYSTEM. 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 !Sins dos rev 916 Title 5 Moist lmpxfan FOTO, SLIG.Sk Sce SHrage Dismal System•nage 13 st 1s Commonwealth of Massachusetts t= � 4 Title 5 Official Inspection Form Iit�l_ -,� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments q7477:77:77;",✓ 710 NORTH FARMS ROAD Property Address ROBERT& LORRAINE BATES Owner Owners Name information is NORTHAMPTON MA 01060 NOVEMBER 16. 2017 required for every — -- - - - - page. City/Town _ State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failurelevel of ponding, condition of vegetation, etc.)'. Privy(locate on site plan). Materials of construction'. _ Dimensions -- Depth of solids '— Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) :osdoc Fav arts nne 5 Onium In oecban Form Subsurface Sewaox n!srwn System.Par d ar LrN Commonwealth of Massachusetts m �'p Title 5 Official Inspection Form ( _ _ f�, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1Y d 710 NORTH FARMS ROAD_ Property Address ROBERT & LORRAINE BATES Owner Owner's Name information isrequ.etl far every NORTHAMPTON MA 01060 NOVEMBER 16, 2017 page - -- --- - fI page City/Town State Zip Code Date of Inspection D. System Information (cant.) 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 L1 }- — ct �A '1,., . 9-P,_y t- V \ I _iv' . G.�.� ‘ 3 'Tr . 5 ?'',Ix7 " ' 55 C 3 D--,6/x \ 2- '-i,- o / 13 ? j ' 7 /cA 1 -1,,7 -,:io r., 7-., 7.. ir l him dw'rev 6/16 rare 5 Official mspecton Form Subsurface sewage Disposal Synem.Page 15.of 1i Commonwealth of Massachusetts ,,I fi Title 5 Official Inspection Form 1. V✓ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -, 710 NORTH FARMS ROAD Property Address ROBERT& LORRAINE BATES Owner Owner's Name information Fs NORTHAMPTON MA 01060 NOVEMBER 16. 2017 page. tlfor every — - - - - City/Town Stale Zip Code Date of Inspection D. System Information (cont.) Site Exam. ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells > 120" Estimated depth to high ground water: reel Please indicate all methods used to determine the high ground water elevation- 17 Obtained from system design plans on record 10/25/97 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: ❑ Checked with local excavators. installers-(attach documentation) ❑ Accessed USGS database-explain. You must describe how you established the high ground water elevation: HIGH GROUNDWATER ELEVATION WAS ESTABLISHED DURING A WITNESSED PERC TEST PERFORMED BY TIM MAGINNIS ON JUNE 12, 1997 Before tiling this Inspection Report, please see Report Completeness Checklist on next page. s„xden.rev vis Titin 5 Official lmoection form sWaunece sewage dsrotd System•Pam IS oil Commonwealth of Massachusetts 11,, Title 5 Official Inspection Form U Subsurface Sewage Disposal System Form-Not for Voluntary Assessments «,,,,,-,,-_, 710 NORTH FARMS ROA D Property Address ROBERT&LORRAINE BATES Owner Owners Name rnformTenure for is NORTHAMPTON MA 01060 NOVEMBER 16 2017 Jaye for every -- --- -e page GifyRown 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 3 System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file U 50oc re 6116 The 501M1cal inspection From Sutsuaace Sewage Disposal System•Page 7 cf P