341 Title 5 2018 /e"' Commonwealth of Massachusetts
9'= ,e Title 5 Official Inspection Form
Ti Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
v
341 Audubon Road
Properly Address
Barrett Newsome
Owner Owner's Name
information Is
required for every Northampton, Leeds MA 01053 8/7/2018
page. 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.
Important:When A. Inspector Information
filling out fops
on the computer, Alan Weiss
use only the tab
key to move your Name of Inspector
cursor-do not Cold Spring Environmental Consultants, Inc.
use the return Company Name
key.
350 Old Enfield Roadair
Company Address
Belchertown MA 01007
O �` City/Town State Zip Code
413-323-5957 Title V System Inspector#738
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); I have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
8/7/2018
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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable,and the approving authority.
Please note: 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.
Islnsp am'rev.7126)2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System.Page 1 of 18
„°,f'EIX Commonwealth of Massachusetts
4 - 0 Title 5 Official Inspection Form
pq__ ;b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`r''u, '' 341 Audubon Road
Property Address
Barrett Newsome
Owner Owners Name
information is
Northampton, Leeds MA 01053 8/7/2018
required for every P
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6.
1) 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:
The septic system at a single family dwelling was inspected and no evidence of failure was found.
Liquid levels were over the outlet invert of the septic tank due to a clogged outlet filter. The outlet
filter was cleaned and the liquid returned to the level of the outlet invert. Liquid in distribution box was
at the outlet inverts with no evidence of high staining. Residence is occupied by three people, and
the system is approximately 4 years old. Distribution box was in good condition and had minimal
solids carryover and good outflow. The outlet filter should be checked annually.
2) 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"(V, 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):
ISinsp.doc•rev.7/2612018 Title 5 Official Inspection Form Subsurface Sewage Disposal System'Page 2 of 1B
Commonwealth of Massachusetts
10 Title 5 Official Inspection Form
vas % Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�-t.laorby
.x v.;" 341 Audubon Road
Property Address
Barrett Newsome
Owner Owners Name
information isrequiNorthampton, Leeds MA 01053 8/7/2018
Page. for every
page. Cify/TDwn State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
E Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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 ❑ V ❑ N ❑ ND(Explain below):
❑ obstruction is removed DVOND ND(Explain below):
❑ distribution box is leveled or replaced DYDN ❑ 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 ❑ V ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ V ❑ N ❑ ND(Explain below):
3) 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.
a. 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:
cinsp.doc'rev.112612018 Title 5 official inspechon Form:subsurface Sewage Disposal System•Page 3 M 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I{ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
341 Audubon Road
Property Address
Barrett Newsome
Owner Owners Name
Informations
Northampton, Leeds MA 01053 8/7/2018
required for every P
Page- City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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 ala 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.
c. Other:
4) 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
LSInsp doc•rev 712614018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 18
'^\ Commonwealth of Massachusetts
R.=_tea ,e Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
fit
s, 341 Audubon Road
Property Address
Barrett Newsome
Owner Owners Name
infoation is
required for every Northampton, Leeds MA 01053 8/7/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Z 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 C.4.
Yes No
D ❑ 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
temp mc.rev.7n612018 Title 5 Official Inspection Form Subsurface Sewage Oisposel System•Page 5 M lS
Commonwealth of Massachusetts
�_. ,r
� Title 5 Official Inspection Form
_) Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
*a;- 1.,- 341 Audubon Road
Properly Address
Barrett Newsome
Owner Owners Name
information isrequiNorthampton, Leeds MA 01053 8/7/2018
page. for every P
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section C.4 above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently oras 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?
Z 0 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.
❑ ® 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)]
tsnmaoa•rev.7126¢018 Tines gfitial Inspedioo Form:Subsurface Sewage Disposal System'Page 6 of 18
Commonwealth of Massachusetts
; i< Title 5 Official Inspection Form
, -'r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1`
341 Audubon Road
Property Address
Barrett Newsome
Owner Owners Name
information is Northampton, Leeds MA 01053 8/7/2018
required for every P
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 660
Description:
Septic system consists of a 1,500 gallon septic tank with PVC tees,a distribution box and a leachfield
(40'x 50'+/-)that was installed in 2014.
3
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? 0 Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? Z Yes 0 No
Current
Last date of occupancy: Date
t5rnsp doe•rev.7)26/2018 Tide s Official Inspection Fum.Subsurface Sewage Disposal System'Page 7 of 18
< `\ Commonwealth of Massachusetts
RTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I47
,v, 341 Audubon Road
Pmpedy Address
Barrett Newsome
Owner Owners Name
information isrequiNorthampton, Leeds MA 01053 8/7/2018
page. for every
page. Dry/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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/sq.ft., etc.):
Grease trap present? 9 Yes ❑ No
Water treatment unit present? ❑ Yes 9 No
If yes, discharges to:
Industrial waste holding tank present? D Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Not pumped since installed 4 years ago.
Was system pumped as part of the inspection? ® Yes 9 No
If yes,volume pumped: 1,800(Tank nearly overtopped due to clogged filter)
gallons
How was quantityMeasured
pumped determined?
Reason for pumping: Inspection and clogged filter.
L5iinsp.doc•rev.7/2612018 Title 50MGal Inspection Form.Subsurface Sewage Disposal System•Page 13 of 18
�� Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
341 Audubon Road
Property Address
Barrett Newsome
Owner Owner's Name
information Is
required for every Northampton, Leeds MA 01053 8/7/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components,date installed(if known)and source of information:
System is approximately 4 years old based on records.
Were sewage odors detected when arriving at the site? 0 Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.75
feet
Material of construction:
0 cast iron ®40 PVC 0 other(explain):
Distance from private water supply well or suction line: Over 10'
feel
Comments (on condition of joints, venting, evidence of leakage, etc.):
Building sewer was in good condition with no evidence of leakage.
isinsp do[.rev.777612018 Title OMuaI Inspection Form subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
aSubsurface Sewage Disposal System Form-Not for Voluntary Assessments
1x t�
341 Audubon Road
Property Address
Barrett Newsome
Owner Owner's Name
reton, Leeds MA 01053 8/7/2018
reqquireduired is
for every Northampton,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1.25
feat
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10.5'x 5.5'x 4.2'
Sludge depth: 24
Distance from top of sludge to bottom of outlet tee or baffle 12
Scum thickness 6
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 12"
How were dimensions determined? Measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The 1,500 gallon septic tank had PVC tees in place and was structuraaly sound and in good
condition. Liquid levels were over the outlet invert due to a clogged filter. Filter was cleaned.
t5'nsp aoc•rev.7126r2018 ride 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 Of 1e
_ Commonwealth of Massachusetts
p Title 5 Official Inspection Form
;f .1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1
341 Audubon Road
Property Address
Barrett Newsome
Owner Owner's Name
rati is
required
Northampton, Leeds MA 01053 8/7/2018
page. for
r every
page. City/Town State Zip Code Dale of Inspection
D. System Information (cont.)
7. 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
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
LNsp.6oc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 11 o118
Commonwealth of Massachusetts
r-fft,
�_F Title 5 Official Inspection Form
W.74/N1= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
341 Audubon Road
Property Address
Barrett Newsome
Owner Owner's Name
information is Northampton, 8/7/2018
page. Leeds MA 01053 for every -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes 0 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? D Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert Outlet Inverts
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.):
The distribution box was located, inspected and found to be level and in good condition with equal
flow to the outlets. No leakage or solids buildup was observed. Liquid level was at the outlet inverts.
151nsp dec-rev.I2e12018 Title 5 OTtla!Inspect=Form.Subset(ace Sewage Disposal System•Page 12 W 18
Commonwealth of Massachusetts
'cir—esiaiP Title 5 Official Inspection Form
_ ‘114 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
vs ,p
'-
«w-l ' 341 Audubon Road
Property Address
Barrett Newsome
Owner Owners Name
informationrequired
for every is Northampton, Leeds MA 01053 8/7/2018
tl
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located,explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
40'x 50'
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
15insp.doc•rev.7/7612010 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 al 18
��'• Commonwealth of Massachusetts
Title 5 Official Inspection Form
rp Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
341 Audubon Road
Property Address
Barrett Newsome
Owner Owner's Name
reformation isrequirNorthampton, Leeds MA 01053 8/7/2018
page. for every City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation,etc.):
No evidence of hydraulic failure, ponding or damp soil conditions was observed. System was
functioning as designed.
12. 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
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
151nsp.0oc•rev 7¢6/2016 Tills 5 Oficial Inspection Form Subsurface Sewage Rsposel System•Page 14 o116
! \ Commonwealth of Massachusetts
9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
quit?
�=w `� 341 Audubon Road
Property Address
Barrett Newsome
Owner Owner's Name
information is
Northampton, Leeds MA 01053 8/7/2018
required far every P
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
151nsp doe•rev_7/2912019 Title 5 Official Inspection Form subsurface Sewage Disposal System'Page 150118
Commonwealth of Massachusetts
Title 5 Official Inspection Form
iy Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
341 Audubon Road
Properly Address
Barrett Newsome
Owner Owner's Name
requirac orsr every F Northam ton, Leeds MA 01053 8/7/2018
page. ffo
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
I5insp doc•rev.71262016 Title 5 Official Inspection Form.Stud ace Sewage Disposal System•Page 16 o118
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
341V. Audubon Road
Property Address
Barrett Newsome
Owner Owners Name
information is
Northampton, Leeds MA 01053 8/7/2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
❑ Surface water
Z Check cellar
❑ Shallow wells
Estimated depth to high ground water: 4'+ mounded
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: 2014
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
2014 Design Plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Based on topography, observed setting&records.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
tainsp eoa.rev.7126/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal system.Piga 17 N 18
ft\ Commonwealth of Massachusetts
9 Title 5 Official Inspection Form
e__ _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a. 341 Audubon Road
Property Address
Barrett Newsome
Owner Owners Name
information is
Northampton, Leeds MA 01053 8/7/2018
required for every P
page. City/Town State Zip Cede Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked
Z C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
• D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
ISmspiaoc•rev.712612018 me 50flldel Inspection Famr Subsurface Sewage Disposal System•Page IB of
HERITAGE SURVEYS, INC.,
Professional Surveyors and Engineers
241 College Highway & Clark Street
Post Office Box 1
Southampton, Massachusetts 01073-0001
Bruce A. Coombs, President Telephone (413) 527-3600
Professional Surveyor, MA, CT& VT Facsimile (4131527-8280
E-mail: bnece( eritagesurveys.corn Website: heritagesurveys.com
Title V Certificate of Compliance
DESIGNER & INSTALLER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental code: Title V, Minimum Requirements for
the Subsurface Disposal of Sanitary Sewage, Section 15.021 (3), the Designer and Installer of a
system are required to sign this form as a condition for issuance of a Board of Health Certificate of
Compliance for the onsite septic system.
This is to certify that the onsite sewage disposal system that Heritage Surveys, Inc., designed as:
X new construction
_repair/upgrade(existing system)
SIFE: 341 Audubon Road— Lot I, Lecd (Northampton)
FINAL INSPECTION DATE: ✓G &11 /4i
DWCP #: ///4
OWNER: Elizabeth Vizentin & Barrett Newsome
has been constructed in compliance with 310 CMR 15.00, and all local requirements. Any changes
to the original approved plans have been reflected on an as-built plan that has been submitted to the
Board of Health.
DESIGNER INSTALLER
Heritage Surveys, Inc. Craig Malanson
241 College Highway & Clark Street 4 Leadmine Road
P.O. Box 1 Southampton, MA 01073
Southampton, MA 01073 413-297-4572
(413)527-3600
Signature Date Signature \ Hale
NOTE: This certificate represents no warranty, expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system.Rather,the plan and installation are in compliance with all applicable rules and regulations as
are in effect at the time of plan submittal.
Y:PROJECT DOCIJMENTSt7131 Seney633 lcuedoc
DATE: IL-18-14 OWNER: EllZAeetN VIZENTI.J ( BAKRETf' l)S)5Ot E
JOB#:7151-140212_ INSTALLER: LRA14 HAL*,Jso rJ
LOCATION: 541 AciAN7CorJ RAAb, Lactic LOOLIW4HPIai.J)
AS-BUILT PLAN FOR SEPTIC SYSTEM
#1 THRU #4=CORNERS OF
LEACH FIELD
C=CENTER COVER OF TANK
D=D-BOX (DISTRIBUTION BOX)
I.P.=INSPECTION PORT
rp0f E • EXIST. WELL
11' FROM HOUSE
co
LEACH FIELD
(40'x50')
#4
1500 GAL JL3 VENT
CCA SEPTIC TANK "'
SYSTEM TIES �1
A-C=20.0' I.P.
E-D=72.5 �2I"'• #1
A-D=220.0' 'ILL■•��.��■•■__•
B-D=60.0'
A-I.PORT=211.0'
13-1.PORT=75.0'
A-VENT=222.5'
13-VENT=84.8' NOTE:
8-##1=44.0' STONE RETAINING WALL & BARRIER
VENT-//1=50.0' INSTALLED PER PLAN. SEE PICTURES.
8-12=78.5'
VENT-#2=63.5'
B-//3=107.0' PROPERTY LINE B
VENT-//3=41.0' IRON PIPE
B-//4=85.0'
VENT-#4=12.0'
NOT TO SCALE
241 College Highway & Clark Street
P.O. Box 1
Southampton, MA 01073
(413) 527-3600
peritay $uriwgs, Inc.
Application for Disposal System $150.00
4,,,,,.. 9 Construction Permit nee
Foran 1A
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescabed on-Ms
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code end
not top ace the system in operation until a Certificate of Compliance has been issued by this Board of
Health. . - — '/' /
1t `F I
Signature DN
Application Approved
y�54
i z oars
N
le tad
Application Disapproved for the following reasons:
., '.:."" :..'.....__ NORTHAMPTON BOARD OF HEALTH
212 MAIN STREET
/_ +�� R }MPi,1N MA 0105
: 34''/ Aldi. •GV.J £2!. L 1—
cagultdoer
I).Smarr Nelsen mat tweet N nate i wring
That the.ews ditpnui totem wn Smiled
h.a aden•with the approved pia wad trii5.
2).IS We it In maim with the SAS.e.emared r
Tido 5 nit the Swam Detipernen preset.beam
i.pecdos etdsi t>DrvOd area prior I.S Sean
OS We It
J}No Chanr we be aside thing easensettee by as
Leiner wham pike apgre.J by beth lb System
DS Beard aZH.SkAced
D
t5formla.doc•NM Application for Disponi System Construction Perna•Pape 3 013
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Leeds, MA
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Leeds, MA
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