625 Title 5 2018 Commonwealth of Massachusetts
• =e% Title 5 Official Inspection Form
rl- .
, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
's4
�:,���� 625 WESTHAMPTON ROAD
Property Address
THOMAS B. MALSBURY&TINA MCELMOYL
Owner Owners Name
information is NORTHAMPTON MA. 01062 APRIL 27, 2018
required for every City/Teem State Zip Code Date of Inspection
page.
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out fors
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not PHILIP J. PASIECNIK
use the return Name of Inspector
key.
GREG'S GREG'S WASTE WATER REMOVAL
V; Company Name
239 GREENFIELD ROAD
Company Address
II— O SOUTH DEERFIELD MA. 01373
City/Town State Zip Code
413-665-3989 S11526
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 0 Fails
❑ Needs Further Evaluation by the Local Approving Authority
70 stelae,
April 30, 2018
sped, s "•not
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.
rue 5 Oficial Inspection Form: W
Subsace Sewage Disposal System.Page 1 of 17
i5im.am�rev.6/16
Commonwealth of Massachusetts
-r, Title 5 Official Inspection Form
Yd "�. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
625 WESTHAMPTON ROAD
Property Address
THOMAS B. MALSBURY&TINA MCELMOYL
Owner Owners Name
information is NORTHAMPTON MA. 01062 APRIL 27,2018
requiCity/Town
ed for every
page. State Zip Code Dale 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 OYONO ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced fine ❑ 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
SSins.tloc•Fey.6116 TNe 5 Official Inspection Form:Subsurface Sewage Dispose System Page 3 m17
Commonwealth of Massachusetts
is;:irMfi Title 5 Official Inspection Form
bl y Swp ubsurface Sewage Disposal System Form-Not for Voluntary Assessments
4. 625 WESTHAMPTON ROAD
Property Address
THOMAS B. MALSBURY 8 TINA MCELMOYL
Owner Owners Name
information is NORTHAMPTON MA. 01062 APRIL 27, 2018
required for every
page. 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.
❑ E My 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.
O Z Any portion of a cesspool or privy is less than W0 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria Indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑
0 the system is within 400 feet of a surface drinking water supply
❑
0 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.
ThDnda Inspmnpn Foran.Subsurface Sewage Disposal System•Page 5 d 17
t5 cEac•rev.6'16
Commonwealth of Massachusetts
fi Title 5 Official Inspection Form
M= 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'1/4,7„-el 625 WESTHAMPTON ROAD
Property Address
THOMAS B. MALSBURY&TINA MCELMOYL
Owner Ownees Name
information is NORTHAMPTON MA. 01062 APRIL 27, 2018
e
required for every
pagCity/Town State Zip rep Date of Inspection
page.
D. System Information
Description:
EXISTING 3 BEDROOM DWELLING WITH GARBAGE DISPOSAL
2
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? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
112 gpd
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
LAST 2 YEARS USAGE= 10,900 cu.ft. =81,750 GALLONS/730 DAYS= 111.99 gpd Average
Sump pump? ❑ Yes E No
CURRENT
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
N/A
Type of Establishment
N/A
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
N/A
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? 0 Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
N/A
Water meter readings, if available:
rsins.tlnc•rev.6116 IS 5 Oficial Inspection Form:Subsurface Sewage Deposal System.Page 7 of 17
Commonwealth of Massachusetts
%Fain Title 5 Official Inspection Form
_ !: � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
iPW
'1/4.,,t;" 625 WESTHAMPTON ROAD
Property Address
THOMAS B. MALSBURY&TINA MCELMOYL
Owner Owners Name
informations NORTHAMPTON MA. 01062 APRIL 27, 2018
required for every
page. Cfly/rown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
SEPTIC TANK 50+/-YEARS OLD — SAS 31 +/-YEARS OLD—DATES INSTALLED UNKNOWN
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
5.5+/-
Depth below grade: feet
Material of construction:
®cast iron ❑40 PVC ❑other(explain):
TOWN WATER
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
BUILDING SEWER REPLACEMENT IS RECOMMEDED WITH SCHEDULE 40
PVC.VENT PIPE WAS VISIBLE ON THE ROOF. NO LEAKAGE VISIBLE AT THIS TIME. AGE OF
BUILDING SEWER DETERMINED THIS RECOMMENDATION.
Septic Tank(locate on site plan):
5
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
N/A
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
7• Lx4'Wx5' D
Dimensions:
6"
Sludge depth:
lige5 Official hspestlon Form:Subsurface Sewage Disposal System•Page 90117
t51m.Ex•rev.&16
Commonwealth of Massachusetts
ti Title 5 Official Inspection Form
r - ; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
‘ -R1
"' 625 WESTHAMPTON ROAD
Property Address
THOMAS B. MALSBURY &TINA MCELMOYL
Owner Owner's Name
information is NORTHAMPTON MA. 01062 APRIL 27, 2018
required
gee. for every 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.):
N/A
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
N/A
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
N/A
N/A
Dimensions:
N/A
Capacity: gallons
N/A
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
N/A
Alarm level: Alarm in working order: ❑ Yes ❑ No
N/A
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
N/A
`Attach copy of current pumping contract(required). Is copy attached? 5 Yes ❑ No
t5l s doc•rev.8116 'nue 5 offdal Inspection Form:Subsurface Sesvago Disposal System•page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
!!, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
cl I_It"
tar tns 625 WESTHAMPTON ROAD
Property Address
THOMAS B. MALSBURY&TINA MCELMOYL
Owner Owner's Name
information is NORTHAMPTON MA. 01062 APRIL 27, 2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
1
leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation,etc.):
ONE LEACHING PIT WITH INSIDE DIMENSIONS OF 9' Lx 5'W x 5' D.
THERE WAS 48"OF LIQUID IN LEACHING CHAMBER WITH ONLY 4" OF AVAIALBLE VOLUME
TO THE INVERT IN. HYDRAULIC FAILURE DUE TO SOIL CLOGGING SEEMED TO BE THE
CAUSE. ROOT INFILTRATION INTO SYSTEM SAS VISIBLE.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
N/A
Number and configuration
N/A
Depth—top of liquid to inlet invert
N/A
Depth of solids layer
N/A
Depth of scum layer
N/A
Dimensions of cesspool
N/A
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
tsin:doc•rev.6/16 TMe 5 Official Inspection Form:Subsurface Sewage(Nyasa'Syelem•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
W _= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
If _
625 WESTHAMPTON ROAD
Properly Address
THOMAS B. MALSBURY&TINA MCELMOYL
Owner Owners Name
information is NORTHAMPTON MA. 01062 APRIL 27, 2018
required for every City/Town State Zip Code Date of Inspection
page.
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
Islnsdoc.rev.alta Tree 5 Ofdal Inge:bon Form:Suballam Sewage Disposal System.Page 16of 17
Commonwealth of Massachusetts
Ar= Title 5 Official Inspection Form
e'MI - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Nr„, q 625 WESTHAMPTON ROAD
Property Address
THOMAS B. MALSBURY&TINA MCELMOYL
Owner Owners Name
information is NORTHAMPTON MA. 01062 APRIL 27, 2018
for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
/.4 Inspection Summary:A, B, C, 0, or E checked
E Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
5ins.Mc•rev.6/16 Tib 5 Official Inspection Fn Subsurface Sewage Disposer System•Page 17 of 17
Existing
3 bedroom Existing
house gorge
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`!,000 gallon teaching it nannde cover c'D')
Top of' leaching plc el 64'
Westhampton Road ( Rt. 66 )— Northampton, Massachusetts
To Northampton
Title-5
Inspection Plan
AS—BUILT DIMENSIONS
'A' to 'C' = 42' - 0'
625 Westhampton Road
'A' to 'D' = 48' - 0' Northompton, MA.
'B' to 'C' = 58' - 6'
'B' to 'D' = 70' - 0' For:
625 Westhampton Rd.
Northampton, Mo.
01062
April 21„ 20t8 Tel:
INLET END OF SEPTIC TANK COLLAPSED
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SYSTEM LOOKING AT FRONT OF HOUSE
LEACHING CHAMBER COVER 64' DEEP
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