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1443 Title 5 7-6-17 Commonwealth of Massachusetts P i Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •t> N a 1443 West Hampton Road Propety Address Christine E.Young Ovmer Demers Name information e Florence-NOampton MA 01062 July 6,2017 required for ror even M Cele/TownState Zip Code Data of Impaction pose 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. pnportentman A. General Information filling out forms on the computer, useonyele tab 1. Inspector: key to mow your cursor-do not Michael Beausoleil use the return Nana of Inspector Bushey Sanitary Service, Inc. MIConpeny Name 119 Nelson Road Is'I ' Corpry Address Colrain MA 01340 Ciy1Town State Zip Code 413-772-6531 17 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.lam 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 yip*/ Jury 6 2017 4aure 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 sane or different conditions of use. 15,¢eke.rev ens Tie alkiel Inspection Form'.9MaO Swage Mixed Bytom•P41 M17 Commonwealth of Massachusetts • j Title 5 Official Inspection Form • n Subsurface Sewage Disposal System Form-Not for Voluntary Assessments IL. 1443 West Hampton Road Proper Address Christine E.Young Oyster Ovaries Name informationb Florence-Northampton MA 01062 July 6, 2017 requiredrequiredfofor even Gay/TownState Zip Cede oats of inspection Pva. B. Certification (cont.) Inspection Summary: Check A,B,C,D or E l always complete all of Section 0 A) System Passes: O 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: Needs a new distribution box,current one is cracked. 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,NO)for the following statements. If'not determined,'pease 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 exfittration 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): tans dm.,w.616 Tib 5 Officiel Inspecbre Fant'9,Lviece Seat Sydow'sop 2 all, Commonwealth of Massachusetts Title 5 Official Inspection Form M0 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1443 West Hampton Road Property Address Christine E.Young Owner Overer's Name nbrrri. 0n" Florence-Northampton MA 01062 July 6,2017 rpured for every Pape_ Cxy/rown State ZipCede Date of Inspection B. Certification (cont.) 0 Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont): Fzi 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 OVONO ND(Explain below): ❑ obstruction is removed ❑ Y 0 N 0 ND(Explain below): ❑ distribution box is leveled or replaced ® YONO ND(Explain below): Dishihutinn box sides are(sacked cover was hrnkan when we dug it up We pad plywood over it for a temporary cover. ❑ 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 0 N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: 0 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 dinedoc•re:.6116 rite5 001S1lam roan:BDWdwe Sewage Ripon!Solon•Page 3w 17 Commonwealth of Massachusetts �F.f Title 5 Official Inspection Form M`7_' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments m„I,,, 1443 West Hampton Road Properly Address Christine E.Young Ower Ovmees name Infornstion s Florence-Noempton MA 01062 July 6,2017 iaquired d for everyM ray/Twat State Zip Cede Cate of lnnpcaen Oaa>. B. Certification (cont.) 2. System win 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 were. Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal cdifcrm 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 Wes"or"No"to each of the following for all Inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or dogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6'below invert or available volume is less than%day flow t&td%•IN.e'15 Tine 5 Official Inspeclim Pam:HOWIIM sewage Clip:sal System'Pap 4.117 Commonwealth of Massachusetts Title 5 Official Inspection Form --'.-1111t-- ; Subsurface Sewage Dispel System Form-Not for Voluntary Assessments , „" 1443 West Hampton Road Properly Address Christine E.Young Omer Owner's Nems lnfwmadom s Florence-Northampton MA 01062 July 6, 2017 required for even City/Tam State Zip code Date at Inspection rose B. Certification (rant.) 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. ❑ ® Anypo to a surface If cesspool r Pd supply.whin 100 feet of a surface water supply or tributar ❑ ® 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 flaw of 2000g0- 10,000gpd. ❑ ® The system(all$.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. 15nae%.rev.UI6 Tile 5 glial irspecdon Fong,.dIEa,Rea Sewer Disposal System'P45 of 17 Commonwealth of Massachusetts I=. ,_ 't Title 5 Official Inspection Form f % Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1443 West Hampton Road Properly Address Christine E.Young ()valor Owrr's Name intonation amain(' Is went amain('roFlorence-Northampton MA 01062 July 6,2017 rose. cxyrte..l sane Zip cede Date of McPeeeen C. Checklist Check if the following have been done.You must indicate'yes'or no as to each of the following: Yes No ® 0 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? ❑ 0 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) • 0 Was the facility or dwelling inspected for signs of sewage back up? ® 0 Was the site inspected for signs of break out? ® 0 Were all system components, excluding the SAS, located on site? • 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? 127. ❑ 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. la 0 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)] D. System Information 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): 440 lana e%•ret 916 ase5 macs hipeaal rpm:9lYla sensemac 6yeen'6Y bel 17 Commonwealth of Massachusetts Title 5 Official Inspection Form • a Subsurface Sewage Disposal System Form-Na for Voluntary Assessments ,51:-f ',,.a 1443 West Hampton Road Rorty Address Christine E.Young Owner Owner's Name information is Florence-Northampton MA 01062 July 6, 2017 required tor every CiryInspectionState Zip Code Data of Inspection reg D. System Information Description: 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 intonation in this report) Laundry system inspeded? 0 Yes 0 No Seasonal use? ❑ Yes 0 No None 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: N/A Type of Establishment N/A Design flow(based on 310 CMR 15203): Gallons per day Napa) N/A Basis of design flow(seats/persons/sett.,etc.): Grease trap present? 0 Yes 0 No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? 0 Yes 0 No N/A Water meter readings,if available: neat oc•,w.6.16 Ties ones wp. on Ftlm:sondem sane Depose%YNW•nem U17 Commonwealth of Massachusetts II Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • ,—;,s" 1443 West Hampton Road Properly Address Christine E.Young Owner Owner's Name inre"1B"0e is Florence-Northampton MA 01062 July 6,2017 required for every pays. City/Town State Zip coda Data of Nepocton D. System Information (cont.) N/A Last date of occupancy/use: Dem Other(describe below): N/A General Information Pumping Records: Source of information: Approximately3 years per owner Was system pumped as part of the inspection? ® Yes ❑ No 1,500 If yes,volume pumped: yens How was quantity pumped determined? Pumper truck Check Tank 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): tsr tc.,w.6,(6 11e5 Chit impethern Fenn.subsumes swig Meese syn•P.O.San Commonwealth of Massachusetts I' _;yl' Title 5 Official Inspection Form E ' ,, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - ,,: " 1443 West Hampton Road Properly Address Christine E.Young Owner Owner's Name nfon"'uon Is Florence-Northampton MA 01062 July 6, 2017 required for every City/Tenn State Zip Code nab et Inspection page. D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: August 17, 1998 design by Maginnis Were sewage odors detected when arriving at the site? 0 Yes ® No Building Sewer(locate on site plan): At Floor,walk out basement Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): 46' Distance from private water supply well or suction line: yet Comments(on condition of joints,venting, evidence of leakage,etc.): Septic Tank(locate on site plan): Inlet 13" Middle and Outlet 12" Depth below grade: ten Material of construction: ®concrete 0 metal ❑fiberglass 0 polyethylene ❑other(explain) If tank is metal, list age: win Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes 0 No 10'6"X 5' Dimensions: 11" Sludge depth: 19ee<•IW.we Tib 5 MOO Iisps:lien Faro:Sl:curia,Sewage Disposal Silken•Page 9 S 17 \ Commonwealth of Massachusetts Title 5 Official Inspection Form ^ l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . ,s1 1443 West Hampton Road Property Address Christine E. Young Owler Ovmer's Name 1donnBtion is Florence-Northampton MA 01062 July 6,2017 required for every CiWrevm able Zip Code Deb of Inspection Page. D. System Information (cont.) Septic Tank(cont.) 20" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 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 2'below Ruler 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.): Inlet end outlet'TY are ok,the wastewater was at the bottom of Me outlet invert,it is a two compartment tank no filter,no leakage seen. Grease Trap(locate on site plan): N/A Depth below grade: feet Material of construction: ❑concrete 0 metal ❑fiberglass 0 polyethylene 0 other(explain): N/A N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle N/A N/A Date of last pumping: Dale Mato:•m.8/16 Tiles MOS roped*,cam.SWvlwa serge pM1"al%atm•Page 10a 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,Il,r 1443 West Hampton Road Properly Address Christine E.Young Ostler Cwer'a Nemo info""'tlen is Florence-Northampton MA 01062 July 6,2017 moulted for ovary City/Tow Snare Zip Code Data of Impaction page. 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: 0 concrete 0 metal 0 fiberglass 0 polyethylene 0 other(explain): N/A N/A Dimensions: N/A Capacity: allure N/A Design Flow gallons per day Alarm present: 0 Yes 0 No N/A Alarm level: Alarm in working order: 1:1Yes 0 No N/A Date of last pumping: Dm Comments(condition of alarm and float switches,etc.): N/A *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No ISM doe•rem&16 Tb 5 CelS Inyefa Fmm:SSYnm swap nvosal SNr•Page 11 a117 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1443 West Hampton Road Property Andress Christine E.Young Dreier OeNer's Name infpinia°°n 15 Florence-Northampton MA 01062 July 6,2017 ige for every PaD {ovn state 2b Gods Date of Inspection wve D. System Information (cont.) Distribution Box(it 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.): Distribution box needs to be replaced. Broken and cracked. We put a piece of plywood over the cover. Has solids carryover, no leakage seen, 16"below grade to the cover. Pump Chamber(locate on site plan): Pumps in working order: 0 Yes 0 No' Alarms in working order. ❑ Yes ❑ No' Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): N/A •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: N/A t5mhc•rev.e15 Ise 5 Mast Inspema hum.SutM0ce Sewage Deposa1System•Page 1211117 Commonwealth of Massachusetts Ut Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1443 West Hampton Road Property Address Christine E.Young Owner Owner's Name intimation is Florence-Northampton MA 01062 July 6, 2017 required for every Sage Cay/Town Stet Zip Code Date of Inspection P9e D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Infiltrators, 7 rows 36'long each Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): No Hydraulic failure,no ponding,weeds were over the top.Took the information ott the design from Tim Maginnis 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 0 Yes ❑ No %snow•rev.6'16 Tile 5 Official InspeCton Form:SULaelace Sewage Woosal System•Page 13 d17 Commonwealth of Massachusetts Lli, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1443 West Hampton Road Property Address Christine E.Young Owner owner's Name tldOni°°"" Florence-Northampton MA 01062 July 6. 2017 required for every IfeR, City/town State Zip Code Dare of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): N/A Materials of construction: N/A Dimensions - Depth of solids N/A Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.)- N/A tc.):N/A rensdoc.rm.WS Title 5Mae)neps-Yn Fmn:Stlawace Sewer oNw Ssten-Page 14 a11 Commonwealth of Massachusetts T-e Title 5 Official Inspection Form r'.� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ay(id 1443 West Hampton Road Properly Address Christine E.Young Owner Owner's Name information is required for every Florence-Northampton MA 01062 July 6.2017 h peLa City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below ® hand-sketch in the area below 0 drawing attached separately well house chicken coop Garage Oc G H O NO SCALE A-C 327" A-D 35' A-E 38'5" G-F 962" B-C 21'3" B-D 272" B-E 29'6" H-F 89'5" F mns ,c•we one Title 5Masi Inspection Fenn SubsNece Sway Deposit SJmn•Pape 15 0117 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1443 West Hampton Road Property Address Christine E.Young Owner Oxner's Name reeked to formatfon° Florence-Northampton MA 01062 July 6,2017 Page- tor every Page- City/Town Mete Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 36" 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: August 17, 1998 nem ❑ 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: From design by Tim Maginnis dated August 17, 1998 Before filing this Inspection Report,please see Report Completeness Checklist on next page. tb¢e%.rev.6116 me s More unwed Foss 6uevrlxe Sewage ap06M Sys1ei•Page 16 off? Commonwealth of Massachusetts _� ry Title 5 Official Inspection Form 111.,--,i` Subsurface Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t �ti s 1443 West Hampton Road Property Address Christine E.Young Owner Owner's Name 'Promotion is Florence-Northampton MA 01062 July 6,2017 requited for every Mgt OW/Town State Zip Code Deb of Inspection E. Report Completeness Checklist 21 Inspection Summary: A, B, C, D, or E checked a Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file tam ax•rev.6/16 ribs grim)Inye.Yn Form:SueSNare Sewage Deposal SKbn•Page 17>1l