453 Septic Inspection 2000 COMMONWEALTH OF MASSACHUSETTS DEC 8
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION-
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Name of Owner:
Address of Owner
Date of Inspection
Name of Inspector:
Company Name:
Mailing Address:
Telephone Number:
453 Audobon Road
Leeds,MA
John&Linda Brandts
453 Audobon Road
Leeds,MA 01053
November 28,2000
Gregory J. Newman
Newman Environmental Engineering
P.O.Box 395,
Worthington,MA 01098
413-238-5383
CERTIFICATION STATEMENT
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 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:
Inspector's Signature:
x Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Date: 12
141 ro
The System Inspector shall submit a copy of th's inspection report to the Approving Autho ity(Board of Health or
DEP)within 30 days of completing this inspection. f the system is a shared system or has a design flow of 10,000 gpd
or greater,the inspector and the system owner shall ubmit the report to the appropriate reg'onal office of the DEP. The
original should be sent to the system owner and copies sent to the buyer,if applicable,and he approving authority.
Notes and Comments:
1. Board of Health review Is required since inspection of the D-box Is not considered feasible due to 10-ft of cover soils.
Inspection of D-box Is normally required to determine if the leach field is clogged or surcharged. In lieu of
Inspecting the D-box,this Inspection included shallow test holes excavated adjacent to the leach field(at locations
west of leach field with shallower depth of cover soils). These shallow test holes did not find evidence of a clogged
or surcharged leach field.
2. It is recommended that the existing garbage disposal be removed,to extend the life of the leach field.
****This report only describes conditions at the time of inspectionand 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.
Prepared by Newman Environmental Engineering Page 1 of II
Based on DEP form revised 6/15/2000
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 453 Audobon Road
Leeds,MA
Owner: J.8 L.Brandts
Date of Inspection: November 28,2000
Inspection Summary: Check A,B,C,D,or E l ALWAYS complete all of Section D
A. System Passes
y I have not found any information which indicates that any of the failure conditions described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments: It was not considered feasible to inspect/evaluate the D-box due to 10-ft of cover soils.Inspection of D-box is
normally required to determine If the leach field Is clogged or surcharged. In lieu of Inspecting the D-box,this
Inspection Included shallow test holes excavated adjacent to the leach field.These shallow test holes did
not find evidence of a clogged or surcharged leach field.
B. System Conditionally Passes
N 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.
Answer yes,no or not determined(Y,N,or ND)in the for the following statements. If"not determined",please
explain.
N The septic tank is metal and over 20 years old* or the septic tank(wheteher 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 ifa Certificate of Compliance
indicating the tank is less than 20 years old is available.
ND explain:
N Observation of Sewage backup or breakout or high static water level observed 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 the
approval of the Board of Health):
N broken pipe(s)are replaced
N obstruction is removed
N distribution box is levelled or replaced
ND explain:
N The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with the approval of the Board of Health):
N broken pipe(s)are replaced
N obstruction is removed
ND explain:
Prepared by Newman Environmental Engineering
Based on DEP form revised 6/15/2000
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
453 Audobon Road
Leeds, MA
Owner: J.&L. Brandts
Date of Inspection: November 28,2000
C. Further Evaluation is Required by the Board of Health:
y Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect the public health,safety,or the environment.
1. System will pass unless the Board of Health determines in accordance with 310 CMR 15.303(1)(3)that the
system is not functioning in a manner which will protect public health,safety and the environment:
N Cesspool or privy is within 50 feet of surface water
N Cesspool or privy is within 50 feet of bordering vegetated wetland or salt marsh
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 the environment:
N 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.
N The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply well.
N The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
N 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 coliform bacteria
and volatile organic compounds indicates that the well is free from pollution from that facility 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:
y This septic system is constructed with about 10-ft of fill(sand)over the leach field and 0-box. It is not considered
feasible to excavate/access the D-box due to safety considerations and without significant damage to the
landscaped yard(contains ornamental shrubs,block wall,buried sprinkler system,etc.).Inspection of 0-box is
normally required to determine if the leach field is clogged or surcharged. In lieu of Inspecting the D-box,this
inspection Included shallow test holes excavated adjacent to the leach field.These shallow test holes did
not find evidence of a clogged or surcharged leach field.
Prepared by Newman Environmental Engineering
Based on DEP form revised 6/15/2000
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
453 Audobon Road
Leeds,MA
J.&L.Brandts
November 28,2000
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
Unk Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool. "unk"=status unkown;Liquid level in distibution box not observed(buried 10-ft deep)
N Liquid depth in cesspool is less than 6 inches below invert or available volume is less than %day flow.
N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped:
N Any portion of the SAS,cesspool,or privy is below high groundwater elevation.
N Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
N Any portion of a cesspool or privy is within a Zone 1 of a public well
N Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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.(
No (Yes/No)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: NOT APPLICABLE
To be considered a large system,the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above.)
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 2 of a public water supply well).
If you 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.
Prepared by Newman Environmental Engineering
Based on DEP form revised 6/15/2000
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
453 Audobon Road
Leeds,MA
J.&L.Brendle
November 28,2000
Check if the following have been done. You must indicate either"yes"or"no"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two-week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as-built plans obtained and examined? (If they were not available note as N/A)-BOH plans
x Was the facility or dwelling inspected for signs of sewage backup?
x Was the site inspected for signs of breakout?
x Were all system components,excluding the SAS,located on the site?-per plans,D-box not excavated
x Were the septic tank manholes were uncovered,opened,and the interior of the septic tank inspected
for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,
and depth of scum?
x Was the facility owner(and occupants,if different from owner)provided with information on the
proper maintenance of subsurface disposal systems.
Copy of "Your Septic System-A Reference Guide for Homeowners" (prepared by DEP)submitted to
Owner with this report.
x
X
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Existing information. For example,plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of
distance is unacceptable)[15.302(3)(b)]
Prepared by Newman Environmental Engineering
Based on DEP form revised 5/15/2000
Page 5 of I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection
453 Audobon Road
Leeds,MA
J. &L. Brandts
November 28,2000
FLOW CONDITIONS
RESIDENTIAL:
Number of bedrooms(design): 4 Number of bedrooms(actual): 5 (based on total of 11 finished rooms)
DESIGN flow based on 310 CMR 15.203(for example : 110 gpd x#of bedrooms) 660 gpd (4 bdrm w/garbage disposal)
Number of current residents: 2 NOTE:Leach field design oversized by 25+%;estim.capacity=825 gpd
Does residence have garbage grinder(yes or no): yes
Is laundry on separate sewage system(yes or no): no (if yes,separate inspection required)
Laundry system inspected(yes/no): Na
Seasonal use(yes/no): no
Water meter readings(gpd),if available(last two years usage): not available-private well
Sump pump(yes/no): yes' 'sanitary sump pump only-discharges to building sewer,for basement bathroom
Last date of occupancy: currently occupied
COMMERCIAL/INDUSTRIAL'
Type of establishment: NOT APPLICABLE
Design flow(Based on 310 CMR 15.203)
Basis of design flow:
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(Describe):
gpd
GENERAL INFORMATION
Pumping Records
Source of information: Per Owner,system pumped in 1995/96(at purchase)and in 1998/1999
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped(gallons): n/a How was quantity pumped determined?
Reason for pumping: maintenance
TYPE OF SYSTEM
X 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/Altemative technology.Attach copy of current operation&maintenance contract(obtained from owner)
Tight Tank Attach a copy of the DEP Approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information: -13 years old,installed in August
1987,per date on BON Certificate of Compliance from Application for Disposal Works Construction Permit
Were Sewage odors detected when arriving at the site(yes or no):
no
Prepared by Newman Environmental Engineering Page 6 of 11
Based on DEP form revised 6/15/2000
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
453 Audobon Road
Leeds,MA
J.&L.Brandts
November 28,2000
BUILDING SEWER(locate on site plan):
Depth below grade: -20"
Material of construction: cast iron 40 PVC yes Other(explain)
appears to be schedule 40 ABS
Distance from private water supply well or suction line: -95-ft
Comments(condition of joints,venting,evidence of leakage,etc.):
Joints appear sound at foundation wall and septic tank,venting appears o.k.,there is no evidence of leakage
SEPTIC TANK: yes (locate on site plan)
Depth below grade: 12-14"
Material of construction: X concrete metal fiberglass
1,500 gallon septic tank
polyethylene Other(explain)
If tank is metal,list age n/a Is age confirmed by Certificate of Compliance(yes/no): n/a
Dimensions: Internal dimensions:10'x 5'x 49"liquid depth
Sludge depth: -2 Inches
Distance from top of sludge to bottom of outlet tee or baffle: -32 inches
Scum thickness: <'Y.Inch
Distance from top of scum to top of outlet tee or battle: -6 inches
Distance from bottom of scum to bottom of outlet tee or baffle: -15 inches
How dimensions were 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.):
pumping does not appear necessary at this time;concrete baffles appear in good condition;tank appears to be structurally sound
liquid level at outlet Invert; no evidence of leakage
(attach copy of certificate)
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
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:
Comments:(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Prepared by Newman Environmental Engineering
Based on DEP form revised 6/15/2000
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
453 Audobon Road
Leeds, MA
J.&L. Brandts
November 28,2000
TIGHT or HOLDING TANK:
Depth below grade:
Material of contraction: concrete metal
N/A (Tank must be pumped prior to, or at time of inspection)(locate on site plan)
fiberglass polyethylene Other(explain)
Dimensions:
Capacity(gallons):
Design flow(gallons per day):
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments: (condition of alarm and float switches,etc.):
DISTRIBUTION BOX: yes (if present must be opened)(locate on site plan)
Depth below grade: -10-ft
Depth of liquid level above outlet invert: unknown
Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
Unable to excavate D-box,due to about 10-ft of sand fill placed over 0-box&leach field;excavating of 0-box presents safety
concerns&potential for significant damage to landscaped yard(contains ornamental shrubs,block wall,buried sprinkler system,
etc.). Inspection of 0-box is normally required to determine if the leach field is clogged or surcharged. In lieu of inspecting the 0-
box,this inspection included shallow test holes excavated adjacent to the leach field to the approximate elevation of the leach field
stone.These shallow test holes did not find evidence of a clogged or surcharged leach field;i.e.did not observe weeping or sewage
backup.
PUMP CHAMBER: N/A (locate on site plan)
Depth below grade:
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.):
Prepared by Newman Environmental Engineering
Based on DEP form revised 6/15/2000
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
453 Audobon Road
Leeds,MA
J.&L.Brandts
November 28,2000
SOIL ABSORPTION SYSTEM(SAS): yes (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:
x leaching fields,number:
overflow cesspools,number:
innovative/alternative system:
dimensions:
dimensions:
1 dimensions: 56'x 25',per design plan
Type/name of technology:
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
No signs of hydraulic failure near leach field:no damp soil;vegetation o.k.;no ponding observed. Soils down gradient,in field to
west,are wet but do not appear to be contaminated with sewage.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—tap of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
PRIVY: N/A (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
Prepared by Newman Environmental Engineering
Based on DEP form revised 6/15/2000
Page 9 of II
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
453 Audobon Road
Leeds,MA
J.&L.Brandts
November 28,2000
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100-ft(locate where public water supply comes into house)
SEE ATTACHED SITE PLAN
Prepared by Newman Environmental Engineering
Based on DEP form revised 6/15/2000
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
453 Audobon Road
Leeds, MA
J.&L.Brandts
November 28,2000
ESTIMATE OF SEASONAL HIGH GROUNDWATER ELEVATION:
NRCS Report name: Soil Survey of Hampshire and Hampden Counties,Western Part Massachusetts prepared by USDA,
Soil Conservation Service,December,1995
Soil Type: Charlton(CrC)at house&leach field site; Paxton(PbB)In field to west
Typical depth to groundwater: Charlton(ere)>6.0 ft; Paxton(PbB)=1.5-2.5 ft(perched)
SITE EXAM Slope
Surface water
Check cellar
Shallow wells
gentle downward slope west of SAS
surface water&damp soils noted In field to west,down gradient of SAS
cellar appears dry,no water marks;does not have groundwater sump
not available
Estimated Depth to Groundwater: 5.0-6.0 feet below original grades at SAS location(see note 1,below)
Please indicate(check)all methods used to determine the high groundwater elevation:
yes Obtained from system design plans on record-If checked,date of design plan reviewed BOH review 11/3/86
yes Observed Site(abutting property/observation hole within 150 feet of SAS)
yes Checked with local Board of Health-explain: to obtain&review design plan
no Checked local excavators,installers(attach documentation)
no Accessed USGS database-explain:
You must describe how you established the high groundwater elevation:
It is noted that the leach field,soil absorption system(SAS),has about 10-ft of sand fill cover. Estimated high
groundwater elevations determined herein are based on natural(original)grades prior to 1987 construction as presented
in the design plan received from the Board of Health.
The Application for Disposal Works Construction Permit,dated 11/3/86,Indicates the following depth to groundwater
observed during 1986 site evaluation: Test Pit No.1 (TP-1)<6'-3"; Test Pit No.2(TP-2)=5'-0". These depths to hgih
groundwater are consistent with the typical depth to high groundwater for Charlton soils as presented in the NRCS report
referenced above.
3. Based on the design plan,the following elevations(relative to the design plan site bench mark)are estimated:
TP-1 grade:-89.5' TP-1 groundwater:<83.3' (located Immediately west of leach field)
TP-2 grade:-87.5' TP-2 groundwater:-82.5'
A shallow test hole(TH-C on site plan)was excavated on 11/28/00 and determined to have high groundwater at-16
inches. Assuming an approximate elevation of the bottom of the vertical drop equal to the design plan D-box inlet,the
following elevations are determined:
TH-C grade:-84.7 TH-C groundwater:-83.4'
This data is consistent with the groundwater data presented on the design plan.
The above data indicate that the high groundwater may be about 83.3'(relative to design site bench mark)in the vicinity of
the SAS. The bottom of the SAS(leach field)stone is about 87.9'per the design plan,indicating that the SAS is above the
high groundwater elevation.
Prepared by Newman Environmental Engineering
Based on DEP form revised 6/15/2000
Page I l of II
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TITLE 5 SEPTIC SYSTEM INSPECTION- 11/28/00
453 AUDOBON ROAD, WILLIAMSBURG, MA
FOR LINDA 8 JOHN BRANDT
NEWMAN ENVIRONMENTAL ENGINEERING
P.O. BOX 395, 21 GUARD ROAD, WORTHINGTON, MA 01098
TEL: 413-238-5383 FAX: 413-230-4276