89 Septic Inspection Form 2015 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owner Owner's Name
information is
fn Florence
reforms on every (Northampton)pion) MA 01062 9/02/2015
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. General Information
filling out forms
on the computer,
use only the tab 1 Inspector:
key to move your
cursor-do not Alan Weiss
use the return
key.
Name of Inspector
Cold Spring Environmental Consultants, Inc.
Company Name
350 Old Enfield Road
Company Address
Belchertown MA 01007
Cdy/Town State Zip Code
413-323-5957
Telephone Number
Registered Sanitarian#933
License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes
❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
9/2/2015
Inspectors 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 is a shared system or
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.
MSns•3/13 Title 5 Oficial Inspection Fo1m:subsurface Sewage Disposal system.Page 1 of 17
Owner
information is
required for every
page
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Autumn Drive
Properly Address
Gary Mongeon
Owner's Name
Florence(Northampton) MA 01062 9/02/2015
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system consisted of a 1,000 gallon, concrete septic tank connected to a leach tank. The
liquid level in the septic tank was at the outlet pipe invert with no signs of high staining. The septic
system serves a 3 bedroom home with one resident at the time of inspection. The leach tank (4'x 81)
had 2 feet of effective height below the inlet piip , clean stone and no high staining or standing liquid.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or not determined" (Y, N, ND)for the following statements. If not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiiltration 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):
t5ire-3/19 Title 5 Official Form Subsurface Sewage Disposal System.Page 2 of 17
Owner
information is
required for every
page.
isms.3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owners Name
Florence (Northampton) MA 01062 9/02/2015
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
❑ Y
❑ y
❑ N ❑ ND (Explain below):
❑ N ❑ ND(Explain below).
❑ Y ❑ N ❑ ND(Explain below)•
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below).
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Tees Official Inspection Form:Subsurface Sewage Disposal System.Page 3 of 17
Owner
information is
required for every
page.
Bins•3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owners Name
Florence(Northamptonk MA 01062 9/02/2015
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y day flow
Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17
Owner
information is
required for every
page.
t5ins•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owner's Name
Florence(Northampton)
MA 01062 9/02/2015
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.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
The system 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
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
❑ ❑
Title 5 Official Inspection Form Subsur1 Ce Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owner Owner's Name
information is Florence(Northampton) MA 01062 9/02/2015
page.required for every
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following.
Yes No
❑ ❑
® ❑
❑ ❑
▪ Z
® ❑
® ❑
® ❑
® ❑
® ❑
O IN
® ❑
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 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)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
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 Of 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).
Unknown
Number of bedrooms (actual).
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms).
3
Unknown
t5ins.3/13 Brie 5 Official Inspection Form Subsurface Sewage Disposal System.Page
or 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owners Name
Florence(Northampton)
MA 01062 9/02/2015
City/ own
State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of one 1,000 gallon septic tank with a 4'Wide x 8' Long x 2' High leach
tank(2' effective height).
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
® Yes ❑ No
❑ Yes ® No
❑ Yes ❑ No
❑ Yes ® No
Sump pump? ® Yes ❑ No
Last date of occupancy: Da event
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? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
thins•3113 Title 5 OmaalInspeCion Form:Subsurface Sewage Disposal System'Page I of 17
2\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owner Owner's Name
information is Florence(Northampton) MA 01062 9/02/2015
required for every ( P
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use-
Other(describe below):
Date
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped
How was quantity pumped determined?
Reason for pumping:
Type of System:
Owner& Karl's: Pumped in November, 2014
1,000
gallons
Measured
Inspection
Z Yes ❑ No
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) Of 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):
Septic tank and leaching tank.
LSins•3113 Title 5 Official wvecion Form Subsurface Sewage Disposal System•Page e M 17
Owner
information is
required for every
page.
thins•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owners Name
Florence(Northampton) MA 01062 9/02/2015
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
39 Years +/-
Were sewage odors detected when arriving at the site?
Building Sewer(locate on site plan):
Depth below grade:
Material of construction:
❑ cast iron
®40 PVC ❑ other(explain):
Distance from private water supply well or suction line.
2
feet
❑ Yes ® No
10'+ from water line.
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
The building sewer was in good condition with no evidence of leakage.
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
1
feet
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
The septic tank had an intact inlet and outlet baffle and liquid levels at the outlet invert.
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
8.5'x 4.5'x 4.2'
Dimensions:
Sludge depth:
1'
Title 5()Opal Inspection Form:Subsurtam Sewage Disposal System.Page 9 or 17
Owner
information is
required for every
page.
Lyme•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owner's Name
Florence(Northampton)
City/Town
MA 01062 9/02/2015
State Zip Code Date of Inspection
D. System Information (cant.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
24"
10"
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 septic tank was structurally sound with no evidence of leakage. Liquid levels were at the outlet
invert and both concrete baffles were in place. Some corrosion was noted at the top of the outlet
baffle.
Grease Trap(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
feet
❑ 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
Title 5 Official nspection corm:Subsurface Sewage Disposal System•Page 11)0117
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owner's Name
Florence(Northampton) MA 01062 9/02/2015
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.):
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
Alarm present: ❑ Yes ❑ 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? ❑ Yes ❑ No
thins•3/13 Titles Official Inspection Form Subsurface Sewage Disposal System.Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w" 89 Autumn Drive
Property Address
Gary Mongeon
Owner Owner's Name
information is Florence(Northampton) MA 01062 9/02/2015
required for every
page. State
C ty/Town Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box Of present must be opened) (locate on site plan):
NA
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.):
No distribution box.
Pump Chamber(locate on site plan).
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
15ins•3113
Title 5 Official lnspecbon Form:Subsurtew Sewage Disposal System.Page 12 of 17
rr\ Commonwealth of Massachusetts
Owner
information is
required for every
gage-
thins•3113
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owner's Name
Florence(Northampton) MA 01062 9/02/2015
City/Town State Zip Code Date of Inspection
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
4'x 8'x 2'
Effective Height
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The leaching tank had no standing liquid with 2' effective height(4' x 8'area). No high staining,
ponding, damp soil or impacted vegetation were observed. No evidence of hydraulic failure or
groundwater was observed.
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
Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17
Owner
information is
required for every
page
tsns•3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owner's Name
Florence(Northampton)
CitylTown
MA 01062 9/02/2015
State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Title 5 Official nspenlon Form:Subsurface sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mungeon
Owner Owner's Name
information is Florence Northampton MA 01062 9/02/2015
pagefor every City/Town ( ' Sete Zip Code Date of Mooed On
page
15111 3113
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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Autumn Drive
Property Address
Gary Mongeon
Owner Owner's Name
information is
required for every Florence(Northampton) MA 01062 9/02/2015
page. City/Town State Zip Code Date of Inspection
15ms•3113
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water:
4.5+
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: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Work in area.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Work in area, observations and topography.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 ORmal Inspection From Subsurface Sewage Disposal System•Page 16 of 17