9 Septic Inspection 2001 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTEC
TITLE 5
1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: D•Y'Lts, L&Lie_
4• .4ib(.,rt
(-� N l o
Owner's Name: if
Owner's Address: 9 FY)r� cG. Lgt.
tlbz^YY.:4 W0 ' /t/f
Date of Inspection:
Name of Inspector: ( lease print) St:rl.q{ y L �Fqq
Company Name: _2___b-el EYt VihnN otOkt'/ �s2UU liter
Mailing Address: T SO /IiOh'F(1 P//91g1.1a S'*DQ2±
Awakevrt, I4 otoo7..
Telephone Number: t3- a56- POOR
e
CERTIFICATION STATEMENT
I certify that I have personally 'inspected the sewage disposal system at this address and:hat the lnfomtacion reported
below is Due, accurate and complete as of the time of the inspecttion.The Inspection was performed based on my
training.and experience in the proper function and maintenance of on sire sewage disposal systems- I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CyfR 15.000). The system'
Inspector's Signature:
Passes
Conditionally Passes
feeds Further Evaluation by;I:
Fa
dc,n
The system inspector shall submit a opy of this insp o on report to the Approving Authority (Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shares system or has a design flow of 10.000
gpd or=eater,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.
Notes and Comments
I'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.
Title 5 Inspection Form 6/15/2000 page I
• 2age2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
Q
CERTIFICATION (continued)
Property Address: #.q Bf�ll
Owner: (T' le.u.$ON
Date of Inspection:
CSC/c
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 :n 10 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below_
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Condihona'. ?ass" section need tc be replaced or
repaired. The system. upon completion of the replacement or repair. as approved by:he Board of Health. •vili pass.
Answer yes,no or not determined sY N ND) in the for the following statements ined"please
explain.
The septic tank is metal and over 20 years old`or the septic tank whether mem'. or not is structurally
unsound exhibits substantial infiltration or exfiltratior. or tank failure is imminent. System'.viil 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.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
oostmcted pipe(s)or due to a broken. settled or uneven disribution 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
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipets).The system will
pass inspection if(with approval of the Board of Health):
ND explain:
broken pipe(s)are replaced
obstruction is removed
Page 3 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIF
ICATION(continued)
Property Address: 4frt? Shsha41p
Not- aiiir-o i
Owner: V �PQ,SO
Date o Inspection: de gG
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 15303(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 wPhir s0 f^' of a bordering vegetated wetland or a salt mash.
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 he SAS is within IOC feet of a
surface water supply or aibutary to a surface water supply.
The system has a septic tank and SAS and the SAS.is within a Zone _ afa public water suppiv_
The system has a septic tank and SAS and the SAS is within 50 feet of a aria ale water swiftly well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but50 feet or more Mom 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 conform
bacteria and volatile organic compounds indicates that the well is Gee from pollution from that facility and
the presence of ammonia niaogen and nitrate nitrogen is equal to or less than 5 rpm,provided that no other
failure criteria are aiggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
QQ . r
Property Address: F>6(� In[J„
//--tt nb-*- tarp Ali
Owner: \T JEn$ tN
Date of Inspection: (, go/
D. System Failure Criteria applicable to all systems:
You must indicate 'ies'or"no"to each of the following for all inspections:
Ye No
_ {3x chino of sewage into facility or system component due to overloaded or clogged SAS or cesspool
.y'Discharge or ponding of effluent to the surface of the round or surface waters due to an overloaded or
V clogged SAS or cesspool
_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cspool
(/Liquid depth in cesspool is less than 6" below invert or available volume is less than '1 day flow
t l+vcquired pumping more than S times in the last year NOT due to clogged or obstructed pipets).Number
times pumped
v portion of the SAS, cesspool or privy is below high round water elevation.
onion of cesspool or privy is within 100 feet of a surface water suppiy or tributary to a sur,a
ter supply.
portion of a cesspool or privy is within a Zone I of a public well.
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 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.'
lie}(YesftVO)The system fails. I have determined that one or more of thz above failure criteria exist as
/4 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.
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 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.
4
Page 5 all
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: ' 84,4
p' Neo-"f'laubp�'ou
Owner: lI � 6 //o' /a 1
Date of Inspection: .
Check if the following have been done. You must indicate'yes'or "no'as to each of the following:
Yes/No
Pumping information was provided by the owner. occupant. or Board of Health
Ware any ofthe system components pumped out in the previous two weeks
C.7-1 Has the system received normal flows in the previous two week period?
1 /{/ Have large volumes of water been introduced to the system recently or as pan of this inspection ?
V 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'he interior of the tank inspected for the condition
ofthe baffles or tees. material of construction. dimensions. depth of liquid, depth of sludge and depth of scum
I/ 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:
Yes 0
Existing information.For example, a plan at the Board of Health.
I/Determined in the field(if any of the failure criteria related to Pan C
is unacceptable) [310 CMMR 15.302(3)(b)]
5
t issue approximation of distance
Page 6 of l I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
M
p Q .c. SYSTEM INFORATION
Property Address: - f Ol, Q..-Owner:
lrietLS Mid
Date of Inspection:
67eh/
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): ( Number of bedrooms(actual): G
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x = of'bedrooms
Number of current residents: 3
Does residence have a garbage minder(yes or no): Y ,S
Is laundry on a separate sewage system (yes or no):/4 ;1[if yes separate inspection required'
Laundry system inspected(yes or no): to
Seasonal use:(yes or no):11.,'p
— Water meter readings,if available(last 2 Years usage(gpd)):
Sump pump(yes or no): /2/0 [�
Last date of occupancy: Qeurc&tW ect1:t
COMMERCIALINDUSTRI AL
Type of establishment:
Design flow(based on 310 CNfR 15.2031: gpd
Basis of desi°tt flow(seats/persons/softietc_l:
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-:
Las date of occupancy/use: _
27- .3
OTHER(describe):
(� GENERAL INFORMATION
t e,w,y� ��ilet; - L iIc
Pumping Records
Source of information:
— Was system pumped as pan o
If yes. volume pumped:
Reason for pumping:
d L
f th inspection (yes or AL A,JO
gallons— How was ouantirwoumoed determined?
TYPE OF SYSTEM
I/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)
Tight tank Attach a copy of the DEP approval
Other(describe):
Approximate a e of all components,date,instal edJif known)and source of information:
l L� �o (rc 3 l9'
Were sewage od rs detected when arriving at the site(yes or no): Ai k)
C, W N C V
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
-� p SYSTEM INFORMATION (continued)
c� B
Property Address: ! ;It leA LMe_
Owner: G teo. io 11
Date of Inspection: 676/17(
BUILDING SEWER(locate on site plan)
Depth below grade. /L,feej
Materials of construction: cast iron o PVC other(explain):
Distance from private water supply well or suction line: re
Comments(on condition of joints, venting, evidence of leakage. etc.):
14 (1 ) u rr er, A f;am noel, Jstt - o"r / ease_
SEPTIC TANK:_(locate on site plan)
Depth below grade: p7(l cFR71-7
Material of construction: oncrete metal fiberglass oolyethvlene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance 'v es or no: (atach a copy of
certificate) ja i 1
Dimensions: ^
S7 . x 4 x �1
Sludge depth: (2-1 t '/ fiei
Distance from top of sludge to bottom of outlet tee or baffle: 1 �� - 1 LL5
Scum thickness: CI ILE / o gre4 �f�.A/Aw 'raj
9 p
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:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, scccmral inter-ir'. liquid levels
as related to outlet invert, evidence of leakage, etc.)
Nk Stre •k. , Net/7C fAerni
i-!!S!ill. •
GREASE TRAP: (locate on site plan)
Depth below 3ade:
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.):
7
hvuge.
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:
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth'below made:
Material of construczioni concrete meta: fiberglass oolvethvlene omenexclaml-.
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order ryes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOK: (if present must be opened)(locate on site plan)
"
Depth of liquid level above outlet rove .
invert:
Comments (note if box is level and disnibution to outlets equal.any evidence of solids caryover. any evidence of
leakage into or out of box. etc.): q� . a n^��G�Y
- /2-(f-di fvr deuce o f s0 /1 d S cai
LC° ev dokev 0f %?. oq
PUMP CHAMBER: (locate on site plan)
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.):
8
Page 9 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
yy��
SYSTEM INFORMATION(continued)
Property Address: I G'J "-q.47_
/4/O F' 2 w-.��bL
Owner:of Gic ion: Y 6/67
Date of Inspection: 6/670/
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 wenches,number. length:
I/ieaching fields,number, dimensions:qc j • x '
overflow cesspool,number J
innovativelalternative system Tame:name of tecnnolow-
Comments(note condition of soil signs of hydraulic failure.level of pond:nu damp soi!, condition o
etc.): CA S I> ( / - �
Se;i l�u (AS {�4 l� �i �c/laPr-
fete 'oy ppNw� '1`9okJI J et.l9donMt��2ackj�'e(y S/ohe-
CESSPOOLS: (cesspool must be pumped as par:of inspection)(locate on site pian)
egemr.on.
Number and configuration:
Depth—top of liquid to inlet invern
Depth of solids layer:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of'oundwater inflow(yes or no):
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.):
9
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: GlQll1Ol'1
Date of Inspection: (9Eq/
Q
SITE EXAM
S ^'6(d
Surface water Al 0
Check cellar ap.0
Shallow wells Wes
Estimated der . :o=oune w ate: e_.
P!ease indicate (check i all methods used to dete.tine _he :hi oh r-oLndwater se
9bained & na s — dsi� tar c :._or c ked a
( Observed
site abutting properhoobsersalicn hole withal ]S0 __ _A_
Checked with vocal Board of Health-exniain•
Checked with local excavators. '.nstallers- attach dccumev_ticn:
?.c_sled ISSGS database-exriair:
ou m r r 'b how sou established he high 'ground water cue an n
itS i ac j C [can di *ea f �rel� oad Sc ,1/200 �c7
t6 ix1 Ft` t
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: G 6/( LAC--
Owner: YIesva
Date of Inspection: C C/
O
(
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 00 feet.'Locate where public water supply enters the building.
S C-
10
Not to scale
failed leachfield
41 ft. x 8 ft.
Test Pit for
new system
6 bedroom house
5 f
Town water+buried
utilities enter here.
37ft ?0 ft_ deck
R
dbox
driveway
9 Birch Lane,Northampton
1,000 gallon
septic tank