27 Septic Inspection 2004 TITLE 5
OFFICIAL INSPECTION FOR.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 27 Coldawe Drive Northampton.MA
Owner's Name: John Tt®pktoa
Owner's Address: 27 Cullinane Terrace
NnrtWmwne_ MA 01060
Date of In
spection: Jane 9. 2004
Name of Inspector.Alan E Webs, RS#933
Company Name: CiWSm3rr EtNrssema te(4ac
Mailing Address: 350 OW&. TSjR...s
Telephone Number:(413)323-5957 fax:413-323-4916
mdimmarszketinz
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 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 Tide 5(310
CMR 15.000). The system:
XX Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: / Date:June 09,2004
The system Spector 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 Spector 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
Dry well was in good structural condition,(7-8ft depth. x 4ft Diana.)with 28"liquid
noted,(84"to effective height).There is no sign of current failing condition. Sewer
is reported in street &Tank was a good shape.Baffles were in good shape. No
signs of hydraniie failure noted. Septic tank was pumped down.
"This report only describes condition 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
different conditions of use.
1
Page 2 all
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: .-Lr..h�( --�-�r-
Owner:
Date of Inspection:
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
.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
1. 2 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,ND)in the 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 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 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
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
ND explain:
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
obstruction is removed
ND explain:
T'rl S i r P t.,,6/15/9(1011.
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Z� l„L,r'lnve Tr,nl'
Property Address:
Owner:
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Ai
&Conditions exist which require further evaluation by the Board of Health in order to deterrrtine 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 CMIi 15.303(1)(6) 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
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 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:
Title S lncnrrtinn Fnrm Fns/Mon
3
Page 4 of I1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 27- (qknt1,cy.¢ Tef4
Owner:
Date of Inspection: (oVgluLI.
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%day flow
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 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.]
(Ye 'N 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 most 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
15304.The system owner should contact the appropriate regional office of the Department.
Title 5 lncnprtinn Pnrm fif1 snarl°
4
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 72- c-ciknt hareirc p
Owner: (o'q'n
Date of Inspection: T M( p ec-t✓J
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Ai f>_ Pumping information was provided by the owner,occupant,or Board of Health
No Were any of the system components pumped out in the previous two weeks?
1-r- Has the system received normal flows in the previous two week period?
NO 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)
if _ Was the facility or dwelling inspected for signs of sewage backup?Was the site inspected for signs of break out?
5 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
o 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
aintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on
Yes no
.rI ' Existing information.For example,a plan at the Board of Health.
x
405 Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
Is unacceptable)[310 CMR 15302(3)(b)]
Title 5 Incnernnn cnrn, fin moon
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2-} (�kd1 -c Itrr,
Owner: -TempCikna
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Z 9 Number of bedrooms(actual): ,3 # ({a(c)ct}` 5ec6c,
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x ff of bedrooms):
Number of current residents: V
Does residence have a garbage grinder(yes or t a.N'
Is laundry on a separate sewage system 0$oC$0):4p[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes ore: Ato
Water meter readings,if available(last 2 years usage(gpd)): N/n
Sump pump(yes or&: 110
Last date of occupancy: L/-+rew±•
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
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):
GENERAL INFORMATION
Pumping Records
Source of information: gtuil\ r JAI.) , Oz-
Was system pumped as part of the inspection es r no):
If yes,volume pumped: /cm gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_ptic 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 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 age of all components,date installed(if known)and source of information:
30—YD 1,-5 J— �.
Were sewage odors detected when arriving at the site(yes or no
Title S rncnprtinn Form 6/15/71111(1
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Zk (tt1,t1la.t —Fe n-
Owner: He.,s(IG it.,
Date of Inspection: GkSlott
BUILDING SEWER(locate on site plan)
Depth below grade: IL`
Materials of construction: cast iron ' 40 PVC other(explain): �cCPtS�-e-
Distance from private water supply well or suction line: to f *-
Comments(on condition of joints,venting,evidence of leakage,etc.):
0 I--
SEPTIC.,....., ,Vrt,
c to on site plan)
It
Depth below grade: 1 V �/
Material of construction:_✓concrete metal fiberglass polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: sit x /O2"t X Gi/
Sludge depth: S
Distance from top ofelludge to bottom of outlet tee or baffle: j�r
Scum thickness: 3
Distance from top of scum to top of outlet tee or baffle: ,S`
Distance from bottom of scum to bottom of outlet tee or baffle: /Z were dimensions determined: Si let,%„e,-
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
3u, 4 S5 CAS. Lark
GREASE TRAP
(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.):
Title 5 t cnprt' F rm 6/15/9000'
7
Page 8 of II
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2?- (aht{(t{ err
Owner:
Date of Inspection: t'rq,o-(
TIGHT or HOLDING TANK: slw.(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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Dale of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: f(' (if present must be opened)(locate on site plan)
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.):
PUMP CHAMBER: Pin (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.):
Title S incnprfnn Pn.m F/1 5/9nnn
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
(41M)\Pre/ N
Property Address: Z1
Owner: Tt npisD
Date of Inspection: 649 Icf
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,excavation not required)
If SAS not located explain why:
Type r i
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20— C4Gst(`a --(•-fK'
Owner: ' ,,r t�imN
Date of Inspection: q(ntf
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 feet.Locate where public water supply enters the building.
Title 5 rncnerhnn Pnrn, fin warm
l0
rage 1Uof 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21. Cq't.V eine
Owner: Pup,. tcoa
Date of Inspection: •
—09/ay
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 feet.Locate where public water supply enters the building.
DAMe•JS+JJS
A--s1 = 19
A = zo
A - -i = 23`
A -» y 31'
C
c = 321
WZI
10
'Not
•
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: al Cah.(\o{ Tr it
Owner: -1-«0412,v
Date of Inspection:
SITE EXAM
""Slope
/Surface water
Check cellar
Shallow wells
Estimated depth to ground water�d'1O feet
Please indicate(check)all methods used to determine the high ground water elevation:
✓Obtained from system design plans on record-If checked,date of design plan reviewed:
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:
Titlr ertinn Form 6/1 snnnn
II