446 Septic Inspection 2004 COMMONWEALTH OF MASSACHUSETTS
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: 9
Owner's Name:
Owner's Address:
Date of Inspection: li—a/—ccif
Name of Inspector: (pI ase print) DOb !/
N
Company Name: '/,//c 6
Mailing Address: -- _ C d d
Telephone Number: ///t- 3,y5— /i$51
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 Title 5(310 CMR 15.000). The system:
asses
• Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fa/ails
C� / 1
Inspector's Signature•
Date: (o —pit - 6 °/
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 Beater, 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
*""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 6n 5/2000 page I
Page 2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
-{C�ERTTIFICATION (continued)
Property Address: - / ' Ac :¢ //
fiC S .
Owner: /t...-
Date of Inspection: 6t—c9I- o`/
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:
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.
Answer yes,no or not determined(Y,N,ND)in theo 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(wit •
approval of Board of Health):
ND explain:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
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):
ND explain
broken pipe(s)are replaced
obstruction is removed
2
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
,C.ERTIFICJATION(continued)
Property Address: yy6 "Ae}/r td ,P�
Ss Mer
Owner: / T.r.v
Date of Inspection: (e - .1</ - d L)
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 fai ing 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
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 conform
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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 4///esn 1t 'kN/b7d
/<C" G
Owner: Iran*/.,,t
Date of Inspection: c. - / -O
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
ti Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
r"---Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
/I//) Liquid depth in cesspool is less than 6"below invert or available volume is less than 'L•day flow
r 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 round water elevation.
T 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 forma
(%esfNo)The system fails. 1 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.
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—1 WPA)or a mapped
Zone 11 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 CAR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: /'/b Cytest ryir/� O)
Owner: %u
Date of Inspection: (c - / C'I
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
t/Were any of the system components pumped out in the previous two weeks ?
t/ 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?
L/ _ 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 no
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 at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
5
Page 6 of II
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
- SYSTEM INFORMATION
Property Address: 76. I Nn// ,C9.M-iP// Pei
�cls .
F s r
Owner:
Date of Inspection: - a/- O
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x ', of booms): 4/1/4)
Number of current residents: x2-
Does residence have a garbage grinder(yas-or no): 4o
Is laundry on a separate sewage system (ye -or no). h o [if yes separate inspection required]
Laundry system inspected (yes-or-no): (It
Seasonal use: (yerorno): /), ,,p
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yesorno)' )l o
Last date of occupancy: 612r Ace...xi"-
COMM E R C IA L/I ND U S TRIA L
Type of establishment:
Design flow(basedbn 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 ofoccupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: W 2., -` Y'
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: pig gallons-- Flow was quantity pumped determined?
Reason for pumping: �(,.�., �.r rim..
TYPE OF SYSTEM
L--S-
eptic 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(m be
obtained from system owner)
Tight tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date ins tyllI d4ifk(cnown)and source of information:
Alf `: , / ,,SS�l
Were sewage odors detected when arriving at the site(yes-or-no): /9c
6
Page 7 of I1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: G �%`` r/ - n
YY S /in.7
Owner: 71,-,
Date of Inspection: /o - 02 - Cel
BUILDING SEWER(locate on site plan)
Depth below grade: r2-
Materials of construction: cast iron //40 PVC_other(explain):
Distance from private water supply well or suction line: > /p, '
Comments(on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade: /
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:
Sludge depth: Sr"
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: /al. "
Distance from top of scum to top of outlet tee or bale: 4/
Distance from bottom of scum to bottory of outlet tee or baffle: //
How were dimensions determined: /lJPOCU i +, ei"„
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
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.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
h�./--
Property Address: 1/4/G, �n
(o [� SJC rAG/- yt��
Owner: Fri /h."—
-
Date of Inspection: (o — ed /— Oa/
TIQHT 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/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: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: cc
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: (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
SYSTEM INFORMATION(continued)
Property Address: 4(4/./., efSijr d
ct.1-; ' (Kc)
Ag#
Owner: r ��.
Date of Inspection: (c, -�,!' /-pa/
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 trenches,number, length:
(/leaching fields,number, dimensions: 4 - o�
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level ofponding, damp soil, condition of vegetation
etc.):
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 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 ofponding, condition of vegetation, etc.):
9
Page 10 of II
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: L{4G
L eels , mc'
Owner: r 17—,
Date of Inspection: /o- a. /- O4(
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.
10
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No.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH J I
OF 71 4-ccar
FEE
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application tor u Permit to Const mCl ( ) Repair (Riltpgradc I ) Abandon ( ) - ❑Complete System `Individual Components
Type of Building: S • "P • 14 •
Dwelling—No.of Bedrooms FOU IZ
Other—Type of Building No.of persons
Other fixtures
Lot Size eOJLi`"Sy. f.,r
Garbage Grinder (.Ld>
Showers ( ). Cafeteria
'%DNrtS.- �}�/�
Design Flow(min. required) P 0 easy Calculated design flow-T7(! gpd Design flow provided gpd
Plan: Date 9)24 Number of sheets Revision Date
Title RS f¢2"CAcc b/s'eOSA-/ - SYS`%t' 'L-
C'L(Description of Soil(s) S4 ,5'OV 1._.
Soil Evaluator Form No. Name of Soil Evaluator tetisf ignisafa Date of Evaluation .77$/�i 7-
DESCRIPTION OF REPAIRS OR ALTERATIONS
I —s
17-8
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLES and furt�h/e/rpryr/eees not to place syste7ip operation until a Certificate of Compliance has been iss by the Board of Health.
Sgned 1:-.0_41-4- t
Inspections V
Date
re,'„ 26, 777
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
Description of Work:
v
THE COM ONWE LTH OF MASSACHUSETTS FEE i✓' L' -
BOARD OF HEALTH
ERTIFI FATE OF COMPLIANCE
❑ Individual Component(s) fomplete System
The undersigned hereby certify that the Sewage Disposal System:Constructed l3p
ructed( ),Repaired(1 graded( ).Abandoned( )
by: C A i. .i &tr
at
44 D c-L4 ;A
has been installed in accordance with th 'provisions of 310 CMR 15-0 (Title 5) and the approved design plans/as-built
plans relating to application No. 4.6-- dated /t '.J 5'�Cf 7 • Approved Design Flow 505/ (gpd)
Installer %/ I�(1 /Y/l � C4-;12--4-6 A
Designee tK____&_g__ &*47t-2�+ Inspector ate �/ 6/7-r
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
kit cc, Medal
4 C i ci
4' /&r& �M ��
Uxafw
Own -Fame
414, ckes-eFtt a Rv LEaS want
ddri,
(pa) .S9C —996 c3
Telcphooe Y
p,rs2e�<
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l,mmlle°`v°m°
HOWARD ENVOI N MEWTAL SERVICES
750 NORTH PLEASAd1LD I HEE I (REAR)
514HEDa7 uA ma,
Telephone It
Admen
cphc P
Td on
Type of Building: S • "P • 14 •
Dwelling—No.of Bedrooms FOU IZ
Other—Type of Building No.of persons
Other fixtures
Lot Size eOJLi`"Sy. f.,r
Garbage Grinder (.Ld>
Showers ( ). Cafeteria
'%DNrtS.- �}�/�
Design Flow(min. required) P 0 easy Calculated design flow-T7(! gpd Design flow provided gpd
Plan: Date 9)24 Number of sheets Revision Date
Title RS f¢2"CAcc b/s'eOSA-/ - SYS`%t' 'L-
C'L(Description of Soil(s) S4 ,5'OV 1._.
Soil Evaluator Form No. Name of Soil Evaluator tetisf ignisafa Date of Evaluation .77$/�i 7-
DESCRIPTION OF REPAIRS OR ALTERATIONS
I —s
17-8
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLES and furt�h/e/rpryr/eees not to place syste7ip operation until a Certificate of Compliance has been iss by the Board of Health.
Sgned 1:-.0_41-4- t
Inspections V
Date
re,'„ 26, 777
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
Description of Work:
v
THE COM ONWE LTH OF MASSACHUSETTS FEE i✓' L' -
BOARD OF HEALTH
ERTIFI FATE OF COMPLIANCE
❑ Individual Component(s) fomplete System
The undersigned hereby certify that the Sewage Disposal System:Constructed l3p
ructed( ),Repaired(1 graded( ).Abandoned( )
by: C A i. .i &tr
at
44 D c-L4 ;A
has been installed in accordance with th 'provisions of 310 CMR 15-0 (Title 5) and the approved design plans/as-built
plans relating to application No. 4.6-- dated /t '.J 5'�Cf 7 • Approved Design Flow 505/ (gpd)
Installer %/ I�(1 /Y/l � C4-;12--4-6 A
Designee tK____&_g__ &*47t-2�+ Inspector ate �/ 6/7-r
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
Twod ar( Nec44kCpy
HOWARD ENVIRONMENTAL SERVICES
TITLE 5 SPECIALISTS
rarer
750 NORTH PLEASANT STREET,REAR
AMHERST, MA 01002
PHONE:(413)256-8008 FAX: (413)549-1850
Board of Health
City Hall
210 Main Street
Northampton, MA 01060
Dear Board,
July 11, 1998
On July 8, 1998 a representative of our firm inspected the soil absorption system
installed at 446 Chesterfield Road at the home of Bill Mellen. The system was
installed by Tom Childs of Leeds, MA.
Our representative found the soil absorption system to be installed in accordance
with our approved septic system design dated September 22, 1997 with the
following exceptions:
The D-Box and pipe configuration was modified slightly.
The final grading associated with the breakout fill had not yet been
completed.
See the accompanying as-built sketch for locations of the systems components.
This letter shall serve as engineer and installer certification that the system was
installed in accordance with Title 5 and our approved system design. If there are
any questions, please contact our office.
Si - -
4r� avi e Ph.D., M.P.H., A.S.E.
I hereby certify that the above
Title 5 and the , .proved see
Services.
'a
erenced system was installed in accordance with
stem design prepared by Howard Environmental
Tom Childs
PERC TESTING • SEPTIC SYSTEM ENGINEERING • ENVIRONMENTAL CONSULTING