56 Septic Insection 2009 Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
ifi Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 56 Dunphy Drive
Owner Owner' Name: Michael & Mary McComb
information is
required for City/Town: Northampton, MA 01060 Date of Inspection: 4/16/09
every page
B. Certification (cont.)
E] Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 to
15,000 gpd. For large systems, you must indicate either YES (Y) or NO(N)as to each of the following, in addition to
the questions in Section D.
N the system is within 400 feet of a surface drinking water supply
N the system is within 200 feet of a tributary to a surface drinking water supply
N 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 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.
C. Checklist
Check if the following have been done. You must indicate YES(Y)or NO (N) as to each of the following:
Y Pumping information was provided by the owner, occupant or Board of Health._
N Were any of the system components pumped out in the previous two weeks? _
Y Has the system received normal flows in the previous two week period? _
N Have large volumes of water been introduced to the system recently or as part of the inspection?
Y Were "as-built" plans of the system obtained and examined? (If not available note as N/A)
N/A Was the facility or dwelling was inspected for signs of sewage back up?
Y Was the site was inspected for signs of break out?
Y Were all system components. excluding the SAS. located on site?
Y Were the septic tank manholes uncovered, opened, and the interior of the septic tank inspected for the
condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and
scum?
Y 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:
N Existing information. For example, a plan at the Board of Health.
N Determined in the field Of any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR15.302(5)).
T5 Revised.doc• 12/07 The 5 Official Inspection Form:Subsurface Disposal System•Page 4 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
3• y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Owner
Information is
required for
every page.
D. System Information
Property Address: 56 Dunphy Drive
Owner' Name: Michael & Mary McComb
City/Town: Northampton• MA 01060 Date of Inspection: 4/16/09
Residential Flow Conditions:
Number of bedrooms (design)
3 Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# bedrooms)
1 Number of current residents
Y Does residence have a garbage grinder?
N Is the Laundry a separate system? [If yes, separate inspection required]
N Laundry system inspected?
N _ Seasonal use?
115 _ Water meter readings, if available(last 2 years usage) (gallons per day)
N Sump Pump? _
continuous Last date of occupancy=
COMMERCIAL/INDUSTRIAL
Type of establishment. =
Design flow (based on 310 CMR 15.203)1 _ gpd
Basis of design flow(seats/persons/sift. etc.)'.
Grease trap present?
Industrial waste holding tank present?
Non-sanitary waste discharge to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
General Information
Pumping Records Source of information: Owner pumping records
Y Was system pumped as part of the inspection (Y or N)
If yes, volume pumped- 1500 gallons
How was quantity pumped determined? pumper receipt
Reason for pumping. maintenance
Comment: Pump on 3 to 4 year interval.
Type of System:
X Septic tank,distribution box, soil adsorption system
Single cesspool
Overflow cesspool
Privy
N Shared system (Y or N) (if yes, attach previous inspection records. If any) _
Innovative/Alternative technology. Attach 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): _
T5 Revised doe• 12/07 Title 5 Official inspection Form'.Subsurface Disposal System•Page 5 of 9
Owner
information is
required for
every page.
b. System Information (cont.)
Commonwealth of Massachusetts
Title 5 Official Inspection Form
n; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 56 Dunphy Drive
Owner' Name: Michael & Mary McComb
City/Town: Northampton, MA 01060 Date of Inspection: 4/16/09
!Approximate Age: All components, date installed, and source of info.
'Septic plan: about 32 years old, says Owner
N _ Were sewage odors detected when arriving at the site (Y or N)
Building Sewer: (locate on site plan)
30 Depth below grade (inches) Estimated Average
ABS plastic Material of Construction
26 Distance in feet from private water supply well or suction line
Comments: No problems seen.
Septic Tank: (locate on site plan)
26 Depth below grade (inches)
Concrete Materials of Construction
If tank is metal, list age
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate)
0 Riser depth (inches)
58 Septic tank width (inches) Inferior dimensions
_ 126 _ Septic tank length (Inches) Interior dimensions
59 Septic tank height (inches) Interior dimensions
1 ,871 _ Calculated gross volume (gallons) Calculated
9 Air space in tank (inches)
1 ,500 Net Volume (gallons) Calculated
26 _ Baffle depth (inches)
3 Sludge thickness (inches) very e
30 Top Sludge _ Bottom Baffle (inches) Calculated
3 Scum thickness (Inches) Avera e
15 Bottom Scum Bottom Baffle (inches) Calculated
6 Top Scum : Top Baffle (inches) Calculated
Measured How were dimensions determined?
Comments:
No operational or structural problems seen.
Baffles in place.
'Recommendations:
Pump on 3 to 4 year interval.
A riser over center would facilitate maintenace .
T5 Revised doc• 12/07 The 5 Official Inspection Form-Subsurface Disposal System•Page 6 of 9
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address:
Owner Name:
City/Town:
56 Dunphy Drive
Michael & Mary McComb
Northampton, MA 01060 Date of Inspection: 4/16/09
D. System Information (cant.)
Grease Trap:
N
Comments.
(Usually present in certain commercial systems)
Grease Trap part of system?
Depth below grade (inches)
Materials of construction:
Dimensions:
Scum thickness (inches)
Top of scum to top of outlet tee
Bottom of scum to bottom of outlet tee
Date of last pumping
condition
Tight or Holding Tank:
N Tight tank part of system?
Depth below grade
Materials of construction
Tank width
Tank height
Design flow:
Alarm Level
Alarms in working order?
Date of last pumping
Comments. (condition of alarm and float switches, etc.)
Measured
Average
Calculated Inches
Calculated Inches
(tank must be pumped at time of inspection)
(inches)
Tank length
Capacity
gallons/day
(inches)
Measured
Attach copy of current pumping contract (required). Is copy attached?
Soil Absorption System (SAS):
If SAS not located
explain why
(locate on site plan, excavation not required).
(inches)
(gallons)
leaching pits & number.
leaching chambers and number:
leaching galleries and number.
leaching trenches, number, length:
leaching fields. number, dimensions: estimated at 20 ' x 30 '
overflow cesspool. number: _
innovative/alternative system, Type'
Comments. (note soil condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc_)
No surface problems seen. Very sandy soil .
Gravel media exposed and no retained water seen.
Minimal biosolids seen in gravel media.
T5 Revised doe•12107 Title 5 Official Inspection Form'.Subsurface Disposal System•Page 7 of 9
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 56 Dunphy Drive
Owner Name: Michael & Mary McComb
City/Town:
Northampton, MA 01060 Date of Inspection:
4/16/09
mspecnon results must oe suomnrea on tnls Corm. mspe,
Owner Address'. 56 Dunphy Dr. , Florence, MA 01062
Copy to:
Witness:
y not oe auerea in any way.
Board of Health, Northamoton Michelle Latour, Murphy Realtors
owner
Homestead Inc.#: SSDS-1312
A. General Information
1. Inspector
Name of Inspector: Thomas S. Leue R.S.
Company Name: Homestead Inc.
Company Address: 1664 Cape St. , Williamsburg MA 01096
Telephone Number: ( 413 628-4533 License Number: SI130
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 septic system condition must be evaluated and classified into one of the following four
conditions:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
The system condition Passes
Inspector's Signature:
Date. 4/16/09
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. It the system is a shared system or has a
design flow of 10,000 gpd or gr=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 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.
15 Revised doc• 12/07 Tnle 5 Official Inspecting Form Sub=wrace Disoosai System-Page 1 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
jt Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 56 Dunphy Drive
Owner Name: Michael & Mary McComb
City/Town: Northampton, MA 01060 Date of Inspection: 4/16/09
Owner
information is
required for
every page.
B. Certification (cont.)
Inspection Summary: Check A, B, C, D or E/always complete all of Section D
A. System Passes:
Y I have not found any information which indicates that any of the failure criteria as 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:
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(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if
the existing septic 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
N 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
by the Board of Health): broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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 approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain'.
C. Further Evaluation is Required by the Board of Health:
N 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 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.
T5 Revised doc• 12/07 Title 5 Offcial Inspec5on Form.Subsurface Disposal System•Page 2 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15W.-4-'
5G Property Address: 56 Dunphy Drive
Owner Owner' Name: Michael & Mary McComb
Information is
required for City/Town: Northampton, MA 01060 Date of Inspection: 4/16/09
every page.
B. Certification (cont.)
2) System will fail unless 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 I 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
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 either YES (Y)or NO (N) as to each of the following for all inspections:
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.
N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
N Liquid depth in cesspool is less than 6" below invert or available volume less than 1/2 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 ground water elevation.
N Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
supply.
N Any portion of cesspool privy is within a Zone I of a public well.
N Any portion of 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
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 must be attached to this form.]
N The system is a cesspool serving a facility with a design flow of 2000 gpd-10,000 gpd.
N The system fails: I have determined that one or more of the above failure criteria exist as defined in 310 CM
15.303. therefore the system fails. The system owner should contact the Board of Health should be contacted
to determine what will be necessary to correct the failure.
COMMENT:
T5 Revsed doc•12/07 Title 5 Official Inspection Form Subsurface Disposal System•Page 3 of 9
Leachfield, estimated layout
Excavation site
Septic Tank
-ED
Distribution Box
ir
deck {-
2
(D 24,
• House Outline
r
-- - 4 -- NORTH
Town water in
As-Built Drawing Date Owner: +o?`�N OF 4�SS�cyG HOMESTEAD INC. `
Existing Septic System 4/16/09 Mary 8, Michael McComb A 7NOMA @5, Thomas S. Leue R.S.
- - - -- 56 Dunphy Drive LEU�'
Scale: 1 : 20' Revision Date: Florence, MA 01062 a. �J . 1664 Cape St.
9F. T Williamsburg, MA 01096
Except as Noted sreREO sr�`�� 14131 628-4533
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 56 Dunphy Drive
owner Owner' Name: Michael & Mary McComb
information is
required for City/Town:
every page.
D. System Information (cont.)
Northampton, MA 01060 Date of inspection: 4/16/09 --.
Distribution Box: (if present must be opened) (locate on site plan) ("D-box")
Y D-box part of septic system?
Depth of liquid level above outlet invert Inches
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, and
out of D-box, etc. Box located under deck could not be excavated.
Hole dug in field to determine backup possibility.
Pump Chamber: (locate on site plan)
N Pump part of septic system?
Pumps in working order (Y or N)
Alarms in working order: (Y or N)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Cesspools: (cesspool must be pumped as part of inspection) (locate on site plan)
Cesspool part of system?
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
Comments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Privy:
Comments:
(locate on site plan)
Privy pal of system?
Materials of construction:
Dimensions:
Depth of solids:
(soil conditions. signs of hydraulic failure, level of pending, condition of vec-
Site Exam: (Source of Information)
Y Check Slope Official Perc Date
Surface water Official Plan Date
Y Check Cellar Other Official Sour:
N Shallow wells Other Source
60+ Estimated depth to ground water (inches)
Please indicate all the methods used to determine high groundwater elevation:
Y Observed site (abutting property/observation hole within 150 feet of SA+,
Checked with local Board of Health-explain:
Checked with local excavators, installers-explain:
You must describe how you established the high ground water elevation:
Porus soils showed no groundwater evidence.
Area perc tests are this depth or greater.
T5 Revised doc• 12/07
tc.)
Title 5 Official Inspection Form.Subsurfacz n•Page 8 of 9