87 Septic Inspection Form 1996 Commonweahh of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
Property Address:
Date of Inspection:
Owner's Name:
Owner's Address:
Copy to:
Mailing Address:
Witness:
Name of Inspector:
Company Name:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A - CERTIFICATION
87 Dunphy Drive Northampton,MA
1/12/96
Mike Routier
87 Dunphy Drive, Northampton, MA 01060
Joanne Laplante
Canon Real Estate,199 Northampton St., Easthampton,MA 01027
none Number: SSDS-70
Thomas S. Leue
Homestead Inc., 1664 Cape St., Williamsburg, MA 01096 (413) 628-4533
CERTIFICATION STATFMFNT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true,
accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the
prop r function and maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature:
VW, Date: January 12. 1996
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspecton. If the system is
a shared system or has a design flow of 10,000 and or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
Department of Environmental Prolec6ah. The onginal should be sent to the system owner and copes to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY: Check A,B,C,or D.
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
BJ
SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y,N,or ND). Describe basis of determination in all instances. (If not determined, explain why not)
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is
imminent. The system will pass inspection if the septic tank is replaced with a conforming septic tank as approved by
the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The 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
The system required pumping more than four 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
Homestead Inc. Page 1
Property Address:
Owner's Name:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A - CERTIFICATION (continued)
87 Dunphy Drive Northampton,MA
Mike Routier
1/1 2/9 6
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
the public health, safety and the environment:
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN AMANNER THAT PROTECTS PUBLIC HEALTH,SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or a tributary to a
surface water supply.
The system has a septic tank and a soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and a soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well unless a well water analysis 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. If the
well has been analyzed to be acceptable, attach copy of well water analysis for coliform,volatile organic compounds,
ammonia nitrogen,and nitrate nitrogen.
D] SYSTEM FAILS:
I have determined that the system fails one or more of the following failure criteria as defined in 310 CM 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to
correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to 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 less than 6"below invert,or available volume less than 1/2 day of calculated daily flow?(Part 7)
Required pumping 4 times or more in the last yearNOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy below high groundwater elevation.
Any portion of a cesspool or privy is within 100'of a surface water supply or a tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
- Any portion of a cesspool or privy is within 50'of a private water supply.
- Any portion of a cesspool or privy is less than 100'but greater than 50'from a private water supply with no acceptable
water quality analysis.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and
the environment because one or more of the following conditions exist:
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 I I of a
public water supply well)
The owner or operator of any such system shall bring the system and the facility into full compliance with the groundwater treatment
program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
Homestead Inc. Page 2
Property Address:
Owner's Name:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B - CHECKLIST
87 Dunphy Drive Northampton,MA
Mike Routier
1/12/96
CHECK IF THE FOLLOWING HAVE BEEN DONE:
1 Pumping information was requested of the owner,occupant and/or Board of Health.
i 2 None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
NIA 3. As built plans have been obtained and examined. Note if they are not available with N/A.
4 The facility or dwelling was inspected for signs of sewage back-up.
L 5. The site was inspected for signs of breakout.
6 All system components,excluding the Soil Absorption System,have been located on site.
L 7. The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction,dimensions,depth of liquid, depth of sludge, depth of scum.
6. The size and location of the Soil Absorption System on site has been determined based on existing information or
approximated by non-intrusive methods.
9 The facility owner(and occupants,if different from owner)were provided with information on proper maintenance of
Subsurface Sewage Disposal Systems(SSDS).
FLOW CONDITIONS
RFSIDFNTIAL-
Design Flow: gallons/day
,3 Number of bedrooms
3 Number of current residents
Garbage grinder(Y or N)
Y Laundry connected to system(Y or N)
N— Season use(Y or N)
Water meter readings,if available: 165 gallons per day
Date of last occupancy: comtinuouc
COMMERCIAL/INDUSTRIAL•
Type of Establishment:
Design Flow- gallons/day
Grease trap present(Y or N)
Industrial Waste Holding Tank present(V or N)
Non-sanitary waste discharge to the Title 5 system(Y or N)
Water meter readings,if available:
Date of last occupancy:
OTHER) (Describe)
gallons per day
Date of last occupancy:
Homestead Inc. Page 3
Property Address:
Owner's Name:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C - SYSTEM INFORMATION
87 Dunphy Drive Northampton,MA
Mike Ratifier
1/12/96
PUMPING RECORDS and source of information:
oumned about years ago
X_ System pumped as part of inspection(Y or N)
If yes,volume pumped: 1.500 gallons
Reason for pumping: tank insoertion
Name of Septage Pumper: Karl's Fxravating
TYPE OF SYSTEM:
X Septic tank/distribution box/soil adsorption system.
- Single cesspool
- Overflow cesspool
- Privy
51_ Shared system(Y or N),if yes,attach previous inspection records,if any.
- Other(explain)
APPROXIMATE AGE of all components. date installed Of known)and source of information:
About 1975
Sewage odors detected when arriving at the site:(Y or N) N
SFPTIf TANK.
V (located on site plan)
Average depth below grade: 19"
Material of construction' concrete_metal_FRP___pther(explain)
Dimensions: 00•-6"long x 5'wide x 5'-0"deep 152"dean liquid levell
(A) sludge depth
24:— (8) top of sludge layer to bottom of outlet tee or baffle
14" (C) bottom of scum layer to bottom of outlet tee or baffle
�= (D) scum thickness
�= (E) top of scum layer to top of outlet tee or baffle
Comments: (recommendation for pumping,conditions of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,
structural integrity, evidence of leakage, etc.)
Baffles in nlare nn nrnhlems seen
INLET
ACCESS HATCHES
;1 p- AIRSPACE ---- Top N scum to top of
i 1 sSi:BSi : ieyyi.Y,^! '...... . ........�.....n� /\ cutlet lee (E)
W
:epws:.. $WMIAIER a:.a:.a:.: .�►OURFf
b •J.............::::a:r..
I Bottom tt scum to bottom
,//// moaner tee (D)
/
v.r
/
/
/
C,
Scum depth(C) J/".P.:
Homestead Inc.
SCHEMATIC DIAGRAM OF A TYPICAL SEPTIC TANK
Page 4
Top of sludge to bottom
of outlet tee (B)
Budge depth (A)
Property Address:
Owner's Name:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
87 Dunphy Drive Northampton,MA
Mike Routier
1/12/96
GREASE TRAP: (Usually present in certain commercial systems)
Depth below grade:
Material of construction'_concrete_metal_FRP_other(explain)
Dimensions:
(A) scum thickness
(B) top of scum layer to top of outlet tee or baffle
(C) bottom of scum layer to bottom of outlet tee or baffle
Comments: (recommendation for pumping,conditions of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,
structural integrity, evidence of leakage, etc.)
TIGHT OR HO! nINn TANK
Depth below grade:
Material of construction:_concrete_metal_FAP_other(explain)
Dimensions:
(Special circumstances only)
Capacity: gallons
Design flow' gallons/day
Alarm level:
Comments: (conditions of inlet tees, condition of alarm and float switches,etc.)
O ISTRIRIITION BOX; V (locate on site pan)("D-box")
Depth of liquid level above outlet invert: a/8"
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,
recommendations for repairs, etc.)
Some solids rarrvnver into d-hnx I icuid above invert dun to solids in nutlet nines not field failure Sox level and flow
e
SOIL AnSORPTION SYSTEM ISAS1• V
Locate on site plan,i f possible:excavation not required,but may be approximated by non-intrusive methods. I f not
determined to be present,explain:
Type:
a. leaching pits 8 number:
b. leaching chambers and number:
c. leaching galleries and number:
d. leaching trenches,number,length:
e. leaching fields,number,dimensions: 1 about 1d by 15'
f. overflow cesspool,number:
g. other(explain):
h. Comments: (note soil conditions,signs of hydraulic failure,level of ponding,condition of vegetation,
recommendations for maintenance or repairs,etc.)
Homestead Inc. Pages
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 87 Dunphy Drive Northampton,MA
Owner's Name: Mike Routier
Date of Inspection: 1/12/96
PUMP CHAMBEf (part of pump-up systems only)
Pumps in working order:(Y or N)
Comments:(note condition of pump chamber,condition of pumps and appurtenances,etc.)
CESSPOOLS. (locate on site plan,if any)
Note: Cesspools must be pumped as part of the inspection.
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.)
p RIV Y.
Materials of construction:
Dimensions:
Depth of solids:
(locate on site plan,if any)
Comments: (note soil conditions,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
SKETCH OF SEWAGE DISPOSAL SYSTEM: (attached)
include ties to at least two permanent references to landmarks or benchmarks;locate all wells within 100'radius.
'GO',
DEPTH TO GROUNDWATER:
method of determination or approximation:C
inches
COMMENTS:
RESOURCES:
Department of Environmental Protection, Western Regional Office, 436 Dwight St., Springfield, MA
01103, (413) 784-1100
Title 5 Hotline - (800) 266-1122
Homestead Inc.
Page 6
lot
•
A
A5-built Drawing of Owner: Mike Routier HONESTEA) INC.
Existing Septic System nom' 87 Dunphy Pr. 1664 cape St.
g p y Some Dimensions Approximated Northampton, MA 01060 Willia43J62 01096