661 Septic Inspection 2006 TITLE 5
OFFICIAL INSPECTION FOR- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 661 Florence Road Florence MA 01062
Owner's Name: Estate of Rita Wilkins
Address:: C/O AttLisa Halbert,Esq.,Bacon&Wilson 31 Trumbull Rd.Northampton
Date of Inspection: October 25 2006
Name of Inspector:Alan E. Weiss, R.S 0 933,Hrdrogeologist,M.S.
Company Name: Cold Spring Environmental Inc.
Mailing Address: 350 Old Enfield Road
Belchertown.Massachusetts 01007
Telephone Number: (413)323-5957 fax:413-323-4916
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the informatio
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:
Inspector's Signature:
X Passes
_ Conditionally Passes
_Needs Further Evaluation by the Local Approving Authority
ails
Date: October 25,2006
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 greater,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:
Septic Tank had good level upon inspection. System otherwise appears old but oh.
All levels&staines ok at D.box. Field&tank are 34 yrs old. Outlet&inlet
baffles are inplace with 1250 gals.tank. Pumping of tank was completed.All
staining was proper. All D.box levels OK and walls competent,with mulitple(3)
lines out Design records from 1972 noted 900 SF.
'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
different conditions of use.
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 661 Florence Road Florence,MA
Owner: Wilkins
Date of Inspection: October 25,2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
yes 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. No signs of failure
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 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
NI)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:
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 661 Florence Road Florence,MA
Owner: Wilkins
Date of Inspection: October 25,2006
C. Further Evaluation is Required by the Board of Health:
NO 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 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
colifonn 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:
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 661 Florence Road Florence,MA
Owner: Wilkins
Date of Inspection: October 25,2006
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or"no"to each of the following for all inspections:
Yes No
x_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
x Liquid depth in cesspool is less than 6"below invert or available volume is less than K day flow
x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
x Any portion of the SAS,cesspool or privy is below high ground water elevation.
x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
x Any portion of a cesspool or privy is widen a Zone 1 of a public well.
s Any portion of a cesspool or privy is within 50 feet of a private water supply well.
x 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 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./
- NO (Yes/No)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 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 syst em is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II ofa 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.
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 661 Florence Road Florence,MA
Owner: Wilkins
Date of Inspection: October 25 2006
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
YES 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?
NO 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?
_N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
yes Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
yes Were all system components,excluding the SAS,located on site?
Yes _ 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?
Les _ 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
YES Existing informat ion.For example,a plan at the Board of Health.
yes Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 661 Florence Road Florence,MA
Owner: Wilkins
Date of Inspection: October 25,2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x i!of bedrooms): 330
Number of current residents: I,(weekends only)
Does residence have a garbage grinder(yes or no):YES,GRINDERS ARE NOT RECOMMENDED)
Is laundry on a separate sewage system(yes or no):*no [if yes separate inspection required]
Laundry system inspected(yes or no):n/n
Seasonal use:(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): N/a
Sump pump(yes or no):_NO
Last date of occupancy:Current
COMMERCIAL/INDUSTRIAL
Type of establishment:N/A
Design flow(based on 310 CMR 15.203): ppd
Basis of design flow(seaWpersons/sgfLetc.):
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 infonnation: (owner )
Was system pumped as part of the inspection(YES or no): YES
If yes,volume pumped: 1250 1lons—How was quantity pumped determined?Measured
Reason for pumping: Time/Insp. ?unknown since last pumping
TYPE OF SYSTEM
x 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)
lnnovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from ystem 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:35 vears+/-(town BOH
called),
Were sewage odors detected when arriving at the site(yes or no):NO
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OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 661 Florence Road Florence,MA
Owner: Wilkins
Date of Inspection: October 25,2006
BUILDING SEWER(locate on site plan)
Depth below grade: 10"
Materials of construction: cast iron X 40 PVC other(explain):
Distance from private water supply well or suction line: 10'+
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: Yes(locate on site plan)
Depth below grade: 36"Material of construction:X 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: 4.5'w x957 x4.5'd
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 40"
Scum thickness: 10"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: 4"
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid
levels as related to outlet invert,evidence of leakage,etc.): TANK CONDITION OX
baffles (OK), in place,Should be pumped(every 2 years).
GREASE TRAP:N/A(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
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 661 Florence Road Florence MA
Owner: Wilkins
Date of Inspection: October 25.2006
TIGHT 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
Marm 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: YES (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: boxes found all levels below inv. 28"+ cover material
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.): box dry,hydraulic cemented one unused outlet cap,box r
OK condition
PUMP CHAMBER: NO (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.):_
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 661 Florence Road Florence,MA
Owner: Wilkins
Date of Inspection: October 25 2006
SOIL ABSORPTION SYSTEM(SAS): YES (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: 2'x 60'
1 leaching fields,number,dimensions: 30 x 30'+/-(900 SF on permit)
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.):No signs of failure(stone not saturated),no Groundwater observed
No staining above piping inverts of system,no evidence of stone in EHGW.
CESSPOOLS: N/A (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:N/A(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: 661 Florence Road Florence,MA
Owner: Wilkins
Date of Inspection: October 25,2006
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.
See Attached.
124) 54'
' y F a1,D •
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 661 Florence Road Florence.MA
Owner: Wilkins
Date of Inspection: October 25,2006
SITE EXAM
Slope YES
Surface water
Check cellar YES '
Shallow wells
Estimated depth to ground water 5' feet
Please indicate(check)all methods used to determine the high ground water elevation:
X 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:
Water level based on on-the data&from topography&vegetation and soil type (NO evidence of high
g. water observed in area of field, deep holes done in area see record).
11
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