Loading...
29 Septic Inspection 2007 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ertification petty Information rty Address' 's Name: 's Address: f Inspection: o: s: ector: of Inspector: my Name: (Address: gone Number: 29 Sylvan Lane, Northampton, MA Deb & Kim Abell 29 Sylvan Ln. , Florence, MA 01062 6/6/07 Board of Health Northampton Jeff Hutchins Owner Number: SSDS-1187 Thomas S. Leue Homestead Inc. 1664 Cape St. . Williamsburg MA 01096 ( 4131 628-4533 cation Statement: y 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 g and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP ved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The septic system condition le evaluated and classified into one of the following four conditions: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails (stem condition: Passes actor's Signature: Date: 6/6/07 ystem Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 •greater, the inspector and the system owner shall submit the report to the appropriate regional office of the The original should be sent to the system owner and copies to the buyer, if applicable and the approving and Comments: its report only describes conditions at the time of inspection and under the conditions of use at that This inspection does not address how the system will perform in the future under the same or different tions of use. 14•$Q ODD doc• 11/2004 Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System • page 1 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form nification (Cont.) rty Address: 29 Sylvan Lane. Northampton. MA r' Name: Deb & Kim Abell if Inspection: 6/6/07 :tion Summary: Check A, B,C, D or E/always complete all of Section D. System Passes: 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. rents: 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, or ND) in the_for the following statements. If not determined" please explain. J The septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is structurally nd, exhibits substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if isting septic tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic gill pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank than 20 years old is available. plain: 4 Observation of sewage backup or break out or high static water level in the distribution box due to 1 or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if approval by the Board of Health). broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced plain: J The system required pumping more than four times a year due to broken or obstructed pipe(s). The n will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed plain: Other explain: rrther 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 to protect the public health, safety or the environment: System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the m 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. .doc• 112004 Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System •page 2 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form rtification (Cont.) rty Address' 29 Sylvan Lane, Northampton, MA ' Name: Deb & Kim Abell if Inspection: 6/6/07 System will fail unless Board of Health (and Public Water Supplier, if any)determines that the system ;boning 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 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 supply well"Method used to determine distance system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and k.organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia m and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy analysis must be attached to this form. her: System Failure Criteria applicable to all systems: lust indicate either"Yes" or"No"as to each of the following for all inspections: Y) or NO (N) Backup of sewage into facility or system component due to an 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 less than 1/2 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 cesspool privy is within a Zone I of a public well. Any portion of 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 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] The System Fails: I have determined that one or more of the above failure criteria exist as defined in 310 5.303, therefore the system fails. The system owner should contact the Board of Health should be contacted to nine what will be necessary to correct the failure. AENT: doc• 11/2004 Homestead Inc. Title 5 Official Inspection Form:Subsurface Disposal System •page 3 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form mortification (Cont.) rty Address: 29 Sylvan Lane. Northampton, MA r' Name: Deb & Kim Abell if Inspection: 6/6/97 rge Systems: considered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd. ust indicate either"Yes" or"No" as to each of the following. (lowing criteria apply to large systems in addition to the criteria above: Y) or NO (N) 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 =_d Zone II of a public water supply well) answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in h D above the large system has failed.The owner or operator of any large system considered a significant under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The n owner should contact the appropriate regional office of the Department. iecklist if the following have been done. You must indicate YES (Y)or NO IN)as to each of the followingi Pumping information was provided by the owner, occupant or Board of Health.= Were any of the system components pumped out in the previous two weeks? = 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 the inspection? = Were"as-built" plans of the system obtained and examined? (If not available note as N/A) Was the facility or dwelling was inspected for signs of sewage back up? Was the site was 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 septic tank inspected for the .ion of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and scum? ize and location of the Soil Absorption System (SAS) on the site has been determined based on: a) Existing information. For example, a plan at the Board of Health. b) Determined in the field (if any of the failure criteria related to Part C is at issue approximation of ice is unacceptable) 05.302(3)(bl]. The facility owner(and occupants, if different from owner)were provided with information on proper enance of Subsurface Sewage Disposal Systems (SSDS). .doc• 11/2004 Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System • page 4 of 9 rty Address: r' Name: rf Inspection: IENTIAL Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 660 4 3 4 Y Y N _ N N/A N ntinuous 29 Sylvan Lane, Northampton, MA Deb & Kim Abell 6/6/07 FLOW CONDITIONS DESIGN flow based on 310 CMR 15.203 (gallons/day)_ Number of bedrooms(design)_ Number of bedrooms(actual)__ Number of current residents_ Is there a garbage grinder? (Y or N) Is there a Laundry Hookup?(Y or N)= Is the Laundry a separate system?(Y or N) (If yes, separate inspection required)_ Seasonal use (Y or N)= Water meter readings, if available (last two years usage) (gallons per day)_ Sump Pump (Y or N)_ Date of last occupancy_ 4ERCIAL/INDUSTRIAL )f establishment:_ i flow(based on 310 CMR 15.203): _ gpd of design flow (seats/persons/sgft, etc.):_ e trap present(Y or N): _ rail waste holding tank present(Y or N): = meter readings, if available: _ ate of occupancy/use: _ R (describe): __ GENERAL INFORMATION ping Records: Source of information: Pumped 3/26/04, says earlier report Y Was system pumped as part of the inspection (Y or N) yes, volume pumped:_1500 gallons ow was quantity pumped determined?_pumper report eason for pumping: maintenance jmment: Pump on 3 to 4 year interval. OF SYSTEM: Septic tank, distribution box, soil adsorption system. __ Single cesspool __ Overflow cesspool __ Privy __ Shared system(Y or N) Of 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): _ doc• 11/2004 Homestead Inc. Title 5 Official Inspection Form.Subsurface Disposal System •page 5 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form rty Address: 29 Sylvan Lane, Northampton, MA I.' Name: Deb & Kim Abell N Inspection: 6/6/07 ROXIMATE AGE All components, date installed, and source of info. Itic plan: Design date of 5/13/97 :ce of Info: BoH N Were sewage odors detected when arriving at the site (Y or N) _DING SEWER (located on site plan) 16 Depth below grade (inches) Estimated Average 34 Distance in feet from private water supply well or suction line 3S plastic Materials of Construction tments: No problems seen. TIC TANK (located on site plan) Concrete Materials of Construction 14 Depth below grade (inches) 0 Riser depth (inches) 58 _ Septic tank width (inches) Interior dimensions • 120 Septic tank length (inches) Interior dimensions 59 _ Septic tank height (inches) Interior dimensions 1,782 Calculated gross volume (gallons) Calculated 6 Air space in tank (inches) 1,500 Net Volume (gallons) Calculated 21 Baffle depth (inches) 7 Sludge thickness (inches) Average 7 Scum thickness (inches) Ayaas er 31 Top Sludge : Bottom Baffle (inches) Calculated 10 Bottom Scum : Bottom Baffle (inches) Calculated 2 Top Scum Top Baffle (inches) Calculated lments: operational or structural problems seen. outlet filter found. omrnendations: np on 3 to 4 year interval. ling a filter might help protect leaching system from carryover doc• 11/2004 Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System •page 6 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form rty Address: 29 Sylvan Lane, Northampton, MA ' Name: Deb & Kim Abell f Inspection: 6/6/07 3 CHAMBER N Pump part of septic system: (Y or N) Pumps in working order. (Y or N) Alarms in working order: (Y or N) nents: RIBUTION BOX (located on site plan) ("D-box") Y _ _ D-box part of septic system: (Y or N) 0 Depth of liquid level above outlet invert inches nents: Box appears level and flow distributed equally. a biosolids carryover found in box. ADSORPTION SYSTEM(SAS): Technology Used (located on site plan by estimate): leaching pits& number: leaching chambers and number: leaching galleries and number: Y leaching trenches, number, length: 3 trenches , each 51-1/2 ft lon5 leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system, Type: nents: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Llow system. No surface problems seen. not located n why: T OR HOLDING TANK (tank must be pumped at time of inspection) Tight tank part of system: (Y or N) Depth below grade (inches) Measured Tank width Tank length (inches) Tank height Calculated gross volume (gallons) Materials of construction Design flow: gallons/day Pumps in working order: (Y or N) Alarms in working order: (Y or N) Date of last pumping tents: (conditions of inlet tees, condition of alarm and float switches, etc.) doc• 11/2004 Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System •page 7 of 9 rty Address: r' Name: f Inspection: Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ry N ments: SPOOLS N ments: '.ASE TRAP N 29 Sylvan Lane, Northampton, Deb E. Kim Abell 6/6/07 MA (locate on site plan,if any) Privy part of system: (Y or N) Materials of construction: Dimensions: Depth of solids: (soil conditions, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) (cesspool must be pumped as part of inspection) Cesspool part of system: (Y or N) 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(cesspool must be pumped as part of inspection) (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) iments'. (Usually present in certain commercial systems) Grease Trap part of system: (Y or N) Materials of construction: Depth below grade (inches) Dimensions: Depth of solids layer Depth of scum layer Top of scum to top outlet Date of last pumping Bottom of scum to outlet. Scum thickness (recommendation and conditions) (inches) Measured Calculated Inches Calculated Inches Average E EXAM (Source of Information) Y Slope Official Pert Date Surface water 5/13/97 Official Plan Date Y Check Cellar Other Official Source N _ _ Shallow wells _ Other Source 120 Estimated depth to ground water (inches) ase indicate (check) all the methods used to determine high groundwater elevation: Y Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: rmation: From perc test report. _ SOURCES: Department of Environmental Protection, Western Regional Office, Dwight St_, Springfield, MA 01103, (413)784-1100;Title 5 Hotline- (800)266-1122 .doc• 11/2004 Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System • page 8 of 9 low'' WdLCI III L.1. __ _ _._. . __ --- Up Outline of House A. L. Septic Tank I ,, ° NORTH I (51'� deck S "'8 I 7/q, v, Distribution Box Leaching trenches, approximate layout COMMENTS: Recommend pumping on a 3 to 4 year schedule. Also, a copy of this plan posted in the basement/utility area would keep this information accessible in future years for maintenance. Date: Owner: o-1e�N OF �S'Ge� HOMESTEAD INC. As-Built Drawing * yon Existing Septic System 6/6/07 Deb & Kim Abell fro Tttoaaes Thomas S. Leue R.S. 29 Sylvan Lane I o I.EUF� ~ Scale: 1 : 20' Revision Date 1, r2J ',cI` ea4 Cape St. Florence, MA 01062 ��a No sF�"��F W' i 14131 Williamsburg,A 0:096 ` Except as Noted .1.