24 Septic Inspection 2001 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTIONL
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
!perty Address: 24 Westhampton Road. Northampton MA
ner's Name: Todd Zuzula
nets Address: 24 Westhampton Rd. . Florence. MA 01062
e of Inspection: 8/23/01
>yto: Board of Health. Northampton; Jones Hutchins Realty
ness: Owner. Ed Hennessey Number: SSDS-593
ne of Inspector: Thomas S. Teue
rnpany Name: Homestead Inc.
ling Address: 1664 Cape St. . Wi J J i amsburg. MA 01096
ephone Number: (41.3) 628-4t33
AIS 2 8 2001
AMPTON BOARD OF HEALTH
'sRTIFICATION STATEMENT
ertify that I have personally inspected the sewage disposal system at this address and that the information
orted below is true, accurate and complete as of the time of the inspection. The inspection was performed
red on my training and experience in the proper function and maintenance of on-site sewage disposal
tems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (310 CMR 15.000).
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
system condition: Passes
ArYlt'e E
pector's Signature:
Date: August 24. 2001
System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health
DEP) within thirty (30) days of completing this inspection. If the system is a shared system or has a design
.v of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
ional office of the DEP. The original should be sent to the system owner and copies to the buyer, if
tlicable and the approving authority.
tes and Comments
'*This report only describes conditions at the time of inspection and under the conditions of use at that
re.This inspection does not address how the system will perform in the future under the same or
ferent conditions of use.
e 5 Inspection Form 6/15/2000
page I of 10 Homestead Inc
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
perty Address: 24 Westhampton Road, Northampton. MP,
Her: Todd Zuzula
e of Inspection: 8/23/01
pection Summary: Check A, B,C, D or E/AJ•WAYS 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.
nments:
System Conditionally Passes:
L 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
cturally unsound,exhibits substantial infiltration or exfiltration,or tank failure is imminent. The system will
s inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of
dth. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
npliance indicating that the tank is less than 20 years old is available.
explain:
N Observation of sewage backup or break out or high static water level in the distribution box due
,roken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass
section if(with approval by the Board of Health). _ broken pipe(s) are replaced
obstruction is removed
_ distribution box is levelled or replaced
explain:
N The system required pumping more than four times a year due to broken or obstructed pipe(s).
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
explain.
Other: explain:_
Further Evaluation is Required by the Board of Health:
L Conditions exist which require further evaluation by the Board of Health in order to determine if the
tem is failing 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
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.
5 Inspection Form 6/15/2000
page 2 of 10
Homestead Inc
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
terty Address:
ter: Todd Zuzu10.
of Inspection: 8!23/07
I +.11• •1. •• \• 0 .,11• • I w4
System will fail unless Board of Health (and Public Water Supplier,if any) determines that the
:m 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
Ice 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
ate water supply well** Method used to determine distance
his system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria
volatile organic compounds indicates that the well is free from pollution from that facility and the presence
umonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
riggered.A copy of the analysis must be attached to this form.
)ther:
System Failure Criteria applicable to all systems:
mild indicate either"Yes" or"No"as to each of the following for a inspections:
i (Y) or NO(N)
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.
• 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 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
1 15.303, therefore the system fails. The system owner should contact the Board of Health should be
ttacted to determine what will be necessary to correct the failure.
5 Inspection Form 6/15/2000
page 3 of 10 Homestead Inc.
TCIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
erty Address: 24 Westhampton Road . Northampton, MA
er: Todd Zuzula
of Inspection: 8/23/01
mrge Systems:
e considered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd.
must indicate either"Yes" or"No"as to each of the following:
following 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
3 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
ped Zone II of a public water supply well)
m answered "yes"to any question in Section E the system is considered a significant threat, or answered
in Section D above the large system has failed.The owner or operator of any large system considered a
ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310
R 15.304. The system owner should contact the appropriate regional office of the Department.
PART B• CHECKLIST
ok if the following have been done. You must indicate "yes"or"no" as to each of the following;
i (Y) or NO(N)
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?
A Were as built plans of the system obtained and examined? (If they are 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 condition
ne baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
size 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
lance is unacceptable) [15.302(3)(b)].
The facility owner(and occupants, if different from owner)were provided with information on proper
intenance of Subsurface Sewage Disposal Systems(SSDS).
e 5 Inspection Form 6/15/2000
page of 10
Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C: SYSTEM INFORMATION
erty Address: 24 Westhampton Road. Northampton. MA
er: Todd Znzuln
of Inspection: 8/23/03
FLOW CONDITIONS
IDENTIAL
330 DESIGN flow based on 310 CMR 15.203 (gallons/day)
3 Number of bedrooms(design)
4-5 Number of bedrooms (actual)
4 Number of current residents
Y Is there a garbage grinder ?(Y or N) _
Y Is there a Laundry Hookup?(Y or N)
N Is the Laundry a separate system? (Y or N) (If yes,separate inspection required)_
N Seasonal use(Y or N)
124 Water meter readings,if available (last two years usage) (gallons per day)
Sump Pump(Y or N)_
mtinuoit_s Date of last occupancy _
%IMERCIAL/INDUSTRIAL
e of establishment:
ign flow (based on 310 CMR 15.203): gpd
is of design flow (seats/persons/sqft,etc.):
ase trap present(yes or no):
1strail waste holding tank present(yes or no):
er meter readings, if available:
:date of occupancy/use:
-IER(describe):
GENERAL INFORMATION
aping Records
rce of information: Owner says J ast pu ped in 1995.
_N Was system pumped as part of the inspection(Y or N)
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
PE OF SYSTEM:
Septic tank,distribution box, soil adsorption system.
Single cesspool
_ Overflow cesspool
Privy
_ Shared system(Y or N)(if yes, attach previous inspection records,if any)
_ Innovative/Altemative 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):
e 5 Inspection Form 6/15/2000
page 5 of 10 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
erty Address: 24 Westhampton Road. Northampton. NA
en Todd Zuzula
of Inspection: 8/23/01
Were sewage odors detected when arriving at the site (Y or N):
ROXIMATE AGE of all components, date installed(if known)and source of information:
Doll permit dated 3/22/85.
WING SEWER: (located on site plan)
Average depth below grade 20' Distance from private water supply well or suction line
Material of construction: _cast iron X Sch.40 PVC _other(explain)_
,ments: (condition of joints, venting, evidence of leakage,etc.) No problems seen.
TIC TANK: Y (located on site plan)
Material of construction:_l _concrete_metal _FRP_polyethylene_other(explain)
r 16 Depth below grade (inches)
58 Septic tank width (inches)
122 Septic tank length (inches)
58 Septic tank height (inches)
1 781 Calculated gross volume (gallons)
9 Air space in tank (inches)
1,500 Net Volume (gallons)
24 Baffle depth (inches)
6 Sludge thickness (inches) Represents average
7 Scum thickness (inches) Represents average
Top of sludge layer to bottom
28 of outlet tee or baffle (inches)
Bottom of scum layer to
10 bottom of outlet tee or baffle (inches)
Top of scum layer to top of
5 outlet tee or baffle (inches)
nments: (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.)
Wank structurally OK Baffles intact.
v dimensions were determined: Measured.
e 5 Inspection Form 6/15/2000
page 6 of 10 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
erg Address: 74 Westhamnton Road, Northampton. MA
ier: Todd ZuzuJ a
of Inspection: 8123/01
H' CHAMBER: N/A (part of pump-up systems only)
ps in working order: (Y or N)
ms in working order: (Y or N) _
:ments: (note condition of pump chamber, condition of pumps and appurtenances, etc.)
TRIBUTION BOX: I (if present must be opened)(locate on site plan) ("ID-box")
th of liquid level above outlet invert: 0"
tments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into
ut of box, recommendations for repairs, etc.) Box appears level and flow equal .
er replaced.
L ADSORPTION SYSTEM(SAS);.Y (locate on site plan, excavation not required)
4S not located explain why.
e:
hing pits & number:
hing chambers and number:
hing galleries and number
hing trenches,number,length:
hing fields, number, dimensions: JO' x 50• field
rflow cesspool,number:
wative/alternative system,Type/name of technology:
nments: (note soil conditions, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
problems seen on surface. No evidence of breakout.
e 5 Inspection Form 6/15/2000
page 7 of 10
Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(continued)
erty Address. 24 Westhampton Road . Northampton. HA
.er: Todd 211zula
of Inspection: 8/23/01
HT OR HOLDING TANK: W® (tank must be pumped at time of inspection)(locate on site plan)
h below grade:
!vial of construction:_concrete metal _FRP_polyethylene_other(explain)
:nsions:
tcity: gallons
gn flow: _ gallons/day
m level: _ Alarm in working order Yes No
of last pumping:
invents: (conditions of inlet tees, condition of alarm and float switches,etc.)
SPOOLS- N/A (cesspool must be pumped as part of inspection) (locate on site plan
any)
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)
iments: (note soil conditions, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
VY: N/A (locate on site plan,if any)
erials of construction-
tensions:
rth of solids:
nments: (note soil conditions, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
EASE TRAP: NA (Usually present in certain commercial systems) (locate on site plan)
serial of construction: concrete _metal _FRP polyethylene other(explain)
rth below grade: inches
tensions: inches
m thickness: inches
i of scum layer to top of outlet tee or baffle: _ inches
torn of scum layer to bottom of outlet tee or baffle _ inches
e of last pumpingi
ttments: (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.)
e 5 Inspection Form 6/15/2000
page 8 of 10 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(continued)
24 Westhampton Road. Northampton. MA
Todd Zuzula
8/23/01
erty Address:
er:
of Inspection:
?EXAM
ice water
it Cellar
low wells
nated depth to ground water: 3.5 feet
-e indicate (check) all the methods used to determine high groundwater elevation:
IL Obtained from system design plan on record- If checked, date of design plan reviewed: 3/1/85 perc
_ Observed site(abutting property/observation hole within 150 feet of SAS)
_ Checked with local Board of Health-explain:
_ Check local excavators, installers - (attach documentation)
Accessed USGS database- explain:
must describe how you established the high groundwater elevation.
Ortainal_deep hole obsgrvation
VIMENTS:
;OURCES:
Department of Environmental Protection,Western Regional Office,436 Dwight St., Springfield,MA
01103, (413)784-1100;Title 5 Hotline-(800)266-1122
e 5 Inspection Form 6/15/2000
page 9 of 10 Homestead Inc.
Partial House Plan North
0
septic tank
Deck ,v
7 1/4' w
a
1
3 1/4
■11111111 1, D-box
Leachfield
Note: No drinking water sources within 100' radius.
Date: Owner: •
As-Built Drawing HOMESTEAD INC.
Existing Septic System 8/23/01 Todd Zuzula Thomas S. Leue R.S.
24 Westhampton Road / 'r ' ,"' �. . 664Cape st.
Scale: 1 : 16' Revision Date: Florence, MA 01062 ""� williamsburg,MA 01096
14131628-4533
Except as Noted 1