597 Septic Inspection 2000 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application for Binomial 31Worhs fQonstr..,.�^
Application k hereby made for a Permit to Construct +s+alltnrrmtt
System at: ( ) or Repair (� an Individual Sewage Disposal
Y
Location-Aad.ess ..... ............. .._.
or Lou no. ........._......_....
Owner
Address
Installer .._....._._._
Type of Building
Address
Dwelling—No. of Bedrooms.................................... ..... Size Lot_.._.._._..........
Other- - Expansion Attic r feet
Type of Building -
g ---..-_.._._...._ ( ) Garbage Grinder ( )
- -. No. of persons.._..._._._.._.. Showers
Other fixtures ...._...._..-..._._... .. ( ) — Cafeteria ( )
Design Flow .. .._._..._.._. -
ons per person per day. ..d.i.y._.__._.._._...__......_.._._......_........_.._..
Septic Tank—Liquid capacity_.._._..-gaflons Length.__P._._. Width-I daily floDiametea._._.�-.. Depth_.._.._._..
Disposal Trench— - gallons
ft.
No. _.._.._.._.._.. Width._.._._.._._... Total Length..._._.._.._... Total leaching area
Seepage Pit No Dimneter.._._.._..
Other Distribution box g t.. Depth below inlet
........_..,...,.. Total leaching area s ft.
( ) Dosing tank ( ) q,
Percolation Test Results Performed by...._.._.._._... _
Test Pit No. 1_... minutes per inch Depth of Test Pit_
Test Pit No ._._- -__ Depth to ground water._._.._.._._..._..
Date...................... .. ......
. 2............ minutes per inch Depth of Test Pit__ Depth to ground water
Descriptionof Soil
.................._._......._._....._..................._.._
vaturc of - _.. .
-
Repairs or Alterations Answer when applicable ....•
gr tint: /
"'"..:..
The undersigned agrees to install the aforedescribed Individual Sewage Dis
le provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
teration until a Certificate of Compliance has been issued by the board of health.
Disposal'System in accordance with
n
PPlication Approved B •
Signed ..., . -
?plicuion Disapproved
.................Disapproved for the following reasons:..__.._.._.._._.._._.._ _.._._-..,...-
Date
__.••"'
_.._..._._._.._._..._......_._....._._.._._.._....._._._Date
Permit No..._...._;:_
.... Issued
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Tgrtifiratr of atnittplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (Vi
by
at -
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No tit dated lire
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAIRANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector r
No
Permission
o Construct (
N
THE COMMONWEALTH OF MASSACHUSETTS
H EA LTH
BOARD OF
-74 OF
iltivrinal arks Tunstruninn Ignittit
is hereby granted "i""
) or Repair (p") an Individual *wage Disposal System
t o
street
s shown on the application for Disposal Works Construction Permit No
,f
DRM 1255 MOBS & WARREN. INC., PUBLISHERS
FEE
Dated
Board of Heakh
3O PAUL CELLUCI
erty Address:
er's Name:
ar's Address:
to:
ass:
9 of Inspector:
pany Address:
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF.
DEPARTMENT OF ENVIRONMENTAL PROTECTI
ONE WINTER STREET,BOSTON MA 02198(617)292-5500
TRUDY COXE
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
597 Westhampton Rd., Northampton, NA Date of Inspection: 7/18/00
Susan Christenson
c/o JC a Co., PO Box 571, Northampton, NA 01060
Board of Health, Northampton;
Jim Demos Number: SSDS-456
Thomas S. Leue Company Name: Homestead Inc.
1 am a DEP approved system Inspector pursuant to Section 15.340 of 1111e 5(310 CMR 15.000)
1664 Cape St. , Williamsburg, MA 01096 Telephone: (413) 628-4533
fIFICATION STATFMFNT
ity that I have personally inspected the sewage disposal system at this address and that the Information reported is true,accurate
wmplete as of the time of the inspection. The inspection was performed based on my training and experience In the proper
on and maintenance of on-site sewage disposal systems. I do not represent or warrant the operation or proper function of this
m for any period of time. The septic system conditbn must be evaluated and classlied into one of the following four conditions:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
ystem condhion: passes
ctor's Signature:
Date: July 18. 2000
ystem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this Inspection. If the
r is a shared system or has a design lbw of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
al office of the Department of Environmental Protection. The original should be sent to the system owner and copies to the buyer,ff applicable
e approving authority.
ECTION SUMMARY:Check A, B, C, or D:
SYSTEM PASSES:
_ I have not found any information which indicates that any of the failure criteria as described In 310 CMR 15.303 exist. Any
failure criteria not evaluated are Indicated below.
MENTS.
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.
de yes,no,or not determined(Y, N,or ND).Desert*basis of determination in all instances. (11 not determined,explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate -
of Compliance(attached)indicating that the tank was Installed within twenty(20)years prior t0 the date of the
Inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exliltration,or tank failure is Imminent. The system will pass Inspection tt the septic tank is replaced with a complying
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). Describe observations:
broken pipe(s)are replaced
obstruction's removed
distribution box is levelled or replaced
ed 9/2/98 Page 1 of 7 Homestead Inc.
arty Address:
sr's Name:
of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A - CERTIFICATION (continued)
597 Westhampton Rd. , Northampton, MA
Susan Christenson
7/18/00
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
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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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.
I) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS PUBUC HEALTH AND SAFETY
AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)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 SAS and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and a SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and a SAS and the SAS is Tess than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for colilorm 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.Method used to determine distance (approximation not valid).
I) OTHER
SYSTEM FAILS:
Indicate either'Yes"(Y)or"N0"(N)as to each of the following:
I have determined that 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.
or NO
Backup of sewage Into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or frontline of effluent to surface of the ground or surface waters due to an overloaded or dogged 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 year NOT 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 feet of a surface water supply or a tributary to a surface water supply.
Any portion of a cesspool,privy or any portion of the Soil Absorption System is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply.
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
quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for col0orm bacteria,volatile
tic compounds,ammonia nitrogen and nitrate nitrogen.
LARGE SYSTEM FAILS:
ollowing criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 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 It of a public
water supply well)
wner or operator(Many such system shall upgrade the system in accordance with 314 CMR 15.304(2). Please consult the local
mi office of the Department for further information.
ed 9/2/98 Page 2 of 7 Homestead Inc.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B-CHECKLIST
erty Address: 597 Westhampton Rd., Northampton, MA
er's Name: Susan Christenson
of Inspection: 7/18/00
CK IF THE FOLLOWING HAVE BEEN DONE:
or NO
Pumping information was provided by the owner,occupant or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal Clow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
flk As built plans have been obtained and examined. Note 11 they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components,excluding the Soil Absorption System,have been located on site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
as, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
e size and location of the Soil Absorption System on site has been determined based on.
a) Existing information on file with the Board of Health.
b) Determined in the field(i1 any of the failure criteria related to Part C is at issue,approximation of distance is
ceptable)If 5.302(3)(b)].
The facility owner(and occupants,if different from owner)were provided with information on proper maintenance of
surface Sewage Disposal Systems(SSDS).
FLOW CONDITIONS
IDENTIAL:
unknown
3
995+
2
N
Y
N
N
N/A
N
vontin n,te
Design Flow gallons/day/bedroom for SAS
Number of bedrooms.(design)
Number of bedrooms(actual)
Total DESIGN flow gpd
Number of current residents
Is there a Garbage grinder?(Y or N) _
Is there a Laundry Hookup?(Y or N)
15 the Laundry a separate system?(Y or N) (If yes,inspection required)
Seasonal use(Y or N)
Water meter readings, it available(last two years usage)(gallons per day)
Sump Pump(Y or N)_
Date of last occupancy_
PING RECORDS and source of information:
po information.
System pumped as part of inspection(Y or N)
If yes,volume pumped:
Reason for pumping:
gallons
Comments: Recommend rmmoino at this time.
age odors detected when arriving at the site:
ROXIMATE AGE of all components,date installed(if known)and source of information:
Said to be built in 1950's from Owner's information
.ed 912/98 Page 3 of 7 Homestead Inc.
arty Address:
ar's Name:
of Inspection:
OF SYSTEM:
Septic tank/CiriaiGtMiwbeSCsoil adsorption system.
Single cesspool
Overflow cesspool
Privy
Shared system(Y or N),if yes,attach previous inspection records, it any.
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank
Other(explain)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C-SYSTEM INFORMATION
597 Westhampton Rd. , Northampton, MA
Susan Christenson
7/18/00
GENERAL INFORMATION
DING SEWER: X. (located on site plan)
Average depth below grade
Material of construction: X cast iron _Sch.40 PVC _other(explain)_
Distance from private water supply well or suction line
Diameter
rents:(condition of joints,venting,evidence of leakage,etc.) No problems seen.
-IC TANK: $ (located on site plan)
Average depth below grade
rlel of construction: X concrete metal_FRP polyethylene other(explain)
t is metal,list age_Is age confirmed by Certificate of Compliance(Y or N)
Septic tank width(inches)
Septic tank length(inches)
Septic tank height(inches)
Calculated gross volume(gallons)
Air space in tank(inches)
Net Volume(gallons)
Baffle depth(inches)_
Sludge Thickness Average
Scum thickness(inches) (Ave vane 1
Top of sludge layer to bottom 01 outlet tee or baffle(inches)
Bottom of scum layer to bottom of outlet tee or baffle(inches)
Top of scum layer to top of outlet tee or baffle(inches)
dimensions were determined: Measured
nents: (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.)
[filet removable baffle deteriorated and should be replayed with tee. Riser over
inlet and central cleanout to within 6" of surface. Riser over central cleanout
rtructurallv unsound and could collapse into tank possibly trapping a person or
nimal. This cover surrounded with warning tape. but a more oermanant repair is
&commended at the first opportunity.
;ed 9/2/98 Page 4 of 7 Homestead Inc.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C-SYSTEM INFORMATION(continued)
party Address: 597 Westhampton Rd. , Northampton, NA
ner's Name: Susan Christenson
e of Inspection: 7/18/00
EASE TRAP: Nth (Usually present in certain commercial systems)
)th below grade: _
erial of construction:_concrete_metal_FRP_polyethylene_other(explain)
ensions: _ (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
(D) date of last pumping
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.)
TRIBUTION BOX: n(8 (locate on site pan)("D-box")
th of liquid level above outlet Invert:
Iments: (note if level and distributions equal, evidence of solids carryover, evidence of leakage into or out of box,
immendations for repairs,etc.) No d-box in system. single pine from seoti c to leach tank
L ADSORPTION SYSTEM(SAS); y
de on site plan, tf possible;excavation not required,but may be approximated by non-intrusive methods. If not located,explain:
leaching pits 8 number: one pi t found not opened
leaching chambers and number:
leaching galleries and number:
leaching trenches,number,length'
leaching fields,number,dimensions'
overflow cesspool,number:
Alternative system, name technology:
Comments: (note soil conditions,signs of hydraulic failure, level of ponding,condition of vegetation,recommendations for
maintenance or repairs,etc.)
problems seen on surface.
SPOOLS: Eg (locate on site plan,if any)
Cesspools must be pumped as part of the inspection.
Number and configuration:
Depth-top of Iiqufd 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 pad of inspection)
Tents: (note soil conditions,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
'Y: )(/A (locate on site plan,If any)
rials of construction
nsions:
1 of solids:
rents: (note soil conditons,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
red 9/2/98 Page 5 of 7 Homestead Inc
erty Address:
Dr's Name:
of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C-SYSTEM INFORMATION(continued)
597 Westhampton Rd., Northampton, MA
Susan Christenson
7/18/00
P CHAMBER: NSA (part of pump-up systems only)
is in working order:(Y or N)
is in working order:(Y or N) _
rents:(note condition of pump chanter,condition of pumps and appurtenances,etc.)
T OR HOLDING TANK: $IA
1 bebw grade:
rial of construction:
nsions:
city:
In flow-
1 level:
nents: (conditions of
(Special circumstances only)
_concrete_metal_FRP polyethylene other(explain)
gallons
gallons/day
Alarm in working order Yes No
inlet tees,condition of alarm and float switches,etc.)
MATED DEPTH TO GROUNDWATER: >74 inches
3 Report name
Soil Type
Typical depth to groundwater
3 Date webslte visited
Observation Wells checked
Groundwater depth: Shallow_ Moderate_ Deep_
EXAM Slope
Surface water
Check Cellar
Shallow wells
;8 indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plan on record
Observation of Site(Abutting property,observation hole,basement sump,etc.)
Determine it from local conditions
_ Check with local Board of Health
_ Check FEMA Maps
_ Check pumping records
Check local excavators, installers
_ Use USGS Date
ribe how you established the High Groundwater Elevation (Must be completed)
Dry ridge, abuttor's property has no groundwater to below this depth
1L
MENTS:
DURCES:
Department of Environmental Protection,Western Regional Office,436 Dwight St.,Springfield,MA 01103, (413)784-1100;
Title 5 Hotline-(800)266-1122
;ed 9/2/98 Page 6 of 7
Homestead Inc.
!ILIUM I1U Ill/WW/11.111/1R1119 Milt' 5UUICCS MUMM 1UV raaIUS.
Leaching Pit
\r:11..
Septic tank +,
Called North o
ti*
Partial House Plan I -
Porch
As-Built Drawing Date: Owner:
r
Existing Septic System
7/18/00 Susan Christenson n HOMESTEAD INC.
597 Westhampton Rd. Thomas S. Leue R.S.
Northampton, MA 01060 1
Scale: 1 : 20' Revision Date: � . 1664 Cape St.
Williamsburg,MA 01096
` Except as Noted \ ' s 1413162 -4533