517 Septic Inspection 2008 Ter
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 517 Westhampton Road
Owner' Name: Marie Cooper
CitylTown: Northampton, MA 01060 Date of Inspection: 12/16/08
Certification (cunt.)
System will fail unless Board of Health (and Public Water Supplier,if any)determines that the system
unctioning 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
er 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
er supply well**Method used to determine distance_
his system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria
icates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided
t no other failure criteria are triggered. A copy of the analysis must be attached to this form.
Other:
System Failure Criteria Applicable to All Systems:
1 must indicate either YES(Y)or NO(N) as to each of the following for all inspections:
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
1 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.
V Liquid depth in cesspool is less than 6" below invert or available volume less than 1/2 day flow.
J Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of
times pumped
V Any portion of the SAS, cesspool or privy is below high ground water elevation.
1
My portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
supply.
V Any portion of cesspool privy is within a Zone I of a public well.
4 Any portion of cesspool or privy is within 50 feet of a private water supply well.
4 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 fecal coliform bacteria indicates absent 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.]
N The system is a cesspool serving a facility with a design flow of 2000 gpd-10,000 gpd.
4 The system fails: I have determined that one or more of the above failure criteria exist as defined in 310 CM
15.303, therefore the system fails. The system owner should contact the Board of Health should be contacted
to determine what will be necessary to correct the failure.
COMMENT
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 5) 7 Westhampton Road
Owner'Name: Marie COO$er
Cityrrown: Northampton, MA 01060 Date of Inspection: 12/16/08
ertification (cont.)
arge Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 to
)0 gpd. For large systems, you must indicate either YES(Y)or NO(N)as to each of the following, in addition to
uestions in Section D.
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
ped Zone II of a public water supply well)
I answered"yes°to any question in Section E the system is considered a significant threat, or answered"yes" in
ion D above the large system has failed. The owner or operator of any large system considered a significant
it under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The
rm owner should contact the appropriate regional office of the Department.
;hecklist
:k if the following have been done. You must indicate YES(Y)or NO(N)as to each of the following:
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 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 of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and
scum?
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:
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR15.302(5)1.
levised.doc•12/07 Title 5 Official Inspection Form:Subsurface Disposal System•Page 4 of 9
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/Page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 517 Westhampton Road
Owner Name: Marie Cooper
City/Town: Northampton, MA 01060 Date of Inspection: 12/16/08
'stem Information
ential Flow Conditions:
3 Number of bedrooms(design)
3 Number of bedrooms(actual)
526 DESIGN flow based on 310 CMR 15.203(for example. 110 gpd x#bedrooms)
2 Number of current residents
N Does residence have a garbage grinder?
N Is the Laundry a separate system? [If yes, separate inspection required]
N Laundry system inspected?
N Seasonal use?
N/A Water meter readings, if available (last 2 years usage) (gallons per day)
Y
tinuoua
Sump Pump? _
Last date of occupancy_
MERCIALJINDUSTRIAL
of establishment: _
In flow(based on 310 CMR 15.203): — gpd
a of design flow(seats/persons/sift, etc.):
se trap present?
atrial waste holding tank present?
sanitary waste discharge to the Title 5 system?
ar meter readings, if available:
date of occupancy/use:
ER (describe):
General Information
a ping Records: Source of information: pumped in 2007 , says Owner
N Was system pumped as part of the inspection (Y or N)
If yes, volume pumped:ggallons
How was quantity pumped determined?T
Reason for pumping:_P
Comment: Pump on 3 to 4 year interval.
e 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):
tevised.doc• 17/07 Title 5 Official Inspection Form:Subsurface Disposal System•Page 5 of 9
ation is
N for
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 517 Westhampton Road
Owner'Name: Marie Cooper
City/Town: Northampton MA 01060 Date of Inspection: 22/16/08
ystem Information (cont.)
roximate Age: All components, date installed, and source of info.
rtic plan: plan dated 3/18/08
N Were sewage odors detected when arriving at the site(Y or N)
ding Sewer:
12
3S plastic
40
7ments:
tic Tank:
9
Concrete
0
58
126
59
1,871
9
1,500
(locate on site plan)
Depth below grade (inches)
Material of Construction
Distance in feet from private water supply well or suction line
No problems seen.
Estimated Averaae
20
4
35
2
10
6
Measured How were dimensions determined?
mments:
perational or structural problems seen.
.ter level appropriate. Outlet and inlet tees used.
commendations:
.mp on 3 to 4 year interval.
(locate on site plan)
Depth below grade (inches)
Materials of Construction
If tank is metal, list age
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate)
Riser depth
Septic tank width
Septic tank length
Septic tank height
Calculated gross volume
Air space in tank
Net Volume
Bathe depth
Sludge thickness
Top Sludge . Bottom Baffle
Scum thickness
Bottom Scum : Bottom Baffle
Top Scum : Top Baffle
(inches)
(inches)
(inches)
(inches)
(gallons)
(inches)
(gallons)
(inches)
(inches)
(inches)
(inches)
(inches)
(inches)
jnterior dimensions
Interior dimensions
Interior dimensions
Calculated
Calculated
Averaae
ul
Average
Calculated
Calculated
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L\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Non is
I for
age.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
property Address: 517 Westhampton Road
owner Name: Marie Cooper
City/Town: Northampton MA 01060 Date of Inspection: 12/16/08
(stem Information (cont.)
se Trap: (Usually present in certain commerdal systems)
N Grease Trap part of system?
Depth below grade (inches) Measured
Materials of construction:
Dimensions:
Scum thickness (inches) average
Top of scum to top of outlet tee Calculated Inches
Bottom of scum to bottom of outlet tee calculated Inches_
Date of last pumping
imenfs: condition
it or Holding Tank: (tank must be pumped at time of inspection)
N Tight tank part of system?
Depth below grade (inches) Measured
Materials of construction
Tank width Tank length (inches)
Tank height Capacity (gallons)
Design flow: gallons/day
Alarm Level (inches)
Alarms in working order?
Date of last pumping
nments: (condition of alarm and float switches, etc.)
Attach copy of current pumping contract(required). Is copy attached?
it Absorption System(SAS):
AS not located
lain why:
(locate on site plan, excavation not required):
leaching pits&number:
leaching chambers and number:
leaching galleries and number:
leaching trenches, number, length:
Y leaching fields, number, dimensions: 20 ft. by 40 ft.
overflow cesspool, number:
innovative/alternative system, Type:
mments: (note soil condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
surface problems seen. —I
vised doc•12/07 Tie 5 Official Inspection Form:Subsurface Disposal System•Page 7 of 9
j Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 517 Westhampton Road
Owner'Name: Mari a C000er
City/Town: Northampton, MA 01060 Date of Inspection: 12/16/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ilan is
I for
age.
/stem Intormatlon (cant.)
ribution Box: Of present must be opened) (locate on site plan) ("D-box")
Y D-box part of septic system?
0 Depth of liquid level above outlet invert Inches
tments(note if box is level and distribution to outlets equal, any evidence of solids carryover, and
of D-box, etc. Box level and flow distributed.
significant biosolids seen.
rip Chamber: (locate on site plan)
N Pump part of septic system?
Pumps in working order. (Y or N)
Alarms in working order: (Y or N)
nments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
;spools: (cesspool must be pumped as part of inspection) (locate on site plan)
N Cesspool part of system?
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
nments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
ry: (locate on site plan)
Privy part of system?
Materials of construction:
Dimensions:
Depth of solids:
nments: (soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
e Exam: (Source of Information)
Y Check Slope 6/11/02 Official Perc Date
Surface water 3/18/03 Official Plan Date
Y Check Cellar Other Official Source
N Shallow wells Other Source
90 Estimated depth to ground water (inches)
lase indicate 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:
Checked with local excavators, installers -explain:
u must describe how you established the high ground water elevation:
:pth to groundwater in perc test.
vised.doc•12107 Title 5 Official Inspection Form:Subsurface Disposal System•Page 8 of 9
Iu.. flaw, _1
Partial House Outline ,„i-
Ft I
-
NORTHI
J- -22 y�q o �A to
d
.
—
Septic Tank -1�, \ '? Distribution Box
/
/ /
/
/, /
/
J
Leachfield, approximate layout -
COMMENTS:
Recommend pumpina on a 3 to 5 year schedule. Also, a copy of this plan posted in the
basement/utility area would keep this information accessible in future years for maintenance.
M , HOMESTEAD INC. %
As-Built Drawing
Date: Owner: - .
Existing Septic System 12/16/08 Marie Cooper _` � Thomas S. Leue R.S.'MOOS S.
517 Westhampton R. .
Scale: l : 20 Revision Date Florence, MA 01062 / ^ pr arm b g,Mwo1a96
,�t� 1413]628-4533
Except as Noted D e�
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age.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 517 Westhampton Road
Owner'Name: Marie Cooper
CityfTown: Northampton, MA 01060 Dateoflnspection: 12/16/08
inspection results must De suomittea On mis rerrll. Inspection rorms may not De altered in any way.
Owner Address: 517 Westhampton Rd. Florence MA 01067
Copy to: Hoard of Health. Northampton Ray Hi tpnld. ,Tnnea-Rutrhina
Witness: Homestead Inc.#: ssn6-1101
A. General Information
1. Inspector
Name of Inspector Thomas S. Leue R.S.
Company Name: jipmestead Inc.
Company Address: 1664 Cane St . Williamsburg, MA 01096
Telephone Number. 441.31 628-4533 License Number: 51130
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the information
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 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
The system condition: Passes
Inspector's Signature:
Lih,et-o 5 Date: 12/16/08
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 to the
buyer, if applicable, and the approving authority.
""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
or different conditions of use.
vised doc•12107 Title 5 Official Inspection Form:Subsurface Disposal System•Page 1 of 9
ton Is
Ifor
rge.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 517 Westhampton Road
Owner'Name: Marie Cooper
CitylTown: Northampton MA 01060 Date of Inspection: 12/16/08
rtification (cont.)
:tion Summary: Check A, B, C, D or E 1 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.
lents:
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.
r yes, no, or not determined (Y, N, or 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
rid, exhibits substantial infiltration or exriltration, 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.
tal septic tank will pass inspection if it is structurally sound not leaking and if a Certificate of Compliance
ling that the tank is less than 20 years old is available.
plain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
acted pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval
Board of Health): broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
:plain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
nspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
(plain:
urther 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.
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