721 Septic Inspection May 2006 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification
1. Property Information
Property Address: 721 Westhampton Road No th
Owner's Name: gton am
ev R
Owner's Address: PO Box 384 . Ashfield, MA 01330
Date of Inspection: 5/30/06
Copy to: North
Board of Health, Northampton: Pat Goggins gains Realty
Number: SSDS-1073
2. Inspector:
Name of Inspector
Company Name:
Mailing Address:
Telephone Number
Thomas S. Leue
Homestead Inc.
1664 Cape St. , Williamsburg. MA 01096
4413-1-1
Certification Statement:
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: Conditionally Passes
Inspector's Signature: -/ , 5 iRte_____.
Date: May 30. 200€
the System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hearth of DEP)
vithin 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or
Treater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The
rriginal should be sent to the system owner and copies to the buyer, if applicable and the approving authority.
cotes and Comments:
"This report only describes conditions at the time of inspection and under the conditions of use at that
ne. This inspection does not address how the system will perform in the future under the same or different
tnditions of use.
?@45,4'$280 *3
nsp.doc• 11/2004
Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System
•nann t of in
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Certification (Cont.)
perty Address: 721 Westhampton Road Northampton. MA
ner' Name: Steve Barry
e of Inspection: 5/30/06
section Summary: Check A,B,C, D or E I 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
nments:
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.
• The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally
ound, exhibits substantial infiltration or exfitration, or tank failure is imminent. The system will pass inspection if
existing septic tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic
<will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank
ass than 20 years old is available.
explain: found leakiner septic tank. to be repaired or reol aced.
N Observation of sewage backup or break out or high static water level in the distribution box due to
ken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if
:h 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). The
tern will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
explain:
N Other: explain:_
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
ing 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
stem 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.
isp.doc•11/2004 Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
.nano o s-r In
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
:ertification (Cont)
*Hy Address: 721 Westhampton Road. Northampton. MA
ter Name: Steve Barry
of Inspection: 5/30/06
System will fail unless Board of Health(and Public Water Supplier, if any)determines that the system
motioning 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
=.r 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
or supply well'Method used to determine distance
his system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and
Rile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
)gen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy
to analysis must be attached to this form.
Other:
System Failure Criteria applicable to all systems:
I must indicate either"Yes° or°No° as to each of the following for all inspections:
5(Y)or NON)
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 My 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.
N 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
A 15.303, therefore the system fails. The system owner should contact the Board of Health should be contacted to
termine what will be necessary to correct the failure.
)MMENT-
nsp.doc•11/2004
Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
•nuna•2 n11n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Sewage Disposal System Form
ertification (Cont.)
erty Address: 721 Westhampton Road, Northampton MA
er Name: Steve Barry
of Inspection: 5/30/06
arge Systems:
a 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)
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
sped Zone II of a public water supply well)
u answered"yes°to any question in Section E the system is considered a significant threat, or answered"yes" in
tion D above the large system has failed. The owner or operator of any large system considered a significant
at under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The
em owner should contact the appropriate regional office of the Department.
Checklist
iLk if the following have been done You must indicate"yes" or"no"as to each of the followina:
3(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?
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 of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and
depth of scum?
e 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.
N b)Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
stance is unacceptable)[15.302(3)(b)].
The facility owner(and occupants, if different from owner)were provided with information on proper
aintenance of Subsurface Sewage Disposal Systems (SSDS).
nsp.doc•11/2004 Homestead Inc. Title 5 Offidal Inspection Form:Subsurface Disposal Seyste m
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
rty Address:
r Name:
N Inspection:
)ENTIAL
unknown
2
2
Y
Y
N
N
N/A
N
ontinuous
221 Westh• pton Road. Northampton.
Steve Barry
5/30/06
FLOW CONDITIONS
MA
DESIGN flow based on 310 CMR 15203(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)i
Date of last occupancy
IMERCIALIINDUSTRIAL
•of establishment:
gn flow(based on 310 CMR 15.203):® gpd
of design flow(seats/persons/sgft,etc.):
ise trap present(Y or N):
strail waste holding tank present(Y or N):
;r meter readings, if available:
date of occupancy/use:
IER(describe):
GENERAL INFORMATION
tying Records: Source of information: No information on previous pumpina, says
ter
tJ Was system pumped as part of the inspection(Y or N)
If yes, volume pumped: _ gallons—How was quantity pumped determined?_
Reason for pumping:
Comment: Recommend pumping as part of the repair. Somewhat overdue.
'E OF SYSTEM:
Septic tankariStierrtrrsoil adsorption system.
Single cesspool e�
Overflow cesspool
Privy
Shared system (Y or N) Of yes, attach previous in hedoonerecords, if operation and maintenance contract(to be
_ Innovative/Alternative technology. Attach copy
obtained from system owner)�.
Tight tank(Attach a copy of the DEP approval)
Other(describe):
tsp.doc•11/2004 Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
.na,.e t nnn '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
rty Address:
r' Name:
d Inspection:
721 Westhampton Road Northampton. MA
Steve Barry
5/30/06
ROXIMATE AGE All components, date installed, and source of info.
■tic plan: Age unknown, technology from late 1970 ' s.
-ce of Info: Owner, photographs
N Were sewage odors detected when arriving at the site (Y or N)
LDING SEWER (located on site plan)
24 Depth below grade (inches) FSflmated Averana
4 Distance in feet from private water supply well or suction line
cast iron Materials of Construction
nments: Located above water supply line.
'TIC TANK (located on site plan)
Concrete Materials of Construction
26 Depth below grade (inches)
0 Riser depth gnches)
42 Septic tank width (inches) Interior dimensions
88 Septic tank length (inches) Interior dimensions
50 Septic tank height (inches) Interior sltgamigni
802 Calculated gross volume (gallons) Calculated
20 Air space in tank (inches)
400 Net Volume (gallons) Calculated
24 Baffle depth (inches)
20 Sludge thickness (inches) Average
4 Scum thickness (inches) Averaoe
6 Top Sludge : Bottom Baffle (inches) Calculated
1 Bottom Scum : Bottom Baffle (inches) Calculated
17 Top Scum : Top Baffle (inches) Calculated
amments:
✓erdue for pumping. Must be pumped under Title 5 code.
riser over center to near surface would facilitate maintenance.
ater level indicates leakage, level below outlet despite usage.
eak probably at side seam, based on static water level.
ecommendations:
ump tank soon. Excavate exterior of tank to
id-seam, clean exterior grove and plaster with
ydraulic cement on all sides. Pump every 2 years.
rsp doc•11/2004 Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
rty Address:
Name:
4 Inspection:
/21 Westhampton Road Northampton. Ma
Steve Barry
5/30/06
IP CHAMBER
N Pump part of septic system: (Y or N)
Pumps in working order: (Y or N)
Alarms in working order: (Y or N)
intents:
FRIBUTION BOX (located on site plan)(•D-box")
N D-box part of septic system: (Y or N)
Depth of liquid level above outlet invert
invents:
L ADSORPTION SYSTEM(SAS): Technology Used (located on site plan by estimate):
leaching pits&number:
Y leaching chambers and number: 1500 gal. nominal concrete box
leaching galleries and number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system, Type:
nments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
surface issues, located adjacent to septic tank. Photo documentatir�M
flow has entered chamber for extended period of time.
AS not located
lain why:
;HT OR HOLDING TANK (tank must be pumped at time of inspection)
N 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
)mments: (conditions of inlet tees, condition of alarm and float switches, etc.)
sp.doc•11/2004 Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
rty Address:
r' Name:
if Inspection:
22-1 Westhampton Road, Northampton. NA
Steve Barry
5/30/06
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Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal Snyste^
ry
N
(locate on site plan, if any)
Privy part of system: (Y or N)
Materials of construction:
Dimensions:
Depth of solids:
iments:
(soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(SPOOLS
N
(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)
nments:
(note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.
EASE TRAP
N
(Usually present in certain commercial systems)
- Grease Trap part of system:N or N) - -
Materials of construction:
Depth below grade (inches) Measured
Dimensions:
Depth of solids layer
Depth of scum layer
Top of scum to top outlet Calculated Inches
Date of last pumping
Bottom of scum to outlet. Calculated Inches
Scum thickness (inches) Averals
imments:
(recommendation and conditions)
sp doc• 11/2004
Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal Snyste^
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
ty Address:
Name:
'Inspection:
721 Westhampton Road. Northampton. MA
,Steve Barry
i
E EXAM (Source of Information)
I Slope Official Pere Date
I Surface water Official Plan Date
I Check Cellar Other Official Source
N Shallow wells Other Source
60 Estimated depth to ground water (inches)
ase indicate(check) all the methods used to determine high groundwater elevation:
I Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Based on perc test in immediate area. Dry basement without
sump pump. Sandy soil.
trmation:
:SOURCES: Department of Environmental Protection, Western Regional Office,
6 Dwight St. Springfield MA 01103 (413)784-1100.Title 5 Hotline- (800)266-1122
;p.doc•1112004
Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal Saystem ref ill
nona
3
o
Hi
I /
I
Back yard face of house.
d. >Approx. 700 gallon net volume septic tank.
• • i.:;7
Approx. 1000 gal. leaching tank.
NORTH _
Note: No known drinking water sources within 100 foot radius.
COMMENTS:
Recommend pumping on a 2 year schedule. Also. a copy of this plan posted in the basement/utility
area would keep this information accessible in future years for maintenance.
As-Built Drawing Date: 1Owner: HOMESTEAD INC.
Existing Septic System 5/30/06 Steve Barry %=
Thomas S. Leue R.S.
721 Westhampton Rip. : 1664 Cape St.
Scale: 1 : 20' Revision Date: Northampton, MA 0106( °� Williamsburg,MA 01096
to 1g0 14131628-4533
Except as Noted