669 Septic Inspection 2003 TITLE 5
OFFICIAL INSPECTION FOR• NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 669 Westhampton Ro ' - -' tha t MA
Owner's Name: Dr.Robert Grossman
Owner's Address: 669 Westhampton Road
Northampton.MA 01062
Date of Inspection: April 23,2003
Name of Inspector:Alan E. Weiss. R.S#933
Company Name: Cold Spring Environmental Mc
Mailing Address: 350 OIdE f ldR d
BelcI,ertown,Massachusetts 01007
Telephone Number:(413)323-5957 fax:413-323-4916
CERTIFICATION STATEMENT
1 certify that 1 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 system:
_XX Basses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
�'Fails
Inspector's Signature: • ¢/�,t/ Date: April 23, 2003
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 sent to
the buyer, if applicable,and the approving authority.
Notes and Comments
L.Tank was in good condition, (5 ft.diameter with 20" of liquid noted,50"to
effective height). S. Tank was in good condition (Karin put new outlet tee on)). No
signs of hydraulic failure noted. System serves front bathroom.
****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
different conditions of use.
1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 669 Westhampton Road
Owner: Grossman
Date of Inspection: April 23,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
XX I have not found any information which indicates that any of the failure criteria described in
310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments: System is old however,liquid and staining is below inlet pipe invert at 1.tank.
B. 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,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 unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will
pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass
inspection if(with approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
_ The system required pumping more than 4 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
ND explain:
2
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: : 669 Westhampton Road
Owner: Grossman
Date of Inspection:April 23,2003
C. 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 public health,safety or 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 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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)detercines
that the
system 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 feel
of a surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private wate].-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 water supply well**.Method used to determine distance
**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.
3. Other:
3
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: : 669 Westhampton Road
Owner: Grossman
Date of Inspection: April 23,2003
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_x_ 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 is less than'A day flow
_x_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped—
_x_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
x_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
x_ Any portion of a cesspool or privy is within a Zone l of a public well.
_ x Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ x_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well 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.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist
as described in 310 CMR 15.303,therefore the system fails.The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system i
ithin 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-I W PA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section ID shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: : 669 Westhampton Road
Owner: Grossman
Date of Inspection: April 23,2003
Check if the following have been done.You must indicate"yes"or`no"as to each of the following:
Yes No
__ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
x Has the system received normal flows in the previous two week period?
x Have large volumes of water been introduced to the system recently or as part of this inspection
_VA Were as built plans of the system obtained and examined?(If they were not available note as N/A)
2_ Was the facility or dwelling inspected for signs of sewage back up?
5_ Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
I
_x _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum 7
x _ 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:
Yes no
X Existing information.For example,a plan at the Board of Health.
_x_ _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(611
5
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: : 669 Westh.motor}Road
Owner: Grossman
Date of Inspection:April 23,2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): ? Number of bedrooms(actual):j-4_
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): e
Number of current residents:2_
Does residence have a garbage grinder(yes or no): Yes-NOT RECOMMENDED
Is laundry on a separate sewage system(yes or no)}: YES [if yes separate inspection required]
Laundry system inspected(yes or no):YE5
Seasonal use:(yes or no):1±€.5
Water meter readings,if available(last 2 years usage(gpd)): N/a
Sump pump(yes or no):Yom_
Last date of occupancy: CURRENT
COMMERCIAL/INDUSTRIAL
Type of establishment:N/A
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft eta):
Grease nap present(yes or no):,
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(ves or NOT
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe)
GENERAL INFORMATION
Pumping Records
Source of information: Unknown
Was system pumped as part of the inspection(YES or no): Yes
If yes,volume pumped: 1000 gallons--How was quantity pumped determined?lleasured
Reason for pumping: REOUEST
TYPE OF SYSTEM
x Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a 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):
Approximate age of all components,date installed(if known)and source of information:30+/-years
Were sewage odors detected when arriving at the site(yes or no):NO
6
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: : 669 Westhampton Road
Owner: Grossman
Date of Inspection: April 23,2003
BUILDING SEWER(locate on site plan)
Depth below grade:-18"
Materials of construction: X_cast iron _40 PVC other(explain):
Distance from private water supply well or suction line; 10'+
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:Yes(locate on site plan)
Depth below grade:_310_
Material of construction:X concrete metal fiberglass polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a
copy of certificate)
Dimensions: 4.'w x 8.'I x 4.5'4
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle:.3_
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc): TANK CONDITION OK
S. tank has built in inlet bye and needed new outlet Tee instated by Karts.
GREASE TRAP:N/A(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
7
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: • 669 Westh oto Roe
Owner: Grossman
Date of Inspection:April 23,2003
TIGHT or HOLDING TANK: NO_(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene otherexplain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alann present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: NO(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc.):
minimal carry over
PUMP CHAMBER:JN.Q_(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: • 669 Weslh pton R oad
Owner: Grossman
Date of Inspection:April 23,2003
SOIL ABSORPTION SYSTEM(SAS): YES (locate on site plan,excavation not required)
If SAS not located explain why:
Type
1_leaching pits,number: 5 ft.diam.5 ft.deco,20"liquid(buried 3 ft.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
irmovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.):No signs of failure stone ok, and no Groundwater Top of LT(a)36"
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
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(yes or no):
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
PRIVY:N/A(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc):
9
age 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
)caner: 6^of5mar.J
)ate of Inspection: A z3 \o3
;KETCH OF SEWAGE DISPOSAL SYSTEM
'rovide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
lenclmaarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
5tih# I ELrcn_)
k-c z ( cu)
0
-
100'4
r
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pts/z,
_ c'J1Anh 11
_ ear tet*c55
_ LtSUaAliPRw`=20
12 ILL
>=4 Fvy �r, ■eA�
_ef,c Nk =vc0`- le6
NC cdf4in000)" pipe. I-waft,
IIeS
5 '
y etn = 15 '
131
OLPz = 11
Tier 5 In nertinn Form fill ifMf
10
_ Mo 57R vr :6 coot
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Aaz = za'
–7r=zu-' 391 = z9
G—`/= 291 c,z = SiI
Uw r= SL ra z= Yg1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: : 669 Westhampton Road
Owner: Grossman
Date of Inspection: April 23,2003
SITE EXAM
Slope YES
Surface water
Check cellar YES `Dry
Shallow wells
Estimated depth to ground water 9-10'+/-feet
Please indicate(check)all methods used to determine the high ground water elevation:
N/A Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
au a.11 hed i hi h r' ndw: levati
Water lave used on in-site d
grade comma 50-75 feet away.
11
top
TITLE 5
OFFICIAL INSPECTION FOR- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 669 Westhampton Roaorthampton MA
Owner's Name: Dr.Robert Grossman
Owner's Address: 669 Westhampton Road
Northampton MA 01062
Date of Inspection: April 23.2003
Name of Inspector:Alan E. Weiss R.S it 933
Company Name: Cold Spring Environmental Inc.
Mailing Address: 350 Old Enfield Road
Belchertown.Massachusetts 01007
Telephone Number: (4131 323-5957 fax 413-323-4916
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 s
disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of'Fide 5
(310 CMR 15.000). The system:
XX Passes
_Conditionally Passes
Needs Further Evaluation by the Local Approving Author
Tits
Inspector's Signature: - :'(' Date: April 23, 2003
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 sent to
the buyer,if applicable, and the approving authority.
ty
Notes and Comments
L.Tank was in good condition, (5 ft. diameter with 36"of liquid noted,42-44" to
effective height). S.Tank was in good condition(baffles built in across). No signs of
hydraulic failure noted. Serves back bathroom, kitchen and laundry.
****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
different conditions of use.
1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 669 back Westhampton Road
Owner: Grossman
Date of Inspection: April 23,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX I have not found any information which indicates that any of the failure criteria described in
310 CMR 15303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:_System is old however,liquid and staining is below inlet pipe invert at 1.tank._
13. 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,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 unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will
pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)of due to a broken,settled or uneven distribution box. System will pass
inspection if(with approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
_ The system required pumping more than 4 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
ND explain:
2
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: ; 669(back)Westhampton Road
Owner: Grossman
Date of Inspection:April 23,2003
C. 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 public health,safety or 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 public health,safety and the
environment:
Cesspool or privy is within 56 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines
that the
system 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 surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 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 water supply well**.Method used to determine distance
**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.
3. Other:
3
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: ' 669 (back)Westhampton Road
Owner: Grossman
Date of Inspection:April 23,2003
11 System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for ai inspections:
Yes No
x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_x, Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_x Liquid depth in cesspool is less than 6"below invert or available volume is less than Vi day flow
,x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
y_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
x_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
x_ Any portion of a cesspool or privy is within a Zone I of a public well.
_x Any portion of a 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 well 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.'
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist
as described in 310 CMR 15303,therefore the system fails.The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
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 II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: : 669(back)Westhampton Road
Owner: Grossman
Date of Inspection: April 23,2003
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
x Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
_x _ Has the system received normal flows in the previous two week period?
g Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
x Was the facility or dwelling inspected for signs of sewage back up?
x Was the site inspected for signs of break out?
g _ Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
x _ 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:
Yes no
g_ _ Existing information.For example,a plan at the Board of Health.
x _ Determined in the field(if any of the failure criteria related to Pan C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' SYSTEM INFORMATION
Property Address' • 669(back)Westhamoton Road
Owner: Grossman
Date of Inspection: April 23,2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): ? Number of bedrooms(actual):3_
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): ?
Number of current residents:_2_ Jg
Does residence have a garbage grinder(yes or no):yes-NOT RECOMMENDED
Is laundry on a separate sewage system(yes or no) YES [if yes separate inspection required]
Laundry system inspected(yes or no):YES
Seasonal use:(yes or no):_YES
Water meter readings,if available(last 2 years usage(gpd))' N/a
Sump pump(yes or nop
Last date of occupancy: CURRENT
COMMERCIAL/INDUSTRIAL
Type of establishment:N/A
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
N n-sanitary waste idhschahled to the Title 5 svltem Dues or NO}:
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe)
GENERAL INFORMATION
Pumping Records
Source of information:Unknown
Was system pumped as part of the inspection(YES or no): Yes
If yes,volume pumped:Z2gallons—How was quantity pumped determined?Measured
Reason for pumping:REOUEST
TYPE OF SYSTEM
s Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology.Attach a 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):
Approximate age of all components,date installed Of known)and source of information:25+/-years
Were sewage odors detected when arriving at the site(yes or no):NO
6
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: • 669(back) Westhampton Road
Owner: Grossman
Date of Inspection: April 23,2003
BUILDING SEWER(locate on site plan)
Depth below grade: -18"
Materials of construction:_X cast iron _40 PVC other(explain):
Distance from private water supply well or suction line: 10'+
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: Yes(locate on site plan)
Depth below grade: 30"_
Material of construction:X_concrete metal fiberglass polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a
copy of certificate)
Dimensions 4.'w x 8.1x 4.5'd
Sludge depth: ]4"
Distance from top of sludge to bottom of outlet tee or baffle: 44"
Scum thickness:_3
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):_TANK CONDITION OK
S.tank has built in cross baffles
GREASE TRAP: N/A(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or battle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc):
7