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878 Septic Inspection 2002 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECT .1/ TITLE 5 �MPr- q` OFFICIAL INSPECTION SUBSURFACE FORM EWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 8 7 CO Owner's Name: Owner's Address: Date of Inspection: Name of Inspector:(please pA tPamela / Cary Bissell Company Name:Affordable Domino eptic Inspections Inc Mailing Address:_51 Laurel St._ _Holyoke<Ma.01040 Telephone Number:413-532-8600 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.lam a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: /Passes _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Q Inspector's Signature: 'Fd rodeo- �V r:a kd t4 Date: 1/1/69— 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 ****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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL AYSTEM INSPECTION FORM PART CERTIFICATION (continued) Property Address: CakeOwner: Date of inspection: Inspection Summary: Chec6B,C,D or E f ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 1 03 or in 310 CMR 15.304 exist.My failure criteria not evaluated are indicated below. Comments: 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 = k failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic t ., as approved by the Board of Health. •A metal septic tank will pass inspection if i ' structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 ,.: s old is available. NI)explain: Observation of ge backup or break out cc high static water level in the distribution box due to broken or obstructed pipe(s) ue to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Boar. •CHealth): 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 wi11 pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page ofll OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM TS PART A CERTIFICATION(continued) C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by Board of Health in order to determine if the system is failing to protect public health,safety or the envir""- I. System will pass unless Board of He determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a m er which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water te elated wetland or a salt marsh Cesspool or privy is within 50 feet of a bordering g 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 rypply. The system has a septic tank and and the SAS is within a Zone 1 of a public water supply. _ The system has a septi r k and SAS and the SAS is within 50 feet of a private water supply well. The system ha : septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water •• y well".Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform ity and bacteria and volatile organic compounds indicates that the well is free from pollution from that ilno other the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided faihre criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. Page 4 of I I OFFICIAL UBSURFACE SEWAGE FORM POSAL SYSTEM INSPECTION FORM ASSESSMENTS-NOT PART A CERTIFICATION(continued) Property Address: t7 Owner: Date of Inspection D. System Failure Criteria applicable to all systems: You must indicate`yes"or`no"to each of the following for all inspections: Yes No Discharge of orwagainto of effluent to the surface of the ground or surface waters dogged e to an overloaded ce or clogged SAr ponding clogged 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 is less than 6"below invert or available volume obstructed to y fl o).Number Required pumping more than 4 times in the last year NOT due to clogged times pumped • J My portion of the SAS,cesspool or privy is below high ground water elevation. 7_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. —T/ My 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 conform 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.) (Yes/No)The system fails.]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 gld. 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 wi 00 feet of a surface drinking water supply the sys is within 200 feet of a tributary to a surface drinking water supply system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)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 D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL SUBSURFACE SEWAGE D SPOSAL SYSTEM INSPECTION FORM ASSESSMENTS PART B CHECKLIST Property Address: (,(� Owner. Date of Inspection: Check if tbe followin:have been done.You most indicate` es"or"no"as to each of the followi yes No I 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 this inspection? _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage backup? Was the site 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 tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of 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: Yss no Existing information.For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(6)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL R SYSTEM INSPECTION FORM SYSTEM INFORMATION Property Address: $ Y Lt.) • """K*1" Owner: Date of Inspection: FLOW CONDITIONS RESiDENPIAL actual);a. bedrooms design): Number of bedrooms(actual):k of bedrooms) 30 95�°�" Number IGN of fw based ( rd DESIGN flow based on 310 Cpfli\15203(for example: 110 gpd � Nab Number of current ce have residents: a der(yes or no): attar^^'P-°g Does residence have a garbage grin Of yes separate inspection required) Is laundry on a separate sewage system(Xes or no): [ Y P Laundry system inspected(yes or no): n A Seasonal use:(yes or n f available(labt 2 years usage gpd)):T U'k_'`''- Sump p meter readings, ): env-�rsP Sump pump(Yes or no): Last date of occupancy COMMERCIAL/INDUSTRIAL Type of establishment: gpd Design flow(based on 310 CMR Basis of design flow(seats/ onshgft,etc'): Grease trap present "' ' no): Industrial waste I ,ing tank present(yes or no):-- Non-sanit .ste discharged to the Title 5 system(y es or no):— Water , er readings,if available:�---- Last „ e of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Was system steinformation:pumped as part of the inspection Was solum lions--Ho If yes,volume pumped:__gallons Reason for pumping:_----- TYEE OF SYSTEM i/Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Of attach previous inspection records,if any) Innovative/Alternative system(yes or technology.( yes, of the current operation and maintenance contract(to be _hmrrvativdAltematrve technology.Attadr a copy obtained from system owner) Tight tank _Attach a copy of the DEP approval /tn or ro): determined? was quantity pumped Other(describe): Approximate age ,f: I components,date tg lied(if kn, )and ource of information: Were sewage odors detected when arriving at the site(yes or no):to Page 7 of II OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL YSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:SA,` A, Ki) Owner: I Date of Inspection: a BUILDING SEWER(locate on site plan) 1 r Depth below grade: 3 ha- Materials of construction:_cast iron 1_40 PVC_other(ex I ):- Distance front private water supply well or suction line: Comments ; condition of Joints,venting, den a of leakage,e SEPTIC TANK: r (locate on site plan) Depth below grade: aza Material of constructs concrete metal fiberglass polyethylene other(explain) If tank is metal list age: age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: ro %a X 5 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle: 1/4.93 Scum thickness: Distance from top of scum to top of outlet tee or baffle: 7 " Distance from bottom of scum to bottom of outlet tee or baffle: `" How were dimensions determined: 31 - - integrity, q Comments(on pumping recommendations,in h t, d • tiet or baffle ci dition,structural liquid levels • as re l. 40 to quflet ipyer,evidence of leakage,etc.): elf ;WYE— Mr GREASE TRAP: (locate on site plan) Depth below grade:_ other Material of construction: concrete metal_fiberglass polyethylene (explain):_ Dimensions Scum thyi Din[ 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: integrity,liquid (on pumping recommendations,inlet and outlet tee or baffle condition,structural inn i li uid leve s as related to outlet invert,evidence of leakage,etc.): Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: P 78 wa �r Owner: 'E• Date of Inspection: TIGHT or HOLDING TANK: must be pumped at time of inspection)(locate on site plan) Depth below grade: fiberglass_polyethylene_other(explain): Material of construction:_concrete metal Dimensions: Capacity: Design Flow: Alarm pre Alarm el. Dat of last pumping: Comments(condition of alarm and float switches,etc.): lions Bons/day s or no): Alarm in working order(yes or no): DISTRIBUTION BOX:/ (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, leakage into o� t of box,eta): . • -: a • PUMP CHAMBER Pumps in work" : ,rder(yes or no):_ Alarms in „king order(yes or no):_ Con„, (note condition of pump chamber,condition of pumps and appurtenances,etc.): (locate on site plan) any evidence of Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION(continued) Property Address: $7t- - .,� Owner, Date of Inspection' • 'o' /� SOIL ABSORPTION SYSTEM(SAS):T(locate on site plan,excavation not required) If SAS not located explain why: TyPe leaching pits,number_ leaching chambers,number: leaching galleries,number:_ leaching trenches,number, rash: leaching fields,number, overflow cesspool,number: innovativelaltemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of pending,damp soil,condition of vegetation, / , f etc. : / '� ° 1 • CESSPOOLS:_(cesspool must be pumped as pan of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Materials of con coon: Indication of groundwater inflow(yes or no): level of ponding,condition of vegetation,etc.): Comments(note condition of soil,signs of hydraulic failure, Pon PRIVY:_(locate on site plan) Materials of consort: Dimensions: Depth of Ids: Com is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 3S a4 I5 it So. a° Page 10 of II OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL T SYSTEM INSPECTION FORM SYSTEM INFORMATION(continued) Property Address 8 7 k SICETCII OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pertnanent the bunce landmarks or benchmarks.Locate all wells within 100 feet Locate where public water supply d Page 11 of II OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI ON ORM PART C SYSTEM INFORMATION (continued) Property Address: $78 �ut55Q Owner: 03 Date of inspection: r Surf eck cell Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: ti Obtained from system design plans onecoh Ie checked,date fe of dsign) _ plan reviewed: Observed site(abutting property/observation Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain:�---- Yo _ust descri be ow you establishadYB high ', ignd w er elevatia art Affordable Home Inspections Title 5 Septic Inspection Evaluation Agreement I.) Affordable Home Inspections represented by Cary/Pamela Bissell as the septic inspectors has been contracted for: '� 1 I.) To inspect the property septic system located at r!8 W L 2)By client rfr- 3)for the fee of$ 350°p this fee represents the standard time schedule of three hours for the onsite inspection Time exceeding this shall be charged at$45.00 per hour. On site inspection commences at the time of arrival at the above address. 4.)By your signature,it is understood that this inspection does not serve as a warranty implied or expressed.Nor any form of surety,and does not absolve the seller of any possible liability. 5.)Further more it is understood that this inspection and the opinion contained within the report are performed and based upon the abilities,knowledge and experience of the named inspector regarding Title 5 Septic Inspections. II.) The Inspector Intends To: I.) Visually inspect all major structural components of the septic system relative to Title 5 requirements. 2.) Visually identify obvious,existing problems and where possible indicate areas of potential problems. III,) Inspector will not 1) Make repairs,nor enter septic,nor be responsible for any damage to the septic system or Property. IV,) Inspector is not a guarantor of the future life,adequacy or performance of the septic system. V,) Inspections are limited to visual defect and general appearance of the septic system and property at the time of the inspection. VI,) Neither the contents of this report nor any representations made herein are assignable without the expressed written consent of Affordable Home Inspections VII,) Affordable Home Inspections liability is limited to the cost of the inspection. VI V,) s are filed with the local Board of Health as required by Title V §§ �•t - Date /l� ( Z^ affordable H. : Inspections representative