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