90 Septic Inspection 2007 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
t. Certification
Property Information
roperty Address:
wner's Name:
wner's Address:
ate of Inspection:
opy to:
'fitness:
Inspector:
ame of Inspector:
ompany Name:
ailing Address:
rlephone Number:
90 Whittier Street, Northampton, MA
Bipinchandra Mistry
90 Whittier St. , Florence MA 01062
8/17/07
Board of Health, Northampton
Kim Goggins , Goggins Realty
Number: SSDS-1211
Thomas S. Leue
Homestead Inc.
1664 Cape St. , Williamsburg MA 01096
(413 ) 628-4533
License Number SI130
ertification Statement:
Certify that I have personally inspected the sewage disposal system at this address and that the information reported
?low is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
wining and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP
)proved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The septic system condition
ust be evaluated and classified into one of the following four conditions:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
1e system condition: Passes
Ispector's Signature:
Date: 8/17/07
to System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
_P)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
rd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
EP. The original should be sent to the system owner and copies to the buyer, if applicable and the approving
ithority.
rtes 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
mditions of use.
'44 5!412 ars
rspdoo• 11/2004
Homestead Hc. Title 5 Official Inspection Form Subsurface Disposal System
•page 1 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Certification (Cont.)
)perry Address: 90 Whittier Street Northampton, MA
mer' Name: Bipinchandra Mistry
to of Inspection: 8/17/07
ppection Summary: Check A, B, C, D or E/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.
mments:
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.
N The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
sound, exhibits substantial infiltration or exfiltration, 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
ik will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank
ess than 20 years old is available.
explain:
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
th approval by the Board of Health). broken pipe(s)are replaced
obstruction is removed _
distribution box is levelled or replaced
1 explain.
N The system required pumping more than four times a year due to broken or obstructed pipe(s). The
stem 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:
I Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
ling 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• 1112004
Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System
•page 2 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
k. Certification (Cont.)
'roperty Address:
)wner' Name:
)ate of Inspection:
90 Whittier Street, Northampton. MA
Bipinchandra Mistry
8/17/07
'.) System will fail unless Board of Health (and Public Water Supplier, if any)determines that the system
s 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
eater 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
later 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
olatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
itrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy
f the analysis must be attached to this form.
I Other:
System Failure Criteria applicable to all systems:
ou must indicate either"Yes" or"No" as to each of the following for all inspections:
ES (Y) or NO(N)
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 Any 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:
Isp doe• 11/2004
Homestead Inc. Title 5 Official Inspection Form'. Subsurface Disposal System
•page 3 of 9
(sO Commonwealth of Massachusetts
ate\ 7 Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Certification (Cont.)
perty Address: 90 Whittier Street Northampton, MA
ner' Name: Bipinchandra Mistry
e of Inspection: 8/17/07
Large Systems:
be considered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd.
I 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
N the system is within 200 feet of a tributary to a surface drinking water supply
N the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a
pped Zone II of a public water supply well)
ou answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in
otion D above the large system has failed. The owner or operator of any large system considered a significant
eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The
:tem owner should contact the appropriate regional office of the Department
Checklist
eck 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._
d 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? =
4 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 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
edition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and scum?
e size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Y a) Existing information. For example, a plan at the Board of Health.
b) Determined in the field Of any of the failure criteria related to Part Cis at issue approximation of
dance is unacceptable) [15.302(3)(b)].
Y The facility owner(and occupants, if different from owner)were provided with information on proper
aintenance of Subsurface Sewage Disposal Systems (SSDS).
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Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System
•page 4 of 9
Commonwealth of Massachusetts
i2 Title 5 Official Inspection Form
perry Address:
ner' Name:
e of Inspection:
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
90 Whittier Street, Northampton, MA
Bipinchandra Mistry
8/17/07
FLOW CONDITIONS
1IDENTIAL
unknown DESIGN flow based on 310 CMR 15.203 (gallons/day)_
3 Number of bedrooms(design)
4 • Number of bedrooms (actual)_
4 Number of current residents
Y Is there a garbage grinder? (Y or N)_
Y 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)
124 Water meter readings, if available (last two years usage) (gallons per day)=
N Sump Pump (Y or N)__
:ontinuous Date of last occupancy=
MMERCIALIINDUSTRIAL
e of establishment. =
iign flow (based on 310 CMR 15.203): _ gpd
is of design flow(seats/persons/sqft, etc.):_
ase trap present(Y or N):
rstrail waste holding tank present (Y or N):=
ler meter readings, if available:=
t date of occupancy/use: _
-IER (describe): =
GENERAL INFORMATION
nping Records: Source of information: Pumped Aug. or Sept. 2005 says Owner
N 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. To be pumped later on current date. 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).
sp.doc• 11/2004 Homestead Inc. TNe 5 Official Inspection Form: Subsurface Disposal System
•page 5 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
perry Address: 90 Whittier Street, Northampton, MA
ter' Name: Bipinchandra Mistry
'PROXIMATE AGE All components, date installed, and source of info.
=_ptic plan: Said to be 1983 system with new leaching tank added in 1996
:urce of Info: BoH
N Were sewage odors detected when arriving at the site (Y or N)
11ILDING SEWER (located on site plan)
30 Depth below grade (inches) Estimated Average
18 Distance in feet from private water supply well or suction line
ABS plastic Materials of Construction
omments: No problems seen.
EPTIC TANK (located on site plan)
Concrete Materials of Construction
24 Depth below grade (inches)
0 Riser depth (inches)
57 Septic tank width (inches) Interior dimensions
122 Septic tank length (inches) Interior dimensions
60 Septic tank height (inches) Interior dimensions
1,811 Calculated gross volume (gallons) Calculated
7 Air space in tank (inches)
1,500 Net Volume (gallons) Calculated
26 Baffle depth (inches)
2 Sludge thickness (inches) Average
1 Scum thickness (inches) Average
32 Top Sludge : Bottom Baffle (inches) Calculated
18 Bottom Scum : Bottom Baffle (inches) Calculated
5 Top Scum : Top Baffle (inches) Calculated
omments:
'o operational or structural problems seen.
affle intact with no sign of acid erosion.
recommendations:
'ump on 3 to 4 year interval. _.
riser over center to near surface would facilitate maintenance.
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Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System
•page 6 of 9
perry Address:
der' Name:
e of Inspection:
IMP CHAMBER
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
90 Whittier Street, Northampton, MA
Bipinchandra Mistry
8/17/07
N Pump part of septic system: (Y or N)
_ Pumps in working order (Y or N)
Alarms in working order: (Y or N)
mments:
3TRIBUTION BOX (located on site plan) ("D-box")
D-box part of septic system: (Y or N)
0 Depth of liquid level above outlet invert Inches
mments: Box added in 1996. Flow balanced.
III_ADSORPTION SYSTEM (SAS): Technology Used (located on site plan by estimate):
leaching pits& number:
Y leaching chambers and number.
leaching galleries and number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number.
innovative/alternative system, Type:
mments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
surface problems seen. 2nd tank added in 1996.
2 tanks, nominal 1000 gal. eacH
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.)
ap.doc• 11/2004 Homestead Inc. Title 5 0ffdal Inspection Form: Subsurface Disposal System
•page 7 of 9
Commonwealth of Massachusetts
I Title 5 Official Inspection Form
/ Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
perty Address:
ner' Name:
e of Inspection:
31W
omments'.
ESSPOOLS
N
omments:
90 Whittier Street, Northampton, MA
Bipinchandra Mistry
8/17/07
(locate on site plan, if any)
Privy part of system: (Y or N)
Materials of construction:
Dimensions:
Depth of solids:
(soil conditions, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
(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)
(note soil conditions,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
REASE TRAP
N
omments:
ITE EXAM
Y
(Usually present in certain commercial systems)
Grease Trap part of system: (V or N)
Materials of construction:
Depth below grade (inches) Measured
Dimensions:
Depth of solids layer
Depth of scum layer
Top of scum to top of outlet Calculated Inches
Date of last pumping
Bottom of scum to bottom of outlet. Calculated Inches
Scum thickness (inches) Averaae
(recommendation and conditions)
Slope
Surface water
Y Check Cellar
(Source of Information)
9/4/96 Official Perc Date
Official Plan Date
Other Official Source
N Shallow wells Other Source
108. _ _ Estimated depth to ground water (inches)
lease indicate (check)all the methods used to determine high groundwater elevation:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
formation:
Estimated seasonal high water table from report.
ESOURCES: Department of Environmental Protection, Western Regional Office,
36 Dwight St., Springfield, MA 01103, (413)784-1100;Title 5 Hotline - (800) 266-1122
tp.doc• 11/2004
Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
• page 8 of 9
Partial Outline of House
I.
• -
Townwaterin. If
.sicy 57,7� 4g,2 54' I
Ao\l2 N.
29
I i
Leaching chambers, approximate layout - , '1- ,',I
J
I. —- _ Septic tank
i
NORTH
Distribution Box
Note: No known drinking water sources within 100 foot radius.
COMMENTS:
Recommend pumping on a 3 to 4 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: Owner: ?���te OF �xss+oy`� HOMESTEAD INC.
Existing Septic System 8/17/07 Bipin Mistry r, TMoMnes Thomas S. Leue R.S.
90 Whittier Street �� �EU�
Revision Date: 72 r msb Cape St.
Scale: l : 20' `' '� wn]amsbur MA 010%
Florence, MA 01062 leo, .m el 141316284533
Except as Noted ,hBED 501,