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87 Septic Inspection 2011 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information Important: When tilling out 1. forms on the computer,use only the tab key to move your cursor-do not use the return key. 11� Property Information: 87 Chesterfield Rd Leeds Ma. 01053 Property Address Erica Hemandez Owner's Name same Owner's Address City/Town Date of Inspection: 2. Inspector: Ray Champagne Name of Inspector Whiteley Septic Service Company Name 21 Old County Rd. Company Address Southampton Crty/Town 413-527-1835 Telephone Number Ma. State 10/25/11 Date Ma. State Zip Code 01073 Zip Code B. Certification 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 system: ® Passes El Conditionally Passes ❑ Fails ❑ Needs F rther Evaluation by the Local Approving Authority C c ` — 10/25/11 Inspector's$Ignyfi € i Date 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. ****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. Leeds Ma.Erica Femandesdoc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System_ Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 87 Chesterfield Rd. Property Address Leeds City/Town Erica Hemandez Owner's Name Ma. State 10/25/11 01053 Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E/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 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: This system consists of a 1000 Gal. septic tank with 2 trenches from tank, one trench (60')is not protected with baffle but still accepting 30 min.flow of water. The second leach trench has plastic baffle and is teed off to a 40'trench.The 60'foot trench is handeling the load and the 40',trench is reserve being 1/2 higher in the tank. This is an older system but appears to be working properly 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 exflltration 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: Leeds Ma.Erica Fernandesdoc•03/2006 Title 5 frwial Inspection Form:Subsurface Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 87 Chesterfield Rd. Property Address Leeds CRyrrown Erica Hemandez Owner's Name B) System Conditionally Passes(cont.): Ma. State 10/25/11 Date of Inspection 01053 Zip Code ❑ 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: C) Further Evaluation is Required by the Board of Hearth: ❑ 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 Leeds Ma.Erica Fernandes.doc•03/2006 Tit le 5 Official Inspection Form:Su ace Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 87 Chesterfield Rd. Properly Address Leeds City/Town Erica Hernandez Owner's Name Ma. Stale 10/25/11 Dale of Inspection C) Further Evaluation is Required by the Board of Health (cord.): 01053 Zip Cade 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 indicates absent 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: Leeds Ma.Erica Fernandes doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• Commonwealth of Massachusetts Q Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cent.) 87 Chesterfield Rd. Property Address Leeds City/Town Erica Hemandez Owner's Name Ma. State 10/25/11 Date of Inspection 01053 ZipCode D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ Z Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Z Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Z Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Z Liquid depth in cesspool is less than 6' below invert or available volume is less than ''A day flow ❑ Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd. 10,000gpd. Yes No ❑ Z 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. Leeds Ma Erica Fernandes dac•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cunt.) 87 Chesterfield Rd. Property Address Leeds City/Town Erica Hernandez Owner's Name Ma. State 10/25/11 Date of Inspection 01053 Zip Code 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. For large systems, you must indicate either yes"or"no"to each of the following, in addition to the questions in Section D. 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_ Leeds Ma.Erica Fernandes.doc•03/2006 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 87 Chesterfield Rd. Property Address Leeds Ma. City/Town Stale Erica Hernandez 10/25/11 Owner's Name Date of Inspection 01053 Zip Code Check if the following have been done.You must indicate"yes"or"no"as to each of the following: YES NO N ❑ ❑ N ❑ ❑ N ❑ N N ❑ N ❑ N ❑ N ❑ ❑ 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 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 back up? 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: ❑ ❑ Existing information. For example, a plan at the Board of Health. Determined in the field Qf any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] N ❑ Leeds Ma Erica Fernandes doc•032006 Title 5 Official Inspection Form Subsurface Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information 87 Chesterfield Rd. Property Address Leeds City/Town Erica Hernandez Owners Name Ma. State 10/25/11 Date of Inspection 01053 Zip Code Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual). 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [f yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available Oast 2 years usage reading d Present meter 9 � y g (gpd)): rei 103935 Sump pump? ❑ Yes ® No Last date of occupancy: Dasently e Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): Gallons per day(gpd) Basis of design flow(seals/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 103935 Last date of occupancy/use: Date Other(describe): -. Leeds Ma.Erica Fernandes doc•03/2006 Tale 5 Official Inspection Form:Su rface Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 87 Chesterfield Rd. Properly Address Leeds Cltyrrown Erica Hemandez Owner's Name Ma. State 10/25/11 Date of Inspection General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank,distribution box, soil absorption system owner gallons ❑ Single cesspool ❑ Overflow cesspool 01053 Zip Code ❑ Yes ® No ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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): Leach trenches 40'&60' Approximate age of all components, date installed (if known) and source of information: Approx 30+/-yrs Were sewage odors detected when aniving at the site? ❑ Yes ® No Leeds Ma Erica Fernandes.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System_ Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 87 Chesterfield Rd. Property Address Leeds Ma. Crty/Town State Erica Hernandez Owner's Name Building Sewer(locate on site plan): Depth below grade: Material of construction: ® cast iron 10/25/11 Date of Inspection ❑ 40 PVC ❑ other(explain): 2.5 feet 01053 Zip Code Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.) No evidence of leakage observed, Septic Tank(locate on site plan): Depth below grade: Material of construction: ® concrete 2 feet ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 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 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Leeds Ma.Erica Fernandes.doc•03/2006 1000 2 36 15 hook Title 5 Official Inspection Form:Subsurface Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 87 Chesterfield Rd. Property Address Northampton Ma. 01060 City/Town State Zip Code Erica Hemandez 10/25/11 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 2 Yrs Depending on use„for pumping recommendations-----No physical room to assemble a baffle for the 60'trench Grease Trap (locate on site plan) Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ 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: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Leeds Ma Erica Fernandesdoc•03/2006 ❑fiberglass ❑ polyethylene ❑ other(explain): True S Official Inspection Form'.Subsurface Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 87 Chesterfield Rd. Property Address Leeds City/Town Erica Hernandez Owner's Name Ma. State 10/25/11 Date of Inspection 01053 Zip Code Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box Of present must be opened) (locate on site plan): 0 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.): Leach trenches Pump Chamber(locate on site plan): Pumps in working order: Alarms in working order: Leeds Ma.Erica Fernandes.doc•03/2006 ❑ Yes ❑ No ❑ Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cunt.) 87 Chesterfield Rd. Property Address Leeds City/Town Erica Hernandez Owner's Name Ma. State 10/25/11 Date of Inspection 01053 Zip Code Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (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, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: 1-40& 1-60 Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no signs of hydraulic failure observed-- gravel soil Leeds Ma Erica Fernandes doc•03/2006 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 87 Chesterfield Rd. Properly Address Leeds City/Town Erica Hernandez Owner's Name Ma. State 10/25/11 Date of Inspection 01053 Zip Code Cesspools(cesspool must be pumped as part of inspection)(locate on she 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 ❑ No Comments (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.): Privy (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.): Leeds Ma.Erica Fernandes doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• Commonwealth of Massachusetts Q, Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 87 Chesterfield Rd. Property Address Leeds Ma. City/Town State Erica Hernandez 10/25/11 Owner's Name Date of Inspection 01053 Zip Code Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Leeds Ma Erica Fernandes doe•03/2006 Title 5 Official Inspection Form.Subsurface Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 87 Chesterfield Rd. Property Address Leeds Ma. Crty/Town State Erica Hernandez 10/25/11 Owners Name Date of Inspection 01053 Zip Code Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® 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: You must describe how you established the high ground water elevation: no sump pump and known rocky gravel soil area and past inspections Leeds Ma.Erica Fernandes doc•03/2006 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•