70 Title V 2005 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFI CATION
70 Country Way Northampton MA
Richard Dragon
70 Country Way Florence MA 01062
10/26/05
Board of Health, Northampton; Pat Goggins
Number: $SDS-1032
Property Address:
Owner's Name:
Owner's Address:
Date of Inspection:
Copy to:
Witness:
Name of Inspector: Thomas S. Leue
Company Name: Homestead Inc.
Mailing Address: 1669 Cape St. , Williamsburg, MA 01096
Telephone Number: (413) 628-4533
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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).
The septic system condition must be evaluated and classified into one of the following four conditions:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
The system condition: Passes
Inspector's Signature:
Date: Dctober 27. 2005
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health
of DEP) within thirty (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 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.
Tine 5 Inspection Form 6/15/2000
page I of 9
Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 70 Country Way, Northampton, MA
Owner: Richard Dragon
Date of Inspection: 10/26/05
Inspection Summary: Check A,B, C,D or E/ALWAYS complete all of Section D:
A. System Passes:
Y 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.
Comments:
B. System Conditionally Passes:
N 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.
(1) N 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. The system will
pass inspection if the existing septic 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
(2) N 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 by the Board of Health). broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
ND explain:
(3) N The system required pumping more than four 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:
(4) N Other: explain: _
C. Further Evaluation is Required by the Board of Health:
N Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety or the environment:
1) System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(6)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.
Title 5 Inspection Form 6/15/2000
page 2 of 9
Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
Property Address: 70 Country Way, Northampton, MA
Owner: Richard Dragon
Date of Inspection: 10/26/05
2) System will fail unless 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 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 water supply well** Method used to determine distance
** 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.
3) Other:
D. System Failure Criteria applicable to all systems:
You must indicate either "Yes" or"No"as to each of the following for all inspections:
YES (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 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.]
N The System Fails: I have determined that one or more of the above failure criteria exist as defined in
310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health should be
contacted to determine what will be necessary to correct the failure.
Title 5 Inspection Form 6/15/2000
page 3 of 9
Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
Property Address: 70 Country Way, Northampton, MA
Owner: Richard Dragon
Date of Inspection: 10/26/05
E] Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd.
You must indicate either"Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
YES (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
1)S' 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 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.
PART B: CHECKLIST
Check if the following have been done You must indicate " es" or"no" as to each of the following
YES (Y) or NO (N)
Y Pumping information was provided by the owner,occupant or Board of Health.
N Were any of the system components pumped out in the previous two weeks?
Y Has the system received normal flows in the previous two week period?
N Have large volumes of water been introduced to the system recently or as part of the inspection?
N/A Were"as-built" plans of the system obtained and examined? (If they are not available note as N/A)
Y Was the facility or dwelling was inspected for signs of sewage back up?
Y Was the site was inspected for signs of break out?
Y Were all system components,excluding the SAS,located on site?
Y Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
The and location of the Soil Absorption System (SAS) on the site has been determined based on:
a) Existing information. For example, a plan at the Board of Health.
• b) Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [15.302(3)(b)1.
• The facility owner (and occupants, if different from owner) were provided with information on
proper maintenance of Subsurface Sewage Disposal Systems (SSDS). .
RESOURCES:
Department of Environmental Protection, Western Regional Office,436 Dwight St., Springfield. MA
01103, (413)784-1100;Title 5 Hotline - (800)266-1122
Title 5 Inspection Form 6/15/2000
page 4 of 9 Homestead Inc. _
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C: SYSTEM INFORMATION
Property Address: 70 Country Way, Northampton. MA
Owner: Richard Dragon
Date of Inspection: 10/26/05
FLOW CONDITIONS
RESIDENTIAL
unknown DESIGN flow based on 310 CMR 15.203 (gallons/day)
Number of bedrooms (design)
4 Number of bedrooms (actual)
2 Number of current residents
Is there a garbage grinder ?(Y or N) _
Is there a Laundry Hookup? (Y or N)
Is the Laundry a separate system?(Y or N) (If yes, separate inspection required)
N Seasonal use (Y or N)
119 Water meter readings,if available (last two years usage) (gallons per day)
N Sump Pump (Y or N)_
continuous Date of last occupancy _
COMMERCIAL/INDUSTRIAL
Type of establishment: _
Design flow (based on 310 CMR 15.203): —gpd
Basis of design flow (seats/persons/sqft, etc.):
Grease trap present (Y or N): _
Industrail waste holding tank present(Y or N):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: pumped July 2004 . 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: does not need pumping this year
TYPE OF SYSTEM:
X Septic tank,aiiialostienSIT, soil adsorption system.
Single cesspool
Overflow cesspool
Privy
Shared system (Y or N) (if 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):
N Were sewage odors detected when arriving at the site (Y or N)
Title 5 Inspection Form 6/15/2000
page 5 of 9 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
Property Address: 70 Country Way, Northampton. MA
Owner: Richard Dragon
Date of Inspection: 10/26/05
APPROXIMATE AGE All components,date installed, and source of information.
Septic plan: said to be 1961 system with new leaching tank in
Source of Inf Owner
BUILDING SEWER (located on site plan)
18 Depth below (inches) reed Average
12 Distance in feet from private water supply well or suction line
cast iron Materials of Construction
Comments: Pipe under basement floor slab
SEPTIC TANK (located on site plan)
Tank 1
Concrete
15
0
48
86
58
1,039
7
900
23
4
0
31
16
Tank 2
Concrete Materials of Construction
17 Depth below grade
0 Riser depth
48 Septic tank width
86
58
1,039
Septic tank length
Septic tank height
Calculated gross volume
1977
(inches)
(inches)
(inches)
(inches)
(inches)
(gallons)
18 Air space in tank (Inches)
700 Net Volume (gallons)
22 Baffle depth (inches)
2 Sludge thickness (inches)
0 Scum thickness (inches)
34 Top Sludge: Bottom Baffle (inches)
4 Bottom Scum : Bottom Baffle (inches)
5 16 Top Scum : Top Baffle (inches)
Comments:
Two smaller septic tanks with overflow design. New PVC outlet tees.
'Cover of tank one replaced with large blocks. Tank two may be leaking
Recommendations:
Pump on 3 to 5 year interval.
Interior dimensions
Interior dimensions
Interior dimensions '..
Calculated
Calculated
Aver age
Average
Calculated
Calculated
Calculated
PUMP CHAMBER
N Pump part of septic system: (Y or N)
Title 5 Inspection Form 6/15/2000
page 6 of 9
Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
Property Address: 70 Country Way, Northampton, MA
Owner: Richard Dragon
Date of Inspection: 10/26/05
DISTRIBUTION BOX (located on site plan)("D-box")
N D-box part of septic system: (Y or N)
Depth of liquid level above outlet invert
Comments:
SOIL ADSORPTION SYSTEM (SAS): Technology Used (located on site plan by estimate):
_ _ Y leaching pits & number: 2 leach pits in overf low design.
leaching chambers and number:
leaching galleries and number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system,Type:
Comments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
No surface problems seen. Pits not opened. One pit found,
second pit location determined by owner's recollection.
Rf SAS not located
iexplain why:
TIGHT 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 (inches) From Plan
Tank length (inches) From Plan
Tank height (inches) From Plan
Calculated gross volume (gallons 9alculated
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
Comments: (conditions of inlet tees, condition of alarm and float switches,etc.)
PRIVY (locate on site plan, if any)
N Privy part of system: (Y or N:
Materials of construction:
Dimensions:
Depth of solids:
Comments: (soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc
Tine 5 Inspection Form 6/15/2000 page 7 of 9 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
70 Country Way, Northampton, MA
Richard Dragon
10/26/05
Property Address:
Owner:
Date of Inspection:
:CESSPOOLS
N
'Comments:
(GREASE TRAP
(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,
(Usually present in certain commercial systems)
Grease Trap part of system: (Y or N)
Materials of construction:
Depth below grade (inches) Measured
Dimensions:
Depth of solids layer
Depth of scum layer
Top of scum to top outlet s 1_ li a x ch
Date of last pumping
Bottom of scum to outlet.
1 c l t d 1�.e
Scum thickness (inches) Air_e_raSg
(recommendation and conditions)
Comments:
SITE EXAM (Source of Information)
Y Slope _ _Official Pere Date
Y _Surface water _Official Plan Date
Y Check Cellar Other Official Source
N Shallow wells _ Other Source
>60 Estimated depth to ground water (inches)
Please indicate(check)all the methods used to determine high groundwater elevation:
Y Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Very coarse sand soil, raised well above adjacent yard.
Information:
Title 5 Inspection Form 6/15/2000
page 8 of 9
Homestead Inc.
Note: No known drinking water sources within 100 foot radius.
Partial Outline of House
- ------- NORTH
v
Ts
_/ I \
N N C
- - Y .. O
c C C C
N N CO R N
H H H H U
U U o) OI
a Q c_ c_ -o
Cl) Cl) L 0 H rei V V
J 0 a
W
COMMENTS:
Recommend pumping on a 3 to 5 year schedule. Also, a copy of this plan posted in the
basement/utility area would keep this information accessible in future years for maintenance.
Date: Owner: 3N OF We
As-Built Drawing �.�? t+cy� HOMESTEAD INC.
I xistin Septic System 10/26/05 Richard Dragon o +�
Existing P Y r- 7tloxnss, Thomas S. Leue R.S.
70 Country Way a LEU
Scale: 1 : 20' Revision Date Florence, MA 01062 / ∎ ',. 72 4. I - 1664 Cape St.
Except as Noted 94,3,∎- D 51M�'p\' WiIha4)3]628-4533
MA 01096
1413 628-4533