132 Septic Inspection 2006 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 or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
Important:
When filling out 1.
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
Property Information:
132 Cross Path Road
Property Address
Robert Messier
Owners Name
132 Cross Path Road
Owners Address
Northampton
City/Town
Date of Inspection:
2. Inspector:
Timothy E. Maginnis RS
MA
State
June 7, 2006
Date
01062
Zip Code
Name of Inspector
Timothy E. Maginnis&Associates
Company Name
70 Montague Road
Company Address
Westhampton
City/Town
(413)527-5291
Telephone Number
MA
State
01027
Zip Code
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 system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Need /. ;t( F]Dfh :v, the Local Approving Authority
June 7,2006
Inspector . 3 r'0I�'"•"- Date
The syst-`, yr it a copy of this inspection report to the Approving Authority(Board
of Health or s of completing this inspection. If the system is a shared system or
has a design - `�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.
Northampton-132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 1 of 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
132 Cross Path Road
Property Address
Northampton
City/Town
Robert Messier
MA
State
June 7, 2006
01062
Zip Code
Owner's Name
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.My failure criteria not evaluated are
indicated below.
Comments:
This system was designed by Michael Lavigne in October 1999. See plan of record at BOH office.
NOTE:The electric line to the pump chamber crosses the center of the septic tank. Care should be
taken when uncovering during pumping operations and Title-5 inspections.
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 exfltration 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:
N/A
Northampton- 132 Cross Path Rd.Title 5 inspection report.dos• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 2 of 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
132 Cross Path Road
Property Address
Northampton MA
01062
City/Town State
Robert Messier
June 7, 2006
Zip Code
Owner's Name
B) System Conditionally Passes(cont.):
Date of Inspection
❑ 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:
N/A
❑ 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:
N/A
C) Further Evaluation is Required by the Board of Health:
El 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
Northampton-132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 3 of 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
132 Cross Path Road
Property Address
Northampton MA
City/Town State
Robert Messier June 7, 2006
Owner's Name Date of Inspection
01062
Zip Code
C) Further Evaluation is Required by the Board of Health (cont.):
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 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:
N/A
Northampton- 132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 4 of 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
132 Cross Path Road
Property Address
Northampton MA
01062
City/Town State
Robert Messier
June 7, 2006
ZipCode
Owner's Name
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
❑ ® Backup of sewage into facility or system Component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding 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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® 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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any 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 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.]
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.
Northampton-132 Crass Path Rd.Title 5 inspection reporl.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 5 of 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
132 Cross Path Road
Property Address
Northampton MA 01062
City/Town State Zip Code
Robert Messier
June 7, 2006
Owner's Name
Date of Inspection
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.
Northampton- 132 Cross Path Rd.Title 5 inspection repon.doc• Title 5 Official Inspection Form.Subsurface Sewage Disposal System•
11/2004 Page 6 of 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
132 Cross Path Road
Property Address
Northampton
City/Town
Robert Messier
MA
State
June 7, 2006
01062
Zip Code
Owner's Name
Date of Inspection
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
YES NO
LI El
® ❑
® ❑
® ❑
® ❑
Z ❑
® LA
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 (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]
Northampton-132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004
Page 7 of
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
132 Cross Path Road
Property Address
Northampton MA
City/Town State
Robert Messier
June 7, 2006
01062
Zip Code
Owner's Name
Residential Flow Conditions:
Date of Inspection
Number of bedrooms(design): 3 Number of bedrooms (actual). 3
DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x#of bedrooms): 110 gpd
Number of current residents: Vacant
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/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:
Last date of occupancy/use: Date
Other(describe):
Northampton-132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
132 Cross Path Road
Property Address
Northampton
City/Town
Robert Messier
MA
State
June 7,2006
01062
Zip Code
Owners Name
Date of Inspection
General Information
Pumping Records:
Source of information: None available for this inspection
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Yes ® No
gallons
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)Of yes, attach previous inspection records, if any)
❑ Innovative/Alternative 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):
Septic tank and leaching galleries
Approximate age of all components, date installed Of known)and source of information:
6 years-Source of information was Approved plan I Cert of Compliance-3/2000
Were sewage odors detected when arriving at the site? ❑ Yes Z No
Northampton-132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 9 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
132 Cross Path Road
Property Address
Northampton MA
01062
City/Town State
Robert Messier
Owner's Name
Building Sewer(locate on site plan):
Depth below grade:
Material of construction:
❑ cast iron
June 7,2006
Zip Code
Date of Inspection
®40 PVC ❑other(explain):
Distance from private water supply well or suction line:
2
feet
N/A-Town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer pipe is in sound condition. No leakage observed
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
®concrete ❑ metal
(10'L x 5'W x 4'D) = 1,000 gallons
2 feet-With riser
feet
['fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: N/A
years
Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: (10'L x 5'W x 4'D) = 1,000 gallons
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?
N/A
4 feet
c 1" -not consistent in tank
N/A
N/A
Observed/measured
Northampton-132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 10 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
132 Cross Path Road
Property Address
Northampton MA 01062
City/Town State Zip Code
Robert Messier June 7, 2006
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.):
The septic tank is in sound condition and no evidence of leakage. Liquid level at outlet was even with
invert. Inlet/outlet tees in sound condition. Electric line for pump crosses this tank at center of tank.
Recommend pumping at least every three years.
Grease Trap(locate on site plan).
Depth below grade:
Material of construction:
El concrete El metal
N/A
feet
El fiberglass ❑ polyethylene El 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: N/A
Material of construction:
El concrete El metal El fiberglass El polyethylene El other(explain):
Northampton-132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004
Page 11 of 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
132 Cross Path Road
Properly Address
Northampton MA
City/Town State
Robert Messier
June 7, 2006
01062
Zip Code
Owner's Name
Tight or Holding Tank (cont.)
Dimensions: N/A
Date of Inspection
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.):
Distribution Box (if present must be opened) (locate on site plan).
Depth of liquid level above outlet invert No distribution box
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.):
Pump Chamber(locate on site plan):
Pumps in working order:
Alarms in working order:
Z Yes ❑ No
Z Yes ❑ No
Northampton-132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/20D4 Page 12 of 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
132 Cross Path Road
Property Address
Northampton MA
City/Town State
Robert Messier
June 7, 2006
01062
Zip Code
Owner's Name
Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is in good condition. Pumps and appurtenances appear sound and in good working
order. Electric line for pump crosses this tank at center of tank. There is a plastic riser on top of the
pump manhole cover.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
The SAS was located and one galley was examined. At the time of this inspection, I observed no
wastewater in the pit. Stone was clean and free of debris.
Type:
❑ leaching pits number:
❑ leaching chambers number:
leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No signs of hydraulic failure above ground, no damp soil or ponding. Vegetation at this site is grass.
At the time of this inspection, I observed no wastewater in the pit. Stone was clean and free of
debris.
Northampton-132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 13 of 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
132 Cross Path Road
Property Address
Northampton MA
City/Town State
Robert Messier
01062
June 7,2006
Zip Code
Owner's Name
Date of Inspection
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
N/A
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 ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
N/A
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Northampton-132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 14 of 14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
132 Cross Path Road
Property Address
Northampton
City/Town
Robert Messier
MA
State
June 7, 2006
01062
Zip Code
Owner's Name
Date of Inspection
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.
Northampton-132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 15 of 15
As-Built Dimensions
1
0,
Electric
'A' to 'C' = 16-0'
'B' to 'C' = 16-0'
'A' to 'D' = 24-0'
'B' to 'D' = 21.5'
'E' to 'G' = 735'
'F' to 'G' = 67-0'
tine . •
\eak'
Pump chnmbe
9
eejjl1
��
r
L
._
Septic tan all
Existing
3 bedroom
house
,B
E
Oft
Driveway, .t
.
24 t
1 inspection port PG')
Concrete chambers
Cross Path Road - Northampton, Massachusetts
Ttle-5 Inspection
132 Cross Path Rood
Northampton, Massachusetts
Date, June 7, 2006
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
132 Cross Path Road
Property Address
Northampton MA
01062
City/Town State
Robert Messier
June 7, 2006
Zip Code
Owner's Name
Site Exam:
Slope Lpy./2,
Surface water foal-(7
Check cellar IL/ Cetq�
Shallow wells
Estimated depth to ground water: 7 1.6
Date of Inspection
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:
June 7, 2006
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:
a. Examinationm of soild around septic tank&leaching pits
b. Review of USGS Soil Survey maps
d. Personal knowledge of soils and groundwater elevations in area
e. Soil logs on approved plan.
Northampton-132 Cross Path Rd.Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 16 of 16