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279 Inspection Form 2013 Owner information is required for every Page, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner's Name Leeds MA 01053 4/19/2013 City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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 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 must be attached to this form. 3. Other: 0) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No n ® Backup of sewage into facility or system component due to overtoaded 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow Sins•11170 Tie 5 Official Inspection Form:Subsurface Sewage Otsposal System Page 4 of II ;L\ Commonwealth of Massachusetts Owner information is required for every page. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner's Name Leeds City/Town MA 01053 4/19/2013 State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ N 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. ❑ Z 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 SAS, 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 2000 gpd-10,000 gpd. 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. 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 ❑ Z 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. sirs.11)10 TXe 5 Gscel mspe aon Form.Subsurface Sewage Disposal System.Page 5 of 17 Owner information is required for every Leeds MA 01053 4/19/2013 page. City/Town State Zip Code Date of Inspection Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner's Name C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ 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) ® ri 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 (d any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): DESIGN flow based on 310 CMR bedrooms): unknown Number of bedrooms (actual): 15.203(for example. 110 gpd x#of 3 330+ gpd (Sins•11110 Title 5 Official Inspection Form Subsurface Sewage Uspowl System•Page 6 of IT Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Properly Address Brian Lafond Owner's Name Leeds MA 01053 4/19/2013 City/Town State Zip Code Date of Inspection D. System Information Description. 1,000 gallon septic tank, no d-box and single leaching tank. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection ❑ Yes Z No required] Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 65 gpd Detail: 8/13/12 to 10/17/12 @ 200 cu.ft. = 65 gpd. House was unoccupied for some time. Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? Water meter readings, if available: Yes ® No Continuous Date Gallons per day(gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Ems.11/10 Tale 5 Official nspectlon Form:Subsurface Sewage n5W sal System.Page 7 a 1 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner's Name Leeds MA 01053 4/19/2013 City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other(describe below). Pumping Records: Source of information: Date General Information No information on previous pumping. Was system pumped as part of the inspection? ft yes, volume pumped: gallons How was quantity pumped determined? Recommend pumping soon. Reason for pumping: Type of System: [hies ® No Septic tank, 9istributien-box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if 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)and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. Other(describe) Sins 11)10 rifle 5 official inspection form:Subsurface Sewage Disposal System Page ad 17 Owner information is required for every Page, ISins•11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner's Name Leeds MA 01053 4/19/2013 City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed Of known)and source of information: Septic plan: Permit date of 12/4/68. Were sewage odors detected when arriving at the site? Building Sewer(locate on site plan): Depth below grade' Material of construction: ® cast iron [ 40 PVC ❑other(explain): Distance from private water supply well or suction line. 22" average feet Eyes ® No Not determined feet Comments (on condition of joints, venting, evidence of leakage, etc.): Slab on grade, pipes not visible. Septic Tank(locate on site plan): Depth below grade. Material of construction: Z concrete 1 . 3 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 58" wide, 98" long, 50" height Dimensions: Sludge depth: 10" rte 5 Official inspection Form.Sutcu,lace Sewage Disposal Symem•Page 9 ct 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner's Name Leeds MA 01053 4/19/2013 City/Town State Zip Code Date of Inspection D. System Information (cant.) Septic Tank(cont.) 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? 26" 7„ 5" 15" calculated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1,000 gallon tank in good structural condition. Water level at height of outlet invert. Removable baffle outlet, in good condition. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete Dimensions: Scum thickness ❑ metal feet ❑fiberglass ❑ polyethylene ❑ other(explain): 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 Sins•11110 Tab 5 Official Inspection Form Subs urla a Sewage Deposal System•Page 10 of 17 Owner information is required for every Leeds MA 01053 4/19/2013 page. City/Town State Zip Code Date of Inspection Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner's Name D. System Information (cont.) 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 Dimensions. Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: ❑fiberglass ❑ polyethylene ❑other(explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? 7 Yes ❑ No bins.11/10 Tale 5 Official Inspeoon Form.subsurface Sewage Disposal System•Page 11 o117 Owner information is required for every page. t50-5•11M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner's Name Leeds MA 01053 4/19/2013 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box Of present must be opened) (locate on site plan). Depth of liquid level above outlet invert — None Comments (note rf 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: ❑ Yes ❑ Yes ❑ No ❑ No 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: Tale 5 Official InspeNon Form Subsurf ce sewage w I System•Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owners Name Leeds City/Town MA 01053 4/19/2013 State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits leaching chambers ❑ leaching galleries leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/alternative system number: number: number: number, length: number, dimensions: number: One found 44 ft. Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, eta): No surface problems seen. rill reported as block built, 4' x 4' x 4 ' with 4" thick cast cement top. No openings found. Dug hole along outside edge to 38" deep and found retained water at 35" depth. Pit also has outlet trench, reported to be 44 ft. long. Cesspools(cesspool must be pumped as part of inspection)(locate on site 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 15ms.11110 Ties ❑ Yes ❑ No on Form.Subsuface sewage Dspose/System•Page 1a 0117 Commonwealth of Massachusetts g Title 5 Official Inspection Form Owner information is required for every page. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner's Name Leeds MA 01053 4/19/2013 City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): bins-11110 TAa 5 Official mspecton Form subsuFface Sewage oapoaaI System•Page 14 of IT Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owners Name Leeds Cify/Town MA 01053 4/19/2013 State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System. Provide a view 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. Check one of the boxes below'. ❑ hand-sketch in the area below Z drawing attached separately ins 11110 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System Page 15 ot 17 Owner information is required for every Page, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner's Name Leeds City/Town MA 01053 4/19/2013 State Zip Code Date of Inspection D. System Information (cent.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 5 ft feet Please indicate all methods used to determine the high ground water elevation: I I 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: Previous Title 5 Inspection ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Previous Title 5 report included deep hole to 81 ft. and found water at 74 ft. Before filing this Inspection Report, please see Report Completeness Checklist on next page. rnns.11/10 nine 5 Official Inspector Form Subsurface Sewage Disposer system Page 18 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner Owner's Name informaton is required for every Leeds MA 01053 4/19/2013 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary. A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ns.11110 Tale 501liclal Inspecton Form.Su dace Sewage Dsposa!System.Page 17 of 17 Owner information is required for every page. Important:When filling out forms on the computer, use only the tab key to move your cursor-do not use the ret rn key. Inn thin.1110 Commonwealth of Massachusetts Title 5 Official Inspection Form,; Subsurface Sewage Disposal System Form -Not for Voluntary A'gsesshiants 279 Haydenville Road Property Address Brian Lafond Owners Name Leeds City/Town APB .1 MA 01053 4/119 /-2613" State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Thomas S. Leue Name of Inspector Homestead Engineering Inc. Company Name 1664 Cape St. Company Address Williamsburg City/Town 413-628-4533 — _pone Telephone Number MA State SI-130 License Number 01096 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 ] Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority S April 19, 2013. 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. TNe 5 Official Inspecton Form:aulsurtace Sewage Disposal System Page 1 0117 2\ Commonwealth of Massachusetts F, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner Owners Name information Ietar is required mation for every Leeds MA 01053 4/19/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information that 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: 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)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 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. ❑ Y ❑ N ❑ ND (Explain below): 4'ms•11/10 TMe 5 gfical Inspection Form-Subsurface Sewage Dsposal System•Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Haydenville Road Property Address Brian Lafond Owner's Name Leeds MA 01053 4/19/2013 City/Town State Zip Code Date of Inspection B. Certification (cant.) B) System Conditionally Passes(cont.): ❑ 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 ❑Y ❑y ❑Y ❑ N E ❑ N ❑ ND (Explain below): El ND (Explain below): ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y E N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ 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: El 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 thins-11110 The 5 IXr¢al lnspeNOn Form.Subsurface Swage OEspnsel SMem Page 3 of 17 COMMENTS: Recommend pumping on a 3 to 4 year schedule. Also, a copy of this ?Ian posted in the basement/utility area would keep this information accessible in future years for maintenance. Leaching Trench Note: No known drinking water sources within 100 foot radius. _. -- Leaching Pit A NORTH t . : is N Septic Tank--_ 39112 2,,/, I Deck partial House Outline town water in Date: Owner: e° HOMESTEAD INC. .." IN)As-Built Drawing 4/19/2013 Brian Lafond L ist ng Septic System 279 Haydenville Ro. z � e roast Thomas S. Leue R.S. Scale: 1 : of 20' Revision Date: Leeds, MA 01053 V, s 7� Williamsburg,MAm09fi Except as Noted 'g'>ftten sot 14131628-4533