20 Septic Inspection Form 2006 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (Cont)
Property Address: 20 Hawthorn Terrace, Northampton, MA
Owner' Name: Martha Kear 1 y_ D. n Harris
Date of Inspection: 4/24/06
Inspection Summary: Check A, B, C, D or E/a/wavy 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
ND explain:
distribution box is levelled or replaced
(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
ND explain- obstruction is removed
(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)(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.
t5insp.doc• 11/2004 Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification
1 Property Information
Property Address:
Owner's Name:
Owner's Address:
Date of Inspection:
Copy to:
Witness:
2. Inspector
Name of Inspector.
Company Name:
Mailing Address:
Telephone Number.
20 Hawthorn Terrace. Northampton. MA
Martha Kearsley, Dan Harris
20 Hawthorn Tr. . Florence, MA 01062
4/24/06
Board of Health. Northampton; Murphy Realtors
Carolyn Oualls Number. SSDS-1059
Thomas S. Leue
Homestead Inc.
1664 Cape St. , Williamsburg, MA 01096
(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:
• 7,, S 'l-y Date' ,April 24, 2006
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health of 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 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.
5 @®45''4•f340.001,3
t5lnsp.doc• 11/2004
Homestead Inc. Title 5 Official Inspection Form:Subsurface Disposal System
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Property Address
Owner' Name:
Date of Inspection:
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
20 Hawthorn Terrace Northampton. MA
4 06
SITE EXAM (Source of Information)
Y Slope _ Official Perc Date
Y Surface water 7/11/91 Official Plan Date
Y Check Cellar Other Official Source
N Shallow wells Other Source
>36 Estimated depth to ground ware(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:
Information: From original perc test data.
RESOURCES: Department of Environmental Protection, Western Regional Office,
.436 Dwight St. Springfield, MA 01103, (413) 784-1100;Title 5 Hotline- (800)266-1122
t5insp.doc• 11/2004 Homestead Inc.
Title 5 Official Inspection Form: Subsurface Disposal System
Note: No known drinking water sources within 100' radius.
leach trenches, - - -
approximate layout
North
septic tank
i
distribution box nii i 8S •
i
i . 9g, rr,t� 4 '�.
. 2 /./q:A porch
/
shed
T
I
garage II Partial outline of house
COMMENTS:
Recommend pumping on a 3 year schedule lflao, a copy of this Jan posted in the basement/utility
area would keep this information accessible in future years for maintenance.
As-Built Drawing Date: Owner: HOMESTEAD INC.
Existing Septic System 4/24/06 Martha Kearsley, Dan Harris Thomas S. Leue R.S.
1664 cape St.
20 Hawthorn Terrace
Revision Date:
Scale: l : 20' Florence, MA 01060 Williamsburg,MA 01096
Except nc Noted 14131 628-4533
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Property Address: 20 Hawthorn Terrace, Northampton. MD
Owner Name: Martha Kearsley, Dan Harris
Date of Inspection: 4/24/06
PUMP CHAMBER
N Pump part of septic system: (Y or N)
Pumps in working order (Y or N)
Alarms in working order: (Y or N)
Comments:
DISTRIBUTION BOX (located on site plan) ("D-box")
Y D-box part of septic system: (Y or N)
0 Depth of liquid level above outlet invert
Comments: Box appears level and flow equal.
SOIL ADSORPTION SYSTEM(SAS): Technology Used (located on site plan by estimate):
leaching pits 8 number:
leaching chambers and number:
leaching galleries and number:
Y leaching trenches, number, length: 3 trenches each 40 ft. long
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.
If SAS not located
explain why:
TIGHT OR HOLDING TANK (tank must be pumped at time of inspection)
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
Comments: (conditions of inlet tees, condition of alarm and float switches, etc.)
t5insp.doc•11/2004 Homestead Inc.
Title 5 Official Inspection Form: Subsurface Disposal System
Property Address:
Owner' Name:
Date of Inspection:
PRIVY
N
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
20 Hawthorn Terrace, Northampton, MA
Martha KearsJey, Dan Harris
4/24/06
(locate on site plan, if any)
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.)
CESSPOOLS
N
(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 infow(cesspool must be pumped as part of inspection)
Comments: (note soil conditions, signs of hydraulic failure, level of pending, condition of vegetation. etc.
GREASE TRAP (Usually present in certain commercial systems)
N Grease Trap part of system: (Y or N)
Materials of construction:
Depth below grade (inches)
Dimensions:
Depth of solids layer
Depth of scum layer
Top of scum to top outlet
Measured
Calculated Inches
Date of last pumping
Bottom of scum to outlet. Calculated Inches
Scum thickness (inches) Averane
(recommendation and conditions)
Comments:
t5insp.doc•11/2004
Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Property Address: 20 Hawthorn Terrace, Northampton. MA
Owner' Name: Mara Kearcl
th ey. Dan Harris
Date of Inspection: 4/24/06
FLOW CONDITIONS
RESIDENTIAL
660 DESIGN flow based on 310 CMR 15.203(gallons/day)
4 Number of bedrooms(design)
5 Number of bedrooms (actual)_
1 or 2 Number of current residents_
Y ; Is there a garbage grinder? (Y or N)
Y Is there a Laundry Hookup?(Y or N)
N j Is the Laundry a separate system?(Y or N) (If yes, separate inspection required)
N Seasonal use(Y or N)
386 Water meter readings, if available (last two years usage)(gallons per day)
N : Sump Pump (Y or N)_
continuos Date of last occupancy_
COMMERCIAL/INDUSTRIAL
Type of establishment: _
Design flow (based on 310 CMR 15.203):_gpd
Basis of design flow(seats/persons/sgft, 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 summer 2001, says previous 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: Recommend Dumping this year
TYPE OF SYSTEM:
X Septic tank, distribution box, soil adsorption system.
Single cesspool
Overflow cesspool
Privy
N 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):
t5insp.doc• 11/2004
Homestead Inc. Title 5 Official Inspection Form:Subsurface Disposal System
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Property Address:
Owner Name:
APPROXIMATE AGE
20 Hawthorn Terrace, Northampton. MA
Martha Kearsley. Dan Harris
Septic plan: 7/11/91 design date
Source of Info: Previous Owner
N
All components, date installed, and source of info.
Were sewage odors detected when arriving at the site(Y or N)
BUILDING SEWER (located on site plan)
18 Depth below grade (inches) Estimated Average
6 Distance in feet from private water supply well or suction line
ABS Materials of Construction
Comments: Changes to cast iron
,SEPTIC TANK
under driveway
Concrete Materials of Construction
25 Depth below grade
0 Riser depth
56 Septic tank width
124
58
1,748
7
1,500
Septic tank length
Septic tank height
Calculated gross volume
Air space in tank
Net Volume
28 Baffle depth
6 Sludge thickness
2
24
20
4
Scum thickness
Top Sludge . Bottom Baffle
Bottom Scum : Bottom Baffle
Top Scum : Top Baffle
(located on site plan)
(inches)
(inches)
(inches)
(inches)
(inches)
(gallons)
(inches)
(gallons)
(inches)
(inches)
(inches)
(inches)
(inches)
(inches)
Comments:
Slight elevated water level compared to outlet
may be due to some partial clog in pipe under driveway.
Recommendations:
Pump on 3 to 4 year interval.
Hire sewer cleaning service to remove pipe clog.
Interior dimensions
Interior dimensions
Interior dimensions
Calculated
Calculated
Average
Average
Calculated
Calculated
Calculated
invert:
15insp.doc•11/2004
Homestead Inc.
Tille 5 Official Inspection Form:Subsurface Disposal System
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (Cont.)
Property Address: 20 Hawthorn Terrace, Northampton, MA
Owner' Name: Martha Keareley, Dan Harris
Date of Inspection: 4114111
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 colifoml 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 KIl inspections:
YES(V)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 MS 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.]
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.
t5insp.doc• 11/2004 Homestead Inc.
Tine 5 Official Inspection Form: Subsurface Disposal System
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Sewage Disposal System Form
A. Certification (Cont)
Property Address: 20 Hawthorn Terrace. Northampton. MA
Owner' Name: Martha Kearsley, Dan Harris
Date of Inspection: 4/24/0 6
E] Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10000 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
N 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.
B: Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
YES(Y)or NO(N)
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?
• 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?
• Were"as-built" plans of the system obtained and examined? (If they are not available note as N/A)
• 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 size 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.
N b)Determined in the field Of any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[15.302(3)(b)).
Y The facility owner(and occupants, if different from owner)were provided with information on proper
maintenance of Subsurface Sewage Disposal Systems(SSDS).
t5insp.doc• 11/2004
Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System