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25 Septic Inspection 2005 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE V OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 25 Hawthorne Terrace Northampton MA Owner's Name: Shelley Lake Owner's Address:same Date of Inspection:09/21/2005 Name of Inspector. (please print) NickTorretti Company Name: CLEAN SEPTICS Mailing Address:_P.O.BOX 394 LUDLOW.MA Telephone Number:_583-2138 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is Inc.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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority //Fads 66 Inspector's Signature: // � � Date: 09/21/2005 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 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. 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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSEMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Hawthorne Terrace Northampton MA Owner's Name: Shelley Lake Owner's Address:same Date of Inspection:09/21/2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ 1 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: Pump tank annually. Recommend outlet filter and bacteria/enzymes. 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`hot determined"please explain. The septid tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or calibration 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: _ 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): ND explain: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Hawthorne Terrace Northampton MA Owner's Name: Shelley Lake Owner's Address:same Date of Inspection:09/21/2005 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 isnot 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 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: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Hawthorne Terrace Northampton MA Owner's Name: Shelley Lake Owner's Address:same Date of Inspection:09/21/2005 D. System Failure Criteria applicable to all systems: You must indicate`yes"or`no"to each of the following for all inspections. Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ _X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged S.A.S.or cesspool. _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow _X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped— _ X Any portion of the SAS,cesspool or privy is below high ground water elevation_ _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _X_Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _X_Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X 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 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.] NO (Yes/No)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. You must indicate either`yes"or`no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 11 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLLST Property Address: 25 Hawthorne Terrace Northampton MA Owner's Name: Shelley Lake Owner's Address:same Date of Inspection:09/21/2005 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X_ 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? X_ Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,Located on site? _X_ _ 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? X 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. Yes No X Existing information.For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) p 10 CMR 15.302(3)0)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Hawthorne Terrace Northampton MA Owner's Name: Shelley Lake Owner's Address:same Date of Inspection:09/21/2005 FLOW CONDITIONS RESIDENTIAL Number ofbedrooms(design):_4 Number of bedrooms(actual):_4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_440 GPD Number of current residents: 4 Does residence have a garbage grinder(yes or no): YES [ft yes separate inspection required] laundry on a separate sewage system(yes or no) NO Laundry system inspected(yes or no): NO_ Seasonal use(yes or no):NO Water meter readings,if available Oast 2 years usage(gpd)): Town water Sump pmnp(yes or no):NO Last date of occupancy: Present COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):bpd Basis of design flow(seats/persons/sgft,etc.):_ Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available:_ Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped May 1999 per home owner. Was system pumped as pan of the inspection(yes or no): YES If yes,volume pumped: 1500 gallons--How was quantity pumped determined? Measured Reason for pumping: Maintenance TYPE OF SYSTEM _X Septic tank distribution box,soil absorption system Single cesspool Overflow cesspool 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): Approximate age of all components,date installed(if known)and source of information: S.A.S.is approximately 9 years old per home owner. Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Hawthorne Terrace Northampton MA Owner's Name: Shelley Lake Owner's Address:same Date of Inspection:09/21/2005 BUILDING SEWER(locate on site plan) Depth below grade: 11=6^ Materials of construction: cast iron XX 40 PVC other(explain): Distance from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of leakage,etc.): Joints and venting appear okay. No leaks SEPTIC TANK X (locate on site plan) Depth below grade: 14^ Material of construction:_X_concrete metal_fiberglass polyethylene other (explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: L 10'x W S'a D 5' 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 battle: How were dimensions determined: liquid levels as li Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, q related to outlet invert,evidence of leakage,Etc.): Pump septic tank annually. Everything appears to be in good working condition. No leaks GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass polyethylene_other (explain): Dimensions:_gal required tank capacity 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 battle: Date of last pumping Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):_ Page 8 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Hawthorne Terrace Northampton MA Owner's Name: Shelley Lake Owner's Address:same Date of Inspection:09/21/2005 TIGHT or HOLDING TANK:_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) D-box is approximately 20"deep. Depth of liquid level above outlet invert: 0" Comments(note,ifbox is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-box appears Level. Distribution appears equal. No leaks. PUMP CHAMBER: __(locate on site plan) Pumps in working order(yes or no):_ Alarms in working order(yes or no):_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Hawthorne Terrace Northampton MA Owner's Name: Shelley Lake Owner's Address:same Date of Inspection:09/21/2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: _ leaching pits,number: _leaching chambers,number: _ _ leaching galleries,number: _ leaching trenches,number,length: X leaching fields,number,dimensions: 21'x 35' __ 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. Soil and vegetation appear okay. 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(yes or 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: Depth of solids: • Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Hawthorne Terrace Northampton MA Owner's Name: Shelley Lake Owner's Address:same Date of Inspection:09/21/2005 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. Drawing not to state. �RISerr Nl,ai Gav,er 4— a,, b- 130, Page 11 of 11 INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Hawthorne Terrace Northampton MA Owner's Name: Shelley Lake Owner's Address:same Date of inspection:09/21/2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water: none @ 83" Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed: 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: Title V done by Thomas Leue 8/9/99.