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271 (Girl Scouts) Inspection Form 2009 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 271 Haydenville Road Owner' Name: Girl Scouts of Central & Western MA City/Town: Northampton, MA 01060 Date of Inspection: 5/8/09 Inspection results most be submitted on this form. Inspection forms may not be altered in any way. Owner Address' 241 Havdenville Rd. , Leeds, MA 01053 Copy to: board of Health Northampton, Christine Cahillane Goggins Realty Witness: John Hultman Homestead Inc.#: 55D5-1320 A. General Information 1. Inspector: Name of Inspector: Thomas S. Leue R.S. Company Name: Homestead Inc. Company Address: 1664 Cape St. . Williamsburg, MA 01096 Telephone Number: ( 4131 628-9533 License Number: 81130 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 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: 5/8/09 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 origins! should be sent to the system owner and copies 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. T5 Revised dcc. 1249 Title 5 Official Inspection Form.Subsidace Deposal System•Page 1 o`9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 271 Haydenville Road Owner Owner' Name: Girl Scouts of Central & Western MA information Is required for City/Town: every page. Northampton, MA 01060 Date of Inspection: 5/8/09 B. Certification (cant.) Inspection Summary: Check A, B, C, D or E l 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. 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: 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 leveled or replaced ND explain: N 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: 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. T5 Revised doc• 12/07 Title 5 Official Inspection Farm. Subsurtace Disposal System•Page 2 of 9 Owner Inlormation Is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 271 Haydenville Road Owner Name: Girl Scouts of Central & Western MA City/Town: Northampton, MA 01060 Date of Inspection: 5/8/09 B. Certification (cont.) 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 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: D. System Failure Criteria Applicable to All Systems: You must indicate either YES (Y)or NO(N) as to each of the following for all inspections'. 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 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.] N The system is a cesspool serving a facility with a design flow of 2000 gpd-10000 gpd. 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. COMMENT: T5 Revised dot•12107 Title 5 Official Inspection Form.Subsurface Disposal System•Page 3 of 9 Commonwealth of Massachusetts :76 Title 5 Official Inspection Form =-,y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r Owner information is required for every page. Property Address: 271 Haydenvil le Road Owner' Name: Girl Scouts of Central & Western MA City/Town: Northampton, MA 01060 Date of Inspection: 5/8/09 B. Certification (cont.) 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. For large systems, you must indicate either YES (Y)or NO(N)as to each of the following, in addition to the questions in Section D. 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. C. Checklist Check if the following have been done. You must indicate YES (Y)or NO (N) as to each of the following: 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? N 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 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 scum? Y 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: N Existing information. For example, a plan at the Board of Health. N Determined in the field Of any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR15.302(5)]. 15 Revised.tloc• 12/07 Title 5 Official Inspection Form-Subsurface Disposal System•Page 4 of 9 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 271 Haydenville Road Owner' Name: Girl Scouts of Central & Western MA City/Town: Northampton, MA 01060 Date of Inspection: 5/8/09 D. System Information Residential Flow Conditions: unknown Number of bedrooms (design) 3 --- ! Number of bedrooms(actual) 330+ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# bedrooms) 0 Number of current residents N Does residence have a garbage grinder? N Is the Laundry a separate system? [If yes, separate inspection required] Laundry system inspected? N Seasonal use? N/A _ - Water meter readings, if available(last 2 years usage) (gallons per day) Sump Pump? _ none in 9 I Last date of occupancy_ months General Information Pumping Records. Source of information: Not pumped since construction says owner' s rep. Y Was system pumped as part of the inspection (Y or N) If yes, volume pumped: 1500 gallons How was quantity pumped determined? pumper invoice Reason for pumping: owner's request Comment: Pump on 3 to 4 year interval . Type of System: X Septic tank., distribution box, soil adsorption system Single cesspool Overflow cesspool Privy N 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) _ T5 Revised doc•12/07 Title 5 Official Inspection Form.Subsurface Disposal S <.,m•Page 5 of 9 I_. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: Owner Name: City/Town: 271 Havdenville Road Girl Scouts of Central & Western MA Northampton, MA 01060 Date of Inspection: 5/8/09 D. System Information (cant.) Approximate Age: All components, date installed, and source of info. Septic plan: said to be 2003 system N Were sewage odors detected when arriving at the site (Y or N) Building Sewer: 14 cast iron 24 Comments: Septic Tank: 11 Concrete 0 58 122 60 1,843 10 1,500 26 3 (locate on site plan) Depth below grade (inches) Material of Construction Distance in feet from private water supply well or suction line No problems seen. Estimated Average (locate on site plan) Depth below grade Materials of Construction If tank is metal, list age Is age confirmed by a Certificate Riser depth Septic tank width Septic tank length Septic tank height Calculated gross volume (inches) of Compliance? (inches) (inches) (inches) (inches) (gallons) Air space in tank (inches) Net Volume (gallons) Baffle depth (inches) Sludge thickness (inches) 31 Top Sludge : Bottom Baffle (inches) _ 0 Scum thickness (inches) 16 Bottom Scum Bottom Baffle (inches) -- g Top Scum Top Baffle (inches) Measured How were dimensions determined? Comments: No operational or structural problems seen. Compartmentalized tank. Water level appropriate. Recommendations: Pump on 3 to 4 year interval. (attach a copy of certificate) Interior dimensions Interior dimensions Interior dimensions Calculated T5 Revised.dot•12/07 Calculated Average Calculated Average Calculated Calculated Title 5 O9,cial Inspection Form Subsurface Disposal System•Page 6 of 9 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: Owner' Name: City/Town: 271 Haydenville Road Girl Scouts of Central & Western MA Northampton, MA 01060 Date of Inspection: 5/8/09 D. System Grease Trap: N Comments: Information (cent.) (Usually present in certain commercial systems) Grease Trap part of system? Depth below grade (inches) Materials of construction: Dimensions: Scum thickness (inches) Top of scum to top of outlet tee Bottom of scum to bottom of outlet tee Date of last pumping condition Measured Average Calculated Inches Calculated Inches Tight or Holding Tank: (tank must be pumped at time of inspection) Tight tank part of system? Depth below grade (inches) Measured Materials of construction Tank width Tank length Tank height _ Capacity Design flow. gallons/day Alarm Level (inches) Alarms in working order? Date of last pumping Comments: (condition of alarm and float switches, etc.) Attach copy of current pumping contract(required). Is copy attached? Soil Absorption System (SAS): If SAS not located explain why. (locate on site plan, excavation not required). (inches) (gallons) leaching pits & number: _. leaching chambers and number _ leaching galleries and number leaching trenches, number, length: Y leaching fields, number, dimensions: estimated at 20 ' by 40 ' overflow cesspool, number: innovative/alternative system, Type: Comments: (note soil condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Estimate based on surface appearance. Field piping difficult to snake Plans not available on site. T5 Revised doc•12/07 Title 5 Official Inspection Form.Subsurface Disposal System•Page 7 of 9 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form ?., Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 271 Haydenville Road Owner' Name: Girl Scouts of Central 6 Western MA City/Town: Northampton, MA 01060 Date of Inspection: 5/8/09 D. System Information (cont.) Distribution Box: Of present must be opened) (locate on site plan) (D-box") Y D-box part of septic system? 0 Depth of liquid level above outlet invert Inches Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, and out of D-box, etc. Box level, no biosolids seen. Pump Chamber: (locate on site plan) N Pump part of septic system? Pumps in working order: (Y or N) Alarms in working order: (Y or N) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc): Cesspools: (cesspool must be pumped as part of inspection) (locate on site plan) N Cesspool part of system? • 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 Comments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Site Exam: (Source of Information) Y Check Slope Official Pero Date 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 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: Checked with local excavators. installers-explain: You must describe how you established the high ground water elevation. Site built up substantially to comply with current code. T5 Revised.doc• 12/07 Title 5 Official Inspection Form.Subsurface Disposal System•Page 8 of 9