360 Title 5 Report, 2006 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 360 North Farms Road Northampton,Mass.
Owner: Susan S Douglas Jones
Date of Inspection: June 1,2006
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 conditions described in 310 CMR
15.303 or in CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
U 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.
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.
ND explain:
Observation of sewage backup or breakout or high static water level in the distribution box is due to
broken or obstructed pipe(s) or due to a broken, settled, or uneven distribution box. The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
u
ND explain.
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
Title 5 Inspection Form 6/15/2000 Page 2
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5 INSPECTION FORM
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification
Property Address: 360 North Farms Road Name of Owner: Susan & Douglas Jones
Northampton, Mass.
Date of
inspection:
Name of
Inspector:
Company Name:
Company Phone:
June 1, 2006
Philip J. Pasiecnik
Greg's Wastewater Removal
239A Greenfield Road
S. Deerfield, MA 01373
(413) 665 -3989
Address of
Owner:
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
❑ Needs Further Evaluation by the local Approving Authority
Fails
INSPECTOR'S
SIGNATURE:
DATE:
6A/06'
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within thirty (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.
NOTES AND COMMENTS: No failure criteria as described on page four of this inspection form was found at the time of
inspection of this system. System Design Plan was obtained 8/18/97 for a Title Five Inspection done at that time.
***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
Title 5 Inspection Form 6115/2000 Page I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 360 North Farms Road Northampton,Mass.
Owner: Susan&Douglas Jones
Date of Inspection: June 1 290
D] SYSTEM FAILURE CRITERIA applicable to all systems:
You must indicate either"Yes" or "No"to each of the following, for all inspections:
YES NO
n
0
n
I IZI
n
LI
Backup of sewage into facility or system component due to overloaded or clogged SAS cc
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to ar
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.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool, or privy is below the high groundwater
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 I 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 it the
well water analysis,performed at a DEP certified laboratory,for colnorm 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.]
The system fails. I have determined that one or more of the above failure criteria
exists as defined 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
n ® The system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (MP/3,i cx s
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 threat, or answered "yes" it
Section D above the large system has failed. The owner or operator or 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.
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 Page 4
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 360 North Farms Road Northampton,Mass.
Owner: Susan 8 Douglas Jones
Date of Inspection: June 1,2006
Cl 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 the public health, safety, or the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH
310 CMR 15.303 (1)(6)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL
PROTECT THE 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 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 THE ENVIRONMENT:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100
feet to 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
rife 5 inspection Form 6/15/2000
Page 3
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION
Property Address: 360 North Farms Road Northampton,Mass.
Owner: Susan&Douglas Jones
Date of Inspection: June 1,2006
FLOW CONDITIONS
Residential:
Number of bedrooms (design): 3 Number of bedrooms (actual)_2
DESIGN Flow: 330 G.P.D. (based on 310 CMR 15.203-for example: 110 gpd x#of bedrooms)
Number of current residents: 2
Is Garbage Grinder present (yes or no) Yes
Is laundry on a separate sewage system (yes or no) No if yes separate inspection required
Laundry system inspected (yes or no)
Seasonal Use (yes or no) No
Water Meter readings - if available
(last two (2) year usage (gpd) 18,800 Cu. Ft. = 141,000 Gallons = 193 G.P.D.
Sump Pump (yes or no) No
Last Date of Occupancy: Currently Occupied
Commercial/Industrial:
Type of establishment:
Design flow: (Based on 310 CMR 15.203) gallons per day
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)
Last Date of Occupancy/Use:
OTHER (describe):
PUMPING RECORDS
Source of information:
Was system pumped as
part of the inspection:
(yes or no)
If YES -enter volume
pumped
Reason for pumping:
TYPE OF SYSTEM:
N1 Septic Tank/D Box/ Soil Absorption System rl Sinale Cesspool
❑ Overflow Cesspool I Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any) No
Innovative/Alternative technology. Attach a copy of up the current operation
and maintenance contract (to be obtained from system owner)
GENERAL INFORMATION
Septic tank has been pumped by Greg's on 4/11/06, 4/1/03,4/6/00 & 8/18/97.
No, system last pumped 2 months ago. 1500 Gallons removed.
gallons
How was the quantity pumped determined? Tank Dimensions
Tight Tank Attach a copy of DEP Approval
OTHER (describe):
Approximate age of all components, date installed Of known) and source of information:
17 Years Old / 1988 / Design Plan Dated 7/1/88
Were sewage odors detected when arriving at site: (yes or no) No
Title 5 Inspection Form 6/15/2000 Page 6
Property Address:
Owner:
Date of Inspection:
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part B
CHECKLIST
360 North Farms Road Northampton,Mass.
Susan S Douglas Jones
June 1.2006
Check if the following have been done. You must indicate either "Yes" or "No"
as to each of the following:
Yes No
❑ Pumping information was requested of the owner, occupant, or Board of Health.
[i ® 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?
�f ® Have large volumes of water been introduced to the system recently or as part of this inspection?
® n 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 Soil Absorption System, 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)]
Yifle 5 Inspection Form 6/15/2000 Page 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION (continued)
Property Address: 360 North Farms Road Northampton,Mass.
Owner: Susan 8 Douglas Jones
Date of Inspection: June 1 2006
TIGHT or HOLDING TANK: (Tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of Construction: Lf Concrete ❑ Metal ❑ Fiberglass ❑ Polyethylene Other (explain)
Dimensions:
Capacity in gallons
Design flow in gallons per day
Alarm present (Yes or No)
Alarm level Alarm in working order [Yes ❑ No
Date of last pumping
Comments: (condition of alarm and float switches, etc)
DISTRIBUTION ❑ Yes ® No (If present, MUST be opened-locate on site plan)
BOX
Depth of liquid level above outlet invert: No Box Present
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.) No Box Present
PUMP CHAMBER: ❑ (located 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.)
Title 5 Inspection Form 6/15/2000 Page S
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 360 North Farms Road Northampton,Mass.
Owner: Susan 8 Douglas Jones
Date of Inspection: June 1,2006
BUILDING SEWER(Locate on site plan): El
Depth below grade: 14"
Material of construction: _cast iron XXX 40 PVC other(explain)
Distance from private water supply well or suction line Town Water
Diameter 4"
Comments: (condition of joints, venting, evidence of leakage, etc.) Joints were in good condition. Venting was visible
outside the dwelling. No leakage was evident.
SEPTIC TANK (locate on site plan): El
Depth below grade: 6"
Material of Construction: ® Concrete ❑ Metal ❑ Fiberglass ❑ Polyethylene Other(explain)
If tank is metal, list age Is age confirmed by Certificate of Compliance
(Yes/No) (If"Y", attach copy of Certificate of Compliance)
10'6"Lx5'6"Dx5'4"D Dimensions:
None Detected Sludge Depth
N/A Distance from top of sludge to bottom of outlet tee or baffle
Trace Scum thickness
6" Distance from top of scum to top of outlet tee or baffle
19" Distance from bottom of scum to bottom of outlet tee or baffle
Measured How dimensions were determined:
Comments: (On pumping recommendations, inlet& outlet tee or baffle condition, structural integrity, liquid levels as
related to outlet invert, evidence of leakage, etc.) The septic tank should be pumped every two to three years. Cast
in place concrete inlet baffle was in good condition and extends 13" below the flow line Cast in place concrete outlet
baffle was in good condition and extends 19" below the flow line. Structural integrity of the septic tank was good. The
liquid level was at the outlet invert. No leakage was evident at this time. .
GREASE TRAP (locate on site plan): ❑
Depth below grade-
Material of Construction: ❑ Concrete ❑ Metal ❑ Fiberglass ❑ Polyethylene ❑ Other(explain)
Dimensions
Scum thickness
Distance from top of scum to top of outlet tee/ baffle
Distance from bottom of scum to bottom of outlet tee/baffle
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.): .
I We 5 Inspection Form 6/15/2000 Pagel
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION
Properly Address: 360 North Farms Road Northampton,Mass.
Owner: Susan 8 Douglas Jones
Date of Inspection; June 1,2006
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.
**** { SEE EXHIBIT A} ****
Title 5 Inspection Form 6/15/2000 Page 10
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION (continued)
Property Address: 961 North Farms Road Northampton,Mass.
Owner: Susan 8 Douglas Jones
Date of Inspection: June 1,2006
SOIL ABSORPTION SYSTEM
(SAS):
(locate on site plan, if possible; excavation not required.)
If SAS is not located explain why:
TYPE:
Leaching pits & number 1 - Pre-Cast Concrete Leaching Pit Surrounded
by 3 Feet of 11/2" Stone
Leaching chambers & number
Leaching galleries& number
Leaching trenches, number, length
Leaching fields, number,
dimensions
Overflow cesspool, number
Innovative/Alternative system:
Name of Technology:
Comments: (Note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) The soil was
sandy gravel with no clogging evident. No signs of hydraulic failure or ponding. The soil over the leaching
pit wasn't damp or spongy. Vegetation was mowed grass which looked normal in growth. Risers on the pit
cover are 6" below grade. There was 10" of liquid in the pit when opened for inspection with 20" of
available volume..
CESSPOOLS ❑ (Cesspool must be pumped as part of inspection-locate on site plan)
Number& 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,sgns of hydraulic failure,level of ponding,condition of vegetation etc.)
Title 5 Inspection Form 6/15/2000 Page 9
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION (continued)
Property Address: 360 North Farms Road Northampton,Mass.
Owner: Susan&Douglas Jones
Date of Inspection: June 1,2006
SITE EXAM ❑ Slope
Z Surface water
® Check cellar
❑ Shallow wells
Estimated Depth to Groundwater > 5 Feet
Please indicate (check) all the methods used to determine High Groundwater
Elevation:
❑ Obtained from system design plans on record - If checked, date of design
plan reviewed: July 1 1988 William J. Sieruta P.E.
❑ 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:
Design Plan and Site Exam
Title 5 Inspection Form 6/15/2000 Page II
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