360 Title 5 Report, 1997 (revised 04/25/97) —Page 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 360 NORTH FARMS ROAD
Owner:
Date of Inspection:
NORTHAMPTON,MA. 01060
SUSAN EDDIE
AUGUSTS 1997
B] SYSTEM CONDITIONALLY PASSES (continued)
Indicate YES, NO, or Not Determined (Y,N, or ND). Describe basis of determination in all instances. If"not determined",
explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a
Certificate of Compliance (attached) indicating that the tank was installed within twenty(20) years prior to
the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows
substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the
existing septic tank is replaced with a conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed 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): Describe observations:
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
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
❑ obstruction is removed
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 the public health, safety, and environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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
APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS
THE PUBLIC HEALTH AND 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 soil absorption system and the SAS is within a Zone 1 of a public
water supply well.
❑ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply
well.
❑ The system has a septic tank and soil absorption system and the SAS is less than 100 feet BUT 50
feet or more from a private water supply well, unless a well water analysis 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. Method used to
determine distance (approximation not valid).
3) Other
(revised 04/25/97) —Page 1
William F. Weld
Governor
Argeo Paul Celluci
LL Governor
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
ONE WINTER STREET, BOSTON, MA. 02108 617-292-5500
Trudy Coxe
Secretary
David B. Struhs
Commissioner
Property Address:
Date of Inspection
Company Name:
Company Phone:
TITLE V REPORT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification
360 NORTH FARMS ROAD Address of Owner:
NORTHAMPTON, MA. 01060
AUGUST 18, 1997
Greg's Wastewater Removal
239A Greenfield Road
S. Deerfield, MA 01373
(413)665- 3989
(ONLY if different)
AUG 2 n
Name of Inspector: Philip J. Pasiecnik
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
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 inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on-site sewage disposal systems. The system:
® Passes
❑ Conditionally Passes
❑ Needs Further Evaluation by the local Approving Authority
❑ Fails
INSPECTOR'S SIGNATURE:
t 414.4 DATE: p//g// 7
The System Inspector shall submit a copy of this inspection report the Approving Authority 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY: (Check A, B, C, or D)
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in
310 CMR 15.303.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.
revised 04/25(97) —Page 4
SUBSURFACE SEWAGE DISPOSAL SYSTE^1 INSPECTION FORM
Part B
CHECKLIST
Property Address: 360 NORTH FARMS ROAD
NORTHAMPTON,MA. 01060
Owner: SUSAN EDDIE
Date of Inspection: AUGUST 16 1907
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, and Board of Health.
• ❑ None of the system components have been pumped for at least two weeks, and the system has
has been receiving normal flow rates during that period. Large volumes of water have not been introduced into
the system recently or as part of this inspection.
NMI ❑
As built plans have been obtained and examined. Note if they are not available with an NA
® ❑ The facility or dwelling was inspected for signs of sewage back-up.
® ❑ The system does not receive non-sanitary or industrial water flow.
® ❑ The site was inspected for signs of breakout.
® ❑ All system components, excluding the Soil Absorption System, have been located on the site.
O ❑ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for
condition of baffles or tees, material of construction,dimensions, depth of liquid, depth of sludge, depth of
scum.
The size and location of the Soil Absorption System on the site has been determined based on:
O ❑ The facility owner(and occupants, if different from owner)were provided with information on the proper
maintenance of Sub-Surface Disposal System.
❑ ® Existing information. Ex. Plan at B.O.H.
• ❑ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) {15.302(3)(b)}
(revised 04/25/97) —Page 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 060 NORTH FARMS ROAD
NORTHAMPTON,MA. 01060
Owner: SUSAN EDDIE
Date of Inspection: _AUGUST 111,1997
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
❑ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below.The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded 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.
Liquid depth in cesspool is less than 6"below invert or available volume is less the 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 a 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. If the well has been analyzed to be acceptable,
attach a copy of well water analysis for conform bacteria,volatile organic compounds, ammonia
nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
'"`THE FOLLOWING CRITERIA APPLY TO LARGE SYSTEMS IN ADDITION TO CRITERIA ABOVE:"'
The system serves a facility with a design flow of 10,000 gpd or greater(Lame System)and the system is a sgnificant
threat to public health and safety and the environment because one or more of the following conditions exist:
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 II of a public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
(revised 0425,97) —Page 6
Property Address:
SUBSSRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
360 NORTH FARMS ROAD
NORTHAMPTON,MA. 01060
Owner: SUSAN EDDIE
Date of Inspection: _AUGUST 18 1897
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 12"
Material of construction: cast iron X 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 in good condition. Building sewer vented thru dwelling. No evidence of leakage
SEPTIC TANK-
(locate on site plan):
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)
10'x6"x5'x5' Dimensions:
6" Sludge Depth
30" Distance from top of sludge to bottom of outlet tee or baffle
2" Scum thickness
5° Distance from top of scum to top of outlet tee or baffle
14" Distance from bottom of scum to bottom of outlet tee or baffle
Va ruREt How dimensions were determined:
Comments: (Recommendations for pumping,condition of inlet(3 outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.) Pump every 3-5 years depending on number of occupants. Inlet and outlet baffles are in good condition.
Liquid level was at but not over the outlet invert.Tank is in good condition with no evidence of leakage.
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: (Recommendations for pumping,condition of inlet a outlet tees or baffles,depth of liquid levet in relation to outlet invert, structural integrity,
evidence of leakage etc.) .
(revised 04/25197)—Page 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION
Property Address: 360 NORTH FARMS ROAD
NORTHAMPTON,MA. 01060
Owner: SUSAN EDDIE
Date of Inspection: _AUGUST 111 1997
Residential:
Design Flow: 11 o D.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage Grinder (yes or no)
Laundry connected to system (yes or no)
Seasonal Use (yes or no)
Water Meter readings- if available
- (last two (2) year usage (gpd)
Sump Pump (yes or no)
Last Date of Occupancy:
3
1
No
Yes
No
FLOW CONDITIONS
S/000 Gflt,
Yes
Unknown
Commercial/Industrial:
Type of establishment:
Design flow:
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:
OTHER: (Describe)
Last date of occupancy:
PUMPING RECORDS and
source of information:
System pumped as pail of the
inspection: (yes or no)
If YES-enter volume pumped:
gallons per day
GENERAL INFORMATION
Pumped 1/95 by Rays per owner
Yes
1542cgallons
Reason for pumping: Tank inspection
TYPE OF SYSTEM:
® Septic Tank/D Box/Soil Absorption System
❑ Overflow Cesspool
❑ Single Cesspool
❑ Privy
Shared system (yes or no) Of yes, attach previous inspection records, if any) No
.1/A Technology etc. Copy of up to date contract?
OTHER:)
APPROXIMATE AGE of all-components: 8 Years Approx
Date Installed, if Known: 8 years ago
Source of Information: SPlir design plan
Sewage Odors detected when arriving at Site: (yes or no) No
(
ed04/25/97) —Page 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION(continued)
Property Address: 360 NORTH FARMS ROAD
Owner:
Date of Inspection:
NORTHAMPTON,MA. 01060
SUSAN EDDIE
AUGUST 18 1997
SOIL ABSORPTION SYSTEM
(SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
TYPE:
Leaching pits& number 1-750 gallon •
Leaching chambers&number
Leaching galleries& number
Leaching trenches, number, length
Leaching fields, number, dimensions
Overflow cesspool, number
Alternative system:
Name of Technology:
Comments: (Note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Sandy gravel with no sign of claming,
No sign of hydraulic failure No ponding. Vegetation seems normal mowed grass..
CESSPOOLS ❑
(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
inflow(cesspool must be pumped as part of inspection)
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.) _
(revised 04/25/97) —Page 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION(continued)
Propeity Address: 360 NORTH FARMS ROAD
Owner:
Date of Inspection:
NORTHAMPTON,MA. 01060
SUSAN EDDIE
AUGUST%1997
TIGHT I HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan):
Depth below grade:
Material of Construction: ❑ Concrete ❑ Metal ❑ Fiberglass ❑ Polyethylene _Other(explain)
Dimensions:
Capacity in gallons
Design flow in gallons per day'
Alarm level Alarm in working order Oyes ❑ No
Date of previous pumping
Comments: (Condition of Inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ❑ Yes ® No
(locate on site plan):
Depth of liquid level above outlet invert:
Comments: (Note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
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.)
(revised 04/25/97) —Page 10
Property Address:
SJBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOiN FORM
Part C
SYSTEM INFORMATION (continued)
360 NORTH FARMS ROAD
NORTHAMPTON,MA. 01060
Owner: SUSAN EDDIE
Date of Inspection: AUGUST-1B,1997
Depth to Groundwater 6+ Feet
Please indicate all the methods used to determine High Groundwater Elevation
® Obtained from Design Plans on record
® Observation of Site (Abutting property, observation hole, basement sump etc.)
® Determine it from local conditions
❑ Check with local Board of health
❑ Check FEMA Maps
® Check pumping records
❑ Check local excavators, installers
❑ Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.
(Must be completed): See Exhibit "B"design plan for test pit information. Basement
has a sump pump, but was dry at time of inspection at 71t. below grade. Leach pit
had only 4°of liquid with no sign of recharge from groundwater at Mt. below grade.
Pumping records show no sign of a ground water problem
{INCLUDE TIES TO AT LEAST 2 PERMANENT
AND LOCATE ALL WELLS WITHIN 100 FEET}
REFERENCES, LANDMARKS,OR BENCHMARKS
(Locate where publicwater supply comes into house)
(revised 04/25/97) —Page 9
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION
360 NORTH FARMS ROAD
NORTHAMPTON,MA. 01060
SUSAN EDDIE
AUGUST 18 1997
SKETCH OF SEWAGE DISPOSAL SYSTEM:
I'
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