828 Title 5 Application/Permits 1964, 1992, Inspections 1995, 2002 COMMONWEALTH OF MASSACHUSEI I'S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR
DEPARTMENT OF ENVIRONMENTAL PROTEC
TITLE 5 a,yNN
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESS SFhFq<n,
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
operty Address: 828 North Kind Street, Northampton, MA
vner's Name: Tex Douglas
mar's Address: 26 Gore Avenue , Hatfield. MA 01038
to of Inspection: 5/6/02
py to: Board of Health. Northampton•
mess: Owner's representative, realtor Number: 551)5-669
me of Inspector: Thomas S. Leue
!mpany Name: Homestead Inc.
ilingAddress: 1664 Cape St. , Williamsburg, MA 01096
lephone Number: (413) 628-4533
ERTIFICATION STATEMENT
ertify that I have personally inspected the sewage disposal system at this address and that the information
)orted below is true, accurate and complete as of the time of the inspection. The inspection was performed
sed on my training and experience in the proper function and maintenance of on-site sewage disposal
stems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).
ie 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
ie system condition: passes
spector's Signature:
Date: May 6. 2002
ie System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health
DEP) within thirty (30) days of completing this inspection. If the system is a shared system or has a design
iw of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
;tonal office of the DEP. The original should be sent to the system owner and copies to the buyer, if
plicable and the approving authority.
rtes and Comments
**This report only describes conditions at the time of inspection and under the conditions of use at that
ne.This inspection does not address how the system will perform in the future under the same or
Iferent conditions of use.
le 5 Inspection Form 6/15/2000
page 1 of 10 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
operty Address: 828 North King Street. Northampton. MA
vner: Tex Douglas
rte of Inspection: 5/6/0Z
spection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D:
System Passes:
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.
imments•
System Conditionally Passes:
1 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
ucturally unsound, exhibits substantial infiltration or exfiltration,or tank failure is imminent. The system will
ss inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of
:alth. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
:mpliance indicating that the tank is less than 20 years old is available.
) explain
N Observation of sewage backup or break out or high static water level in the distribution box due
broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass
:pection if(with approval by the Board of Health). _ broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
)explain.
The system required pumping more than four times a year due to broken or obstructed pipe(s).
e system will pass inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
) explain-
N Other: explain:_
Further Evaluation is Required by the Board of Health:
I Conditions exist which require further evaluation by the Board of Health in order to determine if the
stem is failing to protect the public health, safety or the environment:
System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that
e 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
le 5 Inspection Form 6/15/2000
page 2 of 10 Homestead Inc.
•
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
operty Address: 828 North Kina Street. Northampton. MA
Amer: Tex Douglas
de of Inspection: 5/6/02
System will fail unless Board of Health(and Public Water Supplier, if any) determines that the
stein 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
rface 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
ivate 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
d volatile organic compounds indicates that the well is free from pollution from that facility and the presence
ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
triggered.A copy of the analysis must be attached to this form.
Other:
System Failure Criteria applicable to all systems:
to must indicate either"Yes" or"No" as to each of the following for all inspections:
(Y) 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 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 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.]
The system fails. I have determined that one or more of the above failure criteria exist as defined in 310
vl 15.303, therefore the system fails. The system owner should contact the Board of Health should be
ntacted to determine what will be necessary to correct the failure.
le 5 Inspection Form 6/15/2000
page 3 of 10
Homestead Inc
FFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
operty Address: 828 North King Street, Northampton, MA
Amer: Tex Douglas
tte of Inspection: 5/6/02
Large Systems:
be considered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd.
to must indicate either"Yes" or "No"as to each of the following:
ie following criteria apply to large systems in addition to the criteria above:
S (Y)or NO(N)
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
lY the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area -IWPA) or a
apped Zone II of a public water supply well)
you answered "yes"to any question in Section E the system is considered a significant threat, or answered
es"in Section D above the large system has failed. The owner or operator of any large system considered a
tnificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310
vIR 15.304. The system owner should contact the appropriate regional office of the Department.
PART B• CHECKLIST
teck if the followino have been done. You must indicate "yes"or "no"as to each of the followino:
,S (Y) or NO (N)
Pumping information was provided by the owner,occupant or Board of Health.
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?
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?
Was the site was inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition
the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Le 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.
b) Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
dance is unacceptable) [15.302(3)(6)].
e The facility owner(and occupants, if different from owner) were provided with information on proper
tintenance of Subsurface Sewage Disposal Systems(SSDS).
le 5 Inspection Form 6/15/2000
page 4 of 10 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C: SYSTEM INFORMATION
operty Address:
Amer:
de of Inspection:
?SIDENTIAL
unknown
3
0
N
Y
N
N
N/A
in_?30_
days
826 North King Street, Northampton MA
Tex Douglas
5/6/02
FLOW CONDITIONS
DESIGN flow based on 310 CMR 15.203 (gallons/day)
Number of bedrooms(design)
Number of bedrooms(actual)
Number of current residents
Is there a garbage grinder ?(Y or N) _
Is there a Laundry Hookup?(Y or N)
Is the Laundry a separate system? (Y or N) (If yes, separate inspection required)
Seasonal use(Y or N)
Water meter readings, if available(last two years usage) (gallons per day)
Sump Pump (Y or N)_
Date of last occupancy _
3MMERCIAL/INDUSTRIAL
lie of establishment:
:sign flow (based on 310 CMR 15.203): gpd
Isis of design flow (seats/persons/sqft, etc.):
ease trap present(yes or no):
Justrail waste holding tank present(yes or no):
ater meter readings, if available:
st date of occupancy/use:
HER(describe):
GENERAL INFORMATION
=ping Records
tree of information:No information on earlier pumpi ng.
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: Recommend numnina at this time
(PE OF SYSTEM:
Septic tank,egerl'aealseiss soil adsorption system.
- Single cesspool
Overflow cesspool
Privy
- Shared system (Y or N) (if yes, attach previous inspection records, if any)
Innovative/Altemative 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):
le 5 Inspection Form 6/15/2000
page 5 of 10 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
operty Address:
viler:
rte of Inspection:
828 North Kina Street, Northampton. MA,
Tex Douglas
5/6/02
- Were sewage odors detected when arriving at the site (Y or N):
'PROXIMATE AGE of all components, date installed(if known) and source of information:
information on ape.
JILDING SEWER: (located on site plan)
Average depth below grade 3' Distance from private water supply well or suction line
Material of construction: X cast iron _Sch. 40 PVC _other(explain)_
)mments: (condition of joints, venting,evidence of leakage, etc.) No problems seen.
;PTIC TANK: Y (located on site plan)
Material of construction: X concrete_metal _FRP polyethylene_other(explain)
30 Depth below grade
48 Septic tank width
76 Septic tank length
58 Septic tank height
ale Calculated gross volume
8 Air space in tank
Net Volume
20 Baffle depth
11 Sludge thickness
13 Scum thickness
(inches)
(inches)
(inches)
(inches)
(gallons)
(inches)
(gallons)
(inches)
(inches) Represents average
(inches) Represents average
Top of sludge layer to bottom
2.7_._ of outlet tee or baffle (inches)
Bottom of scum layer to
3 bottom of outlet tee or baffle (inches)
Top of scum layer to top of
2 outlet tee or baffle (inches)
)mments: (recommendation for pumping, conditions of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert, structural integrity,evidence q�,l�akace, eta boil r
Tank structurally OK. Inlet baffle intact V ifbtJet--cover Sealed in
ace. could not be opened for inspection. Tank overdue for pumping.
commend riser over Center hole to facilitate maintenance.
>w dimensions were determined: Measured.
le 5 Inspection Form 6/15/2000
page 6 of 10 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
operty Address: 828 North King Street, Northampton MJ
vner: Tex Doualas
rte of Inspection: 5/6/02
/MP CHAMBER: N/A_ (part of pump-up systems only)
mps in working order: (Y or N) _
arms in working order: (Y or N) _
>mments: (note condition of pump chamber, condition of pumps and appurtenances, etc.)
:STRIBUTION BOX: N (if present must be opened)(locate on site plan) ("D-box")
:pth of liquid level above outlet invert:
>mments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into
out of box, recommendations for repairs, etc.) No d-box found in system, overflow
roe distribution to two leach tanks.
)IL ADSORPTION SYSTEM(SAS)Y (locate on site plan, excavation not required)
SAS not located explain why
pe:
tching pits& number: 2 leach hits. riser to surface over one of them_
tching chambers and number:
tching galleries and number. _
tching trenches,number,length:
tching fields,number, dimensions•
erflow cesspool, number:
rovative/altemative system,Type/name of technology
>mments: (note soil conditions, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
> problems seen on surface. No evidence of breakout. C•st iron riser
> surface offers no maintenance function, except for Title 5
>servations. Maintenance of system would be to pump septic tank at
>cation shown on drawing. However due to possibility of _pumper
larking easy way out and pumping from cover marked "SEWER", extra
tre should be used to assure that septic tank is proper]y
tintained.
lc 5 Inspection Form 6/15/2000
page 7 of 10 Homestead Inc
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(continued)
operty Address: 828 North King Street, Northampton, MA
vner: Tex Do glas
de of Inspection: 5/6/02
GAT OR HOLDING TANK: NA (tank must be pumped at time of inspection) (locate on site plan)
:pth below grade:
aterial of construction: concrete _metal_FRP polyethylene_other(explain)
mensions:
ipacity: gallons
:sign flow: gallons/day
arm level: Alarm in working order Yes No
tte of last pumping:
torments: (conditions of inlet tees, condition of alarm and float switches, etc.)
?SSPOOLS: N/A (cesspool must be pumped as part of inspection) (locate on site plan,if any)
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(cesspool must be pumped as part of inspection)
torments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
tIVY: N/A (locate on site plan, if any)
aterials of construction.
mensions:
.pth of solids:
torments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
REASE TRAP: NLA (Usually present in certain commercial systems) (locate on site plan)
aterial of construction:_concrete _metal _FRP_polyethylene_other(explain)
:pth below grade: inches
mensions: inches
urn thickness: inches
ip of scum layer to top of outlet tee or baffle: inches
atom of scum layer to bottom of outlet tee or baffle inches
de of last pumping_
torments: (recommendation for pumping, conditions of inlet and outlet tees or baffles, depth of liquid level in
relation to outlet invert, structural integrity, evidence of leakage, etc.)
le 5 Insprrtion Form 6/15/20(X)
page 8 of 10 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(continued)
operty Address: 828 North King Street, Northampton, MA
vner: Tex Douglas
rte of Inspection: 5/6/02
TE EXAM
Dpe
rface water
Lock Cellar
allow wells
timated depth to ground water: 8 feet
.ase indicate(check)all the methods used to determine high groundwater elevation:
Obtained from system design plan 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:
Check local excavators, installers-(attach documentation)
Accessed USGS database - explain:
to must describe how you established the high groundwater elevation.
Depth to dry basement floor without sumo pump
)MMENTS:
Recommend pumping on a 3 to 5 year schedule. Also, a CODy of the
attached plan posted in the basement/utility area would keep this
information accessible in future years for maintenance.
3SOURCES:
Department of Environmental Protection,Western Regional Office,436 Dwight St., Springfield, MA
01103, (413) 784-1100;Title 5 Hotline- (800)266-1122
le 5 Inspection Form 6/1512000
page 9 of 10
Homestead Inc
' s" Called North
Partial House Plan \
//
Porch
i� .
------- r, ,i
lam, 3,
� �
Septic tank 3 o i
/
Leaching pits N
riser to surface
Note: No well water source within 100'
As-Built Drawing Date: Owner: HOMESTEAD INC.
Existing Septic System
5/6/02 Tex Douglas
S P Thomas S. Leue R.S.
828 North King Street �' ,, __
Scale: 1 : 10' Revision Date: Northampton, MA 01060 Williamsburg, on 01096
[413]628-4533
Except as Noted
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
PART A - CERTIFICATION
doperty Address: 828 North King St.Northampton,MA
ate of Inspection: 10/31/97
wner's Name: Mark Battey
wner's Address: P.O. Box 25, Leeds, MA 01053
op to: Board of Health,Northampton
ailing Address:
itness: Owner Number: SSDS-211
ame of Inspector: Thomas S. Leue, Homestead Inc.
om pony Address: 1664 Cape St., Williamsburg, MA 01096 (413) 628-4533
4 '
FRTIFICATION STATEMENT
:edify that I have personally inspected the sewage disposal system at this address and that the information reported is true,
.curate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the
oper function and maintenance of on-site sewage disposal systems. I do not represent or warrant the operation or proper function of
is system for any period of time. The system:
_X_ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
spector's Signature:
4,0 , Date' October 31 1997
e System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. It the system is
:hared system or has a design flaw of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
rear-anent of Environmental Protection. The onginel should be sent to the system owner and copies to the buyer,if applicable and the approving authority.
ISPECTION SUMMARY: Check A,B,C,or D:
SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 OAR
15.303. Any failure criteria not evaluated are indicated below.
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.
)
dicate 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 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 by
the Board of Health):
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)or due to a broken,
settled or uneven distribution box. The system will pass inspection it(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
:vises edition 04/25/97
Page 1 Homestead Inc.
operty Address:
rner's Name:
to of Inspection:
PART A - CERTIFICATION (continued)
828 North King St., Northampton,MA
Mark Battey
10/31 /97
The system required pumping more than four times a year 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
FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine it the system is failing to protect
the public health,safety and the 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 THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS PUBLIC HEALTH,SAFETY AND THE ENVIRONMENT:
_ The system has aseptic tank and soil absorption system(SAS)and is within 100 feet to a surface water supply or a tributary
to a surface water supply.
The system has a septic tank and a SAS and the SAS is within a Zone l of a public water supply well.
_ The system has a septic tank and a SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and a SAS 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). If the well has been analyzed to be acceptable, attach
copy of well water analysis for coliform,volatile organic compounds,ammonia nitrogen, and nitrate nitrogen.
3) OTHER
SYSTEM FAILS:
ist indicate either"Yes"(Y)or"No"(N)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 CM 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.
:S NO
- X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
- :L Discharge orponding of effluent to surface of the ground or surface waters due to an overloaded or clogged SAS 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 less than 6"below invert,or available volume less than 1/2 day of calculated daily flow?(Part 7)
- IL Required pumping 4 times or more in the last year y_Qtdue to clogged or obstructed pipe(s).Number of times pumped_
- A Any portion of the Soil Absorption System,cesspool or privy below high groundwater elevation.
- i Any portion of a cesspool or privy is within 100 feet of a surface water supply or a tributary to a surface water supply.
- 2 _ Any portion of a cesspool or privy is within a Zone I of a public well.
- X Any portion of a cesspool or privy is within 50 feet of a private water supply.
- i 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.
LARGE SYSTEM FAILS:
e following criteria apply to large systems in addition to the criteria above:
_ The design flow is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and
the environment because one or more of the following conditions exist:
- the system is within 400 feet of a surface dunking 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)
e owner or operator of any such system shall bring the system and the facility into full compliance with the groundwater treatment
/gram requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
vised edition 04/25/97 Page 2 Homestead Inc.
"operty Address:
wner's Name:
ate of Inspection:
PART B - CHECKLIST
828 North King St., Northampton,MA
Mark Battey
10/31 /97
-IECK IF THE FOLLOWING HAVE BEEN DONE:
- 1. Pumping information was requested of the owner,occupant and/or Board of Health.
- 2. None of the system components have been pumped for at least two weeks and the system 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.
3. As built plans have been obtained and examined. Note if they are not available with N/A.
4. The system does not receive non-sanitary or industrial waste flow.
5. The facility or dwelling was inspected for signs of sewage back-up.
6. The site was inspected for signs of breakout.
7. All system components,excluding the Soil Absorption System,have been located on site.
8. 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.
9. The size and location of the Soil Absorption System on site has been determined based on:
- a) Existing information on file with the Board of Health.
- b) Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unaccep table)
[15.302(3)(b)]
10. The facility owner(and occupants,if different from owner)were provided with information on proper maintenance of
Subsurface Sewage Disposal Systems(SSDS).
FLOW CONDITIONS
:ESIDENTIAI •
Design Flow unknown gallons/day/bedroom for SAS
Number of bedrooms
_ Number of current residents
L_ Garbage grinder(Y or N)
Laundry connected to system(V or N)
L— Season use(Y or N)
I— Sump Pump into system(Y or N)
Water meter readings,it available' Net availahle gallons per day
Date of last occupancy: continuous
'OM MFRCIAL/INDUSTRIAL•
Type of Establishment:
Design Flow: gallons/day
Grease trap present(V or N)
Industrial Waste Holding Tank present(V or N)
Non-sanitary waste discharge to the Title 5 system(Y or N)
Water meter readings,if available:
Date of last occupancy:
)THFR- (Describe)
gallons per day
Date of last occupancy:
2evised edition 04/25197
Page 3 Homestead Inc.
operty Address:
vner's Name:
ite of Inspection:
PART C - SYSTEM INFORMATION
828 North King St., Northampton,MA
Mark Battey
10/31/97
;WIPING RECORDS and source of information:
System nor nmmned in our 4 years from Owner's rernrds
System pumped as part of inspection(Y or N) [subsequent day]
If yes,volume pumped: 950 gallons
Reason for pumping: System maintenance&inspection also rannoed by code
Name of Septage Pumper: Karl's Excavation
'PE OF SYSTEM:
Septic tank/distribution box/soil adsorption system.
Single cesspool
Overflow cesspool
Privy
Shared system(V or N),if yes,attach previous inspection records,if any.
I/A Technology etc. Copy of up-to-date contract?
Other(explain)
'PROXIMATE AGE of all components. date installed Of known) and source of information:
Dare of rnnstrurfi on unknown
iwage odors detected when arriving at the site:(Y or N) N
JILDING SEWER' Y
(located on site plan)
_2a' Average depth below grade
uerial of construction: X cast iron _Sch.40 PVC other(explainl_rhangRu to nranpeburg
Distance from private water supply well or suction line
4" Diameter
imments: (condition of joints, venting, evidence of leakage etc.)
:PTIC TANK:
Y (located on site plan)
Average depth below grade
Aerial of construction:concrete_metal_FRP_polyethylene_,pther(explain)
nensions
w dimensions were determined:
(A) sludge depth
(B) top of sludge layer to bottom of outlet tee or baffle
(C) bottom of scum layer to bottom of outlet tee or baffle
(D) scum thickness
(E) top of scum layer to top of outlet tee or baffle
mments: (recommendation for pumping,conditions of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,
uctural integrity, evidence of leakage, etc.)
oised edition 04/25/97
Page 4
Homestead Inc.
PART C - SYSTEM INFORMATION (continued)
• perty Address: 828 North King St., Northampton,MA
vner's Name: Mark Battey
rte of Inspection: 10/31/97
TEASE TRAP: N/A (Usually present in certain commercial systems)
'Oh below grade:
iterial of construction:_concrete_metal_FRP_polyethylene_pther(explain)
mensions•
- (A) scum thickness
- (B) top of scum layer to top of outlet tee or baffle
(C) bottom of scum layer to bottom of outlet tee or baffle
- (D) date of last pumping
imments: (recommendation for pumping, conditions of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,
uctural integrity, evidence of leakage, etc.)
RHT OR HOI DING TANK- N/A (Special circumstances only)
ipth below grade:
iterial of construction- _concrete_metal_FRP_polyethylene other(explain)
Tensions'
'pacify: gallons
sign flow: gallons/day
trm level: _Alarm in working order_Yes' _No
imments: (conditions of inlet tees, condition of alarm and float switches, etc.)
STRIRUTION BOX: N/A (locate on site pan)("D-box")
•pth of liquid level above outlet invert:
Foments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,
:ommendations for repairs, etc.)
/IL AJ)SORPTION SYSTFM (SAS • Y___
Locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods. If not
determined to be present, explain.
pe:
leaching pits&number:
leaching chambers and number:
leaching galleries and number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number: 2 huilt of'Under Mork rovers intact
Alternative system,name technology
Comments: (note soil conditions,signs of hydraulic failure,level of pending,condition of vegetation,
recommendations for maintenance or repairs, etc.)
Nn nrnhlemn seen
Iised edition 0425197
Pages Homestead Inc.
PART C - SYSTEM INFORMATION (continued)
operty Address: 828 North King St., Northampton,MA
xner's Name: Mark Battey
Ile of Inspection: 10/31/97
)MP CHAMBER- N/A (pad of pump-up systems only)
imps in working order:(Y or N)
arms in working order:(Y or N)
tmments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
=SSPf101 S; Y (locate on site plan, if any)
rte: Cesspools must be pumped as part of the inspection.
amber and configuration: two overflow tvoe
)pth-top of liquid to inlet invert: first tank' 12"
'Oh of solids layer: 12"
upth of scum layer: 0"
pensions of cesspool: each 6'diameter 6'depth working depth 5'
iterials of construction: cinder bloc concrete rover on first PT wood on second
lication of groundwater inflow' notseen above groundwater
low(cesspool must be pumped as part of inspection) none seen
Imments: (note soil conditions,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Second tank efferlively dry first tank has adequate canard)/
EPTH TO GROUNDWATER: >6'-8" inches
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plan 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 Date
scribe in your own words how you established the High Groundwater Elevation.(Must be completed)
Second tank dry to this denth only a small hit of water in cessnnnl
indirares y-rntndwater at creates depth
)MMENTS:
inlet and outlets not hafflad New ricar to curfaca over #7
:SOURCES:
Department of Environmental Protection, Western Regional Office, 436 Dwight St., Springfield, MA
01103, (413) 784-1100; Title 5 Hotline - (800) 266-1122
rased edition 04125/97
Page 6 Homestead Inc.
/
Partial House Plan
1.
Porch y'
! N
/I
SS
,
. /
Cesspool 1 %
N -- ei •s
Cesspool 2 so?
•
. - - •
Note: No well water source within 100' v J t Called North-
Scale: 1" : s' Owner: Mark Battey HOMESTEAD INC.
As-built Drawing of 828 North King St. 1664 Cape Existing Septic System Note: pp Northampton,MA 01060 Williamsburg, st
Some Dimensions Approximated Williamsbur MA 01096
(413162R-4533 •
THE COMMONWEALTH OF MASSACHUSETTS
BOARD tO/F HEALTH
Cizy OF Mie.7-4?".Wi iP
pplirufinn fur tlispnsul lIUurlcs Cflnnnfrurfinn 1rrniit
Application is hereby made for a Permit to Construct ( ) or Repair (6 an Individual Sewage Disposal
ystem at:
8.11492/. . erti rte- r
27.(977-atipn-Addreea Z_AMP#fig..f.}/... . .... -�`......._..._._
Owner
Installer
ype of Building ,,//
Dwelling—No. of Bedrooms..../C..4 Expansion Attic
Other—Type of Buildiuga 3r Ng. of persons
Other fixtures TRe oar- toe! eh/
gallon
n low
ank—Liquid capacitpr.P00 gallons
)i posal Trench—No. Width
ie page Pit No Diameter
)ther Distribution box
' rcolation Test Results
Test Pit No. I
Test Pit No. 2
Address *-
Size LotI4 OPU-- Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
s per person per day. Thal daily flow ani% gallon.
Length.._C/.._.. Width...4 Diameter Depthr 7
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
)ascription of Soil .SFt.6 .'/L Io 6 s /A/ 102..Q.te-.e..T
Sature of Repairs or Alterations—Answer when applicableeC e ct . /J.Z y4 SNB sreygp 15-YSTC71 44'72/ rafter 7.7•24/.44-
skion Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees riot to place the system in
operation until a Certificate of Compliance has been issucdd[.,by the board of health.//
Sigoed.�1c,.'GIZ ('G Pte- ./ .
Due
Date
Application Approved B
Application Disapproved for the following reasons'
Permit No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ciry of l%O T.yi9! i./ 71Pei/
ppliratiutt fur ilispusttl Works Qlunntrttrtiutt 1erntit
Application is hereby made for a Permit to Construct ( ) or Repair W an Individual Sewage Disposal
ystem at:
'28.1144.67.ereti rte-15Wr
Ad yeas
Installer Addre..
.ype of Building ,,/// Size LoLL4.f70O�- Sq. feet
Dwelling—No. of Bedrooms..../✓.74 Expansion kttic ( ) Garbage Grinder ( )
Other—Type of Buildings e.-377 Ng. of persons Showers ( ) — Cafeteria ( )
Other fixtures Titer l%f2T 'An... te,
gallons per person per da . Tbtal daily �17i/
si n,Flow g P P P e Y y'
ank—Liquid capacity2P0O gallons Length._ /...... Width...4 Diameter
lisposal Trench—No. Width Total Length Total leaching area
Ieepage Pit No Diameter Depth below inlet Total leaching area
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
... gallons.
Depths
sq. ft.
sq. ft.
)ther Distribution box
'ercolation Test Results
Test Pit No. I
Test Pit No. 2
)escription of Soil .�..F ..S '/L .2-4 4S /N �attaP,E'..T
dature of Repairs or Alterations—Answer when applicable i'C 41CC ,4X.GJ7, e4 .SwB ST/]e�pdeb
cten e- cY.57-0711 4/172/Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed /I(cc' iL e�..Z::7 ret
Application Approved By
Application Disapproved for the following reasons
Date
Date
Due
Permit No Issued.
Date
THE COMMONWEALTH OF MASSACHUSETTS
FEE
BOARD OF HEALTH
OF ,tea
- ; ..�-. ...
Appliratinn fur Dismal eli arks @Innntrurtinn iermit
Application is hereby made for a Permit to Construct ( ) or Repair (Y) an India idual Sewage Disposal
System at: _
/ .�. 1.. :'..� ter .: SE
^. P.ocati6T
ddress g{
worn
I
Type of Building
Dwelling— No. of Bedroom
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench–
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria (
gallons per person per day. Total daily flow gallons.
gallons Length Width Diameter Depth
- Width Total Length Total leaching area sfft.
/ Diameter Depth below inlet Total leaching area.Ez i
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary``Code—The undersigned kurther agrees not to place the system in
operation until a Certificate of Compliance has bon issued by the b
Signed.. a.
f ir/
Application Approved By `�� ! Date
Application Disapproved for the following reasons
Permit No t '-
Issued X`
Pate
f ) f t5'
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF lip ` "-nt4'+ . . . .._
urrtifirate of Tuntpliana
I
TFIISIS TO-CERTIFY, Thtitr the Individual Sewage Disposal System constructed ( ) or Repaired t' )
by / 12 c.,.t.
t ...:
at r / lL«-t:t � � -IY
has been installed in accordance with the provisions of Artie) 1 of The State Sanitary Citr(e a described, indhe
application for Disposal Works Construction Permit No i r. dated i1 (7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �?
DATF Inspector ' ::•, -i .,•3 Arta
Inaliller
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF I
BizptauaL iii ffku gott5Mrltttiun tiertnit
Permission is hereby granted!
,, L..
to Construct ( ) or Repair (✓) an Individual wage Disposal System
at No f
Street
as shown on the application for Disposal Works Construction-Permit N
DATE
FORM 1255 HOBBS B WARREN. INC., PUBLISHERS
FEE
Dated
Board of Health
e,�'ti si
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Cry . .. ... OF Mie.7-%ec ef7T ct/
Fx
pplikaiirtt far Binpuottl urlu Cttaimtru tiatt Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ()<5 an Individual Sewage Disposal
System at:
Owner
Installer
? aP.119.9.,rtl at,...N2tac
Address
Address
Type of Building ,,////mo�tt Size LotJ4 0404" Sq. feet
Dwelling—No. of Bedrooms. .o4/.719 Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Buildingo/Zr377 Ng of persons Showers ( ) — Cafeteria ( )
Other fixtures ?Mar OPT fo2G...Ca/.:"
low gallons per person per day. Total daily flow /40 gallons.
ank—Liquid capacityZ000 gallons Length.../. r Width...a Diameter Depths'!w
Disposal Trench—No Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area . sq. ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Description of Soil ,��. .�/G IO 5 /y £0714.4-7-
Nature of Repairs or Alterations—Answer when applicableens e-}1T/2
Sin/4- cvS.Tv "✓/7f 7 r>
2SM
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig 0/2-- }�
Application Approved By
9me
Sa6 Srq vp4RD
Application Disapproved for the following reasons.
Date
Permit No Issued
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(En-tither Af atutnplitnwr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by
Install.r
at
has been installed in accordance with the provisions of TITLE S of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
No 'i1" —i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL J� �
OF ,/l' CIc
FEE
flispusat K'twits T ion rrtnit
1.
Permission is hereby granted 1�/�-:. e...__ q� / ..
to Construct or Repair ( ) an/,�Pdividual Sewage Disposal stem s` /0' I {FH'f� re
at No....r`i.: f�1..Lt-^l�-'�2.._I`'
Street
as shown on the application for Disposal Wo14cdConstruction Permit
DATE
FORM 1255 A. M. SULKIN. BOSTON