8 Septic Inspection 2009 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: She Ards Hollow
Owner Owner Name: Alison MacDonald
information is
required for City/Town: Northampton, MA 01060 Date of Inspection: 11/12/09
every page.
B. Certification (cont.)
Inspection Summary: Check A, B, C, D or E/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 Form:Subsurface Disposal System•Page 2 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 8 Shepards Hollow
Owner Owner' Name: Alison MacDonald
information is
required for City/Town: Northampton MA 01060 Date of Inspection: 11/12/09
every page.
inspection results must oe suommea on mis Corm. inspection corms may not oe anerea in any way.
OwnerAddress 8 Sheoards Hollow Leeds MA 01053
Copy to: Board of Health, Northampton,
Witness: Homestead Inc 0: SSDS-1316
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 628-4533 License Number: 5I130
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:
/
/ %/ S ti.If �
1C.t-mss—_ Date: 11/12/09
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 original 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.doc•12/07 Title 5 Official Inspection Form:Subsurface Disposal System•Page 1 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: 8 Shepards Hollow
Owner Name: Alison MacDonald
City/Town: Northampton, MA 01060 Date of Inspection: 11/12/09
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?
Y 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:
Y Existing information. For example, a plan at the Board of Health.
N Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR15.302(5)].
T5 Reviseddoc•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: 8 Shepards Hollow
Owner' Name: Alison MacDonald
City/Town: Northampton, MA 01060 Date of Inspection: 11/12/09
3. Certification (cont.)
!) System will fail unless Board of Health (and Public Water Supplier, if any) determines that the system
s 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
ndicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided
hat no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3) Other:
1 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-10,000 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:
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Commonwealth of Massachusetts
r Title 5 Official Inspection Form," Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Owner
information is
required for
every page.
Property Address:
Owner Name:
City/Town:
8 Shepards Hollow
Alison MacDonald
Northampton, MA 01060 Date of Inspection: 11/12/09
D. System Information (cont.)
Approximate Age: All components, date installed, and source of info.
Septic plan: Plan dated 5/19/87, permit dated 9/3/87
N Were sewage odors detected when arriving at the site (Y or N)
'Building Sewer: (locate on she plan)
20 Depth below grade (inches)
ABS plastic Material of Construction
30 Distance in feet from private water supply well or suction line
Comments: No problems seen.
Estimated Average
Septic Tank:
16
Concrete
16
58 Septic tank width
126 Septic tank length
58 Septic tank height
1,840 Calculated gross volume
9 Air space in tank
1,500 Net Volume
25 Baffle depth
5
28
9
10
4 Top Scum : Top Baffle
(locate on site plan)
Depth below grade (inches)
Materials of Construction
If tank is metal, list age
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate)
Riser depth (inches)
(inches)
(inches)
(inches)
(gallons)
(inches)
(gallons)
(inches)
(inches)
(inches)
(inches)
(inches)
(inches)
Sludge thickness
Top Sludge : Bottom Bathe
Scum thickness
Bottom Scum : Bottom Baffle
Measured How were dimensions determined?
Comments:
No operational or structural problems seen.
Baffle intact. Water level appropriate.
Recommendations:
Recommend pumping within 1 year.
Interior dimensions
Interior dimensions
Interior dimensions
Calculated
Calculated
Averaoe
Calculated
Averaoe
Calculated
Calculated
T5 Revised.doc•12/07 Title 5 Official 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: B Shenards Hollow
Owner' Name: Alison MacDonald
City/Town: Northampton, MA 01060 Date of Inspection: 11/12/09
). System Information
2esidential Flow Conditions:
3 Number of bedrooms(design)
3 Number of bedrooms (actual)
n 330+ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#bedrooms)
5 Number of current residents _
Y Does residence have a garbage grinder?
N Is the Laundry a separate system? [If yes, separate inspection required]
N I Laundry system inspected?
N Seasonal use?
N/A Water meter readings, if available (last 2 years usage)(gallons per day)
N Sump Pump? _
continuous Last date of occupancy
:O MME RCIALIINDUSTRIAL
type of establishment: =
Design flow(based on 310 CMR 15.203): = gpd
3asis of design flow(seats/persons/sift, etc.): _
3rease trap present? _
ndustrial waste holding tank present? _
Von-sanitary waste discharge to the Title 5 system? _
Nater meter readings, if available: _
ast date of occupancy/use: _
DTHER(describe): =
General Information
?umping Records: Source of information: _pumped a year ago, says Owner
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:_
Comment: Pump on 3 to 4 year interval.
Type of System:
X Septic tank, d' h ' ..' oil adsorption system
Single cesspool
Overflow cesspool
Privy
N Shared system (Y or N) Of 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): =
TS Revised.doc• 12/07 Title 5 Official Inspection Form:Subsurface Disposal System•Page 5 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: 8 Shepards Hollow
Owner Owner' Name: Alison MacDonald
information is
required tor City/Town: Northampton MA 01060 Dateoflnspection: 11/12/09
every page.
U. System Information (cont.)
Distribution Box: (if present must be opened) (locate on site plan) ("D-box")
N D-box part of septic system?
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.
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.)
Privy: (locate on site plan)
N Privy part of system?
Materials of construction:
Dimensions:
_ Depth of solids:
'Comments: (soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Site Exam: (Source of Information)
Y Check Slope 6/7/84 Official Perc Date
Surface water Official Plan Date
Y Check Cellar Other Official Source
N Shallow wells Other Source
>104" 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:
Porus soils showed no groundwater in perc test.
,Recommend minimal use of garbage grinder as leaching system is small.
T5 Revised.doc• 12/07
Title 5 Official Inspection Form:Subsurface Disposal System•Pape 8 of 9
Commonwealth of Massachusetts
Epr Title 5 Official Inspection Form
Owner
information is
required for
every page.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address: S Shepards Hollow
Owner' Name: Alison MacDonald
City/Town: Northampton MA 01060 Date of Inspection: 11/12/09
D. System Information (cont.)
Grease Trap: (Usually present in certain commercial systems)
N Grease Trap part of system?
Depth below grade (inches) Measured
Materials of construction:
Dimensions:
Scum thickness (inches) Average
Top of scum to top of outlet tee Calculated lncheq
Bottom of scum to bottom of outlet tee calculated Inches
Date of last pumping
Comments: condition
Tight or Holding Tank: (tank must be pumped at time of inspection)
N Tight tank part of system?
Depth below grade (inches) Measured
Materials of construction
Tank width Tank length (inches)
Tank height Capacity (gallons)
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):
)f SAS not located
explain why:
(locate on site plan, excavation not required):
Y leaching pits 8 number: 1 @ 750 gal nominal.
leaching chambers and number:
leaching galleries and number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system, Type:
Comments: (note soil condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
NO surface problems seen. Did not open tank,
but dug hole adjacent to tank and found no retained water in upper
two feet of gravel.
5 Revised.doc• 12/07 Title 5 Official Inspection Form Subsurface Disposal System•Page 7 of 9
LUpy UL curs pion posteu in the Dasement/utility area
would keep this information accessible in future years
for maintenance.
95
House Outline
NORTH
o
deck - Septic Tank
i,_i , NQ.
P
Leaching Tank
As-Built Drawing Date: Owner: �yta OF HOMESTEAD INC.
Existing Septic System 11/12/09 Alison MacDonald ± r.
8 P y 8 Shepards Hollow o TMOEUas a Thomas S. Leue R.S.
Scale: 1 : 20' Revisipn Date; / r 1,662czpc st.
Except as Noted - LeedS=MA 07 053 V 'ip hEEO AM��pee W II l4 3J 628 01096
-45