8 Septic Inspection Form 1996 UON
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Address of property: 8 SHEPHERD'S HOLLOW, NORTHAMPTON
Owner: GREGORY & SYLVIA ZAKRZEWSKI
Date of Inspection: 1-25-96
Inspector: James A. Gracia, PE
99 Glendale Street
Easthampton, MA 01027
413-527-5290
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:
XXX Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority(Bd. Of Health)
Fails
Inspectors Signature
4 J de
The system inspecto shall submit a copy of this inspection report to 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 gallons per day or greater, the inspector and 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 and approving authority.
Date: S�9
INSPECTION SUMMARY:
A. System Passes:
XX 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.
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B. System Conditionally Passes:
One or more system components need to be replaced or repaired. The system, upon
completion of the replacement or repair, passes inspection.
(Indicate yes, no, not determined (Y, N, or ND). Describe basis of determination in all instances.
If"not determined", explain why not.)
Septic tank is metal, 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 the approval of 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). 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 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' of a surface water
Cesspool or privy is within 50' 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 the
public health and safety and environment:
The system has a septic tank and soil absorption system and is within 100' of a
surface water supply or tributary to a surface water supply.
8 Shepard's Hollow, Northampton
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The system has a septic tank and soil absorption system and is within a Zone I of a
public water supply well.
The system has a septic tank and soil absorption system and is within 50' of a
private water supply well.
The system has a septic tank and soil absorption system and is less than 100'but
more than 50' 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.
D. System Fails:
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.
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 the invert or available volume is less
than Ya 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 (SAS), cesspool or privy is below the
high groundwater elevation.
Any portion of a cesspool or privy is within 100' 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 water supply well.
Any portion of a cesspool or privy is within 50' of a private water supply well.
Any portion of a cesspool or privy is less than 100'but more than 50' from a
private water supply well with no acceptable water quality analysis. If the well has
been analyzed to be acceptable, attach copy of well water analysis for coliform
bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. Large System Fails:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 GPD or greater and the system is a significant threat
to the public health and safety and the environment because one or more of the following
conditions exist:
8 Shepard's Hollow,Northampton
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The system is within 400' of a surface drinking water supply.
The system is within 200' of a tributary to a surface drinking water supply.
The system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area 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 of Environmental Protection for further
information.
PART B: CHECKLIST
X Pumping information was requested of the owner, occupant, and/or BOIL
X None of the system components have been pumped for at least two weeks prior to
inspection 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.
X As-built plans have been obtained and examined. Note if not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The site was inspected for signs of breakout.
X All system components, excluding the SAS, have been located on the site.
X 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.
X The size and location of the SAS on the site has been determined based on existing
information or approximated by non-intrusive methods.
X The facility owner(and occupants if different from owner)were provided with information
on the proper maintenance of Sub-surface Sewage Disposal Systems.
8 Shepard's Hollow, Northampton
PART C: SYSTEM INFORMATION
FLOW CONDITIONS
Residential:
Design Flow: 495 Gallons per Day
Number of bedrooms: 3
Number of current residents: 4
Garbage disposal: Yes
Laundry connected to system: Yes
Seasonal use: No
Water meter readings, if available: N/A (Private Well)
If vacant, last date of occupancy: N/A
Commercial/Industrial:
Type of Establishment:
Design Flow: Gallons per Day
Grease Trap present:
Industrial Waste Holding Tank present:
Non-sanitary waste discharged to the Title 5 system:
Water meter readings, if available:
Last date of occupancy:
Other: (Describe)
Last date of occupancy:
GENERAL INFORMATION
Pumping records and source of information:
System last pumped in August 1995, per owner and pumper.
System pumped as part of inspection: YES
If yes, volume pumped: 1500 Gallons
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8 Shepard's follow, Northampton
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Type of system
X Septic tank/distribution box/SAS
Single cesspool
Overflow cesspool
Privy
Shared system(If Yes, attach previous inspection reports, if any)
Other
Approx. age of all components/Date installed/Source of info:
System installed new in 1987 per owner and Board of Health records.
Sewage odors detected when arriving at the site: No
SEPTIC TANK: OK
Depth below grade: 15"
Material of construction: CONCRETE
Volume: 1500 GALLONS
Dimensions: 5' W x 10' L x 4' D
2" sludge depth
33" distance from top of sludge to bottom of outlet tee or baffle
0" scum thickness(minimal scum due to recent pumping)
6" distance from top of scum to top of outlet tee or baffle
15" distance from bottom of scum to bottom of outlet tee or baffle
Comments: Tank in good condition. No signs of deterioration. Center access cover has
been extended to grade.
8 Shepard's Hollow, Northampton
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GREASE TRAP: N/A
Depth below grade:
Material of construction:
Volume:
Dimensions:
Comments:
scum thickness
distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
TIGHT TANK or HOLDING TANK: N/A
Depth below grade:
Material of construction:
Volume:
Dimensions:
Design Flow:
Alarm Level:
Comments:
DISTRIBUTION BOX: N/A
Depth of liquid level above outlet invert:
Comments:
PUMP CHAMBER: N/A
Pump(s)in working order:
Comments:
8 Shepard's Hollow, Northampton
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SOIL ABSORPTION SYSTEM (SAS): OK
If not located on site, explain:
Type&Dimensions:
Leaching Pit, Chamber, or Gallery: 4' W x 8' L x 36" D plus stone around and under pit
Leaching trenches
Leach field
Overflow cesspool
Comments: Leach Pit in good condition.
CESSPOOL: N/A
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(during pumping)
Comments:
PRIVY: N/A
Materials of construction
Dimensions
Depth of solids layer
Comments:
8 Shepard's Hollow, Northampton
KES A. GRACIA, PE
aendale Street, Easthampton, MA 01027
:OUNDWATER ESTIMATED TO BE BELOW
EACH SYSTEM BASED ON TOPOGRAPHY
AND ORIGINAL ['ERG TEST REPORT
EXISTING WELL
100' K
1500 GALLON
SEPTIC TANK
I15 BELOW GRADE)
EXISTING
LEACH PIT
4' W X 8' L X 36 p
2r BELOW GRADE
75't
WET AREA
>,L
8 SHEPHERD'S HOLLOW
NORTHAMPTON, MA
SEPTIC INSPECTION PLAN
(NOT TO SCALE/ 1 -25 -96