74 Septic Inspection 2005 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
tperty Address. 74 Soverign Way, Northampton, MA
mer's Name: Karen Barns
ner's Address: 74 Soverian Way, Florence MA 01062
to of Inspection: 6/27/05
py to: Board of Health. Northampton; Jeff Hutchins, Jones-Hutchins
Realty
'tress
Number SSDS-988
ne of Inspector: Thomas S. Leue
'many Name: Homestead Inc.
'sing Address: 1664 Cape St. . Williamsburg, MA 01096
ephone Number. (4131 628-4533
ERTIFICATION STATEMENT
ertify that I have personally inspected the sewage disposal system at this address and that the information
sorted below is true, accurate and complete as of the time of the inspection. The inspection was performed
led 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).
e 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
e system condition: Passes
spector's Signature:
Date. June 77, 7005,
e 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
w of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
ional office of the DEP. The original should be sent to the system owner and copies to the buyer,if
)licable 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
re. This inspection does not address how the system will perform in the future under the same or
ferent conditions of use.
e 5Inspection Form 6/15/2000
page 1 of 9
Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
)pertyAddress: 74 Soverign Way Northampton, MA
'ner: Karen Barns
to of Inspection: 6/27/05
pection 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.
mments:
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. Answer yes, no, or not determined(Y,N, or ND)in the for the following
statements. If"not determined"please explain.
• The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
icturally unsound, exhibits substantial infiltration or exfiltration, or tank failure is imminent. The system will
,s 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
woken 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:
N 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:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
;tem 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
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.
e 5 Inspection Form 6/15/2000
page 2 of 9 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
■perty Address: 74 Soverign Way, Northampton, MA
ner: Karen Barns
t of Inspection: 6/27/05
System will fail unless Board of Health(and Public Water Supplier, if any) determines that the
tem 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
Face 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
/ate water supply well** Method used to determine distance
fhis system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria
volatile organic compounds indicates that the well is free from pollution from that facility and the presence
unmonia 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:
j must indicate either "Yes" or"No" as to each of the following for all inspections:
S (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
4 15.303, therefore the system fails. The system owner should contact the Board of Health should be
%acted to determine what will be necessary to correct the failure.
e 5 Inspection Form 6/I5/2000
page 3 of 9 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
perty Address: 74 Soverign Way, Northampton, MA
ner: Karen Barns
e of Inspection: 6/27105
Large Systems:
pe considered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd.
t must indicate either"Yes" or"No"as to each of the following:
following criteria apply to large systems in addition to the criteria above:
(Y) or NO(N)
N the system is within 400 feet of a surface drinking water supply
1� the system is within 200 feet of a tributary to a surface drinking water supply
ty the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA) or a
)ped Zone II of a public water supply well)
ou answered "yes"to any question in Section E the system is considered a significant threat, or answered
s"in Section D above the large system has failed.The owner or operator of any large system considered a
vficant threat under Section E or failed under Section D shall upgrade the system in accordance with 310
[R 15.304. The system owner should contact the appropriate regional office of the Department.
PART B: CHECKLIST
:ck if the following have been done. You must indicate "yes" or"no" as to each of the following:
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?
L 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 of
the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
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
proximation of distance is unacceptable) [15.302(3)(6)].
The facility owner(and occupants,if different from owner)were provided with information on
per maintenance of Subsurface Sewage Disposal Systems(SSDS).
SOURCES:
Department of Environmental Protection,Western Regional Office,436 Dwight St., Springfield,MA
01103, (413)784-1100;Title 5 Hotline - (800) 266-1122
5 Inspection Form 6/15/2000
page 4 of 9
Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C: SYSTEM INFORMATION
perty Address: 74 Soverign Way, Northampton. NA
Her: Karen Barns
!e of Inspection: 6/27/05
SIDENTIAL
unknown
4
1
Y
Y
N
N
N/A
N
ontinuous
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_
1MMERCIAL/INDUSTRIAL
to of establishment:
sign flow (based on 310 CMR 15.203): gpd
of design flow (seats/persons/sqft, etc.):
ase trap present(Y or N):
ustrail waste holding tank present(Y or N):
ter meter readings,if available:
t date of occupancy/use:
HER(describe):
GENERAL INFORMATION
swing Records
tree of information: not previously pumped. 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: not overdue for pumping.
PE OF SYSTEM: SI-Ic6;C 3;m.i (Oo c
- Septic tank,diotwbetiensberf, soil adsorption system.
- Single cesspool
Overflow cesspool
Privy
Shared system(Y or N)(if 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):
Were sewage odors detected when arriving at the site(Y or N)
5 Inspection Form 6/15/2000
page 5 of 9 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
perry Address: 74 Soverign Way, Northampton, MA
ner: Karen Barns
e of Inspection: 6/27/05
PPROXIMATE AGE All components, date installed, and source of informatior
!ptic plan: said to be built by August, 1996.
Source of Information Owner
UILDING SEWER (located on site plan)
15 Depth below grade (inches) pctimated Average
40 Distance in feet from private water supply well or suction line
ABS Materials of Construction
imments:
3PTIC TANK (located on site plan)
Concrete Materials of Construction
12 Depth below grade (inches)
0 Riser depth (inches)
60 Septic tank width (inches) Interior dimensions
122 Septic tank length (inches) Interior dimensions
57 Septic tank height (inches) Interior dimension,
1,811 Calculated gross volume (gallons) calculated
8 Air space in tank (inches)
1,500 Net Volume (gallons) Cal cui ated
15 Baffle depth (inches)
6 Sludge thickness (inches) Average
1 Scum thickness (inches) Average
36 Top Sludge : Bottom Baffle (inches) calculated
6 Bottom Scum : Bottom Baffle (inches) calcul atag
6 Top Scum : Top Baffle (inches) Calculated
torments:
rtlet tee is somewhat shorter than code requirements.
i outlet filter might protect leachfield better.
commendations:
imp on 3 to 5 year interval.
UMP CHAMBER
B Pump part of septic system: (Y or N)
Pumps in working order: (Y or N)
Alarms in working order: (Y or N)
tnrnrents:
S Inspection Form 6/15/2000
page 6 of 9 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
perty Address: 74 Soverign Way, Northampton, MA
ner: Karen Barns
e of Inspection: 6/27/05
ISTRIBUTION BOX (located on site plan) ("D-box")
Y D-box part of septic system: (Y or N)
O Depth of liquid level above outlet invert
omments: 3 pipes out. Box appears level and flow equal.
OIL ADSORPTION SYSTEM (SAS): Technology Used (located on site plan by estimate):
leaching pits&number:
leaching chambers and number:
leaching galleries and number:
leaching trenches, number, length:
Y leaching fields, number, dimensions
overflow cesspool, number:
innovative/alternative system,Type:
omments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
o surface problems seen.
SAS not located
plain why:
'IGHT OR HOLDING TANK (tank must be pumped at time of inspection)
N Tight tank part of system: (Y or N)
Depth below grade (inches) Measured
Tank width (inches) From Plan
Tank length (inches) From Pl®a
Tank height (inches) From Flan
Calculated gross volume (gallons calculates
Materials of construction
Design flow: gallons/day
Pumps in working order: (Y or N)
Alarms in working order: (Y or N)
Date of last pumping
omments: (conditions of inlet tees, condition of alarm and float switches, etc.)
'RIVY (locate on site plan, if any)
N Privy part of system: (Y or N.
Materials of construction:
Dimensions:
Depth of solids:
'omments: (soil conditions, signs of hydraulic failure, level of ponding,condition of vegetation, et
5 Inspection Form 6/15/2000
page 7 of 9 Homestead Inc.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C:
SYSTEM INFORMATION(continued)
petty Address: 74 Soverian Nay Northampton, MA
Her: Karen Barns
e of Inspection: 6/27/05
ESSPOOLS
N
■mments:
(cesspool must be pumped as part of inspection)
Cesspool part of system: (Y or N)
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)
(note soil conditions, signs of hydraulic failure, level of pending,condition of vegetation,
REASE TRAP (Usually present in certain commercial systems)
N Grease Trap part of system: (Y or N)
Materials of construction:
Depth below grade (inches)
Dimensions:
Depth of solids layer
Depth of scum layer
Top of scum to top outlet
Date of last pumping
Bottom of scum to outlet.
Scum thickness (inches)
(recommendation and conditions)
Imments:
Measured
cal ciliated Inches
Calculated Inches
Average
TE EXAM (Source of Information)
Y Slope Official Perc Date
Y Surface water Official Plan Date
Y Check Cellar Other Official Source
N Shallow wells Other Source
>60 Estimated depth to ground water (inches)
ase indicate(check) 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:
formation: Dry sandy soil, dry basement without sump pump.
5 Inspection Form 6/15/2000
page 8 of 9 Homestead Inc.
Porc ',J
- --- J 52\12
I O N N
1
11 �� •
Septic c tank
box
...-'N'-..„,,, Leachfiekl, approximate layout
Note: No known drinking water sources within 100' radius.
COMMENTS:
Recommend pumping on a 3 to 5 year schedule. Also, a copy of this plan posted in the
basement/utility area would keep this information accessible in future years for maintenance.
As-Built Drawing Date: Owner: HOMESTEAD INC. 1S
Existing Septic System 6/27/05 Karen Barns Thomas S. Leue R.S.
74 Soverign Way
Scale: 1 : 20' Revision Date: Florence, MA 01062 / 1664 Cape St.
Williamsburg,MA 01096
Except as Noted [4131628-4533 ,