135 (N'ton Country Club) Septic Inspection 2012 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
Property Address: 135 Main Street
Leeds.MA 01053
Owner's Name: Bob Berniche
Owner's Address: P.O.Boa 51
Leeds,MA 01053
Date of Inspection: April 12,2012
Name of Inspector: (please print) Michael Lavigne
Company Name: Environmental Design,Inc.
Mailing Address: 477 River Road
Deerfield,MA 01342
Telephone Number: 413-539-1179
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 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 system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:
Date:
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 shal I submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
135 Main Street
Leeds,MA 01053
Bob Berniche
April 12,2012
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR
15303 or in 310 CMR 15304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,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 structurally
unsound,exhibits substantial infiltration or exflltmtion or tank failure is imminent.System will pass inspection if the
existing 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:
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 of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
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:
Page 3 of I I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
135 Main Street
Leeds,MA 01053
Bob Berniche
April 12,2012
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 public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(6)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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system 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
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 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.
3. Other:
Page 4 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
135 Main Street
Leeds,MA 01053
Bob Berniche
April 12 2012
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the 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
N/A Liquid depth in cesspool is less than 6"below invert or available volume is less than "/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped .
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
N/A Any portion of a cesspool or privy is within a Zone I of a public well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. 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./
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
`ryes"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.
Page 5 of II
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 135 Main Street
Leeds.MA 01053
Owner: Bob Berniche
Date of Inspection:_ April 12 2012
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection 7
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage backup?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?.
X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X 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:
Yes no
X Existing information.For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b))
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 135 Main Street
Leeds,MA 01053
Owner: Bob Berniche
Date of Inspection: Apri112.2012
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x a of bedrooms): god
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment: Golf Course
Design flow(based on 310 CMR 15203): N/A gpd
Basis of design flow(seats/persons/sgft,etc.): N/A
Grease trap present(yes or no): Under-sink Model in Kitchen
Industrial waste holding tank present(yes or no): No
Non-sanitary waste discharged to the Title 5 system(yes or no): No
Water meter readings,if available: N/A
Last date of occupancy/use: Current
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping: Pumping recommended to owner,
TYPE OF SYSTEM
X Septic tank,pump chamber,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Altemative technology.Attach a 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):
Approximate age of all components,date installed Of known)and source of information: — 1970 per owner/
1973 DWCP attached.
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
135 Main Street
Leeds,MA 01053
Bob Bemiche
April 12,2012
BUILDING SEWER(locate on site plan)
Depth below grade: (sub-slab)
Materials of construction: cast iron _40 PVC other(explain): N/A—Multiple Pipes-SubSlab
Distance from private water supply well or suction line:_N/A—Town Water
Comments(on condition ofjoints,venting,evidence of leakage,etc.):
No problems noted.
SEPTIC TANK:X (locate on site plan)
Depth below grade: —32"b.g.(w/Risers)
Material of construction: X concrete_ metal fiberglass polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certifi cate)
Dimensions: 4500 gallon.— 14'(L)
Sludge depth: 8— 12"
Distance from top of sludge to bottom of outlet tee or baffle: >24"
Scum thickness: 4—6"
Distance from top of scum to top of outlet tee or baffle: >4"
Distance from bottom of scum to bottom of outlet tee or baffle: > 10"
How were dimensions determined: Tape
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
No problems noted. See Photos.
GREASE TRAP:N/A (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
135 Main Street
Leeds,MA 01053
Bob Berniche
April 12.2012
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspectionxlocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: _gallons
Design Flow: _gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X Of present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):_ No problems noted. See photos.
PUMP CHAMBER: X (locate on site plan)
Pumps in working order(yes or no): Yes
Alarms in working order(yes or no): Yes
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
part of D-box/SAS inspection. Alarms checked. See accompanying photos.
Pump tested as
Page 9 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
135 Main Street
Leeds,MA 01053
Bob Berniche
April 12,2012
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:Via D-box only see photos.
Type
leaching pits,number:
leaching chambers,number:
Leaching galleries,number:
X leaching trenches,number, length: 7 lines,approx.75'(L)
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): No evidence of any problems. System appears to be working well.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
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(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: N/A (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
135 Main Street
Leeds,MA 01053
Bob Berniebe
April 12.2012
i
SKF'.TCH OF SEWACL DISPOSAL SYSTEM
Procidea sketch of the sewage disposal s. tcm including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within I00 feet.Locate where public water supply enters the building.
Page 11 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
135 Main Street
Leeds.MA 01053
Bob Berniche
April 12 2012
Estimated depth to ground water >5' below grade
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,dale of design plan reviewed:
X Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the_ Water level in adjacent brook— 10' below SAS area
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INOU-29-E4 1r'52 =RCM'tORRYlPTOI BUDA: F 413 58712e1
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratian-fur ilispusal Narks (Qmtstrurtwn 'Jertuit
Apll cation is hereby made for a Permit to Construct ( ) or Repair (A') ao Individual Sewage Disposal
Systau It
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Type of ellindirµ SireLoE Sq. feet
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-4 Other fixtures
Design 'low —_..__.__ person per day. daily[[�� dloo• per Total dml flow
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>i Septic l yen Liquid raped). g:Mons Length Width -Total er . DcptE
SW Dispage 'itnd'—Hr WidtR. foul Lengle Total'ceiling arum sq.It
R Seepage 'it No . Dirmeter___.__.__. Depth below inlet . Toed leaching arty... ..... M,.h
Z Other D_trlbutinn hos ( ) Dosing Punk ( )
Percoiat in Test Resat; Performed by.... Date.
J 9'es rs: Pit N a I rutes per inch Depth of Test Pit Dept')to ground water
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C. Tee Pit Na. 2 chutes per v¢L Depth of Test Pir_......_._._Defoe to ground water
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O Descrlpt on of Sad
Nature Repairs n Atentims—Answer a ppl racamenzt u
Agreement: I v V
The mdeoignui egress to install the Lord xei—d Individual ad undersigned fur Diurnal System to r cecdie system with
the provisions d Article U of the State SaeuEry Code—The urdersigtavl further)nal not to place the aystan in
operation until a Certiirate of Con plivma has tae/999lrrrssH' sued by{5�lc Ii t Iris
' ]/ _� V m Ig Application m A%iota! ]y %erSi_}d ET
Applka ion Dis ppi ovai for Ile foaming reasons
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Permit No. q&
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THE COMMONWEALTH OF MABSA C UEETrs
BOARD OF HEALTH
OF
ernifirde of fCautptianre
THIS I5 0 CERTIP Y,That the Iali'ideal Sewage Disposal System cmretrstal ( ) Or ligmr el
)
at-
has bell installed in accordance with the provisions of Article XI of The State S:nimry Code as descried in the
applicat on for Discos Works Construction Permit No dated
TFIi ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE MAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATL__...__..__ Inspector....
THE COMMONWEALTH OF MASSACHUSETTS
,� , BOARD O�FHEALTH
_. OF �/a,/ L�t
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$t5pnr4 bnr tf3J(lljatatrurtinu rant
Peru ission is tereby granted. l6� �V�.
to ConStrna ) ivldual ewes Dispo Syst
as showy on the appicdimn for Disposal Works Construction P mrt Not D
Fee. 0 _.
roam ie., Keens a*Aaaew arc.. euaasnene