6 Septic Inspection 2004 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 6 Sylvan Lane Northampton,Ma.
Owner: Estate of Charles Pitrat
Date of Inspection: August 11,2000
INSPECTION SUMMARY: CHECK A, B, C, D or E/ALWAYS complete all of Section D
A] SYSTEM PASSES:
® I have not found any information which indicates that any of the failure conditions described in 3
15.303 or in CMR 15.304 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 repl,
repaired. The system, upon completion of the replacement or repair as approved by the Board
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
structurally unsound, exhibits substantial infiltration or exfiltration 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
not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years o
available.
ND explain:
Observation of sewage backup or breakout or high static water level in the distribution box i'
broken or obstructed pipe(s) or due to a broken, settled, or uneven distribution box. The sys
pass inspection if(with approval of the 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)
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 Page 2
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5 INSPECTION FORM
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification
\ddress 6 Sylvan Lane Northampton, Ma. Name of Owner: Estate of Charles Pitrat
August 11, 2004
Philip J. Pasiecnik
Name: Greg's Wastewater Removal
239A Greenfield Road
S. Deerfield, MA 01373
Phone: (413)665- 3989
Address of
Owner:
CATION STATEMENT
it I have personally inspected the sewage disposal system at this address and that the information reported below is
ate, and complete, as of the time of the inspection. The inspection was performed based on my training and
'in the proper function and maintenance of on-site sewage disposal systems.
EP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
® Passes
❑ Conditionally Passes
❑ Needs Further Evaluation by the local Approving Authority
❑ Fails
"OR'S t DATE: //
JRE: �3�yC .f /,l(l./V/YL4 ����07
em Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
Tin thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of
pd or greater, the inspector and the system owner shall submit the report to the appropriate regional office
P. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the
J authority.
)COMMENTS: No failure criteria as described on page four of this inspection form was found at the time of
n of this system. An As Built Diagram was obtained for this inspection.
'port only describes conditions at the time of inspection and under the conditions of use at that time. This
n does not address how the system will perform in the future under the same or different conditions of use.
)ection Form 6/15/2000 Page 1
(dress:
'action:
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION (continued)
6 Sylvan Lane Northampton,Ma.
Estate of Charles Pltrat
August11,2004
n ❑ Slope
® Surface water
® Check cellar
❑ Shallow wells
d Depth to Groundwater >5 Feet
Idicate (check) all the methods used to determine High Groundwater
ned from system design plans on record - If checked, date of design
awed:
rved site (Abutting property/observation hole within 150 feet of SAS)
ked with local Board of Health - explain:
ked with local excavators, installers - (attach documentation)
ssed USGS database -explain:
it describe how you established the high ground water elevation:
I pump in the basement of the dwelling which was dry at the time of
in. No surface water in the area of this system. Area is known to be
Ind well drained. Nearby gravel pits have no problems with
ater. Dwellings in this area were built post 1995 and had to comply with
Five Groundwater Regulations and approved by the local B.O.H.
pection Form 6/15/2000 Page I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION (continued)
Property Address: 6 Sylvan Lane Northampton,Ma.
Owner Estate of Charles Pkrat
Date of Inspection: August 11,2010
TIGHT or HOLDING TANK: (Tank must be pumped at time of inspection) (locate on site plz
Depth below grade:_
Material of Construction: ❑ Concrete ❑ Metal ❑ Fiberglass ❑ Polyethylene Other
Comments: (condition of al
Dimensions:
Capacity in gallons
Design flow in gallons per day
Alarm present (Yes or No)
Alarm level Alarm in working order ❑Yes ❑ No
Date of last pumping
arm and float switches etc.)
DISTRIBUTION ® Yes ❑ No (If present, MUST be opened-locate on site plan)
BOX
Depth of liquid level above outlet invert: Not Above
Comments: (note if box is level and distribution to outlets equal, any evidence of solids carryover, t
evidence of leakage into or out of box etc.) Box was level and distribution was equal to all outlet
No solids carryover was in the box when opened for inspection. No leakage was evident into or out
box at this time. Cover to the distribution box was approx. 30" deep below grade.
PUMP CHAMBER: ❑ (located on site plan)
Pumps in working
order: (Yes or No)
Alarms in working order
(Yes or No)
Comments: (Note condition of pump chamber, condition of pumps and appurtenances, etc.)
Title 5 Inspection Form 6/152000 Page 8
Cress:
action:
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
6 Sylvan Lane Northampton,Ma.
Estate of Charles Pitrat
August 11,2004
NG SEWER(Locate on site plan):
low grade: 30"
rf construction: cast iron XXX 40 PVC
other (explain)
from private water supply well or suction line Public Water Supply
4"
ts: (condition of joints, venting, evidence of leakage etc) Joints were in good condition. Venting pipe was
itside the dwelling. No leakage was evident at this time.
PTIC TANK (locate on site plan):
.pth below grade- 24"
terial of Construction: Concrete ❑ Metal ❑ Fiberglass ❑ Polyethylene Other(explain)
ank is metal, list age Is age confirmed by Certificate of Compliance
:s/No) (If"Y", attach copy of Certificate of Compliance)
6"Lx5'6"Wx5'4"D Dimensions:
Sludge Depth
Distance from top of sludge to bottom of outlet tee or baffle
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
asured How dimensions were determined:
Its: (On pumping recommendations, inlet&outlet tee or baffle condition, structural integrity, liquid levels as
3 outlet invert, evidence of leakage, etc.) The septic tank should be pumped every two to three years. PVC
was in place and extends 8" below the flow line. PVC Outlet tee was in place and extends 18" below the
The liquid level was at the outlet invert. Structural integrity of the septic tank was good. No leakage was
The septic tank has two compartments, which means two covers must be dug to pump the tank properly.
sers are on the inlet and outlet covers to within 6"of surface. .
E TRAP (locate on site plan): ❑
glow grade:
of Construction: ❑ Concrete ❑ Metal ❑ Fiberglass U Polyethylene ❑ Other(explain)
Dimensions
Scum thickness
Distance from top of scum to top of outlet tee/baffle
Distance from bottom of scum to bottom of outlet tee/baffle
Date of last pumping:
nts: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as
o outlet invert, evidence of leakage, etc.): .
;pection Form 6/15/2000 Page 7
{Provide a Sketch of the sewage disposal system including ties to at least two permanent reference landn
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buildinc
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION
Property AEEress: 6 Sylvan Lane Northampton,Ma.
Owner: Estate of Charles Pitrat
Date of Inspection: August 11,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM:
**** I SEE EXHIBIT A} ****
Title 5 Inspection Fonn 6/15/2000 Page 10
frees:
ction:
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION (continued)
6 Sylvan Lane Northampton,Ma.
Estate of Charles Pitrat
August 11,2004
SORPTION SYSTEM
(SAS):
site plan, if possible; excavation not required.)
not located explain why:
pits&number
chambers& number
galleries & number
trenches, number, length 3-Trenches 50ft. Long x 2ft. Wide
fields, number,
ns
cesspool, number
e/Altemative system:
Technology:
'Its: (Note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.) The soil was
.avel with no clogging evident. No signs of hydraulic failure or ponding to the surface. The soil
amp over the area of the trenches. Vegetation was mowed grass and seemed uniform throughout
of the trenches..
DOLS ❑ (Cesspool must be pumped as part of inspection-locate on site plan)
& configuration
op of liquid to inlet invert
solids layer
scum layer
ins of cesspool
> of construction
n of groundwater inflow
r No)
nts: (Note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) _
❑ (locate on site plan)
s of construction
ons
f solids
its: (Note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.)
ipection Form 6/15/2000 Page 9
Property Address:
Owner:
Date of Inspection:
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION
6 Sylvan Lane Northampton,Ma.
Estate of Charles Pitrat
August 11,2004
Residential:
Number of bedrooms (design): 4
DESIGN Flow: 440 G.P.D. (based on 310
Number of current residents:
Is Garbage Grinder present (yes or no)
Is laundry on a separate sewage system
FLOW CONDITIONS
Number of bedrooms (actual)21
CMR 15.203-for example: 110 qpd x#of bedrooms)
0
(yes or no)
Laundry system inspected (yes or no)
Seasonal Use (yes or no)
Water Meter readings- if available
(last two (2) year usage (gpd)
Sump Pump (yes or no)
Last Date of Occupancy:
Commercial/Industrial:
Type of establishment:
Design flow (Based on 310 CMR 15.203)
Basis of design flow(seats/persons/sqft,etc.)
Grease trap present (yes or no)
Industrial Waste Holding Tank present (yes or no)
Non-sanitary waste discharged to the Title 5 system
(yes or no)
Last Date of Occupancy/Use:
OTHER (describe):
PUMPING RECORDS
Source of information:
Yes
No if yes separate inspection required
No
N/A
No
April 2004
gallons per day
GENERAL INFORMATION
No records available
Was system pumped as
part of the inspection: Yes
(yes or no)
If YES -enter volume 1500 gallons
pumped How was the quantity pumped determined? Tank Dimensions
Reason for pumping: Tank Inspection and Removal of Solids
TYPE OF SYSTEM:
51 Septic Tank/D Box/Soil Absorption System I Single Cesspool
❑ Overflow Cesspool ❑ Privy
Shared system (yes or no) Of yes, attach previous inspection records, if any) No
nnovative/Alternative technology. Attach a copy of up the current operation
and maintenance contract (to be obtained from system owner)
Tight Tank Attach a copy of DEP Approval
OTHER (describe)
Approximate age of all components, date installed Of known) and source of information:
6 Years Old / 1998 / Executors of Estate
Were sewage odors detected when arriving at site: (yes or no) No
Title 5 Inspection Form 6/15/2000 Page 6
Mien:
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part B
CHECKLIST
6 Sylvan Lane Northampton.Ma
Estate of Charles Pitrat
August Ii,2004
f the following have been done. You must indicate either "Yes" or "No"
ach of the following:
lo
] Pumping information was requested of 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 this inspection?
• Were as built plans of the system obtained and examined? (If they were not available note as N/A)
• Was the facility or dwelling inspected for signs of sewage back up?
• Was the site inspected for signs of break out?
• Were all system components, excluding the Soil Absorption System, located on site?
• 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?
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:
• Existing information. For example, a plan at the Board of Health.
® 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)]
■pection Form 6/15/2000 Page 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 6 Sylvan Lane Northampton,Ma.
Owner: Estate of Charles nitwit
Date of Inspection: August 11,2004
D] SYSTEM FAILURE CRITERIA applicable to all systems:
You must indicate either"Yes° or"No" to each of the following, for all inspections:
YES NO
Backup of sewage into facility or system component due to overloaded or clogged S
cesspool.
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due I
overloaded or clogged SAS or cesspool.
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or c
SAS or cesspool.
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than
flow.
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstruc
pipe(s).
Number of times pumped
® Any portion of the Soil Absorption System, cesspool, or privy is below the high groun
elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributa
surface water supply.
® Any portion of a cesspool or privy is within a Zone I of a public well.
® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from
private water supply well with no acceptable water quality analysis. [This system passe
well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile on
compounds'indicates that the well is free from pollution from that facility and the presence of an
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure anted:
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 trite
exists as defined in 310 CMR 15.303, therefore the system fails. The system
should contact the Board of Health to determine what will be necessary to con
the failure.
I1
E] LARGE SYSTEMS:
To be considered a large system the system must serve a facility with a design flow of 10,00
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
❑ 7
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 (IWF
mapped Zone II of a public water supply well)
If you have answered "yes" to any question in Section E the system is considered a threat, or answered "yes
Section D above the large system has failed. The owner or operator or any large system considered a signil
threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.3
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 Page 4
orlon:
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
6 Sylvan Lane Northampton,Ma.
Estate of Charles Pibrot
August 11 2004
HER 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, 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 THE PUBLIC HEALTH, SAFETY AND THE ENVIRONMENT:
U 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 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 THE ENVIRONMENT:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100
feet to 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 1 of a public water
supply.
n 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
pection Form 6/1512000 Page 3
:WAGE DISPOSAL SYSTEM
r 6 SYLVAN LANE
?RTHAMPTON, MA.
INI
Driveway
Garage
EXHIBIT "A"
INSPECTION DATE 8/11/04
DRAWING NOT TO SCALE
r
4 Bedroom Dwelling
Deck
29'
64'
1500 Gallon Two Compartment Septic Tank
1
Leaching Trenches 50'Long x 2'Wide
1
48'
�Disiribution Box