138 Septic Inspection 2006 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
tification
rty Information
Address: 138 Sylvester Road, Northampton, MA
Name: Francis Burke
kddress:
sped:ion:
.• • - I 'e.
: .
• - I M1 I
• I .
6/22/06
Board of Health Northampton;
Pat Goggins Number.SSDS-1083
Mr.
nspector. Thomas S. Leue
Name: Homestead Inc.
ddress: 1664 Cape St. . Williamsburg, MA 01096
e Number. (413) 628-4533
lion Statement:
tat I have personally inspected the sewage disposal system at this address and that the information reported
true accurate and complete as of the time of the inspection. The inspection was performed based on my
and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP
d system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The septic system condition
evaluated and classified into one of the following four conditions:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
em condition: Passes
tor's Signature:
vino ,S Date: 6/22/06
lem Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health of DEP)
days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or
the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The
should be sent to the system owner and copies to the buyer, if applicable and the approving authority.
id Comments:
report only describes conditions at the time of inspection and under the conditions of use at that
lie inspection does not address how the system will perform in the future under the same or different
ins of use.
{49320`3
c• 11/2004
Homestead Inc.
Title 5 Official Inspection Form: Subsurface Disposal System
.non.I nr In
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
ication (Cont)
kddress: 138 Sylvester _Road. Northampton. Mk
rme: Francis Burke
spection: 6/22/06
1 Summary: Check A, B, C, D or E I always complete all of Section D:
,stem Passes:
lave not found any information which indicates that any of the failure criteria as described in 310 CMR
1.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
s:
/stem Conditionally Passes:
ne or more system components as described in the°Conditional Pass"section need to be replaced or
paired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will
rss. Answer yes, no, or not determined (Y, N,or ND) in the_for the following statements. If not
ttemlined" please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
exhibits substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if
ig septic tank is replaced with a complying septic tank as approved by the Board of Health.*A metal septic
ass inspection if it is structurally sound not leaking and if a Certificate of Compliance indicating that the tank
in 20 years old is available.
n:
Observation of sewage backup or break out or high static water level in the distribution box due to
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if
'oval by the Board of Health). _ broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
in:
The system required pumping more than four times a year due to broken or obstructed pipe(s). The
ill pass inspection if(with approval of the Board of Health).
_ broken pipe(s)are replaced
obstruction is removed
in:
Other: explain:
ter Evaluation is Required by the Board of Health:
Ionditions exist which require further evaluation by the Board of Health in order to determine if the system is
protect the public health, safety or the environment:
iystem will pass unless Board of Health determines In accordance with 310 CMR 15.303(1)(b)that the
is not functioning in a manner which will protect public health,safety and the environment:
;esspool or privy is within 50 feet of a surface water.
;esspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
c•11(2004
Homestead Inc.
Title 5 Offidal Inspection Form:Subsurface Disposal System
.non.9 of In
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
cation (Cont)
,ddress:
me:
ipection:
• - • • r w4
Francis Burke
6/22/06
stem will fail unless Board of Health(and Public Water Supplier,if any)determines that the system
ling In a manner that protects the public health,safety and environment:
a system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface
or tributary to a surface water supply.
a system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
rly well"Method used to determine distance
tern passes if the well water analysis, performed at a DEP certified laboratory,for conform bacteria and
lanic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
id nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy
lysis must be attached to this form.
stem Failure Criteria applicable to all systems:
indicate either"Yes" or'No° as to each of the following for all inspections:
r NO(N)
tckup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
egged SAS or cesspool.
alit liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
quid depth in cesspool is less than 6°below invert or available volume less than 1/2 day flow.
squired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of
nes pumped
ny portion of the SAS, cesspool or privy is below high ground water elevation.
ny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
ipply.
ny portion of cesspool privy is within a Zone I of a public well.
ny portion of cesspool or privy is within 50 feet of a private water supply well.
ny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply
rich no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP
edified laboratory, for colifomt bacteria and volatile organic compounds indicates that the well is he from
ollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
pm, provided that no other failure criteria are triggered A copy of the analysis must be attached to this form.]
he System Fails: I have determined that one or more of the above failure criteria exist as defined in 310
)3, therefore the system fails. The system owner should contact the Board of Health should be contacted to
a what will be necessary to correct the failure.
YI _
• 1112004 Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Sewage Disposal System Form
'cation (Cont)
tddress: 138 Sylvester Road. Northampton" MA
me: Francis Burke
>pection: 6/22/06
Systems:
iidered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd.
indicate either"Yes" or"No" as to each of the following:
ng criteria apply to large systems in addition to the criteria above:
• NO(N)
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
one II of a public water supply well)
vered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in
above the large system has failed.The owner or operator of any large system considered a significant
er Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The
uner should contact the appropriate regional office of the Department.
klist
to followino have been done. You must indicate"yes' or"no as to each of the following
r NO(N)
Pumping information was provided by the owner,occupant or Board of Health.
Jere any of the system components pumped out in the previous two weeks?
as the system received normal flows in the previous two week period? unoccupied
ave large volumes of water been introduced to the system recently or as part of the inspection?
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?
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.
b) Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
is unacceptable)[15.302(3)(b)].
The facility owner(and occupants, if different from owner)were provided with information on proper
ince of Subsurface Sewage Disposal Systems (SSDS).
:•11/2004
Homestead Inc.
Title 5 Official Inspection Form: Subsurface Disposal System
"mane 4 of 1n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
,ddress•
me:
ipection:
1AL
nown
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0
N
Y
N
N
I/A
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138 Sylvester Road, Northampton. MA
grancis Murk,
6/22/06
FLOW CONDITIONS
DESIGN flow based on 310 CMR 15.203(gallons/day)
of bedrooms(design)
Number of bedrooms(actual)
Number of current residents 2 people when occupied
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
CIAIJINDUSTRIAL
tablishment:_
N(based on 310 CMR 15.203): gpd
:sign flow(seats/persons/sgft, etc.):
Ip present(Y or N):
waste holding tank present(Y or N):
:er readings if available:
of occupancy/use:
lescribe):
GENERAL INFORMATION
Records: Source of information: Pumped 4/30/02, says Owner
Was system pumped as part of the inspection(V or N)
, volume pumped: gallons—How was quantity pumped determined?gam
nn for pumping:
vent: Pump on 3 to 4 year interval.
SYSTEM:
eptic tank, distribution box, soil adsorption system.
Ingle cesspool
Iverflow cesspool
rivy
hared system (Y or N) Of yes, attach previous inspection records, if any)
1novative/Attemative technology. Attach copy of the current operation and maintenance contract(to be
btained from system owner)
"fight tank(Attach a copy of the DEP approval)
)ther(describe):
• 11/2004 Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
•nane 5 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
address:
me:
Lpection:
138 Sylvester Road. Northampton. MA
Francis Burke
6/22/06
(MATE AGE
lan: 10 ear old s ste
f Info: Realtor
All components, date installed, and source of info.
Were sewage odors detected when arriving at the site(Y or N)
G SEWER (located on site plan)
16 Depth below grade (inches) Fstimated Averane
45 Distance in feet from private water supply well or suction line
IBS Materials of Construction
its: No sewer problems seen.
TANK (located on site plan)
icrete Materials of Construction
10 Depth below grade (inches)
0 Riser depth (inches)
58 Septic tank width (inches) Interior dimensions
126 Septic tank length (inches) Interior dimensions
58 Septic tank height (inches) Interior dimensions
,840 Calculated gross volume (gallons) Caculated
14 Air space in tank (inches)
,300 Net Volume (gallons) Calculated
22 Baffle depth (inches)
3 Sludge thickness (inches) Average
4 Scum thickness (inches) Average
33 Top Sludge : Bottom Baffle (inches) Calculated
5 Bottom Scum : Bottom Baffle (inches) Calculated
11 Top Scum :Top Baffle (inches) Calculated
nts:
e a slow leak since water level below outlet invert by 6"
is not a significant problem. Tank structurally OK.
nendations:
on 3 to 4 year interval.
• 11/2004 Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
ddress: 138 Sylvester Road. Northampton. MA
me: Francis Burke
pection: 6/22/06
(AMBER
N
ts:
Pump part of septic system: (Y or N)
Pumps in working order: (Y or N)
Alarms in working order: (Y or N)
JTION BOX (located on site plan) (MD-box")
0-box part of septic system: (Y or N)
0" Depth of liquid level above outlet invert
is: Box a• •ears level and flow e• al.
.et •i•es a••ear to •o to trenches
SORPTION SYSTEM(SAS): Technology Used (located on site plan by estimate):
leaching pits 8 number:
leaching chambers and number:
leaching galleries and number:
Y leaching trenches, number, length: 3 trenches, measured 50 len
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system, Type:
its: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
-face problems seen.
it located
a,y.
IR 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 Tank length (inches)
Tank height Calculated gross volume (gallons
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
nts: (conditions of inlet tees, condition of alarm and float switches, etc.)
•11/2004 Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
•nana i Mln
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
ddress:
me:
,pection:
130 Sylvester Road. Northampton. MA
Francis Burke
6/22/06
s:
(locate on site plan, if any)
Privy part of system: (Y or N)
Materials of construction:
Dimensions:
Depth of solids:
(soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
COLS (cesspool must be pumped as part of inspection)
N 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 infiow(cesspool must be pumped as part of inspection)
as: (note soil conditions, signs of hydraulic failure, level of pending, condition of vegetation, etc
TRAP (Usually present in certain commercial systems)
N Grease Trap part of system: (Y or N)
Materials of construction:
Depth below grade (inches) Measured
Dimensions:
Depth of solids-layer
Depth of scum layer
Top of scum to top outlet Calculated Inches
Date of last pumping
-Bottom of scum to outlet. CsIculated Inches
Scum thickness (inches) Average
nts: (recommendation and conditions)
• 11/2004 Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
•none a nr to
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
ddress:
me:
pection:
138 Sylvester Road. Northampton, MA
Francis Burke
6/22/06
(AM (Source of Information)
Slope Official Perc Date
Surface water Official Plan Date
Check Cellar - — Other-Official Source
f Shallow wells Other Source
0 Estimated depth to ground water (inches)
indicate(check)all the methods used to determine high groundwater elevation:
f Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
ition: System area built—up to be out of groundwater. Built to
current DEP code.
IRCES: Department of Environmental Protection, Western Regional Office,
sight St.,Springfield MA 01103 (413) 784-1100 Title 5 Hotline-(800)266-1122
•11/2004
Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal System
.snso m+n
)7,s, Partial Outline of House
N
NORTH
imei Distribution Box Septic tank
.
V
Leaching Trenches,estimated layout
COMMENTS:
Recommend pumping on a 3 to 4 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. *0 HOMESTEAD INC.
Existing Septic System 6/22/06 Francis Burke _ Thomas S. Leue R.S.
138 Sylvester Road Revision Date: \ 8 1664 Cape St.
Scale: 1 : 20' Florence, MA 01062 / 4i: Williamsburg,MA 01096
Except as Noted "'ftnr°f' 14131 628-0533