163 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
ty Address: 163 Selves ter Road. Northampton MA
's Name: Thomas LaFlamme
'sAddress: 83 Crescent St. , Northampton MA 01060
f Inspection: 10/21/05
o: Board of Health, Northampton: Kim Goggins
s: Owner Number: SSDS-1029
of Inspector: Thomas S. Leue
my Name: Homestead Inc.
jAddress: 1664 Cape St. Williamsburg MA 01096
one Number: (4131 628-4531
.TIFICATION STATEMENT
ify that I have personally inspected the sewage disposal system at this address and that the information
ed below is true, accurate and complete as of the time of the inspection. The inspection was performed
on my training and experience in the proper function and maintenance of on-site sewage disposal
ns. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).
2.ptic 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
ystem condition: Passes
ctor's Signature:
Date: Qs-toner 21. 7005
'system Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health
iP) within thirty (30) days of completing this inspection. If the system is a shared system or has a design
if 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
ral office of the DEP. The original should be sent to the system owner and copies to the buyer, if
able and the approving authority.
and Comments
[his report only describes conditions at the time of inspection and under the conditions of use at that
This inspection does not address how the system will perform in the future under the same or
•ent conditions of use.
Inspection Form 6/15/2000
page 1 of9
Homestead Inc.
)FFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
-ty Address: 163 Sylvester Road, Northampton, NA
Thomas La?lanane
f Inspection: 10/21/05
tion 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.
lents:
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.
J The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is
irally unsound, exhibits substantial infiltration or exfiltration,or tank failure is imminent. The system will
ispection if the existing septic tank is replaced with a complying septic tank as approved by the Board of
i. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
fiance indicating that the tank is less than 20 years old is available.
;plain:
!I Observation of sewage backup or break out or high static water level in the distribution box due
ken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass
:tion if(with approval by the Board of Health). _ broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
(plain:
The system required pumping more than four times a year due to broken or obstructed pipe(s).
ystem will pass inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
_ obstruction is removed
Kplain:
Other: explain: _
urther 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
m 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(0(b)that the
m 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.
Inspection Form 6/15/2000
page 2 of 9
Homestead Inc.
DFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
rty Address: 163 Sylvester Road, Northampton, MA
r: Thomas LaFlammg
flnspection: 10/21/05
System will fail unless Board of Health(and Public Water Supplier,if any)determines that the
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
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
water supply well** Method used to determine distance
s system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria
datile organic compounds indicates that the well is free from pollution from that facility and the presence
nonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
ggered. A copy of the analysis must be attached to this form.
her:
System Failure Criteria applicable to all systems:
lust indicate either"Yes" or"No"as to each of the following for all inspections:
Y)or NO (N)
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 invert or available volume less than 1/2 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 SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of cesspool privy is within a Zone 1 of a public well.
Any portion of 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 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
M 15.303, therefore the system fails. The system owner should contact the Board of Health should be
:ted to determine what will be necessary to correct the failure.
Inspection Form 6/15/2000
page 3 of 9
Homestead Inc.
)FFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
ty Address: 163 Sylvester Road, Northampton, MA
Thomas Ler lame
rinspection: 10/21/05
rge Systems:
;onsidered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd.
ust indicate either"Yes" or"No"as to each of the following:
lowing criteria apply to large systems in addition to the criteria above:
0 or 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
d Zone II of a public water supply well)
answered "yes"to any question in Section E the system is considered a significant threat,or answered
n Section D above the large system has failed. The owner or operator of any large system considered a
:ant threat under Section E or failed under Section D shall upgrade the system in accordance with 310
15.304. The system owner should contact the appropriate regional office of the Department.
PART B: CHECKLIST
if the following have been done. You must indicate "yes" or"no" as to each of the following:
P) 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?
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?
to 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
.imation of distance is unacceptable) 15.302(3)(b)].
The facility owner(and occupants,if different from owner) were provided with information on
maintenance of Subsurface Sewage Disposal Systems(SSDS).
1URCES:
Department of Environmental Protection, Western Regional Office, 436 Dwight St., Springfield, MA
01103, (413) 784-1100;Title 5 Hotline - (800)266-1122
'.nspection 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
rty Address:
f Inspection:
163 Sylvester Road. Northampton MA
Thomas LaFlamme
10/21/05
FLOW CONDITIONS
)ENTIAL
330 DESIGN flow based on 310 CMR 15.203 (gallons/day)
3 Number of bedrooms (design)
3 Number of bedrooms (actual)
1-2 Number of current residents
y Is there a garbage grinder?(Y or N) _
Is there a Laundry Hookup?(Y or N)
N Is the Laundry a separate system?(Y or N) (If yes, separate inspection required)
N Seasonal use (Y or N)
254 Water meter readings, if available (last two years usage) (gallons per day)
N Sump Pump(Y or N)_
tinuous Date of last occupancy_
VIERCIAL/INDUSTRIAL
if establishment:
flow (based on 310 CMR 15.203): —gpd
tf design flow (seats/persons/sgft,etc.): _
trap present (Y or N):
mil waste holding tank present(Y or N):
meter readings, if available:_
tte of occupancy/use:
R (describe):
GENERAL INFORMATION
ing Records
of information: pumped about 3 years ago, says Owner
N Was system pumped as part of the inspection (Y or N)
yes, volume pumped: gallons --How was quantity pumped determined?
ason for pumping:
mment:
OF SYSTEM:
Septic tank, cliotoibelrie1ArrX, soil adsorption system.
Single cesspool
Overflow cesspool
Privy
Shared system (Y or N)Of 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)
nspection 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)
rty Address:
r:
t Inspection:
163 Sylvester Road. Northampton. MA
Thomas LaFlamme
10/21/05
'ROXIMATE AGE All components,date installed, and source of information
:lc plan: 6/28/99 for new septic tank, leach tank about 1968.
Source of Information BoH Certificate of Compliance
LDING SEWER (located on site plan)
24 _ Depth below grade (inches) Estimated Average
2 Distance in feet from private water supply well or suction line
ABS Materials of Construction
ments: Located under basement floor slab.
TIC TANK
oncrete Materials of Construction
Depth below grade
Riser depth
Septic tank width
Septic tank length
Septic tank height
Calculated gross volume
Air space in tank
Net Volume
Baffle depth
Sludge thickness
Scum thickness
Top Sludge : Bottom Baffle
Bottom Scum : Bottom Baffle
Top Scum : Top Baffle
30
18
58
124
60
1,873
10
1,500
21
3
2
36
10
7
ments:
br over center cover.
tees installed. New tank.
mmendations:
i on 3 to 5 year interval, depending on
(located on site plan)
(inches)
(inches)
(inches)
(inches)
(inches)
(gallons)
(inches)
(gallons)
(inches)
(inches)
(inches)
(inches)
(inches)
(inches)
IP CHAMBER
N
ments:
Interior dimension%
Interior dimensions
Interior dimension%
calculated
alculated
Average
Average
Calculated
Calculated
Calculated
occupancy.
Pump part of septic system: (Y or N)
Pumps in working order: (Y or N)
Alarms in working order: (Y or N)
nspection 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)
:My Address: 163 Sylvester Road. Northampton. MA
'r: Thomas Laflamme
of Inspection: 10/21/05
;TRIBUTION BOX (located on site plan)("D-box")
N D-box part of septic system: (Y or N) •
Depth of liquid level above outlet invert
tments:
IL ADSORPTION SYSTEM (SAS): Technology Used (located on site plan by estimate):
Y leaching pits & number: one pit identified, nominal 750 gals.
leaching chambers and number:
leaching galleries and number: _
leaching trenches, number, length:
leaching fields, number, dimensions: _
overflow cesspool,number:
innovative/alternative system,Type:
iments: (note soil conditions, signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
surface problems seen. Very stony, sandy soil.
not opened.
■S not located
tin why:
;HT OR HOLDING TANK
N Tight tank part of system:
Depth below grade
Tank width
Tank length
Tank height
Calculated gross volume
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
ments: (conditions of inlet tees, condition of alarm and float switches, etc.)
(tank must be pumped at time of inspection)
(Y or N)
(inches) Measured
(inches) From Plan
(inches) From Plan
(inches) From Plan
(gallons Calculated
VY
N
ments:
(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,
nspection 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)
rty Address: 163 Sylvester Road Northampton, MA
r: Thomas Laflamme
If Inspection: 10/21/05
SPOOLS (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 inflow(cesspool must be pumped as part of inspection)
nents: (note soil conditions, signs of hydraulic failure, level of ponding,condition of vegetation,
:ASE 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. Calculated csigitje_t_e_d_inchea
Scum thickness (inches) nveraae
cents: (recommendation and conditions)
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)
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:
rmatzon: Dry, sandy soil, dry basement without sump pump.
ispeclion Form 6/15/2000
page 8 of 9 Homestead Inc.
1
Deck
Outline of House
91 -v
i+j P yN
to 01' NORTH
Septic Tank
• Note: No known drinking water sources within 100 foot radius.
Leaching Tank
liler
COMMENTS:
Recommend pumoino 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: x'�`tix OF ut�'`�o HOMESTEAD INC.
I xisting Septic System 10/21/OS Thomas LaFlamme T11oNA48 Thomas S. Leue R.S.
163 Sylvester Road �uY
Scale: 1 : 20' Revision Date: Florence, MA 01062 / �'-1� �" •' 7ZJ ' ', 1664 Cape St.
Except as Noted St73NtD 51$ ' Williamsburg,1413]62 -45 301(196