595 Septic Inspection 2006 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Certification
toperty Information
aerty Address:
ten's Name:
ier's Address:
•of Inspection: 7/11/06
yto: Board of Health Northapton; Shauneed Rocot, Goggins
less: Number SSDS-1090
_ .. _ • •4
ispector:
,e of Inspector. Thomas S. Leue
many Name: Homestead Inc.
ling Address: 1664 cape St. . Williamsburg, MA 01096
'phone Number. (4131 628-4533
tification Statement:
rtify that I have personally inspected the sewage disposal system at this address and that the information reported
)w is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
ling and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP
,roved system inspector pursuant to Section 15.340 of Tube 5 (310 CMR 15.000). The septic system condition
st be evaluated and classified into one of the following four conditions:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
s system condition: Passes
spector's Signature:
S41L Date: 7/11/06
e System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health of DEP)
hin 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or
cater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The
ginal should be sent to the system owner and copies to the buyer, if applicable and the approving authority.
des and Comments:
"'This report only describes conditions at the time of inspection and under the conditions of use at that
ne. This inspection does not address how the system will perform in the future under the same or different
,nditions of use.
,®45!4•wm.oma
insp.doc•1112004 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
tification (Cont)
ty Address: _ ••Schneid
Name:
Inspection: Wain
tion Summary: Check A,B,C,D or E I glways 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.
V The septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is structurally
md, exhibits substantial infiltration or exaltation,or tank failure is imminent. The system will pass inspection if
fisting septic tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic
will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank
s than 20 years old is available.
xplain
Observation ed pipe )or due to a broken, settled or uneven uneven distribution ebox, System will pass inspection if
an or oval by Board broken pipe(s)are replaced
approval by the Board of Health) ._ obstruction is removed
distribution box is levelled or replaced
• f• I . 11• • r M.;
explain.
The system required pumping more than four times a year due to broken or obstructed pipe(s). The
em will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced
obstruction is removed
explain:
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 system is
ling to protect the public health, safety or the environment
System stem is not functioning unless
n a manner which Health
willl protect public health,safety and the environment:
that the
_ 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.
insp.doc•11/2004 Homestead Inc.
Title 5 ORidal Inspedion Form:Subsurface Disposal System
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
fication (Cont)
Address:
fame: 7/11 /06
Bys em will Supplier,if any)determines that the system
System wal fail unless that protects t the public health, Water and
shiny in a h manner that ank and the absorption health,safety yS) a and the SAS is
the.system has a septic tank and soil absorption system (SAS)antl the SAS is within 100 feet of a surface
haply 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
system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria an upply well"Method used to determine distance
d
organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
n and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
analysis must be attached to this form.
her:
System Failure Criteria applicable to all systems: e
ins dions.
indicate either"Yes" or"No" as to each of the following for a P
Y)or NO(N) ed SAS or cesspool.
Backup of sewage into facility or system component due to an overloaded or clogg
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool. SAS or cesspool.
I Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
due to clogged or obstructed pipets). Number of
I Liquid depth in cesspool is less than 6°below invert or available volume less than 112 day flow.
J_ Required pumping more than 4 times in the last yearlrQL
times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
(V Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
supply. well.
N Any portion of cesspool privy is within a Zone I of a p
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
at a DEP
compounds water analysis,
alyttheweorsed at with t no acceptable
ry water quality analysis. dtv system passes co if ou dsli indicates s that th performed.
certified laboratory,
from that for ty and t bacteria and volatile am organic
nitrogen compo
triggered. A copy of the analysis must be attached to this form.]
pollution from that facility and the presence of ammonia ntrogen and nitrate nitrogen is equal to or less than
ppm, provided that no other failure criteria are tdgg
The System a'IS: I have determined that one or more of the above failure criteria exist as defined in 310
A 15.303,therefore the system fails. The system owner should contact the Board of Health should be contacted to
termine what will be necessary to correct the failure.
ZMmENI:
insp.doc•1112004
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
Sewage Disposal System Form
fication (Cont)
Address:
Jame:
nspection: 11-1-1116.
le Systems:
nsidered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd.
is indicate either"Yes" or"No" as to each of the following:
'wing criteria apply to large systems in addition to the criteria above:
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)
nt question ilI the answered in
D above the large system has failed. The owneor pera oanlarge sys system considereda significant
,ender Section E or failed under
rSe tits re shall pgra a the D stem in at�rdance with 310 CMR 15.304.The
owner should contact the app P 9
• . . \• .. • tI%• •1•
Jecklist
for NO(N)
Pumping information was provided by the owner,occup ant 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?
tk 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)
the the
Bsited has been
Health determined based on:
a) Existing information. For example, a plan a
b) Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
ance is unacceptable)(15.302(3)(b)1
The facility owner(and occupants, if different from owner)were provided with information on proper
intenance of Subsurface Sewage Disposal Systems(SSDS).
Isp.doc•11/2004
Homestead Inc.
Title 5 Official Inspection Form: Subsurface Disposal System yn ni.•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Address:
lame:
nspection:
fITIAL
tknown
3
3
Y
Y
N
N
N/A
N
fitaDDDLLS
• L+n• • I.
• ve
1��=rtes Schneid
7/11/06
FLOW CONDITIONS
DESIGN flow based on 310 CMR 15 203(gallonslday)
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)® per day)
Water.meter readings if available(last two years usage)(g allons pe
Sump Pump(Y or N)®
Date of last occupancy
!ERCIALIINDUSTRIAL
If establishment
n flow(based on 310 CMR 15203): i gpd
of design flow (seatslpersonslsgfl,etc.):
is trap present(Y or N):
trail waste holding tank present(Y or N):
r meter readings, if available:
fate of oer ipancyfuse:
ER(describe):
GENERAL INFORMATION
ping Records. Source of information. Pura• -d ovembe 2005 s
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: to 4 e•r in ry al e
Comment. •u
'E OF SYSTEM:
Septic tank,
oil adsorption system.
_ Single cesspool®
Overflow cesspool®
_ Privy
_ Shared system (Y or N) (if yes, attach previous inspection records, if any)
_ InnovativelAltemative 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):�s
insp.doc•1112004
Homestead Inc.
Title 5 Official Inspection Form:Subsurface Disposal•5Y r+n
•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Address:
lame:
nspection:
All components, date installed, and source of info.
)XIMATE AGE
is elan: Estimated 1987 construction date
i anees schneid
/Dial
of Info.
N
)ING SEWER
36
4
ABS
ments:
DC TANK
Zoncrete
30
24
57
134
59
1,956
11
1,500
24
2
1
33
12
9
'fitments:0 o•erational or structural •roblems seen. Some outlet
iser over center cover onl°
ecommendations:
um• on 3 to 4 ear interval.
Owner
Were sewage odors detected when arriving at the site(Y or N)
(located on site plan)
F_l101sted e�erane
_Depth below grade (inches)
Distance in feet from private water supply well or suction line
Materials of Construction
No •roblems seen- , unnecessaril dee
(located on site plan)
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
(inches)
(inches) _
(inches)
(inches)
(inches)
(gallons)
(inches)
(gallons)
(inches)
(inches)
(inches)
(inches)
(inches)
(inches)
Interior d imns ons
„r dimensions
dim nse=ns
Qffiloglateg t
al elated
insO.d00. 1112004
Homestead Inc.
end deteriorat
Title 5 Official Inspection Form..Subsurface Disposal Syst?m
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Address:
ame:
ispection:
>AMBER
N
ents:
7y
Pump part of septic system: (V or N)
Pumps in working order: (Y or N)
Alarms in working order: (V or N)
IBUTION BOX (located on site plan)CD-box)
pJ D-box pail of septic system: (Y or N)
Depth of liquid level above outlet invert
rents:
ADSORPTION SYSTEM (SAS): Technology site
nomtinal.an by
leaching pits 8 number:
leaching chambers and number:
leaching galleries and number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
innovativelaltemative system,Type:
iments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
tk located but not o•ened.
£S not located
ain why:
MT OR HOLDING TANK
14 Tight tank part of system: (Y or
Depth below grade
Tank width
Tank height
Materials of construction gallonslday
Design flow:
Pumps in working order (Y or N)
Alarms in working order: (Y or N)
Date of last pumping etc.
omments: conditions of inlet tees, condition of alarm and float switches,
(tank must be pumped at time of inspection)
N)
(inches)
Tank length
Calculated gross volume
sp.doc•11/2004
Homestead Inc.
e u
(inches)
(gallons\
II
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
Address:
game:
nspection:
N
cents:
7/11/06
(locate on site plan, if any)
Privy part of system: (V or N)
Materials of construction:
Dimensions:
Depth of solids:
(soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
;POOLS (cesspool must be pumped as part of inspection)
N Cesspool part of system: (V 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)
'merits: (note soil conditions, signs of hydraulic failure, level of pending, condition of vegetation, etc
EASE TRAP (Usually present in certain commercial systems)
N Grease Trap part of system: (V 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)
omments. (recommendation and conditions)
,sp doc•11/2004
Homestead Inc.
ttigALVLO
l'alculated Inches
r laled Inches
yr
Title 5 Official Inspection Font Subsurface Dispoossal System nf•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
I Address:
Name:
Inspection:
.EXAM
Y Slope
• Surface water
Y Check Cellar
N Shallow wells (inches)
120 Estimated depth to ground water
Ise indicate(check) all the methods used to determine high groundwater elevation:
• Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
tmation: Exceetionall sand soil, no sum
Near b droe—off to ereater than this death.
7/11/06
(Source of Information)
Official Perc Date
Official Plan Date
Other Official Source
Other Source
• unt•
needed in basement.
.SOURCES De
Dwight St.
•
•
n
artment of Environmental Protection,Western R
field MA 01103 413 784-1100-Title 5 Hotline
•
isp.doc•11!2004 Homestead Inc.
onal Office,
800 266-1122
Title 5 Official Inspection Form:Subsurface Disposal Syst t0
South end of house
Town water in NORTH
I,l�--
Septic Tank
0
b6>
N
—__ Leaching Tank
COMMENTS: this plan posted in the
_Recommend pumping on a 3 to 4 year schedule. Also, a copy
basement/utility area would keep this information accessible in future years for maintenance. ,
Date: Owner: HOMESTEAD INC.
mss"
As-Built Drawing „ Thomas S. Leue R.S.
o TpY/aL
Existing Septic System 7/11/06 Frances & Joel Schneid t -
59 Sylvester Road tz)
Williamsburg,MA 01096
Scale: 1 : 20' Revision Date: Florence, MA 01062 / '� 141316 s-asss
Thomas
,
Except as Noted