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275 Septic Inspection 2002 (2) COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION L Mfi 11 nett• He nym= 'eamo Property Address: 275 HATFIELD ST NORTHAMPTON MA Owner's Name:_ROBERT ROTA Owner's Address: SAME Date of inspection: 8/19/2002 Nance of Inspector: (please print) NATHAN TORRETTI Company Name: CLEAN SEPTICS Mailing Address:_P.O.BOX 394 LUDLOW,MA Telephone Number:_583-2138 CERTIFICATION STATEMENT 1 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: Inspector's Signature: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority tV Fails Date: 8/19/02 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 shall 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 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_275 HA than ST NORTHAMPTON MA Owner: KUTA Date of Inspection: 8/19/02 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 determiner in accordance with 310 CMR 15.303(t)(b)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 ofa 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 1 ofa public water supply. The system has a septic tank and SAS and the SAS is within 50 feet ofa private water supply well The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feel 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 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_275 HATFIELD ST _ NORTHAMPTON MA Owner: KUTA Date of inspection:_8/19102 Inspection Summary: Check A,B,C,D or E/ALWAY complete an of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 319 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components m 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 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 sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 year 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) ND explain: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced 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 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: KUTA Date of Inspection: Check if the folio _275 HATFIELD ST NORTHAMPTON, h1A _9/19102 been done. You must indicate or"no"as to each of the fo!lowin ypi No _ Pumpine 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 P eriod V Have large volumes of water been introduced to the system recently or as part of this inspection /Were as built pans of the system obtained and examined?(If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage backup V Was the site inspected for signs of break out / _ Were all system components, excluding the SAS, located on sire ;Thie1/ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of;he s or tees, material of construction,dimensions, depth of liquid, depth of sludge and depth of scum V_ 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 Yes no __ ✓ Existing information. For example, a plan at the Board of Health. __ Determined in the field Of any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15302(3)(b)1 to has been determined based on: Page 4 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:275 HATFIELD ST _ NORTHAMPTON, MA Owner: KDTA_ Date of Inspection: 8119)02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for a! inspections: Yess No Backup of sewage into facility or system component due to 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 V/ 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 is less than f 5 day flow Z. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets).Number of times pumped_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _ f Any portion of cesspool or privy is within 100 feet ofa surface water supply or tributary to a surface water supply 4 Any portion of a cesspool or privy is within a Zone 1 of a public well. t/ 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 a private water supply well with no acceptable water quality analysis. [Thu 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.] nS CMR The system fails.I have 15.303,therefore the sys tem fails.The system owner should cons contact the Board of Health described in to determine 1 G 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 II 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"yes"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 7 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM LNSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:275 HAFIELD ST _ NORTHAMPTON,MA Owner KUTA Date of Inspection: 8/19/02 BUILDING SEWER(locate on site plan) Depth below grade:_r_L: Materials of constriction: cast iron _40 PVC _other(explain): N/A Distance from private water supply well or suction line: Comments(on condition ofjoints,venting h/A N/A J enhng,evidence of leakage, etc.): SEPTC TANK:_(locate on site plan) Depth below grade 1'11" Material of construction _Y\ conaete metal other(expiain) -- _fiberglass polyethylene If tank is metal list age: Is age confirmed by a Cent mate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 10'6" L 5'W 5' D Sludge depth: IV U Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: NONE Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet invert, evidence of leakage,Etc): PUMP TANK WH N I TALL/NG EW LEACH F/ s INTEGRITY K LIGLIGUID LEVELS OK NO BAFFLE APPEAR 0 STRUCTURAL Lgev GREASE TRAP:_(locate on site pan) Depth below grade: Material of construction: concrete (explain): — mew—.fiberglass polyethylene_other Dimensions Scum thickness: Distance from to 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): ?age 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_275 HATFIELD ST NORTHAMPTON, MA Owner: KUTA_ Date of Inspection: 8/19/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design).. _2_ Number of bedrooms(actual):_2_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 Number of current residents: 5 Does residence have a garbage grinder(yes or no).. _YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected (yes or no): _ Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): TOWN WATER Sump pump(yes or no): _NO_ Las:date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment.__ Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): _ Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available. Last date of occupancy/use: OTHER(describe)'. GENERAL LNFORMATION Pumping Records Source of information: PUMPED IN IATEFALL OF 2001 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. TYPE OF SYSTEM Septic tank diary soil absorption system Single cesspool Overflow cesspool Privy __Shared system(yes or no)(if yes,attach previous inspection records,if an y) Innovative/Alternative 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 I/Other(describe): LEACH PIT Approximate age of all components,date installed(if known)and source of information: N/A NEW SEPTIC TANK 1996 Were sewage odors detected when arriving at the site(yes or no):lig Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 275 HATFIELD ST _ NORTHAWTON,MA Owner: KUTA --�_ Date of Inspection: 8!(9/02 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why Type leaching pits, number: 1 leaching chambers,number: leaching galleries, number _leaching trenches, number, length:_ leaching fields,number,dimensions: overflow cesspool, number: innovativeialtemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level ofponding damp Lou,) condition of vegeta'ion, etc.). SOIL OK YES SIG S F HYDRAUL] FAILURE VE ETATION OK EFFLUENT LEVEL( ABOVE TOP OF PIT CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration- Depth-tap 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 ofponding, condition ofvegetatior., etc.}. PRIVY:_(locate on site plan) Materials of construction: Dimensions Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level ofponding, condition of vegetation etc. 'ape 8 of II OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM LNSPECTION FORM PART C SYSTEM LNFORMATION(continued) Property Address:_275 HATFIELD ST_ NORTHAMPTON .MA Owner: KUTA_ Date of Inspection: 8/19/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade. Material of construction: concrete_metal fiberglass polyethylene of her(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: _(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert. NONE any evidence of leakage Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, into or out of box,etc.): PUMP CHAMBER:_(locate 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.)'. Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_275 HATFIELD ST KUTA ,MA Owner: KUTA Date of Inspection: 8/19/02 SITE EXAM Slope Surtace water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed 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 high ground water elevation: TO BE D TERMIPtED AT PERC 1 .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: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks OE benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building. Oup et A 37 ' e 33 Ct 7-1 /Ja s F,e/d 5/ 3 v