115 Septic Application & Permit CHECK OR PILL IN WHERE A
Type of Building 2 Size Lot ra•c77 T HerttS
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder (g )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow 82.5 gallons per person per day. Total daily flow 330 gallons.
Septic Tank—Liquid capacity I5Mgallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching area sq. ft.
Seepage Pit No 1 Diameter Depth)below inlet 3'-0 Total leaching canacity_.699 GPD
Other Distribution box ( ) Dosirt_al* luntley Associates May 23, 1985
Percolation Test Results Performed by KYU 6 Date
Pit No. 1 1 minutes per inch Depth of Test Pit 0 Depth to ground water N 402
Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Test
Test
Description of soil 3" OTS, 1'-01t Sandy Silt, 4'-0" Coarse-Medium Sand, 41-9" GrUel..
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Application Approved By
XSiga
. /'� a
Date
Date
Application Disapproved for the following reasons
Permit No
I C /
Date
Issued
THE COMMONWEALTH OF MASSACHUSETTS
„BOARD OF HE H
erfifirtttt' of tanmpiittnLr
ual Sewage Disposal System constructed ( or Repaired ( )
Installer
has been installed in accordance with the provisions of TITL9E o- The State Sanitary Co —:de
application for Disposal Works Construction Permit No t_ t dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS ; GUARANTEE J HE
SYSTEM WILL FU CTION SATISF C
DATE .. ..�
No /
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
I OF
Oinpnnttl nrkn kinnsiruttinu Permit
Permission is hereby granted , • 4 .(r •'t' . s , f • ,
to Construct O or Repair ( ), an Individual Sewage Disposal System
at No it pi-
stye
as shown on the application for Disposal Works Construction Permit No - Dated
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of Health
OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY of NORTHAMPTON
I.ppliratinu for Tii}xunal 'Marks alrntaurtinn Permit
d= iar}
Fox .)73
Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
System at:
Lot on AlldukQn..Raad
Location-.Address
Joseph Dickinson
J113, PttLitafid
Installer
Type of Building
Dwelling— No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow 82.5 gallons per person per day. Total daily flow 330 gallons.
Septic Tank—Liquid capacity 1500gallons Length Width Diameter Depth
Width Total Length Total leaching area _ sq. ft.
Depth below inlet 3 -0'� Total leaching capectty_.i99 GPO
Date May 23, 1985
Depth of Test Pit 10'-0" Depth to ground water None
Depth of Test Pit Depth to ground water
311 Kennedy Roadr,tNorthampton Ma
\ 1 _ Address
�i�lA�-- Address
2 Expansion Attic
Size Lot 45.299 + Acres
( ) Garbage Grinder (x )
No of persons Showers ( ) — Cafeteria ( )
Disposal Trench—No.
Seepage Pit No Diameter
Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by Ht'D & Huntley Associates
Test Pit No. l 1 minutes per inch
Test Pit No. 2 minutes per inch
Description of Soil 3" OTSa...l'-O" Sandy..Silts...4_-.D" C4arae-Medium. Sand3 4'-9" Gr..asal.,
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
I! ra '
Date
ons
Application Approved By
Application Disapproved for the folio
9
re
. ._ i iCI
Date
Permit No
Date
Issued
PROPOSED DOMESTIC SU3SJRFACE DISPOSAL SYSTEM DESIGN
Prepared For: JOMPH /0/(A NS OA/
Location:
A/JD/450N/ F>J/L )1-7 HAMP7oN
Number of Bedrooms: 2 Garbage Disposal: KZ—CL
LEACE AREA DESIGN
2 Bedrooms x 2 persons/bedroom ■ 471 persons
'%' . Persons z 55 gallons of vascevater/person/day ■ 220 total gallons of
wastewater/day.
x /. S 330
Percolation Rate: 2 min/inch (C/ TY Of NORTHAMPTON REQU/RE/4ENT)
Gallon of wastewater/square feet of leach area for a Percolation Rata of:
2 min/inch - :.. _ Gal/SF Sidevall Area .
- /- O Gal/Sr Bottom Area
If a leach bed is to be installed, no sidesall is allowed.
• If percolation rare exceeds 20 m=/inch, no bottom area is allowed.'
- ScaTIC IASZ. -
* i7ITd007 GARBAGE DISPOSAL:
Gallons of wastewater/day x 1502 -
capacity of septic tank. .
REQUIRED effective liquid
RECO22.'7DED: Septic Tank
* In no case mill the septic tank be less than 1 000 gallons (effective liquid capacity)
** :II3 GARBAGE DISPOSAL:
33 0 Gallons of wastewater/day z 2002 ■ 060 • REQUI2 effective liquid
capacity of septic tank.
RECOl4C_NDEO: ; ,S-0e/ Septic Tank
•* In no case will the septic tank be less than 1,500 gallons (affective liquid capacity
ALMER HUNTLEY,JR., & ASSOCLaTES. INC.
Last SURVEYORS . PROFESSIONAL ECCI.YZfRS • L'NOSCAPE..RCHITECTS
LEACHING PIT DESIGN
Precast Pit Used: J O ' Long x S- ' Wide x z ' Effective Depth
Using Lf ' of stone all around and / ' of stone under pit.
SIDEWALL AREA:
/X ' Long x 3 ' Effective Depth x 2 Sides - / 0 8 SF
' Wide x ? ' Effective Depth x 2 Sides - 7 .? SF
Total of / '/ SF (Sidevall Area) x 2 c Gal/SF - !�or Gal/Pit (Sidevall)
•
BOTTOM AREA:
1
/ 3 ' Long x /3 • Wide - 2344 SF
"---35‘ ST (Sotto Area) x / D Gal/SF - < 39 Cal/Pit (Bottom)
1L 6S Gal/Pit (Sidevall)
23 5' Gal/Pit (Bottom)
(2) 99
TOTAL Gal/Pit (Designed)
* Without Garbage Disposal: Total Cal/Day (REQUIRED)
* With Garbage Disposal: 1.5 x 530Cal/Day (Daily Flow) - 4G95- Cal/d& o4i
(REQUIRED)
Using 99g Gal/Day (Daily Flow) _ C 9 7 Gal/Pit - / Pit(s)
ALMER HL'NTLEY, JR., & ASSOCIATES, INC.
LAND SURVEYORS • PROFESSIONAL ENGINEERS - LANDSCAPE ARCHITECTS
YC1Gd[e r
aeeCdSr
cocced7r
oe,V.Ea
1021
/2141/./ ,VP So/L
Save a•Tf%C
Co✓EQ t4 (
.827,set f
masc.
042Y NEea
b2-a" i'D o
-0
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t
A/arc: •ea woPC Of 4E /'v'Lcrae.CJ WE wires THE 572 TE ENViR o4 /a/drat
cooe - TfltC S.
-1560'5 ro nv4CE e ateirtsr GSCGT%E/NOW04 OEP NEO Ne
IVHICHErE.! /S
G•tEATER.
ALMER HUNTLEY, JR. Q ASSOCIATES , INC
REGISTERED LAND SURJEYORS L CIVIL ENGINEERS.
125 PLEASANT STREET
NORTHAMPTON , MASS .
FAX
CITY OF NORTHAMPTON
NORTHAMPTON
BOARD OF HEALTH
Fax to number:
To:
,; c 11 )..J
,)I.Ck,,,,LA 0!J
Attention:
Date:
/0 — 3 I
- D i7
From:
f -f-Pa
lllc E.i^(0L,
Number of Pages:
-F-
C< --1
Additional
comments:
NORTHAMPTON BOARD OF HEALTH
212 Main Street— Municipal Building
Northampton, MA 01060-3191
Phone: 413-587-1214
Fax: 413-587-1221
).ecte4 f
Relau�,�1
750 CARTON AEA(
All Maio AN/'-O'
STONE UNDER
REJER✓[ I
RfA cr500 DALLON
—152-PAC
1E 217 ACRESt
VIPA
PROPOSED Will,6tl-MAY.fROM
MAR;SO[EACWNC RAC/41721,0
SO MAN FROM NEAREST ASPTIC
TANH.
/
v
PLAN
/ =zo'
•
i.' • tI
L i
I I
OBSERVATION Pli^/ OBSERVATION PIT*A
DATE:S-29-SS DATE S2385
\ SANG R SAND fl O
£RAVEL
0
/A , r �i� GROUNDWATER R Km NONE, PRW GROUNDWATER -NONE
I I / OXIDE. -NONE OXIDE N -Marv(
A °
/ / ///� 1 F,t DEPTH -wr DEPTH RA
ll
/
BOARD Or HEALTH WITNESS'-0f TER MCfflLAIN
i ALLEW
WORK Al BE MRO IN TAL ACCORDANCE MiH
p i RRf 5. STAR ENVIRONMENTAL CODE.
I / \ SEPTIC TANK D BE INSPECTED AND CLEANED
/ / / p I Al LEAST ANNUALLY PER TITLE 5 SEC. 616
/ ' / ALL PIPING FROM HOUSE TO SEPTIC TANK AND
/// FROM SEPTIC TANK TO DSTRBUPON BOX OR
LEACHING PIT TO BE SDR-35. RING TITE, RECOMMENDED I
„^ TO MEN NORCE PRIOR TO BEGINNING CONSTRUCTION
ITO TIONNSTREQUREN"ENGNEER FIELD
CLEAN-OUT MANHOLE TO BE INSTALLED TO WITHIN
/ 6' OF CRAM OVER SEPTIC TANK RECOMMENDED
AND CONFIGURATION OF HOUSE IS SHOWN',
I I LOCATION
FOR REFERENCE ONLY ACTUAL SETBACK DISTANCES
TO HOUSE AND ACCESSORY STRUCTURES SHALL
/ CONFORM TO LOCAL ZONING REQUIREMENTS.
15 II
PLAh� Try
n
ruET/' z L d 11 ' (Meet to L LL onditions:
4,111 subject.
IA . rr..S i i _ _ _.9a _ __ E TEM,coNToIR
'3 Ill IN se PROP NUNA
Es PI
F{ i 11 teo PLAN OP PROPOSED B
SEWAGE DISPOSAL SYSTEM
R { II FOR 107 ON AUDUBON ROAD 5CFFK
p �L? Ta NORTNAVPTON MASS. [ /W
TNIXE•/f000 LY ✓REPARFO FOR CAC
SFPH c DIENINSON scui AS NO710
DATE 7-A3.38
'
p\ A ER^HI1NILEY. o ASSOCIATES. INC us r
ENVIRONMENTAL FIELD SERVICES, INC. fie 2 0 1999
P.O. BOX 518
LEEDS, MA 01053
1-413-586-7200
November 27, 1998
Joe Dickinson
P. 0. Box 357
115 Audubon Road
Leeds, MA 01053
re: Septic System Inspection at 115 Audubon Road, Leeds, MA
Dear Joe:
Enclosed please find a copy of my report for the referenced inspection. I
have forwarded a copy of the report to the Northampton Board of Health per
the requirements of 310 CMR 15.300.
Based on the results of my inspection in accordance with 310 CMR 15.300,
I have concluded that the system does not fail to protect the environment
and/or the public health.
Please call if you have any questions, and thank you for this opportunity to
be of service.
Sincerely yours,
sae —
J. L 'gne
Environme al Engineer
Certified System Inspector
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
BI SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if with approval of the
Board of Health). Describe observations:
_ broken pipets) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_ broken pipets) are replaced
obstruction is removed
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(ailing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
WILLIAM F.WELD
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617-292.5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Address of Owner: JOB'- D cg A):OAJ
Of different) PO )50X 3)5?
L e e d S, n1 g 0/05 3
to Section 15.340 of Title 5(310 CMR 15.000)
hi S milap
Property Address: 115 KK UdU7'
�" Rd
Date of Inspection: //-/S 95
Name of Inspector: al
I am a DV approved system inspector pursuant
Company Name:6%.21)s)1 Can_11 Yt t'Yt (t r ( A
Mailing Address: P �x
Telephone Number: S—kF -7 A-00
TRUDY CONE
Secretes):
DAVID B.STRUMS
Commissioner
3
CERTIFICATION STATEMENT
I 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
✓ Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature:
Date:. /
The System Inspector shall submit a cop?of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
V ST I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances, If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfihration, or tank '
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
Ir.vf•ad 04125197) Page 1 of 10
DEP on the World Wade Web'. http:IN,ww.magnetslatema.uSdeP
C Printed on Recycled Paper
L F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or"No"as to each of the following:
Yes No
Y' Pumping information was provided by the owner, occupant, or Board of Health.
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal
Flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
Nig As built plans have been obtained and examined. Note if they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
•
_ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on: -'
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)lb)I
(revised 04/]5/9]1 Yp• 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D) SYSTEM FAILS:
You must indicate er.'.er "Yes" or"No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged MS or cesspool.
Discharge or ponding of effluent to the surface of the ground.or surface waters due to an overloaded or clogged 5A5 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 is 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a 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 a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen,
E)LARGE SYSTEM FAILS:
You must indicate either "Yes" or No as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
_ The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 01/29/97, Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address:
Owner:
Dale of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:^ .1
Material of construction: _cast iron JL n0 PVC_ other (explain)
Distance from private water supply well or suction line /OU'
Diameter 4/,•
Comments: (condition of joints, venting, evidence of leakage, etc.)
A/o P.-ug/ewnc- nnz6e.J
SEPTIC TANK: v".
(locate on site plan)
8!s Gel-Je fi.e'G. .,..et 2.
Depth below grade./
Material of construction: J4oncrete _metal _Fiberglass _Polyethylene other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes(No)
Dimensions: /a(a Ix' 68 x 61-1 ref •
Sludge depth: -70
Distance from top of sludge to bottom of outlet tee or baffle: /2"
Scum thickness: --fro.,
Distance from top of scum to top of outlet tee or baffle: +A/`
Distance from bottom of scum to bottom of outlet tee or baffle: -42"
How dimensions were determined: C11-7,ne&dcz,
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) Reno'.. irn— /suw,'i.., —rcLed/eQ-
GREASE TRAP: NM
(locate on site plan)
Depth below grade:_
Material of construction: _concrete metal _Fiberglass _Polyethylene other(explain)
Dimensions:
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:_
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage etc.)
(revised 04/15/07) Page L of 10
Property Address:
Ownen
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
ROW CONDITIONS
RESIDENTIAL:VIM Design flow:Al IM g.p dlbedroom for S.A.S.
Number of bedrooms: 4 1
Number of current residents: d.
Garbage grinder ryes or no): 7
Laundry connected to systems or no):I'A.D
Seasonal use (yes or no):IIA
Water meter readings, if available (last two(2)year usage (gpd): NO) O Ua.1 1410 u
Sump Pump(yes or no): ?La
Last date of occupancy:(.U NI"8 u t
COMMERCIAUI ND USTRIAL:
Type of establishment K)
Design flow:_ gallons/day
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)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
last date of occupancy:
PUMPING RECORDS and source of information:
GENERAL INFORMATION
/N/e ve.r per ('..e, t 19f39,
System pumped as pan of inspection: (yes or no)A.(p
If yes, volume pumped: gallons
Reason for pumping:
TYPE SYSTEM
f/Of Septic tank/disPihugenism/soil absorption system
_ Single cesspool
_ Overflow cesspool
Privy
_Shared system (yes or no) if yes, attach previous inspection records, if any)
_I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed if known) and source of information
Sewage odors detected when arriving at the site: (yes or not_u[)
(r.v1med 09/29/97)
Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): V'
(locate on site plan, if possible; excavation not required, but may be approximated by non•intrusive methods)
If not determined to be present, explain: / /
Type
leaching pits, number: /, 77) %Lt( '
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Tis—y — 'a f-Y9i.C` n% !LA y ]inCEup . txcc//C•—' C-Ci■ I1 jot._
CESSPOOLS: Sin
(locate on site plan)
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 pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: NM
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Paye a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: A(/4 Rank must be pumped prior to,or at time, of inspection)
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallonstday
Alarm level: Alarm in working order_Yes;_ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:10
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage Into or out of box etc.)
PUMP CHAMBER:.M4
(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.)
•
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
Depth to Groundwater jar Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
_Check local excavators, installers
Use U5G5 Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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Page 9 of 30