307 Septic Permit & Inspection FEE {ESL--
�° a
THE COMMONWEALTH OF MASSACHUSETTS
MaRTHAMhpTO LI MASSACHUSETTS
'mutton for !topcoat `Sgstzm Construction permit
Application is hereby made for a Permit to Construct( ) o •epair Van On-site Sewage Disposal System at:
Owner's Name.Address and Tel.No.
�oA f MmRy Nr2oi
301 Nutd1300 RD , Sr4 - V SZ3
Designer's Name,Address and Tel.No.
'Ts w�JTwy C Ws A64 rJMS ES x),
r)3 nn0oil-A(z"L' Rt— WESTHker^{Iv
6L7- 5 L9/
Garbage Grinder{—T—
No per Persons Showers( ) Cafeteria( )
Location Address or Lot No.
361) A:vou6odu Romtc
LE-Eros, MnA
Installer's Name,Address,and Tel.No.
Sti ffer
Type of Building:
Dwelling No. of Bedrooms
Other Type of Building C1&)& Fil m
Other Fixtures
Design Flow 4 q S- gallons per day. Calculated daily flow 556. 8 gallons.Plan Date %0 ` 2:7"-9.5"" Number of sheets i Revision Date N A*
Title (tm-,a Or RLOpo_SEP SUBs.4fmcE 6fl.'A6i. 0i-94SAt . SiSial—g.&PA)R
Description of Soil —7-0 ecil , — 5U 6S1) L ` SA'- ccP4A sywn t (SAVO _
(„ r-c f;a' F5 -- {�A/tz MFl7 SAAI(i
Nature of Repairs or Alterations(Answer when applicable)• PER ALE FAI L)MJESc LONG H UJ6
�iht',l i.)D1 Thu
a
Date last inspected' 9-,2 9- 95-
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by this Board of Health.
Signed
Application Approved by Date
Application Disapproved for the following reasons
Date
Permit No
Date Issued
THE COMMONW EAI7TH OF MASSACHUSETTS
MASSACHUSETTS
Qlerttf rite of Qlmnpllancr
T IS IS TO CER TIFF, th. the On- to Sewage Disposal System installed( )or re aired/replaced( on
ll�:—lliS A . for
_ as been construe d in
at
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No 7��S dated
IO - a '7( 4 S Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall
Certificate expires on
i//3 7/9c
DATE
be
nstrued as a guarantee that the system will function as designed. This
Inspector
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Ce
Property Address: 307 Audubon Road Leeds,M rtification (continued)
Owner: Ed Reesman
Date of Inspection: August 29,2005
INSPECTION SUMMARY: CHECK A, B, C, D or E /ALWAYS complete all of Section D
A] SYSTEM PASSES:
® I have not found any information which indicates that any of the failure conditions described in 310 CMR
15.303 or in CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] 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.
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 years old is
available.
ND explain:
Observation of sewage backup or breakout or high static water level in the distribution box is due to
broken or obstructed pipe(s) or due to a broken, settled, or uneven distribution box. The system will
pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND explain:
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:
Title 5 Inspection Form 6/15/2000 Page 2
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5 INSPECTION FORM
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification
Property Address- 307 Audubon Road Leeds, Mass. Name of Owner: Ed Riseman
Date of
Inspection:
Name of
Inspector:
Company Name:
Company Phone:
August 29, 2005
Philip J. Pasiecnik
Greg's Wastewater Removal
239A Greenfield Road
S. Deerfield, MA 01373
(413)665- 3989
Address of
Owner:
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 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:
® Passes
❑ Conditionally Passes
❑ Needs Further Evaluation by the local Approving Authority
❑ Fails
INSPECTOR'S
SIGNATURE:
DATE:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP)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 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: No failure criteria as described on page four of this inspection form was found at the time of
inspection of this system. System Design Plan was obtained for this inspection.
"'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
Title 5 Inspection Form 6/15(2000
Page 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 307 Audubon Road Leeds,Mass.
Owner: Ed Riseman
Date of Inspection: August 29,2005
D] SYSTEM FAILURE CRITERIA applicable to all systems:
You must indicate either°Yes" or"No"to each of the following, for all inspections:
YES 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.
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or dogged
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.
❑ Z 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 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. [This system passes if the
well water analysis,peiformed at a DEP certified laboratory,for conform 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
exists as defined in 310 CMR 15.303, therefore the system fails. The system owner
should contact the Board of Health to determine 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 threat, or answered "yes" in
Section D above the large system has failed. The owner or operator or 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.
Title 5 Inspection Form 6/15/2000 Page 4
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 307 Audubon Road Leeds,Mass.
Owner: Ed Riseman
Date of Inspection: August 29,2005
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 the public health, safety, or the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH
310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL
PROTECT THE 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.
2) SYSTEM WILL FAIL UNLESS 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 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 SAS and the SAS is within a Zone 1 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 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
Title 5 Inspection Form 6/15/2000 Page 3
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION
Property Address: 307 Audubon Road Leeds,Mast
Owner: Ed Riseman
Date of Ina pecDow August 29,2005
FLOW CONDITIONS
Residential:
Number of bedrooms(design): 3 Number of bedrooms (actual)_3
DESIGN Flow: 330 G.P.D. (based on 310 CMR 15.203-for examole: 110 qpd x#of bedrooms)
Number of current residents: 2
Is Garbage Grinder present (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)
Water Meter readings - if available
(last two (2)year usage (gpd)
Sump Pump(yes or no)
Last Date of Occupancy:
Commercial/Industrial:
Type of establishment:
Design flow: (Based on 310 CMR 15.203)
Basis of design flow(seats/persons/sgft,etc.)
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)
Last Date of Occupancy/Use:
OTHER (describe):
PUMPING RECORDS
Source of information:
Was system pumped as
part of the inspection:
(yes or no)
If YES -enter volume
pumped
Reason for pumping:
No
Private Well Not Metered
Yes
Occupied at the time of inspection.
gallons per day
GENERAL INFORMATION
System was last pumped 3 - 4 years ago per owner.
Yes
1500 gallons
How was the quantity pumped determined? Tank Dimensions
Tank Inspection and Solids Removal
TYPE OF SYSTEM:
® Septic Tank/D Box/Soil Absorption System
Overflow Cesspool
[1 Single Cesspool
❑ Privy
Shared system (yes or no) (if yes, attach previous inspection records if any) No
nnovative/Altemative technology. Attach a copy of up the current operation
and maintenance contract (to be obtained from system owner)
Tight Tank Attach a copy of DEP Approval
OTHER (describe):
Approximate age of all components date installed ('f known) and source of information:
Septic Tank 25 Years Old + or-/ SAS 9 Years Old / SAS 11/27/95/C.O.C.
Were sewage odors detected when arriving at site: (yes or no) No
Title 5 Inspection Form 6/15/2000 Page 6
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part B
CHECKLIST
Property Address: 307 Audubon Road Leeds,Mass.
Owner: Ed Wiseman
Date of Inspection: August 29,2005
Check if the following have been done. You must indicate either "Yes" or "No"
as to each of the following:
Yes No
Z ❑ Pumping information was requested of the owner, occupant, or Board of Health.
❑ Z 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 this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ Were all system components, excluding the Soil Absorption System, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the
condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge
and depth of scum?
® ❑ 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 site has been
determined based on:
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [310 CMR 15.302 (3)(b)]
Title 5 Inspection Form 6/15/2000 Page 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION (continued)
Property Address: 307 Audubon Road Leeds,Mass.
Owner. Ed Riseman
Date of Inspection: August 29,2005
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 Other(explain)
Dimensions:
Capacity in gallons
Design flow in gallons per day
Alarm present (Yes or No)
Alarm level Alarm in working order ['Yes ❑ No
Date of last pumping
Comments: (condition of alarm and float switches etc.)
DISTRIBUTION ® Yes ❑ No (If present, MUST be opened-locate on site plan)
BOX
Depth of liquid level above outlet invert: Not Above
Comments: (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box etc.) Box was level and distribution was equal to all four outlet
pipes. Very little solids carryover was in the box when opened for inspection. No leakage was evident into
or out of the box at this time.
PUMP CHAMBER: ❑ (located 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.)
Title 5 Inspection Form 6/15/2000 Page 8
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 307 Audubon Road Leeds,Mass.
Owner: Ed Riseman
Date of Inspection: August 29,2005
BUILDING SEWER(Locate on site plan):
Depth below grade: 18"
Material of construction: cast iron XXX 40 PVC other(explain)
Distance from private water supply well or suction line >100'
Diameter 4"
Comments: (condition of joints, venting, evidence of leakage, etc.) All joints visible in the basement of the dwelling
were in good condition. Venting was visible outside the dwelling. No leakage was evident at this time.
SEPTIC TANK (locate on site plan): EI
Depth below grade: 12"
Material of Construction: M Concrete ❑ Metal ❑ Fiberglass ❑ Polyethylene Other(explain)
If tank is metal, list age Is age confirmed by Certificate of Compliance
(Yes/No) (If"Y", attach copy of Certificate of Compliance)
10'6"Lx5'6"Wx5'4"D Dimensions:
8" Sludge Depth
20" Distance from top of sludge to bottom of outlet tee or baffle
6" Scum thickness
6" Distance from top of scum to top of outlet tee or baffle
14" Distance from bottom of scum to bottom of outlet tee or baffle
Measured How dimensions were determined:
Comments: (On pumping recommendations, inlet& outlet tee or baffle condition, structural integrity, liquid levels as
related to outlet invert, evidence of leakage, etc.) The septic tank should be pumped every two to three years. Cast
in place concrete inlet baffle was in good condition and extends 13" below the flow line. Cast in place concrete outlet
baffle was in good condition and extends 20" below the flow line. Structural integrity of the septic tank was good. The
liquid level was at the outlet invert. No leakage was evident. Concrete risers were on the inlet and center covers to
surface.
GREASE TRAP (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/baffle
Distance from bottom of scum to bottom of outlet tee/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.):
Title 5 Inspection Form 6/15/2000 Page 7
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION
Property Address: 307 Audubon Road Leeds,Mass.
Owner: Ed Rrseman
Date of Inspection: August 19,2005
SKETCH OF SEWAGE DISPOSAL SYSTEM:
{Provide a Sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
**** ( SEE EXHIBIT A) ****
Title 5 Inspection Form 6/15/2000 Page 10
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION (continued)
Property Address: 307 Audubon Road Leeds,Mass.
Owner Ed Rlseman
Date of Inspection: August 29,2005
SOIL ABSORPTION SYSTEM
(SAS):
(locate on site plan, if possible; excavation not required.)
If SAS is not located explain why:
TYPE:
Leaching pits & number
Leaching chambers & number
Leaching galleries &number
Leaching trenches, number, length 4 - Infiltrator Trenches 48ft. Long Each
( Per Design Plan )
Leaching fields, number,
dimensions
Overflow cesspool, number
Innovative/Alternative system:
Name of Technology:
Comments: (Note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) The soil,was
gravely with no clogging evident. No signs of hydraulic failure or ponding. The soil wasn't damp over the
area of the trenches. Vegetation was mowed grass which looked normal in growth over the trenches..
CESSPOOLS ❑ (Cesspool must be pumped as part of inspection-locate on site plan)
Number& 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
(Yes or No)
Comments: (Note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY ❑ (locate on site plan)
Materials of construction
Dimensions
Depth of solids
Comments: (Note condition of soil,signs of hydraulic failure,level of pondinq,condition of vegetation eta)
Title 5 Inspection Form 6/15/2000 Page 9
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION (continued)
Property Address: 301 Audubon Road Leeds,Mass.
Owner: Ed Riseman
Date of Inspection: August 29,2005
SITE EXAM ® Slope
• Surface water
® Check cellar
❑ Shallow wells
Estimated Depth to Groundwater >4 Feet
Please indicate (check) all the methods used to determine High Groundwater
Elevation:
® Obtained from system design plans on record - If checked, date of design
plan reviewed: 12/6/95 Revised Date
® 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:
Design Plan and Observation of Site. Sump pump in the basement was dry at
this time. No surface water nearby to the system. No infiltration of groundwater
into the septic tank after pumping.
Title 5 Inspection Form 6/15/2000 Page 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
QfwA{,A1YMt]`?r'`' PART A
CERTIFICATION (continued)
Property Address: 6 9 rn E
Om r:
Date of Inspection: 4 .fl. (,O
B] SYSTEM CONDITIONALLY PASSES (continued)
The system required pimping 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 pipe(s) 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 failing 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 fee: of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (MD PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE S_TSTEM
IS FUNCTIONING IN A MANNER THAT PROTECT THE-PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply o r
Trioutary to a surface water supply.
he system has a septic tank and soil absorption system and is within a Zone I of a public water supply
well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply
welt.
The system has a septic tank and soil absorption system and is Less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for conform 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.
DI SYSTEM FAILS:
Y t 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.
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.
�T Static Liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS c
cesspool. or
Liquid depth in cesspool is less than Or below invert or available volume is less than 1/2 day flow.
Required pupping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
of u-ped
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 welt.
(revised 9/15/95) 2
William F. Weld
Governor
Trudy Caxe
Sec:e nrY. ECEA
David 9. Struhs
Commonwealth of Massachusens
Executive Office of Environmental Affairs
Department of
Environmental Protection
Western Regional Office
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property spects:307 9vraenf AB•
Date of Inspection: y.et7. fr
Mn of Insp, Address a4 T Ie /.9�V2)e
Company Nam, Address and Telephone Nuiber:
AO, a r>SF wet r cbtz,r7e FA el,9 amt.
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 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 Locai Approving Authority
Faits
or's Sig to
Date:
The System Inspector all submit a copy 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 StPWARY:
Check A, B, C, or D:
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as
defined in 310 CPR 15.303. Any failure criteria not evaluated are indicated below.
BI SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the
replacement or repair, passes inspection.
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, cracked, structurally unsound, shows substantial infiltration or exfiltration, 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.
Sewage backup or breakout or high static water levet observed in the distribution box is due to broken
or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
(revised 8/15/95) 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 5r,m=
Owner:
Date of Inspection: .a7 •ti L>
RESIDENTIAL:
Design f ,53° gallons
Number of bedrooms: t
Number of current res(dents:r�
Garbage grinder (yes or no): lit,o
Laundry on ected to system (fes or no):.7F',Mj
Seasonal use (yes or n ): O 1
Water meter readings, if available: 1553 ?IJ .
FLOW CONDITIONS
Last date of occupancy:CVCRtkl
COMMERCIAL/INDUSTRIAL:
Type of establishment
Design flop: gallons/day
Grease trap present: (ycs 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:
GENERAL I NFONNAT ION
PUMPING RECORDS and source of information:
/`iWN'crt 580 YHEy Pump eavec 4 yt*w t OWNErt Kn5 Nei' oaeblcryi te
4 vr/f air ytfi¢s
System pumped as part of inspection: (yes or no)N,i
If yes, volume pumped: /SOD • gallons
Reason for pumping: Tif/+. - AP)/ u /win, K S t S t-
TYPE OF SYSTEM %�
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of alt components, date installed (if known) and source of information:
4y R Ma. I, M4,(/F Ii ,MeIJ b'E ike ,5.
Sewage odors detected when arriving at the site: (yes or no) LIP
(revised 8/15/95)
4
1'17 3 ,riv tLai
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: > F77 6
Date of Inspection:
D) SYSTEM FAILS (continued):
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.
EI LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 god 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:
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 welt)
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.
PART B
CHECCLIST
Check if the following have been done:
SI Pumping information was requested of the owner, occupant, and Board of Health.
Y{ 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 recentty or as
part of this inspection.
UM_ As built plans have been obtained and examined. Note if they are not available with N/A.
w% The facility or dwelling was inspected for signs of sewage back-up.
u The system does not receive non-sanitary or industrial waste flow
The site was inspegted.for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
x 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.
X The size and location of the Soil Absorption System on the site has been determined based on existing
information or approximated by non-intrusive methods.
y- The facility owner (and occupants, if different from owner) were provided with information on the proper
maintenance of Sub-Surface Disposal System.
(revised 8/25/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
9gn1e
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth 'below grade:
Material of construction: _concrete metal FRP _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm levet:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquia Level above outlet invert:f0 ll 7b *Op
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of Leakage into or out of box, etc.)
A C. e¢E Ibt,-ALE --tii w ,♦ 'B-X
PUMP CHAMBER:
(Locate on site plan)
Punps in working order:(yes or no)_
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/55) 6
SUBSURFACE SEWAGE DISPOSAL STSTEM INSPECTIOM FORM
PART C
SYSTEM INFDRMATIUN (continued)
Property Address: 5 g.L
purer:
Date of Inspection: L( ,A.7` 45'
SEPTIC TANK:
(locate on site N
a'/plan)
Depth below grade: 7
Material of construction: I. concrete metal FRP other(explain)
_PV GeeD 4 '4g&
Dimensions: Aret £. A'
Sludge depth: ei "
Distance from top of sludge to bottom of outlet tee or baffle:,II
UC( }p tap Or 7344A-
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: }u/( 9e Ter et' 79 N 1r
Distance from bottom of scum to bottom of outlet tee or baffle: 54.y r
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid levet in relation to outlet
invert, structural integrity, evidence of leakage, etc.)
µnu sty'h'd to MAX l✓F> o✓e?zP /). YIY/J Jyc4c57z QESvcY FRe'o+ I=•s' i'f 5r i9. 5
infers sr EPFA✓Crner Sbeper/E /n.Vo a l'4t
GREASE TRAP:
(Locate on site plan)
Depth below erade:
baterial of construction: _concrete _metal _FRP 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:
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.)
(rev'_sed 6/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5e ME
Owner:
Date of Inspection: fi . d %' l 5
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ries to at least two permanent references landmarks or benchmarks
locate all wells within 100'
H o
00 64L-• 5. 9.5.
TA Hie
CI CL/ to/9 2
DEPTH TO GROUNDWATER
Depth to groundwater: N TJ feet
method of determination or approximation:�() I I �C b Hr W ci)'/ (t' O1- ryA 'TTT bF
5. 4. I
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C (continued)SYSTEM INFORMATION (continued)
Property Address:
owner:
Date of Inspection: Ci-a 7.R ,
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possi le; excavation not required, but may be approximated by non-intrusive methods)
if not determined to be present, explain: SA ED LP#,kyy Fi.c .5.4. S.
lV T9r/lager' P hJHffN 4�ppy�r�tY 7/fdt
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number_
leaching trenches, amber,length:
leaching fields, number, dimensions: at vat MO
overflow cesspool, number:
Comments; (note conii,tion of soit.,signs of hydraulic failure,
leve of ponding, condition of vegetation etc.) ..7 lkfl,a risro P.c/✓.D t]/ cj .vea7nor TDIJ
f�a»-may .r J 4. L>N »$ re S r ov :t rio Y
CESSPOOLS:
(Locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert
Depth of solids Layer:
Depth of scar. layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pupped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, Level of bonding, condition of vegetation, etc.)
PRIVY:
(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 9/15/95) 7
BOARD OF HEALTH
MEMBERS
JOHN T.JOYCE,Chairman
ANNE BURES,M.D.
CYNTHIA DOURMASHKIN,R.N.
PETER J.McERLAIN,Health Agent
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
nttr
210 MAIN STREET
01060
(413)586-6950 Ext.213
October 12, 1995
Mr.John Herlihy
307 Audubon Rd.
Leeds, MA 01053
RE: Sewage Disposal System Inspection
307 Audubon Rd ,Leeds
Dear Mr. Herlihy:
The Northampton Board of Health is in receipt of a report on the Subsurface Sewage Disposal System Inspection conducted
by Dennis Lacourse at your property, 307 Audubon Rd.,on 9/27/95. That inspection report indicates that your subsurface
sewage disposal system fails to protect the public health and the environment as defined in Section 15.303 of CMR 15.000,
State Environmental Code, Title 5.
Therefore, in accordance with the provisions of 310 CMR 15.000 of the State Environmental Code,Title 5, and under
authority of Massachusetts General Laws, Chapter 2IA, Section 13,you (or the subsequent owner of the property)are
hereby ordered to repair the subsurface sewage disposal system at 307 Audubon Rd., within one year of the date of the
original inspection, (9/27/96). If further degradation of the sewage disposal system occurs(e.g. sewage flowing to the
surface of the ground),you may be required to complete the repairs sooner.
All work to repair/upgrade your subsurface sewage disposal system must be performed by a licensed sewage disposal
system installer, in accordance with the requirements of 310 CMR 15.000,and with plans approved by the Northampton
Board of Health.
Please be advised that you are entitled to a hearing on this order to upgrade your subsurface sewage disposal system,
provided that you file a written petition requesting such a hearing in the Board of health office within seven(7)days of the
receipt of this notice.
Please feel free to contact the Board of Health office,at 586 -6950, ext. 213, if you have any questions concerning this
matter.
Thank you for your anticipated cooperation in this matter.
Vjry truly yours,
Peter J. McErlain
Health Agent
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