Loading...
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 QWeb( Kj 1001 -lc Ek ' EX //8ir 4 Tcf7za /ed - 7/77/95 /s Bdi/f P/kn ELECTRIC BOX Dis-Pribot/®n &X- And Ow/70,7 C TANK Xm9/,mor%renchcs 39 ' 470a 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 Certified Mail 14 P 076 177 875 Vii _;rr Lor r;:, 15,4':' 1U/ : all DUM 4 UNITED STATES POSTAL SERVICE I II Official Business PEN LTV FOR PRIVATE S TO AVOID PAYMENT OF POSTAGE,$300 •Print your name, address and ZIP Code here • _ yard of Health City Hall = 10 Main Street ?:arthampton, MA 01060 III „;,I!II:: IL.Ii:..„II,::,ihELM In;IIII1; L li • SENDER: q • Complete items 1 and/or 2 for additional services. ▪ • Complete hems 3,and 4a 8 b. P • Print your name and address on the reverse of this form so that we can • return this card to you. • Attach this form to the front of the mailpiece.or on the back if space - does not permit. y • Write"Return Receipt Requested"on the mailpiece below the article • The Return Receipt will show to whom the article was delivered e D.delivered. - 3. Article Addressed to: I. 8 I also wish to receive the following services (for an extra fee): 1. 0 Addressee's Address number. 2. 0 Restricted Delivery me set. Consult •ostmester for fee. 4e. Art cle Number P 076-177-875 W tc 5. Sign Lure ddresseel 6. Sig eture (Agent) PS Form John Herlihy 307 Audubon Road Leeds, MA 01053 4b. Service Type • O N o 6 E. cc 0 Registered 0 Insured IA bCertified 0 COD • S 0 Express Mail 0 Return Receipt for Mar handise `o -.. . Date of Delivery / /D /3 1s 8. Addressee's Address(Only.if requested C and fee is paid) s r 1, December 1991 u.e.OPO:1093-359-714 DOMESTIC RETURN RECEIPT ace vn nsr N nI nc m cns n Ins, unss hnsrnuc, 'nl HII HiMPII I :Rf. sFLl. NY tilIEL7Ifr1'r,IjNFl SFXVICFS lave Imv!. e.. .u . II y ,I P.. ,a II F m 1 Wn ryo NT — 1 flbk STEU .r 1� : r i IiE[URN HR I[PT O I O l.e { 1. O �m P 076 177 875 z _ Receipt for Certified Mail D ��• No Insurance Coverage Provided Do not use for International Mail m (See Reverse) 307 Audubon Road rLeeds, MA 01053