521 Septic Inspection 1996 (
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 5a(Alioi40.✓ Rd. LSE DS MA 0/053
Owner. TESS/Ee
Date of Inspection: o &Jpa 96
BI SYSTEM CONDITIONALLY PASSES (continued) /17;t1-
Sewage backup or breakout or high static water level observed in the diatrbution bin 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 pipets) are replaced
_ obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four time,a year due to broken or obstructed pipes). 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: /1UA
Conditions gist 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 15 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 PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
9) OTHER
The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply well
The system has a inept c tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from•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 6 ppm.
(revised 11103195) 3
Commonwealth of Massachusetts
EXecutwe Office of Environmental Affairs
Department of
Environmental Protection
JL; 261585
f i
NORTHAMPTON BOARD OF HEAL),
YAWam F.Weld
Gore. Trudy Cos
Argo rte ul CNluncl David B. Stubs
w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address Sa l A u3v&ou . LEEDS MA, 0/053
Date of Inspection ,uo L.,Y6 Address of Owner
Name of Inspector. WILL rim CuZ ,s (If different)
Company Name.Address and Telephone Number
76i CL Cu Kris /s6 MAC.✓td . C Hes rer F"FCO MA
tom/z
S//3 eizem
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,anoint,
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
y .
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspectors Signature ;,L,La Qaa..w^- W CtvJtf to- Date: 20 No u,96
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is•shared system or has•design Bow 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:
Al SYSTEM PASSES:
I have not found any information which indicates that the system violate. any of the failure criteria as defined in 910 CUR 15303.
Any failure criteria not evaluated an 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 yr, 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 infiltration or tank failure is
imminent. The system will pass inspection if the existing septic tank u replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street • Boston,Massachusetts 02106 • FAX(617)556-1049 • Telephone(617)292.5500
( Peened on Rayed P.ae,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addrvc Sdf RoD✓ / Kci Le cos MP 0/053
Owner. ERvry Tess/E/Z
Date of Inspection Zo rJ o ✓, /6
Check if the folic viog have been done:
rL Pumping information was requested of the owner,occupant, and 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
Ir during that period. Large volumes of water have not been introduced into the system recently or as par[of this inspection.
/V1 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+anitary or industrial waste flow
1/The site was inspected for signs of breakout.
�[AB system component+, excluding the Soil Absorption System, have been located on the site.
V 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 existing information or
UPozimataLby non-intrusive methods.
J /The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Bub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
L,SEPS MN 0/053
Property Addreee:$11 AupoBoN ficl
Owner. ER v/41 -racy/EL
Date of Iaspeotiom ZO Ndv 46
Dl SYSTEM FAILS: Nip
I have determined that the system violates one or more of the following failure criteria as defined in 910 ChM 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 es
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 lass than 1E2 day flow.
Required pumping more than 0 times in the last year NOT due to clogged or obstructed pipe(s).
Number of tunes 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 s 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•cesspool or privy is less than 100 feet but greater than 60 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
toliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS: N/A
The following criteria apply to large systems in addition to the criteria above:
The system serves•facility with•design flow of 10,000 gpd or pester(Large System)and the system is•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•surface drinking water supply
the system is within 200 feet of•tributary to•surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of•public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the poundwater treatment program
requirements of 914 CMR 500 and 6.00. Please consult the local regional office of the Department for Pother information.
(revised 11/03/95) 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addresc 5 IH AVOVSON Ed. LEEIDS /AA 0/oS3
Owner. ER VtN 'TESSIER
Date of Inspection 20 ND c'.76
SEPTIC TANK.
(locate on mite plan)
Net 4 Res 6-4. oF.a-4'• I iL.e`T 1-oUTCEr ALSe
D. below 2 /j A3
Material of stmion: Zooncrete_metal_FRP_otherterplain) -
HA vc- ,E(SEE S
D' fDa' L- 56'L✓-
Sludge depth: u„
Distance from top of sludge to bottom of outlet tee or baffle.]/.,e
Scum thickness: 2—
Distance from top of scum to top of outlet tee or baffle.
Distance f r o m bottom of scum to bottom of outlet tee or bane: ? PArr. e B P o k k.9 54:PC E pL At /J w, TN A N=w D,uC
Comments:
(recommendation for pumping, condition of Wet and outlet ten or baffles, depth of liquid level in relation to outlet invert,et integrity,
evidence of leakage, etc.) ZECcaeLs./ PV mot N f. EVEgY 2 YEAPS — 2EPLACED 6t'TLLT 7AfCLt JLL Jt)
TA! LET RAFFLS /N Goo D CoNOrr. „n( M Sin panic& of LGAICA&.& OR DECAY
GREASE TRAP:_1/A
(buts on site plan)
Depth below grade:_
Material of construction: _concrete_metal_FRP_otherezplain)
Dimensions:
Scum thickets:_
Distance from top of scum to top of outlet tee or battle._
Distance from bottom of scum to bottom of outlet tee or bane:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
widen of leakage etc.)
(revised 11/03/95)
(
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
LC-gv3 MA o/o$3
Property Addasc 5.)_/ AuD u5oni Rd
Owner. Exv/N ESS/r.e
Data of Inspection: 2_-0 NOV.%
FLOW CONDITIONS
RESIDENTIAL
Design Sow: 22p callow
Number of bedrooms: 2
Number of current residents: 3
Garbage grinder(yes or no):02a
Laundry connected to system(yes or no):S'S
Seasonal um bees or no):fl
Water muter reading, if available: l'�/2 i VAT C WELL
Last data of aropanry. Cy
COMMERCIAL/INDUSTRIAL: N/A
Type of establishment:
Design llow:_gallonsiday
Grove tray present: (yes or no)_
Industrial Waste Holding Tank present:(yes or no)___
Nonauitary west.discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Lan date of occupancy:
OTHER(Describe)
Lest date of occupancy.
GENERAL INFORMATION
PUMPING RECORDS and source of information:
u /A Punapo incr. 4co + No 9G
System pumped as part of inspection: (yes or nolyGS
If yea,volume pumped: /Ana gallons
Season for pumping I21Im9FEK OF 1F2orPEKar.�
TYPE OF SYSTEM
1/ Septic tank/distribution ba/soil absorption system
Single carpool
_ OverOow cesspool
Privy
_Shared system(yes or no) (if yr, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of W components,date installed(if known)and source of information: '_'N'Fn
39-YFAes
Sewage odors detected when arriving at the site: (yes or no)410
(revised 11/03/95) 6
>• eni P.CA 4QTDR
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addrss:SZt Auo„ Avi Rd LEEDS M4 o/oS3
Owner. ERv. N TESS iE2
Date of Inspection: 7c A)c✓r6
SOIL ABSORPTION SYSTEM (SAS): V/
Goat.on sit.plan, U pomDle;a=ration not but may be
required, 9 approximated by non-intrusive methods)
If not determined to be present, explain:
4 PCA 4oskFD rr Rr t,( - O 7"r/ ncg ✓CL 63A.mt,eurv)
WAS NGD Sr vG A,J2 yfRF 'ft ORA.v Cr OL,g PrPE
Type:
leaching pits, number_
leaching chambers, number:_
leaching galleries, number:
leaching Wenches, vumber,leng[h: AT LZA T%� APPecK,13(1-onra
leaching fields, number,dimensions: co�ip Sc 4 LEAC.v/NF ac,
overflow cesspool number:_
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
A10 5,rNS OF NYORAuGC FA QE— No LEVEL ef'7o.D//VG VEG,TAi.e v No RMat LAwt ( 4s-
ArvD Log TR,As
CESSPOOLS: /WA
(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(omapool must be pumped as part of inspection)
Comment,: (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.)
PRIVY:_ ///A
(lost,on site plan)
Materiels of construction: Damns:
Depth of solids:_
Comma,,: (note condition of coil,signs of hydraulic failure, level of pending, condition of vegetation, etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
&EEBS /114 O/053
Property Address:5.2/ A„O„a,N d
O.wr. E R v ,Q TESS/CC
Date of Inspection: 20/:0 v,96
TIGHT OR BOLDING TANK: NIA
(bate on site plan)
Depth below grade._
Material of mvrrncion:_comets metal FRP_other(explain)
Dimension:
Capacity: aafoat
Design Dow. plloa/day
Alarm level.
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX: l/
(bate on site plan)
Depth of liquid level above outlet invert: O"
Comment,.
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
2- 3ok WAS LE✓SA-- COVI<'K Pfnc.7n- No Even .vCS ar&e4k4G.E
L,avi ) 12✓r/ -FfluA/ gr130TH OUrLETPIPES
PUMP CRAMBEIt WA-
Goate on site plan)
Pumps in working otden(yes or no)_
Comments:
(note condition of pump chamber,condition of pump and appurtenances etc.)
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addrear dal Aso b BO" =L. LEEDS MA.
Owner. EZviiv rESSiCR.
Date of Inspection: 2-0ti•cv r6
A o .go4} /t0,40
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include tis to at Last two permanent referenced landmarks or benchmarks
Lute all well. within 100'LJATC e W ELL U n.DER CRou r Sr-?
� N
D c
0 V
D b
G p
L r�W
'J
Conk Kurt Se Pr C.
T4Nk /oro G4L,4ppey_
W'TN (2.:Sc25
N
Sy
Ca.% DRA,r
A-LL MC45.,2P MCn.rr 4E< APAAAx irnor<
4'o SC Le-
DEPTH TO GROUNDWATER
Depth to groundwater. t '(nil feet
method of determination or approximation: cou .vO AT/Do} DKA N5 - $4c/cype ckta.r,av
5'414LL POND I S2K r G. r a) A P1 424cnf4 re 3cc' F SAS
(revised 11/03/95) 9