33 Septic Inspection 2015 Owner
Information is
required for every
page.
Important Wien
filling out forms
on the computer.
use only the tab
key to move your
-do not
cursor e return
key.
t5ms•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Properly Address
Tim and Mary Ellen Dachas
Owners Name
Florence MA 01062 04.16.2015
City/Town Stale Zip Code pate of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
A. General Information
Inspector:
Alan Weiss
Name of Inspector
Cold Spring Environmental Consultants,Inc
Company Name
350 Old Enfield Road
Company Address
Belchertown
ciry/Twn
413--323-5957
MA 01007
State Zip Cede
RS 933
Telephone Number
License Number
B. Certification
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 ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspectors Signature
4/16/2015
Dale
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer,if applicable,and the approving authority.
—"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.
al
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and Mary Ellen Dachos
Owner timers Name
information is Florence MA 01062 04.16.2015
page
required Ci Ram Stale Zip Code Date of Inspection
Page. N P
B. Certification (cont.)
Inspection Summary:Check A,B,C,D or E/always complete all of Section 0
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System at single family dwelling was inspected,Staining and Level in tank was good.Two persons
had been using for last several years. A three line Leach trench System was installed about 23+/-
years ago.The Distribution box and 12 feet of the upper line trench was bound up with root growth.
The roots were cleared and pipe replaced and no failure conditions found.The 1500 gallon septic
tank should be cleaned 8 pumped every two years The alarm(was repaired).The system now
passes,reviewed with Health Department inspector.
B) System Conditionally Passes:
i] 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.
Check the box for"yes","no°or not determined(Y,N,ND)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 exfltration 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.
❑ Y ❑ N ❑ ND(Explain below):
Tilt 5(Mod I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and Mary Ellen Dachos
Owner Owners Name
information rs Florence
required for evew
page Citvnam
MA 01062 04.16.2015
State Zip Code Date of Inspection
B. Certification (Pont.)
❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ V ❑ N ❑ ND(Explain below)
❑ distribution box is leveled or replaced ❑ V ❑ N ❑ ND(Explain below):
❑ 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 Healthy.
❑ broken pipe(s)are replaced
❑ obstruction is removed
❑ V ❑ N ❑ ND(Explain below):
❑ V ❑ N ❑ ND(Explain below)'.
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
-ripe s pnaa InspecOon Fo,m.subsurface Sewage£spoaa Syn..•Pace 3 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and Mary Ellen Dachos
Owner Owners Name
information is Florence MA 01062 04.16.2015
qurred for every
page City/Town State Zip Code Date of Inspection
B. Certification (coot.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 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 fecal
coliform bacteria indicates absent 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate"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 clogged SAS or cesspool
• Liquid depth in cesspool is less than 6"below invert or available volume is less
than%day flow
.me s official Inspecton rmm.Subsurface Sewage Disposal sum.Pape 4 or 17
cV Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and Mary Ellen Dachos
Owner Owners Name
atonmation is
required fc every Florence
page- City/Town
MA 01062 04.16 2015
State Zip Cede Dale of Inspection
B. Certification (cant.)
Yes No
❑ Z 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 SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Z Any portion of a cesspool or privy is within a Zone 1 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,performed at a DEP certified
laboratory,for fecal conform bacteria indicates absent 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
and chain of custody must be attached to this form]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
crfteria exist as described 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.
For large systems,you must indicate either"yes"or no to each of the following,in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered'yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
property Address
Tim and Mary Ellen Dachos
Owner owners Name
information
for every is
aw MA 01062 04.16.2015
r ry Florence Slate Zip Code Date of inspection
Page. Ciryrtown
C. Checklist
Check if the following have been done.You must indicate"yes"or no as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as pan 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 SAS, 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 as on
Existing information.For example,a plan at the Board of Health.
Determined in the field Of any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): d Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
700+
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and Mary Ellen Dachos
owners Name
Florence MA 01062 04.162015
Clty(cwn state Zip Code Date of Inspection
D. System Information
Description:
1500 gallon,Septic Tank,pump(1000 gallon chamber),new D box and three(70't)line leaching
trenches
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system?(Include laundry system inspe
information in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings,if available(last 2 years usage(gpd)):
Detail:
2
❑ Yes Z No
on ❑ Yes Z No
❑ yes ❑ No
❑ Yes Z No
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sq.ft.,etc.).
Grease trap present?
Industrial waste holding tank present?
Non-sanitary waste discharged to the Title 5 system?
Water meter readings,if available:
Gallons per day(gpd)
Z Yes ❑ No
current
Date
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Thle 5 mroe Inspectors Form Subsurface sewage o-w=a swarm. a.ae t e
Owner
information is
require for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and May Ellen Dachos
wmers Name
Florence MA 01062 04.16.2015
city/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use.
Other(describe below):
current
Date
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes,volume pumped:
How was quantity pumped determined?
Reason for pumping'.
Type of System:
® Septic tank,distribution box,soil absorption system
❑ Single cesspool
owner
® Yes ❑ No
2000+1-(tank and chamber)
gallons
measured
Inspection and need.
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes,attach previous inspection records,if any)
® Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and Mary Ellen Dachas
Owners Name
Florence MA 01062 04.16.2015
City/Town Stare Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components,date installed Of known)and source of information
23+/-yrs
Were sewage odors detected when arriving at the site?
Building Sewer(locate on site plan).
Depth below grade:
Material of construction'.
❑cast iron
®40 PVC ❑other(explain)
Distance from private water supply well or suction line:
10'+
feel
Comments(on condition of joints,venting,evidence of leakage,etc.):
good condition
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
Z concrete
❑metal ❑fiberglass
❑ Yes E No
reel
❑polyethylene ❑other(explain)
1500 gallon tank has baffles/tees in place,no high staining concrete competent.
If tank is metal,list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
105'x54.5'x 42'
Dimensions:
Sludge depth:
pe PwCOY Page Ool
Owner
mromtationa
required for every
page
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and Mary Ellen Oachos
Owners Name
Florence MA 01062 04.16.2015
City/Town State Zip Code Date of inspection
D. System Information (cant.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
good levels and staining,no corrosion.
8"
meal.
Grease Trap(locate on site plan)'
Depth below grade'
Material of construction.
❑concrete ❑metal
feet
❑fiberglass ❑polyethylene ❑other(explain).
Dimensions.
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Properly Address
Tim and Mary Ellen Dachos
Owner Owners Name
information is Florence MA 01062 04.162015
required for every - -
page. city/Town Stare Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on sae plan).
Depth below grade.
Material of construction:
❑concrete ❑metal
Dimensions.
Capacity:
Design Flow:
Alarm present
Alarm level:
❑fiberglass ❑polyethylene ❑other(explain):
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
Date of last pumping: pate
Comments(condition of alarm and float switches,etc.):
*Mach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Sums vu Tme 5 gfieinsp.ubm Furs Subsurface Seseue Dissusul SNsm'see=I I Of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and Mary Ellen Dachos
Owner owners Name
information required rO 5 Florence MA _ 01062 04162015
page.etl rw rvery City/Town State Zip Code Date or Inspection
D. System Information (cont.)
Distribution Box Of present must be opened)(locate on site plan):
@ inv.
Depth of liquid level above outlet invert
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.):
Ater removing soil and roots, Levels and staining good,No staining liquid nor high staining observed
above invert.No ponding noted. Box at 3"below grade(additional cover soil recommeneded)(Box
was replaced due to cracking and roots,lines were clear and stone was clean upon completion.
Pump Chamber(locate on site plan):
Pumps in working order.
Alarms in working order:
® Yes ❑ No
® Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Pump cycled and working,Alarm switch neeed replacement and was completed.
If pumps or alarms are not in working order,system is a conditional pass.
Soil Absorption System(SAS)(locate on sae plan,excavation not required).
If SAS not located,explain why:
Title 5 Ofloal Far
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and Mary Ellen Dachos
Owner owners Name
Information is Florence
required for every
MA 01062 04.162015
Page. City/Town State Zip tole Date of Inspection
D. System Information (cant.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number,length_
❑ leaching fields number,dimensions
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of
vegetation,etc.):
No signs of ponding,nor high staining or wetness indicative of failure noted once roots were removed
and reinspected with City Health Inspector.
3'.70'x2'Wx1.5'H
Cesspools(cesspool must be pumped as part of inspection)(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 ❑ Yes ❑ No
Trim.5 onciai haven=Fa.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and Mary Ellen Dachas
Owner Owners Name
informationia Florence MA 01062 04.162015
repmred tor even
page cnyrtown state zip code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil,signs of hydraulic failure,level of pending,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.):
Title eman In s.�., sa„ae•Disposal msm•Pepe 14 m„
Commonwealth of Massachusetts
• Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property assess
Tim and May Ellen Dachos
Owner Owes Nine
information Ls Florence
required Mevery cMrtw.n
MA 01082 04.162015
State Zip code Date of Inspection
D. System Information (cont,)
Sketch Of Sewage Disposal System.Provide a view of the sewage drsposal 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.Check one of the boxes below.
❑ hand-sketch in the area below
(Si drawing attached separately
a 5 cea i.w.em.erm staken s..we awe.. rm 1:a 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and Mary Ellen Dachos
Owner Owner's Nane
reromiadf for very Florence MA 01062 04.16.2015
Page. for r e Ciry?ovm State Zip code Date of Inspection
D. System Information (cant.)
Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water:
4•+
feet
Please indicate all methods used to determine the high ground water elevation
® Obtained from system design plans on record
If checked,date of design plan reviewed.
attached.
Dare
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
O Checked with local Board of Health-explain:
record attached, 1992
❑ Checked with local excavators,installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
From records from BOH attached
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
Owner
information is Florence
required for every Flor n
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Birch Lane
Property Address
Tim and Mary Ellen nachos
owners Name
MA 01062 04.16 2015
State np Cede Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A,B,C, D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
9Y 5 09as imce000v Form.Subsurface Sewage Disposal System•Pape 17 of 17
Prior to root removal
33 Birch Lane
Florence, MA
04,152015
Roots in leach pipe
33 Birch Lane
Florence, MA
04.15.2015
Upper Trench after Roots Cleared
33 Birch Lane
Florence, MA
04.16.2015
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form IA
Number
$
Fee
DEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form,check with your local Board of Health to make sure that they will accept it.
A. Facility Information
Important When
filling out forms Application is hereby made for a permit to:❑Construct a new on-site sewage disposal system
on the computer. ❑Repair or replace an existing on-site sewage disposal system
use only the tab ®Repair or replace an evsting system component
key to move your
cursor do not
use the return 1. Location of Facility:
key
33 Birch Lane
--JUj— Address or Lot It
Florence(Northamptor6 MA 01062
Cityfoan State Zip Code
JAM
2. Owner Information
Tim and Mary Ellen Dachos
Name
Address(l different from above)
chyrrown
State Zip Code
413-330-8620
Telephone Number
3. Installer Information
Mike Meadows Karls Site Work
Name Name of Company
River Drive
Address
Hadley MA 01035
City/Town State Zip Code
549-5396
Telephone Number
4. Designer Information
Alan Weiss Cold Spring Environmental Consultants Inc.
Name Name of Company
350 Old Enfield Road
Address
Belchertown MA
Cby?own State
413-323-5957
01007
Zip code
Telephone Number
t51wmta doc•06103 Application for Disposal System Construction Permit•Page I of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
Number
$
Fee
A. Facility Information (continued)
5. Type of Building.
® Dwelling ❑ Garbage Grinder(check if present)
Other:Type of Building 4 Bedroom Single Family
Number of Persons Serves
❑ Showers Numberushowers ❑ Cafeteria ❑ Other fixtures
Specify other fixtures:
6 Design Flow:
Calculated Daily Flow:
7. Plan:
01
440+.
Gallons per Day
700+(1992)
Gallons
Date of Original
Number of Sheets Revision Dale
Part of Title 5,D box replacement and section of leach trench pipe with roots.
Title of Plan
8. Description of Soil:
Fine sand
Nature of Repairs or Alterations Of applicable):
D box replacement and section of leach trench pipe with roots.
10. Date last inspected.
Date
t5fom,I odor 05103 Application for Disposal System Construction Petmil Page 2 Of
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
Number
$
Fee
B. 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.
Signature Date
Application Approved By:
Name Date
Application Disapproved for the following reasons:
t5tomlla dom D6103
Application for Disposal System Construction Permit•Page 3 of
Original Plan
33 Birch Lane
Florence, MA
04,17 2015
A g
1111114411114
1
p
.. pO
Z° w C1
al
. .. • s vip li o
.,
g Sn n
.,AA 'flity n - a sski
■
TisTPN�y�ysx5
te a e"..p
r 1'r.WA:nu al s,∎IHl
.
"AZ: •
r.
a
t'flr%14 JP
*r'
ass
u .m,...w.ar.
.1 "Qi4 .>4av
7wv7
Ouginal permit
33 Birch Lane
Florence, MA
04.17.2015