80 Septic Inspection 2001 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL SYSTEM
PART A
CERTIFICATION
g?
/2/. 1-1-d"WV /b1'f
Property Address: 4 Or//j6,726'lnu, /t{455
Owner's Name:
Owner's Address:
Date of Inspection:
Name of Inspector:
Campany Name:
Mailing Address:
Li/L'/J7✓ ,5//E/7
/.R-7 l vs"».v .2Y!°2 c A,CJC
/Yi74 //FO/l /) /iy.v t/,
/17!72/7� d % HOC r/-
. (please print) L(%/�L//Jn? ✓/f./7c/7/) tE
Lt"/tLr��7 �S/f/1c/7,J fr/vj72 'w27/C/�
,•N•
E @ T
APR 2 2001
ssEsisistreNPARD OF HEALTH
Telephone Number
L9.
f vnh4 . P4-7/9 53
yi 33 5-a5 "
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. 1 am• DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
)( Passes
Conditionally Pa
_ Ne:• Further E 'I .lion • the Local App
F
Inspector's Signature:
Date:
The system inspector shall submit a copy of this inspection report to the Approving Authori ealth or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 1%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 he sent to the system owner and copies sent In the buyer. if applicable,and the approving
authority.
Notes and Comments
*0"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.
Tide 5 Inspection Farm 6115/2000 page I
Page 2'of 11
•
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Fe) Dvv.0.9y On/SASS
Property Address:
Owner: .4/4/O,1 tS 454
Date of Inspection: 3,'.Q7/O /
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 criteria described in 310 CMR
15.303 or in 310 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.7 he 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,ND) in the for the following statements.1f"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.
sA 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 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 pipes)are replaced
_ obstruction Is removed
distribution box Is lkveled a emplaced
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:
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Sir DU,VPNY z .P/6'E
Property Address: 1./0/7014.92 /V 4.1 .t-/.O
Owner: LJA/.0/9 J//E/%
Date of Inspection: , $/%9/0/
C. Further Evaluation is Required by the Board of Health: ,pit/a
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.
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,safely and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of bordering vegetated wetland or a salt marsh
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 I 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:
3
• Page 4 of 11
OFFICIAL INSPECTION FORM-NOT POR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(stained)
Bo 0004 1W 0/2/I/F
Property Address:214O2LiWA mA Ti1(/ /L/A
owner: 4/N.4A S/7,6:4
3/ fJ/p i
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for pJl inspections
Yes No
V 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 inven due to an overloaded or clogged SAS or
cesspool
V' Liquid depth in cesspool is less than 6"below invert or available volume is less than'A day fow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
Hof times pumped
V fsny 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.
Any portion of a cesspool or privy is within a Zone I of a public well.
6/2/9 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
A444 i/4 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private wale:
Y'� supply well with no acceptable water quality analysis. iThis system passes tfthe well water analysis,
performed 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 M INS form)
/pG (Yes/No)The system fag. I have determined that one or more of the above failure criteria 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: 4
To be considered•large system the system must serve a facility with a design Row of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to eachuf the following:
(The following criteria apply to large systems in addition to the coterie 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 11 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 shell upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 10 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: tfo Aao/(I�,/o' /)&aif
, et14
3/.99/0
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including lies to a(least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
°ice !J 11 7(i t /L/P(!
,9vvv/s'y De/44_0
10
IG'PUMPING
Road
103096
CUSTOMERS ORDER NO PHONE CAT
I�,?o3t83 oggy I S�FfjT/ti -00
NAME
go 11 oMi I.dy/ DR
SOLO By VCASH C.O.D.
OTY.
II
CHARGE OH ACCT. MDSE.REED.
DESCRIPTION
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PAID OUT
PRICE
AMOUNT
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AS
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C. �I
.C.SISINSE
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7,my
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TERMS: 15 DAYS
INVOICE NUMBER
RECEIVED ev
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NET.PLEASE SEND
WITH PAYMENT.
TAX
TOTALr
- I
I
I
X10
24
All claims and returned 9oodsMUST be accompWed bymis 011E
THANK YOU
8a Dv/1/4.00// d2/Pc,
9
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3=
0-191
or- 13 (a
.(r nil
■
No.
FORM It - SOIL EVALUAtOJL.
Nage'1
Commonwealth of Massachusetts
, Massachusetts. , ,11 a
Soil Suitability ssessment for On-site sewage
j.,14cti Atm t T!J EViat Date: . T/fu
MI
Performed By:
Witnessed By:
ec: MaYc, /e7r/a d n .5C//
L ew
/yo r/1 o.n,yani
Construction ❑ Repair
Office Review
' Published Soil Survey Available: No ❑ Yes Q�
nn
YBer$ilbllihed Publication Scale
Drainage Class - -- -- . Soil Limitations
Sutficlal Geologic Report Available: No ❑ Yes Cr--
Year Published Publication Scale
Geologic Material (Map Unit) - -------
Landform .. ....._.._........_.__.
Flood Insurance Rate Map:
Above 500 year flood boundary No ❑Yes
Within 500 year flood boundary No QC-es ❑
Within 100 year flood boundary No tiCes ❑
Wetland Area:
tlatiohal Wetland Inventory,Map (map unit)
Watl'edda Conservancy Program Map (map unit)
Current Water Resource Conditions (USGS): Month
Range :Above Normal • BC! ❑Bel(ry Nomlai ❑
Other References Reviewed:
G/•vb/'} s//tart epo...,..M o, •`er a
5'a L
Soil Map Unit
/ 0/' 7 /✓2/C
7 y/
DIP APPROVED/OM'-11101191
Plja-
Ii •
it St wall Printed September 19,
1993
On-site Revisly
'ROW Hal. Number 1.. O.ul T//y/77
.del Ild� enyt�lly en elle paint ... ._. .- - .. .
i /enr,.#7..'6n /. Slop. 1%I
ilfenution /...4141.4.91
E[ term. 04'rw075.41 adf G.
1Im•I
you
Surl.o• Slaw.
RN W
in en landscape '.ketch an the b.ek)
p � . troll,' �t /�
oven W..:: Petty Sf1 " 1..1
Peulble Wet Ate. ,pivrl lea
Drinking.Wewr Well p/t/y lea
,44 c /Ito
W..th.r
unliYf► tl
Appends d Pap 2
Go GO
ffolrte
f/fa GG
Co 4i..1-6Y
Uldnee.w.v -4G�I I.•1
Property One 7t:/ two
Other -
N llefi S.dn.
Unshorn
DEEP OBSERVATION HOLE LOG
Sell Henson
ct
IN Tenure
IuOOAI
s/Leh
54,2c/
�fnrn}7J
ci
.7c /14 re:/
eel CNa
IM.n.Ml
J -3
0 roe
41—'-
io y.e.
G -3
e.11 Maelnl
OIMm
lsewlne.Ira Pelee.IR
Ce.eelrenll.i Pre..e
y
Muriel IBeoloplol �r « tt' ' /,� w.t G1 Depth to Bedroolu a 1
~ / /G t‘i Sanding Wnu In hHole N'""` Woepinp from Plt Roe A/enc 1 1• ' Iv
/rjowT � �d Minuted Sotonel Hlph Claund Weer. /30 "
Percolation Teal
O at No. /2/YC C.l'S/ Tool nn .
ending / Time 7 Il ondlnll Time
Son ( 17 min ) c- Gl !:nl nrnIlun ( 15 mill)
, : rte,
r se a
,Pr-si7 ii, ; (:
x. el Hi et1nch
e re Pete ,'
round Oleo .
sptll of Ilule
•
I'c ry llnle
III oiled ftlev .
III.I11h ill Ilo II•
fJ,—� Deep _Teel PIL/ e �
set Pit % - 'Paid-Olt / e
th Boil-Descrl 11011
e evi /T / Depth Doll Description
'uo r/ ciCY /
/iv S4-'7C% li �Tr� r L'.1".
/
0llc/ Suij
Min/inch
✓oundrater ' De.pth5,j// Plev . t rouudhlnter Depth Slay .
udroak Depth lev . Iledrock Depth 11ev.
(round Elev . n iy/L //IV. Ground Elev .
I.C.B .
Sell Description "-yw.,/J 8eneuun1 High Water Table?
leach Mark: Slay . ,SicC - Ileecri.pllun ,Or✓
off /G� O� .
l�
k
try-7 rrr//re /9
s
Dote :
Client '
/.9C
4War 4r
a L� ia / ..V Al
Engineer :
Ultuaeel p
1.ucut1on of Pere :
cfO
N'
/lldaffits
CF
Lila le
el
JOHN
SIENUIJ "-j
ttVn u
tv
e.
6/
Is
I..
No.
FORM 11 - SOIL EVALtJAtp BQ
Date:
Commonwealth of Massachusetts
, Massachusetts. ,
Soil Suitability Assessment for On-site Sewage., isw$41
Performed By:
Witnessed By:
Lei
Gei/I00,7 /all tat E/aC Date: .Y;
S ri
Ittipy
UIC'04 S 'VS,9
err ao4./oe 0c
/yo r AaMP iati '7
ew Construction ❑ Repair Ltd
office Role*
Published Soli Survey Available: No ❑ Yes
orpo
YEer Pilbl)Ched Publication Scale
Drainage Clas9 _.. Soil Limitations
Steclal Geologic Report Available, No ❑ Yes
Publication Scale
A,b.,...M
L.n.df S/)rent
!'O !'td ua_u,
N.0/2.7.090.120 Dioer
Year Published
Geologic Material (Map Unit)
Landfonn
Flood Insurance Rate Map:
Above 500 year flood boundary No ❑Yes
Within 500 year flood boundary No Erires ❑
Within 100 year flood boundary No LJYes ❑
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program M 5p (map unit)
Current Water Resource Conditions (USGS): Month
Range :Above Normal onus l ❑Belt,v Normal ❑
Other References Reviewed:
70/f y //4//C
7 y/
S./ L
DEP APPROVED POR e -11/91195
Soil Map Unit
.. 0n. •.9 n1
f 5: Art{A Printed September SU, 1993
OOn-si[e Review
e00 H•1• Number/73 O°•' WPY/71 lamp! 9' 60
epbdan .. n alto pier Slope 1%1 /0 Surf ace Stooge
PS Una
a
' .Iaon
ont(vih. ovrwi93N s*sr oofc./
War..
en 1•nd"io•we Wiesen on the b•ckl
avenues tenon
Owen W1:: aodv "p at••■
Peedbl• Wet Am 0414 r•et r,orwrly Lin• 41,0 i.e I
Ur shine w•Y 3G In'
.1 D.Inwr.o.W1•r Wex p�VN Ie.'
a:
4:
Odr•r
W t ether
Appendix 4 Pan
,f�nr�y
Co G.0
SsOone �I7� t C/
f%r%a CJ
ca62.Z.f
44J, /its/
DEEP OBSERVATION HOLE LOG
1A Henan
$0 Flans
MOM
etc con
IMYr•.ei
well MMWIne
OMne
IMMOe,SWIM,11114011 11,
,
r
fna P7
r/ L/
,to /Ll %/
W MnOdd 19eo1o01c1
6117—Ji sL/!PH �,nAer. Depth to Bedrocks
O4/17
3iSilangralt,/a-/ Blending Naar In the Holes from Plt Rron AftK�
`'
1
J$h'tuT d' ENimeud Simons; Mph Glcund Wear: ogokrod /3U
•
5: rgrt Printed September IU, 1993
011-SUE Review
ue Hole Number . . Don'
wagon (Identify en she plan!
Nld Use Sloop PAI .__. Surloco Stones
oration
lndfonn.
{1"
oolden on bndienioo Watch on the boekl
Irarlees /rows,'
Oven •trrr Body ... eel
blo Won Anse ...
DrInking.WOlir WHI
1 liner WOlhrt
Int
lot
Urdnoguw•Y
NOWAY Urns
Other
for
I •t
DEEP OBSERVATION HOLE LOG
tit t;
•
Appendix 4 Parr J
t Mnerbl (prglorlol
Depth w Bodreekl
� Wuepin from Pit+t re Orbundwenr. Blending 'Netrr In the Holy e
Estlmrtrd Senond High Ground Wean
■
FORM 12 - PERCOLATION TEST
Location Address or Lot No.
/I/d/z/v//J 7O Gc/ /9
COMMONWEALTH OF MASSACHUSETTS
Go
, Massachusetts
Percolation Test'
Date: ._ T/ /i/' 7 Time:, 7 3O
Observation Hole N
Depth of Pero
�J-
Start Pre-soak
9, ' ZJ % 3�
v/I /C
E nd Pre-soak
9.93
1
Time st 12"
ej, '33
1 Vi
l'i
Time et 9"
9 38
q
Time et 9"
7V3
'/f
01j
Time 19"-8")
y $/3 ,g-, /g
• Rate Min./Inch .
/Ze'S '1n /foie
Li • 0
"s 't j'9A'e27/ /Led j,'#cni.e cC::
• Minimum of 1 p ooletion test must be performed In both the priniery afil AI D'
reserve area.
'Site Posed It"re 81te Felled El
performed By: 7,%/e-c i nr.'I (1,7/r 0,7/ ,a/
' Witnsoed By: ' /2, /74- 4Cgz , i/?J 641)// .
Comments: ._....._..,.. .. . ... .
eV AReoSW FORM•11111111
•
•
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No. fO .DUti/c/f y Vv//'o-P
,Uo//%&n7/o127:4-, A1A1*...s
Determination for Seasonal High Water Table
Method Used:
A/C
.t 4
El
observed standing in observation hole inches
❑ Depth weeping fro() side of observation hole inches /
❑ Depth to soil mottles inches £'O cr7O////f /7G 1'6/
❑ Ground water adjustment feet
Index Well Number
Reading Date Index well level
Adjustment factor Adjusted ground water level
Depth of Naturally Occurring Envious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system?
If not, what is the.depth of naturally occurring pervious material? !.-ems
Certification
I certify that on VC— (date) I have passed the so 1.evaluator examination
approved by the D artruent of Environmental Protection and that the above analysis
was performed by me cc insistent with the requi ed raining, expertise and experience
described in 310 CMR ', 6.017.
Signature
DEP APPROVED FORM-I t/07I95
_ _..... FO at t2 Ficocwn
COMMONWEAL:M OF j ASSACarreti S . ..
,Massachusetts
'� i .. — '
Start
— — EM Re-soak
lime at it
Time.re-
Time,t
r,n.19•-6-6
.1
111111/1111111111.11111111111 _S
reaarve are,, nety«nr6ti 'prNUty w�ANO. . -.,• '_. .
9b Faasad
- Sta FaFW ❑
_... Mormetl ity _.. ..{
Witnessed 61'
comments:
.o.nm.mat.n.n,.,,n
---_ _--
Location Address or Lot# �d TJI ��
�-^^^-�—" �'N`""'
Deep Hole Number Date
H l l
1�j
I Time I I t 3 0 I Weather l
Location(identify on site plan)
Land Use
I SBDe(%) I Surface Stones
Vegetation
Landform
Position on Landscape(sketch on the back)
Distances from:
Open Water Body
feet
Drinking Water Well
feel
Property Line
feel
Possible Wet Area
feet
Drainage Way
feet
Other
feet
Deep Hole#:
DEEP OBSERVATION HOLE LOG*
'YW WUY Of TWO HOLES REWIRED AT EVERY PROPOSED DISPOSAL AREA
Depth kw
Surface(Inches)
Sol Horizon
Ay
L.Ii) -
O
',J
Sol Tease
(USDA)
sa coke
(Memel)
Sal
boll e
I
Other
(swathe.Stags.Bmtdms,Consistency.%Gravel)
da
NL Cif 1
Parent YAW(aeobgid I
Depth to pwmaoler.SbnSa9 WS b Ilk Hole
Depth bBake* Wig from RFam
Corned Seemnol High Ground Wabr
Deep Hole#:
`DEEP-OBSERVATION HOLE LOG'
'HID W UM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Death km
Sodom(Inches)
Sal Witco
Sol Imam -.:
(USDA)
__:.. .Sol Color
Son
Molina
Oker
(abshse.Sbnes,Bottlers.Consistency.%Gravel)
Parent Matti(geologist
Estimated Seasonal
Water b the Hole
Grave Water
Depth b Biked
Man Pk Face
WILLIAM J. SIERUTA, P.E.
REGISTERED PROFESSIONAL ENGINEER
46 UPLAND ROAD
HOLYOKE, MASSACHUSETTS 01040
(413) 532-8525
Board of Health
City Hall
Northampton, MA. 01060
Attn : Peter McErlain
July 31 , 1997
Subject : L. Shea
80 Dunfey Lane
Northampton, MA.
As discussed , the installed septic system at 80 Dunfey Lane
is not in accordance with the approved plan. An error was made
and a trench system was installed instead of the leachfield which
was designed.
Per the installer , 3-2ft wide by 3ft by 46 feet long trenches
were installed. Effective width=24 inches . Effective depth=24 inches
Maximum allowable . Effective length=138 ft . The trenches are 4 feet
apart .
The following items were approved by P. McErlain, Board of
Health Agent . Removal and reinstallation of the approved leach-
field is not practical at this time. The leach trench system
was approved by the Board of Health to remain in service .
1 ) Board of Health approved a 4 ft . separation between the estimated
high water table and the bottom of the existing trenches . Bottom
trenches @ 192 . 20 .
2) Minimum separation was allowed @ 5 ft as installed. The code
would require 6 ft . , however , there is no practical way to change
the as built conditions .
3) Capacity of as built trenches 828 ft2 is 612 gallons/day . With
the Board of Health variance and the acceptance of the system
changes due to the error , the system as installed will meet 310 CMR 15 .
Liam J .
cc :J .W. Cotton
WJS :mbs
Page 5 of I I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: (dr) 'el/lit/,e-1/21 V »Q%bk-c
/i2O/07//i/fJ/-0N et 7/./
Owner: /2) tT' , 5/,[-//UY /%
Dale of Inspection:
J/,09/0 /
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 ?
V • Has the system received normal Rows in the previous Iwo week period?
V/Have large volumes of water been introduced to the system recently or as part of this inspection?
y _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
V-- Was the facility or dwelling inspected for signs of sewage back up?
1✓_ Was the site inspected for signs of break out ?
Vall 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?he
Was the facility owner(and occupants if different from owner)pi ovided 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:
Yes.s no
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)]
5
Page 7 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
/r/0/1/Ni,'71/P7rw,u / /I
Owner: //'il/J4 ,f//F/%
9/0
BUILDING SEWER(locate on site plan)
Property Address:
Date of Inspection:
Depth below grade:
z‘<
Materials of construction:.cast iron X40 PVC__other(explain).
Distance from private water supply well or suction line: ,0!/4:I L 77 z D
Comments(on condition of joints,venting,evidence of leakage,etc.):
/-p 1/ .di 0Apec• i cr It' y/Joo/) C 0,00, .104/
r,
SEPTIC TANK: _(locale on site plan)
Depth below grade: /0 r
Material of construction;Xconcrete_metal _fiberglass polyethylene
_other(explain)
If tank is metal list age: - Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: /O(' +'5 4(5
Sludge depth: /y/,,Lie
Distance from top of sludge to bottom of outlet tee or baffle: ZZ
Scum thickness: /
Distance from top of scum to top of outlet tee or baffle: , 3 ,/
Distance from bottom of scum to bottom of outlet tee or baffle: 03
How were dimensions determined: /�2.?/15c1/Ly C/
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert evidence of leakage.etc.):
2774/1 /f /.0 /COO, ) CORJ,O/17041
GREASE TRAP:_(locate on site plan) 04/11
Depth below grade:_
Material of construction: concrete metal_fiberglass _polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
'Page 6of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
c5b 0 vNV/$/`! o4/
Property Address: Aia/7 T/-/J„/.���'//� /1//r(
Owner: �r
Date of Inspection: , /ptf/O /
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): t-9
DESIGN flow based on 310 CMR}5.203 (for example: 110 gpd x 11 of bedrooms):
Number of current residents: �f'
Does residence have a garbage grinder(yes or no): /VO OE.S/7/2 /s 67 Z ,O ,ca€ /,/SPcr.,5
Is laundry on a separate sewage system(yes oj.no):/I/Q[if yes separate inspection required]�r /VO.GT/,/7irj/
Laundry system inspected(yes or no): I/ 6d//
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):_Lip
Last date of occupancy: —
COMMERCIAL/INDUSTRIAL 6,444 ■
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgfl,etc.):
breast trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records D.17,.// QPdl'// .S D
Source of information: OGV/fJ/ /L
Was system pumped as part of the inspection(yes or no):4J0 /LP GP/77./y pO/?76ce_
If yes,volume pumped::iallons--How was quantity pumped determined? al/7-7/ /
Reason for pumping: /{/Or `i(l/!J/Jpiif oy yY' "z7 & - C)
l'. ,171 E OF SYSTEM /2 v�/a' d ,7 V``///OO
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
1—_Shared system(yes or no)(if yes,attachprevious inspection records,if any)
Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)
source of information:
/4/517a#j9 lo// 997
Were sewage odors detected when arriving at the site(yes or no):_119()
rent No. /rC L['f/
ending
' 'l'l.ule
Saturation ( 15 uliu) c
/z
//
�!r
1'ercu lol luu 'feel
7
Sc /-,b6 ]
Pe tic Rat grJv/ 7i' G,
lruuod Elev . iS U (11 /Limb
1-
Depth of Ilule
'I'nn1. Nu .
Il ond1na . .. . 1l ills
.'In1 urul. l nn ( 15 111111)
I'nrc 11nle
nrmind 111 nv .
nn n111 ml Ili In
Ni11/111e1(
Cast pit.
el-/ -/ Ueep Teat 1•ll//e
--WISE T111 r/ z
Depth SuH- beecriptiull Depth Dull Description
e', A5` 0r5 Ca/J/r7
/5- c!!✓ . Set r7Siy<uoyejincv
0o --/,-.7,Q lc.,nvS f 1-_ , 561/3 /2/2-7,----/'/ L c�
172 • /.17,-) /24/..--,l v
/7/4..-4-, 5c.j,--/
Groundwater Depth
Bedrook Depth
Dround Elev .
S .C.S . Soil Deecr
9nV/T Elev .
Ele v .-----
/90 -/C /ilk
/ c/
iptluo 5,2E7,,-,2 Seasons ; High linter Tatle7 /%j /lam L
0/
Bench Mark: Elev . „5-7/cc /'4/1 Uescrlpllun "OG
(ll'lllllnds/titer Depth
Iledreck Depth
Ground El ev .
Elev.
Elev .
Dale :
Client ! Z./
sit) Z'
Engineer :
Waimea : .{p
Local k1111 or Pere :
c°12
/9
Cf
lnt D9p
1 EIEEauT/
s tNIL
11 M1 30141/44
4L l
'
Page 9 of I I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
cSt Oo-v,z7i/V P/li/E_
,fiv/Z/7//7/'/®/p,0
Owner: /-/00'042 5,/Ai6l
Date of Inspection: 0 0
SOIL ABSORPTION SYSTEM (SAS): (locate on to plan,excavation not required)
iCP/ kit/
If SAS not located explain why: •
573 t o 047/*a t ,pGr/7a,c/ El -C
Property Address:
Type
_leaching pits,number: _
leaching chambers,number:
leaching galleries,number:
)( leaching trenches,number, length:
Al r c- 5' //, /i 2 �
7
leaching fields,number,dimensions:
overflow cesspool, number:
innovative/alternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): L' 5 j 2, i .L . /C
y /�i<./iv/tiy u.�/� ,tea A.-0,1
CESSPOOLS:_(cesspool must be pumped as pan 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 or no):
Comments(note condition of soil, signs of hydraulic failure, level ofponding.condition of vegetation,etc.):
PRIVY: (locale 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.):
9
Page I I of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
cam, SYSTEM INFORMATION(continued)
Property Address: c L/ De-i-th //V 1-/E/' in, 'F
Owner: /77,or A-/ r-M
1✓✓.vO.4 J./,F/7
Date of Inspection: O m
SITE EXAM,"
Slope 3,'
Surface water Np,f/E
Check cellar pst_
Shallow wells
/Cat/
Estimated depth to ground wale, fret f1>/!C/% 9 Velte s /LeJ
srv /a0tc 7.s / ,cv5.2/
Please indicate(check)all methods used to determine the high ground water elevation:
XObtained from system design plans on record -If checked,date of design plan reviewed: yet 14.-
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain: �/7/
7
I Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
l
You must describe how you established the high ground water elevation:
ni fly, /r 6v/;wets �/E� `%/I 97
/5
r1ve? m
Ova//- Cf Ft ff e7t-� 770et2 it
Ef-iNJT