902 Septic Inspection 2002 ENVIRONMENTAL HELD SERVICES, INC
P.O. BOX 518
LEEDS, MA 01053
1-413-586-7200
March 8, 2002
Dawn Schabacker
902 Florence Road
Florence, MA 01062
Re: Septic System Inspection at 902 Florence Road, Florence
Dear Dawn:
Enclosed please find copies of our reports for the referenced inspections. We
have forwarded copies of the reports to the Northampton Board of Health per
the requirements of 310 CMR 15.300.
Based on the results of our inspections in accordance with 310 CMR
15.300, we have concluded that the systems do not fail to protect the
environment and/or the public health.
Please call if you have any questions, and thank you for this opportunity to
be of service.
Sincerely yours
Mich- .. J. .vigne
Sy em Inspector
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OF I ICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
((77 n own
CERTIFICATION
Property Address: 'I Oa F li ( o R t
F) ore ucsz, n) olaoa
Owner's Name: T)nn On Sr h A ho C V,o
Address: qua Flcn OmC.C. P.d
f)IS) rme . rrfa ct6140a
Date of Inspection: 2 -7-0,2
Name of Inspector: (please print) /%). Let .0:1 irLA
Company Name:FAMUSl'nA)f1Q 1NrO F) t0d .SPAU'tYA
Mailing Address: 3'5.K A, rri P
()010(e.411
I • Woe •• • Bei
Telephone Number:,3 R(.-, —7 an
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 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:
�//�✓
The system inspector shall sub it a co of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of_f 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.
Date:
Notes and Comments
""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 I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PCiAc I
Property Address: gp
Owner:
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section
A. System Passes:
VI 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.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,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 break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due ti)a broken,settled or uneven distribution box. System will pass inspection if(with
approval of 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:
2
' Page 3 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: $.Q f
PRA
Owner:
Date of Inspection:
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(I)(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
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 ofa 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 FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Lit 9 �l
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N
_ /Backup of sewage into facility or system component due to overloaded or dogged 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
(✓/jg Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
A/44 Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
_t//,Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
iditimes pumped
t/ Any portion of the SAS,cesspool or privy is below high ground water elevation.
///3 Any portion of cesspool or privy is within 100 feet ofa surface water supply or tributary to a surface
water supply.
tj/1 - Any portion of a cesspool or privy is within a Zone I of a public well.
_A./�J Any portion ofa cesspool or privy is within 50 feet ofa private water supply well.
_NA Any p6rtion 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 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.]
Ai (Yes/No)The system fails. 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:
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 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.
4
Page 5 of l]
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: la 1 a9,
Owner:
Date of Inspection:
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 I/ 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✓ 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 ?
V Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
Yes_ no
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)J
5
Page 6 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:,,X a-cY V I
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL nn
Number of bedrooms(design): 3 Number of bedrooms(actual): ,Q {�
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x q of bedrooms): J/0(�T�R/tu
Number of current residents:
Does residence have a garbage grinder(yes or no): VO
Is laundry on a separate sewage ystem (yes or no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): MO
Water meter readings,if available(last 2 years usage(gpd)): AJ I A
Sump pump(yes or no): A/O
Last date of occupancy: CU'FCC u-L
COMM ERCIAIJINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgf,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):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system purpped as part of the inspection(yes or0
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYgE OF SYSTEM
V Septic tank,dis tils Grin,soil absorption system
Single cesspool
_Overflow cesspool
_Privy
Shared system(yes or no)(if yes,attach previous 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 stalled(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): DO
6
Page 7of I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:a, kL Poe 0
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
d
Depth below grade: �
Materials of construction: cast iron V IO PVC other(explain):
Distance from private water supply well or suction line: C)) A
Comments(on condition of joints,venting evidence of leakage,etc.):
�pAODtemS «,o- e
SEPTIC TANK: rilocate on site plan)
Depth below grade: 'i �r
Material of construction: ✓concrete 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: /0 7,2/4 3 it 't-L) /500 9 n Q.
Sludge depth: ---
from top of sludge to bottom of outlet tee or baffle: A)I A
Scum thickness: --O"
Distance from top of scum to top of outlet tee or baffle:N ) li
Distance from bottom of scum to bottom of outlet tee or baffle: A)I A
How were dimensions determined: A)h3
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Slits +oho (m. €)me )lextt (?OVriIftnr ) S
prnhl• ms & nt ec\
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 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 of
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:W
Owner:
Date of Inspection:
TIGHT or HOLDING TANK: ^rte(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene odher(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:"r(!�-(if present must be opened)(locate on site plan)
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.):
PUMP CHAMBER: an(locate 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.):
8
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
�J
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): V (locate on site plan,excavation not required)
If SAS not located explain why:
exaa aied and AC) Wt.+
Type
leaching pits,number:
leaching chambers,number:_
✓ leaching galleries,number: I
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.):
.: - :.r 1.1 • fZi K]e tnv (', CeL e,,2f CO-Oriif+ow,
k froIDIPPnS
a
CESSPOOLS:/jfl (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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: tag(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.):
9
Page 90 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _(I Q L
Owner:
Date of Inspection:
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.
a
rlIO '362
Lc-ere .
>atik
t-
10
Page 1:of I I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
``((�� j�J SYSTEM INFORMATION(continued)
Property Address:, �I,JQ.e
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
/u8"
Estimated depth to ground water feet—
Please indicate(check)all methods used to determine the high ground water elevation:
/Obtained from system design plans on record-If checked,date of design plan reviewed:
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:
No. •
THE COMMONWEALTH OF MASSACHUSETTS PEt
BOARD■ OFIHEALTH
C1 �y OF /�ioy—i-l„a�N.T�nt..-
Appliratinn for Binpnnal ystent Tnnstrnrtion Verntit
Application is hereby made for a Permit to Install ( ) or Repair/Replace (X an Individual Sewage Disposal System at:
4oa Kk —2nc e_ PcL
Addrn.
Type of Building
Dwelling—No.of Bedr
Other—Type of Buildii
Other fixtures
Design Flow
n.., ,,. ,,n,.,.,a„ Lo.t 733(¢ Sq.n
Size Lot S S feet
ooms 2 Expansion Attic ( ) Garbage Grinder ( )
rn.A„ar_No.of persons Li Showers ( )—Cafeteria ( )
Disposal Trench—No.
Seepage Pit No. 1
Other Distribution box
Percolation Test Results
Test Pit No. t I
Test Pit No.2 Atg
Description of Soil
gal Ions per person per day.Calculated daily flow___22.sa gallons.
e
D
( N
Septic Tank—Liquid capacity 1500 gallons Length _L26 Width [aft Diameter
Depth
D
With Tocal Length Total leaching area sq.ft.
area H(Sto sq. ft.
water
water 9 ) 10
Diameter 28'X )2' Depth below inlet 1911 Tonal leaching
Dosing tank ( ), p
Performed by f'\. i—t_tly _.I'p, \A-e yi0.It-s—Dale
minutes per inch Depth of Tc t Pit co N 1 Depth to ground
mionits perinch Depth of Test Pit LO ' /O7.1' Depth to ground
/A` - TO" Fr//
tY' - LS` C.L r�I . Ci
'71 /Oct°tdr-
Nature of Repairs or Alterations—Answer when applicable
Date Last Inspected /P — ? -96'
Agreement:—The undersigned agrees to install the.doredescribcd Individual Sewage Disposal System in accordance with the
provisions of TITLE 5 of the State Environmental Code.The undersigned further agrees not to place the system in operation
until a Certificate of Compliance has been issued by the Board of Health.
a Signed
Application Approved By
Application Disapproved for the following reasons:
Date
Dale
Permit No. Issued
mate
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF ILIEALTH
Cnertifirate of CgnUfplianre
THIS IS TO CERTIFY That the On-Site Sewage Disposal System installed ( ) or Repaired/Replaced ( )
on by
for at
has been constructed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the
application for Disposal System Construction Permit No. dated
Use of this system is conditioned on compliance with the provisions set forth below:
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION AS DESIGNED. This Certificate expires on
DATE
No.
THE CO
Dale
Inspector
ONWEALTH OF MASSACHUSETTS