602 Title 5 Application/Permits 1995, Inspection 1995 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
3 number of bedrooms
4 number of current residents
YPS garbage grinder, yes or no
YPS laundry connected to system, yes or no
Nn seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
June-24449-5 Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
Pumped July 21 1994 Information from Grog' s Sept; r Ser
239A Greenfield , Rd. . So Deerfield Ma n117l
8
Yes System pumped as part of inspection, yes or no
if yes, volume pumped 1500 gal from tank and 500 gal from DB Box
Reason for pumping:
Type of system
Yes Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
ion Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
18 years
No Sewage odors detected when arriving at the site, yes or no
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property
Owner's name
Date of Inspection
602 North Farms Road, Florence
Mark Teece
March 31, 1995
PART A
CHECKLIST
Check if the following have been done:
x Pumping information was requested of the owner, occupant, and Board of
Health.
—X___
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
N/A As built plans have been obtained and examined. Note if they are not
available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The site was inspected for signs of breakout.
X All system components, excluding the SAS, have been located on the
site.
x The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
x The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
X The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : Yes
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
approximated by non intrusive methods
Type
leaching
leaching
leaching
leaching
leaching
overflow
pits and number
chambers and number
galleries and number
trenches, number, length
fields, number, dimensions 3 li P ln„ lnfg 90, 301
cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
signs of hydraulic failure, static level in d-hox above outlet invert
CESSPOOLS (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 (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, .
condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. )
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: 1500 gallon
(locate on site plan)
depth below grade: 5 '
material of construction: X concrete _metal _FRP _other(explain)
dimensions: q ' s' lnng 5 ' A" width 6 ' height
1" sludge depth
distance from top of sludge to bottom of outlet tee or baffle
0 scum thickness
Spun distance from top of scum to top of outlet tee or baffle
SEaefj distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
Title - 5 inspection Baffles OK, liquid level 57"
Structural OK No Leakage
Recommend manholes on inlet & outlet
DISTRIBUTION BOX: Yes
(locate on site plan)
5" depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
D R Rnx is 1pvpl Nn cnlidc rarrynvrr
Nn laakagp . , ntn nr not of hnv n_Rnv nR
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
n. Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
12
Y Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
N Required pumping 4 times or more in the last year?
number of times pumped
N Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
N below the high groundwater elevation?
N within 50 feet of a surface water?
N within 100 feet of a surface water supply or tributary to a surface
water supply?
N within a Zone I of a public well?
N within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
N within 50 feet of a private water supply well?
N less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysir
for coliform bacteria, volatile organic compounds,, ammonia nitrogen
and nitrate nitrogen.
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION Continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 ' well 97 ' 5" in back of house
from septic tank and leach
field is 180 ' from well
DEPTH TO GROUNDWATER
N-D depth to groundwater
method of determination or approximation:
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector Henry J.Kocot
Company Name Henry C. Kocot & Sons , Inc. Phone 413-665-2735
Company Address 126 Whately Road, So. Deerfield, Ma. 01373
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
X I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector 's Signature
Date 3/31/95
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
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BOARD OF HEALTH
JOHN T.JOYCE,Chairman
ANNE BLRES,M.D.
MICHAEL R.PARSONS
PETER J. McERLAIN,Health Agent
May 10, 1995
Mr. Mark Teece
602 North Farms Road
Florence, MA 01080
Dear Mr. Teece:
CITY OF NORTHAMTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
RE: Sewage Disposal System Inspection
602 North Farms Road
210 MAIN STREET
01060
(113) 386-6950 Ext.213
The Northampton Board of Health is in receipt of a report on the Subsurface Sewage Disposal Sytem
Inspection conducted by Henry J. Kocot at your property 602 North Farms Rd., Florence, on March 31,
1995. That inspection report indicates that your subsurface sewage disposal system fails to protect the
public health and the environment as defined in Sec.15.303 of CMR 15.000, State Environmental Code,
Title 5.
Therefore, in accordance with the provisions of 310 CMR 15.000 of the State Environmental Code, Title
5, and under authority of Mass General Laws, Chapter 21A, Section 13, you (or the subsequent owner of
the property) are hereby ordered to repair the subsurface sewage disposal system at 602 North Farms
Road, Florence,within one year of the date of the original inspection, (by March 31, 1996). If further
degradation of the sewage disposal system occurs(e.g. sewage flowing to the surface of the ground),
you may be required to complete the repairs sooner.
All work to repair/upgrade your subsurface sewage disopsal system must be performed by a licensed
sewage disposal system installer, in accordance with the requirements of 310 CMR 15.000, and with
plans approved by the Northampton Board of Health.
Please be advised that you are entitled to a hearing on this order to upgrade your subsurface sewage
disposal system, provided that you file a written petition requesting such a hearing in the Board of Health
office within seven (7)days of the receipt of this notice.
Please feel free to contact the Board of Health office, at 586-8950, Ext. 213, if you have any questions
concerning this matter.
Thank you for your anticipated cooperation in this matter.
Ve _truly yours,
eter J. McEdain
Health Agent
Certified mail: # P 076 177 759
PJHc/sepfail
A
0
No itlO _TS
of
THE CO M !NWEALTH.OF MASSACHUSETTS
MASSACHUSETTS
Fir 3-0
-_-
pplicatiAn for !i$l uz T $gs rltt Construction Permit
Application is hereby made for a Permit to Construct( )or Repair A an On-site Sewage Dispo.al System at:
Location Address or Lot No.
Owner's Name Address and Tel.No.
"La_ T-..... „
oota Nd af�.i4ws
% .
last ler's Name.Address,and T1el,No.
o b lit; &d -
Designer's Namc Address an Tel.No.
I a-fra Le p CA-t s
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder( )
Other Type of Building No per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 350
Plan Date
Title
gallons per day. Calculated daily flow
Nun•er of s eets Revision Date
gallons
Description of Soil
•
Nature of Repairs or Alterations(A `wet when appli .ble) ..."
Aix r
Date last inspected.
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 b--n' sued . this Board of Health.
44 i
Signed i�J Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No Date Issued
THFI�OM NWEALTyt OF MASSACHUSETTS
/IfO N i MASSACHUSETTS
THIS IS TO CERTIFY
at O a-
accordans_.,withthe pa•o
va o c r
l.00k..- C. R_
The issuance of this
Certificate of Compliance
6j17e Om-9i Eetivizge Disposal Systemfinstall*f ) r gedlr dk) on
Y ` / C hys ee
bts strutted in
isions of Title and the for Disposal System Construction Permit No ! �O— r dated
Use of this stem is conditioned c m li ace v/ith thdprovisiens setforth below:
SCILYreF url )kC� QCI- � Gn 4e' . Li fCwre '
,-,17 .S
certificate sheer �
of be construed as a guarantee that the
Certificate expires on
7—/2 -JS
DATE Inspect(n
N . / & ?C
No
ill function
designed. This
�jrla,
TyOMMON ALTH GF MASSACHUSETTS
MASSACHUSETTS
!isposnl stem ¶onstrurtion Permit
Permission is hereby panted to %
to construct ( )or repair.( )an On-site Sewage System located at / ° a
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
duty to comply with Title 5 and the following local provisions or special conditions.
All construction mil*be c pleted within tw yeas of the date below.
DATE - / , Approved by
FORM 1255 Rev.3395 A 43OLKEN co•BOSTON.MA
JU! 1 31995 0
LUI0Eill 10N5
at
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(27/ OF 4/Ur(7fNn)PiON
hirrtifiratr of Tnmplianrr
!FY, That the Individual Sewage Disposal System constructed ( ) or Repaired (//c D run OE fox m ,ek" r Tr'
Installer
has been installed in accordance with the provisions of TIT—Lc 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No /G- p=' dated 7-' > 9s
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE S A GUARANT THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
i
DATE 7' /L -93- Inspector�j/ t / '