Loading...
409 Title 5 Inspection 1996 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: BI SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box 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 pipes) are replaced _ obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 CI 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 th public health, safely and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS 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 THA THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: COLUL tank and sell absorption system and is within 100 feet to a surface water suppt; 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 septic 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 a private wau 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 ppm. DI SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to corre the failure. Backup of sewage into facility or system component due to an 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. (revised a/as/951 2 William F.Weld eomm« Trudy Cox• Sonata",ECEA Dam B.SStruhs Commonweatth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION APR g lerty Address:yaf f oLll )[ i& C'ArC l , 7N4,4Pya.J Ma Address of Owner: of Inspection: gnu_ Z %96 Of different) to of Inspector: Rp4,4,,,,,p M/6cZkfl Siel tpany Name, Address and Telephone N ber M1D(Jt1, MA, O/o3S TIFICATION STATEMENT @13) —q' —fof3 lily that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and venance of on-site sewer disposal systems. The system: ector's Signal Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Date )c c\ System Inspector shall submit a copy of this insr (bon report to the Approving Authority within thirty (30) days of completing this ection. 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 report to the appropriate regional office of the Department of Environmental Protection. original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. PECTION SUMMARY: Check A, B, C SYSTE ASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 OAR 15.303. Any failure criteria not evaluated are indicated below. 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. cate yes, 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 exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. - vised 8/15/95) 1 One Winter Street • Boston,Massachusetts 02106 • FAX(617)556-1069 • Telephone(617)292-5500 %$Printed on Recycled P M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) :rty Address: en of Inspection: (STEM FAILS (continued): 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 1/2 day flow. 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 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 a 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 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. RGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above. _ The design flow of system is 10,000 gpd or greater (Large System) and the system is a 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 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) )wner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program rements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. rsed 0/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ferry Address: J °SOPA CLOW Lev U]Orl Kt NG—SI TJ IVD 2754/4/+4?113rJ , ter: of Inspection: A.pe - Z, i59( :k if the j Mowing have been done: V f umping information was requested of the owner, occupant, and Board of Health. V None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates 4during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. A 5 built plans have been obtained and examined. Note if they are not available with N/A. h facility or dwelling was inspected for signs of sewage back-up. he system does not receive non-sanitary or industrial waste flow _T e sit y was inspected for signs of breakout. ysterr components, excluding the Soil Absorption System, have been located on the site. Th eptic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or m rial of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ze and location of the Soil Absorption System on the site has been determined based on existing information or pproximated by non-intrusive methods. The facilityy o"ne: (and occupants, if differed from owner) were provided with information on the proper maintenance of Sub- _ Surface Disposal System. ised B/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Lib% I(.b&T 4JG S7irr%/t tN'/N)4'r'I "/ Owner: JOSEPg efrzi.KilY Date of Inspection/if Wit- SEPTIC TANK:_ (locate on site plan) �� ,/ "oF GRASS 6.L44� --77 A✓iC /5 0 3 c-ci-Far— RrS,.=,eS ;yre Depth below grade: Material of construction: oncrete _metal _FRP_other(explain) Dimensions: 4)cR x5 (/000 63/41(7) Sludge depth: A " 3 r 2 d' 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: 7 l 4/1-J4 (M5 /// ,JSJE//SF Writ r,J %J✓/»^i -9arx 3'IHGH Z/ FLort, purer 6-xs o> TAA/r-- Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, de_pth of liquid level in relation to outlet invert, structural integnty� evidence of leakage, etc) _(/f//,�j /ice Fi siLEC Aber T WOP"JAJ S? `�C AJi /7E LObe`22S G9Ci/NZ 766-:(-1 —�oiu At/.J /r ccz-ce C co%o/ilvnl / ,o S/CA-S ,,F J&AJcro 4®ae-1.40 - L/O01/1 IEVC-z /( EQUAC- red /An/cc- -Q ' Darn fYPc it art 4,4Qc np /A/fie-77-477e - 744th /S GREASE TRAP:_ (locate on site plan] Depth below grade of construction. concrete _metal _FRP_other(explain) Dimensions. Scum thickness. Distance from tap of scum to top of outlet tee or baffle:_ Distance from bottom n Sum r bono.m or oune' lee or bahie 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. etc.) (revised ens/95i 6 ' SUBSURFACE ierty Address: 'N»n n K' ' ter. To5e9I4 Cf(6Latet of Inspection: 44 4L Z, I(19(v SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'Lxeei Noeig404PZ.J ., FLOW CONDITIONS DENTIAL: gn flow: Z3gallons fiber of bedrooms: 3 fiber of current residents: .3 'age grinder (yes or no): Y1ES dry connected to system yes or no): YE S onal use (yes or no):j�p er meter readings, if available: date of occupancy.( L-)t2e�I c-I OCCV P�F 4MERCIAUI NDUSTR I AL: of establishment: gn flow: gallons/day se trap present: (yes or no)_ stria) Waste Holding Tank present: (yes or no) sanitary waste discharged to the Title 5 system: (yes or no)_ u. meter readings, if available: date of occupancy. ER: (Describe) date of occupancy. GENERAL INFORMATION IPINO RECORDS and source of Information: System pumped as pan of inspection (yes or no)�S If yes, volume pumped .7/0*/vallons Reason for pumping: (j tL ,t74j0/�,U °G /AtJeC ,eel-a4 t.44f1- C —PrnPV £7 pia< tl/Inrct" 14. OF SYSTEM Septic tank/distribution box/soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) ROXIMATE AGE of all components, date installed if known) and source of information: AI I wl(. I a ' Z0 yE»LS 'SOOV/4G , / C'or'ot']5✓ ac-- 7>J,JKiEx[ec..ari pai crwa� of d>1F:-PAU- SYSit.�1- age odors detected when arriving at the site: (yes or no) NO sed a/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) Property Address: 17/0yRkr%6 S' l7 '/ cZA.1raRmi Owner ToSEPy nnRcute7 i t Date of Inspection: A-P2u- z, /'" SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intru sive methods) If not determined to be present, explain: Type: leaching pits, number: / r 4 leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number,length. leaching fields, number, dimensions: overflow cesspool, number:_ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.) E-X44097Fl1 bash,/ 2-e --Mane-At oAE.'s' /,J — '%' / Cs.✓ca- _i.e.: - 7D • 'cal /r iv,me wR- — Tusr &�-z -- 6,-,4z2673 6r 1472-Y Pcc--'PN/ou{ d /LP4an m,xN�c- A/o S;4 6V SD/LS u° o6otS NO 011ec,e5;cicc /v. SCAC4CE UCVE/n» 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 pan of inspection) Comments: now condition of soil, signs of hydraulic failure, level of ponding, 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.) l revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /� SYSTEM INFORMATION (continued)/ erty Address: 1''9//�d,,L/7/_K(Aj S/"Y. f�T ,0o./ MIpmz a , er: 7o$G"pf% L,K�t srL&v of Inspection: ,qnt(- 4 /111. IT OR HOLDING TANK:_ :e on site plan) h below grade._ rial of construction: _concrete_metal _FRP_other(explain) nsions: city: gallons to flow: gallons/day 1level: rents: lition of inlet tee, condition of alarm and float switches, etc.) RIBUTION BOX:_ :e on site plan) C)/(/ ALIO _ 974,607- 'hoc /'ern Sca'g6-57/.✓J_ 'p ei3chi hi of liquid level above outlet invert: Tents. If level and dlstribw lur, equal. es idence of solids camp, evidence of leakage into or out of box etc.) P CHAMBER: to on site plan) as in working order:lyes or no) ments: condition of pump chamber, condition of pumps and appurtenances etc.) rsed 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) pem Address: .4/ nn,,,%, __2--? L i,(% Seer /t ti- PIDAi , A�{{�, nen zr w4i CK07s1C y e of Inspection: AO-Lit- Z, /99(x_ TCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 5 f1/779-c//e Steer 7S 'TH TO GROUNDWATER r/ tb to groundwater: /5 feet hod of determination or approximation: 96c I//Zff / 10 'eta. S.. c_. Al g w4'°ty -nm 06Av t c'1' •/ licit at r© tr/c tt€9 used 81t5/95) De— Y smfc /N &4OC 9 #409 N. KING 5TPEET 5E1'T/G TANK >) (/000 GAL) - o - n 4" A,G, o TS l5" PIYU1 LOCATION OF V LrAGh/NS Fir SEPTic SYSTEM LAYOUT OWNER: JOSEPH CROWLEY eeRn ADDRESS: 409 NORTH KING STREET NORTHAMPTON, MA. ExISTINs 8 Ac.SEINER... DATE: APRIL 2, 199(9 INSPECTOR: RAY MIECZKOWSKI #409 N, KING [ C T N N i SAP R8 t • • • X0.00 ��T SEPTIC SYSTEM LAYOIJT OWNER: JOHEI'II CKOWI EY AUURESS: 4U9 NORTH KING STREET NORTHAMPTON, MA. DATE: APRIL 2, 1996 INSPECTOR: RAY MIECZKOWSKI idlegasi 4.1 * � cn THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Raymond Mieczkowski Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. � �12,- May 25, 1995 Acting Director of the /Ain of Water Pollution Control