91 Septic Inspection 2000 !; COMMONWEALTH OF MASSACHUSETTS- EXECUTIVE OFFICE OF ENVIRONMENTAL AF , wty 7 am
• I'p�Yp`,fp111 DEPARTMENT OF ENVIRONMENTAL PROTEC ONE
ONE WINTER STREET,BOSTON MA 02108 (617s 292,5500
}NORTHAMPTON BOARD OF H
TRUDY
Se
ARGEO PALS.(ELLUCCI DAVID B S9
Governor Crn.ru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATOS
98 CL) d.dt ,1f/cr C
Property Adbaa: / fat f�e�-w� (rh. I Ytt,n_ Nor of Owner ¢0 .. 4(4nG.Address of Owner:
Date of Inspector- 9/140-0 (//� a 41 ,1
Name of Inspector (Haase Prim) P/ttt.L&C )I.5,aUl
lam a D EP approved system Inspector pursuant to Section 15.360 of Trde 5 1310 CMS 15.000)
CompanyNams: .a
- eptir Inspections Inc.
MrsIng 5 5 ?r...- . SY - 1-1-3-532-8600 e
Hot y DKErMcr . 01040 ----
CERTIFICATION S rATEMENT
I comfy that I h hi personally inspected the sewage dispose!system at this address and that the information reported below is true,
a
and complete el o the time of inspection. The inspection was performed based on my training and experience k the proper function and
maintenance of on she sewage disposal systems. The system:
_ Passes
Cordnionally Passes
/Needs Further Evaluation By the Local Approving Authority
✓ Fells �t /
Inspector's Signets HE *6.srfis .A. ' s iNaAld Dale: ��/rs/00
he System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP:within thlnv 1301 day
conipietirg this ns,e:tion. If the system is a shared system or has a design flow of 10.009 gpd es greater, the inspector and the system c
shat.submit the re con to the appropriate seg'onal office of the Department of Environmental Protection. The original should be sent to the
system owner aid copses sent to the buyer, if applicable, and the approving authority.
NOTES ANO CCM'. ENTS
',S Fl S AAa IL- mni Ort �.
•
revised '. /2/95 Peetfenl
is ,.r.on Rnxl.e i',
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
• CERTIFICATION(cominsadl
Property A era:
kJ
Owner: titcyLL
One of Inspection:
y//5A,
INSPECTION SUMMARY: Check A. B, C, Of sc/
A. SYSTEM PASSES:
_ I have no ound any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any lailuri
crite not evaluated are indicated below.
CDMMEN
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass'section need to be replaced or repaired. The system, upo.
completion of the replacement or repair.as approved by the Board of Health, will pass.
Indicate yes,no.or not determined IV,N.or N . Describe basis of determination in all instances, If not determined', explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Complian (anachedl indicating that the tank was installed within twenty 120)years prim to the date of the inspection;
the se rc tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or to
lal re is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank r
pproved by the Board of Health.
i
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pip
or due to a broken, settled or uneven distribution box. The system will pass inspection if with approval of the Board of
Health).
broken pipets) are replaced
_ obstruction is removed
_ distribution box is levelled or replaced
_ The system required pumping more than lour times a year due to broken or obstructed pipers). The system will pass
inspection if l with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued!?/ U'am-V& v f /J p /tcr ✓ -mi'i^ -
RapMY Address;Owner: Key,h r2.
Data of Inspection: Y/i!V/d0
C. FURTHER EVALUATION IS REQUIRED EY 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, safety and the environment./
TI
IS FUNCTIONING UNLESS
M OAER WHICH WILL PROTECT THE PUBLIC RHEA HEALTH WITH
SAFETY AND THEIENIVIRONMENT: SY 310 CMR 15.303
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
—
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANYI DETERMINES THAT THE SYS1
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank end}oil absorption system(SAS) and the SAS is within 100 feet of a surface water sup
tributary to a surface water sypply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a seytictank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has frseptic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from
private w ter//stipply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates
well is free/ rom pollution from that facility end the presence of ammonia nitrogen and nitrate nitrogen is equal to or I
than 5 ptm. Method used to determine distance (approximation not walidl.
3) OTHER
revised 9/2/98 Page 3of11
4
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
• PART A
(� �9 CEE�RTIFIICAATION Icmdrued)
property : // U)llbiHhc+ . /te tV7lne(( 'v�
A
Owner: l Emak.
Date of Inspection: Jilt.76-0
D. SYSTEM FAILS:
Yq must indicate either "Yes" or 'No" to each of the following:
O determined o of R
determina0on I have is itlentifietl that one belowor m.re The Board of Health Mfailure ould be conditions contacted exist es b determine described in whet 310 will CM be necessary 15.303. The to basis correct for the this fail
Yes No
_ Backup of sewage into facility or system component due to an overloaded or clogged SAS esspool.
— ../ 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 112 day flow,
i Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets).
Number of times pumped
J 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 lee,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.
JAny portion of a cesspool or privy is within 50 feet of a private water supply well.
_y] Any portion of a cesspool or privy is lessthan 100 feet but greater than 50 feel from a private water supply well with
acceptable water qualify analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis f
coldorm bacteria, volatile organic compounds. ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10.000 gpd or greater(Large System) end the system is a significant threat v
health and safety and the envirgnrtent because one or more of the following conditions exist:
Yes No
the byFiem 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-IWPAI or a mapped Zone II of a r
water supply well)
The owner or operator of any such system shell upgrade the system in accordance with 310 CMR 15.304121. Please consult the local re
office of the Department for further info0nation.
revised 9/2/98 Page of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Q/ r-414r-414011\41% F6.a).0.14
Property A e r:
Owner: wiz
Date of Inspection: 4'Kl pp
Check if the following have/been done: You must indicate either'Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner,occupant, or Board of Health.
• 7' • _ None of the system components have been pumped for at least two weeks and-the system has heenreceiving normal I
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
JA _ As built plans have been obtained and examined. Note if they are not available with NIA.
The facility or dwelling was inspected for signs of sewage backup.
y _
The system does not receive norosanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout.
— All system components,excluding the Soil Absorption System, have been located on the site.
/ The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of b
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
JA Existing information. For example, Plan at B.O.H.
_✓ _ Determined in the field Of any of the failure criteria related to Part C is at issue,approximation of distance is unaccepu
I t 5.302(3)1b)1
The facility owner (and occupants, if different from owner) were provided with information on the proper mantenance
Subsurlace Disposal Systems.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Adb,Sxa: 71 ZRI 14 E'ry ) 4Q et �dti a ..
Owner: If o r,.�.
Dee of Inspection: 9I 15/ao
Flow CONDITIONS
RESIDENTIAL: L
Design Mow: U�-c g.p.d.lbedroo .
Number of bedrooms Ideisign): PLC- Number of bedrooms)actual):3
Total DESIGN flow Lust ,6
Number of current residents:
Garbage grinder(yes or nok AA
Laundry(separate system) es or no): /Lc: If yes,separate inspection required
Laundry system inspected y(yes or no)
Seasonal use(yes or nol:_.ILO (.L�a _
Water meter readings,if•• )able(last two year's usage(glad): I t„
Pump(yes or no): •
Last date of occupancy: t"I"t*QNn51-.
COMMERCIAL/INDUSTRIAL: V
Type of establishment
Design flow: cad I Based on 15.203)
Basis of design flow _,--
Grease trap present: or not
Industrial West ding Tank present:(yes or no)_
Non-sa ni waste discharged to the Title 5 system: (yes or no)_
Wet meter readings.if available:
L st date of occupancy:
OTHER:!Describe)
Last date of occupancy: GENERAL INFORMATION
PUMPING RECORDS and souruppoaf irdor ation:
Lent_ 140-t tY _ — -C-Iii C/ Pointra Au
System pumped as part of inspection: (yes or no) at
If yes, volume pumped: gallons
Reason for pumping:
TYPEoF SYSTEM
_ Septic tankldi.ub 4iemboa!xoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes o r nol l'it yes, attach previous inspection records.if any)
IiA Technology etc. Attach copy of up to data operation and maintenance contract
Tight Tank Copy of DEP Approval
Other 4 APPROXIMATE AGE of ell components,date Installed Pr known)and source of information: a ar s O-c-
Sewage odors detected when arriving at the site: (yes or no) /to
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
• (�SYPSTEM REFORMATION(contrued)
h / ) ftel if 111��1�
Property A Q� -L)R.k'iea�r � y
Owner: l st,.r,4
Date of Inspection: il/A /Dr
BUILDING SEWER:
(Locate on site plan)
Depth below grade:�3
Materiel of construction:_test iron ✓ 40 PVC_other(explain)
Distance from private water supply well or suction line 4/A
Diameter
Comments:Icondilpn of joipts, ven ng/avid/nest of leakage,etc.)
/��jjq_ A-fto d—
SEPTIC TANK: AJL* t
locate on site plan)
di j
Depth below grade.a a /
Material of construction."concrete_metal_Fiberglass _Polyethylene other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_1YesINo)
Dimensions: a X Y A. H
Sludge depth: I la r
Distance from top of ludge to bottom of outlet tee or baffle:
Distance n thickness:e m o '13'
(geee.wak of !o/t
Distance from top of scum to top of outlet tee or baffle: / ` 6 At �_ �`
Distance from bottom of scum to bottom of outlet tee or?attic
How dimensions were determined: c$Ji�r Lacy �IQ.�+c.
a 0 U
Comments:
(recommendation for pumping, condition pi inlet end Pullet tees or baffles, depth . iquid level in;Option to outlet igverrt.st�lural inte
evidence of leakage. etc.), c' ,. t - Litt t 7 UU yVCC��
kati..0 -' I. ....s arin�at�bn�I alrilL ra ' a.. fI��T Aa m— .k1,
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction' concrete metal Fiberglass _Polyethylene_otherlexplain)
Dimensions:
Scum thickness'.
Distance from top of mto top of outlet tee os baffle:_
Distance from b om of scum to bottom of outlet tee or baffle:_
Dale of las roping:
Co ants:
( commendation for pumping.condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural int
evidence of leakage,etc.)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
9
RS
Y FORM
ATION(continued)
Property Ales: / Cc)e ±ix' ' n �aINf
(
DOnwe nerof kupectiiac.
on:
y11O/110
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or et time of, inspection]
(locate on site plan)
Depth below grade:
Material of construction_concretes metal Fiberglass_Polyethylene_other/explain]
Dimensions:
Capacity: ga s
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No
Date of_✓J�* ious pumping:
Comm n(is.
(condition of inlet tee, condition of alarm end float switches,etc.)
DISTRIBUTION BOX:_ LS
(locate on site plan]
Depth of liquid level above outlet invert:
Comments:
(note if level and d ism is equal, evidence of solids carryover,evidence of leakage into m out of box, etc.) •
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(Yes or No)_
Alarms in working oroer Nol_
Comments:
(note conditiow6f pump chamber,condition of pumps and appurtenances,etc.)
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revised 9/2/98 Page of 11
c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prope A ass:
Owner:r: tiY ALL.
Done of Inspection: ha /Ptl j'7
SOIL ABSORPTION SYSTEM(SASI: f/`uta4k
(locate on site plan,if possible;excavation not required,location may be approximated by non intrusive methods)
If not located, explain:
Type:
Inching pits, number:
leaching chambers.number:_
Inching galleries, number:_
leaching trenches, number,length:
leaching fields, number.dimensions:
overflow cesspool.number:
Alternative system:
Name of Technology:
Comments:
(note coalition of
so irl, signs.of M1 tlre ulif failure, o gondlpg, damp soII-sop i�t'n of vegetation, etch
. r ( T r .i v/C U^V '
y • W
!P2/1121.11r7il: I!ll'
m _ t _ L
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 groundv:at
inflow lc col must be pumped as part of inspection)
Corn ants:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.(
PRIVY:
(locate on site plan(
Materials of cons coon: Dimensions:
Depth of sol
Comma
Inotytondition of soil,signs of hydraulic failure,level of ponding. condition of vegetation, etc,(
revised 9/2/98 Page oflt
• SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECDON FORM
SYSTEM INFORMATION(Continue/di
•
• O
Owner:ner: A °°."r`
Data of Inspection: el45/°-a
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks rk house)
locate all wells within 100' (Locate where public water supply comes
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revised 9/2/98 Page 10 of II
SUBSURFACE SEWAGE DISPORT SYSTEM INSPECTION FORM
SYSTEMANFORMATION
Property A
Owner: (Cte-e-C-
Date of Inspection: irt16 100
NRCS Report name •
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM ,5144'
Surface water
Check.ck Cellar
Shallow wells
Estimated Depth to Groundwater 7t Feet
Please indcate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
✓ Observed Site (Abutting property. observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators. installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
�Q/� 2 //�� Ot 7
��qq ) Lt.QX.d.� C,��C al ff1Yea —
YLe YUATwf' u ' . \._‘]I yA � � U
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revised 9/2/96 Page 11 of II
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