628 Septic Inspections 1997&1999 HOWARD ENVIRONMENTAL SERVICES
TITLE 5 SPECIALISTS
750 NORTH PLEASANT STREET, REAR
AMHERST, MA 01002
PHONE: (413)256-8008 FAX: (413)549-1850
June 6, 1997
Mr. Philip Westmoreland
628 Westhampton Road
Northampton, MA 01060
iP THAMJIPTON eOARO OF H:ALT?+
Re: Subsurface Sewage Disposal System Inspection, 628 Westhampton Road,
Northampton, MA.
Dear Mr. Westmoreland
Enclosed please find a copy of my report for the referenced inspection. I have forwarded
copies of the report to the Northampton Board of Health per the requirements of 310
CMR 15.301-15.304.
Based on the results of my inspection in accordance with 310 CMR 15.301-15.304, I
have concluded that the system passes at this time. The Septic Tank, Distribution Box
and approximate Leaching Chamber locations have been clearly identified in the "As-
Built"drawing on page 9 of the Subsurface Sewage Disposal System Inspection Form.
Please call if you have any questions, and thank you for this opportunity to be of service.
Sincerely yours,
J_-2t2^ r.
Dan Nitzsche
SE, Certified Title 5 System Inspector
cc: Northampton Board of Health
PERC TESTING • SEPTIC SYSTEM ENGINEERING • ENVIRONMENTAL CONSULTING
TIMOTHY E. MAGINNIS, RS
Environmental Consultant• Registered Sanitarian
70 Montague Road
Westhampton, MA 01027
(413) 527-5291
Northampton Board of Health
City Hall-Main Street
Northampton, Ma 01060
Attn: Mr. Peter McErlain
Health Agent
Re: Northampton - Lot# 9-Park Hill Road
March 8, 1999
Dear Mr. McErlain:
This letter is to inform you that the individual subsurface sewage disposal system which is
owned and operated by Sue Biggs and Liz Ryan of Lot# 9 Park Hill Road in Northampton,Ma.
has been installed by Mr. Thomas Childs of Westhampton,MA. The newly installed system was
inspected by Mr. David Kochan of your office and myself during the month of December, 1998.
Please be aware that when I inspected the site the soil absorbtion system was covered with snow
and therefore I did not see the final cover. However,in conversations with Mr. Childs and the
homeowner, I have learned that the system is complete but needs finish work in the spring.
As a result of my inspection,I recommended that at lease two permanent reference points be
established near the distribution box which will aid in locating it in the future. 1 also recommend
that two (3')sections of re-bar( or equal) be driven into the ground and measurements be taken
and recorded from them to the distribution box. Said ties should be recorded on the approved
plans for future reference. In addition, l recommend that the raised leaching bed system be
mulched with hay to prevent soil erosion in the spring.
It is my opinion that with diligent maintenance and operation it should provide trouble free
service in the years to come.
If you have any questions please do not hesitate to contact me.
c.c. Ryan/Biggs
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
BI
Property Address:
Owner:
Date of Inspection:
SYSTEM CONDITIONALLY PASSES (continued)
LL Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructec
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of t
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
Lv The system required pumping more than four times a year due to broken or obstructed pipers). The system will pass
inspection if(with approval of the Board of Health):
broken pipers) zre replaced
obstruction is removed
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 protec
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNEI
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
rf./ Cesspool or privy is within 50 feet of a surface water
4,[ 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 TI-
THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
3). OTHER
J.
(revised 11/03/35)
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to
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 o(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 wa
supply well, unless a well water analysis for coli(orm 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 Char
PPm.
2
HOWARD ENV3IRONMENTAL SERVICES
750 NORTH PLEASANT STREET, REAR
AMHERST, MA 01002
(413) 256-8008
HOWARD ENVIRONMENTAL SERVICES
750 NORTH PLEASANT STREET, REAR
AMHERST, MA
(413) 256-8008
Commonwearth of Massachusetts
Executive Office of Environmental Affairs
Deportment of
Environmental Protection
Olen F.Weld
meow
moo Paul C Iluod'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
CERTIFICATION
/ (� A/cRTH'4°-7,TP4✓
L,/[-jTim,-(�Oi✓ 8d) Address of Owner:
Address: % Of different)
Inspector: DA ' j;1
INa e, A reii and dJ TTt hone N
Name, Address and 7elepMne Number.
SCE -4-Be Oc
Trudy Coe•
Davie B.Shahs
TICH STATEMENT
pat I have personally performed based on my training and experience in the proper function and the sewage disposal system at this address and that the information reported below is true,accurate
glare as of the time of inspection. The inspection was Pe
snoe of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the local Approving Authority
_ Fails
• //�/ {/j(�C////�,� Date: 67' ( �
ties Siputure:Da submit a of this inspection report to the Approving Authority within thirty 0the days of owrer completing this
suhmit
Opt,. If the system is a shared system or has a design Bow of 10,000 god or grater,the inspect or and
rate regional office of the Department of Environmental Protectible and the approving authority.
tort al the ld be system owner and copies sent to the buyer, app
riginal should be sent to the cyst
{T1ON SUMMARY:
heck A, B,C,or D:
YSTEM PASSES:
I have not found any information whirls indicates that the system violates any of the failure criteria as defined in 310 CMR 15303.
My failure criteria not evaluated are indiated 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.
iase yes/no or not determined (Y,N,or ND). gibe bas slof ddetermination e substantial in l instances.
If nr e�er lo�, exnplain whys
The input tank is metal,cracked, on if the existing septic tank is replaced with a conforming septic tank as
iimminent. The system will pass inspection
approved by die Board of Health.
1
wised 11/c3/951 • Telephone(617)2fi2-8500
OM Sec Street • Boston,Massachusetts 02108 • FAx(617)556.1049
0 rnmedonaRVU.dr pit
SUBSURFACE SEWAGE DISP05AL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Dale of Inspection:
Clerk if the following have been done:
�%Pumping information was requested of the owner, occupant, and Board of Health.
✓None of the system components have been pumped for at
during that least
tro two weeks and the system has been receiving othis normal Bm
e period. Large volumes o/water have not been introduced into the system :ettn;ly or as pan of inspectior
��As built plans have been obtained and examined. Note if they are not available with WA.
1.----The facility or dwelling was inspected for signs of sewage backup.
CSC system does not receive non-sanitary or industrial waste flow
s-----The site was inspected for signs of breakout.
✓All system components, excluding the Soil Absorption System, have been located on the site.
C-----The
ttees,septic
al of construction, dimensions, dept opened,I quid, depth of sludge, depth of scum inspected for condition of baffle
' The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility owner lard occupants, if different from owner) were provided with information on the proper maintenance of 5
Surface Disposal System.
(reviled 11/03/95)
4
HOWARD ENVIRONMENTAL SERVICES
750 NORTH PLEASANT STREET, REAR
AMHERST, MA 01002
(413) 256-8008
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
CERTIFICATION (continued)
dress: 6 z8 (,,Est °TpAl Rol
WErMU2ELhdilZ
rectbn:
a•20 -
FAILS:
s
rave determined that the system violates one or more of the fallowing failure criteria as termed in CMR 15.303. The r
r this determination is identified below. The Board of Health should be contacted to determine what at will be necessary to correct
e failure.
L Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
J Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
i Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
3 liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
dRequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
11,1 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.
LAny portion of a cesspool or privy is within a Zone I of a public well.
p Any portion of a cesspool or privy is within 50 feet of a private water supply well.
/1 I Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from
attach private
of water dell with
for
acceptable water quality analysis. If the well has been nix nitrogen and acceptable, atta
coliform bacteria, volatile organic compounds,
:E SYSTEM FAILS:
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) and the system is a significant threat to
DuHK 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 II of a
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPM or a mapped Zone
public water supply well)
saner or operator of any such system shall bring the system and facility into full
of the compliance a with the e groundwater program
rernents of 314 CMR 5.00 and 6.00. Please consult the loaf regional
dela 11/03/951
3
HOWARD ENVIRONMENTAL SERVICES
750 NORTH PLEASANT STREET, REAR
AMHERST, MA
(413) 256-8008
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SEPTIC TANK,(' /S?jtj q4C.
(locate on site plan) J �
Depth below grade: /d" /a a;se g. i 4" Atjai= ccl(a v'Act-C
Material of oonstruaion: rconaete _metal FRP otherlexplain)
Dimensions. /O.S ' X CP 8'r K 60,.
Sludge depth: 1(„
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 16 "
Distance from top of scum to top of outlet tee Of baffle:
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, etc.) STkKenaypAL TM-re dairy —C°»- 6 r61014 CNL hT GAME TNVGItT ; 64FQF5 C). . N =E05 Z
l36 Pu
GREASE TRAP:470
(locate on she plan)
Depth below grade:_
Material of construction: -concrete-metal -FRP-otherlexplain)
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:_
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet inven, strucural
integrity, evidence of leakage, etc.)
(revised 11/e3/5s)
6
HOWARD ENVIRONMENTAL SERVICES
750 NORTH PLEASANT STREET, REAR
AMHERST, MA 01002
(413) 256-8008
SUBSURFACE SEWAGE DISPOSAL L SYSTEM INSPECTION FORM
SYSTEM INFORMATION
muss, /g3 WC-57NA. P1D
vies-r-r-vo2ECq.✓A
rpection:
w: 'L —gallons
f bedrooms: 3
if current residents:4
{finder(yes or no1:AIFL5
onneci or no)ed to system(yes 'i_ej.
use (yes or rw):
ter readings, if available
w
2c1
FLOW CONDITIONS
0
of occupancylyYSNi
iRCIANND STRIAE
establishment:
llow:„„gallons/day
trap present (yes or no)_
al Waste Holding Tank present. (Yes or no)�
sitary waste discharged to the Title 5 system: (yes or no)_
neter readings, if available:
to of occupancy:
L• (Desaibe)
ne of occupancy:
GENERAL INFORMATION
PING RECORDS and source of information: /q8 q 6,� eL
KA 's aWArn16_
System pumped as pan of inspection: (yes/or n/o)42s
If yes,volume pumped: S G llo`s S• iA4.�P•
Reason for pumping:_AATI
E OF SYSTEM
Septic tank/distribution box/soil absorption system
_ Single cesspool
-- O✓erflow cessPool
Shared if any)
hare l system (yes or no) (if yes, attach previous inspecion records,
S
Other(explain)
PROXIMATE AGE of all components, date installed (if known) and source of information:
1989 -
wage odors detected when arriving at the site: (yes or no)N()
revised 11/o8/ss1
5
HOWARD ENVIRONMENTAL SERVICES
750 NORTH PLEASANT STREET,TREET REAR
AMHERST,
(413) 256-8008
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM (SAS):S.
34"
(bate on site plan, if possible; excavation not required, but
If not determined to be present, explain:
Type
leaching pits, number:
leaching FltTrst7�ri1 number: /JO C41-
leaching gallF-tes�number
leaching trenches, nurnber,length:
leaching fields, number, dimensions:
overflow cesspool, number:
may be approximated by non-intrusive methods)
co-cAFTE PesaAr-
CArnments: (note condition of soil, of hydraulic failure, level of ponding, condition of vegetation,etc.)_L/put D LSVeC -
Ij e P, VG--, UE A iC/A)
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 conmucion:
Indication of groundwater
inflow(cesspool must be pun sped amino su pars peaf ion)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding condition of vegetation, etc.)
PRIVY:ijr 1
(loarz on site plan)
Materials of constrssainn:
Depth of solids: Dimensions:
Comments: (note condition of soil,signs of hydraulic failure, level o/po Min g condition of
vegetation, etc.)
(revi•ed 33/03/95)
8
HOWARD ENVIRONMENTAL SERVICES
750 NORTH PLEASANT STREET, REAR
AMHERST, MA 01002
)413) 256-8008
SUBSURFACE SEWAGE DISPOSAL CSYSTEM INSPECTION FORM
SYSTEM INFORMATION (continued)
ddress: (✓ LLA TFtAA--PTl.cl R'^
W t4rry paf.-w,t�
9 +bn: S, 0-0
9 �
R HOLDING TANK:
site plan)
low wade.__ metal _FRP other(explain)
of construction: _concrete _
ors:_�-
9allons
low' vallons/day
vet:
nts:
on of inlet tee, condition of alarm and float switches, etc.)
JBUFION BOXY:
on site plan)
1 of liquid level above outlet Invert:, n
evi. na of solids carryover, evidence of leakage into or out of box,etc.) Af CO UeA/CC of
rents: ,J SaE � _ r if level and distribution is equal, - 5 _. R
AP OIAMBER:
ate on site plan
1ps in waking ordehhle or no)
"'merits: m dtamber,condition of pumps and appurtenances, etc)
te condition of pump
revised 2/03/951
7
HOWARD ENVIRONMENTAL SERVICES
750 NORTH PLEASANT 02 REAR
AMHERST, MA 01
(413) 256-8008
SUBSURFACE SEWAGE DISPOSAL
PART INSPECTION FORM
SYSTEM INFORMATION (continued)
ress: GZg WGST -440-1 h/
✓EStMO act AA I>
.coon:
5.20-9�
SEWAGE DISPOSAL SYSTEM:
Jude ties to at least two Permanent references landmarks or benchmarks
ate all wells within 100'
31 '
CVOT TO
Sc at_C /
16.0
�el
T 91
frallw /� 515'
tyr± T T
6-60 166 SEpnc,ngt
100o G�L,.�
CHA, 3ER
N TO GROUNDWATER
h to groundwardr.>�—F �tlon:
pod of determination or an
Aged 11/00/951
c-D
pAC,Es
IESTH k'4 tTd Rt
lath AID tsuraTRArTion/
9
HOWARD ENVIRONMENTAL SERVICES
750 NORTH PLEASANT STREET, REAR
AMHERST, MA
)413) 256-8008
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: G �i Gr/�siha / /3oa/
Owner; 0,7/
Date of lnspecdon: -7_ 7_ 9%
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
V have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Ai
criteria net evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components es described in the "Conditional Pass" section need
completion of the replacement or repair, as approved by the Board of Health, will to be mplacetl or repaired The amt.
Indicate yes. no, o not determined IY, N. or NOI. Describe basis of determination in all instances. If "not determined", explain why
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Comfit
Compliance(attached)indicating that the tank was installed within twenty (20)years prior to the date of the imps
the septic tank. whether or not metal, is cracked. structurally unsound shows substantial infiltration or nfiltratior
failure is imminent. The system will pass inspection if the existing septic tank is
approved by the Board of Health, g e p replaced with a complying septic
vi
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstruct
ore Cue to a broken, settled or uneven distribution box. The em inspection it
syst will pass with approval of the Bae
broken pipelsl are replaced
obstruction is e ved
distribution box is levelled or replaced
The system regained pumpngmaro than four-irnes a yeardue to obarnscled
inspection if l with a broken or pipalsL The vystena gylye,
approval of the re replaced
of HeelMl:
broken pipe{s) are replaced --
obstruction is removed
Page 2 ofII
C' F,
COMMONWEALTH OF MASSACHUSETTS . 1 9
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECPlldATCN comic CF HEALP•
ONE WINTER STREET BOSTON MA 02108 (617) 292x500'-`
TRUDY CORE
Secretary
DAVID B. STRUMS
Commissioner
ARCED PALL CELLUCCI
Governor
SUBSURFACE SEWAGE DISPOSAL ARSYSTEM INSPECTION FORM
CERTIFICATION
Property Add/flit L/x)6?-4417 lm`fh r/ Nn of Ows 17-77/M/
Nor�t+a/PpP y /Lea Address of Owner: --Ces-1 m
Date of Inspector': (Reese R Print' f rh L:J�
Noma of Inspector:1-n a approved system inspector pursuant to Section 15.340 of Title 5 1310 CMR 15.0001
lam a DEP apps v we,. , & 0� �
Company Mats: r� . -�, _ l0//
TeleMa`°Number: ' Cn E 8
1 certify that have personally
inspected sewage disposal system this address and that the information below is true. accurate
CERTIFICATION STATEMENT
and eo inspection. tion w s per fo rm ed based on my training end exptince in the proper function and The
e me ance al on-s the to sewage d sposal systems. The system,
Conditionally Passes Authority
Needs Further Evaluation By the Local Approving y
Fails
Date: Lrm,<
The System Inspector s II submit a copy of this inspection report to the Approving Authority !Board of Health or DEPlwithin thirty 1301 days of
Inspectors Signature: o I1
completing this Inspection. II the system Is a shared system or has a design flow of 10.000 god of greater.the inspector and the system owner
shall submit the report to the appropriate regional office of the Depanmmt 1st4mvionmerdet Protection. The original should be sent 1011141
system owner and copies sent to the buyer. it applicable. and the approving authority.
NOTES AND COMMENTS
NO 1 x111
_eV-Sew 0/2
HOWARD ENVIRONMENTAL SERVICES
750 NORTH PLEASANT STREET(REAR,
AMHERST.MA 01002
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Icondrwedl
Address: .�5 Gj
`s1Lo,,rao4a, ...,_:-/:oad
Owner:
<ain a—. 2 D.te of Iu p.ction
1-7_ •_ 99
D. SYSTEM FAILS:
You must indicate either"Yes.. or No to each of the following:
I have determined that a of the following failure conditions exist as described in 310 is identified below. The Board of Health should be contacted to determine whatwilllbet ec0 nary to basis orect
Yes No necessary
of,e wage lino fadliWso peatern temaonenpdo. 0 an overloaded or-Gagged SAS°ro°aapool. y- s•
- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged S.
cesspool.
Static bgWd level to the distribution box above outlet Invert due to an overloaded or clogged SAS arcesspool.
- Liquid depth in cesspool is less than 5" below invert or available volume is less than 1;2 day flow.
- Required pumping more than 4 times in the lest year NOT
due to clogged or oosiructed pipets .
Number of times pumped
- Any portion of he Soil Absorption System. cesspool or privy is below the high groundwater elevation.
Any po,non or a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
- Any pariah of a cesspool or prier rx avitnin a Zone l of a public well a suppl
.
- 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• han 100 feet but greater than 50 feet from a private water supply well wi
cep
bre wt ! volatile ali y analysis. If the well has been analyzed to be acceptable, att.ach copy of well water e
nalvm-colfor ta ae organic s compounds. e nitrogen and nitrate nitrogen
E LARGE SYSTEM FAILS:
You must indicate either -Yes.' or "No'- to each of Ole 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
and safety and the environment because gpd or earco dysons l x st the st a
health signiXCant threat
t bet a one or more of the fallowing conditions east sy
Yes No
- the system is wiNln 400 feet of a surface drinking water supply
- the system is-within 200 feetol-e-niputeryde a eurNw.d
nrNrirg.watersuM1lY __
- the system is located in a nitrogen sensitive e a Onterim Wellhead Protection Area- IWPAI o
r e mapped Zone If of e
water supply well) re
The owner or operator of any such system shell upgrade the system in accordance with 310 CMR 15 304421. Please consult the local re
office of the Depenmene for further information.
revisea
Poee 4 nn l
SUBSURFACE SEWAGE DISPOSHALASYSTEM INSPECTION FORM
PAT CERTIFICATION(continued)
swan AdErES,: G F G/Cs/ 4, t'lr/0 '47a d
Owls: -do
Date of Inspection: '7— 7- 99
FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health
public health. safety and the environment.
TM IS 15.3031111b)THAT THE
SYSTEM
IS NOFUNCTIONING N A MANNEB WH CRNILL PROTECT THE PUBUC HEALTH AND SAFETY AND THEFNVBONMEKfl
Cesspool or privy is within 50 feet of surface water wetland or a salt marsh.
Cesspool or privy is within 50 feet of a bordering vegetated wetland
1)
order to determine if the system is failing to protect the
HEALTH(AND PUBLIC WATER SUPPLIER.IF ANYI DETERMINES THAT THE SYSTEM IS
21 SYSTEM WILL FAIL UNLESS THE BOARD OF
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface writer supply or
tributary to 5 surface water supply.
The system has a septic tank and soil absorption system and the SAS Is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
t water supply well.unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
The system has a septic tank and soil absorption system and the SAS is less then 100 feet but 50 feet m more from a
private we er su
ell is free from pollution from that facility and the presence of ammonia nitrogen and nitrate mtto9en is equal to or less
than 5 ppm. Method used to determine distance
(approximation not vdidL
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
31 OTHER
as
Page!a 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Ada en: or .Q..27 72 i®5 ihcs7) ->Jadr
Owner: tor,-ib�i �-do /3oct c/
Date of Inspecton:
-- 99
RESIDENTIAL: now cOHOInONS
Design flow: g.p.d./bedroom.
Number of bedrooms (design): — Number of bedrooms factual))
Total DESIGN flow_
Number of current residents:a
Garbage grinder)yes or
no) (y+5
Laundry (separate vsem s o
.NO, If yes. separate inspection rapuired Laung
Laundry system i es t 1 e or nnl
Seasonal s nal u e (yes o no :Aip
Water m readings.if available (last two year 3 sage Igpd)-
Sump Pump Ives or non NV
Last date of occupancy cc��c.,Ny OC a r/
N-
COMMERCIALINDUS TR IA L:
Type of establishment.
Design flow: sod I Based an 15.2031
Basis of design flow
Grease trap present: ryes or no)
Industra( Waste (folding Tank present:Wes or no)_
Non-s or ary waste e discharged to the Title S system: (yes o no
Water n eadin if available
Last date of occupancy:
OTHER: ID escribel
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of Information:
/CM ✓ v — A'G//E '
System pumped as pan of Inspection: Ives or nal ✓! 5
If yes. volume pumped: , Op gallons ✓
Reason for pumping: /�
TYPE OF SYSTEM
\....PP' Septic tankdisblbution box:sail absorption system
Single cesspool
Overflow c esspool
Privy
Shared system or
I/A Technology etc. Attach copy yes.0 mach ate previous nion ands records. if on o
Tight Tank copy Approval
to date ppere0on and maintenance contract
Copy of DEP gppmval
Doer
APPROXIMATE AGE of all components, date instakedAl knownbend source o ieforrnadon:
Sewage Deers detected when arriving at the site: (yes Or no( No
Pace n al II
SUBSURFACE SEWAGE DISPOSALBSYSTEM INSPECTION FORM
PART CHECKLIST
+warty"dr.": In aS l•�•s/1170th/0/Z1.e-7 f3ou c/
)carter: Loth C'Ora0
)ate of Inspection:
Check d the following have been done.You must Indicate either "Yes" or No es to each at the following:
:9 Yes/ Na
_ Pumping information was provided by the owner. occupant, or Board of Health.
.None of the system comPUeats hasedean poopedrleeatleeet two weeks anaktta western hu<aaua eaimgaml Sow
part of this
rates during that period. Large volumes of water have not been introduced into the system recently
Inspection.
10'.... _ As built plans have been obemed and examined. Note if they a e not available with NIA.
]l The facility or dwelling was Inspected for signs of sewage back-up.
The system does not receive non-sanitary o 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.
Or The septic tank m re uncovered, opened, and the Interior of the septic tank was inspected for condition of baffles
— manholes wt eyed, s, d
Tr tees. and location ti n of the Son, bs dimensions, depth of liquid,e site eM1 s been determined based on:of
The size and location of the Sail Absorption System on
]Z.'. _ Existing information. For example, Plan at 8.0.H. sue unacceptable)
Determined in the field Cif any of the failure criteria related to Part C Is at issue, approximation of distance is a¢eptablel
N` 115.3021311b11nemcf
_ The facility owner land.occopaws-it ditlereat Irom�wned wezamcvided with idnsmauomon tba swoer
SubSurtace Disposal Systems.
revised 9/2/98
Page of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION IconurNedl
Address: G, � Gc/�51iiC.ei-p�o." "IOC
Dire of k sp�ecti b4�LJC-
TIGHT OR HOLDING TANK: (Tank must be pumped
(locate on site plan) poor to, or et time of, mspecrnm
Depth below grade:
Material of construction_concrete metal Fiberglass Polyethylene otherlexplein)
Dimensions
Capacity: gallons
Design Pow; gallons/day
Alarm present
Alarm level; Alarm in working order'. Yes Na
Date of previous pumping: — —
Comments;
Icon diti on of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX)
(locate on site plan/
Depth of liquid level above outlet invert.
Comments
ore if level and distribution Is equal,evidence of solids carryover n j O / , evidence of leakage el bax, c.l
3
PUMP CHAMBER:
(locate on site plan)
Pumps in working order: 1Yes or Nol_
Alarms in working order r Yes or Nol
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.]
Page v et I I
SUBSURFACE SEWAGE DISPOSAL
O SYSTEM INSPECTION FORM
SYSTEM INFORMATION}continued)
Prepack Retinas: lr aR ✓es Lho��Fo•-' /-3oo
Owner: Gom
Date of wpe<lon: 7_ 7—q9
BUILDING SEWER:
(Locate on she plan)
Depth below grade
Material of construction: cast %3� ast Iron f<0 PVC_other (explain)
Distance from private water supply well or suction line
Diameter '_ evidence oHaekage.etcl
Comments: (condition of)Dints,venting, me - <pm
• vtirh
SEPTIC TANK:_
(locate on site plan) ZZ��
Depth belowograde.yye /nc metal Fiberglass _Polyemylene otberleeplainl
Material of construction: rata
If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No)
et 4 G y
Dimensions: /
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: '>
Scum thickness: C •, to top of outlet tee or beHle: L _ _
Distance from top f m to bottom of outlet tee or baffle'
How from bower d scum r��
now eimensmna were determined: /%/�
Comments: condition of inlet and outlet tees oo baRlez. depth of li0uitl level in re n to outlet
(recommendation for pumping. con _ h
evidence of leakage. etc.)
GREASE TRAP:
[locate an site plan)
Depth below grade:
Material Material of construction: concrete metal Fiberglass Polyethylene
_
tructu
tegrity.
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:
{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.)
=vises 9/2.9
Page"of(l
'roper--y Adtress:
)artier: II/P-7
)at•of Inspection:
SOIL ABSORPTION
'.locate on site Nan.
SUBSURFACE SEWAGE DISPOSAL C SYSTEM INSPECTION FORM
SYSTEM INFORMATION(contrasted)
F p U_ GI
6.022 /5690
7- 9?
1On
SYSTEM IBASL— not required.lacetion may be approximated by n n Intmelve methods]
if possible: exce ion
If not located. explain:
Type
leaching pits, number_
leeching chambers, number: ///l%% J:1
leaching galleries, n mber-
leaching trenches. mber,length•._
leeching fields, number, dimensions:__
overflow c a sspool. number_
Alternative system:
Name of Technology:
Comments: g oil, condition of vegetation.
(note condition of sod. signs of hydraulic failure. level of pemm� damps on
CESSPOOLS:_
tlocate on site plane
Number end configuration-��
Depth-top of inwa to inlet invert
Depth of solids layer
Depth of scum layer
Dimenaiom of cesspool
Materiels of construction —�
Indication of gw 'cesspool must peaiom
inflow r ey its t be pun/
Comments: f hydraulic (dilute. level of pending. condition el,vegmaupn
mote condition of sou. vgns a
PRIVY:
Locate on site plan/
Materiels of construction.
Depth of solids: ev:.l
(note condition of hydreulic failure.level of ponding, condition of vegetation.c of soil, sign/
Pce. of u
Dim its.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART SYSTEM INFORMATION Icantinsedl
merry Address:
ever:
M1e of Inspection:
KETCH OF SEWAGE DISPOSAL SYSTEM:
'nclude ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes Into house)
(-PIP T. co See Ak )
Page 10 of 11
revLsed 9i
ult SrH Av ?-a n'
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: b?f c" 5/%a, -,t' .
Owner: L.o22 oc..
Date of Inspection:
7- -7 _`/7
NRCS Report name %.-01 0 Li /v4 '
Sod Type /r>r+r it/ry /oam(/
Typical depth to groundwater r.
USGS Date website visited 62'—/5 - y4
observation Wells checked Moderate ✓ Deep
Groundwater depth. Shallow
/` OG 0
{-.r/ //i./-'& /9C/
SITE EXAM
Slope 5 •/'
Surface water .o
Check Cellar 7--
Shallow wells rcy
Estimated Depth to Groundwater / 'Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
y Observed Site (Abutting property, observation hole. basement sump etc.)
't.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) / '�/ ,
J`%Jd crl S.
/ ..�< / 5 o. /5c G
/e//9/r o/ 6/i�/-/-7, rG' 67---/,i�.G/L✓cs Nr G 5 Lam. . ,
7 /102 5 0/ u/o fee—VT la /fvo./-76m
LA,' C..)//1
baS,0r,.2.r 47 r.
revised 9/2, 98
Page 11 of 11