1504 Septic Inspection 1996 ess>{r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: A509 1.4-t5u44/A, t)Ed, jo2TNArvwP1-0NLSr4 _ —
Owner: EDMOND.3DYMPR Co#uvezy _ _
Date of Inspection:- cal ,74 _ _
131 SYSTEM CONDITIONALLY PASSES (continued) r/A
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):
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
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A h
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.
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:
The system has a seouc tank and soil absorption system and is within 100 feet to a sudace water supply or tributary 14 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 wate
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.
0] 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 correct
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.
I revised B/25/95) 2
William F.Weld
poems/
Trudy Coxe
Secretary,EOM
David B.Struhs
commosener
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
{;IN@NOWE
at 2 41996
NORTHAMPTON BOARD OF HEAD.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A 1
CERTIFICATION EDm oaD+DYMP A CONNrLC%
Address: ( 7../ W-4.1 . --*�
/gd Nor-ri/a?ro, Address of Owner. ../S _ Lou OVm CLF �m
(If different/ FAST ZIRP1PTbhs/N1ASS (Jy027
Inspection:, }/ 8u�^?S6 - '
y Name, Address and Telephone Number: '�D MA 5S,o/D/z
C u2TIS 156 M?/N'td. CNESTEeF
CATION STATEMENT information reported below is true, actuate
that I have personally inspected the sewage disposal system at this address and that the-
tplete as of the time of inspection. The inspection was performed Lased on my training and experience in the proper function and
ante of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Date: 11
or's Signature:
r.)).12:t.»— ta. Cw>ty
stem Inspector shall submit a copy of this inspection report to the Approving Authority ewit in thi
nf( 01 eysc of completes g this mit
ion. If the system is a shared system or has a design flow of 10,000 gpd or greater, inspector
port to the appropriate regional office of the Department of Environmental Protection. approving authority.Iginal should be sent to the system owner and copies sent to the buyer, if applicable and the app b
CTION SUMMARY:
tea A, B, C, or D:
STEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below. -'
(STEM CONDITIONALLY ?ASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
ate yes, no, or not determined (Y,
N, or ND1. Describe basis of determination in all instances. If"not determined", explain why not/
The inenic tank is metal, cr structurally-unsosti shows substantial infiltration h or tank failure is
imminent. Th e system will p ass inspect ion i f the existing septic t ank replaced with conforming sept ic tank as
approved by the Board of Health. c- -
feed 8/15/95)
One Winter Street • Boston,Massachusetts 02106
Ce P
1
FAX(617)556-1049
'ed on Receded Pea,
Telephone (617)292-s500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
,erty.Address:./.?!3y tas,srlrfPn✓07�e /1/04TNAns Nsf,
(en. E ■MalzbAL DYMPR C&Arnie-aY — - - - -
of Inspection: ' al Dssroa.lL - - -
YSTEM CONDITIONALLY PASSES(continued) rJ/ ,
Sewage badcup or breakout or high attic water level observed.in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven'diitribution box: The system will pass inspection if(with approval of the
A IAA'
Board of Health): Pefsl are-replamdT�s�ll` �
Od34. na:d=t sN'l s broken pi
obstnsaion is removed
-- distribution box is levelled or replaced - '-
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if(with approval broken oarrMo Health):h)aced of obstruction is removed
FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/R
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT HE SYSTEM IS NOT FUNCTIONING IN A MANNER C?
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
SYSTEM LIS FAIL UNLESS THE FUNCTIONING INOA MANNER ETHAT PUBLIC WATER
PUB SUPPLIER, IFSPPROPRIATE)
AND SAFETY AND HEERMINES THAT
ENVIRONMENT: '
The sysrem has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tubutair 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 water
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 5
ppm.
)1 SYSTEM FAILS: hypr
_ 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 correct
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 of surface waters due to an overloaded or clogged SAS or
cesspool.
2
(revised 0/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
WESrNAnPrsrl 2c4 4 yy, PrO& /HA
acres:.;%So —
EDMaNv t DYM/�NA Co,v.vEc.l..Y _
spection: al x+^+--96
5 FAILS (continued): NIA
_ 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 han.4 times in the last year NOT due to clogged or obstructed pipets).
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.l 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
conform baaeria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E SYSTEM FAILS: NIA
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)
fner or operator such bring tem an facility full with the groundwater e treatment program
ments of14CMR 5.00 nd600. Please consult the local regional office of the Departmentfor further nforati
3
sat 8/:5/951
I
SUBSURFACE SEWAGE DISPOSAL L SYSTEM INSPECTION FORM
CHECKLIST
,ddress: /SO V IVES TNRar'10TO42- Rd ,Uo2THArn Prof" 0'14-
`_D.nOtiD t DVM PNFt CONNe 4-(.Y
spection: }f „ %
re following have been done: -
✓ Pumping information was requested of the owner, •ccupant, and Board of Health. ,
✓None of the system components have been pumped for at least two weeks and the system has been receiving mtal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this
• As built plans have been obtained and examined. Note if they are not available with N/A.
—/The facility or dwelling was inspected for signs of sewage back-up.
/The system does not receive non-sanitary or industrial waste flow
✓//The site was inspected for signs of breakout.
✓ AAll 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 baffles 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 or(( - i e °rb
approximated by non-intrusive methods.
✓The facility owner (and occupants. if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
4
sad an5/9S)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (Continued)
Property Address:_45`O$r _«_r'A e:pr. _, ✓YOZTAJAM?To ray/44
Owner: Eemo,vD + nM PA/A CC6ZLNELLY
Date of Inspection: at
SEPTIC TANK:_
(locate on site plan)
Depth below grade: /al'
Material of construction: ✓oncrete_metal _FRP_other(explain)
Dimensions: y,4°L 4'Z" L) 4k" D
Sludge depth: /O"
Distance from top of sludge to bottom of outlet tee or baffle: h5
Scum thickness: O''
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 invert, structural
integrity, evidence-:}eakage, etc.) This ffouSE HA 5 TEA/Ai VA caul— %i2 S6vseAL V%4is, No Cvm Ea{r
of Leak A4F
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: concrete metal FRF _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom cff MI"' to ponom 01 outle! We or oanie.
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. em.)
Levisec 8/:S/95,
SUBSURFACE SEWAGE DISPOSRATLCSYSTEM INSPECTION FORM
PA
SYSTEM INFORMATION
WESTWAM P.roa✓• .' .RbErMfrlPto& MR
ress; _ISUy
womb t- YMPNA CoNNEL6s/
ction:
FLOW CONDITIONS
agallons
edraoms:Z
orrent residents: NON('
der (yes or no):NO
aected to system (yes or no):. ✓Q C
(yes or no):NO R. Tc W—
readings, if available:
occupancy: 9
N/a
AL/INDUSTRIAL:
blishmenr
:�gallons/day
present: (yes or no)_
taste Holding Tank present: )yes or no)__
/ waste discharged to the Title 5 system: (yes or no)_
r readings, if available:
occupancy
escribel
f occupancy:
GENERAL INFORMATION
I RECORDS and source of information:
• a
lystem pumped as pan of inspection: (yes or no) '/ S
f yes, volume pumped: vallans Y
2eason for pumping: = 5'A'� T
n/ fe AA/ fE2 O.c peoFE.ET
SYSTEM AL, D'�YwEI-� l./'w rTH �ISE2
Septic tank/_./soil absorption system Z' 6ao(c
Single cesspool -
Overflow cesspool
Privy
Shared system (yes orC) (if yes, attach previous inspection records, I any)
Other (explain)
'.IMATE AGE of all components, date installed Of known) and source of information:
odors detected when arriving at the site: (yes or no) HD
5
d a/!5/951
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Address:_/• afire WEST.+f Apra/✓Ed iYhQTl:A M21-0 r14014.
EDMOND +DYM PA/4 COA2-veU-Y
Inspection: a-I 96
TANK:
,n site plan)
elow grade: ta•'
of construction: ✓oncrete metal _FRP_other(explain)
ons: ? PL //Z' W -
iepth: /0" /S
from top of sludge to bottom of outlet tee or baffle:
icknes5: n^
r from top of scum to top of outlet tee or baffle:__ -
from bottom of scum to bottom of outlet tee or baffle:__ -
nts: depth of liquid level in relation to outlet invert, structural .•
nendation for pumping, condition of inlet and outlet tees or baffles, p q
evidencer._Sleakage, etc) TN.5 HousE NAS•6Eta VQCA4T re S6 v92 Ai- Yc7425, No 4%,aEwa'
CAM A6C
TRAP:_
on site plan)
lir .
below grade:_
1 of construction: _concrete metal _FRP _other(explain)
sions:
hick nesr:_
:e from top of scum to top of outlet tee or baffle:
:e from bottom of scum to bottom or outlet tee or same:_
ems:
emendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level In relation to outlet invert, structural
ty, evidence of leakage, etc.', - -
6
Ls<L 8/1S/951
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
.Property Address: /Soy tr/ESTb/Fr/np734) ka NORrIiAMpran/_ _ p'/q- _
Owner: EDAdo,, +D}'Ar pNA CbcvNS4c
Date of Inspection: g):) c,,,�
, „96 — _
SOIL ABSORPTION SYSTEM (SAS):✓
(locate on site plan, if possible; exavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching ttjj. nu�m�ber.
leaching.it�Syc6ir 2,
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 pending, condition of vegetation etc.)
.Vo HYOgAuL'c i{i,C zf - pze G KAv61. -I-WASHED STorr£
Ti 2. We L(-.S HAD NP G10V1D FnP'ry
fO-- CAST Ca.uceET r 0 NAS aisc2S ON CEA/ree Arpne_DC zu" orcouSR.ovfS TAn/K
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:
I:dica:ion of groundwate•'
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
'I/a
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation etc.) -
.revised 8/15/S5) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
ress: ,SU y t4J SI& Al P?0 /--Rd - `✓02TN?/fP-t"os-. MA
anc/vD. -- DVAiPArA 5-vNNEt'1-%
coon:a) -e- %
OWING TANK: N/A
plan)
grade:_-
mstruction: _concrete metal _FRP _otherlexplain)
gallons
gallons/day
•inlet tee. condition of alarm and float switches, etc.)
ON BOX:2/&NE
se plan)
luid level above outlet invert:
I and disulbteien is equal evidence of solids ca:Yov'er, evidence of leakage into or out of box etc.)
\MBER:__
site plan)
^l/A
voriing order:lyes or no)
Ilion of pump chamber, condition of pumps and appurtenances, etc.)
7
e/cs/e5)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
liddress: /SO r/ WES.T FfAM PTa.$)
EDMOrv)7 -FD}'rvl f NA CeNNEL1,y
upection:
ORPTION SYSTEM(SAS):✓._. .
site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
ermined to be present, explainer
Na erg., #44 Prcol_ _ mA-
leaching j. number.
leaching
leaching galleries, number.
leachingtrenches, numbeglength:_
leaching fields, number, dimensions:
overflow cesspool, number._
its: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc) `-
4YOKAULrG' ?=AIL✓v.E'_"_.DZY F RA✓ot t4/AS01E71 STONE ..
V WS'G1,S HAn Nn Ltfl1,P 7) EA Per ova TRmK
rase r_pwa ^crec -' 0) As RiS25 ma rENTEPT APPR-0X 2y" arCnvSK
•
OLS: _
in site plan)
n/
/A
and configuration:
sp of liquid to inlet invert:
if solids layer:
if scum layer:
ions of cesspool:
Is of construction:
on of groundwater of inspection)
inflow(cesspool must be pumped as part lns pect
nts: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Al/A
on site plan)
Dimensions:
als of construction:
Of solids:_ Ievei of ponding, condition of vegetation, etc)
cents: (note condition of soil,signs of hydraulic failure,
8
see erect/em.
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
ddress:-1542471 L✓&STNA'MPro,) PCL
_DMOOD #DVM PNA CON AE L-L}u
spection: %
No4 TM14MQro-71) - MA.
)F SEWAGE DISPOSAL SYSTEM:
nclude ties to at least two permanent references landmarks or benchmarks
orate all wells within 100'
TO GROUNDWATER -
o groundwater feet
of determination or approximation:
°PEn& E,ELD
AvPtat . fZ+u /b"dF Go✓E2 eN SE Pte. TANlt
to 2AccE5
ALL M 4 u P&ms.0-r A'QE APP aokr M ArE'
No Sc4Lg
9
td 0(15/951