136 Septic Inspection 1998 BOARD()F HEALTH
JOHN T.JOYCE,Chairman
ANNE BORES.M D.
CYNTHIA DOURMASHKIN,R.N.
PETER.' McERLAIN.Health Agent
March 19, 1998
Rick Mott
C/o Stella Mott
136 Chesterfield Road
Leeds, MA 01053
Dear Mr. Mott:
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
210 MAIN STREET
01060
(413)586-6950 Ext.2
Re: Septic System Inspection 136 Chesterfield
Rd. Leeds
The Board of Health is in receipt of aleport on a sewage disposal system inspection
conducted at 136 Chesterfield Rd by Greg Newman on March 14, 1998. That report
indicates the following:
• The septic tank needs to be pumped , there is a heavy sludge build up
• Existing baffles are deteriorated
• Distribution("D") Box is deteriorated
• It appears that the dwelling's water line passes under the leach field.
Based on Mr. Newman's report your sewage disposal system has been listed as "passed
conditionally." In order for your sewage disposal system to be classified as "passed"you
must do the following:
• Pump the septic tank
• Install new inlet &outlet baffles in the septic tank
• Replace the deteriorated "D" box and level the lines out of the"D"box (1'2R)
• Seal any leaks around the septic tank
• Clean any accumulated sludge out of the distribution lines
All of the work described above must be done by a licensed septic system installer in
accordance with the requirements of 310 CMR 15.000 and a Septic System Repair Permit
must be obtained from the Board of Health office prior to beginning the work.
In addition,you must determine if the house water line, does indeed, pass under the
leach field. If it does, it is a potential health hazard for the occupants of the dwelling as
well as the other users of the city water, due to the possibility of sewage contamination if
the line should ever leaks. The line would then have to be relocated to a minimum of ten
(10) feet away from the leach field. You must obtain a permit from the City Water
Department prior to working on the water line.
' In accordance with the provisions of 310 CMR 15.000 of the State Environmental Code,
Title 5, and under authority of Massachusetts General Laws, Chapter 21A, Section 13,
you(or the subsequent owners of the property)are hereby ordered to repair the subsurface
sewage disposal system at 136 Chesterfield Rd., within two years of the date of the
original inspection, (by 3/14/2000). In addition von must relocate the water line (if
necessary) within ninety(90) days of the receipt of this Notice. If further degradation
of the sewage disposal system occurs, (e.g. sewage flowing to the surface of the ground),
the repairs will be required sooner.
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 587-1213 if you have any
questions conceming this notice.
Thank you for your anticipated cooperation in this matter.
Very truly yours,
Peter J. McErlain, Agent
Northampton Board of Health
cc: Northampton Water Dept. Superintendent Charles Borowski
Cert. Mail #P 082 852 899
March 16. 1998
Rick Mott
c/o Stella Mott
136 Chesterfield Road
Leeds- MA 01053
NEWMAN ENVIRONMENTAL ENGINEERING
"°A,MPTly Ei1Ai r,
RE: Title 5 Septic System Inspection for 136 Chesterfield Road, Leeds, MTA
11
11
N;-
MAR 18 ISS;t
Dear Rick:
As you are aware. the septic system at the above address was inspected March 14, 1998. The
inspection report (enclosed) presents the details of this inspection_ As discussed during the
inspection.the following repairs to this system are recommended:
• Pumping the existing septic tank
• Installing new plastic baffles in the septic tank inlet and outlet: the baffles should be
constructed of schedule 40 pipe and tees, and should extend at least 19 inches below the
flow line
• Sealing any leaks observed around the top of the septic tank with particular attention
paid to the knockout panels as well as the inlet and outlet ports; a new cover is also
required for the outlet port.
• Installing risers over the septic tank access ports, in order that the system may be more
easily maintained (Le. pumped) and inspected in the future.
• Installing a new D-box with a plastic tee baffle on the inlet; new plastic outlet pipes shall
be level for at least the first two feet from the D-box
• Snaking each of the three leach field distribution pipelines to mechanically remove any
sludge from the inverts of these pipelines & remove any blockage to flow
It was also noted at the time attic inspection that the stater service to the house appears to go
under the existing leach field. A telephone call to Charlie Borowski. Northampton Water
Department Superintendent. indicated that the sen-ice to this house is a copper pipeline installed in
1955 at the approximate location as sham on the site plan in the attached report. It is concluded
that the leach field was constructed (c. 1965) directly mar the nsaterline. This situation presents a
public health concern: potential contamination of the public "cater supply. Therefore,it is
recommended that the existing water service pipeline to this house be abandoned and a new
service installed which avoids the existing leach field and septic tank to the extent feasible_
A permit to conduct the above repairs must be obtained from the Board of Health(413-587-1214).
If you should have any questions.please call me at 4I3-238-5383.
Von tru ■ yours.
NEW AN ANENVIRONMENTAL ENGINEERING
Grego _ ewman. P E.
Ncwn n-I vironmental Engineering
cc_ Northampton Board of Health
WILLIAM F.WILD
U
Governor
AItGEO PAUL CLLLUCCI
13.Governor
COMMONWEALTH OF MASSACHUSETTS ryj
I',XECUTIVE OFFICE OF ENVIRONMENTAL AFFA'1iit$A y�
DEPARTMENT OF ENVIRONMENTAL PROTECTION �8 /998
ONE St IN!! It SIRLE'f. ROSTON, MA 02108 619-292-5500 1+f..�'1
A,dPTCry OOAF00Fl{ /
EAtTF;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 1,14, T-4EE'•i ticnCti,tX11.4d Lte3)r d 0)+5. Address of Owner: cit Fa- A Il'1°11-
Date of Inspection '-S j i41'- (If different) I44 Gn I..'i:F dT l kis0 i7'xjF]
Name of Inspector: 4; IVr Gy t,',41t.„.1 h.C&ti)f, Su lb) (°.1(;
I an a DEI'Approved system inspector pursuant 1.0 Section 15.340 of Title 5(310 OAR 15.000) I
Company Nanie. ,J '1.l'.V4 Aim 1 Pow dL 14(0•
Mailing Address: Zi (ai UFCi') (,_c.;_A—fl, tLi%O.AULt.icrib11,6 M# 0 t IF!.
Telephone Number '}l. , d % , '417' . r
CERTIFICATION STATEMENT
certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection_ 'The inspection was performed based on my training and experience in the proper function and
maiflclst to of on site sewage disposal systems The system.
TRBbY COX
Sccrcfa
DAVIDB.SIRUII
Commission
0-11_;'asses
•..:x16 '-4,i1 Mt!
I�Conditionally Passes IN r_C Jc;4g.. id&rit--✓
/Needs y Needs Further Evaluation By the Local Approving Authority
.ih
inspector's Signature (:Lt✓ k -/}1 LACE Date: :31KP1q `
The System Inspector Shall submit a ropy of this insprttmn report to the Approving Authority within thirty(301 days of completing this
rnspet!ion. If the system is a shared system or has a design flow of 0;000 gpd or great r, the inspector and the system owner shall submit
Me report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent!t the buyer, if appllcahle, and the approving, authority.
INSPECTION SUMMARY: Check A, B, C, or D
Al SYSTEM PASSES:
have not found any information which indicates that the system violates any of the failure criteria as defined in 310[MK 15.303_
Any!aitlee criteria not evaluated are in(1iaurd holnw.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
Yiat
E -- One or more system components as described in the "Conditional Pass' section need to be replayed nr repaired. The system, upnr
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, ur not determined fY, N, or ND). Describe basis of determination in all instances. If"not determined',explain why not.
WSJ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; m
the septa tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure rs imminent. The system will pass inspection it the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(r.va..a 04/251071
vupe ). of 20
DEP en lhu W0112 Wide Wen Up stain ma uSlpen
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
pair A
CERTIFICATION (continued)
Properly Address: 13(, ( *'r te.t— ii t v '¢'_'s i'.E? LA`,Uil� f {'Yll -
Owner. r (SA i?Cf
Date of Inspection }I r„t I. E.
You ust indicate ei>,er 'Yes or No as to each of the following
DI
PC+ I have determined that the system violates one or more of the following failure criteria M 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.
Yes
No/
1/ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or pending of effluent En the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
• Static limed level In the distributmn box above outlet invert due to an overloaded or clogged SAS or cesspool
V 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 obstmned pipe(sl.
Number of times pumped—
1/ Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
▪ Any mutton 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 1 of a public well.
Any ponion of a cesspool or privy is within 50 feel 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
colifonn bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
Ef LARGE SYSTEM TAILS: hits'
You must indicate either"Yes" or"Nn"as 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)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist.
Yes No
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)
The owner or operator of any such system shall bring the system and facility into hill compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for funher information.
Irwllra 04/25/97)
a.pe a of ID
sintriose
A:: .n ....4a.._C_.C..
PART B ...._.....
CHECKLIST
Property Address: 1='I( ( ttE`,i i1t.('y-11/4„t %5 C'=
Owner: - IVtC it l
Date of hope(Bun. .i' fe` 'rl
-41St' ittkot..
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. f-"-,f e/)11 k\ t & !
--- o f'- if"1'cl 11r1 ; I=J.r4 tit t.:i�, { Y.vCls7il tLC' Aryrii ')FlfL )
( G.esetc a'IJ tY6''
✓ _ None of she system cn donne that have been pumped mr at f water er two weeks and the introduced has totth receiving recently cer system
flow rates during that penusl. Large volumes of water have not been introduced into the system recently to
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
V PPf_ The faciliy or dwelling was inspected for signs of sewage back-up. jyduTE
_✓/ The system fines not receive non-sanitary or industrial waste flow.
Y✓ _ _ The site was inspected for signs of breakout.
SAX All system components, excluding the Soil Absorption System,have been located on the site.
i>>✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or sees, 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:
The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System. L-- f fkf Ill r.,
Existing information. Ex. Plan at B.O.H.
Determined in the field Of any of the failure critetia related to Part C is at issue, apprnximation of distance is
unacceptable) (l5.302(311bd
s/
Iravlud 0405/971
Pact° 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
CERTIFICATION (continued)
Properly Address! 1' 2 (Y1(.-+STz... (-1 Ety,
Owner. _j _ K4
Date of Inspection: .r1 'i. 1'iF),
R)SYSTEM LUNDIFrulYnl.a +3ssa
Sewage barker or breakout or high nano water level observed in the distribution box is due to broken or obstructed
pipets)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Brad of Health). Describe observations:
4 broken pipets) are replaced
��A`�,i ahstrunicn is removed
xS.,_l distribution hox is levelled or replaced Z=%^ '-ssst1EA ll SE 1 rl<t 1) i ViaC
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
mspe Ctmn if(with approval of the Board of Flealth).
/�.'._ broken pipes) are replaced
obstruction is removed
Cl FARTHER EVALUATION IS REQUIRED RY THE BOARD OF HI ALTO
Conditions exist whirh require further evaluation by the Board of Health in coder 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 THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
A i Cesspool or privy b within 50 feet of a surface water
an,_ Cesspool or privy is within 5U 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 THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
Ai The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet to a surface water supply or
j tribunary to a surface water supply.
Ai The system has a septic tank and soil absorption system and the SAS is within a Zone I of a pubic water supply well.
IL The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
fy The system has a septic tank and soil absorption system and the SAS is less than 109 feet but 50 feet or more from a
private water supply well, unless a well water analysis for conform bacteria and volatile organic compounds indicates that
the well is tree from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 porn. Method used to determine distance (approximation not valid).
q) OTHER
'O _..asi1' i 'C-t L ( - tCt :LitA0 t WVii \ t'kiF
/�mil -1W L1(v'i #lk"S I1. {31°>x; 4SIx11V i7 55L`. Lk-9A/AL V-1 F-t_ll
(s.v9.aad 04/25/971
P424 2 of 10
SIJflSIJRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 166 C.v9vai1=t2-s- 1 E-L15 SS140> L.,e-Cori OA(\
Ownen `i. CV rr
Date of Inspection: -. I
RESIDENTIAL:
Design flow: j 1 t l g pal/bedroom for S A.S.
Number of bedrooms. 3
Number of current residents: 1
Garbage grinder(yes or no):^,_!
Laundry connected to system (yes or no):Vi:.'�
Seasonal use (yes or no)JJ 1J
Water meter readings, i1 available (last two (2)year usage(gpd):
Sump Pump lyes or nn). AS?? ((Tics 4:'r„)
FLOW CONDGiON;
Last date of orrupanry. 1 ne-r*- LT NtV• (1''.s�:lNScy C,c
YI-Y OtJ I kit V&1-inrr /ieci,
COMMERCIAL/INDUSTRIAL,
Type of establishment: pya-
Design flow:,lgallnns/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system. (yes or nal,__
Water meter readings, if available. -
Cat)taj tit I:(lr,fe)
Last date of ocmpanry:_ __
OTHER: (Describe)
Loa date of occupancy:,.._.
GENERAL INFORMATION
PUMPING RECORDS and source of information
IBC TaisletI rN IWf(y1t. lllrlti SytLE14s t''t'1
System pumped as pan of inspection: (yes or no)hir (^ ilr 1 L%f
If yes,volume pumped: Nyti P iIions 1,-1.1.46 err
Reason for pumping. _ (
TYPE OP-SYSTEM
1/ Septic tank/distribution budsoil absorption system
Single cesspool
Overflow cesspool
Privy
�-Shared system (yes or no) Of yes,attach previous inspection records, if any
f/A Technology etc. Copy of up to date contract?
Other
t:.Ic,Lv s :t,,.h.
rf°. sls
1--.0C 110Clk
•APPROXIMATE AGE of all compnnents, date installed (if known)and source of information: 7' � /6)M12-' (aCl`l.
opri Cu A's fisi'nhc,CttJ1 C:rt?C'A I°I(c>°
Sewage odors detected when arriving at the.site: (yes ur nnl,it!
(reviva 04/25/97) Pogo 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
SYSTEM INFORMATION (continued)
Property Address: j.36
n j.3C. [tt :: 2. G Ct) ii Y\1) L CC 'S 0,1;\ •
r,.. 4 ;;:y
Date of Inspection: -j 1 �al. ''1'J/
BUILDING SEWta:
11
orate on site plan) )
etc r !t"' Lilt
a " r4f'f.. ta. SaJIJr:.. ..aOC.v. : ; 11. LA _.
Depth helow grade, ' TO,')i6 v1 /41 -eat;4': C C 41%i'4Y '
Material of construction �ast iron 40 PVC T other(explain)
01-;;: a-,.. it vS1J,L.n,NCr I, -11r VE !INC" -1C 1'•t CN•'s>+tT“..ts.i'r:.r;
Distance frorn urivate water supply well or suction line 1G/.-j _ 1'11'i Os 1 Via'.-k't CG
Diameter '—T
Comments: (condition of joints, venting, evidence of leakage,etc 1
'ts tit'
Piet'011E1`, i7<1 'd t TWO; )11,d At fi<,( t-h1A.'`. Lcj L 4 -;V:Pit.c. hilE'- ,
NSI(.( 1:. 'i 71 e: tlrt A-;i'r 41(CF) t t s-: v'::t it 1`i Y - al..)-,111411') p1 'I tar:
Y-rth at" CrieklxNt -' eirt , s3 ( 'i "i(, cei• 5'cc %thNk^ ! 7l svt.i c
SEPTIC TANK:,_i_-
(locate on site plan)
Depth below grade:tl4't I:J
Material of construction! jtmcrete metal Fibmglass Polyethylene __pthedexplain)
Iti`Y' tint tt L4
If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: ./'r t �' '�:`' x t'(, t.-I E'! i ii"1E t
Sludge depth: Its)c/:. yr
r ea
Distance from top al sludge to bottom of outlet tee or baffle.:; ^_(--
Scum thickness
Distance from top of scum to top of outlet tee or ba lie:_ 0 t
Distance from bottom of scum to bottom of Outlet tee or baflle_f_
How dimensions were determined: Tltd_EX i4l €fl
Comments:
(recommendation for pumping condition of inlet and outlet teens or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.( lilt N{'- C) (Y)t at E- 11 r'" 4il-raneirr; it.$C )IV1"s r'uivsCiiuf, e IJ
I. t tvi ina. Iia I s' (tit�..\✓i`r\t t c \ 1>I�ISt-t t is I ('. 6 c 'ut v 1.1" II 1 ,
-Grwstv1c 9L c it CNitivitto c- iTer Olt:. {sfa v'kj f II 41r r t Nt r cu&17
1'-. ib..1(CAI y4 Ll(d u tU CJGEI ( > ill"r. ! ' •r 1'+iurLe fi4JCE-1 I OIL WI H 42, 1
t` tC li, Li A - ,-i!1 it ^i''4IIW Et siC (,tt trivial IN I_ t t/ctja I.t'y.) hat (,[w E-t. iS
GREASE TRAP:-Isi/11` •� /. %z - .,titc'�' 41 1101 '10w - IV- tit'e /> ( i'b: 17:\Trk.\' 6t%E:ILY F14vs\ i.)
(locate on site plat l
-A7yta tC_ry% -°>(t.:, , Cc":L. .A.ertVOl4d'Lo tCS-, •yv t1lh�ti. >u•t(ftiZ)
Depth below grade:_
Material of construction concrete,,._metal Fiberglass Polyethylene othedexplainl
Dimensions:
Scum thickness:
Distance from top of scum to top of nutlet tee or Wile.
Distance from bottom of scum to bottom of outlet tee or baffle:
Dare 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
(r vS..a 04/25/97)
cva. 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 11}i4_- Cs tt ' Ci.'¢ tFrt v)
n Atii '
Date of Inspection: • i' Id` ICI i`
TIGHT OR HOLDING TANK: (\) d}ITank must he pumped prior to, or at lime,of inspection)
(Innate on site nlmJ
Depth below grade. _
Material of construction: concrete__meat_Fiberglass _Polyethylene __othedexplan)
Dimensions:
Capacity, gallons
Design (low: g llnns/day
Alarm level. Alarm in working order --- No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOK:toi %'F'" ti C. Ct.. t„ 6011,07.1 )y.
(locate on site plant
Depth of liquid level above outlet invent _I�IU L- t Cy r1 t tl i t`\ v Lyca
Comments:
(note if level and distribution is equal, evidence of solids carryover
IJ
PUMP CHAMBER:1 /1
(locate an site plan)
Pumps in working order: (Yes or No)__,_.
Alarms an working order(Yes or No)__
Comments:
(note condition of pump chamber, condition of pumps and appurtenances etc.)
(fig
vide no of leakage into or out of box, et
-Y-, 'I EIS '-9E42 -
HN)(A? 'J lytt t2P'a
Lt
cis:,., .-i Lteis-St (q..Lt CU.%.1tr.
f .t-L_17 C A OCyt=i7t'j
f� z w1 NlE.4V tr �g L f)l.i'+[�.fNt.
r.:.AYfiivL( ALL_ i-iNC' `it G:ef& ,tat
1t5¢" rr 4 IC.la +il`.lc of
kir%fr4L. tuL+Sr ll.yvC+
lt_ tl (:.._& tL 1f D C-Z1)r'x
Y L w i!C Pit 1 t¢StJ.. r ,.:'- '6 '310 41`stlik
r1"I :l.0 L.a iII tritif '-il(i N t4- iCistii (21 5".t1,-
travine.1 t4 MtEw_ tr L�CL tRl lei txx. - --k'
ltd tAvJ(Yt ♦=ti
: Ift7LYO7 (.:11'14)ST-J tL f•u1L ,t .dh "ftlt`, rvt t ,!+tcew' .
Ai):'E.A ILE t) . 4( f—Ta_ ilt12 (Ct,LLCr. 1 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAICI L:
SYSTEM INFORMATiON (cumirmeut
Property Address: 1440 (Uit.'a IN 1t LSS d1f'01171 ( i L T)e= I iV,(I.'Y
Owner. OA(`t;.,
Date of Inspection: ./ I14 le.:t,
SOii. ABSORPTION SYSTEM ISAS) _,
(locate on site plan, if possible, excavation not required, but may he approximated by non-intrusive methods)
0 not determined to be present. explain.
N3//t
Type
leaching pits, number._
leaching chambers. number__
leaching galleries, number:
leaching trenches, number length:_______ .,-
leaching fields, number, d mensm st (:pt!', t`+L,GT c-, + 1+t rt
overflow cesspool, number. A •l2,-.)h kCITIO "+ii+[.
Alternative system:
Name of Technology:
6
f1f e
Cornmmns_
(note condition of soil, signs of hydraulic failure, level of ponding, condition of v etation,etc.)
INJ ':>itr Act t 'f- .1)yot&tt*Ctt 4, 11-tt rO r-'CLAY( i7Lift I his 27i `'is7it11f
Is,I Ale 'f'3.c Qim,(Ed cV t)1'`:al )T4 1 )i Saf :i IN t, }¢,�]. - r�rx' / lint
(;erf1 tcx,4371 /i to tees f s Sic, 0-r rx : t�' t Ca_h ,
CESSPOOLS: Opt -
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invent
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must he pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponrling, condition of vegetation,etc.)
PRIVY:=[):
(locate o soe plan)
Materials of construction:
Depth of solids:__
Comments:
(note condition of soil. signs of hydraulic failure, level of pondinR, condition of vegetation,etc.)
Dimensions:
(revised 04/25/971 nage 9 of Lo
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 lfeL<• C t tt"'1.-tD-T, t-It t-t)
Owner t) Ilt'Sei 1
Date of inslmmtiu,i: lS�III T'>
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include lies to at least two permanent references landmarks or benchmarks
locate all wells within ron. (Locate where public water supply comes into house)
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SUBSURFACE SEWAGE DISPOSAI. SYSTEM INSPECTION FORM
OAPT
SVSIEM INFORMATION (continued)
Prapeny Address:
Owner. } Itf1t''il`:
One of inspection: 1 a, leek
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Death to Groundwater' a 1 Feet
Pleas7 indicate all the methods used to determine High Groundwater Elevation:
LObtained from Design Plans on record
Y Observation of Site(Abuning property, observation hole, basement sump etc.)
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/ d)etermme n from focal rnnduions
_1011/42,74-Check with local Board
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FLMA Maps
tri'�Check pumping records
Pit'` Check local excavators, installers
T
Use U5G5 Data
Describe in your awn words how you established the High Groundwater Elevation. (Must be completed)
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(revised 04/]5/97)
Page 10 or 10
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