145 Septic Inspection Form 1996 WNW F.Wed
Gear
Arp.o eo Paul CaWad
uGo/ow
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
m�TT
P 15
Noan(ApToN Er;:
ro'n
Devitt!stow
mnearuees
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address I45 CHCStRF1Et,O Rom
Date.t In•p••tfo.r 730 1; I t 199
Name of Inspector.'II Axe-hot C. ✓A A Si NA/$1
� O MONI 6-J -
luer+SN"h+sa(71Df �Mq Oi017
CERTIFICATION STATEMENT 5Z1 -6E11 Sgl}--(7I74
I ussetiy that Have penonally inspected the sewage disposal system at this address oval that 4.information reported below is true,accurate
and complete u of the time of inspection. The iupectio. rforloed based on my training and experience in the proper function and
maintenance of oven*sewage disposal systems
" Pates
_ Conditionally P
_ Needs Further E
Fails p p
Inspector.Signature:i wt.-✓ •\ h _ �Yl % Date OUT. 13 I l `-C
The System Inspector.hall submit • f this "- .: to the Approving Authority within thirty(30)days of completing this
inspection If the system is•shared system or his•beige flow of 10,000 gpd or pester,the inspector and the system owner shell submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
Company Name.Address and T Isphone Numbei
Address of Own.r.
Of different) tIE23 1J I C+lus-S
v, cFuQ RoRP
A)o12.70-0-Mpti1r MA OIU66
Authority
INSPECTION SUMMARY:
Cheek A. C,or D:
AI SYSTEM PASSIM
I haw not found any information which indicates t hat the system violates any of the failure attest as defined in 910 CME 15.503.
My fathom criteria not evaluated are indicated Wow.
BI SYSTEM CONDITIONALLY PASSES:
u/q
One or more system components need to be re$Iso-d or repaired The system,upon completion of the replacement or repair,passes
inepletiop.
Indicate yea no, or not determined(Y, N, or ND) basis of determination in all instances. If"cot determined-,explain why not)
_ The septic tank is metal, rncked, unsound,shows substantial infiltration or ertlltration. or tank failure is
imminent. The system will peas ins n if the existing septic tank is replaced with•conforming septic tank as appn .edd
by the Board of Health.
(revised 11/03/95)
One Winter Street • Boston,Massachusetts 02106
1
•
■
FAX(617)556-1049 • Telephone(617)262-6500
0 ._.ra, ..- .a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION POKY
PART A
CERTIFICATION(oaatlnued)
Property Adder f 45 G R m ia,t) R.o& - N NorCiarNAVibo, AAA .
Over. HERB NILHOL5
Date of Inspection: clot ( I )99b
B1 SYSTEM CONDITIONALLY PASSES(continued)
NA
- Sewage backup or breakout or high eta tk wa level obserM in the d stnbution box a due to broken or obstructed papas)
or due toe broken. settled or uneven distrlbuc n bon. The system will per inspection if(with approval of the Board of
Health).
_ broken pipe(s)ar4 replaced
_ obstruction is
dietrtbution boa is{smiled or replaced
- The system required pumping mon than four
inspection if(with approval of the Board of H
broken pipes)en jwplaced
obstruction is re
a pm due to broken m obstructed pip(s). Tim system will pee
CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N
Conditions exist which require further evaluation by the Board of Health in order
public health,mien end the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY
- Cesspool or privy u within 50 feet of•surface water
Cesspool or privy is within 50 Met of•bordering vegetated wetland or•
3) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC W
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THA
SAFETY AND THE ENVIRONMENT.
- The system has•septic tank and soil absorption system and is within 100
surface water supply.
_ The system has a septic tank and soil absorption system and is within a Za
The system has•septic tank and soil abeorp on system and ia within 50
- The system has•septic tank and soil absorption system and is leas than 1
supply well,unless•wan water analysis for noblotm bacteria and volatile
from pollution from that facility and the presence of ammonia nitrogen
3) OTHER
determine if the system S failing to proem the
E SYSTEM IS NOT FUNCTIONING IN A
THE ENVIRONMENT.
mash.
SUPPLIER IF APPROPRIATE)
PROTECT THE PUBLIC HEALTH AND
to•surface water supply or tributary to
4 of•public water supply well
of•private water supply well
feet but 50 feet or more from•private water
r
compounds indicate that the wall is free
nitrate Singers is equal to or Yes than 5 ppm
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (motioned)
Property Address: 145 C HESTE FIsLD, ROAD- NU i ihtt To$J rw✓a
Owner. HI R.I3 AlILH-OLS
Date of Inspection: OG'S; I 1 I 61 e
DI SYSTEM FAITH:
1174_ I have determined that the system Slates one or more of doe following failure criteria is defined in 310 CMR 15.303. Moe ben b
this determination is identified below. The Board of Health should be contacted to determoe what will be osoaeeap to cornet the
t4 b Backup of sewage into facility or system component dm to an overloaded or roped SAS or cesepoot
$4J) Discharge or poking of effluent to the surface of the ground or surface waters du,to an overloaded or clogged SAS or
oaspooL
Static liquid loved in the distribution box above outlet invert due to an overloaded or cogged SAS or orspool.
Liquid depth in cesspool is km than 6 below invert or available volume is Ise then 12 day Bow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_
Any portion of the Soil Absorption System,cesspool or privy I.below the him gromdwater elevation
Any portion of•cesspool or privy is within 100 feet of•surface water supply ce tnbutag to•surface water supply.
Any portion of•mapool or privy is within•Zone I of•public well.
Any portion of a cesspool or privy is within 50 feet of•private water supply well.
Any-portion of•cesspool or privy is In than 100 feet but pester than 50 feet from a pri ste water supply well with no
acceptable water quality analytic If the well has been analysed to be acceptable,attach copy of well wane analysis for
colifom bacteria,volatile organic compounds,ammonia nitrogen and nitrate Monsen.
El LARGE SYSTEM FAITS:
The following criteria apply to large systen in addition to the criteria above:
The Salines a fatality with a design flow of 10,000 gpi or peaty(tarp System)and the system is•significant threat to public
health and safety and the environment because one or more of the following conditions nose
the systems within 400 feet of a surface drinking water supply
the system it within 200 feet of•tributary to•surface drinking water supply
the system ie located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone D of•publc
water supply well)
The owner r operator of any such system shall bring the system and facility into Ml compliance with the groundwater trsment popgun
equinmen of 314 CMR 5.00 and 600. Please consult the local regional office of the Department for further information.
(revised 11/03/95)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addawea C - ES1 w$'jaLD ROAD - \A p-Z)f 1, M A
Owner: tic-ER,B NIC -FOLS
Date of Inspection:
- OT, 11 1°m6 -
Check if the following have been done:
yt s Pumping information was requested of the owner,occupant,and Board of Health.1/
1"Nov of the system components have been pumped for at least two weeks and the anima has been receiving normal flow rates
during that period. Large volumes of water hen not been introduced into the eynam recently or as part of this inspection.
yt5 As built plans have been obtained and asmioed. Note if they an oat available with N/A
VzSTb.facility or dwelling was inspected for signs of sewn.bask-up. No e$ CK.-up o65r&RVaP
N[119 The eynem does not receive non+anitaey or industrial waste flow RES L Dan,i/i C-
Z L The site was inspected for Mims of breakout. /4 C 4 kbPtV-C
y2 S All ere=components,excluding the Soil Absorption System,have been located on the site.
yL S The septic tank manholes were uncovered,opened, and the interior of the septic tank was impacted for condition of baffles or
ter,material of construction, dimension., depth of liquid,depth of sludge,depth of scorn.
yt>The aix. and location of the Soil Absorption System on the site has been determined based on existing information or
appt®mated by non.intrnsive methods.
y{'The facility owner land occupants, if different from owner)were provided with information on the proper maintenance of Sub
SurLa Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION . ..
Property Adds j4S C teSTbtpl Gut, ROAD - NoCailitNI A.p1U0.1 , NON
Owner: viCRB NICHOLS
Date of Inspection: O&T, 11/ 1c `iL
RESIDENTIAL
De.ipr Boar 13 C sellout
Number of cadre,.• '3
Number of current ns denta:Q
Garbage grinder(yes or m): t 5
Iaoadry omoacW to system(yam or ot:O.
Seasoned use(yew or oo):
Water meter readings, if available: IJ/A
FLOW CONDmONS
(Z,GCO wA1ty„e Rac,ov.4l. OF
GPI a BR(>E OtSPOSgt.
Lest date of oauponry: CU29-6151-LN/ QGcc0 nEP
COMMERCIAL/INDUSTRIAL
Typo of establishment:
Design flow: yelows/day
Gnaw trap present: (gee or no)_
Industrie'Waste Holding Tank present:
Non+aotlary waste discharged to the Ti
Water meter readings, if available:
N/A
yea or no)_
5 system: (yes or am_
Let data of cc uponcc_
OTHER:(DrmLe)
Last date of occtipancy.
GENERAL INFORMATION
PUMPING RECORDS and mime of informyytioo:
So JRGG ac INf-o 'Iloig - HS-'R13 IC)-1-01.,
System pumped as part of inspect' tai
If ys, volume pumped: /Uam ns
Rsa.on(er pumping kVYi(. ESTATE -i-P-pttosFER
TYPE OF SYSTEM
✓ Septic taW/dinaDweimhoil absorption system
Stagy teeseool
Overflow carpool
Privy
Shand system(yes or no) (if yea,attach previous inapettion Words,if my)
Other(explain)
APPROXIMATE AGE of 41 components, date instated(if known)end source of information: T 40 Yc35RS
Bongo odon detected when arriving at the site (yes or no) n1O
(revised 11/03/95) 5
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM
PART C
SYSTEM INFORMATION(continued)
Property Addre.c. l4S C ltba l-RFICL D
Owner N"Ei2.6 NIGr4dLS
Date of Inspection:
00 I. 11 3`14 6
SEPTIC TANK: ✓
(local,on site plan)
p
I u
Depth Lek. 4'grade: 1
Materiel of sth ion:
ROAD —NaRTiA,A lo/J, AAA
metal_FRP_other(.plain)
Dimensions PoL x 4'w x 5 3
Sludge daptb: ro,
Distance from top of sludge to bottom of outlet to or baffle:N'A
Scum thickness: NC=Or! 16 i BC-e:
Dlal,a • from top of scum to top of outlet tee or baffle: W1 A
Distance from bottom of scum to bottom of outlet tee or baffle: U IIAY
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth
evidence of leakage, etc.) &U) O a n. 2 AS N"
t3 OC , A+kuJAt. ,v,pans(. .
R C.NOtR &LOCK fH.+AN6y RAISL:s MFIQHf/ -E
RAGE
of liquid level in ralatio to outlet invert,structural integrity,
O IC 11 744E7
IJc) St trNS - .F TA t-rk -R``•-u Re.
CUVt2 TO t✓,*J /2'. of Fw'SM
GREASE TRAP._
(locate on site plan) N 4
Depth below grade._
Material of construction:
Dante_metal_FRP_other(explain)
Dimensions
Sam thickness
Distance Dom top of scum to top of outlet tee or baffle:_
Distance from bottom of to bottom of outlet tee or be81e:_
Comments:
(recommendation for pump
evidence of leakage. cc.)
condition of inlet and outlet tea or baffles, depth of liquid level in relation to outlet invert,etrrctanl integrity,
1.07-106-PN(DAT1JW MALI.
CIN.JEr2 aLocK
c.rti .Hey
(revised 11/03/93)
•
A" PIPE 601-ID)
1000 GAL.
..:Pi,, TN
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addrosa 145 C i41=Ch ) J koat -n1cRmhrvt pTa J r fA A
Owner. HERS 1.1(CNOI.S
Date of Ia.psotiou:
007 11 lg9b -
TIGHT OR HOLDING TANK— N/jL
( i..
-
Depth blow grade:_
Material of mnstna is mamma�m.tal
FRP_otbrterpl.in)
Mansions:
Cap cat_ gallons
._
and Goat switches,wt.)
Design Sow-, gallons/day
Alarm level:
Comments: ..
(condition of inlet tee, condition of.iann
DISTRIBUTION BOX_
(buts on site plan)
ry/
Depth of liquid level above outlet invert:
Comments:
(not*if level and d str3udion is equal,evi
nee of.olids carryover,evidence of leakage into or an of beg etc.)
PUMP CHAMBER:_
(lame an site plan)
N/A
Amps in working ord.r.(yes or no)_
Comments:
(note condition of pump chamber condition pump and appurtenances etc.)
(revised 11/03/95)
1 (SS/Will Pm$IMJ)
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MUM NOIL'SdSNI W316;B TBOdela 80YM2B BJYnW16flnB
Owner.
145 CHESTERFIELD ROAD, NORTHAMPTON, MA.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
TION(continued)
SLOPE 1:1
e EXISTING SAS —voi 1.4--
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include Si ton least two permanent Wa en
but.all waDa within 100'
MAPLf, E
EXISTING .1000 GALLON
,SEPTIC TANK
6 or
11.
4" SOLID PIPE
33'
BREEZE
WAY
__ J
PINE\ TREE
\_l
EXISTING
3 BEDROOM NOUSE
CHESTERFIELD ROAD, NORTHAMPTON, MA.
DWI'S TO GROUNDWATER
Depth to groundwater- ->Z14 (eat
toothed o(dstnmmataemepprtaination: (/PLAND V&&ETATIO.l - Sy5T IS LOCAT IT
aN &RAv€t BANK 4T Thi- of SLOPe
Cc) ->35
(revised 11/03/95)
9