122 Septic Inspection 1997 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
• 81 SYSTEM CO ONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
wroth) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(sl are replaced
obstruction is removed
distribution box is levelled or replaced
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
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
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 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:
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 THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
3) OTHER
The system has a septic tank and soil absorption system (SAS) and the 5A5 is within 100 feet to a surface water supply or
tributary to a surface water supply.
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 septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for<oliform oacteria and volatile organic compounds indicates trial
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. Method used to determine distance (approximation not valid).
Iraviva 04/35/97) Page 3 of 10
WILLIAM F.WELD
Govcme'
ARGEO PAUL CELLUCCI
Lt.Govcmor
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617-l9 -5$00
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: %Z4- C49s5 'Ant dMA/NO QTI4 A44417/✓Address of Owner:
Date of Inspection: 811519+ If different)
Name of inspector: D-M/ Wir fl6
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Environmental Field Services. Inc.
Mailing Address: P 0. Box 518 Leeds, MA 01053
Telephone Number: -_J4131 586-7200 .. '
CERTIFICATION STATEMENT
I 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 an my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
_ Needs Funher Evaluation By the Local Approving Authority
Falls ,
/J pr
Inspector's Signature!/__T Date: //
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the Inspector and the system owner shall submit
the repon 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 appl icable, and the approving authority.
71 riff!
--4,�t
q1i
SEP 1 61997
-- .,.(:?TON BOARO OF HenT
Se cretan
DAVID B STRUHS
Commissioner
INSPECTION SUMMARY: Check A, B, C, or D.
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined In 310 CMR 13.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
81 SYSTEM NDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass' section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). 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
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass Inspection If the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/9 7) Page 1 of vo
DEP on the World Wide Web http IN,ww.magnetstate ma usldep
Pnnted on Recycled Paper
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(4 131 586-7200
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Y.e, No
Pumping information was provided by the owner, occupant, or Board of Health
se- _ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as pan of this inspection.
— 4f 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.
✓ _ 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
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 on:
V _ The facility owner and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) )15.302(3)(blj
(revised 04/25/57) Peg. 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /S C/Lois /41W Ram
Environmental Field Services, Inc.
Owner: S(/EN,4I4— P.O. Box 518 Leeds, MA 01053
Date of Inspection: Q//S/�,} (4 131 586-7200
V
Di SYSTEM FA ;
You m foots either "Yes" or No as to each of the following:
I ha'vai'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.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of eft:I:en( 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 1/2 day flow.
Required pumping more-than 4 times in the last year NOT due to clogged or obstructed pipets).
Number of times pumped _
Any portion of the Sail 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 I 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 bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must inch te either "Yes" or "No" as to each of the following:
e following criteria apply to large systems in addition to the criteria above.
The system serves a facility with a design flow of 10,00n god 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 full 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 iunher information.
(revised 04/25/9f) P•g• 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade
/9
Material of construction: ast iron _40 PVC _ other (explain)
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
Distance from private water supply well or suction line ,oY--
Diameter 4'
Comments: (condition of joints, venting, evidence of leakage, etc.)
701,✓TS —7- g 1 ,c-() (-'r_;/ 741CC iF 6::(-`F.
SEPTIC TANK:
(locate on site Ian)
SOa 3AU.o.3
6 °
Depth below grade: 7
Material of construction: ^concrete _metal _Fiberglass =Polyethylene _otherlexplain)
If tank is metal, list age_ Is age confirmed by Cenificate of Compliance _(Yes/No)
Dimensions: 89 X 5o " k 118 acer) ,fr. D.]
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 2/ ''
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: / /?v
Distance from bottom of scum to bottom of outlet tee or baffle: /
How dimensions were determined: Tit Pr: fit-AS-co& I 065ER'tin
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet Inv
•
integrity evidence of leakage, etc.) "r Jain - a - a
s r , n / I is-, a•
tructural
GREASE TRAP:/
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
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.)
lr.vi.ed 04/25/37) Page 6 of 10
Properly Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
RESIDENTIAL:
Design flow. 2e//L v.p^.�d/bedroom for S A3.
Number of bedrooms: J
Number of current residents: 2
Garbage grinder(yes or no1:4,0
Laundry connected to system (yes or no):Y e--C
Seasonal use ryes or no):
Water meter readings, if available (last two (21 year usage (gpd)) /a- / ✓CPS%
Sump Pump ryes or no):S2
Last date of occupancy:
COMMERCIAL/INDUSTRIAL-A.44--
Type of establishment
Design flow:, gallons/day .
Crease trap present: (Yes or no)_
Industrial Waste Holding Tank present: (yes or nol_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy'
OTHER: (Describe)
Last date of occupancy.
GENERAL INFORMATION
PUMPING RECORDS and source of Information.
7�ZS 99 /7/1-en's r�c.a��,E�
System pumped as pan of inspection: ryes or o)
If yes, volume pumped' b'a D gallons
Reason for pumping 76 Ti e Sim T%- —
TYPE_OF SYSTEM
'T/ Septic tank/distribution box/soil absorption system
_ Single cesspool
_ Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE ACE of all components, date Installed (if known) and source of information: Seri
SEEr &c P/
Sewage odors detected when arriving at the site: (yes or no) NTA
(revised 04/25/97) P•g• 5 of 10
3p+ yrs
26 / irs.
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
4a" $aau a MOc
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
(locate on site plan. if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leach in
number 8c " k B B. 3'drz 4 --P°
leachin ambers, number:_
leaching galleries, number:_
leaching trenches, number,length:
leaching fields, number, dimensions.
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
• .. • C • nr4•L . _w ♦ ♦ • •
CESSPOOLS.
(locate on 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 groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY
A-
(locate on site plan)
Materials of construction: Dimensions.
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic fall ure, level of ponding, condition of vegetation, etc.)
tr.vi..d 04/25/97) Page a of le
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: in- CROSS P,{`nf
OwneryNr4k_
Date of Inspection:
%s9
RI
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
TIGHT OR HOLDING TAN Y�.__� (lank must be pumped prior to or at time, of inspection)
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallonsrdav
Alarm level: Alarm in working order _Yes; _ No
Date of previous pumping
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX
(locate on site plan)
Depth of liquid level above outlet invert:
Comments'.
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
PUMP CHAMBER/kik
(locate on site plan)
Pumps in working order: (Yes or Nol_
Alarms in working order ryes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
Irv/mod 04/55/57)
Pogo 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
.�ff.�,r
Depth to Groundwater%
Property Addr ss: (47- C/a
Owner: e_N(A/G
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Pte{- o by
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
(Azr n SCALE)
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
C e2oss 2A-777 /?-04Z
S.PMQdAI.[A�'r Y r 4 YT 2. eTh.
re �A,JL (crit.) 315 ' 26.6'
'F.et4& ?if Cadeal 52.a' 73.6 `
Invited 04/1519])
lags 9 of 10
Environmental
Field
Services
P.O. BOX 518, LEEDS, MA 01053
(413) 586-7200 • FAX 587-3100
September 12, 1997
Mr. Bill Blizniak
122 Cross Path Road
Northampton, MA 01060
Re: Subsurface Sewage Disposal System Inspection, 122 Cross Path Road,
Northampton, MA.
Dear Mr. Blizniak,
Enclosed please find a copy of my report for the referenced inspection. I have forwarded
a copy 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 and Seepage Pit
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,
Dan Nitzsche
SE, Certified Title 5 System Inspector,
cc: Northampton Board of Health
Perc Testing • Septic Designs • Title V Inspections • Wetland Delineations