132 Septic Inspection 1996 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 13a C ro S m1(AM
Rd.
Owner: Dwai
Date of Inspection: r}I (Q I%
g]SYSTEM CONDITIONALLY PASSES (continued)
•
_ Sewage backup or breakout or high static 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
Board of Health):
broken pipe(s)are replaced
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
C] FURTHER EVALUATION IS REQUIRED BY HE 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.
t1 UNLESS BOARD ADETERMINES TE OT FUNCTIONING IN A MANNER
WM CH WILL PROTECTTHE PUBC HEALTH AND FETY 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) THE SYSTEMLIS FAIL UNLESS FUNCTIONING IN A MANNNERETHAT PUBLIC
PUBLIC HEALTH AND SAFETY AND HLTEERMINES THAT
ENVIRONMENT:
and Is .lit 1 0 fcct :; c sc1._: y:a.rr sp; , . ...__
.w.,. u.. a sewn ma it •uy .,,.. ...,y.v,1y.. ss;;a,V, '
- surface water supply.
_ The system hat 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 absorpton system and is within 50 feet of a private water supply well
The system ha.a septic tank and sod 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 colifoms 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.
D] SYSTEM FAILS:
_ I have determined that the system violates one or more of the following failure aiteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be cornered to determine what will be necessary to conect
the failure.
Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool.
_
Discharge or ponding of ef0uent to the surface of the ground or surface waters due to an overloaded or dogged SAS or
cesspool.
3
treyased 9/15/95)
WRWrn F.Weld
esese:Cw
Dudy Isawari.Gam
Ord B.
Strolls
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
AUG 5199& LJ
NORTHAMPTON BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 13 a Cro Ss S kW\ Address of Owner: Y41A.Q. Du.jn C
Date of Inspection: r}la(019(p
Of different)
Name of Inspector: C. S;\s OS
Company Name,Address and Telephone Number:
ci1(os EcAec cygC\\rc-
(a9 ?e\h .m �od.) nt\hect ,(• f■ o(OOa
CERTIFICATION STATEMENT y 1 g— a S(0 -$011�Sc
I certify that I have personally inspected the sewage-disposal system at this ress 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
maintenance of on-site sewage disposal systems. The system:
%asses
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature:
au GCL Dale: /Id(a/9lo
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 report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner ano copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D
Al SYSTEM PASSES:
V I have not found any information which indiotes that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
Ill SYSTEM CONDITIONALLY PASSES:
_ One or more system components need to be replaced or repaired. The system, upon completion of the replacement Of repair,
passes inspection.
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, cracked, structurally unsound, shows substantial infiltration or exfltration, 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.
(r.vi•ed B/15/957
One WMntar Sews • Boston,aMwehra•tta 02101 • FAX(617)386-10•S • TeOpnen.(617)262-5500
0 Printed en aaWal Pape
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 13 a CC(:)(:) 4Gkt\
Owner. \L &\
Date of Inspection: a1019(o
DJ SYSTEM FAILS(continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or dogged 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 4 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 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
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
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 safer
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 IIWPA) 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 further information.
Irevand s/15/e5)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
CHECKLIST
Property Address: ‘3a Cross Rol\-h
Owner ' \
Date of Inspection: r 19(,
Check if the following have been done:
aVicmping information was requested of the owner, occupant, and Board of Health.
_✓None of the system components have been pumped for at least two weeks and the system has been receiving nomsal flow sates
during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection.
N//i As built plans have been obtained and examined. Note if they are not available with N/A.
e facility or dwelling was inspected for signs of sewage back-up.
he system does not receive non-sanitary or industrial waste flow
4/The site was inspected for signs of breakout.
II system components, excluding the Soil Absorption System, have been located on the site.
4/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 existing information or
approximated by non-intrusive methods
The facilit ov.re: and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
1 tevnsed 1/15/95;
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 132. Cross Poi QC•
Owner. p KUCS\
Date of Inspection: rig acol96,
SEPTIC TANK:_(O 00
(locate on site plan)
1,
Depth below grade:
Material of construction: concrete_metal_FRP_otherlexplainl
Dimensions: SC,5 k S x cf Dee iJ
Sludge depth: 'Y- /a 0 5 n
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness: t/A - I / ct
Distance from top of scum to top of outlet tee or baffle: I6 1�„
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.)
GREASE TRAP:
(locate on site 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._
Dts:ance morn oonor: 1^ nnnr,m o1 tnmr• iee c• odr.e
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, e¢.,
Irevased a/:51951 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: l3a C t S
Owner: �lwU0.�
Date of Inspection: `}I a(of 96
JtESIDENTIAL:
Design flow: gallons
Number of bedrooms:
Number of current resident9:j
Garbage grinder(yes or no): , �p5
Laundry connected to system (yes or no),i�
Seasonal use Wes or no)._e(:I
Water meter readings, if available:
FLOW CONDITIONS
/02 &A ft per year. 66W)
Last date of occupancy: DT(1k-
COMMERCIA L9 N D USTR IA L:
Type of establishment'
Design flow: ullonsrday
Crease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Tide 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 I
System pumped as pan of inspection yes or no)
I(yes, volume pumped fOrir, gallons
Reason for pumping. r
TYPE OF SYSTEM
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)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known)and source of information: r/'Y
Sewage odors detected when arriving at the site: (yes or no)L!D
(revised 1/15/951
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 13 a Cx O$5
Owner: u`0,_\
Date of Inspection: `}-I a(Q /9(p
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible;excavation not required, but may be approximated by mrfintnisive methods)
DAY\ ?d
If not determined to be present, explain:
Type:
leaching pits, number.
leaching chambers, number:
leaching galleries, number._
leaching trenches, numbeglength: a�
leaching fields, number, dimensions.
overflow cesspool, number:_
Sift, anthcw
-'
n
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.)
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.
Indication of ground ate-
inflow (cesspool must be pumped as pan of Inspection)
Comments: (note condition of sod, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil,signs of hydraulic failure, level of pending, condition of vegetation etc)
Irsvased 1/35/95)
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: c a CCOSS Rc *b td•
Owner: \7uuc \
Date of Inspection: ` -(a(o (9 b
TIGHT OR HOLDING TANK:_
(lose on site plan)
Depth below grade:_
Material of construction:_concrete_metal _FRP_athertexplain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:t
(locate on site plan)
/G xao
a au+le45
Depth of liquid level above outlet invert
Comments
(note ii level and distnbunon Is equal, es oence of solids carryover, evidence of leakage into or out of box etc.)
PUMP CHAMBER:_
(loam on site plan)
Pumps in working order:lyes Or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances etc.)
(tensed a/1S/95I
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: \Sa, C'rc' 1 \ "?..d
Owner: 'pnt30.\
Date of Inspection: efothicK0
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indude ties to at least nvo permanent references landmarks or benchmarks
bate all wells within 100'
C _ _ - 2
b-sox Of C - _1
T4l,\E to
E
Dcue
beef-
HousE, "fi _
I Gat •
�0 c'ch
be■ u2
C, c css
Rash d .
DEPTH TO GROUNDWATER
Depth to groundwater. 1 feet
method of determination or approximation:
Ry ( hand ntise )
Ir.vi.ee ./1e/95)
9