439 Septic Inspection Form 2001 Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 439 flaydenville Road
Owner: Kerry F. Meehan
Date of Inspection: 10-02-01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
Recommend that the septic tank be pumped every two years as regular maintance.
B. System Conditionally 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound.exhibits substantial infiltration or exfdtration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 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
ND explain:
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL a.QN
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
OCT 2 Z 2001
;,;CTpi Li;:i;✓:iF HEAL',
Property Address: 439 Haydenville Road,Haydenville MA. 01039
Owner's Name: Kerry F.Meehan
Owner's Address:30 Ladyslipper Lane
Date of Inspection: 10-02-01
Name of Inspector: Dennis R.Lacourse
Mailing Address: 18 Soaker Road,Williamsburg MA.01096
Telephone Number: 413 296-4022
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 the inspection. The inspcition was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Inspector's Signatur: Date: /o• z• o/
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 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
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
This system appears to have no visible problems. I would recommend that the septic
system be pumped before sale. I would also recommend that it be pumped every two years
after that as routine maintenance.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 4 of 11
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 439 Haydemille Road
Owner: Kerry F. Meehan
Date of Inspection: 10-02-01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no' to each of the following for all inspections.
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspw1
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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. [This system passes if the well water analysis,performed
at a DEP certified laboratory,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 provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
NO (Yes/No) The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the Large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
c
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 439 Haydemille Road
Owner: Kerry F.Meehan
Date of Inspection: 10-02-01
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 public health safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)0)that the
system is not functioning in a manner which will protect public health,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 any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,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,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 439 Haydenville Road
Owner: Kerry F. Meehan
Date of Inspection: 10-02-01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): ? Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms) 330
Number of current residents. 1
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] NO
Laundry system inspected(yes or no): YES
Seasonal use: (yes or no): NO
Water meter readings,if available(last 2 years usage(gpd):03050.39 CUBIC FEET
Sump pump(yes or no): YES
Last date of occupancy: THIS WEEK
COMMERCIALIINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/personsisgft.etc.):
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 no):
Water meter readings.if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X 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)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information: 15 YEARS
Were sewage odors detected when arriving at the site(yes or no): NO
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 439 Bayderille Road
Owner: Kerry F.Meehan
Date of Inspection: 10-02-01
Check if the following have been done. You must indicate"ves"or`no" as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two-week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined? (If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components, excluding the SAS,located on site?
X Were the septic tank manholes uncovered, opened and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge
and depth of scum?
X Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X Existing information.For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR I5.302(3)(b)1
Page 8 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:439 Haydenville Road
Owner: Kerry F. Meehan
Date of Inspection: 10-02-01
TIGHT or HOLDING TANK (tank must be pumped 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: gallons/day'
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover. any evidence of
leakage into or out of box,etc.):
The distribution box appears to be level and in excellent condition. No evidence of solids carryover. No
evidence of leakage in or out of the distribution box.
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances.etc.):
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 439 Haydemtlle Road
Owner: Kerry F. Meehan
Date of Inspection: 10-02-01
BUILDING SEWER(locate on site plan)
Depth below grade: 15"
Materials of construction: X cast iron 40 PVC other(explain).
Distance from private water supply well or suction line: 10'(City water line)
Comments(on condition of joints.venting,evidence of leakage,etc):
The building sewer appears to be in excellent condition. There is no evidence of leakage. The joints are
sound. The system is vented.
SEPTIC TANK: (locate on site plan)
Depth below grade: 12"
Material of construction: X concrete metal fiberglass polyethylene other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 60"X 102"X 78"
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle: 46"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle. 10^
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions determined: By ruler at time of inspection
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc):
No evidence of leakage in or out of tank. Both baffles were sound. Liquid level with the bottom of the
outgoing line. The tank appears to be sound. Recommend pumping before sale.
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of constmction: _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(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc):
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 439 Haydensille Road
Owner: Kerry F. Meehan
Date of Inspection: 10-02-01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.1 gate where public water supply enters the building.
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Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 439 Haydeoyille Road
Owner:Kerry F. Meehan
Date of Inspection: 10-02-01
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why.
Type
leaching pits,number:
leaching chambers, number:
leaching galleries,number:
leaching trenches, number. length:
leaching fields.number,dimensions: ONE,4 outgoing legs 30'long Estimated size 38 X 30
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
No evidence of hydraulic failure. No ponding or damp soil. Nothing unusual about the vegetation.
CESSPOOLS:_(cesspool must be pumped as part of inspection)(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 groundwater inflow(yes or no):
Comments(note condition of soil,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 ponding,condition of vegetation,etc.):
•
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 439 Haydenville Road
Owner: Kerry F. Meehan
Date of Inspection: 10-02-01
SITE EXAM
1%Slope
200+' Surface water
YES Check cellar
NO Shallow wells
Estimated depth to ground water 5+-feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
X Observed site(abutting property/observation hole within 150 feet of SAS)
X Checked with local Board of Health-explain: Spoke with the health Agent
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
This system is constructed on mound. The wetlands are over 200+'down hill from the site. I spoke with the health
agent whom has been on the abutting property. (City owned). The homeowner says that the sump pump only is used
when the get an excessive amount of water from the roof The cellar shows no signs of water staining due to water
infiltration.
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��{• q• �P' — 2PROOLE +
— -9K-- _ ro N ltCHME F e," / ,,,-/ ) o�pa % ) •
Whiteley Excavating
52 Maple St.
Southampton, MA 01073
May 21, 2009
Northampton Board of Health
Attention: Ellen Bokina
Dear Ellen:
It appears that I may not have realized there was a change in the Board of Health.
I am aware of the fact that this project has already been reviewed by the Board of Health and the
Conservation Commission. Peter McErlaine was involved in the process at the time.
I have been in contact with Peter McErlaine,and he is willing to talk with you about this project if you
have any questions.
Please find attached,the full size plan for the project as you requested.According to the plan,there is
no increase in the number of bedrooms or occupants.The street address you also requested is on the
plan.
Thank You for your attention.
Sincerely,
Thomas Whiteley