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180 Title 5 Construction Permit 1991, Report 1999 2001, 2003, Water Application 1991 RESIDENTIAL OR COMMERCIAL BUILDING WATER APPLICATION LC&) To the City of NORTHAMPTON, MASSACHUSETTS: The undersigned, being the Owner of the Owner, Owner's Agent property located at 180 Maple Ridge Road , does (Number) (Street) hereby request a permit to install and connect a 1" Water (Size) Service to the Residence at said location. (Residence, Commercial Bldg. , etc. ) 1. "Owner shall mean the person holding title to the property served or to be served by the water service. 2. The name and address of person or firm who will perform the proposed work is Harris and Gray Excavating, Ashfield 3. Plan/Sketch and specification for the proposed water service shall be attached to permit. In consideration of the granting of this permit, the undersigned agrees. 1. The Water Department shall make all taps to the water main. 2. WATER ENTRY PERMIT fee is $200.00. 3. Additional work performed by City forces from the water main to streetline shall be paid at the prevailing labor rates and cost of material. Water Meters 5/8'• $100.00 .. .. 3/4•• $150 00 .. .. la $200.00 Water Meters 1 1/2" and above shall be purchased by the owners - using city specs. 4. The Water Superintendent shall be notifed for water line inspection prior to backfill of trench. Water Entry Application DATE: July 23, 1991 SIGNED: (Ap 62 Parsons St Ro Eabtham (Address of Applicant) 11 {angregorio $ 200.00 entry fee Paid_ 7/�3/fl r,6 72- Application approved and permit issued: DATE: 7 IL 3 / // SIGNED (Directo f blic ) Water Meter o; ?AA,-c. van-ins 4-c pre-.-k. S:c_�wk ;t a'c.2 , 50 : 1r1- 6 „.• 4 S.: y n— 14 1 l9 91 - 'U°'--.r S°-e-t --c-c- EIQJ.,4-;.w , v Samuel IL Bnndls,P.E. area Ory Engine Peter J.MUluay.Sr. Assists abm,of Pubic Ilbb June 14, 1991 CITY OF NORTHAMPTON,MASSACHUSETTS DEPARTMENT OF PUBUC WORKS 125 Locust Street Northampton, MA 01060 413-582-1570 Frank Sienkiewicz, Building Inspector Municipal Office Annex Main Street Northampton, MA 01060 Re: Water Service Grade Line Elevation Dear Frank: The City's water consultant has recently completed an evaluation of our water distribution system's capability to provide adequate domestic water at a minimum allowable pressure of 35 psi. The study assumes that both City wells are on line and the Turkey Hill tank is at its overflow elevation. The results show that any service located at an elevation of approximately 290 feet or lower will have adequate pressure for normal service during peak hour demand. Between elevation 290 feet and 330 feet, services will experience reduced pressures, especially during peak hour demand. Above elevation 330 feet, the system cannot provide adequate pressures. The first phase of the proposed water improvements will increase the system's grade line to an elevation of approximately 350 feet. We expect said improvements to be completed by the summer of 1993. At that time, the system will be evaluated and you will be notified of any changes. Please call me or George Andrikidis at 582-1574 should you have any questions. Very truly yours, Samuel B. Brindis, P.E. Director of Public Works BBB/G.A./m1 C-A. cc: Planning Board Zoning Board of Appeals Fire Chief Planning Department Peter McNulty Charles Borowski III\Georgea3\grdeleva.H2o ARGEO PAUL CELLUCCI Governor COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFW'AUtS ra z DEPARTMENT OF ENVIRONMENTAL PROTECTION . ONE WINTER STREET, BOSTON MA 02108 (617)2925600.' KIC){ HAP/ d'L VIA pr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �,I CERTIFICATION t�� Property AdM1ea:. t dJ IT\A}LG' RID 6&L Name of Owner CLO l.b7As4 Ti Address of Owner, I PSn MPi p R10 6 Date of Ywpecton: . ■ Name at Mapeeto:(PIea.Print( . A 1..,7 . A V Company Name: i one:I am a DEP appiovd intern inspector pursuant to Sec ti o 15.340 of-Ti tlrf5�13N�C v�1 5.000u TTeMp ate Numb.t: -V), 2- 5 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 on my training and experience in the proper function and maintenance of on-site sewage-disposal systems. The system: TRIMNI CO CRTHAMPTON BOARD OF II vto n. b11aL11 Conuoies;oner Passes IV-Conditionally Pa _ Needs Further Ev Fails Inspector's Signature: 1 (Ass- ng Authority The System Inspector shall submit a copy completing this inspection. If the system is shall submit the report to the appropriate regio system owner and copies sent to the buyer, if applicab a, NOTES AND COMMENTS revised 9/2/98 C. ■ Date: Co I) ?y the Approving Authority(Board of Health or DEPIwitin thirty(301 days of e design flow of 10.000 gpd or greater,the inspector and the system owner epertmmt ofrEmvkenmentel Protection. The original should be sent toff and the approving authority. • t -)I':; d h' 1- r dA( (AL � rA( �. Tht I- H. r\ .�- L)' IL C Paget of 11 C7 v coded on Receded Pape SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icarrtiaredl Propay Adtroaa: 160 YThPPLE R'O6e Owner: R UjJA L O PAAY,ri D a ft Inspiratory f 5 �ti 26 1 `'r9 `j INSPECTION SUMMARY: Chock A,(B, or D: A. YSTEM PASSES: NI have not found any information which indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any failure criteria not evaluated are indicated below. CO MINTS: B. SYSTEM CONDITIONALLY PASSES: SY 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 NO). 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•Certificate of Compliance(attached)indicating that the tank was installed wit in twenty(201 years prior to the date of the inspection:or the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial infiltration or infiltration, or tank failure is imminent. The system will pass inspection it the existing septic tank is replaced with a complying septic tank M approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed panels) or due to a broken,settled or uneven distribution box. The system will pass impaction if(with approval of the Board of Health). broken pipes)are replaced obstruction is removed distribution box is levelled replace The system required pumpingmore than tourimes a yaerdue to broken or abstracted pipele). The.yatem veiayaer' inspection If Iwith approval of the Board of Health): - -_ broken pipets)are replaced obstruction is removed revised 9/2/98 Page 2 of it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIRCATION(canmas•d) Property Address: ( o \Ppc6 R\p U- Owner: ` V h.I Dm of Inspection: 6- -C? C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A 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. I) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES N ACCORDANCE WITH 310 CUR 16.30311061 THAT THE SYSTEM ISMOTFUNCTIONING N A MANNER WHICH—WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE BIVJBONMEML NA- Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM 5 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has •septic tank and soil absorption system ISAS)and the SAS is within 100 feat of a surface water supply or tributary to•surface water supply. The system has •septic tank and soil absorption system and the SAS is within•Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of•private water supply will. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from• - private water supply well,unless a well water analysis for coliform 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 ppm. Method used to determine distance (approximation not valid). 31 OTHER revised 9/2/98 _ . Page 3 of Il SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION IccndruM) Property Adams: lac) v\\Rpv-L R,vD6e Owner: R DLO VhP S %- Dofkuc6 peon: �]C Me O. SYSTEM FAILS- You must indicate either "Yes' or 'No' to each of the following: Ni/s1 I hove determined that one or more of the following failure conditions exist as described 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 Nom Backup of sewage imoeecikt yer-ay etemcemponent.doa4o en overloaded arNaggedSA Swswe,ad. ' - • Discharge or ponding of effluent 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 pipers). -. 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 feat of a surface water supply or tributary to a surface water supply. Any portion 01 a cesspool or privy iswithin 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 wpply 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 organiccompounde,ammonia nitrogen and nitrate nitrogen. - E. LARGE SYSTEM FAILS: 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: N Yi The system serves•facility with a design flow of 10,000 gpd or greater(Large System)end the system is a significant threat to public health and safety 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 ia-mitlwt 200 fatuf-eeneadery4eeeurfeo.d.in&rg.wateraupply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area.IWPA)or•mapped 2oni II of•public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304121. Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM PART B CHECKLIST Property Adduk: Ieon Wy1PLE RtO&t Owner: Roster LA PflApScli Data of Inspection: 6-z / Check if the following have been done:You must indicate either "Yea" or"No' as to each of the following: Yevi No ✓ — Pumping information was provided by the owner,occupant, or Bond of Health. _ -Nona of theaysemcomaoerW.karw.Wan pumpadttormIsuut Iwo awoke ansksbe mutton hudrs:wag awl Sow rates during that period. Large volumes of water have not been introduced into the system recently or es part of this inspection. 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 don-sanitary or industrial waste flow. 2c Sl7c1V lI l r!L TM eite was inspected for signs of breakout.fJ C t?i G r_\`_ C. 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 bates or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The sire and location of the Soil Absorption System on the site has been determined based or:- Existing information. For example. Plan at 8.0.1\, Determined the field lii any of the failure-criteria related to Part C is at Issue, approximation of distance is unacceptable) 115.3021311b11 The facility ownm and occupams_il differaat barn.aaawU.wuapsavided.wishioformeYOO.on'en- t SubSUrisu Disposal Systems. revised 9/2/98 Page 5 or II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Prows Aridness: o P AP LC t�‘O G Db ` 6 aof(nepstobon: - Z - y ROW coNDTONs RESIDENTIAL: Design flow: /(G c.o.d./bedroom. Number of bedrooms(design): 4 Number of bedrooms(actual): Total DESIGN flow 0/(C, C ii Number of current residents: Garbage grinder(yes or no):._i4(Z.4 Laundry(separate system) ( es or no/flj_Q: If yes,sepaaMinspectlon required Laundry system inspected ' es r no) Seasonal oil(yes-or no): ..11 Water• meter readings,if available Bast two years usage(god): IY�� Sump Pump)yes or nol: ISO Last date of occupancy: (a-.--"K a Crap act vl%I COMMERCIAL)W OUSTRIAL: Type of establishment: N I A Design flow: god 1 894 ed on 15.2031 Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank prose t: (yes or no)_ Non-sanitary waste discharged to thr 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. System pumped as part of in/R/action: (yes or noljLp If yes. volume pumped: 1‘1/ , gallons R V . —w✓✓,a O f° v yVt Reason for pumping: {� I N TrSYSTEM - - 1/ Septic tank/distribution box/soil absorption system Overflew-cesspool _ Privy Shared system(yes or no) (if yes. attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of ell components,date installed/if knawnl end source of bon -,+ {J tt=-A- Sewage odors detected when arriving at the site:(yes or no)N revised 9/2/98 Page 6 of SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ICOIIYlatsdl Property Address: !EC m f PL L l )0“. Owner; jiJNE) C.ID �` L-rl Date of Enpecbon: 6-26 - 9 7 v BUILDING SEWER: (Locate on site Men) G t Depth below grad,)O- Ll/1 -t ��/ Material of construction:_cast iron Jv 40 PVC other(explain) Distance from private water supply well or suction line N/ir} Diameter 4 't Comments: condition of joints.venting,evidence of Inkye.atc.1 ALL —ti1nTJS Art€ Sr..-.`-'J — ti <, L 1oc • SEPTIC TANK:: - (locm on site plan) As 11 - Depth below grade:l Material of construction: concrete_metal Fiberglass _Polyethylene_otherlexplainl If tank is metal, list age_ ls.age confirmed by Certificate of Compliance_(Yes/Nol Dimensions: QQ.5 X S X Sludge depth: < 4 r' / nr Distance from top of sludge to bottom of outlet tee or belle: 2.-0 Scum thickness: NE 62.16F-194-r- PIGAllnC M SS Distance from top of scum to top of outlet tee or baffle:N� Distance from bottom of scum to bottom of outlet tee or baffle: N/A- /low Now dimensions were determined: M tMit•t O Comments: Irecommendation 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 ) CC AA Krm,'D 1.)1.-A‘ JA.)C r k l„_LL. 1n , =ci - -Co lz < _ ,J — n, v >v. ' t r- .- • ( '_ ,- .y1 1. 1 1.. 1 -.1h ✓ e GREASE TRAP:_ /R. [locate on site plan) Depth below grade: Materiel of constructio :_concrete_metal_Fiberglass _Polyethylene_other(explainl Dimensions: Scum thickness Distance from top of sc m to top of outlet lee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Date of last pumping: Comments: • (recommendation for pu ping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage.etc. revised 9/2/98 - Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ri SYSTEM YiFORMATION(continued/ PropertyA,�tresa: t e ITV P r UOcG °Nest: co�P/.i Dote of impaction: 6- 26 - I TIGHT OR HOLDING TANK: NI i ETank must be pumped prior to.or at tim.of. inspection) (locate on site plan' ��rlll Depth below grade: ( 1//T Material of constructgn:_concrete_metal Fiberglass_Polyethylene_othnpzplain) Dimensions: - Capacity: -- gallons Design flow: gallonelday Alarm present Alarm level: Alarm in working order:Yes_ No Date of previous pump ng: Comments:- (condition of inlettee, ondition of alarm end float switches.etc.) DISTRIBUTION BOX: (locate on sit.plan Depth of liquid level above outlet invert: NA I o 13 & REPLACED. Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.I ke n-LUt X£4 Cf✓C:i C+[:iC u)i Lem. c c l Icu . LiiVL I Y., _ — " .., i 1. PUMP CHAMBER:_N il. (locale on site plan) /I Pumps in working order Alarms in working order Comments: (note condition of pump Yes or No)_ Yes or No) hamber,condition of pumps and appurtenances.etc.) revised 9/2/98 Page g or It SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icerrbretedl Property Ada : te?o ly\(lye(.,€ I210Crc. - Owner: t/.lr r� / D (?HH'oC - Dete of lr.pechort: ( — ? - `) SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible; excavation not required,location may be approximated by nontintrutive methods) If not located, explain: Type: leaching pits. number:_ leeching chambers,number_ leaching galleries,number: / —�leeching trenches.number.length:&TRC! n K65 (it y % ,4. X '.5 k) leaching fields.number,dimensions: overflow cesspool,number._ Alternative system: Name of Technology: Comments: 'note condition of soil, signs of hydraulic failure. level of ponding. dem condition of veeetatton. etc.) NC 6N i HDt'v-lLd c Co,ze/ l v.V,,. i „ll� — ter r 1t .< f-<.c wNl _ CESSPOOLS: (locate on site plani Number end 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 perpped as pert of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of pending,condition...vegetation.etc.) PRIVY: (locate on site plan) Materials of construction: I Dimensions: Depth of solids: Comments: (note condition of soil.signs of hydrau'c failure,level of ponding, condition of vegetation:etc.) revised 9/2/98 Page 9 or II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Mainland) Property Adds,: iQ& MAP(—C �Z..\OGC owrr: iLivdot GO P inscI} Dsm of Inspection: (0 Zu SKETCH OF SEWAGE DISPOSAL SYSTEM. include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) e XtSTkIC� 150o GaL K SEp--ac TANG_ I aF 411Pvc P1Q=. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icmti..d Property Address: ((Cp�� vV ` e Date of Irsacbfa: (p -26 (Cr NNCS Report name Soil Type Typical depth to groundweter USGS Date websit.visited Observation Wefts checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope- Surface water Check Cellar Shallow walls Estimated Depth to Groundwater Feet 0 Rt6I0-AL 5vRFAC6 Please indicate all the methods used to determine High Groundwater Elevation: tanned from Design Plans on record O0served SIteA�prrt4 observation hole.basement sump etc.) Determined-from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records V Checked local excavators,Installers t/ Used USGS Dale Describe how you established the High Groundwater Elevation.(Must be completed) Rw1CL.icy7 ft./ KN JJ,c ) r) SC-Ve l�`Jri i. CoNDI l ✓n- 7 Rc✓iG� .9 U5GS tivaJs revised 9/2/98 Page It of II • v COMMONWEALTH OF MASSACHUSETTS �I ))ry EXECUTIVE OFFICE OF ENVIRONMENTAL Aj '?AI tS:P 17 LJ DEPARTMENT OF ENVIRONMENTAL PROTEf TION_. NOF: AMFTOK Eu:.rz . 5::: TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 180 Maple Ridge Road Northampton, MA Tel: ( 413) 585-0742 Owner's Name: Dr. Ronald Paasch Owner's Address: 180 Maple Ridge Road Northampton, MA 01060 Date of Inspection: September 10, 2001 Name of Inspector: (please print)Timothy E. Maginnis RS Company Name: Mailing Address: 70 Montague Road Westhampton, MA. Telephone Number: (413) 527 5291 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 inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.1 am a DEP approved system inspector pursuant to Section 15. 0 of Title 5(310 CMR 15000). The system: Inspector's Signature: (w-a X ion by the Local Approving Authority Date: September 16,2001 The system inspector shall submit a ' .n report to the Approving Authority(Board of Health or DEP)within 30 days of completing this i spection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the syst m 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 site is occupied by one individual. ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of I1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 180 Maple Ridge Road Northampton, MA Tel: ( 413) 585-0742 Owner's Name: Dr. Ronald Paaseh Owner's Address: 180 Maple Ridge Road Northampton, MA 01060 Date of Inspection: September 10,2001 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:THIS SYSTEM HAS(3)- 3' DIAMETER CONCRETE COVER OVER THE INLET, OUTLET AND CENTER COVER. THE CENTER COVER IS FOR PUMPING THE SYSTEM. B. System Conditionally Passes: N/A 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 detertined"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 exfiltration 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): ND explain: Tltlo G Ino..er.6nn Cnen,an G/Innn broken pipe(s)are replaced obstruction is removed 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 180 Maple Ridge Road Northampton, MA Tel ( 413) 585-0742 Owner's Name: Dr. Ronald Paasch Owner's Address: 180 Maple Ridge Road Northampton, MA 01060 Date of Inspection: September 10,2001 C. Further Evaluation is Required by the Board of Health: N/A 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)(6)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 ofa 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: N/A Tn cr c ..., an snnnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 180 Maple Ridge Road Northampton, MA Tel: ( 413) 585-0742 Owner's Name: Dr. Ronald Paasch Owner's Address: 180 Maple Ridge Road Northampton, MA 01060 Date of Inspection: September 10,2001 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 cesspool 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 N/A 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. N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a public well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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: N/A 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. Tso c r",...e,..:,...c,...., en c norm 4 Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 180 Maple Ridge Road Northampton, MA Tel: ( 413) 585-0742 Owner's Name: Dr. Ronald Paasch owner's Address: 180 Maple Ridge Road Northampton, MA 01060 Date of Inspection: September 10,2001 Check if the following have been done.You most indicate"yes"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 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? NO BACK-LIP _X_ Was the site inspected for signs of break out'? NO BREAK OUT OBSERVED _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. - PLAN REVIEW. _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 15.302(3)(6)] 7`:.10 c r.,....o. :,.., c ....en mono 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 180 Maple Ridge Road Northampton, MA Tel: ( 413) 585-0742 Owner's Name: Dr. Ronald Paasch Owner's Address: 180 Maple Ridge Road Northampton, MA 01060 Date of Inspection: September 10,2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15203 (for example: 110 gpd x#of bedrooms): 680.60 GPD Number of current residents: 1_ Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): NO Last date of occupancy: CURRENTLY OCCUPIED BY ONE OCCUPANT COMMERCIAL/INDUSTRIAL N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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 LAST PUMPED ABOUT 5 YEARS AGO Source of information: DR.RONALD PAASCH—home owner Was system pumped as part of the inspection(yes or no): NO—PUMPING IS RECOMMENDED If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system LEACHING TRENCHES Single cesspool _Overflow cesspool Privy NO 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 Of known)and source of information: 10 YEARS - TIMOTHY E.MAGINNIS DESIGNED THE SYSTEM. Were sewage odors detected when arriving at the site(yes or no): NO m.. . . .. .,. 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner's Name: Owner's Address: Date of Inspection: 180 Maple Ridge Road Northampton, MA Tel: ( 413) 585-0742 Dr. Ronald Paasch 180 Maple Ridge Road Northampton, MA 01060 September 10,2001 BUILDING SEWER(locate on site plan) Depth below grade: 18"—24" Materials of construction: cast iron _X 40 PVC other(explain): Distance from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of leakage,etc.): NO EVIDENCE OF LEAKAGE,JOINTS ARE OK. BUILDING SEWER IS IN GOOD CONDITION. SEPTIC TANK:_X_(locate on site plan) Depth below grade: 3 CONCRETE COVERS—OVER INLET,OUTLET AND CENTER 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:_10.5'L x 5'W x 5'D Sludge depth 2" Distance from top of sludge to bottom of outlet tee or baffle:_4.5'_ Scum thickness: NEGLIGABLE-FLOATING MASS_ Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Recommended pumping at least every three years,inlet and outlet baffels are sound,no leakage, liquid level at outlet is even with invert. INLET AND OUTLET BAFFLES ARE SOUND. TANK IS IN GOOD CONDITION. NO EVIDENCE OF EXFILTRATION OR INFILTRATION. OUTLET INVERT IS LEVEL. RECOMMENDED PUMPING NOW AND EVERY OTHER YEAR IN THE FUTURE. GREASE TRAP: (locate on site plan) N/A 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): /1 cnnnn 7 Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 180 Maple Ridge Road Northampton, MA Tel: (413) 585-0742 Owner's Name: Dr. Ronald Paasch Owner's Address: 180 Maple Ridge Road Northampton, MA 01060 Date of Inspection: September 10,2001 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) N/A 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:_X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_EVEN WITH INVERT 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.):BOX IS LEVEL,NO EVIDENCE OF CARRYOVER OR LEAKAGE. THERE IS A 3'COVER OVER"D"BOX. VERY HEAVY. PUMP CHAMBER: (locate on site plan) N/A 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.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 180 Maple Ridge Road Northampton, MA Tel: ( 413) 585-0742 Owner's Name: Dr. Ronald Paasch owner's Address: 180 Maple Ridge Road Northampton, MA 01060 Date of Inspection: September 10,2001 SOIL ABSORPTION SYSTEM(SAS): X_(locate on site plan,excavation not required) if SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: _X_ leaching trenches,number,length: 6 TRENCHES @(43'1,x 3'W x l.5'H)EACH leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of pending,damp soil,condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE,VEGETATION=GRASSES, NO PONDING, SOIL OK, THERE IS AN IRRIGATION SYSTEM OVER THE SAS. GRASS IS OFTEN WETTED BY THE IRRIGATION SYSTEM. NO APPARENT DAMAGE TO SAS. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) N/A 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 pending,condition of vege on,etc.): PRIVY: (locate on site plan)N/A Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): m:n c r c ...,,an ao(1nn 9 i BLACK TOP DRIVEWAY ARDEN 7 'APACE „-._:AGE ENCE 1 .500 SA. ION SE;-'C TANK I) SIHH\ ICN 3CX] I X THCNCH I AC- NC S"STEIV RECOMML H. AND EVERY C9 NOR NC SITE. 180 MAPLE ROSE ROAD NORTHAM PTC,A, AlA_ CR_ 7R RON A; R PAASCH LIRE =T SERIE . 9 P' 16, 2O01 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART M w C /y�, SYSTEM INFORATWN Icar .Jl a Pr<ny Am...: Vora MA P L-t G C at.otthwCCOn��Z. /Ycl} S[ETCH OF SEWAGE DISPOSAL SYSTEM: include Cos to.t bast two permanent raeren •landmarks or b.nchmarks locals all walls within 100'(Locate whirs public weter supply comes into house) —x ExLs-T1Ncv.„ Soo GAL K ScpT∎` TAIV(. I 111 r'1/G P(PL S, v11 dS9a T SoiL AG&Z. SCI$lEtA, 1p1 REJ•Ceft-5 43.95 X3XIS (SCE pt ) ye■4TlPJ6,, tL {SJv i< Page ID of tl I Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner's Name: Owner's Address: Date of Inspection: 180 Maple Ridge Road Northampton, MA Tel: ( 413) 585-0742 Dr. Ronald Paasch 180 Maple Ridge Road Northampton, MA 01060 September 10,2001 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. Locate where public water supply enters the building. SEE ATTACHED THIS SITE AND SURROUNDING HOMES ARE SERVED BY MUNICIPAL WATER SUPPLY OF NORTHAMPTON,MA. T'o c , + n .... Fn moon 10 Page I I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 180 Maple Ridge Road Northampton, MA Tel: ( 413) 585-0742 Owner's Name: Dr. Ronald Paasch Owner's Address: 180 Maple Ridge Road Northampton, MA 01060 Date of Inspection: September 10,2001 SITE EXAM Slope—SAS IS LOCATED IN BACK YARD. Surface water—NO SURFACE WATER OBSERVED.YARD IS IRRIGATED BY UNDERGROUND IRRIGATION SYSTEM. NO APPARENT DAMAGE. Check cellar—CELLAR IS FINISHED AND DRY—NO SUMP PUMPS Shallow wells—NO SHALLOW WELLS Estimated depth to ground water: 5' FROM ORIGINAL SURFACE OF GROUND. Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked, date of design plan reviewed: Sept. 1,2001 _X_Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: GRAOUNDWATER WAS ESTABLISHED BY ON-SITE INSPECTION OF PROPERTY AND ADJACENT LOT. KNOWLEDGE OF GROUNDWATER IN VACINITY OF SITE,REVIEW OF EXISTING (PREVIOUS) SOIL LOGS FOR THIS SITE. OBSERVATION OF LOCAL UP-LAND VEGETATION AND THE OBSERVANCE OF NEAYBY WETLAND ELEVATION. THE SOILS AROUND THE SEPTIC TANK SHOWED NO SIGNE OF GROUNDWATER. ALSO CHECKED GROUNDWATER DATA IN U.S. SOIL CONSERVATION COMMISSION'S SOIL SERVEW OF HAMPSHIRE COUNTY. TLI. S Inomr.f• r......Fn moon 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A p 100/2/C71.-r.-CERTIFICATION Property Address: 80 7/2/91i,c /!/.00 %'e->A0 ArileInnea Owner's Name: lS / Ownec's Address: a r ( /.0 5/ a►wc f /ice ,»4 .Uaf,._r vrar7/211o4.) An. Date of Inspection: Name of Inspector:(please print) /,1f/(1 / V=SfF�U%%� /°L Company Name: G - ,« 4 .c/e--� C-16 Mailing Address: a Air �pqd //OLyn/c,t /✓7)5 5 Telephone Number: 44'J - sa j— 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 inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.lam•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 Authori q Is Inspector's Signature: //,4 /_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Elea 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 report oniydescribes conditions at the time of inspection and under the conditions of use at that time. This inspection don not address how the system will perform In the future under the same or different conditions of use. Page 2 of l 1. OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSN ENT$ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONTORM PART A CERTIFICATION(msttmed) Property Address: d4 , /7/P 2J4f7tek: £ 2/(YGr7/,9,22,23 . t/4 5 owner fans 4 p ,0,94-cdy Date of Inspection: �y//V 03 Inspection Summery: Check A,B,C,D or E/AI.WAYR completeai of Section I) A., System Panic: 1 hsve'nm Mad any information which indicated that any of the allure cicala described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: J`IJS���yJ ;%ou-'s 770 :S/9// 5 G, G'rJ ro o CrIS B. System Conditionally Panes: One or mate 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 pus. Answer yes,no or not determined(Y,N,ND)in the_for the following statements.If'bob determined"please explain. The septic tank Is metal and over 20 years okl•or the septic tank(whetter metal or not)is structurally unsound,exhibits substantial infiltration or exBltnton or tank failure h lo'f't.System wit pm Impeetlon 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 Inking 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 oat or high steno water level in the attribution 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 Heal h): broken obaaucan hammed . distribution boat is tetrad ormplactd ND explain: _ The system required pumping more than 4 tines ayer dal to broken or obstructed pipe(s).The system win pan inspection if(with approval of the Board ofHahh): broken pipe(s)are replaced obstruction la removed Tage 3 6f 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A pp CERTIFICATION(continued) Property Address:/et /y%�id� .4#6E£j7 Owner: je/7 FON,9, 0 /0i9,95-0(7 Date of Inspection: /2/9/c33 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(6)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 I 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 490 7/4.OG` �� 4)O/ 2- /✓,9/11.2/G'C./ Owner: ag, 2O.0/ .(J /✓A/35C/-/ Date of Inspection: /t/'7/ca D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool s/ Discharge or ponding of effluent 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 ,04'4 Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow t/Requ red pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped— • 1/Any portion of the SAS,cesspool or privy is below high ground water elevation. QAny portion of cesspool or privy is within 100 feet of asurface water supply or tributary to a surface water supply. /!'WY Any portion of a cesspool or privy is within a Zone 1 of a public well. /7jTi/ 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. [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.] (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. 4VV E. Large Systems: 11/21 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: MARGE /2/x04=7 Pa/761 .L' ,v1,1SS 4ca /0 9SC61 I,/4,1n Date of Inspection: Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No t/ Pumping information was provided by the owner,occupant,or Board of Health t//Were any of the system components pumped out in the previous two weeks? — Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection? — Were as built plans of the system obtained and examined?(If they were not available note as N/A) Vthe facility or dwelling inspected for signs of sewage backup? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? 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? 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 I/ Existing information.For example,a plan at the Board of Health. Y _ Determined in the field Of any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(6)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: A. ARIL-Aria / Lss' f / #c'-SL ,se/00E- /d.7/, TO4 14-1A? W CONDITIONS RESIDENTIAL Number of bedrooms(design): 0 Number of bedrooms(actual):V DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): //a f 9' = V 9'0 Number of current residents: 2- ,�p�9 `S-0 Does residence have a garbage grinder(yes or no): fra Is laundry on a separate sewage system(yes or no):"±a0[if yes separate inspection required] Laundry system inspected(yes or no): y_Q,C Seasonal use:(yes or no): /16 Water meter readings,if available(last 2 years usage(gpd)): — Sump pump(yes or no): Nc2 Last date of occupancy: — COMMERCIAL/INDUSTRIAL %d1/rr Type of establishment: Design flow(based on 310 CMR 15.203): god Basis of design flow(seats/persons/sgfl,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): GcsIERAL INFORMATION Pumping Records ,000J/te. /4/S,2-e C.Y—IC`(/ Source of information: Was system pumped as part of the inspection .r no):_ / If yes,volume pumped:/,5 .Gallons--How was quantity pumped determined? /Tt-6'117 dam% Reason for pumping: /70,L1 TYPE OF SYSTEM 2(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/Altemative 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(descnbe): Approximate age of all components, to installed(if known)and sour of information: ‘1/0 9 / olUy i7 1 /7 S- Were sewage odors detected when arriving at the site(yes or no): 4/0 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r� SYSTEM INFORMATION(continued) Property Address: /80 /%7+Q®Ge A:W/%%6,a '®AD ane0 /V Owner: jeatl A/gcery Date of Inspection: /20/4/40,S BUILDING SEWER(locate on site plan) // Depth below grade: A9/r , 2V Materials of construction:_cast iron g_40 PVC_other(explain): Distance from private water supply well or suction line: Q.(/% Comments(on condition of joints,ven g,evidence of leakage,etc.): /{/n/oroh iim s /f r�rt 0 SEPTIC TANK:_(locate on site plan) Depth below grade: /CI yy//9•L/40leS /7 -//s /x/ SA 74.647 Material of construction: ti-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) // .Y _-v. r Up 11.4'o ci Dimensions: re (p 6 5- Sludge depth: e? " Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 3 " Distance from top of scum to top of outlet tee or baffle: 3 / Distance from bottom of scum to bottom of outlet tee or baffle: 2/ How were dimensions determined: I 't '%75c4'.tc/ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert evidence of.leakage,etc.): >We} .a&7*' 2C Pia at COL, ccci€2,77amu GREASE TRAP:_(locate on site plan) DMA 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /�° jn/9,PeC # I&6O, /�7 /-O�J /01 Owner: 624-/ p94s'c,7/ /'/ i/a.$ Date of Inspection: 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.): .co Co/0..: 0/57" 'ear DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Q■ r� ©„ Depth of liquid level above outlet invert: EG'BXJ 1.tlind /d/!/.S2T 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.): p 75rg/JL ZS" ,5'/$77s ".9 /Xf COlc/AiJ7G- N47tS ltc'//,Cli' 's-n2 x, PUMP CHAMBER: (locate on site plan) get./.4/ 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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Cp J/ SYSTEM INFORMATION(continued) Property Address: /882 /%2.4/'G,E. Owner: Date of Inspection: > / «///3. 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: (p /P/7G///-(.tom j t/Zjej'/f _leaching fields,number,dimensions: _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.): tatif/yiLl / , Ggc-b 6/PAs/ay 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 laver: 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.): evv-1 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 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: 4570 ,n29,06.6 1t/Dl6 ,'0A19 ,wrrrsz Tait/ iCi,ls irfar au/06_6 ,044nscy /2/y/a3 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 Locate where public water supply enters the building. �P rr/oc 41,6-6 10 Page H of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /60 , 4T.O4 /2,ivAe,e0 z) 4 Its d / /YZLU ,t7fl Date of Inspection: �/>/44/3 Owner: SITE EXAM Slope ■ Surface water A/0.-1L47 I✓0TF�%1J Check cellar ,(/O So-n, Shallow wells /'c>Sit//KCdc[l u--c?di' , yp, Estimated depth to ground water /f feet 077/9/..0V/?c p&1s/y.ci p /0 4./j Please indicate(check)all methods used to determine the high ground water elevation: ✓9�btained from system design plans on record-If checked,date of design plan reviewed: t/Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: ae.1//J L[/i97%/Z k lPValnliiC i .[.o,'.O/ 1t2i c? O/2/2r/,r- C -7 1500 GALLON SEPTIC TANK DISTRIBUTION BO 0(7( Aix 6 TRENCH LEACHING SYSTEM RECOMMEND PUMPING NOW AND EVERY OTHER YEAR IN THE FUTURE. SITE: 180 MAPLE RIDGE ROAD NORTHAMPTON, MA. FOR: DR. RONALD PAASCH DATE: SEPTEMBER 16, 2001 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PANT C SYSTEM NFORMATION.IcouuNrW) h^P.ny Amr...: L C60 M ?LE G D.n of bLJ2 Pd HSGF} SSETCN pF.SEWAGE DISPOSAEISYSTEY- mduE�u..to n l08 two_P.rmsnmGSfnsnes N Gnarka or Mnchmnks:. loan.II w 4a thin 100`Ikons.toner.puN c w4. auPPlY�eom.a into house) /.y 1&Oc.) GA& s ScjfT■C- TAf C_ oI- et-IIPvc p147• L )(.\LflPJ& C 130x. X I 7,9 -' \ . _,,i \ - i NJ Al tuna r : • ' �' � w� 4 a r 58 = 448 8F0 r �i A > FT. LAN rte. • (43.75' 1 x 3'w x 1.5'h ) I(�t S'IoES = 787.5 SQ. F7• * 0.50 = 393.75 0. )8s '54 SQ. FT. x 0.50 = 27 0. orwp . = 181.5 9Q. FT w0.33 = 259.87 Q, t gallons + 259.81 gallons = 880.6 gallon° , I0 3 LOT 25 � - a l „ — �u A 987 /9c RE 5 `` __ ,V� {'1 'f SI. re°" EmISTTNG ' i LS LDCA a11 WITHIN 10 LEACHING FACILITY. PROPERTY SER1Ep. -`x a z r SITE P49N/ MUNICIPAL WATER SUPPLY NORTMMTTON s (NT) ) LOCATION AND CONFIGURATION OF HOUSE IS /j/A,��� R SHOWN FOR REFERENCE ONLY. ted I O� V Lu THE REOIJIREPENT OTIE WETLAND PROTECTION SA, G.L TOC COMPLY, s. A CONTRACTOR TO NOTIFY NORTHAMPTON OONSERVAT ION CONMI SSICN BEFORE CONSTRUCTION BEGINS Plan app.s c� d ■ 2/4 Tarr This PLAN NOT FOR WETLAND DETERMINATION of,the „ n 1 a • o Health subject to the following conditions: ALL WOW TO BE DONE OUTSIDE BUFFER ZONE � — Design Engineer net Inspect EROSION CONTROL DEVISES TO BE INSTALLED BEFORE CONSTRUCTION BEGII and verify 311 writing that This SYSTEM DESIGNED TO THE STATE SANITARY th0 G?eai �° CCOE TITLE-5. WHEREAS THE DESIGNER CANNOT GUARANTEE to performed, few, it 1988, yithithe ed 3n aocoldallce THE INSTALLATION OR USE OF This SYSTEM, THE DESIGNER appro'v'e plena. CANNOT tlJARANTEE AGAINST FAILURE OF THE SYSTEM. 0 - 6" 6" - 30.. P®1C TEST DATA. 00" $4• omth;Y"TP n Div • eta Wei !F -,P J1IIPineeripq •, n •:^.. . „nl ,±. .. :._. PPo/)OSLD 5QI SURFACE 5G4AG °102° 6RC'N "1ESBEGIN *GAec,MLt lI JJ1• . •.� LO7 X25 - Mw1-4.E f?1D64. � END SOMA: 9:15 AM SCALE: As No7E0 °T�M O7NY E i $ 1 S 10 9:43 AM DATE : 6 -10- 91 (4n) SZ? 529( —„s 20 NFlee1Nq} 4" 10132 AM FoR' 6/FlNci14eCa/C.) CoPPOR/ RATE = 17 MINS/INCH - DESIGN 20 MINS/INCH EFl�rrtAnlPTaA/ IA. 72Alorn;y�,4 E.. MHG.INN/S Rs TJ MGNTAd vE 1<o/ie.) Kt ttFf/r, -1 r 4 N90 niNint .:li� Ob ° 440 DO PLRC BATE = 11 M, PER "03" OESlJ9 FOR 20 MIIafl'Ea PER INGI $10 LLS. a 2.0. 94. P . PER GALLON L50°!'dALLONE PER SG. P.T. 3.0 SQ. PT'PEI1 A4 LON 0.336 Ll.ONS 0.0. Sc. ft b TREN�+ES - iHF.ILTRMVRS - 0 (43.75' 1 x 3'M x 1.S'n )` z. 393.75 0, SIU Ss(43•75' 1 -x 1.9`h)12 SIDES 187.5 S%.0 27 tl.. n ENi6t (3w x 1.S' 1)12 . . . (43.75'1 x 3'w)S EO17Q16 z 7$7.5 54. F-I'.xO.33 254.51 G. L Chun: 393.75 gallons + 27 gallon, + 259.07 9411d1a a 635_,s—°a�ta i a x, q .. e ". .,t. a a LO T z 4 1 $GALL : G 20') i3R6Fl = 1. 987 6/cRGS .1`l' No c2 '7.j THE COMMONWEALTH OF MASSACHUSETTS BOARD HEA OF H /� d1/4/ /5/ OF . �Ai' FEE—S� Einpuaql Wurkn QIunntrnrtiun Perm Permission is hereby granted /1/4-0l G./ A/Co 2 C Qi 0 to Construct_kX),Qr Re air ( n In ibiduat m jexage Dispgsll yste 0 Snect // as shown on the application for Disposal Works Construction Perm'p'�Io. .6``421. Dated.1GP .�1�.�_/ LAc ot Health DATE FORM 1255 HOBE S & WARR EN. INC.. PUBLISHERS (tc ///ate ,c' -