Loading...
235 Title 5 Application/Permits 1987,1999, Reports 1987,1999,2009 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 235 Maple Ridge Road Owner' Name: Dorothy Rosenthal City/Town: Northampton, MA 01060 Date of Inspection: 9/7/09 Inspection results must oe suomntea on ups form. Inspection forms may not be arterea In any way. Owner Address: 235 maple Ridge Rd., Florence MA 01062 Copy to: Board of Health, Northampton, Pat Gogctins Witness: Owner information is required for every page Homestead Inc. #: SSDS-1310 A. General Information 1 Inspector: Name of Inspector: Thomas S. Leue R. S. Company Name: Homestead Inc. Company Address: 1669 Cape St. Williamsburg, MA 01096 Telephone Number: (413 ) 628-9533 License Number: 5I130 B. Certification 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. l am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The septic system condition must be evaluated and classified into one of the following four conditions Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails The system condition: Passes Inspector's Signature: Date: 4/7/09 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 to the buyer, if applicable, and the approving authority. ""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. T5 Revised.der:• 12/C7 Titre 5 Official Inspection Form. Subsurface Disposal System•Page 1 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form �.i! Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 r, Property Address: 235 Maple Ridge Road Owner' Name: Dorothy Rosenthal Owner information is required for every page. City/Town: Northampton MA 01060 Date of Inspection: 4/7/09 B. Certification (cont.) Inspection Summary: Check A, B, C, D or E/always complete all of Section D A. System Passes: Y I have not found any information which indicates that any of the failure criteria as described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N 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, or ND) in the_for the following statements. If not determined" please explain. N 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. The system will pass inspection if the existing septic 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: N 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 by the Board of Health)- broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: N The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system win pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: C. Further Evaluation is Required by the Board of Health: N 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 or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)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. T5 Revised doc•12/07 Title 5 Official Inspection Form Subsurface Disposal System•Page 2 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �.. 7°r• Property Address: 235 Maple Ridge Road Owner Name: Dorothy Rosenthal Owner information is required for every page. City(Town: Northampton, MA 01060 Date of Inspection: 4/7/09 B. Certification (cant) 2) System will fail unless 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 indicates absent 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: D. System Failure Criteria Applicable to All Systems: You must indicate either YES (Y) or NO (N) as to each of the following for all inspections: N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N Liquid depth in cesspool is less than 6" below invert or available volume less than 1/2 day flow. N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped N Any portion of the SAS, cesspool or privy is below high ground water elevation. N Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N Any portion of cesspool privy is within a Zone I of a public well. N Any portion of cesspool or privy is within 50 feet of a private water supply well. N Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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.] N The system is a cesspool serving a facility with a design flow of 2000 gpd-10.000 gpd. N The system fails: I have determined that one or more of the above failure criteria exist as defined in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health should be contacted to determine what will be necessary to correct the failure. COMMENT: T5 Revised doc• 12/07 Title 5 Otfieal Inspection Form. Subsurface Disposal System• Page 3 of 9 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 235 Maple Ridge Road Owner' Name: Dorothy Rosenthal City/Town: Northampton, MA 01060 Date of Inspection: 4/7/09 B. Certification (cont.) E] Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd. For large systems, you must indicate either YES (Y)or NO (N) as to each of the following, in addition to the questions in Section D. N the system is within 400 feet of a surface drinking water supply N the system is within 200 feet of a tributary to a surface drinking water supply N 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 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. Checklist Check if the following have been done. You must indicate YES (Y)or NO (N) as to each of the following: Y Pumping information was provided by the owner, occupant or Board of Health. N Were any of the system components pumped out in the previous two weeks? = Y Has the system received normal flows in the previous two week period? _ N Have large volumes of water been introduced to the system recently or as part of the inspection? = Y Were'as-built" plans of the system obtained and examined? (If not available note as N/A) _ Y Was the facility or dwelling was inspected for signs of sewage back up? _ Y Was the site was inspected for signs of break out? Y Were all system components. excluding the SAS, located on site? = Y Were the septic tank manholes uncovered, opened, and the interior of the septic tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and scum? Y 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: Y Existing information. For example. a plan at the Board of Health. N Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR15.302(5)]. V Revised doc• 12/07 Title 5 Official Inspection Form.Subsurface Disposal System•Page 4 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form s"•5 ".. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ue;; Property Address: 235 Maple Ridge Road Owner Owner' Name: Dorothy Rosenthal information• required far City/Town: Northampton, MA 01060 Date of Inspection: 4/7/09 every page. D. System Information Residential Flow Conditions: 3 Number of bedrooms (design) 3 Number of bedrooms (actual) 330+ DESIGN flow based on 310 CMR 15.203 (for example. 110 gpd x#bedrooms) 1 Number of current residents N Does residence have a garbage grinder? _ N _ Is the Laundry a separate system? [If yes, separate inspection required] N Laundry system inspected? Seasonal use? 101 Water meter readings, if available (gallons per day) Last quarter use _.N Sump Pump? _ - - continuous Last date of occupancy COMMERCIAL/INDUSTRIAL Type of establishment. Design flow(based on 310 CMR 15.203): _ gpd Basis of design flow(seats/persons/sift, etc.): Grease trap present? Industrial waste holding tank present? Non-sanitary waste discharge to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: OTHER (describe). General Information Pumping Records. Source of information: Previously pumped 5/31/08 N Was system pumped as part of the inspection (Y or N) If yes, volume pumped: _ oallons How was quantity pumped determined? _ Reason for pumping. _ Comment. Pump on 3 to 4 year interval. Does not need pumping this year Type of System: X Septic tank, distribution box, soil adsorption system Single cesspool Overflow cesspool Privy N Shared system (Y or N) Of yes. attach previous inspection records, it any) _ Innovative/Alternative technology. Attach 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): T5 Revised doc 12/07 Tnle 5 Official Inspection Form.Subsurface D•sposa.S, 'em•Page 5 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Owner information is required for every page. Property Address: Owner' Name: City/Town: 235 Maple Ridge Road Dorothy Rosenthal Northampton, MA 01060 Date of Inspection: 4/7/09 D. System Information (cont.) 'Approximate Age: Septic plan: All components, date installed, and source of info. said to be a 1999 septic system_ installation N Were sewage odors detected when arriving at the site (Y or N) Building Sewer: 16 ABS plastic 6 Comments: Septic Tank: 9 Concrete (locate on site plan) Depth below grade (inches) Estimated Average Material of Construction Distance in feet from private water supply well or suction line No problems seen. on site plan) Depth below grade (inches) Materials of Construction If tank is metal. list age Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 0 Riser depth Septic tank width Septic tank length Septic tank height Calculated gross volume Air space in tank Net Volume Baffle depth Sludge thickness Top Sludge : Bottom Baffle Scum thickness Bottom Scum Bottom Baffle Top Scum Top Baffle 58 126 58 1 ,840 9 1,500 26 2 30 1 16 7 (inches) (inches) (inches) (inches) (gallons) (inches) (gallons) (inches) (Inches) (inches) (inches) (inches) (inches) Measured How were dimensions determined? Comments: No operational or structural problems seen. Pump within next 3 years . Baffle intact. Recommendations: Pump on 3 to 4 year interval. Interior dimensions Interior dimensions Interior dimensions Calculated Calculated .Average Calculated Average Calculated Calculated level appropriate. T5 Revised doc• 12/07 Title 5 Official Inspection Form:Subsurface Disposal System•Page 6 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form -The"". Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Owner information is required for every page. Property Address: Owner' Name: City/Town: 235 Maple Ridge Road Dorothy Rosenthal Northampton, MA 01060 Date of Inspection: 4/7/09 D. System Grease Trap: N Comments. Information (cons) (Usually present in certain commercial systems) Grease Trap part of system? Depth below grade (inches) Materials of construction: Dimensions. Scum thickness (inches) Top of scum to top of outlet tee _ Bottom of scum to bottom of outlet tee _ Date of last pumping condition Tight or Holding Tank: N Tight tank part of system? Depth below grade Materials of construction Tank width _ Tank height Design flow: Alarm Level _ Alarms in working order? Date of last pumping Comments: (condition of alarm and float switches. etc) Measured Averave Calculated Inches Calculated Inches (tank must be pumped at time of inspection) (inches) Tank length Capacity gallons/day (inches) Measured Attach copy of current pumping contract(required)- Is copy attached? Soil Absorption System (SAS): If SAS not located explain why: (locate on site plan. excavation not required): (inches) (gallons) leaching pits & number leaching chambers and number leaching galleries and number. leaching trenches. number, length: Y leaching fields, number, dimensions: 10r x 50 ' N6„it nhl; srZQ- overflow cesspool, number. Innovative/alternative system. Type: Comments- (note soil condition of soil, signs of hydraulic failure, level of pending. condition of vegetation, etc.) No surface problems seen. Recommend mowing over leachfield annually. T5 Revised doc• 12/07 Title 5 Official Inspection Form Subsurface Disposal System•Page 7 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address: 235 Maple Ridge Road Owner Owner' Name: Dorothy Rosenthal information is required for City/Town: Northampton, NA 01060 Date of Inspection: 4/7/09 every page. U. System Information (cont.) Distribution Box: Of present must be opened) (locate on site plan) (D-box") Y D-box part of septic system? 0 Depth of liquid level above outlet invert Inches Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, and out of D-box, etc. Box appears level and flow equal. 2 pipes out. About 1 foot below grade. Pump Chamber: (locate on site plan) N Pump part of septic system? Pumps in working order: (Y or N) Alarms in working order: (Y or N) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Cesspools: (cesspool must be pumped as part of inspection) (locate on site plan) N Cesspool part of system? 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 Comments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy: (locate on site plan) N Privy part of system? Materials of construction. Dimensions: Depth of solids- Comments. (soil conditions, signs of hydraulic failure, level of pending. condition of vegetation, etc.) Site Exam: (Source of Information) Y Check Slope 6/30/99 Official Perc Date Surface water Official Plan Date Y Check Cellar Other Official Source N Shallow wells Other Source 48 Estimated depth to ground water (inches) Please indicate all the methods used to determine high groundwater elevation: Y Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain. Checked with local excavators, installers-explain_ You must describe how you established the high ground water elevation. Site built up to be code required depth above groundwater. T5 Revised doe• 12/07 Title 5 Official Inspection Form Subsurface Disposal System•Papa 8 of 9 li i NORTH House outline Note: No known drinking water sources within 100 foot radius. deck Town water in 'K Septic Tank 12" white birch '� - --Leachtield, approximate layout 2T NN N Distribution Box 12" oak / Date: Owner: �`1N°vw�r,G>y HOMESTEAD INC. As-Built Drawing '� cN Existing Septic System 4/7/09 Dorothy Rosenthal r° THOMAS So a Thomas S. Leue R.S. -- - - ----- 235 Maple Ridge Road ' ° LEu Scale: 1 : 3(1' Revision Date: Florence, MA 01062 r1, #1 7J & r • — 1r164 Cape St. cklV WilliagOt0y6 Except as Noted �hACt 14131 fi .gc3A OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Part A Certification (continued) Property Address: 235 Maple Ridge Road Florence,Moss.01062 Owner Jerome&Rosenthal Date of Inspection: September 22,2006 INSPECTION SUMMARY: CHECK A, B, C, D or E/ALWAYS complete all of Section D A] SYSTEM PASSES: ® I have not found any information which indicates that any of the failure cohditions described in 310 CMR 15.303 or in CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: 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, or 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 exfiltration or tank failure is imminent. System will pass inspection'ifthe existing tank is replaced with a complying septic tank as approved by the Board of Health *A metal septic tank yl%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 breakout or high static water level in the distribution box is due to broken or obstructed pipe(s) 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 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 inspectiomrf with approval of the:Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 Page 2 Property Address Date of Inspection: Name of Inspector: Company Name: Company Phone: COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 INSPECTION FORM OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Part A Certification 235 Maple.Ridge Road Florence, Name of Owner: Jerome A Rosenthal Mass. 01062 September 22, 2006 Philip J. Pasiecnik Greg's Wastewater Removal 239A Greenfield Road S. Deerfield,MA01373 (413) 665-3989 Address of Owner: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system*this address and that the information reported below is true, accurate, and complete, as of the hme of the inspection Theinspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems I am aDEP approved system inspector pursuant to Section'15.340 of Title 5(310CMR 15.000). The system: Z Passes ❑ Conditionally Passes ❑ Needs Further Evaluation,by the local Approving Authority ❑ Fails INSPECTOR'S SIGNATURE: DATE: epailod, The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection.:If the system isashared 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: No failure criteria as described on page four of this inspection form was found at the time of inspection of this system. System Design Plan was obtained from the property owner for the purpose of this inspection. "'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 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Part A Certification(continued) Property Address: 235 Maple Ridge Road Florence,Mrs.01062. Owner: Jerome A.Rosenthal Dab of Inspection: September 22,2006 D] SYSTEM FAILURE CRITERIA applicable to all systems: You must indicate either"Yes" or"No"to each of the following, for all inspections: YES NO ❑ Ig Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. ❑ Discharge or pending of effluent to-the surface of the ground or surface waters due to an overloaded or cloggediSAS or cesspool ❑ ® Static liquid level-in the distribution box above outlet invert due to an overloaded or clogged MS or cesspool. ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. ❑ Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pplpe(s) Number of times pumped_ ❑ ® Any portion of the Soil Absorption System, cesspool, or privy is below the high groundwater elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z 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. ❑ [XI 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. [mis system passes If the well water analysis,perfomied atj MEP certified laboratory,for colifmm bacteria and volatile organic conipoundstndirstesthat Mc Mdlns fieehorn polrullonfrom tatfactlry and the presence of ammonia nitrogen and nitrate nitragen is*Walt orbas than 5 ppm;provided tiatno other failure criteria are triggered. A copy of the analysts:most be attached to't Is font) ❑ ® The system fails. I have determined that one or more of the above failure criteria exists as defined 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 threat, or answered "yes" in Section D above the large system has failed. The owner or operator or 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. Title 5 Inspection Form 6/15/2000 Page 4 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL ;SYSTEM. INSPECTION FORM Part A Certification (continued) Property Address: 235 Maple Ridge Road Florence,Mass.01062 Owner. Jerome A.Roeembal Dab of Inspection: September 22,2006 - - CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety, or the environment. 1) SYSTEM WILL PASS UNLESS BOARD-OF HEALTH-DETERMINESIN-ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEPLISNOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE 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 bordering vegetated'wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTlONING IN A'MANNER THAT PROTECTS THE PUBLIC HEALTH, SAFETY AND THE ENVIRONMENT: ❑. The system has a septic tank and soiLapsorption.system,(SAS) and the.SAS is within 100 feet to 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 1of 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, per(onned are tEP certified laboratory, for coliform bacteria and volatile organic compounde indicates.Matte weft is free from pollution from that facility and the presencerof.ammonia nitrogen.and-nitrate nitrogen is equal to or less than 5 ppm, provided that no otherfailure•afteria are triggered. A copy of the analysis must be attached to this form. 3) Other Title 5 Inspection Form 6/15/2000 Page 3 Property Address: obaer: Date of Inspection: OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Part C SYSTEM INFORMATION 275 Maple Ridge Road Florence,Nest ttiOn Jerome A.Rosenthal September 2212006 Residential: Number of bedrooms(design): 3 . Numberof bedrooms.(actual) 3 DESIGN Flow: 330 G.P.D. (based on 310 CMR 15.203-for example:110 gpd x#of bedrooms) Number of current residents: 2 Is Garbage Grinder present.(yes or no) No Is laundry on a separate sewage system (yes or no) No if yes separate inspection required FLOW CONDITIONS Laundry system inspected (yes or no) Seasonal Use (yes or no) No Water Meter readings - if available (last two (2) year usage (gpd) ,22,700 Cu. Ft. = 165 750 Gallons=227 G.P.D. Sump Pump (yes or no) No Last Date of Occupancy: Currently Occupied Commercial/Industrial: Type of establishment: Design flow: (Based on 310 CMR 15.203) gallons per day Basis of design:flow(seats/persons/sgft,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) Last Date of Occupancy/Use: OTHER (describe): PUMPING RECORDS Source of information: Was system pumped as part of the inspection: (yes or no) If YES -enter volume 1500 gallons pumped How was the quantity pumped determined? Tank Dimensions Reason for pumping: Tank Inspection and Solids Removal GENERAL'INPORMA oN System septic tank was last pumped 2 years ago per owner. Yes TYPE OF SYSTEM: Z Septic Tank/D Box/Soil Absorption System Single Cesspool LI Overflow Cesspool ❑ Privy Shared system (yes or no) (if yes, attach previous inspection records if any) No nnovative/Altemative technology. Attach a copy of up the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of DEP Approval OTHER(describe): Approximate age of all components, date installed (if known) and source of information: Tank 20 Years Old -SAS 7 Years Old / 1986- 1999 / Owner and Design Plan Were sewage odors detected when arriving at site: (yes or no) No Tide 5 Inspection Form 6/15/2000 Page 6 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOS7Rk•gSYSTEM INSPECTION FORM CHECKLIST Properly Address: 236 Maple Ridge Road Florence.Mee.01062 Owner Jerome A.Rosenthal Dab of Inspection: September 22,2006 Check if the following have been done. Y:asia must indicate either "Yes" or No as to each of the following: Yes No ® ❑ Pumping information was requested of the owner, occupant, or Board of Health.' ❑ ® Were any of the system component's 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 introducedto 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) ❑ Was the facility or dwelling inspected for of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding-the SoifAbsorption Systems 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? -Z ❑ Was the facility owner(and occupants if different froritowher)-providedwith information on the proper maintenance of subsurface sewage disposal systems? -' The size and location of-the Soli AlzaziapftiorzSysitern(SAS)-on the site has been determined based on: ® ❑ Existing information. For example, a plan at.the Board of Health. ❑ ® 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)(b)] Title 5lnspection Form 6/15/2000 Page 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM part=C SYSTBMAN TION (continued) Property Address: 235 Maple Ridge Road Florence,Mrs.01062 Owner: Jerome A Rosenthal Date of Inspection: Seebmber 22,2008 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 T Other(explain) Dimensions: Capacity in gallons - - Desi9nifickWrm.gall :Eer oY Alarm present(Yes OF No) Alarm level Alarm in working order❑Yes ❑ No Date of last pumping Comments: (condition of alarm and float switches, etc.) DISTRIBUTION. El Yes ❑ No (If present, MUST be ppened-locate on siteplan) BOX Depth of liquid level above outlet invert: NotabOVe 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 distributienawas level and.flow_was equal to.• •`t outlet pipes. No solids carryover was in±the • a t©tined tlistiection_Naleakaoe was evidentinto or out of the box at this time. Cover to the box was 17'b r dFadel. PUMP CHAMBER: ❑ (located 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.) Title 5 Inspection Form 6/15/2000 Page 8 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PartcA CertificiatIt fr4ctitntitlued)? Property Address: 296 Maple Ridge Road Florence,Mess.01062 • Owner. Janine A.Rosenthal Date of Inspection: September 222 2006 .. . BUILDING SEWER(Locate`on site plan): ® . . Depth below. 16" Maferlal'of 0:instr uction: cast iron X901 40 PVC other(explain) Distance from private water supply well or suction line Town Water Diameter 4" Comments: (condition of joints, venting, evidence of I retc:) Joints-were-in flood condition. Venting was visible outside the dwelling on the roof. No leakage was evident thistinie 7" --' SEPTIC TANK (locate on site plan): ESI Depth below grade: 10" Material of Construction: ° ''Concrete ❑ Metal ❑ Fiberglass Polyethylene _Other(explain) If tank is metal, list age_ Is age confirmed by Certificate-of-Compliance (Yes/No) (If"Y" attach copy of Certificate of Compliance) 1016%)(513',W 6'4"D Dimensions:..- 25 ., , ,DistiO46,,fronftork to bottom of.outlet tee orbaffle 6" Distance frotTdp of scum to top of outlet tee or baffle 13" Distance from bottom of scum to bottom of outlet tee or baffle Measured How dimensions were determined: Comments: (On pumping recommendations, inlet&outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.) The septic tank should be pumped every two to three.vears. Cast in place concrete inlet baffle was in good condition and extends 15"below the flow line. Cast in olaoeconcreteoutlet baffle was in stood condition and extends 17" below the:flow line. Structural intearity of the septic tankwas good.The liquid level was at the outlet invert.No leakage was evident. . GREASE TRAP (locate on site plan): ❑ Depth below grade: Material of Construction: ❑ Concrete ❑ Metal ❑ Fiberglass ❑ Polyethylene ❑ Other(explain) Dimensions Scum thickness Distance from top of scum to top of outlet tee/baffle Distance from bottom of scum to bottom of outlet tee/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.):_ Title 5 Inspection Form 6/15/2000 Page 7 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Part C Property Address: 236 Maple Ridge Road Florence MTEIN1MfORMATION 062 Owner Jerome&Rosenthal Date of inspection: September 22,2006 SKETCH OF SEWAGE DISPOSAL SYSTEM: **** {"SEE EXHIBIT A) Title 5 Inspection Form 6/15/2000 Page 10 *** OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM 'INSPECTION FORM ParttC SYSTEM. TION 4continued) Property Address: 235 Maple Ridge Road Florence,Mn..01062 Owner Jerome A.Rosenthal Dab of Inspection: September 22,2006 SOIL ABSORPTION SYSTEM El 1(locate on site plan? if possible;excavation not tfS�S�rrofHdt:atsrl�expl�inwfly:.- -'. TYPE: Leaching pits& number Leaching chambers& number Leaching galleries&number Leaching trenches, number, length Leaching fields, number, 2 - Pipe Leachfield 50ft Long x tOft. Wide dimensions ( Per Design Plan.) Overflow cesspool, number .. Innovative/Altemative system: Name of Technology: Comments: (Note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) The 5011 was loamy sand with no substantial clogging evident. No signs of hydraulic failure or ponding to the surface of the around. The soil over the leachfield wasn't damp or spongy.Vegetation was crass which was uniform in growth throughout the area of the leachfield. Grass in the clearing where the leachfield is should be mowed 2 - 3 times annually.. CESSPOOLS ❑ (Cesspool must be pumped as part of inspection-locate on site plan) Number& 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 so9,signs of hydraulic failure,level of ponding,condition of vegetation etc.) Title 5 Inspection Form 6/15/2000 Page 9 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Part C SYSTEM INFORMATION (continued) Property Address: 235 Maple Ridge Road Florence,Mass.01062 Owner. Jerome A Rosenthal Date of Inspection: September 22,2006 SITE EXAM ❑ Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated Depth to Groundwater >4 Feet Please indicate (check) all the methods used to determine High Groundwater Elevation: ® Obtained from system design plans on record- If checked, date of design plan reviewed: 7/7/99 Environmental Field Services Inc. ❑ 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: Site Exam and Design Plan Title 5 Inspection Form 6/15/2000 Page 11 S=0.02 min " U 93.0 a 6 cz• E.x;s 4-i Kg 9 2 7S ( L(OO GALLON SEPTIC TANK 36 r t -11°3' 0'f oy /02 — l02 /sIO°Cyn//oW *tic nab v 64325 / i T1-Par Harked w/f7 &Stake rook( LeeacI Field i 2 3 4 5 6 7 8 9 10 i 12 CONSTRUCTION NOTES 1.) ONE(1)RECTANGULAR LEACHING FIELD,50' LONG AND 10'WIDE,WITH 6"OF 3/4" DOUBLE WASHED STONE BENEATH TWO(2)50' LONG,4"PVC LATERALS, SPAC 4'O/C,CONNECT ENDS WITH SOLID PIPE,COVER PIPE WITH 2"OF 1/8"-1/2"STC 2.) SYSTEM WILL ACCOMMODATE A THREE BEDROOM HOME WITH NO DISPOSAL. 3.) EXISTING SEPTIC TANK TO BE PUMPED AND INSPECTED PRIOR TO CONSTRUCTION REPLACE WITH NEW 1500 GAL TANK IF NECESSARY. FIT EITHER WITH 4" PVC S INLET AND OUTLET TEES. 4.) ALL OTHER PIPE TO BE 4"PVC, SDR 35(OR EQUIVALENT). 5.) TO PREVENT SHORT CIRCUITING OF THE EFFLUENT,THE D-BOX IS TO BE INSTALLE WITH A 4"TEE CEMENTED TO THE INLET AND THE FIRST TWO FEET OF EXIT PIPE TO BE LAID LEVEL. SPEED LEVELERS RECOMMENDED. 6.) ALL TOPSOIL AND SUBSOIL(APPROXIMATELY 30")TO BE REMOVED FROM BENEAT AND FOR FIVE(5)FEET AROUND 5.A M. AND REPLACED WITH TITLE V SAND PRU. TO PLACEMENT OF THE LEACHING FIELD(SEE CUT&FILL). 7.) SET FIELD AT ELEVATION NOTED IN PROFILE,BACKFILL TO PROVIDE AT LEAST 12" COVER AND MOUND PERIMETER TO DIVERT SURFACE RUNOFF. 8.) THE PLAN AS DRAWN REQUIRES A LOCAL UPGRADE APPROVAL FOR A REDUCED SEPARATION TO WATER TABLE. THE APPLICATION ACCOMPANIES THIS PLAN. 9.) ALL CONSTRUCTION TO BE I.A.W.TITLE V,THE STATE ENVIRONMENTAL CODE. 10.) NOTIFY ENGINEER AT LEAST 72 HOURS PRIOR TO THE TIME INSPECTION IS REQU' PERCOLATION TEST RESULTS PERCOLATION TEST NO DEPTH RATE DATE (INCHES) (MIN/INCH) P - 1 S-f " S 6,-3o-91 (3er-For:nta ay ; y� La- , 'yne .4.S. E bt),.rne55eC .ay P. )e Erla;v, 8. 0. H, SOIL LOGS See /Me ornpa fly, ny 2epott0-. HOLE NO.4OH1 HOLE NO. Gli2 o- pr-s SL..& SO// _Loa niy sa red. LOdlnv y sand f i h.'N T. - n'I' E.S. H.w.7.= d-r Ton So:/ SL S,. i -Loa-m y Sand_ E.S. H.w.7.= d-r ENVIRONMENTAL FIELD SERVICES, INC. P.O. BOX 518 LEEDS, MA 01053 1-413-586-7200 August 25, 1999 Board of Health Town Offices Northampton, MA 01060 re: Inspection of Septic System Repair, Courtney Home, 235 Maple Ridge Road Dear Board: On August 23, 1999 a representative from our office performed an inspection of the repair septic system installation referenced above. The system was installed by J.C. and Company of Northampton, MA. Our representative found that the system is installed properly and in accordance with our septic plan dated 7-7-99. The as-built locations of all system components have been documented on the attached sketch. This letter shall serve as Engineer and Installer Certification that the system was installed in accordance with Title V and our approved system design. If there are any questions, please contact our office. Sincerely yours, Micha J. La ne Environmental Engineer T I hereb ertify that the above referenced system was installed in accordance with Title .nd the appro-. septic design prepared by Environmental Field Services. S O l , NO - y' Nt/ld 31IS (Jr.- reC wo , , 22 bb- Er - S 'bv 'uO{dcuf1o� rood �r V a,dam _ / Tl fyJV?� 191c) r .o P'D . t cp — / I. c. r Q$ SE ,fib/p•9 i i i •>H01000e00000,A --- 1J it eg r ", le-a N,t:4m n R �_ I •:; ,-• • e b C> i / i — o .\ i pb � _--Z -r_. Fh j a .-- ' i . Pis- i S t -lib IS • — , i T. ,ec O2O S (ra*Q°714 S — — X01 I (7 151 I ( 7) w m zor • ( _ >I ,Fo "c( U - ?of n y ✓O O \ _ _ _ — _P SLtg !JIB/ u a 0 f/ 1 v w., A/ pill FORM II - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. 3)35 P\ 7 % On-site Review Deep Hole Number I tot Date:(0/3c) 99 Ti, !e e rti>rAl Weather Location (identify on site plan) S-v A. pQ�/ ,�} Land Use Et.300(y Slope (%) /-3 Surface Stones V }%r-% Vegetation £t- . Land form Position on landscape (sketch on the back) S '-C "plc' '- _ Distances from: Open Water Body >/erb feet Drainage way 5Z-15 feet Possible Wet Area >i075 feet Property Line 7.2-o feet Drinking Water Well >/cm feet Other DEEP OBSERVATION HOLE LOG. Depth from Soil Horizon Surface Cinches) 0- fin 6 it Ip 30"- '/5., 7&" )pin 8 Soil Texture Soil Color I USDA( (Munsell) L S C. LS IS Soil Mottling /U`/.Q 3/) yore_y/y /°42 9/3 ).5m)Q98 Other (Structure,Stones, Boulders, Consistency, % Gravel' -ItQ.wci I w1,s a(� 0 - '3 'I I3"-„16" B abk- I;et/ C 5/- iOtl,231a SL /News LS ).5-1/41e513 MINIMUM OF 2 HOLES h ERRED AT Parent Material (geologic) Salty 3 n/) no Depth to Groundwater: Standing Water in the Hole: 9O /L{J iz Estimated Seasonal High Ground Water: )t/ 1 r .)t/ J ADO Nt N rile C. 3q" Iop.ol I Sv4S-c i 1 OScO DISPOSAL AREA DEP APPROVED FORM-12/07/95 Depthtosedrock: , /3 / r ? ISO" p Weeping from Pit Face: tp6'J Environmental Field Services, Inc. P.O. Box 518 Leeds, MA 01053 (413) 586-7200 No. FORM 11 - SOIL EVALUATOR FORM Page I of 3 Date: 'J-/a -9? Commonwealth of Massachusetts )vorftnmptc),v , Massachusetts Soil Suitability Assessment for On-site Sewage Dispoil Performed By:OM I C h 0 e I La U lToe- Witnessed By: __Pe i e 1- IT1c 1 ct_l.�lJ Date 613 99 lam r .oln... 3D- MTh, VV W, Yew Construction ❑ Repair bla e nc) wren Nene. Sin r- l ey CatrINQ "mvLntl 035- maple Qlacre CI rn.q' 130 rt-f■c,m ptn v,me ciotu0 Office Review Published Soil Survey Available: No ❑ Yes ❑ Publication Scale Soil Limitations Year Published Drainage Class Surficial Geologic Report Available: No ❑ Yes ❑ Year Published Geologic Material (Map Unit) Landform Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes Publication Scale Soil Map Unit 1 Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No Eyes ❑ Wetland Area: National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range Above Normal ❑Normal ❑Below Normal ❑ Outer References Reviewed: DEP APPROVED FORM•I2/Of9S Environmental Field Services, Inc. P.D. Box 518 Leeds, MA 01053 (413) 586-7200 Location Address or Lot No FORM 12 - PERCOLATION TEST )35 JY ccpIc RidsQk4 COMMONWEALTH OF MASSACHUSETTS /JO r--ha Ln p-1-0/0 , Massachusetts Percolation Test` Date: t'u ;3Uri ci Time:. Cka)-2 Y iuco t u Observation Hole # P-1 Depth of Perc ,±51//1 Start Pre-soak ) + . 3 9 . End Pre-soak Time at 12" II / 5_� / Time at 9" ) ' 0(C) Time at 6" )3 ) Time (9 -6 ) ) J Rate Min./Inch Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed ® Site Failed ❑ Performed By: 111 i c ha e 1 / t1),7 A) -Q Witnessed By: \--){2 fvi- 1 Y1GiC>,ACutnV Comments: DEP APPROVED FORM-12/07/95 51' Location Address or Lot No. FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Oidcy Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole inches ❑ Depth weeping from side of observation hole.. ... . inches © Depth to soil mottles2l4 ) f/ inches ❑ Ground water adjustment feet Index Well Number _.. Reading Date Index well level Adjustment factor Adjusted ground water level Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in ` II areas observed throughout the area proposed for the soil absorption system? 6 If not, what is the depth of naturally occurring pervious material? Certification I certify that on 1/ - Y' (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature DEP APPROVED FORM 12107/95 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL 'AGE 2 OE 5 4) Typc of existing system privy cesspool(s) t/ conventional system Other (describe) Type of soil absorption system (trenches, chambers, pits,etc•) iT=e1nch /� 5) Design flow based on 310 CMII 15.203 a) Design flow of existing system R.) gpd Approved? yes appioval date _no why? b) Design flow of proposed upgraded system39Q gpd c) Design flow of facility ,33Qgpd 6) Proposed up nail,' of existing system is a) Voluntary Required by order, letter, etc. (attach copy) Requited following inspection required by 310 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) • b) Describe the proposed upgrade to We system Q L3eLC 6G '_X (O' L ochbiet4 nrlded ±0 eXraft,ud sc.x) c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) Percolation rate of 30-60 minutes per.iuch (slate actual perc rate) uFr APPne veu Fo nM• urn U, FORM YA - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE I OF 5 Commonwealth of Massachusetts kionliI amp-km) . Massachusetts Application fur Local Upgrade Approval Title 5, 310 CMR 15.000 DEP Approved form required by 310 OAR 15.403(1) To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or nonconroruriug system with a design low of < 10,000 gpd, where full compliance, as defined in 310 CAR 15.404(1), is not feasible. To be submitted to DLI': For the upgrade of a failed or nonconforruiug system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of a state or federal facility, where full compliance, as defined in 310 CMR 15.404(1), is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that Includes the addition of new design flow to n cesspool ur privy or the addition of new design flow above the existing approved capacity of a system constructed hi accordance with either the 1978 Code or 310 CMR 15.000. 1) Facility/system ow ter nn Name S h i 1-1-e L l '(">l;t r- Address 9 al Jl2'lc Phone hi SiSfo -l9037 Address of facility a3s YYIr, Applicant (if different froth above) Name c>Q,--)r. Address Phone I/ G4007/-q- Type of faci fresidential commercial school institutional T' (Specify) in'APrnovEJ,FORM-11/07/15 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 4 OF 5 8) Notice to Abutters No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shad be complete until the applicant has notified all abutters whose properly or well is affected by certified mail at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include We date, time and place where the upgrade approval will be discussed. If the Department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the Department. The notices to abutters sitall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. List of affected Abutters: Abutter Maine Address Abutter Name Address Abutter Name Address Abutter Name Address Dale notified Date notified Date notified Date notified Explain why full cotupliauce, as defined in 310 CMIt 15.404(1), is not feasible (each section must be completed): a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible: COS-C C at) S/(19t(ka b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible: Aid' it)PC'2SShrt-( ort Arrnono FORM. u/mms r t FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 3 OF 5 Up to 25% reduction In submit race disposal area design requirements (state tequ ired & proposed size). Relocation of water supply well (identify well, describe relocation) L.,/ Reduction of required separation between bottom of SAS & nigh groundwater (specify proposed reduction & pert rate) j ! S.epQaaPOE( ) Other requirements of 310 CMR 15.000 UM cannlot. 6met (specify sections of One Code) System upgrades that cannot be performed In accordance with 310 CMR 15.404 & 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMIt 15.410-15.417. 7) If One proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance front soil absorption system to high groundwater ta? feet As determined by: Evaluator's name o rritCilq,P/ /aut�2r.f Evaluator's signature Date of evaluation OS'Arrao vEo FORM. 12,0105 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 5 OF 5 c) a shared system is not feasible: NCYL QCrate(i d) connection to a sewer is not feasible: 00} CtUQAQ a\lQ 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & sped ficat ions, site evaluation forms), must accompany this application. Is We OSCP application attached? /es no II) Certification "I. the facility owner, eerily under penalty or law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware That there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for knowing violations." Facility ow is signature- 1/) I r Leq L ouir i a- Name Print Name 7- 30 - 99 Date ran it Q/YPfcd FoitdbacAt)1cLo 9-30-99 Name of preparer Date 7Jo0 ASS 3,1tdre AJori-h yl,pirw�,� Telephone II & address of preparer b/rr;c,v NOTE: 'Ville 5, 310 CAM 15.403(4), termites the system owner or operator to submit to the Deparuiuent a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of cousuuction. wi'Arrno VItO FORM. urwns FORM 913 - LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts Auor-I hct/nrpick> Massachusetts LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405 Facility/. Meat owner: Name: � � � a?r rns.4 ?d „� Rd / , t!_... II rJZ Al tires. pCQ_ P (1 N r� Address of facility 3� �( 0 1 O Type of facility: residential V7- commercial school design flow per 3111 CM It 15.203 r� gpd System designer: Name £r I— S. Address S Fy\l de Si- Phone No. ,5-6‘-%,9c( 09r-sr-ham t114 Ofo(oo Local Upgrade Approval RI nled for: reduction in setbacks) (specify) perc rate of 30-60 min./inch (specify rate) reduction in SAS area of up to 25% (specify % reduction & size of SAS) redOct on in separation beI'veen SAS & high groundwater (specify reduction & perc rate) relocation of a well (explain) 3 S aicr - Qk 5 vN l /yl ch List local vat iances granted (no DEP approval tenoned per 310 CM It 15,412(4)) List variances granted requiring DEP approval Board of Ile II Approval of pro)m ed upgrade nature Name & Title City/sown THE SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL TO THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OP ENVIRONMENTAL PROTECTION DIVISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY TIIE LOCAL APPROVING AUTHORITY & BEFORE COMMENCEMENT OF CONSTRUCTION. OPT Arrnovan FORM• Eaten PERCOLATION TEST(S) Time: Time: Observation Hole #1 Observation Hole #2 Depth of Perc I1" � 'l Depth of Perc Start Pre-soak , =r Start Pre-soak End Pre-soak End Pre-soak Time at 12" Time at 12' Time at 9' Time at 9' Time at 6' Time at 6' Time(9'—6") Time(9'—6') Rate Min./Inch Rate Min./Inch 'minimum of 1 percolation test must be performed in both the primary area AND reserve area. • • ... . . • • Performed by _ -- Performed by Witnessed by ( Witnessed by Comments: NORTHAMPTON BOARD of HEALTH- Title 5- DEEP OBSERVATION HOLE LOG' Deep Hole It: •MIWMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Location Address or Lot# A n r Owner 2 3:S hi ,O, : tic.,, //1 ..s t ki_14 &I 7` , Date 31 7?‘/ / Time , Soil Color (Munson) Owner's Address - — - /1 'i�" • / En,timer ( }T�-�' ,--, *A _ Weather ` Phone# Land Use %Slope Landform Depth b groundwater: Standing Water in the Hole Ve!etation tar Position on Landscape(sketch on the back) Distances Stop Time Open Water Body feet Drinking Water Well feet Property Line feet Possible Wet Area feel Drainage Way feet Other feet DEEP OBSERVATION HOLE LOG' Deep Hole It: •MIWMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Depth from Sudan(Inches) Son Horizon Sol Texture (USDA) Soil Color (Munson) Sol Mobkg Other (Structure,Stones,Boulders,Consistency.%Gravel) 10 — 17 r I y J- Perenl Matra((geologic) I I Depth lo Bedrock I Depth b groundwater: Standing Water in the Hole I Weeping troth Pit Face I he i-- Estimated Seasonal High Gmund Water Deep Hole#: DEEP OBSERVATION HOLE LOG* .MIWMUM OF?WO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Depth from Surface(Indies) Sd HMasn Sol Texture (USDA) Sol Color (Muroran) Other (Stexwre,Stores,Boulders,Consistency,%Gavel) A Water In the Hole it Ground Water Depth to Bedrock Weeplrm horn Pit Face THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -LOWL) OF Nor- • • 1 PKO APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT %ppIic run Hr.11. IIIIE lo( on.truLt l , I(c1ar l"A l py idc l Ab.ndnn I X( 0111pR c.S\'ALM Wlc ldu.i( np eiih J 35 a (( R i dst.ed st Lc IlI...I shlrie C, &3 C). (r Qd, A) tc ) 5S-6- Goa` iI m S/LVi Coo llU . e L„ I9fd.S2A di ,ASS B/i dcse JL1> Ort-h C j - 7&CO mRo/alga ■cneof Bu&lio¢:Si uQ re / I.ot Size Sq. feet Dlcelhng—No.of Bedrooms a __ Garbage Grinder ( I Other—lope of Building No 01 persons_ (o Shmcers ( )- Cafeteria 1 ) Oilier fixtures Design Floc irinin uiedl330 Cpd ( I Cula l ed design floe _ pd Design !Inc pro'iJed � _pd e Plan Date - / 9 Numh I cfsheet9 R i. t Ile xu t titles-e.wQQe -i Is(Doso/ Scs1em -�,f,Pa-(_A- - ,Lrr+C�. c_ Description of Soil(s) /..Co my 5a, d - Sa v Sc)// 1 -e r r }'S- �l Soil Evaluator Form No. Name of Soil Evaluator Vic.V d 5,pt Dale e of Faluation(o-.30-(7 DESCRIPTION OF REPAIRS OR AEI LRAIIONS a tJ l,..) so'g to) oChb( e 0d Glci-ed -+-o ex is ' / 5(Y) .so/ C rK • The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE S and further agrees not to place the system in operation until a Certificate of Compliance has been issued b the Board of Health. signed Inspections Dale FORM t - APPLICATION FOR D5CP DEP APPROVED FORM 5/96 No. Description of Work: -I fie undersigned herehc sertity that the Sewage Dispuvil Scetem:(onstrucled ( 1.Repaired( THE COMMONWEALTH OF MASSACHUSETTS F-E BOARD OF HEALTH CE TIFICATE OF COMPLIANCE ndiridual Cmnponent(sl U Complete System In: 7. ( '. /.77i hash n installed in acc&&lance with thes{Srovlsions of 310 (MR 15 00 (Iir 5) and the al pr h ed design pltns:as-built plans r lating to application No /� dated "If B<Aji- Approced Design Flow 3/ti (gpd) ��I g .J e� c/t U _ // / Installer l / 21 r ` ` f� Y — ;._ fe�l- Y/YVV ,�Y� < „�.. I ,,tiJ lapaU V' _ P--"? ,ji,.^- z. / /� Des1 The issuance an The Issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 1.Opgraded( L Abandoned f ) No.{-4- f F/>/ "j THE COMMONWEALTH OF MASSACHUSETTS M/e-Ffietnit;kil BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby gran cd to Cons!rpcy ( ) 'pair f�:.) l--pgrade („,j) Abandon ( 1 an indl vi du l s age -3� /JL aC"' � �, f�,� u described disposal system at P / c / / t "�/` .dated _it, in the application for Disposal System Construction Permit No - , Provided: Constryction shall he completed within three years of the date of this permit, All Lpv7 co IrµLLiory mu�r( zt. �r Board of Health /2 / ' 7�-- Date_ 'k' / 7 FORM 2 - DSCP/ DEP APPROVED FORM 5/96 FORM 1255 IREV 5/961 I1mN HoBBS8 WARREN PUBLISHERS - BOSTON THE COMMONWEALTH OF MASSACHUSETTS BOARD OFp HEALTH (� t7�t crry OF . 1lQRT1-1f MC fO1.11 4plirdfinr. far 33ispunat arks Qlnnsirurfiun Prix Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individuate-e, W R System at: � •,,,nu was ..... ......_......__L!73 Location-Address or Let No Owner Address rxi co tiler Address .^ t U Type of Building Size Lot..2a. . Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder a Other—Type of Building No. of persons Showers ( ) — Cafeteria ( ) w Other fixtures Q Design Flow per person per day. Total daily flow � I w 55 gallons r rson 3 �t.�i �°loss. 1:4 Septic Tank—Liquid capacity.I.S�gallons T ength._.(.Q.%z Width..F5:rr.��y' Hirmdt Depth.3.....9._ X• Disposal Trench—No. 3..__-. Width._ZYT Total Length q..cf2.r..}.. Total leaching area_.-.$$4.....sq. ft5 ides i Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.bc $ON z Other Distribution box ( Dosing tank ( ) 5�t 1i 186 '"• Percolation Test Results Performed by_._f} 6411 5' �9-ta,51t-ei.P.DN.. Date . .... It -1 Test Pit No. I 6...minutes per inch Depth of Test Pit 12 Depth to ground water faS (i, Test Pit No. 2 _minutes per inch Depth of Test Pit Depth to ground water a O Description of Soil A.rr ,CE/_ U W VNature of Repairs or Alterations—Answer when applicable Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed I Application Approved By Application Disapproved for the following reasons Permit No — Issued THE COMMONWEALTH OF MASSACHUSETTS Date Date Date BOARD OF HEALTH CITY OF iNlozr AK-PION farrtifirate of Cinmplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (0 or Repaired ( by at L-Dr...2.2.....MAP.1--...��l.D.Ca.E fl t-Lo i E has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE _ Inspector No ?a 9 !Vire THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C I T`i of 1\02T1 FkMPToN FEE Elis.pnsal Rnrkn (Lnnsirnrtinn 'lrrmit /7 TT�n Permission is hereby granted y{. 0(p r to Construct OV or Repair ( ) an Individual Sewage Disposal System at No LoS_Z.Z. ---M./3P.LE._.�1-Il-C�E--- tep t-- " Date Works N /h/ as shown on the application for Disposal orks Construction Permit No v-�- DATE (d//9 Q//�/"/ FORM 1255 XOB64 &/W 0.R .. PUBLISHERS $card!(Health 4/4073, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No 3a 1'7 CIT or Nfor2-T14-AlsetoN FE Eirspnotzt oartrkri Tottolitrtion Ihrtnit Permission is hereby granted riavtl? f.1.6.1±ER, to Construct OC) or Repair ( ) an Individual Sewage Disposal System at No txir..2-2_.„ RA-1>GE---gospc ELOIZENICE ttaL as shown on the application for Disposal Works Construction Permit No DATE /03 y FORM 1255 HOBBS Si W RR INC.. PUBLISHERS 1357vateez t Boart4 Health