203 Application/Permits 1995, Reports 2006, 2000 ARGEO PAUL CELLUCCI
JANE SWIFT
Lieutenant Governor
COMMONWEALTH OF MASSACHUSETT
EXECUTIVE OFFICE OF ENVIRONMENTAL
DEPARTMENT OF ENVIRONMENTAL PROT
ONE WINTER STREET, BOSTON MA 0210B (617)29
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: _ 203 Made Ridge Road
Florence MA
Date of Inspection: March 258 July 14,2COD
Name of Inspector:(Please Print) Roland Dupu's
9�i � 6 00 JUL) '
IJ
an(I
Name of Owner_ Florence Savings Bank
Address of Owner: Main Street Florence
BOARD OFHEALgm
BOB DURAND
SECRETARY
LAUREN LISS
commissioner
I am a DFP"roved system Inspector pursuant to Section 15.340 of Title 5(310 CMR 15 003)
Company Name: D Emineenno
Mailing Address: PO B 47s ton MA 01027
Telephone Number 413478-3861
CERTIFICATION STATEMENT system et this address and that the infornlalion reported below Is hue,accurate and complete
1
as of
certify that I have personally inspected the sewage performed aset experience in the proper function and maintenance of on-site sewage
as of the time of inspection. The inspection was pert0rmetl based on my training and expert ProPe
disposal systems. The system.
Passes
X Conditionally Passes
Needs Further Eval)ption the I Approving Authority / ®®
Fail 3d12(AY I O,v vi Inspectors SignaNre: ', yy". Dale: a a )The System inspec or shall su copy of spection report to the Approving Authority(hoard of M P)'MSiI^Mirty(30)days of completing this inspxken. If the
system is a shared system or has a design flow of 10,003 gpd or greater, the inspector and the system owner shag wamM the report to the appropriate regional office of the
Department of Environmental Protection. The original should be sent bathe system comer and copies zed lo be buyer,if applicable,and the approving authority.
NOTES MID COMMENTS
The first inspection was done in March when the'ID—Box was located/inspected and the second in July- On the first date
the septic tank was inspected and measurements taken of the sludge blanket and scum layer. In doing this inspection the following
items were noted:
1. color/texture of the sludge was odd,
2. the lack of a scum layer and
3. Infiltration through seams of collars
4. odd installation of influent vT' not level runs up hill.
The only recorded record of pumping for this system at the B of H occurred in June of 1999. Inspection of the effluent°T" could not be
done because of the tank's depth of about 5 feet. With the aid of mechanical means of uncovering the influent T this inspection would
be done at a later date(July). During this delay a reason for the odd appearance of the sludge was initiated. Discussions with the
previous owner,who continued to reside in the house(divorce)until the end of May 2000. From these discussions it was ascertained
that the house well water quality was such that it required treatment(filtering),which required frequent back washing of the filter media.
The back wash residue was directed into the septic system. A second pumping of the septic tank occurred in December of 1999. Both
pumpings'were prompted by blockage between house and the septic tank. The filter backwashing is the reason for the odd color of the
sludge. The house has a garbage grinder in the kitchen. The house has 5 bedrooms while the design of the septic system is for only
four bedrooms. This makes the soil absorption area inadequate according Northampton Title 5 regulations. Area available 660 sg st
In discussing the above noted irregularities with Peter McErlain health agent for the Board of Health,the following actions are
area required 825 sg st.
required.
1. the removal of the filter back wash from the septic system
2. a deed restriction be put in the deed banning the installation of a garbage grinder in the house, and
3. removal of the one that exists.
While the soil absorption system showed no signs of failure,the existence of a garbage grinder, 5 bedrooms on a system
the Isoil absorption system discharge he extent of such imhpact on the life of the soil absorptionllsystem is pureespeculati non impact on the life
Removal of the filter backwash residue and the removal of the garbage grinder will allow the soil absorption system to retain a
somewhat more normal life. This abuse was for 2 h years out of a normal expectancy of 20 to 25 years. In addition the installation of
an effluent°T'filter on the septic outlet may recover some of the We lost from the earlier abuses of the system. The sealing off of the
joints on the collars above the septic tank removes the extraneous flow that was allowed to enter the system during wet weather events.
The septic tank should be pumped out every 1 5 to 2 years depending on the occupancy of the house and activity of water
using devises. Limiting washing of clothes to 2 per day, spacing out of other high water use activity showering,automatic dishwashers
(not done concurrently)can prevent hydraulic overloading of a septic absorption system to avoid premature failure.
revised 9/2/98
eage r of
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(coothwed)
Property Addms: 203 Made Ridge Road
Owner: Florence Savings Bads
Date of Inspection:: March 258 JUN 14 21300
INSPECTION SUMMARY:ChedtA R C or
A. SYSTEM PASSES:
Ihavend found any information,which indite that any of the failure conditions described in 310 CME 15 303 exist.Any failure criteria nit evaluated are
indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
XOne or more systan cc/moments as described in the"Conditimal Pass"section need to be replaced or rwaired The system_upon completion of the sq,lawman or repair.
as approved by the Board of Health,will pan.
Indicate yes,no,or not determined(Y,N.or ND).Describe basis of determination in all Stalin If"not determined'.a plan why not
N The septic tank is medal.unless the owner or operator has provided the system inspector with a copy ofa Certificate of Compliance(Stadid)indicating
that thetmk was installed within twaay(20)yeas prior to the date of the mgedim:or the septic tank whether or not naval.is aarked,structurally
wmsemd dhows substantial infiltration or u5aration.or teak failure is man®aa.The system will pan inspection if the eaining septic tank is replaced
with a complying septic tank as approved by the Board of Health.
ti Sewage backup ex breakout or high static water level obsaved nh the distribution box is&tete broken or obstructed pipe(s)or dueto a bunk®.titled or
uneven distribution box The system will pass in odim if(with approval of the Hoard of Health).
broke pipe(s)are replaced
obstruction Is removed
didnbmnim box is leveled or replaced
N
The system maryird pumping more than four times a year due to broken or obstructedpipe(s).The systan will pass inspection if(with approval of the
Hoard of Health)
broken pipe(s)are replaced
obstruction is removed
Y The owner must provide the Board of Health with a copy of the deed of the propaty indicating a rmnidm for the mdallatim of a garbage grinder
Y
The inspector must verify the removal of the garbage grinder,the removal ofthe fiber backwash and rd'vedion to a suitable location
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Addrem303 Maple Ridge Road
owner: Florence Savings Bank
Date of irepecnon:March 258 BIB 14 21110
C, FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
NA Conditions exist whida require fiWUr evaluation bytbe Board of Health in order to determine if the system is failagtopraatte public health,safety and the
avironmatt
1) OT FUNCTIOONING IN A MANNER WHICHCH WILLPROTFECMT THEPIN UBLIC LHEALTH AND WITH 35AFETY ANDD THE ENVIRONMENT:SYSTEM IS
Cusped or privy is within 50 fat of surface water
Cesspool or miry is within 50 fed of a bordering vegetated wetland or a salt marsh.
2) IS SYSTEM WILL FUNCTIONING FAIL MANNER THAT PROTECTS THE PUBLIPUBLIC ALTH SUPPLIER,IF APW)
AND THE ENVIRONMENT: T THE SYSTEM OF HEALTH
The system has a septic tank and soil absorptions system(SAS)and the SAS is within 100 fed of a surf water supply or tributary to a surface weer
The system has a septic talk and soil absorption system and the SAS is within a Zone i of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private weld supply well.
_ The sy4an has a septic tank and soil absdpnon system and the SAS is less than 100 fed but 50 fed or more from a private wad supply well.unless
a well wad analysis fix elilhrm bacteria and volatile argenit compo.mds indicates Mdhd used well isd fleets i distance
that facility and the
presawe ofammonia nitrogen and nitrate nitrogen is espial
(approximation net valid).
3} OTHER
revised 9/2/98
Page aril
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 203 Maple Ridge Road
Owner: Florence Savings Bank
Date oflmpection:Mareh 258 Juts 14,2700
D. SYSTEM FAILS:
You MS indicate either"Yes'or'No"to each of the following:
NA I haveddamined that one or more ofthe following failure wndeians exist as described in 310 CMR 15303.The basis for this determination is identified below.
The Board of Health should be autsctedto determine what will be necessary to meal the failure
Yes No
Radamp of sewage to facility or system component dueto an overloaded or dogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface watas dueto an overloaded or clogged SAS or spool.
SYalic liquid level in the distribution box above outlet invest dueto an overloaded or dogged SAS or cool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Requited pumping nwreWen 4t®®in the W4 year NOT dueto clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System,spool or privy is below the high g oundwaa elevation.
_ Any portion of a=spool or tansy is within 100 fed of a surface weer supply orhibWnryto a surface water supply.
_ Any portion of spool or privy is within a Zone d of a public well.
Any portion of a Dryad or privy is within 50 feet of private weer amply well.
Any portion of a spool or privy is less-than 100 feet but getter than 50 fed from a private water supply well with no affable was quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for mliformbadaia.volatile organic ammo mda ammonia
ni0ogen and nitratene.og i.
E. LARGE SYSTEM FAILS:
You mud indicate either"Ye"or-we to midi of the following
The following criteria apply to large systems in addition to the auaia above:
NA The system serves a facility with a design flow of 10,000 gpdor greater Haste System)andthe system is a significant threat to public health and safety andthe
environment bemuse one or more ofthe following conditions exist:
Yes No
Oe sygan is within 400 fa of a surface drinking water supply
the system is within 200 fa of a tributary to a surface drinking water supply
the system is loaded in a nitrogen sensitive as(Maim Wellhead Protection Ara IWPA)or a mapped Zone 11 of a public water supply well)
The owner or operator of any such system shall upgadethe system in accordance with 310 CMR 15.304(2).Please consult the local regional office of the Department for
fsnher information.
revised 9/2/98
Page or tl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Properly Address: 203 Maple Ridge Road
Owner: Florence Savings Bank
Date of lmpecdon: March 258 JUN 14.2700
Check if the following have been done:Yon mast Indicate either"Yes"or"No"as each of the following:
Yes No
X
Reaping Information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system has been receiving nubs flow rates dating that
period Large volumes of water have not been introduced into the system recently or as pmt of this W pedion.
X As bent plans have been obtained and examined.Note if they are not available with NIL
X The facility or dwelling mu Inspected for signs of sewage back-up.
X The system does not receive non raeilary or idmtriai waste tow.
X The site was inspected for signs of breakout
X All system components,excluding the Soil Absorption System,have been located on the site.
X The
construction. manholes hole depth uncovered, the interior
depth of of the septic lank was inspected for condition of baffles or tees,material of of dodge:
The she and location of the Soil Absorption Systeoi on the site has been determined based on:
X
Existing infornation.For example,Plan at B.O.H.
Determined in the field(H any of the failure attests related to Part C h at bate.approxiadon of distance is unacceptable)II 5302131 @)1
The facility owner(and occupants,if differe t from owner)were provided with Info.m doa on the proper maintenance of Subsurface
DbpneN System.
revised 0/2/98 Pages of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 203 Maple Rkkae Road
Owner: Florence Savings Bank
Dote of Inspection: March 258 Jury 14200D
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 gp.d/boom.
Number of bedrooms(desist): 4 Number of bedrooms(actual): 5
Total DESIGN flow 4 lus 50% NaOmmgm regulation for garbage grinder (660)
Number of arrest rmdmis: 5-7 varied mail May 1999
Garbage grader(yes or no): vet will be removed
laundry(aparde sYleu0(Yes or no): no :If yes,searate(oe@azim required)
Laundry system inspected(yes or no)
Seasonal use(yes or no): no
Water max readings.if available Had two yeas usage( ,d)): wdl
Sump Purrp(yes or no):
Las date of occupancy: May 1999
COMMERCIAL l INDUSTRIAL:
Type ofestabtidw®c
Design flow std(Based on 15203)
Basis of design flow
C ease trap prank:(yes or no)
Ivdudrial Wade Holding Tank prawn:(yes ono)
Non-sanitary wade disdtarged to the Tile 5 system.(yes or no)
Water meter readings,if available
last date of occupancy:
OTHER:(Describe)
Is date of occupancy:
PUMPING RECORDS and some of Mfonnatim:
Prior homeowner
GENERAL INFORMATION
System punped as part of inspection:(yes or n0.) yes
If yes,volume pupped: 1500 gallons
Reason for pumping: inspect tank
TYPE OF SYSTEM
X Sgnictankldidnbaim boa/soil abeaptim system
Single wool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
VA Taioology ac Abadr cupy of W to date operation and maintmage manta
Tight Tank Copy of DEP Approval(
Other
APPROXIMATE AGE of all components, 4 years
dare hla W led(1f lmo.m)
and source of information:
when house constructed 1997
prior owner/B of H
Sewage odors detected when arriving at the site:(yes or no) no
revised 9/2/98
Page of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contieaed)
Property Address:208 Maple Ridge Road
(Omer:Florence SavNYS Bank
Date Of Inspection:March 25&Jdv 14 2ID()
BUILDING SEWER:
(Locate on sleplan)
Depth below grade:
Material ofcoalrnction:_cast Iron X 40 PVC other(explain)
Distance from private water supply well or suction Rae
Diameter 4 inches
Comments:(condition of joints,venting.evidence of!Stage.etc)
NA
SEPTIC TANK: Ys
(locate on she plan)
Depth below grade: 60 tidies
Mate rid of construction:X_concrete metal Pfhergbe Polyethylene_oter(erdainI
If tank is metal,)t age Is age confirmed by Certificate of Compince (YeNo)
Dimensions: StIDr5
Sludge depth: $Inches
Distance from top of sludge to bottom of outlet tee: not meaord since stodge depth so low and recent December pemalog
Scum thicfa®: < Ys inches
Distance from top of scum to top of outlet tee or bathes 9 inches+/
Distance from bottom of scum to bottom of mast tee or bathe: 14 inches+/-
Ham dimeodom were determined: measurement and estimates
Comments:
(recornmendaWn for own ping,condition of Net and outlet ten or bates depth of liquid level In relation to outlet invert,standard hdegdh,evidence of leakage.
etc.) The collar over the influent 9"'appeared to be butafled after the original MaRatim. The collar over the middle of the b about
inches lower. Neither bad their Joints sealed and both showed signs of infiltration dammgm With dirt on teak tom An loInts were sealed on that collan including.
the collar on the effluent"T°. Both"T's"are not level and are somewhat elevated. The inane*"T'more than the diluent"T".
Pomo system out every two years
GREASE TRAP: NA
(Locate an site plan)
Depthbeioco thi Polyethylene other(espials)
Mpthbeow grade: n: concrete metal pibett7ms
Scorn thickness:
Distance from top of seem to top of outlet tee or bathe:
Distance from bottom of scum to bottom of ondet tee or bathe:
Date of last pmnping:
Comments:
(recommendation for pumping edition of inlet and oUdtass or bathes,depth of liquid level in relation to gala Invest,structural integrity,evidence of balsam.etc._
revised 9/2/98
Pagel of li
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(awdbned)
Property Address:294 Manly Ridge Road
Owner:Florence Savings Bank
Date of laspMbn. 6258 JUN 14 200D
TIGHT OR HOLDING TANK: NA(Tank muss be pumped prior to-or at time ot mmedim)
(locate on site plan
Depth below grade:
Material ofcanetrasUw:
metal Fiberglas Poly.dab— other(espial)
Dhoenalons
Capacity:gallons
Design Bow: gallons/day
Alarm present
Alma level: Alarm in Boding order.Yo_No
Date of previous pumping:
Cosmenb:
(condition of inlet tee,condition of alarm and float switches,ac)
DISTRIBUTION BOX: X
(locate on site plan)
Depth of igmd level above outlet invert 0
Comments:
(note if level and didribtaim is equal,evidmco of solids carryover,evidence oflealage into ot one of box etc.)
Iron Is level no dens of earn over.
PUMP CHAMBER:_
(lateen salaam)
Pumps in worNng order(Yes or Non
Alas.Alarnas in tartan order(Yes or Na_
Comments:
(note cantina ofptmq chamber.condition of maps and sppudahan®,Sc)
revised 912198 Page S of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:203 Maine Ridge Road
Owner: Florence Salamis Bank
Date ofInspeAbn:March 25 S July 14 2000
SOIL ABSORPTION SYSTEM(SAS).
(locate an site plan,if possible;excavation not required.location may be appr :d atod by non-intrusive methods)
If not esplain:
Type:
leaching pits,nether:
leaching chambers,number
leaching galleries,number-
leaching Benches,number, 4 length: 45 feet
leaching fields.number dimensions:
overflow cesspool,number
Alternative system:
Name or Tecimology:
Comments:
(note condition of soil,sign of hydraulic failure,(level ofpondmg damp soil,condition of vegetation,etc.)
CESSPOOLS: NA
(locate on Ste plan)
Number and confgnration:
Depth top of liquid to inlet invert
Depth of solids layer:
Depth of scum layer.
Dimensions of cesspool.
Materials ofcmntmction:
Indication or groundwater:
Inflow(cesspool must be pumped es part of inspection)
Comments:
(note condition of soil,signs ofhydraulic failure,level ofpmdmg amditien of v getation,ac)
PRIVY: NA
Qwate on?Replan)
Materials of construction:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of pending condition of vegetation,etc.)
revised 9/2/98
Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION{continued)
Property Address:203 Made Ridge Road
Owner: Florence Savings Bank
Date of Inspection:March 258 Juht 14 2120
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
Mate all wells within tar(Locate where public water supply comes into house)
revised 9/2/98
Page 10 of 11
Noce of land
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(eanaouedl
Properly Address:203 Maple Ridge Road
Owner:Florence Savings Rant
Date of Inspection: Match 25&July 14 2U W
NRCS Report name Soil Survey of Rammhhe Coun/v Mm Central Part
Soft Type Parton till soil side dove
Typical d pth to groundwater Perched Feb—Mar 2.5 feet
USGS pate web site visited Apra 2000 AJdy 2000
Observation We checked WimeheNOO.Sterling,Petersham.Hawke and Dedham
Groundwater depth:Shallow 3' Moderate 15' Deep
SITE EXAM Slope ad at location ofmaponetats. There is drop off of 40phss feat from septictahkto dbox Soil absorption area is fairly lead with further
drapoffs 20 plus fed awn
Surface water none
Check Cellar slab
Sallow wens none
Estimated Depth to Groundwater 3+1- Feet
Please Indicate all the methods d to determine High Groundwater Elevation:
X Obtained from Design Pans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
X Determined from local conditions
X Checked'4 h local Board of health
Checked EEMA Maps
Checked pompMg records
X Clerked local excavators.Matallers
X Used TAGS Data
Describe how you esablthed the High Groundwater Elevation. (Must be completed)
Reviewed the data of the perk/deep hole and noted ground water level+/-7'.Noted time of year for perk. Found wells of
similar soil and topography on USGS site to compare water elevations to mean for month in question. Chose March since
this according to NRCS this is the typical time for the high ground water table for soil this type"Paxton." From the as built
plans found the bottom of trenches+/-2.8 feet,below surface of ground. Comparing all data none of which shoved abnormal
gw elevations the height of+/-3 fed was arrived at. The soils around the D-box were dry on examination. This area has
pockets of gravel.This is based on the perk rate obtained and the poor perk rate of other tests in the area of this development.
Based on the local perk rates done and the results pass/f ail for this development,it was assumed that this soil absorption
system must be located in one of those gravel pockets. The wells in question on USGS showed a drop in gw elevation from
March to June It was noted that the June elevations were about 2 fret above the mean for the month of June. With the water
table according to NRCS soil maps being lower in June than March, I assumed the June elevation for this site to be more
typical of a the perched water table found in March to compensate for the 2 foot rise above the mean note in the other wells
from the USGS sites.
revised 9/2/98
Page hl of I1
TITLE 5
OFFICIAL INSPECTION FOR- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 203 Maple Ridge Road Road,Florence.Northampton,MA 01062
OWNER Name: Clifford&Ellen Scott
Owner's Address: 203 Maple Ridge Road
Florence,MA 01062
Date of Inspection: June 14 2006
Name of Inspector:Alan E Weiss. RS H 933
Company Name: Cold Spring Environmental Inc
Mailing Address: 350 Old Enfield Road
Belchertown.Massachusetts 01007
Telephone Number:(413)323-5957 fax:413-323-4916
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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR
15.000). The system:
Inspector's Signature:
XX Passes
Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
Fails
Date: June 14 2006
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of
Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design
flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if
applicable,and the approving authority.
Notes and Comments
Septic System was in ok condition, There is no sign of current or past failing
condition. S. Tank(1500 gallon) was in OK shape. Outlet& inlet tees baffles were
in place. Septic tank was pumped. D. box was in good shape All stains & levels
were good at s. tank and D. box (SAS 9 years old Approx. Garba¢e Grinders are not
allowed on this system.
****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
different conditions of use.
1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 203 Maple Ride Road,Florence,MA
Owner: Scott
Date of Inspection: June 14, 2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
XX 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: SAS is 9 yrs.Old&all levels were appropriate tank condition ok.
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,
will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or 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):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 203 Maple Ride Road,Florence,MA
Owner: Scott
Date of Inspection:June 14, 2006
C. Further Evaluation is Required by the Board of Health:
NO 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 of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines
that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet
of a surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply
well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more
from a private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for
conform 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
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 203 Maple Ridge Road,Florence,MA
Owner: Scott
Date of Inspection:June 14, 2006
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
x Liquid depth in cesspool is less than 6'below invert or available volume is less than'A day flow
x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets).Number
of times pumped
x Any portion of the SAS,cesspool or privy is below high ground water elevation.
x Any portion of cesspool or privy is within 100 feet ofa surface water supply or tributary to a surface
water supply.
x Any portion ofa cesspool or privy is within aZone I ofa public well.
x Any portion ofa cesspool or privy is within 50 feet of a private water supply well.
x Any portion ofa cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen
and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are
triggered.A copy of the analysis must be attached to this form.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist
as described in 310 CMR 15.303,therefore the system fails.The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system i
ithin 400 feet ofa surface drinking water supply
the system is within 200 feet ofa tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-I WPA)or a mapped
Zone II ofa public water supply well
If you have answered"yes"to arty 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
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 203 Maple Ridge Road,Florence,MA
Owner: Scott
Date of Inspection:June 14, 2006
Check if the following have been done.You must 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?
X Has the system received normal flows in the previous two week period?
x Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
x _ Was the facility or dwelling inspected for signs of sewage back up?.
x _ Was the site inspected for signs of break out?
x Were all system components,excluding the SAS,located on site?
x _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
x _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined
based on:
Yes no
X _ Existing information.For example,a plan at the Board of Health
x Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 203 Maple Rhine Road,Florence MA
Owner: Scott
Date of Inspection: June 14, 2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 5 Number of bedrooms(actual):_5(per letter attached).
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x fS of bedrooms):2?
Number of current residents: 3
Does residence have a garbage grinder(yes or no): NO GRINDERS ARE NOT RECOMMENDED"
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no): no (Owner has no laundry connected)._
Seasonal use:(yes or no): no
Water meter readings,if available(last 2 years usage(gpd)): N/a
Sump pump(yes or no):NO *
Last date of occupancy:Current.
COMMERCIAL/INDUSTRIAL
Type of establishment:N/A
Design flow(based on 310 CMR 15.203): gpd
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 NM:
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe)
GENERAL INFORMATION
Pumping Records
Source of information:Owner&records(2 yrs.)
Was system pumped as part of the inspection(YES or no) Yes
If yes,volume pumped: 1500 gallons--How was quantity pumped deter ned?Measured
Reason for pumping:REQUEST
TYPE OF SYSTEM
x Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:9+/-years old
Were sewage odors detected when arriving at the site(yes or no):NO
6
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 203 Maple Ridge Road,Florence,MA
Owner: Scott
Date of Inspection:June 14, 2006
BUILDING SEWER(locate on site plan)
Depth below grade:-I6+"
Materials of construction: cast iron X 40 PVC other(explain):
Distance from private water supply well or suction line' 10'+
Comments(on condition ofjoints,venting,evidence of leakage,etc.):
SEPTIC TANK: Yes(locate on site plan)
Depth below grade: 60"
Material of construction:X concrete metal fiberglass polyethylene
other(explain)
If tank is metal list age:_ Is age confined by a Certificate of Compliance(yes or no):_(attach a
copy of certificate)
Dimensions: 4.2'w x10.'l x5.'d
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 42"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 5"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
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.): TANK CONDITION OK
S.tank had fees, TANK SHOULD BE PUMPED EVERY OTHER YEAR.
GREASE TRAP:N/A(locate on site plan)
Depth below grade:_
Material of construction: concrete metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid
levels as related to outlet invert,evidence of leakage,etc.):
7
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 203 Maple Ride Road,Florence,MA
Owner: Scott
Date of Inspection: June 14, 2006
TIGHT or HOLDING TANK: NO (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:YES (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Cal inv.
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.): 4 outlet lines level& equal flow noted.
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chanter,condition of pumps and appurtenances,etc.):
8
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 203 Maple Ridge Road,Florence,MA
Owner: Scott
Date of Inspection:June 14, 2006
SOIL ABSORPTION SYSTEM(SAS): YES (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
4 leaching trenches,number, length: 2'x 45'Imp
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.):No signs of failure,stone ok,and no Groundwater noted, Tot,of stone/box A 7'
Woody vegetation should be carefully trimmed and maintained in leach trench area.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:N/A(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.):
9
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 203 Maple Ride Road,Florence,MA
Owner: Scott
Date of Inspection: June 14, 2006
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.
Also See attached
10
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 203 Maple Ridge Road,Florence,MA
Owner: Scott
Date of Inspection:June 14, 2006
SITE EXAM
Slope YES
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 4'+/-feet
Please indicate(check)all methods used to determine the high ground water elevation:
YES Obtained from system design plans on record-If checked,date of design plan reviewed:
_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:
Water level based on on-site data from topography.and 2000 Inspection record .
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Irn in...a)
Property Andres:203 Maple Rldde Road
Owner: Florence$.ulna.Bank
Dele onn.pemee.-0larch ZS b July 14 3100
SKETCH OF SEWAGE DISPOSAL SYSTEM:
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revised 9/2198
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BOARD OF HEALTH
„MEMBERS
CYNTHIA DOURMASHKIN,R.N.,Chair.
ANNE BURES,M.D.
ROSEMARIE KARPARIS,R.N.,MPH
pr rER J. McERLAIN,Health Agent
1413)587-1214
FAX(413)587-1221
MEMO
UI I Y Ut NUN I HAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
TO: Attorney Margo Welch
143 Main Street, Northampton, MA 01060
FROM: Peter McErlain, Health Agent
DATE: January 26, 2001
SUBJECT: Septic System Compliance-203 Maple Ridge Rd.
This memo will confirm that, as a result of actions by you and by Engineer Roland Dupuis on behalf of
the owners, the designation of"Conditional Pass"has been lifted from the septic system serving the
property at 203 Maple Ridge Rd., Florence.
6
210 MAIN STREET,Room 8
NORTHAMPTON,MA 01060-3167
The following have taken place:
• Elimination of the garbage grinder from the dwelling
• Elimination of the dwelling's water system filter backwash from the septic system
• Replacement of the septic tank inlet"T"
• Replacement of the damaged septic tank inlet pipe
• Filing of a deed restriction( on 7/28/2000) which prohibits future installation of a garbage grinder at
203 Maple Ridge Rd.
The above listed actions has therefore resulted in the designation of"Passed" being applied to that septic
system serving the property at 203 Maple Ridge Rd.
Please contact me at the Board of Health office with any questions concerning this matter.
Thank you.
rnnnnmtt tINt INtERING CORP.
39 Mt. Tom Avenue
HOLYOKE, MASSACHUSETTS 01040
(413) 533-7276
SRC Tarr. 74
DEEP KoLE 8 q
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I(a " SILTy a.)13-s: )L.
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CALCULATED BY
CHECKED Er
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DATE
DAIL.
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L04304 CHI $3Gc5 TN T
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•
BOARD OF HEALTH
MEMBERS
CYNTHIA DOURMASHKIN,R.N.,Chair.
ANNE BORES,M.D.
ROSEMARIE KARPARIS,R.N.,MPH
PETER J.McERLAIN,Health Agent
(413)587-1214
FAX(413)587-1221
MEMO
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
TO: Attorney Margo Welch
143 Main Street,Northampton, M 101060
FROM: Peter McErlain, Health Agent j
DATE: January 26, 2001
SUBJECT: Septic System Compliance 203 Maple Ridge Rd.
This memo will confirm that, as a result of actions by you and by Engineer Roland Dupuis on behalf of
the owners, the designation of"Conditional Pass"has been lifted from the septic system serving the
property at 203 Maple Ridge Rd., Florence.
210 MAIN STREET,Room 8
NORTHAMPTON,MA 01060-3167
The following have taken place:
• Elimination of the garbage grinder from the dwelling
• Elimination of the dwelling's water system filter backwash from the septic system
• Replacement of the septic tank inlet"T"
• Replacement of the damaged septic tank inlet pipe
• Filing of a deed restriction (on 7/28/2000) which prohibits future installation of a garbage grinder at
203 Maple Ridge Rd.
The above listed actions has therefore resulted in the designation of"Passed"being applied to that septic
system serving the property at 203 Maple Ridge Rd.
Please contact me at the Board of Health office with any questions concerning this matter.
]-hank you.
p
`.
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C/7y OF taer1f/q,n yz v ,1
Appiirtttinn far 3ainpniui flinrkn Chan itrnrtian 13
FEE
Application is hereby made for Permit to Construct ( tom, or Repair ( ) an Jr}div
o203ftwe�f ( /� ee
Sy�rQSFF �e uric t� Gar? �J17�t�d�l Lot 7yit/✓/OraA/
or o N No.o.
•
4rfroti4'sac;g4.2.t
,Lrs.€ A-(22>J
Address
Owne
Installer 1/�/I tldr.
Type of Building // Size Lot Sq. feet
Dwelling-No, of Bedrooms 7�-v�Pp� Expansion Attic ( QO Garbage Grinder (WIS
Other—Type of Building !-S//1.fry._ of persons Showers (3) — Cafeteria (/Q/(J
Other fixtures ./e'ULG /5/72.1- .t1.C/17-/ 14004-1(9•41511-70a/ 50-e-4/54-S. to GO
Design Flow
/0 gallons per person per d y. Total daily flow // A-414 gallons.
Septic Tank—Liquid capacih/.J.7.14allons Length/L% Width .5— Diameter Depth
Disposal Trench—No. 4z- Width Width._.... 11 as Total Length /$lO Total leaching are//2&2.Q_-sq. ft.
Seepage Pit No Diameter Depth below inlet.Z.T `'Total leaching area sq. ft.
Other Distribution box (7) Dosing tank ( )_m����/�� Date `r7' 8/8 7
Percolation Test Results Performed by /Oy
Test Pit No. 1_Z ..minutes per inch Depth of Test Pit 21,57 Depth to ground water
Test Pit No. 2 & tn. utes per inch Depth ot Test Pit 410- Depth to ground water
..,F� / -1 Q_C 70 5OLG. —,2<! S/C ,f/45
- __- S O/C-
S-77,12iy' con-2/9/2e. f/C /LX / 2U CUles-[7/1O 6/S L'-
/
Description of Soil.. Zci -7Z COr77,12/3r Ja&4W• ' - Li '
f'� SL SLr/G 5/ .-.
7/2.---Z C1 8.1 GPJO/L —fzS/ S e-r �" ,! Silo
Nature of Repairs or Alterations—A wer when applicable
/c.TZj S/3-a�1�y r7Lc_. ..370-90
60//JyA/3Ci J/YAJ/J/ 77L C- Lf/!Y7>! G.Cn"tX l•
Agreement: / /72UC 78 - Cc-fly-T SO/L
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has en . sued y t boar health. _
Signed / _ - rk.
Application Approved By
Application Disapproved for the following reasons: - - - -
Permit No. Issued
Dalt
THE COMMONWEALTH OF MASSACHUSETTS
0 BOARD/IF HEA{L_7-1
OF
j Qlerfificufe of €umplianc!
b THIS IS,TO ,EPtilI/F_/_YrTlyat the Individual Sewage Disposal System constructed ( f/) or Repaired ( )
has been installed in accordance with with the rovisid s of /
the application
r Disposal '/�� / 4 � x
p TITLE 5 of The State Environmental Code as described in
pp Works Construction Permit No. S/-.J.j dated /a --i/—j5
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIIk11 FUNCTION SATISFACTORY. .. �/�
DATE G/'^. / St_ ! /. 2 7 Inspector '� �4.� it 7 .f 1
No
/ 5
THE COMMONWEALTH OF MASSACHUSETTS
i , .ABOARD OF HEALTH
■! OF
1310pusal Trinntrnrtfnn tirrutit
Permission is hereby granted....a:SE-01 4?2( !
to Construct (y-or Repair ( ) an Individ al ewage Disposal System
at No Sewage
street
as shown on the application for Disposal Works Construction Permif/No.. - ! D �.2 -//
Dated.
h[,Aoavd of Health
FEE -s L cn)
DATE
C /l , II-5..i
FORM 1255 AM SULKIN Co
/1