150 Title 5 Reports 2002, 1997 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTIO
DEC - 5 2002 'LT
NOET.NALW ON BOARD OF HEALTH
r.;
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 150 NORTH FARMS ROAD - FLORENCE, MA.
Owner's Name: JOHN KENNEDY
Owner's Address: SAME
Date of Inspection: NOVEMBER 23, 2002
Name of Inspector: (please print)TIMOTHY E. MAGINNIS R.S.
Company Name:
Mailing Address: 70 MONTAGUE ROAD-WESTHAMPTON, MA. 01027
Telephone Number: (413) 527-5291
CERTIFICATION STATEMENT
I certify that I ha -: inspected the sewage disposal system at this address and that the information reported
below is true as of the time of the inspection.The inspection was performed based on my
training am V = '\r function and maintenance of on site sewage disposal systems.I am a DEP
approved t to Section 15.340 of Title 5(310 CMR 15.000). The system:
0
Ofi
ccina ' -
iitIOGIM'f p
E.
MAGINNIS
No.982
itOISIESEO
Inspector's Signature: TI
I/LY
HY E
INV
X_ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
GINNI Date: DECEMBER 3, 2002
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of complet ng 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. I RECOMMEND THAT THIS SEPTIC TANK BE PUMPED EVERY OTHER YEAR.
ALSO,I RECOMMEND LIQUID SOAP FOR WASHER AND DISH WASHER GOOD COMMON SENSE
AND LIMITED USE DURING PERIODS OF SOIL SATURATION.
WARRANTY: THERE IS NO WARRANTY EXPRESSED OR IMPLIED.
****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:
Owner's Name:
Owner's Address:
Date of Inspection:
Name of Inspector:
Company Name:
Mauling Ain't oi.i..
Telephone Number:
150 NORTH FARMS ROAD -FLORENCE, MA.
JOHN KENNEDY
SAME
NOVEMBER 23, 2002
(please print)TIMOTHY E. MAGINNIS R.S.
70 MONTACiI.Ili ROAD WESTI I.\NIPTON, MA. 01027
(413) 527—5291
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15303
or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments: ROUTINE MAINTENANCE SUCH AS ANNUAL PUMPING AND INSPECTION.
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The ay-Wain,upon cnmplolion of Me replacement or repair. as approved by the Board of health,will pass.
Answer yes,no or not determined(Y,N,ND)in the
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.
for the following statements.If"not determined"please
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
uppruval of Dowd ut ticuhl0.
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:
Title 5 Inspection Form 6/15/2000 2
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 150 NORTH FARMS ROAD - FLORENCE, MA.
Owner's Name: JOHN KENNEDY
Owner's Address: SAME
Date of Inspection: NOVEMBER 23, 2002
Name of Inspector: (please print)TIMOTHY E. MAGINNIS R.S.
Company Name:
Mailing Address: 70 MONTAGUE ROAD -WESTHAMPTON, MA. 01027
Telephone Number: (413) 527- 5291
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000
3
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 150 NORTH FARMS ROAD -FLORENCE,MA.
Owner's Name: JOHN KENNEDY
Owner's Address: SAME
Date of Inspection:NOVEMBER 23, 2002
Name of Inspector: (please print)TIMOTHY E. MAGINNIS R.S.
Company Name:
Mailing Address: 70 MONTAGUE ROAD-WESTHAMPTON,MA. 01027
Telephone Number: (413) 527- 5291
A. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Ycs No
NO Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
NO Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
NO Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
NA Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
_ NO Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped SEE COMMENTS ON PAGE#1.
NO Any portion of the SAS,cesspool or privy is below high ground water elevation.
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.'
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
Large Systems: N/ A
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
NO the system is within 400 feet of a surface drinking water supply
NO the system is within 200 feet of a tributary to a surface drinking water supply
NO the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000
4
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 150 NORTH FARMS ROAD - FLORENCE,MA.
Owner's Name: JOHN KENNEDY
Owner's Address: SAME
Date of Inspection: NOVEMBER 23, 2002
Name of Inspector: (please print)TIMOTHY E. MAGINNIS R.S.
Company Name:
Mailing Address: 70 MONTAGUE ROAD-WESTHAMPTON, MA. 01027
Telephone Number: (413) 527-5291
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
YES Pumping information was provided by the owner,occupant,or Board of Health (HOMEOWNER
NO Were any of the system components pumped out in the previous two weeks?
YES Has the system received normal flows in the previous two week period?
NO Have large volumes of water been introduced to the system recently or as part of this inspection?
YES Were as built plans of the system obtained and examined?(If they were not available note as N/A)
YES Was the facility or dwelling inspected for signs of sewage backup?NO BACK-UP OBSERVED
YES Was the site inspected for signs of break out? NO BERAKOUT
YES Were all system components,excluding the SAS, located on site?
YES 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?
YES 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
YES Existing information.For example,a plan at the Board of Health. EXISTING AS-BUILT PLAN
REVIEW,TITLE-5 INSPECTION REPORT OF 4/21/97
YES _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [310 CMR 15.302(3)(6)1
Title 5 Inspection Form 6/15/2000 5
OFFICIIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
PART C
SYSTEM INFORMATION
Property Address: 150 NORTH FARMS ROAD - FLORENCE, MA.
Owner's Name: JOHN KENNEDY
Owner's Address: SAME
Date of Inspection: NOVEMBER 23, 2002
Name of Inspector: (please print) TIMOTHY E. MAGINNIS R.S.
Company Name:
Mailing Address: 70 MONTAGUE ROAD-WESTHAMPTON, MA. 01027
Telephone Number: (413) 527-5291
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4_
DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): 440 GPD
Number of current residents:2_
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): YES[if yes separate inspection required]
Laundry system inspected(yes or no):YES
Seasonal use: (yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no): NO
Last date of occupancy: CURRENTLY OCCUPIED
COMMERCIAL/INDUSTRIAL N/ A
Type of establishment: —
Design flow(based on 310 CMR 15203): 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 no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe): GENERAL INFORMATION
Pumping Records SEE NOTE ON PAGE# I
Source of information: JOHN KENNEDYT—HOME OWNER
Has system pumped as part of the inspection(yes or no):NO-TO BE PUMPED BY TRAK PUMPING SERVICE.
If yes,volume pumped: gallons How was quantity pumped determined?
Reason for pumping: REAL ESTATE TRANSFER
TYPE OF SYSTEM
Septic tank&soil absorption system -TWO LEACHING PITS
Single cesspool
Overflow cesspool
Privy
N Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach a copy of the DEP approval
Other(describe): known)
Approximate mae age of
s detected components,
when arriving installed st if(yes n)and source of information: 17 YRS+NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 150 NORTH FARMS ROAD - FLORENCE,MA.
Owner's Name: JOHN KENNEDY
Owner's Address: SAME
Date of Inspection: NOVEMBER 23,2002
Name of Inspector: (please print)TIMOTHY E. MAGINNIS R.S.
Company Name:
Mailing Address: 70 MONTAGUE ROAD-WESTHAMPTON, MA. 01027
Telephone Number: (413) 527-5291
BUILDING SEWER(locate on site plan)
Depth below grade: In
Materials of construction: cast iron X_40 PVC other(explain):
Distance from private water supply well or suction line: N/A
Comments(on condition of joints,venting,evidence of leakage,etc.): NO EVIDENCE OF LEAKAGE,JOINTS
ARE WATER TIGHT- VENTING IS OK—OUT WALL=SCH.40 - IN TANK=SCH. 35
SEPTIC TANK:_X_(locate on site plan)
Depth below grade: BELOW = 15"
Material of construction:—X concrete metal fiberglass polyethylene
ther(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: ( 10.5'L x 5'W x 5' DEEP)
Sludge depth: N/A
Distance from top of sludge to bottom of outlet tee or baffle: N/A
Scum thickness: N/A-SMALL FLOATING MASS OF FECAL MATERIAL
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: OBSERVED AND 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.):INLET&OUTLET BAFFLES ARE CONCRETE. TANK IN
SOUND CONDITION.NO LEAKAGE OBSERVED.EFFLUENT EVEN WITH OUTLET INVERT.
RECOMMEND PUMPING EVERY OTHER YEAR. TO BE PUMPED WITHIN 3 DAYS OF INSPECTION.
RECOMMEND THE USE LIQUID SOAPS.
GREASE TRAP: (locate on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000
7
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 150 NORTH FARMS ROAD - FLORENCE, MA.
Owner's Name: JOHN KENNEDY
Owner's Address: SAME
Date of Inspection: NOVEMBER 23, 2002
Name of Inspector: (please print)TIMOTHY E. MAGINNIS R.S.
Company Name:
Mailing Address: 70 MONTAGUE ROAD-WESTHAMPTON, MA. 01027
Telephone Number: (413) 527-5291
TIGHT or HOLDING TANK: N/A (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:
Of present must be opened)(locate on site plan) 29" BELOW GRADE
Depth of liquid level above outlet invert:EVEN WITH OUTLET INVERT
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.) BOX IS LEVEL,NO CARRYOVER,NO SOLIDS,BOX IN SOUND
CONDITION. BOX IS A SMALL PLASTIC BOX(9" x 13")AND IS 29"BELOW GRADE
PUMP CHAMBER: (locate on site plan) N/A
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
WARRANTY: THERE IS NO WARRANTY EXPRESSED OR IMPLIED.
****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 8
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 150 NORTH FARMS ROAD - FLORENCE, MA.
Owner's Name: JOHN KENNEDY
Owner's Address: SAME
Date of Inspection:NOVEMBER 23, 2002
Name of Inspector:(please print)TIMOTHY E. MAGINNIS R.S.
Company Name:
Mailing Address: 70 MONTAGUE ROAD-WESTHAMPTON, MA. 01027
Telephone Number: (413) 527-5291
SOIL ABSORPTION SYSTEM (SAS):_X_(locate on site plan,excavation not required)
If SAS not located explain why: THE SAS IS TWO LEACHING PITS.
Type
2 leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
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 HYDRAULIC FAILURE,NO PONDING,VEGETATION IS DRY GRASS. THERE ARE
NO SIGNS OF FAILURE ABOVE GROUND.
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.):
the 5 Inspection Form 6/15/2000
9
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 150 NORTH FARMS ROAD - FLORENCE,MA.
Owner's Name: JOHN KENNEDY
Owner's Address: SAME
Date of Inspection: NOVEMBER 23,2002
Name of Inspector:(please print)TIMOTHY E. MAGINNIS R.S.
Company Name:
Mailing Address: 70 MONTAGUE ROAD-WESTHAMPTON, MA. 01027
Telephone Number: (413) 527-5291
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building.
SEE ATTACHED AS-BUILT PLAN
DATED DECEMBER 3,2002
WARRANTY:
THERE IS NO WARRANTY EXPRESSED OR IMPLIED.
****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 6/1512000
10
EXISTING SEPTIC TANK —
cD
C W°N PUMPING MANHOLE ( 'C" )
ELECTRICAL & WATER LINE ( IRRIGATION )
21•-9" ± of PVC SOLID PIPE O O o
0000
4" PVC SOLID PIPE m
"A 0000
E
W
ED II
EXISTING
^B^ 9 4 BEDROOM
HOUSE °
GARAGE DRIVEWAY 'o.
•UTLET °
EXISTING ( 9" x 13" ) PLASTIC DISTRIBUTION BOX ( "D" )
•
EXISTING 750 GALLON LEACHING PIT
( APPROXIMATE LOCATION ) AS—BUILT DIMENSIONS
'A' to '0' = 275 t
'A' to 'H' = 655' TITLE — 5
'B' to 'C' = 14.5'
AS-BUILT SEWAGE DISPOSAL PLAN
150 NORTH FARMS ROAD - FLORENCE MA.
DECEMBER 3, 2002
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 150 NORTH FARMS ROAD - FLORENCE, MA.
Owners Name: JOHN KENNEDY
Owner's Address: SAME
Date of Inspection: NOVEMBER 23, 2002
Name of Inspector: (please print)TIMOTHY E. MAGINNIS R.S.
Company Name:
Mailing Address: 70 MONTAGUE ROAD-WESTHAMPTON, MA. 01027
Telephone Number: (413) 527- 5291
SITE EXAM
Slope NEARLY LEVEL- 1-2%
Surface water NONE
Check cellar YES—DRY CELLAR—NO SUMP PUMPS-NO WATER MARKS ON FOUNDATION WALLS.
Shallow wells NO SHALLOW WELLS ON SITE
Estimated depth to ground water>4'-PLAN REVIEW,KNOWLEDGE OF AREA,NO WETLANDS NEARBY,DRY
CELLAR.
Please indicate(check)all methods used to determine the high ground water elevation:
X Obtained from system design plans on record-If checked,date of design plan reviewed: 11 /6/02
X Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
X Accessed USGS database-explain: HAMPSHIRE COUNTY SOIL SERVICE
You must describe how you established the high ground water elevation:
GROUND WATER WAS DETERMINED BY•
A. EXAMINATION OF SOILS AROUND SEPTIC TANK
B. INSPECTION OF CELLAR FOR HIGH WATER MARKS.
C. INSPECTION OF CELLAR FOR SUMP PUMPS-NO SUMP PUMPS ON SITE
D. REVIEW 3 TEST PIT DATA FROM APPROVED PLAN DATED 3/22/84
E. REVILEW OF HAMPSHIRE COUNTY SOIL SURVEY
F. OBSERVED NO ADJACENT WETLANDS.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
CERTIFICATION
Property Addr.ec 156 N crit4 FAR,^I\S RD- 'NOOK 1-Hfr17. c N Addrea of Owner CVAJ7H )A IOon-s6
Dare d In.peouon 4- 2I- 4r7 (41+ (If deferent) tau, BOX /0
Nero..rI p.otor .`I art Hy c MAGinikns
Company Name,Address and Telephone Nube S Z I-y L'r m r.
l.: t\\N w.A arc P..0..
Cuc�t ) vvvt.
CERTIFICATION STATEMENT
I oertity teat I have persona/1y inspected the sewage disposal ryrtem at tiu address and that the =formation reported babe is true, amour
end complete a.of the time of inspection. The inspection was performed based on my training and up-enema in the .ro• (uaaa and
maiennaece of oneite sewage deposal system.. The system.
Pane.
_s Conditionally Penn
Needs Further Evaluation By the Local Approving Authonty
rail.
iN. BooT)) d5,-4\ HpRe,
71t. (2o7) 1033- 7`r63-
Inspectors Signature: 1lAv+-
4- 2y
The System inspector shall submit a nip oj.Ihi.ins ietio}port to the Approving Authority within thirty 130\nl l Pry%
mrp.t woe. If the"rota. is•shared system or has•design pow of 10,000 gpd or graver,the inspector and the system owner shall submit the
report to the appropriate regional onion of the Department of Environmental Praatioo.
The original abw1M be.eat to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A B, C,or D:
A) SYSTEM PASSES
/
✓ flan net buod any information which indicates that the system violate any of the failure curs as defined in 310 CIO/ 15.303.
Any failure curia not evaluated us indicated below.
BI SYSTEM CONDITIONALLY PASSES:
/). One or coon rote=component.need to be replaced or repaired The system,upon oompltion of the nplaemeot or npi, pass
inspection. •
yes, no,or not determined(Y, N,or ND). Deemb basis of determination u all instances.if Lm deermioed'. arplae why m1
The erotic tank is metal. cracked structurally unsound, show.substantial infiltration or s>mltretion or tank failure is
imminent. The Lyn.n will pa.s inspection d the tuning septic tank it replaced with a ivNormtng mote tank u appwd
by the Bead of Health.
(revise 11/03/95) _
Ono Witter SYM • Bceton,MassaChunle 0210a • FAA(617) 656.1049 T•Mpno,e(617) 2p2-6600
0 Pmied m enema Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property AAdrwac I?o NocCaA FP�cra: 1Q
Owner. C yAITH I/a �1I H 1 SO,J
Due of InspecUoc APR■t., 2( l cif
Bl SYSTEM CONDITIONALLY PASSES Icootinued)
Sewage backup or breakout or high wtc water level observed in the dwr2.nioo boa is due to broken or obstructed pima/
or due to•broken. settled or uneven dietr,ution bag The system will pass inspection if(with approval of Os Board d
Hwhh):
broken pipe(.)are replaced
obstruction is removed
distribution bog is levelled or replaced
The system required pumping more than four timer•year due to broken or ob tructed pipwa). The syn.m w 1 pea
inspection if with approval of the Board of Health).
_ broken pipets)an replaced
obstruction is removed
CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions sat which require further evahsauoo by the Board of Health in order to dam=if the system u Luling to protem t e
public health, safety and the environment.
U SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM LS NOT FUNCTIONING D.A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
Crpool or privy is within SO feet of•surface water
Cesspool or privy u within SO at of a borderutg vegetated wetland or•salt mash.
1 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER.IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT.
i
f) OTHER
The system has a septic tank and mil absorption system and is within 100 bet to•aurfaoe water supply or tnhwy to•
surface miter supply.
The system has•septic tank and soil ahmrption system and is within•Tone I of•public water supply well
The system has•septic tank end soil absorption system and is within SO feet of•private water supply wall
The system has•septic tank and soil absorption system and r his than 100 Get but SO feet or more from•prate am
supply wall unless•all water saalya for mliform bacteria and volatile orpnic compounds indicates that the all Y Gee
from pollution from that facility and the presence of ammonia nitrogen sad nitrate nitrogen is equal to or Ice than S ppm.
0
(revised 11/03/95) d
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION l000tinued)
Property Addra.c tSo Nokatt R.)- t'L- iarri:,,,,>tcl.! A^.,■
Anon CykfTH 'A (A),PfTSUIJ
Date of Inspection: Ar4z, 2t, 19g7
Dl SYSTEM FAIN
N/I' I lave determined that tba system vioas one or more or the following
this determination le identified bb.. The Bond of H otw.criteria u defined m 310 be awn/7 lb Health be Swaim at to coma Us
IG
Backup of sewage into facility or system component due to an overloaded or obliged SAS or aespocl.
Discharge or ponding of efuent to the surface of the ground or surface water des mat overb.d.d or cam SAS or _
c s.pooL p
i% static liquid level in the distnWtioo Ea above outlet invert due man overloaded a
/ <btdal SAS w or crspoy
N Liquid depth in manioc,'is Iw than 6 below invert or available
1A.�1�� 'ailable wh.me u laths: L2 day Oo.
-YA Required pumping mom than 4 times m the Ian year NOT due to decant or phonated pipets).
Number of times pimped
Any portion of the Soil Absorption System, wspool or privy a below the -
��� Bib groundwater elewuon
= f`
Any portion of•cesspool or privy u vnthan 100 feet of a surface grocer supply a tributary to•surface wear supply
toil Aqy portion o(•aapool or privy is noun a Zone 1 of• public well
1 A Any portion of.carpool or privy is within SO fret of•private water supply well
t t Any portion of•cnepool or privy is la.than 100 feet Litt greener Lima SO feet Reno •pnvate water supply well with m
acceptable water quality analyse. If the will ban been
mliform bact.ry rol.tile analysed and be mNb4 attach my of well water
organic mmycunda, ammonia nitrogen tab wwa attn. ���
£1 LARGE SYSTEM FAILS:
Tb.following criteria apply to large systems in addition to the
mare above
Tb see em rives•futility with •Mein flow of 10.000 gpd or peeve(large Syaeml and the system is•
health and safety and the environment because one or more of the following sipti5adt thrrt to pals
wing mmllCne a
Gm ante=is within 400 Bet of•surface drinking water supply
the'cyan Y within 200 feet of tributary to•surface drinking wear supply
theesystem is bated in•nitrogen sensitive w(Interim Wellhead Protection At.s(IWPAI or•mapped Zone B of•public
reapply well/
The ownerv4 operator-o(.any such system shall bring the system W
facility into full compliance tor ground at trm anmeat progrm nspuesmasa of 314 CMR 5.00 and 6.00. Please consult the local re houl office of th e Department fa nuttier tnfor netoo
(revised 11/03/95)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECIUJST
Property Addrw.c 150 QC-4N l t -'..•.1�`-
°awn Cyed THtA krATSON
Dote of lospwello& APti 2 t
Cbrck if the e following have been dont:
:%Pumping Information was requested of the owner,o cupeat, sad Bond of Rapt.
—Noo.of the system mmponenu have been pumped for at Rest two weeks and ti.
rd" I— during that period. Large wfum.s of water have not been mu-ahead into eta em A hag Seen pen of v.m. e> n.
system �enµy or..part of this inep.nsm
i.5 As bulk plans have been obtained end examined. Note if they are rot available with.N/A
OR The (eddy d Bing was inspected for sins of sewage back-up.
The system does not receive noneanitary or industrial waste pow
/The tuts was inspected for signs of breakout .J G t'+"'"
Ir%t AB system components, excluding the Soil Absorption System, haw been locatd on the site.
i t p_The septic tenk manhole were uncovered, opened, and the=tenor of the septic tank was inspected for condnioa of tames or
Lee, muMriel of construction,dimensions, depth of liquid, depth of Ado, depth of*ma
Y[$The aa:a and location of the Sod Absorption System on the sin has been determined based aiming information or
sppr®mued by non-intrusive m.tbods. PLAN Vi< tc w
oA The fealty rase lead corypents, if different from owner) were provided with information on Om proper ma:ntecaon of S uh
Surrwapnd Syrtrm. ACvcity lac(:
-r-H,5 ':2..-.:;oL L, 5 &. 7nL 5YSL6%.
k'Y:`.
(revised 11/01/95) 4
r. RLC cI .1c3 SAN
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Addrese (50 NORT k Pi.n\:
Owner CyNTHlA Sty der-TS WSJ
Date of Inspection: A tt_ 21 -ty1
BEES IDENTIAL•
Drip Dar 4 It °plbu
Number of bedrooms: 4.
Number W currant nwidsnu: VAC A ti's
Garbage gruLr(yr or oo):4 •
Laundry eom.aed to system(me or now:VC
Seasonal u..(pa or m): ..,
Watar mate ndin1&it available: N'I A
FLOW CONDITIONS
Lan data of occupancy= ( t%
COMM FRC/AL/I NDL'STR(AL /�
Type of rublisbmam:
Design Dow: gallons/day
Crease trap present: (yes or no)
Industrial W.A.Holding Tank piano (yes or no)
Noneanitaq east.dw.barged to the 5 arum (yes or m;_
Water meter readings, if available:
Last data of occupancy__
OTHETL (Descbe)
Lost date of occupancy
GENERAL INFORMATION
PUMPING RECORDS and sore l of rmation:
Syriac pommel u pan of inspection: lyre or no;j_'a 5
If pie chins pumpd:�' n_y Y'•• T
__ //Rrson--for pimping Re ALC'.`t;,Y�` TR:y./ ',: _ "1V� fILLI P'✓
7YPY/[1P SYBTRI[ w I C. A. '71 ■■U v' ly
Septic tek S.utatioo tea oil absorption system
o.expoo
Z 'c 3 .�
Overflew oeesponl
Privy
Sbared 7Mm(yes or ao) (if yes attach previous inspection records. if ay)
__ Otbar(explain)
APPROXIMATE AGE of W omponenta, date installed known)sad man of information:
Sewage odors Masud when arriving at the lite: (yes or no) rc�'
(revs sea 11/03/95)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Owner CynjTNIA (.viATSoo,/
Data of lospeoUoa f'1,,: t Z I t h 17
SEPTIC TANMC
Mat*on m plan)
,
Depth below grad„± I S r
Material of 4t.aion:Kaomnt. metal_FRP_otherlerplain)
DiMe»_w.: It3.Si ,. K C3 • x f: iIA'o
Sludge depth: N.: Kit=
Dietaries hum top of sludge to bottom of outlet tee or bare. 1•':A
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 bale:
Comm•nta:
(ncomrneodatica for pumping mndiuon of inlet and outlet tees or bales, depth of(quid level innlauon to outlet invnrt.strtcsur.l miens.
evidence of Beluga etn.l fela.0 V e _tv ...- :. p C .....G/._,ch/
GREASE TRAP:_
(lout/on site plan)
Depth below grade._
Material of censtruction. _ metal_FRP_otherterplainl
Baca thi.Jmr:_
Distance from top of scum to p of outlet tee or bale:
Distance from bcaom of scum bottom of outlet use or hls:
Comments:
(reoamm.odation for pumping
enlace of leaksgtnic.)
Edition of inlet and outlet teed or bales, depth of liquid level in relation to outlet mK(t, structural
(revised 11/07/451 g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
— SYSTEM INFORMATION(continued)
Preperb Addtac (SO t,,b,A:
-Ower CYN 1h A Lu,gT50,4 Dias of nspec Inspection: rlc2�\1fti..�IC��j a ,
qyt2.( Y i ry 1-7
TIGHT OR HOLDING TANK_N
Ovate on sae plan) /"n
Dept/°"o'cede.=
Mato ial of muputtiooa comet.
most_FRP_oth.r(aaplain)
CepamT - 011on.
Drip Soar plbnWay
Alarm laved
(modaaon of inlet w,condition of
W flat t.itchea, etc.)
V
DISTRIBUTION BOZ l�
(kcal.m.n.plan)
• —
Depth of Ipuid heal shwa outlet invert: '"1
D(5rR■B1/471iu.( Bok Rd.volccO oN 4-13-S7
¶ y P C SC1)lic PLIQ.,\Pil.i(r OF
(.l1LL∎A"A ��jV,RG MA,
Comments:
(now i!iteal end dicnbntion is equal, evidence of solids anyovtr,widows of i°a into w out of box,
r,F Vi-i.T Dlj (R:,r a;t) /.. I r- n� 7)L tti wc.l
�.u0 D�4lRhd TF t1?C.,,a.:t F-.-.,,nt:_7
PUMP CHAMBWi
Ooou an site plan)--
Pomp in embng order(yes or no)
Commons:
(wsu condition of pump chamber,
a of Pumps and&nou snswst,BC.)
(revived 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
ProPerry Andras 150 'co \f�
Owner. C• H Tit liA vas-T5CN
Data of Io.p.ollos t ,:.1 cl ci
SOIL ABSORPTION BYSTIW(BAS)
(loaY ra ago pleoif poorly,anwtioa not required, but may to• Fnima W
PP by noo-mau.ra methods)
If am dmarmired lob pram,explain:
Leaching pits number's..-u) "7 7.)
Saiaa chambers. numb_
Ladling plo* number_
leaching roaches nadir
habmg d&Ids number,dimension.:
~Sow carpool. number
Comments: (ma condition of. il signs of hydraulic failure, kcal of paneling, =Minna of ngetatbn.etc.l G Kit ' ., !C, -1 \ WA S
f Vr (; A is,t 7; c 44'
a e .1J ., l Y . ,.)- A. ( C
CESSPOOLS:
Donna on.ma plan)
Number and conflgtuatjon:
Depth.top of liquid to inlet Moan.
Depth of solids ly.F
Depth of scam Layer
of carpool
Malarial.of construction
Indiotia of groundwater:
info+ (oa iOool mum b pad as put of inspection)
(
COMIDVIILS. (oua allicilt40111 of sod.
of bydnulic failure, k..1 of wading, condition of aviation, mc.l
PRIVY:
Hosea on acne plan)
MasariW of mnetn ction:
Depth of solids: ____
Command: (rota condition of sal,signs of hydraulic 4ilun, hail of ponding, modmon of.yatatmo k)
(revised II/03/9S) _ I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Addreec t5,1, Al“-;ti 1 ) r
Owner. li.F. r� P✓ .. Vl -ti;
NT1q' ) A.r4i SG)J I` / �
Date of lupeo
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include tee to at(east two psrmaunt references landmarks or benchmark.
bun all wells loth= 100'
(Z) " 7y3 rILLuAi
Ll:ACr+,N6z P,Ts
(Arpgsk cocA7t)
As -71-, KtA N.°5 1 -ers_ , .Q
ricLirAt"Q , ` i l i cc)Lk, . ,- .
ALL.cW "M"ts ;y;�L� TJ yl'ch 1P%E M1).11-: .;. TNA_;
Yo R. t ;'cr.i ;r;'cA't.
711A,, ✓16L4 L.
�isll2 i8,': . N- fi.:A
SEE / pppcv�b P[.4,4 lay !-l�u7Li:.y HSxoc4,AiE5 0,171.0 3-.2 -84
DEPTH TO GROUNDWATER
DepN groundwater adwater-+:C Wet
method et deta __:- -or approximation:
revised 11/03/95)
9