Septic Inspection Form 2000 ARGEO PALL CELLLCC:
Governor
COMMONWEALTH OF MASSACHUSE
EXECUTIVE OFFICE OF ENVIRONME
DEPARTMENT OF ENVIRONMENTAL
ONE WINTER STREET. BOSTON MA 02108 (617) 2925500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/n�) 1,1I �//� CERTIFICATION
Property Address:L'1d S B%N $2d c1 F100i Name at Owner l" Q fix,re0
X' niciff*11y 4. Address of Owner t3 year 4 iJ 0n,i Li(3-.2'0'509,
Date oo spec r: ¢ {ly {� NCI -f` e( J �l/T c/038
Name of I an,•Inspector: 1}M( rt0 �eka �C nt Q
1 em a DEP approved system inspector pursuant Odeon 15.340 of TNe 5 1310 CMR 15.0001
Company Name: NO WARD ENVIRONMENTAL RFRVU,ES
Mein9 Address: --140-NORT11-PLEASANT-IITREE ,REAR)
Telephone Number:
AMNERS(,MA 01002
TRUDY CORE
Secretary
DAVID B. STRUHS
Conania:oner
CERTIFICATION STATEMENT
I candy that 1 have personally inspected the sewage disposal system at this address and that the information reposed below is true, accurate
and complete a s t
of the time of inspection The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system
v Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature:
Date:
System Inspector sha I submit a copy of thin inspection report to the Approving Authority (Board of Health or DEP`within thirty 1301 days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 god or greater, the inspector and the system owner
' shall submit the report to the appropriate regio al office at the Department oF£nvinnmental Protection. The original should be sent tope
system owner and copies sent to the buyer, if ppllcable. and the approving authority.
NOTES AND COMMENTS
Pape nl II
HOWARD ENVIRONMENTAL SERVICES
750 NORTH PLEASANT STREET(REAR)
AMHERST,MA 01002
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
c1ERTI FI CATIONL I coputuetl
Property A took:0!d Sprint)e1i I 1 /vCdRCLL7 "" 1
D-ne° Flo Wo Q /
Ogle of Inspector,:la To
INSPECTION SUMMARY. Check B. C. or D
.J SYSTEM PASSES: LVV�
I hove ot found any Information which in icates that any CI the !allure described in 210
coterie co
indicated o
e no. _valuated ere incated below.
COMMENTS.
MR 1E-303 evist. Any tenure
SYSTEM CONDITIONALLY PASSES'
One or more tem _ mo n ncs as tle.onned In the 3 - . to oo eome_o or repaired. The systar-.. 'tape
__mol_.mn _ the,enlacement o. eoair a_ aoproaen h. toe eoaru of Health will „ass.
cr sot tetermines ... N. or NO'. Describe oasis nI n i ell instances , deaf.
Toe se .. is Cthe operator has pmviaed t, sod with a C explain
el aCertificate tank s dial, unless owner - 'aet s
_e sesoic lettac etll m it ncn rn r the tank was installed t wunso:went n ws. rear r to the oer a or The Iution a n.
n w or nd is _.ackec structurally a un.,. snows _c_ ,nn onto
Infiltration o exfiltrvtien. or tani■
faiiure s m he a ass .nso ne existing n corm v_with a comp n6 sent:tank as
stthe a hard of naaIu,.
ye ais
rea unet sumoTornoro tan . . _e o ,dory-. vox"— ors ice
wrtn acorovm or the 3oard n. —_mTr:
tire
it
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
ER11FICATION (continue,
O n.,, ,(a sP'1 4
Ow x:
Date of /Ape
/Uov-'f-ka/Fye
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determined the system is failing to protect the
public health, safety and the environment.
I) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CAR 15.303111(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICHWILL PROTECT THE PUBUC HEALTH AND SAFETY AND THE ENVIRONMEM_
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system ISA S) 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 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 feat of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for cold orm 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. Method used to determine distance {approximation not valid).
31 OTHER
Pave 3n( I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (candruedl
tt Rv i No�f-��,IA ?
Property Atldress:o e dQ� 1
Date of Ittipecn/O[[f%•
D. SYSTEM AILS too
You must indicate either "Yes. or No to each of the following.
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of swage atm iecil.e -er,Yatern componenrdue¢o en overoeded arMegged SAS orceaspoof
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool
Static liquid level in the distribution bon above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6' below invert or available volume is less than 1'2 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or oostructed pipeisl
Number of tomes pumped_.
Any portion of the Soil Absorption System cesspool or privy is below the hign groundwater elevation.
Any portion of a cesspool or prtvx is within 100 feet of a surface water supply or tributary to a surface water supply
Any portion of a cesspool or privy is within a Zone I of a public well
Any portion of a cesspool of privy is within 50 l eet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with n
acceptable water quality analysis. If the well has been analyzed to be acceptable. anach copy of well water analysis for
-conform bacteria. volatile organic compounds. ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS'.
You must indicate either ".ves or No r each of the following.
The following criteria apply to large systems in addition to the criteria above'.
The system serves a facility with a design flow of 10.000 gpd or greater (Large System! and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist.
Yes No
the system is within 400 feel of a surface drinking water supply
the system is-within 200 feet of-ei«buteryde a eurfaoadwrW:wg+wter supply —
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPAI or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(21. Please consult the local regional
office of the Department.for further information.
revised .198 Page 4 of It
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Propatty AOdess: old iFe� (�. /tbd-
Owner: F(cv to c
Date of wpecbon:
$ 12-00
Check if the following have been done: You must indicate either "yes" or "No" as to each of the following-.
res / No
Pumping information was provided by the owner. occupant, or Board of Health.
None of the system comporni56aw.born paapedtor.Jeast twoww&e andthe system hss,eeeaceirog sal flow
rates during that period. Large volumes of water have not been introduced into the system recently or s pert of this
inspection.
As built plans have been obtained and examined. Note it they are not available with N"A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non sanitary or 'industrial waste flow.
The site was inspected for signs of breakout
All system components. excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered. opened, and the interior of the septic tank was inspected for condition of battles
or tees. material of c n, dimensions. depth of liquid. depth of sludge, depth of scum,
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example. Plan at B.o.H.
Determined in the field lit a y of the fawte criteria related to . art C is at issue approximation of distance is unacc eptablei
'15 30213/0311
The facility owner and ocapants.-it differ°^z bptr_oaner) weraprnaiss with aalpzmabonpn tlw prnpet asnS.aa u2-of
Subsurface Disposal Systems.
revised 9/2/98
Page 5 of It
Property Address Ord
Dwner'. RCP-
Date of In
$ (a o0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMA ON
&RJJw.bieiliamlo
now CONnfnONS
RESIDENTIAL:
Design flow: I Il)g.p_d.!bedroom.
Number of bedrooms (design) Number of bedrooms tactual)
Total DESIGN flow 0 J
Number of current residents: �Se(($ep R`
Garbage grinder(yes or no)4 SP
Laundry (separate system) (yes or olidie,It yes. separateinspection required
Laundry system inspected (yes or no) �tp
Seasonal use Ives or no1: �S s usage ( �Y
Water meter readings, f liable (last two year' sage Igndc pi lie P✓
Sump Pump oyes or no)i O ��
Lest date of occupancy LcIt$f2v
COM MERCIALANDUSTRIAL
T ype of establishment'
Design flow: qpd I Based on 15.2031
Basis of design flow
Grease rap present' (yes or
Industrial Waste Molding Tank present' Eves or n
Non-sanitary waste discharged to the-Otte E. system' Eves or noi
Waterm readings. L available' -
_as, date of occupano::
OTHER:(Describe!
Last date or occupancy.
PUMPING RECORDS an_ source of information
GENERAL INFORMATION
t90 F pcc Liver) Fe. r ICJ/ace's
System pumped as part of inspection- l yes or not 5
If yea volume pumped. TOO gallons
Reason for pumoino ri 71,1/4.1.1E/Pt VeVVS t?F E icr w
7
P OF TEM
Septic tank,dhulmruul, brra'soil absorption system
Single ces
Overflow cesspool
Privy
Shared system (yes or not lit yes. attach previous Inspection records,if any)
SA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tent Copy of DEP Approval
Other Jeri-St—Le, �,I
APPROXIMATE AGE of all components, date %net&1ed/if known}-and source ofrafennetion & ar
Sewage odors detected when arriving at the site (yes or not AL L'
revised 9/2/98
Page 6 of 11
Osmea: Ap�e�z: To
Date of Irssl(epi:j
BUILDIN S
(Locate on site plan)
/I "
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Rip INFORMATION Icontinu dl
4 J IVj /�C%f14'Iak�Q�e(t.Ta'',
Depth below grade-
Material of construction:_cast iron (c- PVC_other )explain)
Distance frorp�rivate water supply well or suction line
Diameter Cj. r
Comments; to •ition at joints, vent
SEPTIC TANK:_
(locate on site plan)
Depth below grade: (T
Material of construction. 4,06Cte metai_Fiberglass Polyethylene otherfeeplainl
if tank is metal. list age_ Is.age confirmed by Certificate of Compliance_ IYes!Nol
`.5 ft to '
fk
Sludge depth:_// /• L/
Distance from top of sludge to bottom of outlet tee or baffle'. ,In
Scum thickness'. S--1/ 0 s• /r
Distance from top of scum to top of owlet tee or baffle- `0
Distance from bottom of scum to bottom of outlet tee attic
How dimensions were determined. nfacfxi�eti et4f
Dimensions:
Comments
Irecommendation for pumping
evidence of le kage etc.)
condition
and outle
GREASE TRAP:
(locate on site plan)
er
baffles. •. th of liquid lev&in reation to ou et ioven. s uctu
Depth below grade-
Material
of construction. concrete metal Fiberglass Polyethylene_otherlevplainl
Dimensions-
Scum thickness'._
Distance from top of scum to top of outlet tee or baffle'._
Distance from banom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
Irecommendabon for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98
P.ee 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTED/ FORM
PART C
"'SUM INFORMATION Icmtiruedl �/
Property a. Old Spal�kb�',e - /000 -/Actu 4h
Date of tow(o
cgfaf OO
TIGHT OR HOLDING TANK:
(locate on site plan]
Depth below grade'.
Material of construction concrete Fiberglass Polyethylene otnerl explain`.
Dimensions:
Capacity'. gallons
Design flow: gellonslday
Alarm present
level'. Alarm in working order: Yes _ No
Date of previous pumping.
Comments
I condition of'met tee condition of and float swuches. etc.]
DISTRIBUTION BOX:_
(locate on site plan
Depth of horsed level aeove outlet me
Comments
(note if level and dishlbution Is epua evroenoe of sonde carryover. evidence of leakage into or out of box. etc.] — - - —
PUMP CHAMBER:
(locate on site Olen)
Pumps in working order. (yes or No:
Alarms in working o eer (Yes or No.
note condition of pump chamber. condition of pumps and appurtenances.etc.)
revised 9/2/96
Page 8 or 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION{continued
PmpenYAd&ess:` cd Sr Hd raid goo-Si tart_vrnr /ew
Owner:InFicip40
Dm of
mac bon:
a-00
SOIL ABSO mON YSTEtb(SAS):
(locate on site plan,if possible: excavation nol required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers,number:
leeching galleries, number:_
leech.ng trenches, number, length:
leaching fields, number, dimensions.
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
I note onditi•n
oiL signs of hydraulic failure, level of p•'d'in . da p soil, spotlit' .1 v ration,
i r / /I
CESSPOOLS:
(locale on site plan)
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer.
Depth of scum layer.
Dimensions of cesspool.
Materiels of construction
Indication of groundwater.
inflow (cesspool must be pumped as part of inspection)
Comments:
note condition of soil. signs of hydraulic failure,level of pending,condition of'vegetation. etc.,
PRIVY:
(locate on site pie nl
Materjals of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil. signs of hydraulic failure, level of ponding. condition of vegetation, etc.)
revised 9/2/98
Page 9 of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icaemruedl
property
Address: G' l
r� s,Ortbtf7E1) Re � tAth
Dsmm W ,rre g
S3(al00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent refer a Ian nrks or benchmarks
locate all wells wttnlC1 oo'g(Locate a7w/hh/e�ree public water supply comes into house:
Sego ac `2civvJ
revised 9/2/98
Page Io or 11
Property Address: Old & V
O ww:
Date o : o
:(2•i60
NRCS Report name
Soil Type
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icwronuedl
Typical depth to ground e'er
USGS Date website visited 'Z'BLly
Observation Wells checked
Groundwater depth: Shallow ` Moderate
SITE EXAM Slope a0/
Surface water KI'yZif-
Check Cellar /f/f
Shallow wells NO
Estimated Depth to Groundwater 44-feet
Please indicate all the methods used to determine High Groundwater Elevation
Obtained from Design Plans on record
_ Obsrserved Site IAbutting property. observation hole, basements p t_.
L/Determined from local conditions
Checked with local Board of health
Checked FEMA Macs
Checked pumping records
Checked local excavators. installers
Used USGS Data
Deep
Describe how you established the High Groundwater Elevation. (Must be completed! /
Inks, ra �4c 7T`f(e 5 vcx p k i� hac��ae c-xca6-al�d
c � �v4S � $ aG � GtE�E
u-t.teps [[cAr s 1r lJ[k5 �./Jc.v-e /1(sa 7/4 t for /544- en
kcc le S-et S YY1E?- i{kt l`tor )c�C� R� q— c cede k/e_ Tee
%{ cif is Coo bevvaffve QS )( eiizicc $L
Gut S .Ke a-F
revised 9/2/98
Page 11 or
Connecticut River
3 bedroom mobile home
shed
53 fe
1,500 gallon
septic tank
750 gallon
leach pit
well
> 100 feet
54 feet
Clump of
Maple trees
Not to scale
Old Springfield Road,Northampton