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101 Septic Inspection Form 1999 0 J P , II COMMONWEALTH OF MASSACHUSETTS ' I 6 'Mu U EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA'�nc I iL ' NOARDORNEMTH ONE WINTER STREET, BOSTON MA 02108 (6171 2925500 � —s.,. -07,1* DEPARTMENT OF ENVIRONMENTAL PRO ARGEO FALL C_:,iFCCi Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION property Address, je.l Fail 3-V)Nod kat/ov Date of Inspection: 011 I Name of Dwyer Address of Owner: Name of Inspector:(Rene Prim) —To KO.l L. lMS.SAon of Tree 5(31 D CMR 15.0001 to I sun a DEP approved system inspector pursuant Name: s Maing Address: Telephone hunter: 750 NORTH PLEASANI SIHGtI {HhAH) AMHERST,MA 01002 TRUDY CO)O Secreun DAVID B. STR HS Cotnmiss,oper CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of omsne sewage disposal systems. The-system: Passes Conditionally Passes 1 N Evaluation By the Local Approving Authority _a i l s Inspectors Siglsawre: Date: The System Inspector 1MII sub= a copy Of this inspection report to the Approving Authority (Board of Health or DEPIwithin thirty (301 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 app Dorian regional office of the Department olf r¢ ivironmee1 Protection. The original should be sent trim system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS re sea 9/2/98 Page I or ii it Priors on Recycled noe, HOWARD ENVIRONMENTAL SERVICES 750 NORTH PLEASANT STREET(REAR) AMHERST,MA 01002 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icorrtira dl Property Address: [Q ( Ftrrif • Owner: CU Date of Inspection:3 1 2_8 1 INSPECTION SUMMARY: Check A B, C, at D. A. SYSTEM PASSES: I have not l ound env information which indicates that any of the failure conditions described rn 310 CMR 16.303 exist. Any failure. criteria not evaluated are indicated below. COMMENTS B. SYSTEM CONDITIONALLY PASSES: One or more system components described in the -Conditional Pass' sec need'to be replaced or repaired. The system.upon completion of the replacement Or repai.as approved by the Board of Health.will Indicate yes. n m determined (Y. N. or NDI. Describe basis of determination in an instances. If not determined explain why not. o. or The septic tank is metal. unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance latmmem indicating that the tank was installed within twenty (201 years prior to the dale of the inspection; or the septic tank. whether or not metal. is cracked. structurally unsound. shows substantial Infiltration or exfiltretion. or tank allure Is imminent. The system will pass inspection If the existing septic tank Is replaced with a complying seats tank as approved by the Board of Health • _ Sewage crackup or breakout or high static water level ooe er veb in the distribution nee if clue to prapproval or of obstructed Board pipets] 01 due a broken. se^ilea or uneven butribubon box. The system will H earth ID broken pipelsl are replaced obstruction iz y ved distribution box is levelled or replaced The stztem repulsed pumpm5+nme then tour n year-clue to broken or obstructed pipets). The erar 'nilk'Ves" inspection if(with approval of the Board of Heet P. broken ptpefsl are replaced obstruction is removed sec: 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION IcortweseII Property Address: to l F rt9 Ow Owner Date of Wpectiom / I p/4 V FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) Sy NOTE WILL PASS UNLESS BOARD OF HEALTH CTIONING IN A MANNER WHICH-WILLPROTECT THEIPUBUC HEALTHAND SAFETY AND THE11EN`AHoNMT E SYSTEM ACCORDANCE PATH 310 CMR 15.303 Cesspool or privy is within 50 feet of surface water Cesspool or privy 1s within 50 feet of a bordering vegetated wetland or a salt marsh. 21 WILL FAIL UNLESS THE BOARD HEALTH'AND SUPPLIER. F ANY) R NTMAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE HEALTH AND SAFETY ANDTHE ENVI ENVIRONMENT: The system has a septic tank and soil absorption system I 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 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 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 e private water supply well, unless a well water analysis 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. Method used to determine distance l approximation not vend}. 31 OTHER revised 9/2/98 Page 3 or Il SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 101 Fore. �{ Owner: 3 1,18199 (� Cill Date of Inspection 3 ou must indicate FAILS: 0 List Thai e determined either "des" or "No''or to each of the following: have inavmined enti one or more of the Board owing failure conditions exist to described in in 310 CMR 15.303. y to basis for this determination is identified below. The Brtl of Health should be contacted dg tletermine what will be necessary to correct the failure. Backup of sewage into NCikry-erg dpe¢o an overloaded ern-Sagged SASor•cesseool. • Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _ Static liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool. VLiquid depth in cesspool is less than E" below invert or available volume is less than 1;2 day flow. ic Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipelsl. Number of times pumped_. 7 Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surtace water supply. Any portion of a cesspool or privy iSwvithm a Zone I of a public well VAny portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 1001eet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed nitrogen to be nitrate acceptable,ogmech copy or well water analysis for -conform bacteria.volatile organic-compounds. ammonia E LARGE SYSTEM FAILS: You must indicate either "Yes" or N oo each the in ollowiing to the criteria above: The following criteria apply to large systems The system serves a facility with a design flow of 10,D00 gpd or greater(Large System) and the system u 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 feet of a surface drinking water supply the system is-wi*ie 200 feet 40-rseibotert4ea eurfwdrktkia9awateraufly — --.- -- - _ the system is located in a nitrogen sensitive area(Interim Wellheed Protection Area-IWPAI or a mapped Zone II of it 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 9/2/98 Pace 1 of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: I v Fz rrV `e Owner: Date of Inspection: 3p_g/ Yct • Check if the following have been done: You must indicate either "Yes" or No as to each of the followin Yes V Pumping information was provided by the owner, occupant. or Board of Health. yaw-Pen ppaspadJOratleast two weeks aecenat yatem hasbaeacafa9 wed Bow .Noes during the g that priori Larges. recently or as part of this rates tluring 2M1at period Large volumes of water have not been introduced into the system recent) inspection. As built plans have been obtained and examined. Note II they are not available with N1A. The facility of dwelling was inspected for signs of sewage hack-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 baffles zees.or material of construction. dimensions,depth of liquid, depth of sludge. depth of scum. The i size and location of the Soil Absorption System on the site has been determined based on. `∎ Existing information. For example. Plan at 51.0.H. Determined In the field 1'd any of the failure criteria related to Pan C is at issue. 15.302131(b1! The facility owner and occvlpanu-if GHauenl Lemowaerl.were.➢rnvideE!uW Subsurface Disposal Systems. revised 9/2/98 Page 5 of 11 approximation of distance is unacceptable) ipfn n tioa.on the n•nper of SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address: 10 I Pe r'`' V St! Owner: U 7laslg9 FLOW coNOFUONs RESIDENTIAL: Design flow: ° dlbedroom.9 P .1.6— Number of bedrooms lactualba Number of bedrooms (design)._ Total DESIGN flow Number of current residents. Garbage grinder(yes or no):_eNC Laundry(separate system) (yes ar nol If yes. separate:nspection required Laundry system inspected -1 or no) Seasonal use(yes or no)JJt yl U6( f I yJ Water meter readings,it available(last two year's usage Igpd): /� Sump Pump ryes or no): NC Last date of occupancy: _ COMMERCIAL/INDUSTRIAL: Type of establishment'. and 1 Based on 15.2031 Design flow of design flow Grease trap present: (yes or nol_ Industrial Waste Holding Tank present:(yes or nol_ Nornsanitary waste discharged TO the Title 5 system: (yes or nol_ - Weer meter readings.if available'. Last date of occupancy:__ OTHER: (Describe) Last date of occupancy- PUMPING RECORDS and source of intormaticn'. System pumped as pan of inspection,f yyress or nol_ If yes, volume pumped: ga l Reason for pumping'. GENERAL INFORMATION TYPE 9>!SYSTEM Seotic tank/distribution boarsoil absorption system Single cesspool Overflow cesspool Privy records.if anyl Shared system(etc. Attach copy Sof up to date operation atndnmaintenance contract Ti Technology e Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components. date instal ed.Nf known/And source efwdermetion: -^ Sewage odor detected when-arriving at the site:I yes or no)40 revises 9/2/98 Page 6 of tl Itik0A to SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued/ -.perry Adm.: -i0 -Farr 3f owner: Dew of Inspec>^^:7 j�.6 IG i BUILDING SEWER: • 1 (Locate on site plan}q// Depth below grade. 2'I qg PVC other lexpleinl Material of construction: cast iron_ _ Distance tram,11�p/ivete water supply well or suction line Comments: T ^ D� 'I comments: mopaimn of iS venting. evidence yr 1«k.ge,<tgl a e U r d,C-P 1U1 N� S Cj'v.K./ fl�YLii ft et SEPTIC TANK:_ (locate on site planl 1p Depth below grade: G O metal Fiberglass Polyethylene oNerlexplainl Material o1 construction:�f notate_ — It tank is metal. list age._ ls.age confirmed by Certificate of Compliance IYesINoi Dimensions: - - - /A Sludge depth'M..'' - a Distance from top of sludge to bottom of outlet tee ortmffle:t`ill Scum thickness'. Distance from top of to top of outlet tee or battle scum M tbpn1' t4 bathe HHow dimensions were determinedeST , ied4 LS u fa- Coen Comments. -1 liquid laud in relation to outl t invert, strucrwdwnegrity. evidence of l(ka for pumping. condition of I n l-t and outlet tees o r-•:f Fl e ..t• � � rn 144;Y[/nh/. dance le ka.e etc. g ' eZl1l1� - %'A�%e'�ar'�yir1� GREASE TRAP: (locate on site plan) Depth below grade._ Material of construction'. —concrete_metal_Fiberglass Polyethylene_otherlexplain 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: (recommendation 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 9/2/96 Page t of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Adacs: ` © { F2rr � Si Deal I Q[ Dee al v Inspection: 12 0 TIGHT OR HOLDING TANK:. (Tank must be pumped prior to. or at time of. inspection) (locate on site plan( Depth below grade-:_ Material of construction:_concrete_metal Fiberglass_Polyethylene_otherlesplainl Dimensions; Capacity: gallons Design flow. gallons/day Alarm present order. Yes_ No_ Alarm level; Alarm in working Date of previous pumping: Comments'. (condition of inlet tee, condition of alarm and float switches.etc.) DISTRIBUTION BOX: l locate on she plan) Depth of liquid level above outlet invert r Comments'. p t itlence of leakage into r out of box, etc.) - - O (note ihlevel a d distribution is ecgal.84rnP of fr /eD(CAC P 5°7�/f!C /r'o%v ynr AP f/' �+ pi_vn.4 I n C PA) a r 7 ,/ V PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or Nol_ Alarms in working order (Yes or No)_ Comments: appurtenances.earl (note condition of pump chamber.condition of pumps and revised 9/2/98 Page 8 of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued' Property Address: 10 I Eli r:r�i sf Daner: �' I??? DM N lrsspectiop: I SOIL ABSORPTION SYSTEM'SASE_ I locate on site plan. if possible;excavation not required.location may be approximated by non-intrusive methods) If not located. explain'. Type. leaching pits, number:_ leaching chambers,number:_ leaching galleries:number_ ir leeching trenches,number,length: leaching fields.number, dimensions. overflow cesspool.number:_ Alternative system: Name of Technology: Comments'. (note condition of soil, signs or hydraulic failure.level of ponding. damp soil, condition of vegetation. etc.) CESSPOOLS: (locate on site planl 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 (cesspool must be pumped as per of inspection) Comments condition of vegetation, etc.) (note condition of soil, signs of hydraulic Whim el of pending.con PRIVY: (locate on site plan) Materials of construction. Depth of solids: Comments: (note condition of soil,signs of hydraulic failure. level of ponding, condition of vegetation;etc.) Dimensions: r evised 9/2/96 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Ico tiraredl Property Ada.: TO I F1irr N GH Owner: V Date of inapectws: z-laq • SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locale all wells within 100' (Locate where public water supply comes into house) Old Ferry Road, Northampton 1111.luIII1I I1111111111111ILO(.II111.11111.I111IYII-IIIIII111111111111111111 1111111: —• : m IIIIIIIINIIIIUlIII1U 111IIIIIIIII. II111I --=-- _ _ IIIIlllI1111111 (IIIIIt11111IIIIIl.1I1111 IIIIIIIIIUIIIIIIIIII•IIIII 11111 IIIIIII=-----_`:--_ 111111111111111U 11111 I111111IIIIIIII II 111111IUIIIIIIIIIIIIIIIII III1111111111 111I11111.�=_--y— m-- 111111111111111111111111111111111111111111111 I I I 111111 111-1 uII11111111(III 11�11 11X11 111 11= .___._--__ IUII1lUIIR1I 1111 IUIIIII11111111IIIIIIIIIIIIIIIIll11I11I1 IIIIIIIIII O III- 111111111111111111111111I11111IIIIIII111 111111 11111111111111111111111111111111 MI 11111111m=21110—e= — --- - 0-1111111111011111111 1/111111 --=---= _= 111111111111 11111111111111111111111111111111111111 1 IIIIIIIIIIIIIII111111I i II11111MIIIIIII111I 11 11111 11- — 9—: 111111111 1111111 11111111111111111 IN iim1111II11II I11III1IIIIIII111 ' tII11111I111I 111111111 Iii 111111 MI 111111111111111111 1111111111111111111111111 1IIIII 111 1111IIO11IIIII1111111111111111 1 11111. 111111.1111111 IIII1111IiI111IIIIIIIIllI1111111 II■IIIUIUIIIIUI11111l.I111111 1111111= --a- I;IIIIIIII1;1..i.IRI. ... ..I;I1aO;1..M1.;;g1;;1;1-I..•1tl-1;fq:. __:__ —_- =: = _— ma-m.- Septic Tank retr_sed 9/2/988 Leach Field Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM C PART SYSTEM INFORMATION(continued) Property Address: I o I F QV a ur - Owrrar: /VI Date o, 1z?IQq Soil Typ Typical epth to ground star uses Date w bsite visited g7/6/4fi Obsery ton Wells checked Groundwater depth: Shallow_ SITE EXAM Slope Oj Surface water \no 0. Check Cellar nt± Shallow wells Pb u Srtiuve D Woe14 iSh FI"e _ NAGS Report nem eautrowiam Moderate Estimated Depth to Groundwater Feet Please Indicate all the methods used to determine High Groundwater Elevation- Obtained from Design Plans on record Observed Site(Abutting property. observation hole basement sump etc.! Determined from local conditions Checked with local Board of health Checkeo FEMA Maps Checked pumping records Checked local excavators. installers Used USGS Data Deep �l Describe how you established the High Groundwater Elevation. (Must be completed) o &/OLIN d. GVG���+� %r/ �.I000t IG k3-S1 SO( ( kuvvt(.( oT �T46•�{�SL;UCCvwtiYi. revised 9/2/96 Page 11 of It