61 Septic Inspection 1997 •1
Property Atdress.
Ow
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
BJ SYSTEM CONDITIONALLY PASSES Icontrnuedl
- Sewage backup or breakout or high static ter level observed in the distribution box is due to broken or obstructe
Pipe(sl or due to a broken, settled or u ven distribution box. The system will pass Inspection if(with approval of
Board of Health). Describe observat ins:
broken pipets) . e replaced
obstruction i removed
d rstrrbution •ox Is levelled or replaced
- The system required puma ng more than four times a year due to broken or obstructed pipe(s). The system will pas
inspection if(with appr• al of the Board of Health):
. • en pipes) are replaced
oatrurnon is removed
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 T the system is failing to
public health, safely and the environment.
g protec
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNEI
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
- Cesspool or privy is within 50 eet of a surface water
- Cesspool or privy is within • feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE :OARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES TI-
THE SYSTEM IS FUNCTIONIN• IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
- The system has . septic tank and soil absorption s
tributary to a dace water supply. y stem
(SAS)and the SAS is within 100 feet to a surface water supply
_ The system •as a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well
_ The syste • has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well
_ The syst• has a septic tank and soil absorption system and the SAS is less than 100 feet but 50
private ater supply well, unless a well water analysis for coliform bacteria and volatile organic cfeet
ompou compounds and indicates ti
the -II is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to
les than 5 ppm. Method used to determine distance
(approximation not valid).
3) OTHER
tr.veu.a 01/25/92j
Page. 2 of 10
WILLIAM F WELD
Governor
ARGEO PAUL CELLUCCI
Ls.Govcmor
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI
DEPARTMENT OF ENVIRONMENTAL PROTE
ONE N INTER STREET. BOSTON. MA 02108 617-292-5500
SUBSURFACE SEWAGE DISPOSAL A
SYSTEM INSPECTION FORM
CERTIFICATION
Property Address: I// 54 y YTEI Rf3'I Ue<TNRNT°N Address of Owner:
(If different)
Date of Inspection: l}•D 1}'tF7R j_,4!Ot✓a eE
Name of Inspector:
I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (310 CMR 15.000)
Company Name: S nI ,ry /app d/05'U
Mailing Address: �iN' MEV( OW
Telephone Number: t 4022
I ndr y that I have personally inspected ed the sewage disposal errthat s reported below is
, accurate
time of The ins he was performed based on training and experience in the proper function and
and mainte anceofone sewage disposal system Tsystem:
Passes
Conditionally Passes
the Local Approving Authority
0T (
JAN I41998
OBTHAMPTON BOAFtO O:' ->`._
TRUDY COKE
Sccretan
DAVID B STRIA-IS
Commissioner
_ N Further E aluatii
c �/ ]i Date }_r
Inspector's Signature: - � completing this
The System Inspecor s all submit a copy of this inspection report to the Approving Authority within thirty(30) days of comp 6
000 or greater, the inspector and the system owner shall submit
the report If the pp system is a regional system or has a design flow of 1 r gpd g
the report to the appropriate regional oHlce of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer. if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303
Any failure criteria not evaluated are indicated below.
COMMENTS-
El) SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional the oaldPas Health,section need peso be replaced or repaired. The system. woo.
completion of the replacement or repair, as approved
Indicate yes, no, or not determined (Y, N, or NDI. Describe basis of determination in all instances. If "not determined", explain why not
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate o1
shows substantial prior to
infiltration or f the h nap , or tan:
Compliance tanached) indicating that the tank was installed within twenty (20] years poor to the date of te inspection,
the septic tank, whether or not metal, is cracked, structurally unsound,
failure is imminent The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
tr.vi..d 04/25/97)
hag. 1 of 30
DEPon the Worldwme Wm tip were mg 1 tt mausdep
0 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
DI SYSTEM FAILS:
You must indicate ev er "Yes" or No as to each of me following
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to c
the failure.
Yes No
_ — Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS
cesspool.
— Static liquid level in the distribution box ab e outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than . below invert or available volume is less than 1/2 day flow.
_ Required pumping more than (Imes in the last year NOT due to clogged or obstructed pipel9.
Number of times pumped
— — Any portion of the So Absorption System, cesspool or privy is below the high groundwater elevation.
_- — Any portion of - esspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
— — Any portio of a cesspool or privy is within a Zone I of a public well.
— _ Any p. ion of a cesspool or privy is within 50 feet of a private water supply well.
/
_ y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
acceptable water quality analysis. li the well has been analyzed to be acceptable, attach copy of well water analysis f
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or No as to each of the]pllowing.
The following criteria apply to large system addition to the criteria above:
The system serves a facility with a ign flow of 10,000 gpd or greater (Large System) and the system Is a significant threat to
public health and safety and th- -nvlronment because one or more of the following conditions exist:
Yes No
- the sys
is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA; or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 3.00 and 6 00 Please consult the local regional office of the Department tot further information
,r.va..a 04/33'3lt
P.9. 3 of 13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:.51 5 L ry ue*-re a RA
Owner: .T,bw + ]U 7t Ly 41,0A
Date of Inspection: li 47
Check if the following have been done. You must indicate either "Yes' or "Na as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None rates the system components that t have
period.been Large vvollumes at least water have not been introduced into the system recently or
flow rates °/Si O during that pe i 6
as part of this inspection.
As built plans have been obtained and examined. Nate if they are not available with N/A.
A _ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
.X. — The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
.X- — The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.v The size and location of the Soil Absorption if different from the site been determined
withbased
f�obon on the proper maintenance o•
+'r — The facility owner land occupants,
Sub-Surface Disposal System.
Yr. _ Existing information. Ex. Plan at B.O.H.
— Determined in the field (if any of the failure criteria related to Pan C at issue, approximation of distance is
unacceptable) 15.3021311611
Ir.vimed 04/25/97)
Page • of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9-/ $ Ly �= yt j
Owner: J.4,. , 4LDy Lyro>
Date of Inspection:
!.).-Ix i
TIGHT OR HOLDING TANK (Tank must be pumped -
(locate on site plan) prior or at nine, of inspection)
Depth below grade:_
Material of construction: concrete metal _Fiberglass Polyethylene _other(explain)
Dimensions
Capacity gallons
Design flow- gallons/day
Alarm level. Alarm in working order Yes, No
Date of previous pumping:
Comments
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on she plan)
Depth of liquid level above outlet invert:
Comments
(note if level and distribution is equal, eviden . of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments
(note condition of pump chamber, co tion of pumps and appurtenances, etc.)
(I-myriad 04/2S/97)
Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
perty Address: 5) S4yL syr>'e.
ner:.?s4 •+ �7aoy y
e of Inspection: IA . 1.1 .12
ILDING SEWER:
rate on site plan)
oth below grade at.'
terial of construction. cast Iron ][40 PVC other (explain)
stance from private water supply well or suction line
meter
mments. (condition of joints, venting, evidence of leakage, etc.) -.0 xrTr •�
f .+r si t (k'7C'a•.r.•..E •Q..tine LE O
N LNFFvS & fond t W
> g7t Oated2
PTIC TANK:L
care on site plan)
Dvc 125 tea,v7 cc. >
tr
epth below grade. EY
aterial of construction: jconcrete _metal _Fiberglass Polyethylene orhegexplain)
tank Is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
imensions: /n07 it 02- X ( /
udge depth. Imo" •r
!stance from top of sludge to bottom of outlet tee or baffle: /Z.
:um thickness. ahi'n LI'v1m %t ,r
istance from top of scum to top of outlet tee or baffle: 4:
iistance from bottom of scum to bottom of outlet tee or�lT
low dimensions were determined: 'F% Iwt4Y
'.ommenty [h o!liquid level in relation to outlet invert, structural
'ecommendation for pumping, condition of inlet an0 outlet tees or baffles,(� n pt iof e U
tegrnty, evidence of leakage, etc.) jO+uk- /.V 4.pD
5REASE TRAP:_
locate on site plan)
Depth below grade._ Polyethylene o[her(explain)
Material of construction. concrete metal F •erglass _
Dimensions:
Scum thickness:
from top of scum to top o •utlet tee or baffle:_
Distance from bottom of scum t• •ottom of outlet tee or baffle.__
Date of last pumping.
Comments structural
(recommendation to •umping, condition of inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert,
inteerty, evidenc of leakage. etc.)
Page 6 of 10
(rev:eee 04 107)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 57 L y el:reit RD
Owner:fiSn v .I'U p1 f-yr•• •
Date of Inspection: II..
SOIL ABSORPTION SYSTEM (SAS): 9.
(locate on site plan, if possible, excavation not required. but may be approximated by non-intrusive methods)
If not determined to be present. explain:
Type'.
leaching pits, number_
leaching chambers, number. r
leaching galleries, number:
leaching trenches, numberlength.
leaching fields, number, dimensions.
overflow cesspool, number:_
Alternative system:
Name of Technology.
Comments:
(note condition of soil, signs of hydraulic failure level of ponding, condition of vegetation, etc.)
ONp 75-0 44//em c•se•ce-'7r CH+/ 4.) c
CESSPOOLS:
(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 (cesspool must be pumped as .. of inspection)
Comments:
(note condition of soil, sign . hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction.
Depth of solids.
Comments
(note condition of soil, signs of hydraulic f ilure level of ponding, condition of vegetation, etc)
Dimensions:
(v."r..a 04/25/97)
P.9e 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
erty Address: Sf 51-y IfESTE_0Z R •
ter:,jph.0 +SoDy Lysta
of Inspection: IA L Z, 4%
FLOW CONDITIONS
DENTIAL: ''��,.,1l
,gn flow:bmkMst p d./bedroom for S A.5.
nber of bedrooms: ryi
nber of current residents. 4
cage grinder (yes or no):MO
'dm connected to system (yes or no)ft)
,oval use (yes or no)PP
er meter readings, if available Ilan two (2) year usage (gpd): NO rtet° R
ip Pump (yes or no):,V O
date of occupancy. 4 =°t"'7
MMERCIAUI NDUSTRIAL:
e of establishment:
;ign flow: gallons/day
rase trap present: (yes or no)_
ustrial Waste Holding Tank prese . (yes or no)_
n-sanitary waste discharged t. e Title 5 system. (yes or no)_
Ler meter readings, if ay.
.1 date of occupan
"HER: IDesc
it date of occupancy:
GENERAL INFORMATION
JMPING RECORDS and source of Information:
System pumped as pan of inspection: (yes or nolri
If yes, volume pumped: /OOD gallons
Reason for pumping ..7—e•-ye t Tr a 41
fPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
_ Overflow cesspool
Privy
Shared system (yes or no) Of yes, attach previous Inspection records, if any)
I/A Technology etc. Copy of up to date contract?
)ther
-PPROXIMATE AGE of all components, date installed (if known) and source of information
1yYe
sewage odors deterred when arriving at We site lyes or no)
(revised 04
Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3) 54 U T
Owner:�/TN�JpP ( t>Tc2
Date of Ins Y
Inspection: ) • /z
Depth to Groundwater 7 Fee
Please indicate all the methods used to determine High Groundwater Elevation:
_Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
X Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
VD/ Tc S /06 or= �x ,anD a4iE-nuaboo
At 50
5.p A-E /t 0. o•» .1-,t'1.T 4i,no < fl / s)y f� yr�tr.
(revised 04/2s/97)
Peg. 10 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
ty Address:5I Sly I ESiE/e
Crib at a 7vny Lyon.*
if Inspection: I • 17 •47
zsz
:H OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or m es house)
locate all wells within 100" (Locate where public water supply m
NoT To seylc
1revised 01/15/99)
l ✓a
Page 9 of 10
• ra as-tsf) $
- : 2 :%ii
is
agar
-L----i--c---- ----7-
I_
\=.
'ARD OF HEALTH
T.JOYCE.Chairman
i C.KENNY M.D.
AFL R.PARSONS
1 I.McEKLAIN.Health Agent
Mr. & Mrs. Jack Lyons
51 Sylvester Road
Northampton, MA 01060
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
December 9, 1985
Re: Septic System
210 MAIN STREET
01060
14191 586-6950 Ext.213
Dear Mr. & Mrs. Lyons:
On December 7, 1985, I inspected the existing septic system on your property at
51 Sylvester Road, Northampton. That inspection revealed that the septic system
consisted of the following:
1. A 41/2' x 41/2' x 3' concrete tank with a wood
plank top. There were no baffles or tees
found.
2. No leaching facility was found.
The septic system described above does not comply with the requirements of Title 5
of the State Environmental Code. Therefore, the existing septic system must be
replaced with an approved subsurface sewage disposal system consisting of (as a
minimum) a 1,000 gallon septic tank and a 4' x 8' x 4' leach pit with at least two
feet of stone around it.
You must obtain a Sewage Disposal Works Repair Permit from the Board of Health
Office prior to commencing the work which must be completed by a Licensed Septic
System Installer.
If you have any questions concerning this matter, please contact the Board of
Health Office.
Very truly yours,
Peter J. McErlain
Health Agent
PJMc:mr
-ss
Eea /b'ez)
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY or NORTHAMPTON
Application for ElISpooat nrkfi Utuu trur jnn Derma
Vppliation is hereby made for a Permit to Construct ( ) or Repair
mat:
Individual Sewage Disposal
Astro
Size Lot Sq. feet
•Dwelling Building Expansion Attic ( ) Garbage Grinder ( )
Otherin No. of Bedroom nassion
6 � Showers l ) —Cafeteria ( )
Other-Type of Building _ - -_. .... . No. of persons
Other fixtures - day. Total daily flow - gallons
gcn Flow gallons per person per Y y
Liquid pad Y� Ilons Length Width Diameter Depth
osal i Tnnk—L� -o t Width Tond Length. Total leaching area .
age Pit No—No Total leaching ea]J
rage Pit No box/ Diameter . Depth below inlet_q h -/�r�
r Distribution box ( ) Dosing tank ( ) {Y/Y/ Date
/-�
elation Test Results Performed by.. . .. 1 er
Test Pit No. 1 minutes per inch Depth of Test Pit Depth
to gro water
Test Pit No. 2 minutes per inch Depth of ,TeesttPPitj Depth ground
cription of Soil / sis-- Y'
airs or Alterations— . er hen=ppli •le 3
/$J/ .
The undersigned e.7 a s n g Disposal System The provisions T agrees to install the aforedescribed Individual Sewage he I S t to place accordance system with
provisions of TITLE 5 of the State Sanitary =• —The undersigned further agrees not to place the syzmm m
nation until a Certificate of Compliance h. ed by the boar
v/ys—
oof
tpliation Approved By
rptication Disapproved for the following reasons-
Pmnit No
Issued...._._/a-L,FJ %1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY/DENORTHAMPTON
Q[ertifirate of Qlnmplianre
THIS IS T T(f.Y,P12et Ara ipt ual Sewage Disposal System constructed ( ) or Repaired y�r
W lam- -A
As[ _ oflg11m , p [ The State Sanitary CM de'%ribed in the
n 'n for Dip ace Works ons tl p .. mw •1-s _ RS dated../AO 3.`x.$}with
triplication SS ANCEl Works Construction Permit E S AL NO 0. ^ U ifEE /2r'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE LONST UED A GU N EE X •THE
SYSTEM WILL a./ 3N gM SATISFACTORY. Inspector
DATE J
,c Atrat
N
o l on truct on
at No
as shot on th
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITYOF NORTHAMPTON __..7_y....
Ell0PLINL_Li 9r4 cono, mutton {permit
�is hereby hereby gra ttA -- - stm
o n� e Du oral
erS D
application OLDlspo 1 \\ rks Coast Pecan
D4T F..
Fee/'�