349 Septic Inspection Feb 1997 William F.Wald
Governer
Trudy Con
grown.Wee
David B.Svuha
commosponer
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
.Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
rty Address: a q 9 COI-Er/Vtflh o R' Address of Owner: TRm es FNfj EL
of Inspection: / —5 7 (If different)
of Inspector: a/ m/a P. E.
any Name, Address and Telephone 4 umber:
/66 I/JOV�Tx+'✓ Hti�
410 •SesV /72.47 7- Sd•6
IFICATION STATEMENT information accurate
fy that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
omplete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
enance of an-site sewage disposal systems. The system:
ea Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Date:
/
actor's Signature: y In
System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty 130) days of completing this
action. 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
epon to the appropriate regional office of the Department of Environmental Protection.
original should be sent to the system owner and copies sent to me buyer, if applicable and the approving authority.
d- /9- 97
'ECTlON SUMMARY:
Check A, B, C,or D:
SYSTEM PASSES: •
4 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.
SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
late yes, no, or The septic tank is etal,uacked,Onsctt structurally to sound, shows substantial infiltration ltration"not
or ex6ltnoono r explain why
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.
1
wised a/15/951
One Winder Street • Boston,MaStaehuselb 02106 • FAX(617)556-1049 • Telephone(617)222-5600
V Nsv.4me nmNur
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
CERTIFICATION (continued/
IT Address: 3 c{9 C04-t.s MaAOow)
r: Sft i 4 s ,b—rag g c_
if Inspection: —is- 9 >
iTEM CONDITIONALLY PASSES (continued)
20
iv/a
_ Sewage backup or breakout or high static water level absented in the distribution box is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s)are replaced
_
obstruction is removed
_ distribution box is levelled or replaced
_ The system required pumping more than four 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
URTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /1//0._
_ 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.
I) SYSTEM EH WILL PASS UNLESS
THE PUBLIC BOARD OF HEALTH DETERMINES TER AND THE THE
Y SYSTEM IS
S NOT FUNCTIONING IN A MANNER
_ 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) THE SYSTEMLIS FUNCTIONINGE IN BOARD
A MANNERETHAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE DETERMINES THAT
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface ware' supply or tributary to a .
surface water supply.
_ The system has a septic tank and soil absorption system I of
ppublicw water ssup l well!a
_ The system has a septic tank and soil absorption syste m and is within 50 feet
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well;unless a well water analysis for coliform bacteria and volatile organic compounds indiates 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.
SYSTEM FAILS:
_ have determined that the system violates one or more of the following failure criteria as defined 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 n> n ary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or
cesspool.
2
:evieed a/15/951
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
rty Address: 3519 C <,S
503 ,e—s 4_
of Inspection: — 9 fr - 7
STEM FAILS (continued): /g//4
_ Static liquid level in the distribution box above outlet invert due to an overloaded or dogged 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 dogged or obstructed pipets).
Number of times pumped
_ 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 surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
_ Any 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 100 feet but greater than 50 feet from a private water supply wplyr sell with
for
no
acceptable water quality analysis. If the well has been analyzen to be and nitrate acceptable, attach copy
coliform bacteria, volatile organic compounds, nitrogen
1RGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
_ The design flow of system is 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:
the system 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 Proteaidn Area(IWPA) or a mapped Zone II of a
public water supply well) •operator of •
!owner
u ementsrof 3 4 such system shall
600. leaser consult the loot regional al office of the Department for further information'.
program
3
evicted 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
ty Address: 3`(9 Co c .s a 90Ow
cra, 6 s En-t C c
if Inspection:
/-
a-F - D >
RD
if the following have been done:
'7 t. Pumping information was requested of the owner, occupant, and Board of Health.
g_17—None during Mat to period. Large components
volumes water have pnotfbeen introduced linos the system has
ty or as pan of receiving inspection. rates
pen
SAS built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
RIV The system does not receive non-sanitary or industrial waste flow
1 The site was inspected for signs of breakout.
ic,All system components, excluding the Soil Absorption System, have been looted on the site.of the septic tank was
Ito The septic terial of construction, dimensernss depth opened, quidhdepter'ofrsludge,depth of scum_inspected for condition of baffles or
tees,
1,10-a_The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
1 e L.The facility owne- ;and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
surface Disposal System.
4
wssed 9/35/951
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM C
SYSTEM INFORMATION
y Address: 3 s/9 Co.§'s P-4:04,.+ RD
CA-m.0-5 6,v4a `
f Inspection:
/- a-,-9
FLOW CONDITIONS
:NTIAL:
flow: gallons
✓ of bedrooms:
:r of current residents:_
• grinder(yes or no):_tiO ,,//
y connected to system (yes or no): /°O
al use(yes or no): NO �� W 4 Tas!Z
meter readings, if available:
ate of occupancy:__
AERCIAUINDUSTRIAL: /v/A
of establishment:
I flow: gallonvday
trap present: (yes or no)_ - -
rial Waste Holding Tank present: (yes or no)_
anitary waste discharged to the Title 5 system: (yes or no)_
•meter readings, if available:
ate of occupancy:
ER: (Describe)
late of occupancy:
GENERAL INFORMATION
PING RECORDS ay9d{source of information:
/1-. $ te'sal•es/c .Sy: .
System pumped as part of inspection: (yes or no)
If yes,volume pumped.
Reason for pumping:
OE SYSTEM
>_G 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)
Other(explain)
PROXIMATE AGE of all components, date installed (if known)and source of information: 999�/-S .c / /57_? U Pat aOE
rage odors deeded when arriving at the site: (yes or no)_LI:)v
vised 9/3S/951
5
SUBSURFACE SEWAGE DISPOSAL C STEM INSPECTION FORM
SYSTEM INFORMATION (continued)
rty Address: 3,9 Co..9 / ie'c d w
n. Js.n£s E,wt E'z
of Inspection:
C TANK:_
e on site plan)
Ro
t below grade:_
Sal of construction: (encrete metal FRP otherlex plaint
�g re ./
, a (- r..o 0%
nsions:
,e depth: Z .1'Pt from top of sludge to bottom of outlet tee or baffle:
I thickness: Jr
nce from top of scum to top of outlet tee or baffe:2ia .
nce from bottom of scum to bottom of outlet tee or baNiea
ments: structural
mmendation for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,
rity, evidence of leakage, etc.)
ASE TRAP:_
se on site plan)
th below grade.__
erial of construction: concrete _metal FRP_other(explain)
tensions:
m thickness:__
ance from top of scum to top of outlet tee or baffler
ance from bottom nt =cum to bottom of outlet tee or battle:__
nments:
ommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural
;grity, evidence of leakage, etc.)
6
,evised c/is/sv
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
^FP40w RD
ty Address:( 3 of 9 CO,rJr s
r: 1di E t_
5f Inspection:
! "bb -27
F OR HOLDING TANK:_
on site plan)
I below grade:_
ial of construction: concrete _metal _FRP other(explain)
nsions:
city: gallons
;n flow: gallonsidav
) level:
tents:
Minn of 'Met tee, condition of alarm and float switches, etc.)
rRIBUTION BOX:_
ne on site plan)
th of liquid )eve) above outlet invert:
Air ,2,-A.--/E2 !
invents:
e if level and dstnb) '` equ_l, evidence of solids carryover, evidence of leakage into or out of box, etc.)
MP CHAMBER:_
ate on site plan)
nps in working ordec(yes or no)_
cements:
rte condition of pump chamber, condition of pumps and appurtenances, etc.)
7
:evicted 8/15/95)
SUBSURFACE SEWAGE DISPOSAL C
SYSTEM INSPECTION FORM
SYSTEM INFORMATION (continued)
y Address: 3 Y 5 Co.£r /ehEtO
• (---S et. En-C “
Inspection: 4 —ate - S 7
,BSORPTION SYSTEM (SAS):_ 5 t R 73 df4,?
on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
letermined to be present explain: -
Ro
leaching pits, number_
leaching chambers, number:_ • _
leaching galleries, number: SEE �OJ S�'
leaching trenches, number,length( d D.r
leaching fields, number, dimensions: -
ovenlow cesspool, number:_
cents: (note condition of soil, signs hydraulic failure, level of ponding, condition of vegetatian,etc.
'OOIS: _
e on site plan)
ber and configuration:��-
h-top of liquid to inlet invert: _
h of solids layer:
h of scum layer:
ensions of cesspool:
ties of construction:
��--
ation of groundwater:
inflow(cesspool must be pumped as part of inspection)
menu: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc)
W:
ate on site plan)
Dimensions:
aerials of construction:
ath of solids:
nments: (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.)
a
wised 9/15/951
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
ty Address: 3 V.5 Co i. ES
`JR-as easy#_-c-
if
Inspection:
—af - 3
p'1G9-%D-J
!1e
:H OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
loose all wells within 100'
PTH TO GROUNDWATER
pth to groundwater. _few PER c co 67-2
r
:shod o •etermination or approximation: L// u ,a ri
/N SVA" "� E‘.0
evised 0/15/951
9
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ripe eE Be
Pre
0 01
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4
la
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2
3
4
8
9
10
11
12
13
14
IS
19
120
21
22
23
24
25
25
31
32
33
34
35
36
31
38
a t s MGAnow KOAD
•
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m
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W
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1h morals
:HARD SEPTIC TANK SYSTEMS, INC.
14 DOLLAR AVENUE
WILBRAHAM, MA. 01095
(413) 596-8003 (413) 596-8004
FAX # (413) 596.4252
•I gtf u Q ter/lie Z_
l
Ada � qL �j/
/G
3 7 / fizei5 69n) ,e-9
03' g/t
(7
ORMOO ECG
R HUNTLEY, Jr., & ASSOCIATES, INC.
legistered Land Surveyors Y. Civil Engineers
30 Crafts Avenue
Northampton, Mass.
Telephone IAreo1413I 15t4-7449
July 27, 1965
Board of Health
City Hall r'
Northampton, Mass.
Gentlemen:
I have made a percolation test at land belonging to
Carey located on the Easterly side of Coles Meadow Road on a lot
to be purchased by a one L' ber'Engel.
I find the soil at this site to be coarse to medium sand,
no silt or large stones. The percolation rate is 1" in 1 minute.
I feel that a leaching trench or trenches should be constructed
at this site due to ledge in the area to the South and North of this
lot. However, no ledge was encountered in this test hole , nor was
ground water encountered.
Very truly yours,
Almer Huntley, Jr.
Registered Sanitarian
es
cc - Mr. Ralph Farrick
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE/\LTH
OF 1
Qlrrtifiratr of flnm#Iliaarr .
THIS IS TO CE FY, lzat b- Individual Se:Dispoal System constructed ( ) or Repaired (/..)K
y
at Sit 9 ' f len uer_s
a '
has been installed in accordance with the provisions of TITLE of The State Sanitary Code as described the
application for Disposal Works Construction Permit No g��3. dated /a--f 3
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSter!!((////j1
TRU S A GUARANTEE HAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE of 1-5/U Inspector �/,tI
THE COMMONWEALTH OF MASSACHUSETTS r✓` /3f,
BOARD OF EALTH j,,,,,�(((I
//, V7 OF / FEE /.�
No 'l �...??
3lispssal Ulars inn 41 it
Permission is hereby granted .1.._
to Construct ( ) or Repair ( I`}�ivielu 1 Sewag{� Dispo ,�Mst
at No 3. .Q �*WS/raMh2'�`� —s' •
s root _/J�
as shown on the application for Disposal Works Construction Pups'.
ermjq'� �3
/ //� ll,,�t��// Board of ealtla
DATE y{(..��
FORM 1255 / M. SULKIN, INC.. BOSTON A.•