41 Septic Inspection 1995 — -„--
- Wm Ban°Ø ••rons
rr 7 MI
Ilan ea c..-y
SUBSURFACE al DISPOSAL SYSTEM INSPECTION FORM
Tess of property 4/ al Ferry /2d fotiM ,T Durand PealEs/eke
em's name aLJ.D. F. O. $ ex a
e of Inspection Hudson, PTA . er749
Y/ �9/4S FART A 68-6'800
CHECKLIST 5 0 B' .s
ck if the following have been done:
_ Pumping information was requested of the owner, occupant, and Board of
Health.
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently cr as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
7_ The facility or dwelling was inspected for signs of sewage back-up.
v The site was inspected for signs of breakout.
_ All system components , excluding the SAS, 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 or tees,
material of construction, dimensions, depth of liquid, depth of
sledge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
$na&e d,t aaee
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
5uc1er : !Curt Bic A
5 l _F /01 St
i✓cr1Aamp /a-n MA
PA ; 58e -5'708
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anus
NORTHAMPTON 1W OF SUN
SUBSURFACE SEWAGE DIS PST SYSTEM INSPECTION FORM
SYSTEM INFORMATION continued
'IC TANN: 1250 gel
:ate on site plan)
ZT „
:h below grade:
trial of construction:
✓concrete _metal __FRP __other(explain)
ansions • 8 x SAX 72 dQe?
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from top cf scum to top of outlet tee or baffle
_ distance from bottom of scum to bottom of outlet tee or baffle
f3ala ,O user level by 3
ments:
commendation for pumping, condition of inlet and outlet tees or baffles,
th of liquid level in relation to outlet invert, structural integrity,
dence of leakage, recommendations for repairs, etc. )
TRIBUTION BCY._ none
cate on site plan)
depth cf liquid level above outlet, invert
utents:
,te if level and distribution is equal, evidence of solids carryover,
.dente of leakage into or out of box, recommendation for repairs, etc. )
iP CHAMBER:
=ate on site plan)
pumps in working order, yes or no
nments: s and appurtenances,
ote condition of pump chamber, condition pumps
commendations for maintenance or repairs,ofc )
SUBSURFACE SEWAGE DISPOSAL C SYSTEM INSPECTION FORM
SYSTEM INFORMA TION continued
3SORPTION SYSTEM (SAS) : Orr We 1 but may be
a on site plan, if possible, excavation not required,
imated by non-intrusive methods)
ng pits and number —�---
ng chambers and number
ng galleries and number ern length
ng trenches, number, 9
.ng fields, number, dimensions
.ow cesspool , number
Its '
con,,ofi vn of soil ,
signs of hydraulic failure, level of ponding,
:ion of vegetation, recommendations for maintenance or repairs,etc. )
COLS (locate cn site plan) :
✓ and configuration
-top of liquid to inlet invert
of solids layer
of sour. layer
signs of cesspool
ials of construction
atior, of groundwater
ow (cesspool must be pumped as
of inspection)
en`s' . tio , signs of hydraulic failure, level of ponding,
condition e.
.t ion of vegetation, recommendations for maintenance or repairs,etc. )
r:
i• e cn site plan)
rials of construction
nsions
h of sclids
eats : ondin
e condition of soil , signs of hydraulic failure, level of ponding,
ition of vegetation, recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOASRAT SYSTEM INSPECTION PORM
FAILURE CRITERIA
.e yes , no, or not determined (Y, N, or ND) . Describe basis of
.nation in all instances. If "not determined" , explain why not)
ickup of sewage into facility?
ischarge or ponding of effluent to the surface of the ground or
arface waters?
tatic liquid level in the distribution box above outlet invert?
iquid depth 'n cesspool <6" below invert or available volume< 1/2 day
low?
equired pur..ping < times or more in the last year?
unber of tines pumped
',eptic tank is metal? cracked? structurally unsound? substantial
.nfiltration? substantial exfiltration? tank failure imminent?
:s any portion of the SAS, cesspool or privy:
'elm: the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone 1 of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, pot the SAS) ?
70 t
within 50 feet of a private water supply well?
r
less than 100 feet but greater than 50 efrom
lasprivaIe waterell
supply well with no acceptable water quality if well water analysis
has been analyzed to be acceptable, attach copy
for colifort bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
C Inspector Fred /C/lbs
y Name
f:iias Enierpris es Inc
// m Aro Jens 7 gA• oiCa
2
y Address ( ry Pr a �o`zG✓
/cation Statement
ify that I have personally inspected the sewage ,disposal system at
ddress and that the information reported is true, accurate and
to as of the tine of inspection. The inspection was performed and
commendations regarding upgrade, maintenance and repair are
tent with r..y training and experience in the proper function and
nance of on-site sewage disposal systems.
one:
have not found any information which indicates. that the system fails
o adequately protect public health or the environment as defined in
10 CMR 15. 303 . Any failure criteria not evaluated are as stated in
he FAILURE CRITERIA section of this form.
have determined that the system fails to protect public health and
he environment as defined in 310 CMR 15.303 . The basis for this
eterminaticn is provided in the FAILURE CRITERIA section of this
orm. //
'tor s Signature
'/i9 /95
lal to system. owner 1-1 LI
0
i to: 504 rd thAid
(if applicable)
Dying authority
Kur/ /J la h 4