--~----

o.

Commonweatth Of Massachusetts . t~~~~ Exec'Jlive OffiCe of Environmenl01 Affairs

D~,-artment 0' E;lvironmental Protection D E ~p'.;

IVBSlJRFACE IEWAGE DIllPOIAL IYITEM INIPBCTIQI'I PORM

L J c.q~q/ofJ2 ..... s C "'-v'.s"tO" PI F I)A.w-/~ -r ... i H ..... '" t.:JQ.'I' 0&1 .. '1.1 lWa:oc.4 q 199(' )II ... ,., ~Iow: c..... "'1 ~ ; sse I f c....." NUDe, Add,.... .... id Telephone Number:

PART A ~

CERDD9ATlON

A ...... It."~s l. Md.- ,., 0-.... nfdllf_tl

Affordable Home & Septic Inspection Inc. 342 West Rd, Westfield Ma. 01085.

ClRnncA]]oN UATEMEl'o'T 4 1 3 - 5 6 8 -4 2 8 9

Trud,~ DewIcI .. lInN

Cec .....

I .rtif)o u..t I bo .. ,.rocNlly iDlpt<:~ th ........ cIiopouJ I)' ... m . t ttu. ._ ."d that the wo ...... io~ .. portae! below II u..., _ ADd CI01Ilp1ete AI of lb, tim, of iupeet.jon. Tht: iNlpeetion .u ptrf'ormtd baNd on my ~ and nptrieACI in \be In'OPIf ~ ADd aalJl..".". 0( ~-ci ......... cIiopouJ .,........ Th. """"l'

.lcC'P ..... ConciitioNlly h ....

_ i ·! I fC1I Tu.rthtr EvaJu,tion By the Loc&l ApPl"Ovina Authority ~ Tallo

~ .... I""'t""' ~ ~ Date: Oc-l. q 199(..

'I'lIt s,..... be,*"" UaIl oubmi. a 00P1 ol.tu. iDlpt<:lio~ "port to tho Appr<Mz>i Au.hority wI.hin .hirty (30) dayo of _pI....., tlIiI iDIJ 7;" Utho.,.... .. II •• huod.,.... .. or boo. d .. ip oowor 10,000 IIPd or _ .. r, tho iIIoptotor cd th • .,.... .. _r .boII_ the .<.,.. .. to the app"",ria" .. poW olli .. or tho DopartmlAt or E.';"''''''.nl~ P~on. :,110 oriCIAII abouIcI be .... to tho .,.... .. own.r aJId oopi" .. nt to tho buyer, If applicabl. aJId tho awr<Mz>i .lIthori.,..

INIP~ON IIt1MMARY:

C~J, C, or D,

AI IYWTIDl PAllEt:

_ ..... '-<1"0:: bow II1II fouad uy wonutioll which in4ioa ... that tho .,.... .. 'rioJa ... uy or tho ~ critma' u do4Ded ill 310 cam 150303 . .., failwoo critoria DOt ..aIuatad oro iJ>clicatad bolow. .

. WI IYITDI COJilDmONAl.oLY PAlSU:

Jaotioata ,., .... ar "'" _rmiDed /y, N, OT NIlI. Doocribo wit or dotonolna.ioo iJ> all........... It_ dotoraiM4", .plaiD why II1II)

'.

_ - on.. 'Mptie taaIL II mota!. aoaekod, ~1 """"",d •• ho .. oubotaJl.ial inIIItrauoo or odIItre.ion, ..... taaIL faiIuroI it .......... t. 'I'bo.,.... .. w!Ilpaao iDopt<lion if .h ... itt"" oeptic taIIk II ropJatad wI.h. ~orminr aoptie taaIL .. .,,:0:04 . by tho Jou,j or HatJ\h.

( ..... '.Id ,,'113195> I

OM WI"te< IIFNI • Io.,on, M ..... chu .. tt. 0210a • ,~ (117) 156-104. • T.leph_ (117) 112-Il00

SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A

CERTlnCATlON (OODUnued)

... , itiAdd"CC J';k -r ...... ~ (\.i~ OwDor: C ... ~,."",c9......-? Date .rI .. _U.... 10 _"\

IjlYlTEM CONDmONALLY PASSE'S ( ..... w.uo4)

...... backup or broaIrout orlUp oIabe wow .... 1 ,~. i .04 in the cIiJtributIcna ... iJ .............. or oIub :1" piJJo(.)

........... broken, _ or ....... D <IiotrilMl=.... "not.,..,m will _ iDIJ>oetioD II (willi .ppI'IIftI of. loud or !IMlth):

....... plpol.) art..,­_ oIutnIctioD"-..! _ cIiJtributIcna boo " IovoIIod or ..,Ia*

"not .,...,. nqWPod pump..., _ u.u tcnu _ • ,... .... 10 brobD .. oIut ........ pipol.). "not.,..... will _ iDlJIOCI.ion II (with .pproval 01 \be loud or Health),

..... ken pip'c,) aN Nplaood _ oIumIctioD iJ ....... 04

C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH,

___ ConditioDJ _ "bleb I'Iq\IIJ't fwoth.r .. a1uation by tho Boar<! or H.aIth in mler 10 c1t1mllill. It tho .,..... iJ WliDc 10 P""oICI the publie lIo.aIth, uJ"7 ... d tho .nvUolUiI.nt.

I) SYSTEM WILL PASS tJNL&!IS BOARD OF HEALTH DETERMINE!! THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WRICS WILL PROTECT THE PtJBUC HEALTH AND SAFETY AND THE ENVlRONMEPrn

c:...pool ar PMOI)' it within 60 , .. t or • wrtact water C-Opool .. pri.,. iJ within 50 rOft or. _nne .... toted _land or. MIt IIUII'Ih .

I) SYSTEM WILL FAIL tJNL&!IS THE BOARD OF HEALTH (AND PUBUC WATER StJPPUER. IF APPROPRIATE) D!:TI:RMlNES TSAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBUC HEALTH AND SAFETY AND THE ENVlRONMEPrn

• ) OiBLk

"not.,..... boo • ".,.io tank aDd ooU .boorption.,.., ... and iJ within 100 rOft 10. ourl __ .. r IIIWIy .. triINIaJ7 .... ourIaoo -..r oupply. "not .,..,m boo ... ptio tank ... d .. U .boorJ>tion .,..,m and iJ witlWl • Zen. I or. publie _tor ouppq ... 11. "not .,..,m boo ... ptio tank aDd ooU .boorJ>tioD .,.., ... and iJ withlD 50 COft or • p" .... _ .. r ouwly ... 11. "not .,..,m boo ... ptio tank aDd .. U .boorptiOD .,.., .. and iJ .. u.u 100 (Oft but 50 ("" .. _ ""'" • priYato _ "'Wly ... 11. .......... U _ .. r ..w,.iI ror ... lifo.". bacteria toDd YOlatllt 0I'pZIic _pound. 1Ddlca .. tMl the ...u iJ ... ""'" pollutioJa ""'" that £acllrty toDd Iht _DOt 01 AlDlDoDil aitJqoll toDd _to """"" " aqua! ... or ... u.u 5 WID .

_~i------~-------------------------------------'.

SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A

CERTIFICATION (ooaliDued)

DJ i.ilEM FAIL!:

___ I .... ,1, jaed lllal tI>o.,..w", ... \a ....... or "'0" o{lllt (oUowlAr f&ilurt oriI.trio .. cltllaod iD 310 CKR 15.803. '!'lIt ..... ror tIIlI ___ II idaDlilIod btlow. '!'lIt lou:! or HoaltI> IboWd bt _laNe! \0 deIermiDI wbat will lot ~ \.0 _* a.Dun.

DIocbarp or ,.....su., or .mutnt to \lit _co o( \lit .,...w>d or 0IIrl0c0 ... \oro due to an ..... _ or cJospd lAS o. _I .

... tic IiqWd w..l iD 11M cIiotn1nrtioft looI '._ outlot iII .. rt duo \0 OIl ovorloallod 01' cJospd SAS 0. ~1.

LiqWd cltt>th iD ~I iI .... 1lI0II S" btlow ;" .. rt or .voiIabl ... lwo. II .. than 112 da, no ...

JIeqWrod pwoplDt ...... 1lI0II 4 tim.. i:I Ill. lui 10M W duo \0 clop 0' 0_ pipo<.) . Nwobtr or tim. pwopt<! __

M, po!"'tion ot the Soil Abtorpticn S)"It.em. ctupool or J'rivy i.I 0.10'010' lb. hilh I'I"'OW\dww.ter elevation .

Azl, portioo 0(. _pool or privy iI wi.hin 100 ( ... or. Nrlaeo ....... IUpply or .ribuw,. \0 • &IUfact ...... aupply.

Nq portiOtl 0( ..... poel CIT pri\l)' iI within. Zon. I of. publje •• 11 .

M1 porUoD or .... pool or privy iI withm 60 (Nt o( • privat.t ",.&otT INPply WItU.

Azl1 portioo or. _pool or pri'")' iI I .... hao 100 ( ... bu. _ .. r than 60 r ... fro", • priv ........ r IUpply .. U with DO _ptablt ..... r quality iUWyo. . U Ih .... U hu lotto ..w,..td \0 bt aoeop .. bl •.• 1UCh GOp)' o( ... U ..... r ....t,wiI ror ooliCono baetaria, ".\atil. o,....,uc CODlpow>dt ............ 1Ii...,..0 ... d 1li1N" ";"""'0.

1:1 LAROE IYITEM FAILS:

'!'lIt r.UowIAr oriI.trio Ippl, to \arJt .,....,... !o addi.ion \0 .h. m .. rio .bov" Tho .,.... _ • ra.IlIty with • d.;'" no... or 10,000 rpd or _ .. r a-. S,...",) ad tho .,..w", 10 • Dp'ftM ., '-"-t to po>I>Uo

IoaI!th u4 ..roty u4 tI>o 10,.;,0 ...... 01 boca ........ or ....... r tho rouowlAr amdItiau ..... ,

tIIo .,..wID iI wIthiD 200 rat. or. tribu...., \0 I Nrlaeo IIriIIlo:iDc ... tar IUpPJ.y

tI>o .,.... 10 Ioc:atacl !o • 1IiI ..... _iii ....... a..1ariID Wallhaad P ........... Nwa CIWPA) or I _ppad Z- II or. po>I>lic

-1OIPPb' woU)

'!'lIt ........ .-or _ aucb .,.... .. ahaU briDt tho .,..wID ad facility iDlO full _pliuot with tho ___ tar - _

~ ot 11. CKR 5.00 ad '.00. PIaut......wt \lit 100aI ",;cui oI!Ict or tho Dopartmallt (or fI&rtIIotr _Ilon ..

( ... llad 11'03195) s ,

.. 8t1BSllRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTB

CBECKLIST

Pieper., Add 8M I').. ... """t~ I(ilo(",-w~ 0..... C<"SSO><.cQ....o.-o Dale of IMp .U... 10 _ q -'1(,.

~ IAIormatloa .... roqu.....s or tho _. -..,...t. and Jotrd or Hulth.

~JI'_ or \he _ ...... _'" how boo. pumped {or .t lout ."" _Iu and \he .,.... .. boa booD .-MDc _ 0- ..... IIvirIDI that ptriocI. t.rp.., ....... 0( "."'r how DOt boo. iIltroducod iAto tho .,.... ... .-.. tl1 or ........ or t.IIlo iatpoc:tlo".

~ bWlt p ..... ho .. boon .bIaiDad and aamlzlocl. 11' ... j{ u..,. aN DOt .vailable with N/A.

..L"fi,a facility or d_1IiAc .... iAI~ ror .ipa or ....... back·up .

.lC'ho • .,....... Go. .. ot .-iw ..... -..I\&>y .r iIIdlUtrial ...... no",

":;::--n. rile .... iAlpoctad ror .;,no or bNakout .

.,:::--'AiI.,....", "''''po ........ aclu4intl tho SoU Al>oorption S,...m. hayt boo .. localad 0 .. tho .i .. .

--h. .. ptic tack muhol ....... _Nd. .,.ned • ."d .bt in .. ';.r or \he .. pt.i< tack .... iAIpoeWd ror ooditio .. 0( baIIloo or . _ ..... 1iaI or ................. clm.uio .... doptb or Iiqwc!, d.pth or .Judp. depth or ..,..,..

V"'n. .. cc! locat.ion of the Soil AlaecrpUOD S"wm on tiM lit.. baa been thWl"IIII.inec! 'bued 01' ~ Woraat"'~ Of

- opp_ttd '" ..... ·iIltNliw ~ .

.::::--TIll Iadlity ...... r (ud ..... ,... ... j{ di6 ..... t from ....... 1 ..... provided with mt ........ lon on \he proper 1IIIlIl_ 0( 8ub-IurWa DiIpoaaI 8,... ... .

c ... ,.tcf 11/03/95)

-'-I

.. '

; . . '

"I'P!t"AL!

SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECnON FORM PART C

BYlTEM INFORMAnON

FLOW CONDmONS

DMpIow: ,550: ,'lon' ope .... pe'tl'satJ X ..... ", .... o:-!L X .... fII---.t r IS .... .3 O"-" ...... (,·~ ... ):·Ve.s '-*' _'dd to .,.... (,.0 01' .. ):~)

i '

I I

· 1 ;!

! • • !-(,.o ... ):~ / W ....... ~It8'fail&b1t: l~t' f<..( 'Pa ~-\. y av= I~ als. - Q- gd€ db,

O! 0 I 0 00 c.",_ ft . !

x.. .... 01_: C H v_q I'< of "

COMMlRCW,OHDUITBW.: 'J)pe of .... '!:t!'." .. nt:;;:::-::=-_________ _ DMp low: ''''''DIIda, a-vap ..-t: (,.0 01' !>O)_

~ w_ Holdiq Ta.ok _Dt: 11M or DO)_

X .. ....usar, _ ~ to lb. Titl. 5 .,.... ... : 11M 0' no/_ W __ ,......siDp. itaYailabl,, ________________________________ _

1.-_01_:_

0'IlDR:~) 1.-_0I..u~--, ---------------------------------------------------------------

GENERAL INFORMAnON

PtIIIIPIHG It8CORDS aD4 ....",. of iAlormation: 4 '-tg-t99 C - f?Q(..- 0(1),,,0,-- J ~e,.(?/ III

.,... _pd .. pan of iDIpooI.ioD: 11M 0' Do!BO i II 701. OONme _pd, plio ... ___ for _pu." ____________________ __

nnor nai&M ......... Iopdo ~D IaIooU abocl1Jlloa .,....m

__ It.ato~ __ o..Gow~

---:~~.,.... (,.0 OI'!>O) (itJOl,.~ p~ iDlpeclioD.-n\a, it&DJ') __ 0II00r (8pIaIa)_

-' .

i

' .

APPIIOXDlATI: AGE 01 all _poeata, _ iutaIlocI (it _) aD4 ....",. of iDIonoatioD, ______________________ -,

6

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/ i

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1 .1

: ~

': ~ .:

~ I~ , '1 "f : ~ . ~

t , J

:l , , /

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i .: i ;

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arne. TAHK:_ CIoooIo _ ... JIIoa>

~ - pwIa:.aL"

8t1J1BURFACE .EWAGE DISPOSAL 8YSTEM INSPECnON FORM PARTe

8YSTEM INFORMAnON (CIODliDued )

M....w fII_ .71"''= : ~ .. _r-tal_FRP _otber<aplaiD)

...... ~ J-? •. Dlo&a.. *- ... 01 oIudco 10 __ of --. _ 01' b.1Il.:~ ' ___ nkb : A - I h

J)Irt,p= *'- top or ICUa to top of O\ltltt ... or bt.me: (9 t'

~ *- '*- or ....... 10 bottom of --. _ or b.1Il.:.J.f..::...

~--~============~---------------------_'Ncb :_ ~ *- ... at _ 10 lOp or --. _ 01' bUII.:_ Dir' *-__ at _ 10 __ 01--' _ or bUIIt: __

C k:

... -... .;;;-

(j ndaUaa for pwoplDc, _4ition or iDIot ozu! outl.l '"' or b.1Iltt, d'plh of ~quid itY.l in .. !alion 10 outltt in .. rt, IINcOIINl ialil'·.e, . ...... 01 ...... * .) .

4

.... y i: : " ' . .

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'I'IGBT OR BOLDING TANX:_ (IooMo _ .. pIaA)

Do,t.Ia ........ :_

IRIBStJRFACE SEWAGE DISPOSAL SYSTEM INSPECnON FORM PARTC

I'YSTEM INFORMAnON (oo"UZI\.ed)

Ma&erioI lilt _ ........... , _-_~ _TRP _oIIaer<aplain)

,W dx': ____ -::-_________ _

~~-------~p~'~ D-ap ..... ; pllOMl4a)' ...... a...l: __ _

Ce=znt.l: ~ 0( iIlIot 1M, oodi,jo" of aIann ... d !Ioo, "';t.ch .. , _.J

DlITIUBtITIONBOX:..o:::"" (Iocato _ .... pIazo)

DopIIollltliqllida...lIl>ovoCNtltlill .. ,,; C,Ue\! WI bo-\40",- of o<.d \00 ts .

0= t.I: (aoaIo II a...l ...s dio\riIMio" II equal. m.s._ 0( lO~cII O&n1OVOr, ,

PVIIP CILUIIIItR:_

(Iocato - """ JI!an)

..... Ia wwldat -<100 or DO)_

C= I,: (aoaIo ='I!!_ lilt,..., cIaazaI>or, ooDdl<io" of,...,.....s .,P""O....,-, _.) ___________________ _

,

' .

-.. 8UBSURFACE IEWAOE DllPOSAL IInTEM INIPEC110N FORM

PART C SYSTEM INFORMATION ( .... l1li_)

Pi; t)McIrMm I~ -c_~1l\1oo(~ W;. o...r. c. ......... ,,",,-().~ Dele ., I" U"", I 0 _ .. -'1 (,

8OD .. U80RPTION I'ftTDI (8A.!I~ _ _ .......... II~; .... fttioD _ NqI&IN4. 1M _, he "FF .... t.oc! b7 _-_iYo~)

II ..... __ to he _to -V1aiD:

'. "J»a:

C to: (_ .....tru.D .r oou. lipI .r hyQralllie WI ..... . lovel .r pon4inl. ~tioD .r ...... ti .... 01<.)~ __________ _

$6,1 is $0,..,4,. 8tOdff - ,Vb ecl' cOe<y.o of eo"& ' ",

C&iFOOU: _ _ ..... pIu)

M-.aad ..apntlon:-:-_______ _ DasO lOp 01 liquid to _ ia ..... , ______ _ DasOoI_ .. ' ________ _ DasO oI-IaJoor...,.... ________ _ 1)'- 1' .. 01..,...1, _________ _

II&tWJI of ClDDrtraeticD: J ,. He :.t~ ..... ,:: _________ _

\ I

Idoow (..,...1 __ he ,...pod II part .riaopoctio~) _______________________ _

PIIIVI': _ _ ..... JIoa)

""'''''IU'' 1 2'=: DimuaioDI: ----DasO 01 aoIIdo,_ c- -. c_ 1 ...... oIaoII, ..... 01 hyQrallli< WI_. J.ooI 01 POWac. OODdItioa 01 ....... o!e.J, __________ _

(,."I.ocI 11103195) •

" .

-, ' . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECnON FORM PARTC

SYSTEM INFORMATION (OODtlnUed)

a&l:lCB OrlnAGE DISPOSAL 8YITEM: ......... to • IIlut t.WO)Wi 'Milt ref.NACIM laDdmaru or beDCbmaru __ l1li ..u. wblIiD 100'

r

I

tr==·. __ .... = ___ . ____ = .......... == ...... ..

(...,( ... Il/UJ95) •

--

; "

'.

'>,.so ~.

<1~~a ,,' 21A-35-3

210-61

•

" ~ ",

HO

/.' 210·90

\.

\

LO.

~. •

\.,

-1>. • ..

210·70

,"' .. 210-66

.~ "

~ .~

. 4'":- 21A-35-3

~ .t

" ~ 210·176

12 & 18 Trillium Way

Lot Line, .- FClrfNtPropertyline - SubdMslon Lot line

· e_1I o Surrounding Commun

G .... map2009 . Tfa ll$

... Ral Llnu ,,-Guiding FOU'daIion or in const ~orM_ Deck. Pon:I\, Stain or

• MobiIII home. T""ijer . S~PooI

• GuidIrI!l Ruins • Waler 'IO~ Ulnk R ..... rsand Siroams

$lrHml Majot Cuii/o""

-"""'""'" - Ha/Id'W ..... F-*

"""""" e.n.t\ and ICfUb YCiIt" TIM 11M fofHI ~&g&I CoMivlItltdfoeld

"""" '" a_. • Mise ImptlMr:>us Surfa

" ..... Park;.,g P .... ed Parlr:IngU....-ed

Drt.lowlI)'l DrIYI"'ty Pave<:! DriIISWII'I' UnPll'Yltd

~ Sidllwalks

' ........ .. P ....... 111M! poIygorw Unpavtd Ilrwet poIyg ,-

• 8mg. lIoKlr.ing Ind Sir • FOQt BrIr:Ige • Ra~BricIge

Ii<lrrizMIaI Datum. MA Stateplarre CoordiIIatfl Syll8n'I. Zon& 4151 . Dalum NA~J. F8(lt Vertlelll Datum: NAVOI:I8. F_t

P'II!n;1nlI1tIt: & IOpOgraphie basemap I!!ature, eompUed a1 t"-4()' _Ie from Allri. 2009 Ae<IaI PholOlJrtophy. Parcel!; c:on'Ipiled to "",tell the bitse.....,: r8YisIDns ..,. ongoing .

The onIormIIlion depil:tlMton dlis map I!; fof pili"'*'!! purpoon 0...,.. It may no! be adequate tor legal bound"'Y

~. ~lnIerptlltalio". orpn:>pe<ly~i ~. UI~ity.lrucIureoIand"""grouncrlllility IocalIonIllre appro~lrMta 11M requlre!lold ~rx!flcatlon •

THE TOWN OF AMHERST MAKES NO WARRANTIES. EXPRESSED OR IMPLIED. CONCERNIIIK) THE ACCURACY. COMPLETENess. RElI .... BILITY. OR SUlTABn.1TY OF TlfESE DATA. THE TOWN OF AUHERST DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INfORMATION. ~

1"=119ft W a m herstma.gov / maps July 18, 2013

"'/''1/J.Ol~ ' . FOI{~ cq ..-.. ~/d.....'J;/ #~P'/.cJ"KA...( - "'I'{' ctA(I...;":Je~ . d· ... ci.--t , ~ Jtlf"]...- ~ ; (J.(j.o..c.erJ.~ .. p e-ff{(, ... (t. //'1. - (!..L<-t...fa............. ~~ J~ e..Jf!C« 11 .. (/ iVo ~u."'("c !(--(~ ~. 1/Ci:7:.. / A8c)~

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