HomeMy WebLinkAboutTitle V Inspection Report - 544 FOSTER STREET 10/26/2000 "I
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS p°
a d DEPARTMENT OF ENVIRONMENTAL PROTECTION :
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: may' Fpm►'E r2 S ace�T
o 2'r1-t --AAJ DaJC(2
Owner's Name: tt <sL ,-w ^ M.-c�Sa� �'�
Owner's Address:
Date of Inspection: 2b 0 .
Name of Inspector: (please print) '?7EIVS-A u.2 C C9s� at5 s 2'
Company Name: IVG ✓ N(r4►4,N G► �'�Gt��'�� ��'''
Mailing Address: 012AVC
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Telephone Number: �i ZB--b-6 6 1 703
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 the inspection.The inspection was performed based on my
training and experience in;the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Date: 6 J _
Inspector's Signature � + it
The system inspector shall submit a copy'of this inspec'on report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.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 the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the Time of inspection and under the conditions of use at that
I
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
,rM
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWA:GV,DISPOSAL:SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
'ROPER`I'Y ADDRESS: 544 FOSTER ST.
NORTH ANDOVER,MA
DWNER:WASHINGTON`MUTUAL
BANK
DATE OF INSPECTION: 10/26/00
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of'Section D
System Passes:
I have not found any information which indicateds that any of the failure criteria described in 310 C
15.303 r in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditional Passes:
One or more system co onents as described in the"Conditional Pass"section need to be replaced or
repaired;The system,upon comp tion of the replacement or repair,as app ved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N, )in the for the fo owing statements.If"not determined"please
explain.
The septic tank is metal and over 20 yea old*or e septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or gxfil do r tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic t as approved by the Board of Health.
*A metal septic tank will pass inspection if it is c rally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years'o is avai ble.
ND explain:
Observation of sewage ba p or break out or high stati water level in the distribution box due to broken or
obstructed pipe(s)or:due to a ken,settled br uneven distribdtio box.System will pass inspection if(with r
approval of Board ofiHeal
broken pipe(s)are replaced
obstruction is removed
distribution box is leveledor replaced
ND'explain:
e system required pumping more than 4 times a year due to broken or obs cted pipe(s).The system will
pas spection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
i
ND explain:
Titlr S Tncnrrtinn Form 6/15/2000 2
Page 3 of 11
Y.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNV }
PART A
CERTIFICATION(continued)
i UFhKIY AU1JKhJJ: '44 YON MR N1.
NORTH ANDOVER,MA
OWNER:WASHINGTON MUTUAL
BANK
)ATE OF INSPECTION: 10/26/00
C.' Further Evaluation is Required by the Board of Health: /
i
Conditions exist which require further evaluation by the Board of Health in order/to/determine if the system
is failing o protect public health,safety or the environment.
1. System ill pass unless Board of Health determines in accordance with` 10 CMR 15.303(1)(b)that the
system is t functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or ivy is within 50 feet of a surface water
_ Cesspool or pn is within 50 feet of a bordering vegetated wetland or a salt marsh
j;
2. System will fail unless the Board o ealth rid Public Water Supplier,if any)determines that the
system is functioning in a manner that p tect the public health,safety and environment:
_ The system has a septic tank and so' sorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a s rface ater supply.
_ The system has a septic tank d SAS and SAS is within a Zone 1 of a public water supply.
The system has a septic t nk and SAS and the S is within 50 feet of a private water supply well.
The system has a se c tank and SAS and the SAS is s than 100 feet but 50 feet or more�&om a
private water supply we **.Method used to determine distanc
**This system passd1s if the well water analysis,performed at a DEP c feed laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free fro ollution from that facility and
(; the presence Qf ammonia nitrogen and nitrate nitrogen is equal to or less than pm,provided that no other
failure icriteria are:triggereo.A copy of the analysis must be attached to tliis form.
3. Other:.
T;tl, S Tnznf-.r.tion Form 6/1 S/?Ooo 3
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Page 4 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACk SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A t '
CERTIFICATION(continued)
&UPEK'1'Y ADDRESS: 544 FOSTER ST.
NORTH ANDOVER,MA i
)WNER:WASHINGTON MUTUAL
BANK
)ATE OF INSPECTION: 10/26/00
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D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_,Z'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
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of 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 1 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 well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform 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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria-exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. a Systems:
To be con ' red a large system the system must serve a facility with a klesign flow of 10,000 gpd to 15,000
gpd.
You must indicate ei `des"or"no"to each of the following:
(The following criteria app large systems in addition to the criteria ab
+
yes no
_ the system is within 400 feet of a s ce g water supply
the system is within 200 feet of Wary to a ace Drinking water supply
the system is locat a nitrogen sensitive area(Interim ahead Protection Area—IWPA)or a mapped
Zone II of a is water supply well i
I f
If you hav swered"yes"to any question in Section E the system is considered a sr 'ficant threat,or answered
"Yes" - Section D above the large system has failed.The owner or operator of any large s em considered a
significant threat under Section E or failed under Section D shall upgrade the system in accor with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11 niti
� V
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURI�A'rCE SEWAGE DISPOSAL SYSTEM INSPECTION FORM;
1 PART B '
CHECKLIST
&OPERTY ADDRESS: 544 FOSTER S'1'.
NORTH ANDOVER,MA
` )WNER:WASHINGTON MUTUAL
BANK
)ATE OF INSPECTION: 10/26/00
f _
Check if the following have been done. You must indicate`yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
''—Were any of the system components pumped out in the previous two weeks?
v'-"Has the system received normal flows in the previous two week period?
v,`' Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
f Were all system components,excluding the SAS,located on site?
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_
_----was!the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
I i
Yes - Existing information.For example,a plan at the Board of Health.
`/Determined in the field(if any of the failure criteria related to Part C is jat issue approximation of distance
is unacceptable)(310 CNN 15.302(3)(b)]'
Title S rncn(-rtion Form 6/1 sonnn 5
Page 6 of 11' `
:1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS �
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C X
IROPERTY ADDRESS: 544 FOSTER ST.
SYSTEM INFORMATION
NORTH ANDOVER,MA
i OWNER:WASHINGTON MUTUAL
BANK
DATE OF INSPECTION: 10/26/00
-- - ---J-- - -- --- -- FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): _
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:_Q_
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):� [if yes separate inspection required]
Laundry system inspected(yes or no): -!
Seasonal use: (yes or no):
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): I✓'O
Last date of occupancy: u✓Ak,Aowr
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(sea0persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: u N V_t-C N
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic-Link,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,'if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1a(1� y
Were sewage odors detected when arriving at the site(yes or no):A "D
Title 5 Insnection Form 6/15/2000 6
Page 7 of I I trf
2.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS,
§UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'ROPERTY ADDRESS: 5.44 FOSTER ST.
NORTH ANDOVER,MA `
OWNER:WASHINGTON MUTUAL
BANK
DATE OF INSPECTION: 10/26/00
BUILDING SEWER(locate on site plan)
Depth below grade: `
Materials of construction:-Zcast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
Pp- iA Cap S Lo,S,KN. t h�,set7ti�1
SEPTIC TANK:_(locate on site plan)
.,-I
Depth below grade: 145
Material of construction: ✓concrete_metal_fiberglass___polyethylene
—other(explain)
If tank is metal list age:— Is age confirmed by'a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: l o z o G-a L�w rJ 5
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How were dimensions determined:
Comments(on pumping recommendations,,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,:evidence of leakage,etc.):
i GREASE TRAP; (locate on site plan) i
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions: lk
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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
t �
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11 ' p
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS K.F°
l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "
PART C '
SYSTEM INFORMATION(continued)
'ROPEKI'Y ADDRESS: 544]KOSTER ST.
NORTH ANDOVER,MA
OWNER:WASHINGTON MUTUAL
BANK
DATE OF INSPECTION: 10/26/00 —
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete__metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
1 L n U nc�
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, condition of pumps anal;appurtenances,etc.):
Title 5 Insnection Form 6/15/2000 8
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Page 9 of 11
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OFFICIAL.INSPECTION:FORM—NOT FOR VOLUNTARY ASSESSMENTS
SU$SURFACE SEWAGE DISPOSAL!SYSTEIV�INSPECTION FORM:
PART C � .
SYSTEM INFORMATION(continued)
'ROPERTY ADDRESS: 544 FOSTER ST.
NORTH ANDOVER,MA
DWNER:WASHINGTON MUTUAL
BANK
DATE OF INSPECTION: 10/26/00
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches number, length: r p( jae � 5
leaching fields,number, dimensions:
overflow cesspool,number:
innovativeWternative system Type/name of technology:
Cd'nments(note condition of soil,signs of hydraulic failure,level of ponding,'damp soil,condition of vegetation,
etc.): t 1 / I
S '5 r<.,� hP�u,� wC-k4. Y��ak 2le✓�.f �.� i Cz&ac v/J
CESSPOOLS:ff (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,sign$of hydraulic failure, l�vel of podding,condition of vegetation,etr,.):, I
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Title 5 Inspection Form 6/15/2000 9
f1p�
Page 10 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
s r...
PART C
SYSTEM INFORMATION(continued)
'ROPERtY ADDRESS: 544 FOSTER ST.
NORTH ANDOVER,MA
DWNER: WASHINGTON MUTUAL
BANK
DATE Of INSPECTION: 10/26/00_
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
C�1
h�
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Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM r
y f PARS' C i
'ROPERTY ADDRESS: 544 FOSTER TEM INFORMATION(continued)
NORTH ANDOVER,MA
DWNER:WASHINGTON MUTUAL
BANK
DATE OF INSPECTION: 10/26/00
- -SITE EXAM---- -- --- — --
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Title 5 Inspection Form 6/15/2000 I 1