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Home My WebLink AboutTitle V Inspection Report - 1020 SALEM STREET 10/30/2013 Commonwealth of Massachusetts M Subsurface Sewage Disposal System Form ® Not for Voluntary Assessments 1020 Salem Street .�°� ; "01 Property Address ��d h�k ti. i t�ia;w�a;u~t� r fl LP =n14 ii Anthony Warren iE _u DE 1 F -------------Owner Owner's Name information is required for every North Andover MA 01845 10-30-2013 _ _._ page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When aural Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not oo Benjamin C. Osgood Jr. use the return Benjamin � - - key. Name of Inspector Pennon)Associates ,ee Company Name 13 Branch Street 111111 . --- __.. Company Address �n North Andover MA 01845 — - — — __ — City/Town State Zip Code 978-749-9929 870 __ ---- - -- - - Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority fns t ' i not 10-31-2013 p or g ure Date The system inspecto shall submit a copy of this inspection 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. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 '.. Commonwealth of Massachusetts ` Title 5 Official Inspection F orm Subsurface Sewage D|sposm|'Systemm Form - Not for Voluntary Assessments 1020 Salem 8tnaat Property Address Anthon VV Owner Owner's Name information is | required for every North Andover MA 01845 10-30'2013 � page. City/Town State Zip Code Date vfInspection B. Certification (cont.) Inspection Summary: Check A,8'C,DorE/always complete all cf Section O ' AQ System Passes: I have not found any information which indicates that any of the failure criteria described / in 310 CK40 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are | indicated below. Comments: � | EM System Conditionally Passes: Fl One nr more system components esdescribed in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repeir, as approved by the Board of Health, will pass. Check the box for^vea . "no" or"not determined" (Y' W, ND)for the following statements. If"not determined," please explain. � Thasaptiobankismeba| endnver2Oyearao|d*ordheaepdctankkmhedhormoba| ornobisobnotunaUy unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. | � °A metal septic tank will pass inspection if it is structurally sound, not leaking and if Certificate of Compliance indicating that the tank is |emm than 20 years old is available. [l Y F1 N El ND (Explain be|ow): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Off"Icial Inspection Form Subsurface Sewage Disposal System Form ® Not for Voluntary Assessments 1020 Salem Street Property Address Anthony Warren Owner --..._— ----- -- Owner's Name informatics is North Andover .- page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cant.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box, System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection orm Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 1O2D Salem Street Property Address Anthony Warren Owner Owner's Name information i's � required for every North Andover MA 01845 10-30-2013 | page. CityTuwn State Zip Code Date ofInspection B. Certification (cont.) 2. System will fail mn|eee the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: n The system has a septic tank and soil absorption system (SAS)and the SAS is within 1OO feet ofesurface water supply or tributary toa surface water supply. � F-1 The system has e septic tank and SAS and the SAS is within a Zone 1 of public water supply, R The system has e septic tank and SAS and the SAS is within 50 feet ofa private water supply well. F] The system has a septic tank and SAS and the SAG is less than 100 feat but bO feet or more from m private vvetar oupp|ywe||°*. � Method used tn determine distance: � This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal co|iform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or|nas than 5 ppm, provided that no other failure criteria are triggered. A copy ofthe analysis must be attached to this form. 3. Other: � O0 System Failure Criteria Applicable tmAll Systems: You must indicate'"Yea" or"No"to each of the following for all inspections: Yee No Fl �� Backup of sewage into facility or system component due to overloaded or clogged SAS orcesspool Fl �� Discharge or ponding of effluent to the surface of the ground or surface waters due toan overloaded nr clogged SAS orcesspool Fl �� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS orcesspool �l �� Liquid depth in cesspool is less than G" below invert or available volume in less �� than 1/2day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1020 Salem Street Property Address Anth ny Warren ----- .............-- Owner Owner's Name information is North Andover MA 01845 10-30-2013 required for every - — _ -- - page. City/Town State Zip Code Date of Inspection B. Certification (coat.) Yes No El ® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® 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 Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 5 of 17 '.. Commonwealth of Massachusetts T°0 w 5 Offi a l I nspec on F orm Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments 1020 Salem Street Property Address Anthony VV Owner Owner's Name information i's required for every North Andover MA O1845 10-30-3013 page. CityrFown State Zip Code Date vfInspection � C. Checklist � � Check if the following have been done. You must indicate"yes" "or no^ aoho each of the following: Yen No Z [l Pumping information was provided by the owner, occupant, or Board of Health Fl Z Were any of the system components pumped out in the previous two weeks? M n Has the system received normal flows in the previous two week period? Fl �� Have large volumes of water been introduced to the system recently or as p� of �� this inspection? �� Fl Were oe built plans of the system obtained and examined? (If they were not | available note ooNA\) * Fl Was the facility or dwelling inspected for signs of sewage back up? * El Was the site inspected for signs of break out? * El Were all system components, excluding the SAS, located on mite? M E] Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the boMlee or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth ofscum? �� Fl 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 ofthe Soil Absorption System (SAS) on the site has been determined based on: Z Fl Existing information. For example, a plan at the Board of Health. �� Determined in the field (if any of the failure criteria related to Part is at issue �� approximation of distance ia unacceptable) [31OCK4Fl16.3O2(5)] | D. System Information Residential Flow Conditions: Number of bedrooms (design): —4 5------- Number ofbedrooms (actual): �--------- 440 DESIGN flow based on310C[WF< 15.2U3(for example: 110gpdx#ofbodrooms>: --------�� 151ns-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F orm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1020 Salem Street Property Address Anthony Warren Owner Owner's Name information is � required for every North Andover MA 01845 10-30-2013 � pogo. Qty/To=n State zip Coda Date ofInspection D. System Information Description: / Number ofourr � 5 ent[esidan � ----- Does residence have a garbage grinder? El Yes M No � Is laundry on a separate sewage system? (Include laundry system inspection �l yes �� No | information in this reporL> �� Laundry system inspected? El Yea M No Semoona| uom? [l Yea H No Water meter readings, if available(lamt2 years usage (gpd)}: Detail: � Sump pump? El Yes N No � current Last date of000upancy� � Date / Conornerc|aNndusdMm| Flow Conditions: Type cfEstablishment: Design flow(baoedon31OCK4R1�203)� ` � � Ga Ion v pa,dvy(QPd) Basis of design flow(eeats/peroons/sqƒt, etc]: Grease trap El Yea [l No Industrial waste holding tank present? EJ Yam [l No Non-sanitary waste discharged to the Title 5 system? El Yes [l No Water meter readings, if available: m/"s.3/13 Title o Official Inspection Form.Subsurface Sewage Disposal System'Page rm`, Commonwealth of Massachusetts Title 5 Official Inspection Form n6 — - Subsurface Sewage Disposal System Form m Not for Voluntary Assessments 1n 1020 Salem Street Property Address Anthony Warren Owner Owner's Name -- — information is North Andover MA 01845 10-30-2013 required for every -_ -_-- _—_ _._-. _.. _. ... - -----------_....------- page. Cltyrrown State Zip Code Date of Inspection D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): - - .. ...... ....... ...... ........ ....... ......_ General Information Pumping Records: Source of information: Pumped 11/23/11 per BOH records Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: _ --- -- gallons How was quantity pumped determined? Reason for pumping: Type of System: ® 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts T"Itle 5 Official Inspection Form Subsurface Sewage Disposal System Form ® Not for Voluntary Assessments tir { - 1020 Salem Street Property Address Anthony Warren Owner Owner's Name information is required for every North Andover MA 01845 10-30-2013 — _ - -- --- page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2 Depth below grade: -- - feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): ---------- -- Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe behind finished walls in basement, Pipe OK in tank. Septic Tank(locate on site plan): 1' Depth below grade: f..eet__.....- ---...........— Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years -_ - ---...-__— Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 ❑� Commonwealth of Massachusetts Title 5 Offulcmial Inspection Form Subsurface Sewage Disposal System Form o Not for Voluntary Assessments A. 1020 Salem Street Property Address — - -- -- Anthony Warren ........- — Owner Owner's Name information is North Andover MA 01845 10-30-2013 required for every _—_—— ------ page. City/Town State Zip Code Date of Inspection D. System Informati®n (cant.) Septic Tank(cant,) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness <1 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measure Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition, liquid level normal, sch 40 PVC tees mood condition. Grease Trap(locate on site plan): Depth below grade: f e e It ........ ......... ....... Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 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: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Offidal Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1020 Salem Street .......................................................................................................................................................... Property Address Anthony Warren Owner Owner's Name information is required for every North Andover MA 01845 10-30-2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ------------- ....... .................... . .......... --------111,11,............. ----------------------------------------------- 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: gallon s per day .ay ------------------------ --------------------------— Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ........... — - - ------------- ---- ———----—----------------------- -------------------------- ----—------------------------ ---............ Attach copy of current pumping contract(required). Is copy attached? ❑ Yes [:1 No 15ms•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts ................... Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1020 Salem Street ----------------------- ............................. --------- .. ...............................................-- ----------- . .............................................................. ............... Property Address Anthony Warren _______ —------------------------------------------------ Owner _..... Owner's Name information is required for every North Andover MA 01845 10-30-2013 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): Box in good condition. No evidence of leakage in or out, distribution equal. Depth below gra,de ................, . . . ...................... ------------ ..........--................- ------------- --—--—--------------------- ------------ ------------- ................. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): . ................ ........ --—- ----–---------------------- ------ ............... ------------------ ........................................................................... If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ............... ............... - -----................ ................. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form ® Not for Voluntary Assessments 1020 Salem Street - ---------- Property Address Anthony_Warren Owner Owner's Name information is North Andover MA 01845 10-30-2013 required for every _ -.-- ----- - ----.--- page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2-2'deep x 3' wide x 60' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: ........- ---------------- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of leach trenches looks normal, no pondin , damp soil, or unusual vegetation. Cesspools (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 ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Farm - Not for Voluntary Assessments 1020 Salem Street .. Property Address Anthony Warren -....— - _ Owner — Owner's Name information is required for every North Andover MA 01845 10-30-2013 __._. ------__ page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 '..... (zo_\\ Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Farm ® Not for Voluntary Assessments 1020 Salem Street _ Property Address Anthony Warren Owner ------ Owner's Name information is North Andover MA 01845 10-30-2013 required for every — --- _ — - page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately P . C Z T t>"i V"1 air law., m v., � m> J r1; l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form m Not for Voluntary Assessments 1020 Salem Street ......................... ....... . Property Address Anthony Warren -----------------------------—------------- -- -- Owner Owner's Name information is required for every North Andover MA 01845 10-30-2013 ............. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water Check cellar Shallow wells Estimated depth to high ground water: 6' —-------------- _---- feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 1 Date 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: Soil evaluation for original system design performed by this inspector ............................................................ .. ................ ........................................ ........- --- ------------------------- ----------- -------------- —----------... .... ................................................................................ ........................ ............ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Offolcolal Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1020 Salem Street -- ------------------------------------- .................... Property Address Anthony_Warren Owner _.. _ ---- - Owner's Name information is required for every North Andover MA 01845 10-30-2013 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist M inspection Summary: A, B, C, D, or E checked M Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Z System information- Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17