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Home My WebLink AboutTitle V Inspection Report - 1550 SALEM STREET 9/10/2014 � | C��00K�K��w��h �f��h�� / U ~ Title 5 Official Inspection Form U � ' Subsurface Sewage Dispmsa| SystemmFornm - NoLforVo|unbaryAsoesomonCa \~ 155O Salem St�� Property Address | Pamela Smith � Owner Owner's Name information i's ' required for every NAndover MA 9/10C2014 page. City/Town State Zip Code Date ofInspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist mtthe end of the form. Important:mv � A. General Information �� filling out forms ~ ~~^^`~^~^ ^^ ^^^^~~ ~'`^ on the computer, use only the tab 1� � �y»nmovvyou Inspector: . cursor'wnot David Chandler use the return | key Name of | Sewer Works � Company Name `---� 2M Hillside Ave. Company Address VVesMbvd MA 01880 ------- city/Town State �ip000e 978'682-4410 S137 Telephone Number License Number B. Certification | certify that| have personally inspected the sewage disposal system ot 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 ayek*ma. | am m OEP approved system inspector pursuant to Section 15.340 of Title 5 (310CK8R15.000). The system: F] Passes [] Conditionally Passes Fails � � [] Needs Further Evaluation by the Local Approving Authority � 9-1-4' -,�, "e', 9/10/2O14 Inspector's-6ignature Date The system inspector shall submit o copy of this inspection report to#heApprovinAAuthordy (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 DER The original should be sent to the system owner and copies sent to the buymr, if applicable, and the approving authority. °°°°This report only describes conditions mt the time wf inspection and under the conditions ofuse at that time. This inspection does not address how the system will perform in the future under the same or different conditions ofuse. mms.uxo Title o Official Inspection Form:Subsurface Sewage Disposal System'Page,m,r � " Commonwealth of Massachusetts Title 5 Official Inspection Form s� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ❑. 1550 Salem St Property Address Pamela Smith Owner Owner's Name information is required for every N Andover MA 01810 9/10/2014 — — ---------- --- — -- — page. City/Town State Zip Code Date of Inspection B. Certification (cant.) ❑ 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 CHAR 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 1~I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15S0 Salem S( Property Address Pamela Smith � Owner Owner's Name � information i's required for every NA»do«e' 1yy\ (01{y10 9/10/2014 page. mtynown mnos Zip Code Date u,Inspection B. Certification (cont.) Yee No Required pumping more than 4times in the last year NOT due bzclogged or �~ obstructed pipe(s). Number of times pumped: ____. [] E Any portion of the SAS, cesspool or privy is below high ground water elevation. | El E Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary toa surface water supply. El E Any portion ofe cesspool or privy ie within m Zone 1 ofm public well. � E] F� Any portion of cesspool or privy is within 50 feet ofa private water supply well. [] M Any portion of o cesspool or privy is |eae 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 mtaDEPcertified laboratory,for fecal ou|ifornm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal tpmr less than 5 ppnm, provided that no other failure criteria are triggered. A copy of the analysis and chain mf custody must bmattached to this hmrrn.] El E The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. [] The systenmf�0s. | have determined that one or more wf the above failure criteria exist as described in 310 CMH 15.303. therefore the system fails. The system owner should contact the Board of Health (o determine what will be necessary to correct the failure. E> Large Systems: To be considered a large system the system must serve o facility with a | design flow of 10'008 gpd to 15,000 Opd. � � For large myahemm, you must indicate either"yes" or"no" to each of the foUowing, in addition to the � questions in Section D. | � Yes No El [] the system is within 400 feet ofe surface drinking water supply El F� the system is within 200 feet ofm tributary to a surface drinking water supply � � �� the system is located in e nitrogen sensitive area (Interim Wellhead Protection ^~ Area— |VVPA) or mapped Zone || of public water supply well If you have answered ^yae^ to any question in Section E the system is considered a significant threat, or answered "yes" in Section O above the large system has failed. The owner oroperator of any large system considered a significant threat under Section Eorfailed under Section O shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office wf the Department. t5ins-3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i - - — Subsurface Sewage Disposal Systern Form - Not for Voluntary Assessments 1550 Salem St Property Address - Pamela Smith Owner -.. -._.- --- -- - Owner's Name information is required for every N Andover MA 01810 9/10/2014 .....---- - -- - — .....--------- page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gp d))� private well Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date 3 Date Commercial/Industrial Flow Conditions: Type of Establishment: ---- --- - - Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): ------- - Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ Na Water meter readings, if available: -- t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 '....... ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal SyshmmnFormm -NotfbrVo|untaryAoaeeamentn 155O Salem St Property Address � | Pamela Smith Owner Owner's Name � information is ' required for every NAnduver MA 9/10/2014 page. oityn»wn State Zip Code Date ufInspection D. System Information (Cont) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels ae related 10 outlet invert, evidence of leakage, etoj: � � � Tight orHolding Tank (tank must be pumped cd time of inspection) (locate on site p|an): Depth below grade: Material of construction: F-1 concrete [] metal F-1 fiberglass El polyethylene F] other(exp|ain): Dimensions: Capacity: ou|wno Design Flow: gallons xuay Alarm present: [] Yes [] No Alarm level: Alarm in working order: El Yee [] No � Date of last pumping� � oat e / � Comments (condition of alarm and float switches, *tcJ: °Attach copy of current pumping contract (required). Is copy attached? Ej Yea F-1 No t5i" 'xnx Title s Official Inspection Form:Subsurface Sewage Disposal System'Page``m,, / ` Commonwealth of Massachusetts = ~tU 5 Off°B ~ 0 Inspection Form Subsurface SexxageDisposafSymhmmmFornm - NotforVu|untoryAemeemmento 155O Salem S1��_ Property Address Pamela Smith | Owner Owner's Name information is required for every NAndo«er MA page. City/Town State Zip Code Date n,Inspection D. System Information (cont.) Type: 0 leaching pits number F-1 leaching chambers number F� leaching galleries number: ' | | [] leaching trenches number, length: / F] leaching fields number, dimensions: [] overflow cesspool number: [] innuve(ive/a|hernetivomyatem Type/name oftechnology: Comments (note condition of soil, signs of hydraulic failure, level ofponding. damp eoi|, condition of vegetation, etc.): gravelly soils mbeervad, no signs of hydraulic failure, no ponding, grass over leaching area with trees onedges. Note: hand_dug into ld b d cleandrysoils and eto Cesspools (cesspool must be pumped ae part of inspection) (locate on site p|on)� � � � Number and configuration Depth—\op of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions ofcesspool Materials ofconstruction Indication of groundwater inflow [] Yee [:1 No wm".xno Title s Official Inspection por=.o"bs"n"cen°°ag°o."po"a/o=*m'rag°mof`r � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ........... 1550 Salem St Property Address Pamela Smith Owner Owner's Name information is required for every N Andover MA 01810 9/10/2014 page. City/Town State Zip Code Date of Inspection D. System Information 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: F-1 hand-sketch in the area below drawing attached separately t5ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts r6 Title - - Subsurface Sewage Disposal system Form o Not for Voluntary Assessments �l n 1550 Salem St Property Address Pamela Smith Owner Owner's Name information is N Andover MA 01810 9/10/2014 required for every - ----- —---—---...------------------------- ---- --- ------ -— page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form m Not for Voluntary Assessments 1550 Salem St Property Address Pamela Smith Owner Owner's Name information is required for every N Andover —---------------------- MA 01810 9/10/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed 1970 Were sewage odors detected when arriving at the site? ❑ Yes E No Building Sewer(locate on site plan): Depth below grade: 191. — feet --------- Material of construction: E cast iron F-1 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): ----------------- ---—-—----------- -------------- ...... ------------------- —------ Septic Tank (locate on site plan): Depth below grade: 9 ----11 —-------- feet 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: 5,x8, Sludge depth: 10, -I---------- !Sins 3/13 Tille 5 Official inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 ED (D CD { rte' i� CD IF-j °s {3h t Ti cD 3 CD _0 l s7} W 3 {U 3° -1- o D CD o �� ri CD 3 (JI 0- {�7 0 ® m cG Q CD CD LT, LO (D 3 {p 3 C tra CD Ul 3