HomeMy WebLinkAboutTitle V Inspection Report - 1312 SALEM STREET 10/31/2009 f�
commonwealth ; f Massachusetts pp pry
x Title 5 Offic"al Inspection Form
Subsurface Sewage Disposal stem Form Not for Voluntary Assess ent
p y
1312 SALEM ST REE -_ ---- --- r rte- r t t --
.
i�roperty Address
GAY NEiLSON
Owner owner's Name
information is Notch Andover MA 01645 10/31/09 °
required for — - - —
every page. Cityrrown State Zip Code Gate of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered In any
way. Tease see completeness checklist at the end of the form.
Impaortant: r Information
When filling out "
forms on the
computer,use 1, inspector:
only the tab key
to move your Benjamin C. Osgood, Jr. ----
cursor-do not Name of Inspector ---_�-- -----_-_--use the return
key. none __ --------.—.---- — —-- -
Company Name
Q 224 Migh -
Company Address
6M NewburY� --------------- MA -- ------- 01950 -- — -
Cityrrown state Zip Code
976-255-2261 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 S(310 CMR 16.000).The system-.
® passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
--- _—_ 10/31/09----- - -
Inspeot s Signature date
The system inspector 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 DER 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.
Commonwealth of Massachusetts
Title 5 r
Subsurface Sewage Disposal System Form_Not for Voluntary Assessments
1312 SALEM STREET
Property Address
GAY NEILSON
Owner Owner's Name
information is North Andover MA 01846 10/31/09
required for State Zip Code Date of Inspection
every page. Cityrrown
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes.
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 16.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally 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 a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form A Not for Voluntary Assessments
�< 1312 SALEM STREET
Property Address
GAY NEILSON
Owner Owner's Name
information is North Andover MA 01845 10/31/09
required for
every page. GityR'own State Zip Code Date of inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form®Not for Voluntary Assessments
y< 1312 SALEM STREET
Property Address
GAY NEILSON
Owner Owner's Name
information is North Andover MA 01845 10/31/09
required for State Zip Code Date of Inspection
every page. Cityrrown
B. Certification (cont.)
2. System will fall unless 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:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply. 1
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for ail inspections:
Yes No
El Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® 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
Commonwealth of Massachusetts
Title 5 Official
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1312 SALEM STREET
Property Address
GAY NEIL.SON
Owner Owner's Name
Information is North Andover MA 01845 10/31/09
required for
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cunt.)
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 to 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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1312 SALEM STREET
Property Address
GAY NEILSON
Owner Owner's Name
information is North Andover MA 01845 10/31/09
required for State Zip Code Date of Inspection
every page. Citylrown
C. Checklist
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?
® ❑ Has the system received normal flows in the previous two week period?
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?
❑ 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?
® 11 information 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:
® ❑ 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 at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design):
4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
440
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form Not for Voluntary Assessments
fi
1312 SALEM STREET
Property Address
GAY NEILSON
Owner Owners Name
information is North Andover MA 01845 10/31/09
required for State Zip Code Date of Inspection
every page. City/Town
D. system information
Description:
4
Number of current residents:
Does residence have a garbage grinder? ❑ Yes 0 No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
current
Last date of occupancy: bate
Commerciallindustrial 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 ❑ No
Water meter readings, if available:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1312 SALEM STREET
Property Address
GAY NEILSON
Owner Owner's Name
information is North Andover MA 01845 10/31/09
required for State Zip Code Date of Inspection
every page. cityrrown
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
i
General Information
Pumping Records:
Source of information: NOT SINCE NEW
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)
z 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):
Fast Tank
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1312 SALEM STREET
Property Address
GAY NEILSON
Owner Owner's Name
information is
required for North Andover MA 01845 10/31/09
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Built 2005
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1.5
Depth below grade: feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
NIA
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipe new in basement
Septic Tank(locate on site plan):
1.5
Depth below grade: 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
1500 Gallons
Dimensions:
1"
Sludge depth:
Commonwealth of ssachuse
Title 5 Official
t Subsurface Sewage Disposal System Form m Not for Voluntary Assessments
F
1312 SALEM STREET
Property Address
GAY NEILSON
Owner Owner's Name
information is
required for North Andover MA 01845 10/31/09
every page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
N/A
<1
Scum thickness
Distance from top of scum to top of outlet tee or baffle
N/A
Distance from bottom of scum to bottom of outlet tee or baffle
N/A
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 Outlet is Fast Treatment System
Grease Trap(locate on site plan):
Depth below grade: feet
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
Commonwealth of Massachuseft
Title officialInspecti®n orm
t Subsurface Sewage Disposal System Form a Not for Voluntary Assessments
1312 SALEM STREET
Property Address
GAY NEILSON
Owner owner's Name
information is
required for North Andover MA 01845 10/31/09 _
@Very page, City/Town State Zip Code Date of Inspection
D. System Information (cant,)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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 per day
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 ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form o Not for Voluntary Assessments
�~ 1312 SALEM STREET
Property Address
GAY NEILSON
Owner Owner's Name
information is North Andover MA 01845 10/31/09
required for
every page. City/Town 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 N/A
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.):
No D,8ox Pressure distribution system
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.):
Pump and appertinances in good condition Water in pump chamber clear
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form m Not for Voluntary Assessments
1312 SALEM STREET
Property Address
GAY NEILSON
Owner owners Name
required is North Andover MA 01845 10/31/09
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (coat.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
leaching galleries number:
❑ leaching trenches number, length:
leaching fields number, dimensions: 1 -9.51 X 66,
❑ 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 field looks normal No evidence of ponding, 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
Commonwealth of Massachusetts
Title 5 Officlual Inspection Form
Subsurface Sewage Disposal System Form 4 Not for Voluntary Assessments
1312 SALEM STREET
Property Address
GAY NEILSON
Owner Owner's Name
information is North Andover MA 01845 10/31/09
required for
every page. City/Town State Zip Code Date of Inspection
Do System Information (cunt.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction: T
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form®Not for Voluntary Assessments
1312 SALEM STREET
Property Address
GAY NEILSON
Owner Owner's Name
information is North Andover MA 01845 10/31/09
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 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 Ian reviewed: 11-17-05
g p 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:
usgs maps
You must describe how you established the high ground water elevation:
System built 4 feet above ground water
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Fora a Not for Voluntary Assessments
1312 SALEM STREET
Property Address
GAY NEILSON
Owner owner's Name
Information is
required for North Andover MA 01845 10/31/09
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
Commonwealth of Massachusetts
Official Title 5
t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yr 1312 SALEM STREET
Property Address
GAY NEILSON
Owner Owners Name
information is
required for North Andover MA 01845 10/31/09
every page. CitylTown State Zip Code Date of Inspection
D. System Information (coot.)
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
COW-MEP, .-[
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LEACF4 I nt C, PAC 11"1TY 24
elleC iaie, Pamela
From: Sawyer, Susan
Sent: Wednesday, October 21, 2009 11:24 AM
To: DelleChiaie, Pamela
Subject: FW: Title 5 Inspection for home resale
From: Golden, Claire (DEP) [mailto:Claire.Golden @state.ma.us]
Sent: Wednesday, October 21, 2009 11:18 AM
To: Sawyer, Susan; theneilsons @comcast.net
Subject: RE: Title 5 Inspection for home resale
Gay and Susan,
When there is an alternative technology included as part of a septic system, the alternative technology, in this case a
FAST unit, is inspected twice yearly. However, this inspection does not qualify as a system inspection as required by 310
CMR 15.301 of the State Environmental Code. This is because the alternative technology is but one part of the septic
system. The building sewer, pump chamber and soil absorption system (the leaching area)will also need to be
inspected. When the System Inspector inspects your system s/he will include with the inspection report a copy of the
most recent FAST inspection form.
I hope that this clarifies things for you. If you have any additional questions, my contact information is found below.
Claire
Claire A. Golden
Environmental Engineer TV
Watershed Permitting Program
MassDEP/NERO/8RP
2058 Lowell Street
Wilmington, MA 01887
direct: 978-694-3244
fox: 978-694-3498 or 978-694-3499
claire. olden @state.ma.us
From: Sawyer, Susan [mailto:ssawyer @townofnorthandover.com]
Sent: Wednesday, October 21, 2009 11:11 AM
To: 'Golden, Claire (DEP)'
Subject: FW: Title 5 Inspection for home resale
Hi Claire, Below is a question from a resident. I scanned the inspec. Section of title V and found no real reference to
answer this. Can you help?
Thx
Susan
1
From: Gay Neilson [mailto:theneilsons @comcast.net]
Sent: Wednesday, October 21, 2009 10:53 AM
To: Sawyer, Susan
Subject: Title 5 Inspection for home resale
Hi Susan,
I left a voice mail this morning, and then discovered I still had your email in my contacts list, so I'll elaborate on the
message.
You may remember my Septic System replacement which began in 2005 and was completed in 2006, the final certificate
(for tax purposes), was generated in 2007. It was a long ugly process!
We are moving to New Hampshire and preparing to put the house on the market. I know I will need to pass a Title 5
inspection. We have one of those"FAST" systems that is inspected twice per year by Wastewater Treatment Systems.
It was last inspected in May and I expect it will be inspected again in November. The paperwork I get from the inspection
includes a"DEP Approved Inspection and O&M Form for Title 5 1/A Treatment and Disposal Systems". Is this the same
as, or the equivalent of a Title 5 inspection? Will I need a separate inspection, or will this be sufficient?
Can you call or email me to confirm what I will be required to provide as sufficient evidence of a successful Title 5
inspection?
Many thanks,
Gay Neilson
978-807-5122 (cell, always available)
2