HomeMy WebLinkAboutTitle V Inspection Report - 300 RALEIGH TAVERN LANE 11/4/2003 Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of Environmental Protection
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TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:300 Raleigh Tavern Ln.North Andover MA 01845
Property Owners Address:300 Raleigh Tavern.Ln.North Andover MA 01845
Owner:Stephanous Loisou
Date of Inspection: 11/04/2003
Name of hvspector:(please print)Bruce Butterworth
Company Name:_ Wind River Environmental
Mailing Address: 577 Main St.Suite 110 Hudson MA 01749
Telephone Number:978-562-4500
CERTIFICATION STATEMENT
I ccrtify 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
Inspector's Signature: Date: / b 0 3
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 repokt—o 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 time.This
inspection does not address how the system will perform in the future under—same or different conditions of use.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A CERTIFICATION(continued)
Property Address:300 Raleigh Tavern I a North Andover MA 01845
Owner:Stephanous Loisou
Date of Inspection: 12/08/2003
Inspection Summary:Check A,B,C,D or E ALWAYS complete all of Section D
System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310
CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
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.
Answer yes,no or not determined(Y,N,ND)in the`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:he 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.
ND explain:
Observation of sewage backup or break out or high static water level in the distribuijon box due to broken or
obstructed pipe(s)or due to a broken,shifted or uneven distribution box.System will pass inspection if(with approval of Board of
Health):
broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced
for the following statements.If not determined"
ND explain:
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
obstruction is removed
Not Determined explain:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A CERTIFICATION(continued)
Property Address:300 Raleigh Tavern Ln.North Andover MA 01845
Owner:Stephanous Loisou
Date of Inspection: 12/08/2003
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.
System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not hinctioning
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
2. System Will fail 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.
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 and volatile organic
compounds indicates that the well is free from pollution from said 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.
Other:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A CERTIFICATION(continued)
Property Address:300 Raleigh Tavern Ln.North Andover MA 01845
Owner:Stephanous Loisou
Date of Inspection: 12/08/2003
System Failure Criteria applicable to all systems:
You must indicate'yes"or"no"to each of the following for all inspections:
Yes No
x Backup of sewage into facility or system component due to overloaded or clogged SAS or
cesspool
_ x Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
_ x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool
x Liquid depth in cesspool is less than 6"below invert or available volume is less than 114 day flow
_ x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ x Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ x Any portion of cesspool or privy is within TOO feet of a surface water supply or tributary to a
surface water supply.
x Any portion of a cesspool or privy is within a Zone 1 of a public well,
_ x Any portion of a cesspool or privy is within 50 feet of a private water supply w(—.
x 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
colifprm 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.]
No (Yes or 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 falls.The system owner should contact the Board of Health to determine what will be necessary
to correct the failure.
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
You must indicate either yes"or no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)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-DEP)or a
mapped wetland
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 CUR 15.304.The system owner should contact the
appropriate regional office of the Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:300 Raleigh Tavern Ln.North Andover MA 01845
Owner:Stephanous Loisou
Date of Inspection: 12/08/2003
Check if the following have been done You must indicate yes'or no as to each of the following:
Yes No
x _Pumping information was provided by the owner,occupant,or Board of Health
_ x 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?
x 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)
x _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
x _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)f sludge and
depth of scum?
x _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:
Yes no
x _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)[3 10 CMR 15-302(3)(b)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATIONFLOW CONDITIONS
Property Address:300 Raleigh Tavern Ln.North Andover MA 01845
Owner:Stephanous Loisou
Date of Inspection: 12/08/2003
FLOW CONDITIONS
RESIDENTIAL
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 gpd
Number of current residents: 2
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system yes or no): No (if yes separate inspection required)
Laundry system inspected(yes or no): No
Seasonal use:(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/INDUSTRL4,L
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sqfi,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):No-Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records Source of information: Owner supplied pumped yearly
Was system pumped as part of the inspection yes or no): Yes
If yes,volume pumped:gallons 1000 gallons
How was quantity pumped determined?Sight tube on truck Reason for pumping:To check the condition of the tank
TYPE OF SYSTEM
X Septic tank,D-Box,and 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: 30 Years.The soure of the information
was a plan dated 10/15/73
Were sewage odors detected when arriving at the site yes or no): No
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:300 Raleigh Tavern Ln.North Andover MA 01845
Owner:Stephanous Loisou
Date of Inspection: 12/08/2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:(locate on site plan)
Depth below grade: 12"
Material of construction: X concrete_metal_fiberglass_or polyethylene
other(explain)
tank is metal list age:
copy of certificate)
Dimensions: 1250 gal
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:no sludge
Scum thickness: no scum
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,structure integrity,liquid
levels as related to outlet invert,evidence of leakage,etc.):Tank condition good.Inlet and outlet tee's intact.liquid level
equal with outlet invert.No evidence of leakage.
Is age confirmed by a Certificate of Compliance(yes or no): No (attach a copy)
GREASE TRAP: (locate on site plan)
Depth below grade:—
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to
outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:300 Raleigh Tavern Ln.North Andover MA 01845
Owner:Stephanous Loisou
Date of Inspection: 12/08/2003
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: Yes (if present must be opened and 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 level,distribution equal,no sign of solid carryover,no evidence of leakage
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 and appurtenances,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C SYSTEM INFORMATION(continued)
Property Address:300 Raleigh Tavern Ln.North Andover MA 01845
Owner:Stephanous Loisou
Date of Inspection: 12/08/2003
SOIL ABSORPTION SYSTEM(SAS):_X_(locate on site plain,excavation not required
if SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,Iength:
X leaching fields,nwnber 1,dimensions:96ft.X 54ft.
_overflow cesspool,number:_
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
Soil is course.No signs of hydraulic failure now or in the past vegetation normal
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 scam layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Continents(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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLINTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INFO FORK
PART C
System information(continued)
Property Address:300 Raleigh Tavern Ln.North Andover MA 01845
Owner:Stephanous Loisou
Date of Inspection: 12/0812003
SKEi TCI1 OF SEWAGE DISPOSAL SYSTEM
Provide:a sketch of the sewage disposal system including ties to at least Mo permanent reference landmark s or benchmarks_Locate
all wells withbl 100 feet.Locate where public water supply enters tie building.
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OFFICIAL INSPECTION FORM-(NOT FOR VOLUNTARY ASSESSMENTS)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:300 Raleigh Tavern Ln.North Andover MA 01845
Owner:Stephanous Loisou
Date of Inspection: 12/08/2003
SITE EXAM
Slope Medium slope
Surface water None
Check cellar Dry no sump pump
Shallow wells None
Estimated depth to ground water 6 ft.
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:
x 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)
x Accessed USGS database-explain: I accessed USGS database
You must describe how you established the high ground water elevation:
I took the high ground water level from the USGS web site.I also angered a hole 4 feet below the field and no ground
water was encountered.
Title 5 Inspection Form 6/15/2000
DEPARTMENT OF ENVIRONMENTAL PROTECTION
NOTE TO FILE RE 300 Raleigh Tavern Lane:
• Called by Neil Bateson on June 25, 2003 for SSDS inspection on conditional pass.
With Neil inspected site and asked homeowner to expose two lines that were doubtful
and let me know when done.
• Saw ad for house— 12 rooms! Far exceeds design capacity.
• Neil called 7/2/03, reporting that standing water at level of pipe. Went out, inspected and
told homeowner that with size of house and standing water where there should be none,
that system appears to be failed. Explained process, (hire engineer; do soil tests;have
plan designed; obtain approval; hire installer; construct system; get inspections done;
obtain CoC.) and apologized for giving bad news.
S. Starr