HomeMy WebLinkAboutTitle V Inspection Report - 1459 TURNPIKE STREET 5/17/2001 CommoNwEALTH OF MASSACHUSETTS
_ ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
VW�4
TITLE
OFFICIAL INSPECTION FO ®NOT FOR VOLUNTARY ASSESSMENTS
SUBSURF ACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: .
Owner's Name:
Owner's Address:
� w &
Date of Inspection: IT I I uC91
Name of Inspector: (please print)-I 0. T.
Company Name: '
Mailing Address: Lay;no*&in s5t #6
Telephone Number:--922- gsi-88:39
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
eeds Further valuation by the Local Approving Authority
ails
Inspector's Signature: i Date:
The system inspector shall subm' a copy of this ' spection ort to the Approving Authority(Board of Health or
DEP)within 30 days of comple ng this inspection.If the system is a shared system or has a design now of I0,000
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.
.dv^ :a '0 iu /.
Notes and Comments . �z
A m.
*"**This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address hpw the system will perform in the future undenthcsamifnt
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: J! T _
_L)b- o-
—
Owner•
Date of Inspection: h
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. stem Passes:
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:
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.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
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
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM ®NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 ko c .
hi8, l oo,p r 1AQ
Owner: )M n . Air t—n .A-a
Date of Inspection: ,� l 1-4 1
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
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 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.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM®NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:1�/ T( rnpi�_
Owner: ttL&hEL q
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N
YBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
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 1/2 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. 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—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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
'Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Ye 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?
— 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/
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)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM®NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: / T _
Owner: �—
Date of Inspection: s/ I I X11
RESIDENTIAL
FLOW CONDITIONS
2
Number of bedrooms(design):�. — Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 2
Number of current residents: [
0
Does residence have a
garbage grinder(yes or no): N ,
Is laundry on a separate sewage system s or no):_@_0 [if yes separate inspection required]
Laundry system inspected es
Seasonal use: (yes or no): 0
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no);
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment: I
Design flow(based on 310 CMR 15.203): gad
Basis of design flow(seats/persons/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: ,� ,�
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: allons--How was quantit'pumped determined? C
Reason for pumping:
cti
TYP vOF SYSTEM
eptic 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)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
proximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):1J�'U
6
Page 7 of 11
OFFICIAL INSPECTION FORM®NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 Tn�
Owner:
Date of Inspection:SST /O�_
BUILDING SEWER(locate on site plan)
Depth below grade: yr�
Materials of construction:_cast iron V/40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leaks e,etc.):
SEPTIC TANK: 'locate on site plan)
Depth below grade: Q"
Material of construction:_✓ oncrete_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:_(Q i C",
Sludge depth: &"
Distance from top of sludge to bottom of outlet tee or baffle:_ 37
Scum thickness: 1 '4
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to butt m of outlet tee or b e Sl
How were dimensions determined: 1k tt an IL
Comments(on pumping recommendation A,in and outlet tee o affle condition,structural integrity,liquid levels
as related to ou et invert,evidence of leaka e,etc.):
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.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM®NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
r
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: allons
Design Flow: Qallons/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: J
(if present
must be opened)(locate on site plan)
Depth of liquid level above outlet invert: O
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leaka into or ou of box,etc.j.
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.):
8
Page 9 of l l .
OFFICIAL INSPECTION FORM®NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:/x/59 T&rnA'kn
Owner:_ _, —��-
Date of Inspection: //?/M
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: .
V leaching trenches,number,length:
aching fields,number,dimensions:.�t
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.):
J�
CESSPOOLS: esspool 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,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: i
t
l
ocae 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.):
9
Page 10 of 11
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: )q,! 7—,ri_r r,_0A
Owner:
Date of Inspection:_,Cq7 ZQ j_
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.
oe
a � ass
Q 80,
z
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: A 9 TI rn n�E'o
Owner: HIV►,, LS
Date of Inspection:s,1/z10 i_
SITE EXAM �T
Slope
§urface water
✓Check cellar
Shallow wells
Estimated depth to ground water �r
$60 o .bw
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:
ou must describe how you established the hip round water elevati n:
f r�
11
qqK� PAYMENTS To TOWN OF NORTH ANDOVER 18586
AN OF NORTH ANDOVER " 2001 WATER/SEWER BILL CYCLE 032 ULL 6 E
P.O. BOX B�i/27/2001
NO. ANDOVER= 045 '°`t''
; ,� A ,Fs Account• 2100007
A �' `" " Q, Meter: 2100007
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Service: 1459 TURNPIKE ST
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DETACH Please detach here and return the bottom voucher with your payment DETACH
970 L ` • V0 TOWN OF NORTH ANDOVER Account #
DIVISION OF PUBLIC WORKS-WATER & SEWER DEPARTMENT 6
Application for Abatement of Water/ wer Charges Date
Water Current Abate ® � Net Due O
Water Arrears Abate Net Due
Sewer Current Abate Net Due
Sewer Arnars_ _ Abate _ Net Duee il
Total ated: ) Tot. Due 4
Reason for Abatemen Or &
ReGY�y 306
Name I � � .J
Payable to the Town of North Andover,
Locatio 120 Main St.
No. Andover, MA 01845
Authorized
MAKE PAYMENTS TO TOWN OF NORTH ANDOVER 10423
TOWN OF NORTH�;}ANROVER " 2000 WATER/SEWER BILL CYCLE #22
18/2000
P.P.0 BO =124 n
NQ� r,ANI ?VER 'Mp A,84'
i, 4 T qj jA Account: 2100007
"�,� b Meter: 2100007
KERRY A`; RUD`E �- Service: 1459 TURNPIKE ST
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COLLECTOR:, : ° „r Ut
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Bill Date: 04/14/99 Account#: 01-2281000-0
TOWN OF NORTH ANDOVER
Bill#: 0009031 Due Date: 05/14/99
Water and Sewer Bill
M.M.-MR .. ..... Svc Addr: 1459 TURNPIKE ST
....................................
Mtr Previous —Present Bill
ED e Usag Date Reading Date Reading Code Water Sewer
001 11130/98 236 2/05/99 255 EST. 19 _$51.87 $0.00- $5 .87
NEW WATER RATE IS$2.73 PER 100 CF. Previous Balance $0.00
SEWER RATE REMAINS$2.75 PER 100 CF. Penalty Charge $0.00
UNPAID BALANCES WILL BE SUBJECT TO 14% INTEREST Interest 0.0 0
a51.8 7
thig agaign fbLxq rjegQEQ
Please include this portion with your payment
Water and Sewer Bill
Bill Date: 06/15/99 Billing and Service Information:
Bill#: 0009031 DEPARTMENT OF PUBLIC WORKS
Account#: 01-2281000-0 384 OSGOOD STREET, NO. ANDOVER
TEL: 978-688-9570
Service Address: 1459 TURNPIKE ST HOURS: MON-FRI 8:30 A.M.-4:30 P.M.
Due Date: 07/15/99 Remit to:
TOWN OF NORTH ANDOVER
Total Due: $51.87 TREASURER-COLLECTOR'S OFFICE
Witter Rate is$2.73 and$a.wer Rate is$2.75 Per 100 CF. P.O. BOX 124, NO ANDOVER, MA 01845
Unpaid balances will be subject to 14% interest.
HOURS MON-FRI 8:30 A.M. -4:30 P.M.
* � � 8 � 888 � 8 � � *
TOWN OF NORTH ANDOVER
TREASURER-COLLECTOR'S OFFICE
120 MAIN STREET
NORTH ANDOVER, MA 01845
RICHARDS,WILEY
1459 TURNPIKE STREET
N. ANDOVER MA 01845
MAKE�PAYMENT$ TQ � TOWN OF NORTH ANDOVER BILL NUMBER 2680
TOWN OF -NORTH 'ANDOVEk"�"'7,
2000 WATER/SEWER BILL CYCLE #12 BILL DATE: 09/27/1999
C
P.O. oox��1124,�"�,""-,�',�-",''�""
1`NO.0,rMD,0.V
4
018 5� a
Account: 2100007
Meter: 2100007
kv'�'N",'R.P*HONE):� Service: 1459 TURNPIKE ST
CTO
,COLLECTO
RICHARDS, WILEY
1459 TURNPIKE STREET
N. ANDOVER MA 01845
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Bill Date: 01/06199
Accoun,#: 01-2281000-0
Bill#: 0009031 TOWN OF NORTH ANDOVER
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Water and Sewer Bill Due Date: 02/05/99
Svc Addr: 1459 TURNPIKE ST
57:::7
Mtr Previous Present Bill
ID Date Rea n Date Readin Cndsh Usage Water Sewer
001 7 13 98 216 11 30 98 236 EST. 20 _____�$54.60 0.00 54.60
....................
NEW WATER RAI"li; IS $2.73 PER�100�CF �� Previous Balance
SEWER RATE REMAINS$2.75 PER 100 CF. Penalty Charge _00 0
UNPAID BALANCES WILL BE SUBJECT TO 14% INTEREST Interest $0.00
00