HomeMy WebLinkAboutTitle V Inspection Report - 67 RALEIGH TAVERN LANE 6/8/2011 Y
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CAA RK DE CLARK, INC,
TITLE V
SEPTIC SYSTEM PROFESSIONALS '......
INC.
ge
June 15, 2011 N OF Not1 R MMOVVI
UWARYM tit°'
Mr. Darrell Hamann
67 Raleigh Tavern Lane
North Andover, MA 01845
�I
RE: Title 5 Inspection
67 Raleigh Tavern Lane,North Andover
Dear Darrell:
Please find enclosed the Subsurface Sewage Disposal System Inspection Report for the
above referenced property. As noted on Part B (Certification) of the report, the system
Passes the inspection criteria. This inspection is good for the next two (2) years; you may
extend the life of the inspection to three (3) years by having the septic tank pumped
annually (before anniversary date of inspection).
Thank you for allowing us to be of service to you on this project. Please contact us if you
have any questions regarding this matter.
Sincerely,
D.F. Clark, Inc.
tl
George F. Norris X, 'r'6
..
Title 5 Inspector r°
. ,
Enclosure
cc: �, North Andover Board o
D.F. Clark, Inc. file
P
PO Box 265 24A lvlitchell Read 1pswich, MA 1)1935
978-356-5638 Fax 978-356-551317 Toll Free 888-DF-CLARK
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
67 Raleigh Tavern Lane — — -
Property Address
Darrell Hamann _ ------ — — --
Owner Owner's Name
information is North Andover MA 01845 June 8, 2011
required for --
every page. Ci#y[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: A. General Informati®n
When filling out
forms on the
computer, use 1. Inspector:
only the tab key
to move your George F. Norris — -
cursor-do not Name of Inspector
use the return
key, D.F. Clark, Inc. ------- --
Company Name
rQ 22 Mitchell Road, P.O. Box 265_ —_— —_ -- --
Company Address
Ipswich MA-- --_. 01938 —
ietan
City/Town
State Zip Code
978 356-5638 — _S14051 ----
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
Zor's Signa#ure 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title f i i l Inspection r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is North Andover MA 01845 June 8, 2011
required for
every page. City/Town State Zip Code Date of Inspection
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 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is maintained twice a year by Clear Water Industries, last maintenance report and copy of
current contract attached Ratio box is in good condition.
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):
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
F Title fi i l Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann -
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
every page. City/Town 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
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
_ v Title Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 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 all inspections:
Yes No
El ® Backup 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 '/z day flow
15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title Official Inspection r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is North Andover MA 01845 June 8, 2011
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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.
El 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.
El 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.
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17
Commonwealth of Massachusetts
Title Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is North Andover MA 01845 June 8, 2011
required for
every page. City/Town State Zip Code Date of Inspection
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?
El ® 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:
® ❑ 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
440
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
t5ins•09/08
Commonwealth of Massachusetts
u Title Official Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
As per design plan
3
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ® Yes ❑ No
Currently
Last date of occupancy: Occupied
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 ❑ No
Water meter readings, if available:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title fi i l Inspection r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
System was last pumped one (1) year ago according
Source of information: to the owner.
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):
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title Official Inspection r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
every 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:
System was installed in the 1997 according to the owner.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: e.08 (37")
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.):
Building sewer pipe is in good condition no signs of leakage
Septic Tank(locate on site plan):
Depth below grade: ee 1 (29")
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
SWx10' Lx4' D
Dimensions:
5"
Sludge depth:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title ffi it Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
every page. City/Town 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
29"
0"
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
Tape measure and sludge judge
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet tees are in place, liquid level is normal, septic tank is in good condition and pumping
is not required at this time.
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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title fi i Inspection r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
every 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.):
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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title ffi ial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
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
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.):
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.):
The pumps and floats in both the Recirculating and Dosing chambers are working properly. All floats
were cleaned during the inspection
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title Official Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
1 field - 30'W x
® leaching fields number, dimensions: 49' L
❑ 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.):
SAS is Pressure Distribution, SAS is under lawn area in the front yard, flushed all five (5) laterals,
there are no signs of ponding or hydraulic failure.
Cesspools (cesspool must be pumped as pan`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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
F Title i i l Inspection r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title ff i i l Inspection r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
Deck Sunroom
A
Sand ilter
Porch
3 #2— Septic Tank(Out et w/filter)
water
° ® B 0 sewer 0
#1 —Septic Ta
° (Inlet cover) Paved
Driveway
Rati O #4—Dosing Pump Chamber
#3 —Recirculating amber ;
A- 1 = 13'8"
B- 1 = 12'6"
A-2 = 20'
B-2 = 18'6"
A-3 =25'
V0ich, 41 B — 3 = 16'8"
A-4 = 33'10"
nD.E B-4 = 30'8"
SEP71C SYSTEM PROFESSIONALS Raleigh Tavcm Lane
INC. L
t5ins-09/08 9,81 C6�56J� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title fi i l Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
W 67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
every 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: 3
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: August 27, 1997
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 testing was performed on June 25, 1997 by B. Dufresne, ESHGW was determined in both test
holes - OP3 @ 38" and OP-4 @ 36", according to design plan bottom of SAS is 4' above ESHGW in
hole OP-4. At time of inspection a site exam was made, slope was level, no surface water was
observed cellar was dry with a sump pump and no shallow wells were located.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title fi i l Inspection r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 Raleigh Tavern Lane
Property Address
Darrell Hamann
Owner Owner's Name
information is
required for North Andover MA 01845 June 8, 2011
every page. Cityfrown 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
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
_ ar
July 10, 2009
Mr. Darrell Hammann
67 Raleigh Tavern Lane
North Andover, MA 01845
RE: Maintenance and Service Contract for the Recirculating Sand Filter System located at
67 Raleigh Tavern Lane,North Andover
Dear Darrell:
Clear Water Industries proposes to provide service and maintenance for the Recirculating Sand
Filter(RSF) System at the above referenced address. The following maintenance and service
schedule is for the next two (2) years of operation commencing upon receipt of signed contract
and Annual Cost received in full.
Scheduled Annual Service:
Cost: 2 inspections and 2 field effluent testing @ $205 = $410
(Note: Access cover for all components must be at the ground surface.)
1. Check sludge, scum depth and clean the effluent filter in the septic tank annually.
2. Check panel and alarm system.
3. Check ejector pump and float switches in Recirculating Pump Chamber and the Dosing
Tank.
4. Take effluent sample as required by Massachusetts D.E.P. Sample will be analyzed for
the following:
*Dissolved Oxygen,
*Turbidity,
and *pH.
5. Check function of Recirculating Sand Filter.
6. Flush out Pressure Distribution field as needed.
7. Notify Client verbally of any problems encountered.
(Note: There may be instances when the high water alarm will sound. In the event of an
alarm condition, you are requested to silence the audible alarm and contact
(978) 356-0779 for instructions and/or a follow-up field visit by
an CWI representative. See unscheduled service costs.)
I have read and agree with the above Scope of Work: lL
CWI's initials- Dq z Owner's initials
PO Box 825, Ipswich, MA 01938 . 978-356-0779 • Fax 978-356-5500 -www.clearwaterindustries.com
Page 2
Mr. Darrell Hammann
July 10, 2009
Unscheduled service:
1. Unscheduled emergency service calls will be billed at the following hourly rates:
*Monday through Friday lam—5pin: $85
*Monday through Friday 12am—7 am, 5 pm— 12pm: $100
*Saturday and Sunday: $100
with a minimum of a 2 hour charge.
2. If results of field effluent testing for pH, Dissolved Oxygen or Turbidity do not
comply with Massachusetts Department of Environmental Protection limits,
additional testing for Total Suspended Solids and Biochemical Oxygen Demand
would need to be done at a certified laboratory. Owner would be contact prior to
additional testing. Additional testing of effluent would be $95.00 per sample.
Certified technician:
The service technician shall be a Massachusetts Certified Operator. The certified
operator will be David F. Clark, Steven S. Cottrell, George F. Norris or Mark Cottrell.
Reporting requirements:
In accordance with DEP's Title V Regulations, CWI will file semi-annual reports with
the property owner and the local Board of Health. Annual reports will be forwarded to
the DEP transmitting the data from the sampling of the effluent, as well as a review of
any unscheduled service.
Sincerely,
Clear Water Industries
T1 Qte�'f Qts�
David F. Clark
Owner
Acceptance by Owner:
Darrell Hammann Date
PO Box 825, Ipswich, MA 01938 . 978-356-0779 • Fax 978-356-5500 •www.clearwaterindustries.com
8 V
RECIRCULATING SAND FILTER SYSTEM
ROUTINE INSPECTION
ADDRESS: 67 Raleigh Tavern Lane, North Andover OWNER: Hamann
DATE: December 16, 2010 OPERATOR: Marls Cottrell
SYSTEM STATUS
Septic Tank
Effluent Filter: Cleaned, rinsed out
Scum Depth: 0 55/48"
Sludge Depth 4 5748"
(Measured on December 3, 2009)
Recirculating Pump Chamber
Pump H-O-A Setting: Auto
Pump Cycle Timer: N/A
Alarm Selector: On
Level Alarm: Normal
Exercise Pump: Yes
Test& Clean Floats: O.k., cleaned
Tank Condition: Good
Dosing Pump Chamber
Pump H-O-A Setting: Auto
Pump Cycle Timer: On Demand
Alarm Selector: On
Level Alarm: Normal
Exercise Pump: Yes
Test& Clean Floats: O.k, cleaned
Tank Condition: Good
Sand Filter
Sand Condition: Clean
Diffusers Condition: Clear, flushed and brushed all (3)laterals on 12/16/10
Effluent Quality
Visual Inspection: Clear, no odor
Sample: pH = 6.5, Dissolved Oxygen= 8.75 mg/L, Turbidity= 2.85 NTU
Comments:
r
Signature: Certificate # 11739
PO Box 825, Ipswich, MA 01938 - 978-356-0779 • Fax 978-356-5500 ■ www.clearwaterindustries.com
Massachusetts Department of (Environmental Protection
Bureau of Resource Protection - Title 5
ration 1 t
Inspecti®n Checklist
A. Installation & Service Information
67 Raleigh Tavern Lane December 16, 2010
Facility Street Address Date of Service
North Andover Mark Cottrell/Clear Water Industries
City Operator/O&M Firm
Inspect& note B. Septic tank(s)
if pumping is
required. Sludge Pumping Required: Yes ❑ No X X Sludge Depth: 4"
Inspect& clean
effluent tee Effluent tee filter: Yes X No ❑ If yes, inspect X & clean at least yearly X
filter.
Clean as C. Recirculation tank
necessary.
Inspect for ❑ Check if sludge accumulating Pumping required: Yes ❑ No X
sludge.
Odor problems: Yes ❑ No X If yes,description
Inspect for D. Equalization tank (if installed)
sludge.
❑ Check if sludge accumulating Pumping required: Yes ❑ No ❑
Inspect pumps E. Pumps, switches, floats, alarm system
& electrical
switches, test X Pump Inspections (all units)
as necessary. If problems,describe
Run pumps in X Test pump alternator, or record hours Not applicable for this system
manual mode. Hours of operation
Record X Float switches 0.k.
readings from Check all switches for operation
meters & X Test alarm
counters. If non-functioning,corrective action(s)
Note if weeds &F. Recirculation Sand Filter
debris are
present on bed. X Inspect for ponding Ponding Present: Yes ❑ No X
Clean/maintain
bed surface to X Clean bed: Yes X No
allow proper
operation of the X Distribution pipes Flush: Yes X No Brush: Yes X No
system.
X Check head loss in pipes 0.k.
Headloss and comments
G. Sample Collection (Field Sample)
Yes X No
If yes: BOD TSS X pH ❑TN X Other- Dissolved Oxygen and Turbidity
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1
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and OM Form for Title 5 I/A
Treatment and Disposal Systems
A. Installation
Important: Darrell Hamann
When filling out Owner
forms on the
computer,use 67 Raleigh Tavern Lane
only the tab key Facility Street Address
to move your North Andover 01845
cursor-do not City Zip
use the return
key. Mailing address of owner, if different:
rab
Street Address/PO Box:
City State Zip
( ) - ext.
Telephone Number
B. Authorized Service Provider
Clear Water Industries
0&M Firm
P.O. Box 825
Street Address
Ipswich MA 01938
City State Zip
(978) 356 -0779 ext.
Telephone Number
Mark Cottrell 11739
Certified Operator Name Certification Number
C. Facility/System Information
DEP ID Manufacturer ID Model Number
Installation Date Start of Operation
Approval Type: ❑ General ❑ Provisional ❑ Piloting ® Remedial
Seasonal Residence—used less than 6 mo./year: ❑ Yes ® No
D. Operating Information
December 16, 2010 June 1, 2010
Inspection Date Previous Inspection Date
Sludge Depth(to be checked yearly) Pumping Recommended ❑ Yes No
®
t5aiom.doc•rev. 11-07-05 Page 1 of 3
4 I
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and ®&M Form for Title 5 I/A
Treatment and Disposal Systems
E. Field Testing
Field Inspection:
Color: ❑ gray ❑ brown ® clear ❑ turbid
❑ Other(specify):
Odor: ❑ musty ❑ earthy ❑ moldy ❑ offensive ❑ turbid
Effluent Solids: ❑ no ❑ some
pH 6.5 SU DO 8.72 mg/L Turbidity 2.85 NTU
6 to 9 2 or greater 40 or less
Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected
per Standard Methods and analyzed for BOD and TSS.
F. Sampling Information
Samples Taken: ❑ Influent ❑ Effluent
Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use
nitrogen reducing systems:
gpd
Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑ TN ❑ Other(list below)
Other 1 Other 2 Other 3
G. Inspection and Maintenance
Description of any maintenance performed since previous inspection & during this inspection:
Notes and Comments:
Field sample was clear with no odor.
t5aiom.doc•rev. 11-07-05 Page 2 of 3
a
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
6A DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
H. Certification
I certify: I have inspected the sewage treatment and disposal system at the address above, have
conducted the required Field Testing and/or sample collection in accordance with Standard Methods,
have completed this report and the attached technology operation and maintenance checklist, and
the information reported is true, accurate, and complete as of the time of the inspection. I am a
Massachusetts certified operator in accordance with 257 CMR 2.00.
December 16, 2010
Operator Signature Date
System owner must submit this report, technology O&M checklist, and any required sampling results
to the local board of health and DEP as follows for each inspection performed:
Remedial Use—by January 31St of each year for the previous calendar year
Piloting Use -within 45 days of inspection date
Provisional Use—by March 31 t of each year for the previous 12 months
General Use—by September 30th of each year for the previous 12 months
Send to:
Department of Environmental Protection
Attention: Title 5 Program
One Winter Street, 6th Floor
Boston, MA 02108
t5aiom.doc-rev. 11-07-05 Page 3 of 3