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Home My WebLink AboutTitle V Inspection Report - 141 MARIAN DRIVE 4/3/1996 yr � r �' ti• �R y.{'. �. Commonwealth of Massachusetts ,. Executive Office of environmental Affairs Protection William F.Weld �+ Gowmor ° Trudy Coxe - Secretary,EOEA ' David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM q PART A CE�,TIFICATI N a bval W14 Property Address: Address of Owner: tj Date of Inspection: / (If different) Name of Inspector: Company Name, Add re ;angTel e phone Number: CERTIFICATION STATEMENT 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 inspection. The inspection w;sS performed based on my training and experience in the proper function and maintenance of on-sites ge disposal systems. l h, _ Passes Conditionally Passes Needs Furthej Evaluation 13y 'approving Authority Fails ,l Inspector's Signature: Date: • � l ( J I The System Inspector shall sub a copy of this in pection repo to the Approving Authority within thirty (30) days of completing this inspection. If the system is a s red system or has a cie, ;n t',,)\% of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the De;t,,,tmen! of Environmental Protection. The original should be sent to the system owner anc i u,. n: to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicat,.cd below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection, Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances, if"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street 0 Boston, Massachusotts 02106 9 FAX(617) 5545-1049 a Telephone (617) 292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) / X11 Property Address: I V r I A a/ (` t 14o c 2n V—� V I►`)d4—f OWner. Date of Inspection: J DJ SYSTEM FAILS (continued) 'f 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), a' Number of times pumped : Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. _ Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5,00 and 6.00. Please consult the local regional office of the Department for further information. F (revised 8/15/95) 3 +' +i ti� t M!i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ;z CHECKLIST {' Y i Property Address: 1 q 1 lop'- , /01 r�A 46✓�m Owner: � ��u✓z � „ Date of Inspection: + Ll S) (� } Check if the Poll ing have been done: _ Pumping information was requested of the owner, occupant, and Board of Health. ✓None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ As built plans have been obtained and examined. Note if they are not available with N/A. YThe facility or dwelling was inspected for signs of sewage back-up, _✓fhe system does not receive non-sanitary or industrial waste flow /The site was inspected for signs of breakout. 2I system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or, t s, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Yp a The s ize and location of the Soil Absorption System on the site has been determined based on existing information or roximated by non-intrusive methods.e facility owner (and occupants, if different front owner) were provided with information on the proper maintenance of Sub--M,,, Surface Disposal System. `s• ' f 7>� F �s. x �Ar t+ (revised 8/15/95) 4 " ,'A y .'•�Gr'4 J '. • jJ r .f ylotlF"i 1j t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C y `` SYSTEM INFORMATION Property Address: I LI n Wan i Owner: c� YI. Date of Inspection; FLOW CONDITIONS s, RESIDENTIAL: Design flow: Qallons Number of bedrooms: + Number of current residents: nn ,r� Garbage grinder (yes or no): AA—(-e ; )2t c S)Z S�)D�e� &-e �Q kW-0V---"D. Laundry connected to system (yes or no): t� Seasonal use (yes or no):�C� Y Water meter readings, if available: S02. --(-{-c�c-�•,_�� ec�rQfi,( ,, ; s Last date of occupancy: C_c-Al2 t2.e"J ". COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: ¢allons/day 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: f Last date of occupancy: �f OTHER: (Describe) S'> Last date of occupancy: GENERAL INFORMATION .t�. PUMPING RECORDS and source of inf rmation: S System pumped as pan of inspection: ye c If ves, volume pumped. (Oc�(D al ns Reason for pumping:' S r2C6 rC i.5 �vvti�1;1��(/ff� �0✓z �LQ��Sa TYPE (�F SYSTEM i �/ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach pre,�ious inspection records, if any) Other (explain) N � �,,�� 14if'v APPROXIMATE AGE of all components, date installed (ii known) and source of information: 1_! FjC n Sewage odors detected when arriving at the site: (yes or(n��'� `'�` °° - "� 4 (revised 8/15/95) S �r -•r fir`.�. ' D �nA r�y I SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM � PART C SYSTEM INFORMATION (continued) t- Property Address: L// GtI2 a4--� op, Owner: Date of Inspection: TIGHT OR HOLDING TANK:_/ /14 (locate on site plan) Depth below grade: «a; Material of construction: _concrete _metal _FRP other(explain) Dimensions: Capacity; gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc,) ,I DISTRIBUTION BOX: (locate on site plan) .;;..; Depth of liquid level above outlet invert: Comments: t , (note if level and distributicr is equa:, evidence o: :o!u: c rr•,over, evidence of leakage into or out of box, etc.) U . PUMP CHAMBER: J/4 •• (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Z. r� y z :.. r ,t �& I. (revised 0/15/95) t � r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) r'; Property Address: V Y ►0j-1 f 6M ��vt/QJ� Owner: I � i Date of Inspection: W +S SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ' f � a 7 . 3 to ` F, n yD� e gc 60 )-X ,Z5n 3,67) DEPTH TO GROUNDWATER k� Depth to groundwater: feet method of determination or approximation: ITf r_ A.., (revised 8/15/95) 9 N i tia��Sr� ✓ T T' ll' S ERVICE, INC. 47 RAILROAD STREET BRADFORD, MASSACHUSETTS 01830 Telephone 372-7471 �r ��) III IIIIII11�►— S ' �r t'> A c,, 5'a i i r,7N� BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. J 00 8 t y 79 c-0-0 C-g L a is c 3 vc, Lc L r / 1. NAME Jam. DATE 2. ADDRESS LOT NO. 2 TEL. 3. NO. OF BEDROOMS DEN YES NO _ 4. GARBAGE GRINDER YES NO c/ _ 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. READING DATE i ; i WATER & SEWER BILL PRESENT' PREVIOUS AMOUNT DESCRIPTION :' I WATER R TC , MINIMUM' USAGE — ° ° ® . • • o J �R� m ® e • USAGE PER 100 C1 - --- SEWER RATE RE'Ai I Y0,; COO J_, i,f: ' USAGE pg�i aOQCI ra• r• t ,"T`� t °RTC IF PAID ON OR BEFC • f �I' 12/18/ 7 71 '5,9� ., , iy'• SSACHUSEt t �4 T..... IF PAID AFTER READING DATE WATER & SEWER BILL PRESENT 'PREVIOUS —- .-- AMOUNT DESCRIPTION WATER RATE MINIMUM USAGE . USAGE PER 100 CF --— - SEWER RATE RETAIN FOR YOUR REcOrl S r� �� ® . � � •�� 1 t;.ii USAGE PER 100 CF x of"OFT IF PAID ON OR BEFC s ° y9SSFCHUSj.+ .. , IF PAID AFTER U � READING DATE f / WATER & SEWER BILL PRESENT PREVIOUS AMOUNT DESCRIPTION WATER RAT. I MINIMUM USAGE • • ��:r . �I ` � • • USAGE PER 100 C _ -- -- SEWER RAT USAGE PER 100 C It fad• r• 1-I' 1 WATER & SEWER BILL READING DATE PRESENT PREVIOUS AMOUNT < DESCRIPTION WATER RATE MINIMUM—1 USAGE wr M �,., • ° ° `° • • • USAGE;PER 100 Cl IW r 7 a2i fl li _ SEWER RATE RETAIN FOh Y'iUR RECORDS USAGE PER 100 CF A • :°; X315 , r �3 n °• 1 -. I• ,(.r;P 'i 111 t{I �.IO1 YIIdS J�u�C '. o Nogr e IF PAID 7yiON OR BEFC A P 9SSACHUSf- IF PAID AFTER READING DATE WATER & SEWER BILL PRESENT PREVIOUS AMOUNT DESCRIPTION WATER RATI MINIMUM USAGE, ,a -- • ° � �° `I°� • ® USAGE PER 100 C 1� l ® • • ------ SEWER RATI RETAIN Edl i YOUR REGORJS _ � — - USAGE PER 100 C Ho rH IF PAID ON OR BU o I- M�SSAC.,us IF PAID AFTER WATER & SEWER BILL READING DATE PRESENT PREVIOUS AMOUNT DESCRIPTION WATER RA' MINIMUM USAGE- e ° �� a +.' �K e • ' USAGE PER 100 WAI I ,. 9 SEWER RA RETAIN I �i''� ''UI,)F1 USAGE PER 10C ��' ® p • ® o li!) '� U r - _— - U SAGE PER 100 CF � I — — — - -- SEWER RATES RETAIN FOR YU)f'I L� ' '" USAGE PER 100 CF IF PAID ON OR BEFORE ri o v tau, t � IF PAID AFTER :ADING DATE " " WATER 8, SEWER BILL PRESENT < PREVIOUS AMOUNT DESCRIPTION WATER RATE MINIMUM USAGE — - - USAGE PER 100 CF . 1 " 1— _ — SEWER RATES RETURN .r-HIS COPY [-!-I PA`I'i 'I USAGE PER 100 CF 0 � • t rl - -- IF PAID ON OR BEFOR'. q r 9y -HUSE IF PAID AFTER :ADING DATE WATER & SEWER BILL AMOUNT ( DESCRIPTION WATER RATES; MINIMUM �, o • o ® + USAGE PER 100 CF f�< SEWER RATES tETAIN FOR YOUR R O DS USAGE PER 100 CF rc I r F „ TH "I — IF PAID ON OR BEFORE 1 fi1gRI. , o qti AN1 60V 3= 0 p \ Sp CHASE - - IF PAID AFTER