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Home My WebLink AboutTitle V Inspection Report - 88 HAY MEADOW ROAD 3/10/2008 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 88 Hay Meadow Road Property Address Wendy McKernon Owner Owner's Name information is No. Andover MA 01845 3/10/08 required for State Zip Code Date of Inspection every page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General 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. New England Engineering Services, Inc. Company Name tab 1600 Osgood Street Suite 2-64 Company Address No. Andover MA 01845 enan State Zip Code City/Town 978-686-1768 — 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: Z�Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority " ,4)® � Inspe is 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 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 TITLE 5 FORM 2007.DOC•08/06 Corr`monwealth of Massachusetts Title Inspection Subsurface Sewage Disposal System Form e Not for Voluntary Assessments M 88 Hay Meadow Road Property Address Owner Wendy McKernon Owner's Name information is required for No. Andover every page. City/Town Mae 01845 3/10/08 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: te !�I have not found any information which indicates that in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteriaunot evaluated are described 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): r ❑ broken pipe(s)are replaced ❑ obstruction is removed A 15 TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Official Title 5 Subsurface Sewage Disposal System Form Not for Voluntary Assessments N 88 Hay Meadow Road Property Address Wendy McKernon Owner Owner's Name information is No. Andover MA 01845 3/10/08 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): I Yes No ❑ Er Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ [a'- 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- u 10,000gpd. ❑ ET� 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 ❑ R1, the system is within 400 feet of a surface drinking water supply ❑ [J"' the system is within 200 feet of a tributary to a surface drinking water supply El Area 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. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title I Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Hay Meadow Road Property Address Wendy McKernon Owner Owner's Name information is No. Andover MA 01845 3/10/08 required for State Zip Code Date of Inspection every page. City/Town 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 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? ❑ 5a--- 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. ❑ r LA, / Determined in the field (if any of the failure criteria related to Part C is at issue Y approximation of distance is unacceptable) [310 CMR 15.302(5)] TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sev+age Disposal System•Page 6 of 15 Commonwealth of Massachusetts Official Title 5 i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 88 Hay Meadow Road Property Address Wendy McKernon Owner Owner's Name information is No. Andover MA 01845 3/10/08 required for every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 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 N No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): 120 6-P T> Sump pump? 9 Yes ❑ No Last date of occupancy: (Date � �� 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: Last date of occupancy/use: Date Other(describe): TITLE 5 FORM 2007.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 88 Hay Meadow Road Property Address Wendy McKernon Owner Owner's Name information is No. Andover MA 01845 3/10/08 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: 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) ❑ Tight tank. Attach a copy of the DEP approval. Other (describe): r Approximate age of all components, date installed (if known) and source of information: �6"�* z_0®z VC-,L� Pf-, - 0,, H7 Were sewage odors detected when arriving at the site? ❑ Yes � No TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Hay Meadow Road Property Address Wendy McKernon Owner Owner's Name information is required for No. Andover MA 01845 3/10/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: ✓ feet Material of construction: ❑ cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: [a 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 -------------------------------------------------------------------------------------------------------------------------- Dimensions: If Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? � 0.1, TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Hay Meadow Road Property Address Wendy McKernon Owner Owner's Name information is No. Andover MA 01845 3/10/08 required for 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.): Grease Trap (locate on site plan): /V kT 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): f I Tight or Molding Tank(tank must be pumped at time of inspection) (locate on site plan): d Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): TITLE 5 FORM 200ZDOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal system Form - Not for Voluntary Assessments 88 Hay Meadow Road Property Address Wendy McKernon Owner Owner's Name information is required for No. Andover MA 01845 3/10/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ,VjkTight or Holding Tank (cont.) 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 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.): Ot'K IN (_--b0 P CoytPt7?Zr" rj>evlc-E OF _so(- D S C A-�L k-V o J ex- ®z ldF,AK,t, Pump Chamber(locate on site plan): Pumps in working order: Eg"Y"es ❑ No Alarms in working order: Yes ❑ No TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 !. Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Hay Meadow Road Property Address Wendy McKernon Owner Owner's Name required for is No. Andover required for MA 01845 3/10/08 every page. City/ own State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): PL) M P C K t9 M g 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: ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ 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.): biz ON Js 0Ve,6-TA--17-,b Al> TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 88 Hay Meadow Road Property Address Wendy McKernon Owner Owner's Name information is required for No. Andover MA 01845 3/10/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ,A/I'A' 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): J 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.): TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 88 Hay Meadow Road Property Address Wendy McKernon Owner Owner's Name information is required for No. Andover MA 01845 3/10/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. L.1 tie-4 - TAtj r-,, ® B' �a 1,4 M11, I x,51 C - 9",F 10.q' P.2 .20.41 ° D ` A P TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Hay Meadow Road Property Address Wendy McKernon Owner Owner's Name information is required for No. Andover MA 01845 3/10/08 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 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 plan reviewed: 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: qc.A V A- E> aJL TITLE 5 FORM 2007.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Mar 03 08 01 : 44p p. 3 Summary Record Card generated on 3/3/2008 10:32:35 AM by Lisa Evans Page 1 Town of North Andover Tax Map # 210-1043-0104-0000.0 88 HAY MEADOW ROAD MCKERNON, WENDY NARDIN, FIL Since Jan 2006 88 HAYMEADOW ROAD NORTH ANDOVER, MA 01846 Class 101 Single Family --- _ __._._. .------ ----._ _ _ ----------------- Property Type 1 Residential Size Total 1 Acres FY 2008 _UB Mailing Index --_- _- --- Name/Address Type Loan Number Active/Inact. From Until WENDY MCKERNON Owner PHILIPO NARDIN 88 HAY MEADOW ROAD NORTH ANDOVER,MA 01845 SCIOLLA,JANICE Previous Customer Inactive 7/1/2005 88 HAY MEADOW ROAD NO.ANDOVER,MA 01845 UB Account Maint. Account No Cycle occupant Name Active/Inactive Bldg Id.18128.0-88 HAY MEADOW ROAD Last Billing Date 1/15/2008 3180156 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7,82 11 WTR WATER 01 ALL METER SIZE 61.03 11 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 13242486 a Active 00 METE METE w Water 0.63 0.63 0 Date Reading Code Consumption Posted Date Variance 12/17/2007 512 a Actual 17 1/22/2008 156% 9/14/2007 495 a Actual 6 10112/2007 -62% 6/21/2007 489 a Actual 18 7/20/2007 2% 3/16/2007 471 a Actual 17 4/16/2007 -26% 12/13/2006 454 a Actual 21 1/19/2007 50% 9/19/2006 433 a Actual 15 10120/2006 -20% 6/20/2006 418 a Actual 19 7/10/2005 14% 3/20/2006 399 a Actual 15 4/17/2006 -30% 12/27/2005 384 a Actual 25 1/17/2006 -73% 9/21/2005 359 a Actual 79 10/14/2005 198% 6/29/2005 280 f Final Bill 35 6/2912005 22% 3110/2005 245 a Actual 22 4/5/2005 -16% 12/1512004 223 a Actual 24 1/14/2005 -74% 9/28/20D4 199 a Actual 122 10/8/2004 58% 6/15/2004 77 a Actual 39 7/30/2004 125% 4/23/2004 38 a Actual 38 5/17/2004 Doha 12/29/2003 0 n New Meter 0 12/29/2003 0%