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HomeMy WebLinkAboutTitle V Inspection Report - 223 FOREST STREET 5/3/1999 ,.. a ENGLAND _ .�. _......._ . .._... .............w.......... ..................... I w I SERVICES I INC March 8, 2000 North Andover Board of Health. Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 233 Forest Street.,North Andover Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system failed our inspection. If there are any questions please call me at my office, 686-1.768. Sincerely Benla in C. Osgoo Jr., E.I.T. President � N w„ 9 a �......�..,w............. k"#G�.EC . ..�. D DRIVE.- ORT]�.w ANDOVER, MA 0184� -(978)686,1768- seal 9-7e45 FaX(.ara)e85w1099 ....................m-...... ................w.............—........................................ ............................—........................_.,.......1..111........... ...... ,................_. �.� t` CbMMONWEALTH OF MASSACHUSE'I"PS 4 EXECUTNE'OFFICE OF ENMONMENTAL AFFAIRS DEPARTME NT OF ENVIRONMENTAL PROTECTION s ONE WINTER STREET, BOSTON MA 02108 (617)292-6500 n F =UDY.CO r DAVID ARGEO PAUL CELLUCCI Comtniscager}: Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM{FISPECTION FORM - PART A CERTIFICATION Property Address: 2.Z3 f_o g si S-f- Name of Owner en bf J�—C N._ Address of Owner: 7 2 5T j N�ate-( A-liX5ue Date of Inspection: �f Jx 19 g Name of lrapectorf(Pfcase r�,tt]l Beni amin C. Os2ood,Jr. 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310•CMR 15.0001 CornpanyName: New England -Engineering Services Inc. MaZiingAddress: 60 Beechwood Drive, North Andover, MA Telephone Number: 978-686-1768 CERTIFICATION STATEMENT 1 certify that 1 have personally inspected the sewage disposed system at this address and that the Information.reported below is true,accurate and complete as of the'time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails- Inspectors Signature: Date: ©� The System Inspector shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wtthin thirty(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 "if submit the report to the appropriate regional office of the Department of*£nvironmentat Protection. The original shouid°be sent 10-Ow system owner•and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS 1°t`t`�. Yl-iu 2e 40�2T u �tIfJ TI-lE pw �JElz aF J-(C-7 j'2o PC(?--I �v� me/V� H ��N,�� 77o w►TNc5En P>Lt -rHL's CC 1"D P2. revised 9/2/98 Psee I of It SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION rORM r2 • PART•A ' s, • CEn nFICATIOFf(continued) ' Proporty Address: 3 rf sT s%- ,v_ eA/�) Owner: Date of ksspection: x tNSPECTION SUMMARY: Check A, B, 0, of D: A SYSTEM PASSES: t 1 have not found any Information wfiich Indicates that any of the failure conditions described In 310 CMR 15:303 exist. Any failure^ criteria not oval`1 ated 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. 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,unless the owner or operator has provided the system inspector with a copy of a Certificate of ® Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the data of the inspectioh;or the septic tank,whether or not metal,is 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 complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ - The system required pumping-more than•fourtimes 4 yeardue to broken or obstructed pipe(s). The aystam Will Fuzz" Inspection if(with approval of the Board of-Health): - broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property 1 ddrv": 2 3 3 owner• �IJ/%L)iz L)6,C 6" Bc✓1C /L : Date of(nspecti -✓ /�/g C. FURTHER EVALUATiON IS REQUIRED BY THE BOARD OF HEALTH: : CoAditiohs exist which require further evaluation by the Board of Health In order to determine It the system Is falling to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DE uIMWES IN ACCORDANCE WITH 310 CMR 15.303(11(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH-KILL PRQTECT.THE PUBLIC HEALTHAND SAFETY.AND THE ENMIRONME6:1- ; _ Cesspool or privy Is within 50 feetof surface water Cesspool or privy Is within 50 feet of a bordering vegetated wetland or a salt marsh. i 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DEiERMINES-THAT THE SYSTEM IS. FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well: _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic.tank and soil absorption system and the SAS is less than 100 feet but 60 feet or more from a private water supply well,unless a well water analysis 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 then 5 ppm. Method used to determine distance (approximation not vafid). 3) OTHER revised 9/2/98 Page 3of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) . Property Address: Z 3 3 ,Z ES i S%(L Owner: Date of Inspection: D. SYSTEM FAILS: You must Indicate either'Yes"or"No" to each of the following; � up y_ 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 16.303. The basis for this C7�— determination is identified below. The Bpard of Health should be contacted to determine what will be necessary to correct the failure. Ye No Backup of'sewage into•facilityor•sT3tamcomponent•dueKo en over k-dedor-c4oggedSA&or-ces spool. ' sy- 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. 6l 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_. ® J 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 SO feet of a private water supply well. _ Any portion of a cesspool or privy is less-then 100 feet but greater than 60 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 Ycoliform bacteria,volatile organic compounds,ammonia nitrogen-and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 1:0,000 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: Yes No the system is within 400 feet of a surface drinking water supply" - ® _ the systamd9-within-200 teatof�tributaryteasuriaud g water surydY••• -�•• __ _ 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 upgrade the system in accordance with 310 CMR 16.304(2). Please consult the local regional office of the Department for further Information. revised 9/2/98 Page 4oru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIQN FORM PART B CHECKLIST r IV t` tie L /�- N property Address: - a' Owner: G (7(r� 40 VV___r JSv 2T t1 Date of kispection: , Check If the following have been dorfe:You must Indicate either"Yes"or"No" as to each of the following: Yes No Piping information was provided•by the owner,occupant,or Board of Heallth. Nona of the syctemcompowuiu.l<a+ralwenpump,* for-ate"%ttw o.auaaks+n"b"r yctemhas 6►eauscalair�gwslaRafflow rates during that period. Large volumes of water have not been introduced into the system recently or-as port of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All 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 tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on'the site has been determined based on:' Existing information. For example,Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / 115.302(3)(b)l _✓ _ _ The facility owner(and.o=pants.lf diHerent frost.owned•wete-Prnuided.with tnfaun goann f SubSurface Disposal Systems. revised 9/2/98 Page sorit .a � I i SUBSURFACE SEWAGE DISPOSAI SYSTEM INSPECTION FORM PART C ! SYSTEM INFOFIMATION Prpperty Address: 233 �fL r 5T Owner: Xv/Z7- w G-G C-'A18 lL&-6 ' Date of Wpectfon: Flow conlrimoNs RESIDENTIAL: Design flow: g.p.d./bedroom. j Number of bedrooms;(design):_ " Number of Bedrooms(actual):_ Total DESIGN flow Nurmber of current residents:_ i Ghrbage grinder(yes or no):_ „ Laundry(separate system) (yes or no):_; If yes,separale.Inspection.required Laundry system Inspected (yes or no) Seasonal use (yes or no):_ Water meter readings,if available (last two year's usage(gpd): Sump Pump(yes or no):_ Lest date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 16.203) Basis of design flow 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: O]HER:(Describe) Lest dote of occupancy: • GENERAL INFORMATION PUMPING RECORDS and source of Information: System pumped as part of inspection:(yes or no)_ If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shated system(yes or no) (if yes,attach previous Inspection records,If any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date Installe"f known)-end source of4itformation: Sewage odors detected when arriving at the site:(yes or no)_ revised 9/2/98 Pate 6ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC71ON FORM PART C SYSTEM.INFORMATION(continued) Property Address: 7/ nJ owner: You 2G ' Date of kupection: 'i BUILDING SEWER.: t , ' (Locate on she plan) i Depth below grade: Material of construction:_cast Iron_40 PVC_other(explain) Distance from private.water supply well or su tion line Diameter Comments:(condition of joints,venting,evidence of fvakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:�j-(L14DL Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank Is (petal,list age_ 1s.age.confumed by Certificate of Compliance—(Yes/No) Dimensions• Sludge depth: _• _. Distance from top of sludge to bottom of outlet tee orfraffle: 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 dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles,depth of liquid level In relation to outlet invert,•structurel4ntegrity, evidence of leakage,etc.) TAAJ 6 (S �L� I AN )� SHo�1�C� 2rc�LiA C EO 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: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquld.level in relation to outlet Invert,structural Integrity, evidence of leakage,etc.) revised 9/2/98 Poge7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOgM PART C ' SYSTEM INFORMAgTiON(continued) �7 Property address: 2 3 3 Ems? S7` /L'• /r D D J C vt. Owner: '~_ Data of kupection: �'`,2 G UGG(�✓ g�S/Vcl TIGHT OR HOLDING TANK: (Tank must bo pumped prior to, or at time of,Inspection) (locate on site plan) t Depth below grade:, Material of construction:_cpncrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarni level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of Qquid level above outlet invert: " Comments: _r (n a If level and distribution is equal,evidenoe of solids carryover,evidence of leakage into or out of box, etc.) of &)7 Q Avt i-0 YC b Sys 7-E PUMP CHAMBER (locate on site plan) Pumps In working order:(Yes or No) • Alarms in working order(Yos or No) Comments. (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8ofit SUBSURFACE SEWAGE DISPOSALJSYSTEM INSPECTION FORM t PART ac SYSTEM INFORMATION(continued) ' Property address: 33 f� s r Oviner: K,, r� 6�& C�v 0 E 2(r 6 2 t �4 Date of Inspection: q i SOIL ABSORPTION SYSTEM(SAS). ri. 1 ,r• (locate on site plan,If possible;excavation not required,location may be approximated by non-(ntrusive methods) If not located,explain; Ty e: leeching pits,number:_ leaching chambers,number:_ leeching galleries,number•._ / leeching trenches,number,length:�PG.cln )2e•�c �. leaching fields,number,dimensions: overflow cesspool,number:__ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition vegetation, eta G 1�2L•� of St'STtn� - v ' c--)11 / K101 5� .tJ17 CESSPOOLS: (locate on site plan) Number and configuration: , Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimenslohs of cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of Inspection) Comments: (note condition of soil,signs of hydraulic failurer level of ponding,condition ofrvegetation, etc.) PRIVY:A�A (locate on site plan) Materals of construction: Dimensions• Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of pending,condition of vegetation;etc.) revised 9/2/98 Psee9of11 a� l` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C SYSTEM INFORMATION(continued) Property Address: 7i��. ✓l Gtr S%.2 t�� N. �n�0 0✓�� . Date of k►spec$(n: . SKETCH OF SEWAGE DISPOSAL SYSTEM: ' Include ties to at least t*o permanent reference landmarks or benchmarks I locate all wells within 100'(Locate where public water supply comes Into house) We(L Ao ju, _D"r12a i3� )0A./ ( L)X revised 9/2/98 Page 10 of It SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION RM Y PART C. , SYSTEM INFORMATION(continued) Property Address: 2 33 owner: )Ao;LT is-UG &e A--9e 26rC 2 y Date of linspectiort: NRCS Report name l ' Soil Type_ ' Typical depth to groundwater i USGS Date website visited Observation Weil checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please Indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health ; Checked FEMA Maps Checked pumping records Checked local excavators, Installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) itl D /4S ���� c�% � revised 9/2/98 Page ueru