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HomeMy WebLinkAboutTitle V Inspection Report - 141 STONECLEAVE ROAD 1/21/2005 ,..� ..,.................. .... -- ....... .........................................-.... ......... .....„ ... ......., ..... ...........W,.«:. " ......�_............ w.....��.. . w � 3 SERVICES .......�� � .� .... � I .-------- �.�w��. R � w U\N 2 7' 2005 TOWN N 0F'TIC ?,T H ANDOVER HEAL.T'I DEPARTMENT January 25, 2005 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01.845 RE: TITLE V REPORT: 141 Stonecleave Road,North Andover,MA Dear Sir or Madam: 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, 686-1768. Sincerely �� Benjamin C. Osgood, r., P.E. Certified Title 5 inspector ... .... Ri . WW. o BEEC�IV1tc�f�C).DRIVE NORTH ANDOVER,MA 01845 45-(978)686-1768 �d(888)359-7645- FAX(978)685-1099 COMMONWEALTH OF MASSACHUSETTS E+YMCUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS EPARTMENT OF R Oh1MENT " w „SAN 2, 7 DEP TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: I y l S ic>0j; c L.EAu U 1Z"o �tjD0 rC/L Owner's Name: Vo tip/+ P A U L U s Owner's Address: L`1 I 2 iro N C t✓�A �Jw: � ju O 2T1 ( Aij D©JG� Date of Inspection; i ) 1 s' Name of Inspector;(please print) Beni amin g. Osgood, Jr. CompanyNamesNew England Engineering Services Inc. W ingAddress:64 Beechwood Drive, North Andover,` Ate 0,1845 Telephone Number: 978-686-1768 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 4f � Date. The system inspector shall submit a ropy 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. Notes and Comments ""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'Ilse, Page 2 of la OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 11-11 s To d J E Owner. V @�IV P A t11 S Date of Inspection: t z'10!5_- Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. .System Passes: \f O 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: IV 0 One or more system components as descxiibed 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 septle 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 tunes a year due to broken or obs±*ucted 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: Page!of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 101 2D t-)c&t�AVJ fLo W.0 2TN A; jo o jM AAA Owner: v L-u Date of Inspection: 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which wfll 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 fee_t 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 septio 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: i 4I : R o )-2Tq jkN D o U eA_ Owner: y n W o� ,PRU w s Date of Inspection:_ o 5 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no!'to each of the following for ail inspections: Ye$ No — 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 — Required pumping more than 4 times m the last year NOT clue 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 welt _ 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.] kA ()teslNo)Ike system fails.I have determined that one or more of the above failure criteria exist as descu-bed in 310 CMR re 15.303,therefo 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 You must indicate er"yes"or"no"to each of the following- (TUC following criteria ly to large systems in addition to the criteria above) yes no — the system is within 400 feet surface drinlcing.wafer supply — the system is within 200 feet of a_tribu o a surface drinking water supply — the system is located iii a nitrogen sensitive area Wellhead Protection Area–IWPA)or a mapper Zone II o£a public water supply well If you-have answered"yes"to any question in Section E the system�co 'dered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or erator o y large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_1­1 I !MSC_C_P �9 N '� A 000L .rA Owner: V oO oR PA,)Lv, Date of Inspection: 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? 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? _ v✓ Were all system components,excluding the SAS,located on site? /Were flee 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 same?. _ 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 Absorptioa 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)] Page 6 of'i 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: I ti S io N t; m o aM4 60000U_ .,A Owner: v onJ P YA- PA v L us Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Lj Number of bedrooms(actual): DESIGN flow based on 310 C 15.203(for example- 110 gpd x#of bedrooms): 6,00 G--F D Number of current residents: j Does residence have a garbage g ritnder(yes or no): Is laundry on a separate sewage system(yes or no):LX) [if yes separate inspection required] Laundry system inspected(yes or no):�J Seasonal use:(yes or no),; W AL ater meter readings,if available(last 2 years usage(gpd)): j ju E"._ Sump pump(yes or no):,YD Last date of oupancy 1� c r p• - cc ----- ------------ — CObIMERCIAUINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/personslsq%eta): 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 occ upancyluse: OTHER(descn'be): GENERAL INFORMATION Pumping Records Source of information: �,� ,�,r 7 ��F j_ F E P- 0,A_.N& Was system pumped as part of the inspection(yes or 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) _InnovativelAltemative 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): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):AL) Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) :Property Address: R9 Owner: k j oI,)(Z, QAy Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: /0 Materials of construction: ,,�c ast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc): �l P� i�eFCw D A Vts�3c E SEPTIC TANK:_(locate on site plan) Depth below grade: _j�,," _ Material of construction:_L/-concrete 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: 150,:, &-a 1--i-0,'j 5. 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): NAT t,jS pip c7 GRF.AW TRAP:/�,1(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): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ..Property Address: 141 1 s-rn Q v&L-c►4vc- RD 0 u 0-�f Owner: do N,p A Date of Inspection:_ oS TIGHT or HOLDING TANK:/V (tank must be pumped at time of inspection)(locate or,site plan) Depth below grade: Material of Construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallonsiday 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: (iifpresent must be opened)(locate on site plan) Depth of liquid level above outlet invert: b 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 CHAMBE L-A(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.): 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: 191 Qoan-e J-\ NP000 .AA Owner: Vo�k,pAAt� �v5 Date of Inspection: Z" SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number leading galleries,number: leading trenches,number,length: leaching fields,number,dimensions: c,`y 7-:�) x K overflow cesspool,number: innovativelalternative system Type/name of technology. Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �2Gffi of �rGc p Leo u,s .�,2n.c.4L ivy �o� n uG- yJan� P CESSPOOIS:10 (cesspool must be pumped as part of inspeetion)(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: (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.): Page 10 cf 11 OFFICIAL INSPECTION FORM ' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I f-i( E t2.D --0 9-111 A.,j D o e/Z M� Owner: U0,-C)4 Pf4Jws Date of Inspection: t I zi o 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. - too Page 11 of 11 OFFICIAL INSPECTION FORM=-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: t,i t sTb c rAgC Q� �o yTl-t tSw f70,I?A Owner: ll o D F� gu c u S Date of Inspection: 0 5 SM EXAM Slope Surface water Check Cellar Shallow wells Estimated depth to ground water 3 feet 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: You must describe how you established the high ground water elevation: Are°._ rL� s s< <� s i t c Ca 4 c2"1\') ( �J C__P R( is a-) u [3 e L-b 1 tE2 1 �4 D 5 S rP vim'`