HomeMy WebLinkAboutTitle V Inspection Report - 124 STONECLEAVE ROAD 3/7/2007 Commonwealth of Massachusetts
s Title 5 Official ..
Subsurface Sewage Disposal System Form - Not for Voluntary Assess ents ;
f
124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
every page. City[Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: eneralInformation
When filling out A.
forms on the
computer,use 1. Inspector:
only the tab key
to move your Chad Jablonski
cursor-do not Name of Inspector
use the return
key. Jablonski & Sans Inc.
Company Name
+ 206 Kenoza St.
Company Address
Haverhill MA 01830
Cityrrown State Zip Code
978-360-9358
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 CIViR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
l pt 0-7
Ins Sign re "` Date
The cyst spector shall submit a copy of this inspection report to the Approving Authority(Board
of Hea 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.
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
Commonwealth of Massachusetts
Title i i I Inspection
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
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:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditi Pass" section need to be
replaced or repaired. The system, upon completion of th placement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over years old*or the septic tank(whether metal or not)is
structurally unsound, exhibits bstantial infiltration or exfiltration or tank failure is imminent.
System will pass inspet2ealth.he existing tank is replaced with a complying septic tank as
approved by the Boar
" A metal septi ank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Complian indicating that the tank is less than 20 years old is available.
ND Explain;
❑ Observation of sewage backup or�re high static water level in the distribution box due
to broken or obstructed pipe(s) or ken, settled or uneven distribution box. System will
pass inspection if(with approval Board of Health):
❑ broken pipe(s),a e replaced
0
i
❑ obstrucfio'n is removed
i
l5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title fi i I Inspection
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ /n: ed umping more than 4 times a year due to broken or obstructed pipe(s). The
pection if(with approval of the Board of Health):
e(s)are replaced
n is removed
ND
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 env' onment.
1. System will pass unless Board of Health determin in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a anner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of surface water
❑ Cesspool or privy is within 50 f et of a bordering vegetated wetland or a salt marsh
2. System will fa/ater and of Health (and Public Water Supplier, if any)
determines that tfunctioning in a manner that protects the public health,
safety and envir
❑ The systec tank and soil absorption system (SAS) and the SAS is within
100 feet of a surfaply or tributary to a surface water supply.
The systic 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.
t5insp•06106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title i i I Inspection r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is I s 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 vy er analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and th,6 presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided ttfa{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
❑ ® 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 Yz day flow
❑ ® 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.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 '..
Commonwealth of Massachusetts
Title i i I Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6107
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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.
❑ ® 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 o ollowing, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 4 feet of a surface drinking water supply
❑ ❑ the system is ithin 200 feet of a tributary to a surface drinking water supply
❑ ❑ the sys 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"iK Section D above the large system has failed. The owner or operator of any large
system conside d a significant threat under Section E or failed under Section D shall upgrade the
system in ac rdance with 310 CMR 15.304. The system owner should contact the appropriate
regional o ' e of the Department.
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title fi i l Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
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?
❑ ® 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)]
l5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
u
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: 5
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)): Private Well
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallop-per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank presen ❑ Yes ❑ No
Non-sanitary waste dischar to the Title 5 system? ❑ Yes ❑ No
Water meter reading , If available:
Last date of o upancy/use: Date
Other (describe):
t5insp-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title ffi i I Inspection r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: NA BOH Pumped 1000 gal 8-1-01,4-20-05 by
Andover Septic
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: n/a
gallons
How was quantity pumped determined? n/a
Reason for pumping: n/a
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):
Approximate age of all components, date installed (if known)and source of information:
34 yrs As-built plan dated444c Z— 099 ' 9/-ZY/78
Were sewage odors detected when arriving at the site? ❑ Yes ® No
l5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
r Title 5 Official Inspection ■
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 32"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Watertight at foundation no evidence of leaking
Septic Tank (locate on site plan):
Depth below grade: 18"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: n/a
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
8' * 5'8 * 5'
,.
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
less than .5"
Distance from top of scum to top of outlet tee or baffle greater than 2"
Distance from bottom of scum to bottom of outlet tee or baffle greater than 2"
How were dimensions determined? Title V calibrated stick
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
Title i i I Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
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.):
Last pumped 4/20/05, pumping recommended annually
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 scu top of outlet tee or baffle
Distance from botto of scum to bottom of out tee or baffle
Date of last pu ping: 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.):
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):
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title i i I Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gall
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping/larm Date
Comments (condition oat s witches, 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
0"
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.):
box level, distributing evenly, no sign of solid carryover
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working orde- El Yes El No
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 !.
Commonwealth of Massachusetts
Title i i I Inspection r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump cha_m,be'rgopdibTn of pumps and appurtenances, etc.):
f
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.):
ryo S1G. N c4 ?0 w1:)iN � c2 try,. f fiYA�e�vi.r�
t5insp-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
Title i i I Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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 groundwat inflow ❑ Yes ❑ No
Comments (note c dition 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 condi ' n of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
c Commonwealth of Massachusetts
Title i i I Inspection
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s.•°''r 124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
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.
STC)NtE CLE� Y 1Z1�
v
i
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i
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
w Title i i l Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 124 Stonecleave Rd.
Property Address
Natalee Papell
Owner Owner's Name
information is
required for North Andover MA 01845 3/6/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
heck Slope L Z 0f°
[Surface water w
❑`Check cellar y
❑Shallow wells NO
"
Estimated depth to ground water: feet 0
Please indicate all methods used to determine the high ground water elevation:
[l' Obtained from system design plans on record
If checked, date of design plan reviewed:
Date AUo V /9, P777
❑ 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:
CEL-L- rat WA )7�sQy — �E2C
L--r!c- 0"
t5insp-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15