HomeMy WebLinkAboutTitle V Inspection Report - 121 OLD CART WAY 9/14/2001 COMMONWEALTH OF MMSACHUSEM
txEcuTm OFFicE®F
5
OITICIAL INS PECTION FORM—NOT FOR VOL
SMURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTMCATION
Property.add
121 Old Cart Way
Owner's Name:.d� ° N. Andover MA 01845
' 'Weiss
Date of on: 09-14-01
Name of Inspector:(please Print) %EnARD50N
Company Name: uaR Fi,vir�rret w
Mailing Add P.O.Box 5062
RIO _
Tel hone Nn 1_- _ �® 71i1�,
CERTIFICATION
I °fy that I have personally WWeded the sawage disposal system at this address and that the fidbrination reported
below is true,accurate and complete as of the time of the inspection.'The° °on was performed based on my
ftining d experience in the proper fitnetion and maintenance of4h site sewage disposal systems.I am n.1E P
approved r pursuant to Section IS340 of Title 5 10 CNR 11&009� The system-,
Passes
° ,o y Paws
Needs er Evaluation by the Local Approving A ity
trr's
zzlatla_-� 4—
te:Sipature: Da
shall 11m system inspector submit A copy of this inspOction report to tha Appmving of Haft or
D , 30 days of completing ft impectiaL If the system is a shared system or has a design flow of 1 ,
gpd or greater,the inspector and the system owner WWI submit the mpxt to the appropriate noonal office ofdw
buyer,DEP The on&d dmM be sent to t116 system WNW ad Copies son to the if applicable,and ae •appwmg
Notes and Co t$
****Thls report only describes conditions at the awe of on and under the conditions of use at tbat
time.This fiLapecOn does not address the system win perform the intore under the same or dWmw
conditions of n
Page2ofll
OFFICIAL INSP —NOT F
SUBSURFACE E
PART A
,.,
'Wress. 121 Old Cart Way
N. Andover,MA 01845
Owner. . Weiss
)Dana of ins n: 09-14-01
Sm rl.~ D r o E an of Section D Inspection ABC,
A. Systein Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
1 .303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One more system components at described in the"Conditional Pass"section need to be replaced or
rePdMd.The upon comply ion of&Wreplgoement or repair,as approved by the Board of Health,will pass.
Answer yes,no or t demmined(y,N,ND)in the for the following statemeum If"not determined"please
The septic tank is and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits infiltration or a Mmdon or tank.faih re,is imminent.System will pass inspection if the
existing tank is replroed a c_9mplying septic tank as approved by the Board of Health.
*A metal septic tank will pass' pection if it is structurally sound,not leaking and if a Csatificate of Compliance
indicating brat the tank is less 20 years old is available.
ND explain:
Observation of sewage backup bnmk out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, or uneven distribution box.System will pass inspection if(with
vat of Board of Health):
bra s)arerephtced
removed
distribution X is leveled or replaced
ND explain:
The system required pumping more than 4 times year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are repla
obstruction is removed
ND explain:
Page 3 of l l
OFFICIAL SPECTION FO -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
PART A
CERTIFICATION(continued)
Property Address: 121 Old Cart Way
N. Andover,MA 01845
Owner: Weiss
Date of Inspection: 09-14-01
C. Further Evaluation is Required by the Board of Health: T
Cc itions exist which require finther evaluation by the Board of Health in order to determine if the system
is failing to public health,safety or the environment.
1. System pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is n functioning in a manner which will protect public health,,safety and the environment:
Cesspool privy is within 50 feet of a surface water
_ Cesspool or rivy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the and of Health(and Public Water Supplier,if any)determines that the
system is functioning in a man n r that protects the public health,safety and environment:
The system has a septic soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary t surface ware Supply-
The system has a septic tank and S and the SAS is within a Zone I of a public water supply.
_ The system has a septic tank and SA d the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS an a SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to de ine distance
ed at a DEP certified laboratory,for coliform
**This system passes ifthe well water analysis,perf pollution from that facility and
bacteria and volatile organic compounds indicates that a well is free from po provided that no other
the presence of ammonia nitrogen and nitrate nitrogen is ual to or less than 5 PP m,Pr
failure criteria are triggered.A copy of the analysis must be hed to this form.
3. Other:
Page of 11
FFI INSPECTION F —NOT FOR VOLUNTARY
SUBSURFACE SEWAGEPISPOSALSMM INSPECTION FORM
I "PART A
Property Address: 121 Old Cart Way
N, Andover,MA 01845
Owner; Weiss
Date of Inspecttonz 09-14-01
D. System Failure Criteria applicable to all systems:
You 1111 indicate`y+es"or'W to each of the following for a,�i inspections:
Yes No
✓Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
L,/Discharge or pondmg 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
L--'Liquid depth in cesspool is less than 6"below invert or available volume is less than 14 day flow
Required pumping more than 4 times in the last year aMdue 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
—r- water supply,
✓ 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 6assm if the well water analysis,
performed at a DEP certified laboratory,for eoliform bacteria a volatile organic compounds
indicates that the well is free ftirom pollution from that facility and a presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,prove that no other ihilure criteria
are triggered.A copy of the-analysis must be attached to this form,
(yie 0) e system f i I have determined that one or more of the above failure criteria exist as
bed in 310 CMR 0.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the MM.
E. La Systems:
To be on Bred a largo system the system must serve a facility with a design flow of 10,000 gpd to 15,000
Std•
You must in ' either"yes"or"ao"to each of the following:
{The following apply to large systems in addition to the criteria above)
yes no
_ _o the system is 400 feet of a surface drinking water supply
the system is within feet of a tributary to a surface drinking water supply
the system is looted in a en sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water sup well
If you have answered W to any question 'on E the system is considered a significant threat,or answered
"yes"in Section D above the large system has 'ed.The owner or operator of any large system considered a
significant threat under Section E or failed under 'on D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the approp . regional office of the Department.
Page 5 of 1 l
OFFICIAL INSPECTION FO ®NOT FOR VOLUNTARY
INSPECTION ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYS
PART B
CHECKLIST
Property Address: 121 Old Cart Way
N. Andover,MA 01845
Owner: Weiss
Date of Inspection: 09-14-01
Check if the followinP have been done You must indicate"yes"or"no"as to each of the following:
Yes or Board of Health
Pumping information was provided by the owner,occupant,
_ ,../Were any of the system components pumped out in the previous two weeks?
J_ Has the system received normal flows in the previous two week period?
J 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?
J 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?
r/ 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 Sol]Absorption 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 l l
OFFICIAL INSPECTION FO VOLUNTARY ASSKSShWffS
SUBSURFACE SEWAGE4)ISPOSAL SYSTEM 111
PART C
SYSTEM
Property Address:. 121 Old Cart Way
N. Andover,MA 01845
Owner: Weiss
Date of Inspection: 09-14-01
RESIDENTIAL -- -^---
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 ChdR 15.203(for example: 110 gpd x#of bedrooms).
Number of current residents-
Does residence have a garbage grind er (ye r
Is laundry on a separate sewage system s o§no:',1*M3
[if yea inspection required]
Laundry system inspeetedes or no):4k
Seasonal use:(yes or no):
Water meter readin if available(last 2 years usage(gpd)):
Sump pump(yes or ho
Last date of occupancy:
CO C TAUMUSTRIAL
Type of lishment:
Design flow ed on 310 CMR 15.203): s god
Basis of design fl (seats/persons/sgft,ete.):
Grease trap present or no):
industrial waste holding present(yes or no):—
Non-sanitary waste=if to the Title 5 system(yes or no):
Water meter readinilab
Last date of occupancy/use:
OTHER(describe):-
G INFORMATION
Pumping Records ( `
Source of information: 14 311610
Was system pumped as part of the inspection&S or no):
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYP"F SYSTEM
vSeptic 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:
Wvm-wmagre.odoadetected when arriving at-the site(yes q&
Page 7 of 11
OFyICIAL INSPECTION FO —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DIS POSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 121 Old Cart Way
Owner: N. Andover,MA 01845
Date of Inspection: Weiss
09-14-01
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron V 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on co ditioneof joints,vent evidence of leakagg,,etc.):
� v
SEPTIC TANK:✓vate on site plan)
Depth below grade: 2p �
Material of construction: 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) ``11 aa
Dimensions: lg-w qa&
Sludge depth: Z` __ 1+
Distance from top of sludge to bottom of outlet tee or baffle: _
Scum thickness: k
Distance from top of scum to top of outlet tee or baffle: 5�+ +{
Distance from bottom of scum to bottom of et or aflle: _
How were dimensions determined: ---,° y`QA
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relate too et' vert,evidence of leakage,etc.):
GREASE TRAP: (locate on site plan)
Depth below grade:_
Material of construction: concrete metal fiberglass__polyethYlene other
(expo):
Dimensions:
Scum thickness:
Distance from top of scum to top o utlet tee or baffle:
Distance from bottom of scum to bolt of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendatio ,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of 1 e,etc.):
Page g of 11
OFFICIAL SPE ION FORK—NOT FOR VOLUNTARY S
SUBSURFACE SEWAGEMIROSAL SYSTEM INSPECrION O
PART C
SYSTEM-90tinned)
Property Address: 121 Old Cart Way
Owner: N, Andover,MA 01845
Date of Inspection:• Weiss
09-14-01
TIG r HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth Belo e:
Material of co coon: concrete metal fiberglass __polyethylene other(explain):
Dimensions:
Capacity; RAlons
Design Flow: day
Alarm present(yes or no):
Alarm level: Alarm' orking order(yes or no):
Date of last pumping: I
Comments(condition of alarm and fl switches,etc.):
DISTRIBUTION BOX: present must be opcn_ed)(locate on site plan)
u
Depth of liquid level above outlet invert: C)
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.): j
ov- o •►
PUMP CHAMBER: (locate on site plan)
Pumps in working order(ye r no):
Alarms in working order(yes no):
Comments(note condition of p p chamber,condition of pumps and appurtenances,etc.):
1
Page 9 of 1
OFFICIAL INSPECTION FO —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
WS
TF INFORMATION(continued)
Property Address 121 Old Cart Way
N. Andover,MA 01845
Owner: Weiss
Date of Inspectiol 09-14-01
SOIL ABSORPTION SYSTEM(SAS):=(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
1e�hing galleries,number: I
.,� ching trenches,number,length: 2 7G S'"
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.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and confi on:
Depth—top of liqui inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater' ow(yes or no):
Comments(note condition of il,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 draulic failure,level of ponding,condition of vegetation,etc.):
Page 10of1I
OFFICIAL SPE ION F T FOR VOLUNTARY ASSnSAMM
SUBSURFACE SEWAGE DISPOSAL
PAKr C
SYS
Property Address: 121 Old Cart Way
N. Andover,MA 01845
Owner: Weiss
Date or Inspection: 09-14-01
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.
(i
O
r.,
anK
a` -
Is�
t� 4 , o
Page 11 of 11
OFFICIAL INSPECTION FO NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 121 Old Cart Way
Owner:
N. Andover,MA 01845
Date of Inspection; Weiss
09-14-01
SITE EXAM — —
Slope -,-"
Surface water/
Check cellars/
Shallow wells
Estimated depth to ground water _feet
Please indicate(check)all methods used to determine the high ground water elevation:
-'�Qbtained from system design plans on record-If checked,date of design plan reviewed:
�Observed site(abutting property/observation hole within ISO 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: