HomeMy WebLinkAboutTitle V Inspection Report - 30 OXBOW CIRCLE 11/23/2005 COMMONWEALTH OF MASSACH U 91'T
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OFFICIAL INSPECTION FORM m-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:_30 Oxbow Circle
—North Andover_
Owner's Name: Robert Maclunis
Owner's Address: 30 Oxbow Circle
®North Andover,l�la 01$45m
Date of Inspection: 11/23/2005_
Name of Inspector: Neil J.Bateson
Company Name: Bateson Enterprises Inca
Mailing Address:_111 Argilla road_
_Andover,Ma.011110
'telephone Number:_(978)475®4786_
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
Fai
Inspector's Signature: � f ,��, .. � �.. .� Date: ®11/23/2005
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
DER 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 haw the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PANT A
CERTIFICATION (continued)
Property Address: 30 Oxbow Circle_
_North Andover_
Owner:_MacInnis_
Date of Inspection:_11/23/2005_
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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"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):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a 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 replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL, INSPECTION FORM ® NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_30 Oxbow Circle_
_North Andover_
Owner:_MacInnis_
Date of Inspection:_11/23/2005_
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.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15,303(1)(b)that the
system is not functioning in a manner which will 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 feet 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 septic 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: 30 Oxbow Circle_
North Andover_
Owner:_Maciunis_
Date of Inspection:_11/23/2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
_ _No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_Nos Liquid depth in cesspool is less than 6"below invert or available volume is''/z day flow.
_No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
—No Any portion of the SAS,cesspool or privy is below high ground water elevation.
_No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _No_ 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.]
_No_(Yes/No)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•
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)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
— 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
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.
Page 5 of 11
OFFICIAL INSPECTION FORM®NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAIN D
CHECKLIST
Property.Address: 30 Oxbow Circle_
_North Andover_
Owner:_MacInnis_
Date of Inspection:_11/23/2005_
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Yes _ Pumping information was provided by the owner,occupant,or Board of Health
No Were any of the system components pumped out in the previous two weeks'?
Yes _ Has the system received normal flows in the previous two week period'?
No Have large volumes of water been introduced to the system recently or as part of this inspection?
Yes_ _ Were as built plans of the system obtained and examined?
_Yes_ , Was the facility or dwelling inspected for signs of sewage back up?
Yes _ Was the site inspected for signs of break out?
Yes_ _ Were all system components,excluding the SAS,located on site?
_Yes_ _ 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?
_Yes_ _ 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:
Yes no
_Yes_ — Existing information.
_Yes_ _ 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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM M INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 30 Oxbow Circle
North Andover
Owner:_Maclnnis�_
Date of In-spection:_11/23/2005_
I•LOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_4_ Number of bedrooms(actual):—4
DESIGN flow based on 310 CMR 15.203_440
Number of current residents:4_
Does residence have a garbage grinder(yes or no): No_
Is laundry on a separate sewage system(yes or no); lira
Laundry system inspected(yes or no);
Seasonal use: (yes or no);—No—
Water meter reading:—Yes-
Sump pump(yes or no):—No—
Last date of occupancy:_Current_
CO E RCUL/MDUSTRUL
Type of establishment;_
Design flow(based on 310 CMR 15.203):___gpd
Basis of design flow(seats/persons/sgfl,etc.):
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 teeter readings,if available:
Last date of occupancy/use:
OTHE R(describe):
GENERAL INFORMATION
Pumping Records
Source of information:^Pumped last year,owner_
Was system pumped as part,of the inspection(yes or no):_Yes_
If yes,volume pumped:_150(l�gallons--How was quantity pumped detennined? Measured tank_
Reason for pumping: _Inspect tank&tees_
PE Or 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:_7 years old,6/17/1995,
as built plan_
Were sewage odors detected when arriving at the site(yes or no):_No_
Page 7 of 11
OFFICIAL, INSPECTION FORM ®NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 30 Oxbow Circle_
_North Andover_
Owner:_ acInnis_
Date of inspection:—
BUH,DING SEWER_X_ (locate on site plan)
Depth below grade:_13"
Materials of construction: _X_cast iron _X 40 PVC_other
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.) _4"Cast Iron thru wall.3"PVC in house,
no leaks visible
SEPTIC TANKS: X
Depth below grade:_1"
Material of construction: X_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: 10'x 5'x 4'—
Sludge depth: 3"_
Distance from top of sludge to bottom of outlet tee or baffle:_2411
Scum thickness:_2"
Distance from top of scum to top of outlet tee or baffle:_0"
Distance from bottom of scum to bottom of outlet tee or baffle:_l9"—
How were dimensions determined:_Tape Measure_
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc._Pumped septic tank.Inlet tee ok.Outlet tee ok. Depth of
liquid at outlet invert.No evidence of leakage.
GREASE (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 FO ®NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_30 Oxbow Circle_
North Andover_
Owner:_MacInnis
Date of Inspection:_11/23/2005_
TIGHT or BOLDING T (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
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 BOXES:X
—
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.):_D-box level&distribution equal.No evidence of leafage.Evidence of
carryover,pumped d-box to clean_
PUMIP CHAMBER:®(locate on site plan)
Pump in working order(yes or no):s
Alarm in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OF'F'ICIAL. INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PANT C
SYSTEM INFORMATION(continued)
Property Address: 30 Oxbow Circle-
_North Andover
Owner: _
_MacInnis _
Date of Inspection:_11/23/2005
SOIL ABSORPTION SYSTEA_(SAS):_X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
® leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
_X leaching trenches,number,length: 2 trenches 60'long_
leaching field,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.):_Soil ok.Vegetation ok.No sign of ponding to surface_
CESSPOOLS:
Number and configuration:®_
Depth—top of liquid to inlet invert:_
Depth of sludge 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.):_
P (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 of 11
OFFICIAL. INSPECTION FO —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 30 Oxbow Circle_
_forth Andover_
Owner:_Maclnnis_
Date of Inspection:_11/23/2005_
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.
B
Driveway House
Water Meter
Septic
A Tank
D-Bog
*to Tank=13'
A to D-Bog=25'
B to Tank=36'
B to D-Bog=4911"
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PANT C
SYSTEM INFORMATION(continued)
Property Address:_30 Oxbow Circle_
_North Andover-
Owner:_MacInnis_
Date of Inspection:_11/23/2005_
SI'Z'E EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water _6'_
Please indicate(check)all methods used to determine the high ground water elevation:
_X_ Obtained from system design plans on record-If checked,date of design plan reviewed:_5/5/1998_
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: As per design plan_
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Summary Record Card generated on 11/18/2005 2:42:02 PM by Lisa Warren Page 1
Town of North Andover
Tax Map # 210-107.B-0146-0000.0
6-®®®®.6
30 OXBOW CIRCLE
MACINNIS, ROBERT & KIMBERLY
30 OXBOW CIRCLE
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 0.65 Acres
FY 2006
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
MACINNIS, ROBERT& KIMBERLY Payor
30 OXBOW CIRCLE
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 14098.0- 30 OXBOW CIRCLE Last Billing Date 8/31/2005
2100040 02 Cycle 02 Active
Bldg Id. 13337.0- 30 OXBOW CIRCLE Last Billing Date 8/31/2005
2100041 02 Cycle 02 Active
UB Services Maint.
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.63 5/8 7.82 1/
WTR WATER 01 ALL METER SIZE 669.48 /1
UB Meter Maintenance
Serial No Status Location Brand Type Size YTD Cons
43993604 a Active R ENC F.RT. ? w Water 0.63 0.63 0
Date Reading Code Consumption Posted Date Variance
11/8/2005 2160 a Actual 99 -20%
Trouble Code:03
8/10/2005 2061 a Actual 134 9/12/2005 360%
Trouble Code:03
5/5/2005 1927 a Actual 24 6/8/2005 55%
2/14/2005 1903 a Actual 17 3/15/2005 -75%
Trouble Code:03
11/18/2004 1886 a Actual 76 12/17/2004 -25%
Trouble Code:03
8/10/2004 1810 a Actual 89 9/20/2004 267%
Trouble Code:03
5/14/2004 1721 a Actual 24 6/14/2004 1%
2/17/2004 1697 a Actual 28 4/16/2004 0%
11/6/2003 1669 n New Meter 0 11/6/2003 0%
Tel: (978) 475-4786
Fax: (978) 475-5451
Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 30 Oxbow Circle, North Andover
Owner: Maclunis
Date of Inspection: 11/23/2005
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil J. Bat son
Bateson Enterprises, Inc.