HomeMy WebLinkAboutTitle V Inspection Report - 158 OLYMPIC LANE 10/8/2001 COMMONWEALTH OF MASSACHUSETTS
s ExECLTTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
y
TITLE 5
OFFICIAL.INSPECTION FORM®NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM FORM
PART A
CERTIFICATION
Property Address: rrs� 'l��ti tm"
Et tittle
AND
V
Owner's Name: i :t
Owner's Address:
Date of Inspection: /p—e-®/ ..
o�
Name of Inspector: (please print) Qh fi&e . R o. .,x
Company Name:
Mailing Address: . 13 P�+fen► 2d.
k a . IYI .04674,
Telephone Number:(?78) (.!,e
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
l
Inspector's Signature: � , ,✓� �,�f Date: /D
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
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 use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1,_7—A 4
('1 4.2,21y
Owner: //
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
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:
�I
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be r aced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board o ealth, will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statemen . f"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank ether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure i mminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved the Board of Health.
*A metal septic tank will pass inspection if it is structurally soun ,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 high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or ven distribution box. System will pass inspection if(with
approval of Board of Health):
broken ipe(s)are replaced
obs ction is removed
di ibution box is leveled or replaced
ND explain:
The system required p ping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with appr val of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: t—,q ()4T(,4T�r
Owner:
Date of Inspection:
C. Further Evaluation is Required by t/rotect of Health:
Conditions exist which require furthtion by the Board Health in order to determine if the system
is failing to protect public health, safety or nment.
1. System will pass unless Board of termine accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manh will rotect public health,safety and the environment:
_ Cesspool or privy is within 50 face water Cesspool or privy is within 50 ordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and PZZone er Supplier,if any) ermines that the
system is functioning in a manner that protects the pu ,safety and env' nment:
_ The system has a septic tank and soil absorption AS)and th AS is within 100 feet of a
surface water supply or tributary to a surface water s
_ The system has a septic tank and SAS and the Sin Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the Sin 50 feet of a private water supply well.
The system has a septic tank and SAS and the S han 100 feet but 50 feet or more from a
private water supply well".Method used t ,dete he distance
"This system passes if the well w/ate formed at a DEP certified laboratory, for coliform
bacteria and volatile organic comphat the well is free from pollution from that facility and
the presence of ammonia nitrogen en is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copmust be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: /S C
Owner:
Date of Inspection:
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 clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or s ce waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet inve due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below inve r available volume is less than '/z day flow
Required pumping more than 4 times in the last ar NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or pri s below high ground water elevation.
Any portion of cesspool or privy is wi in 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or pri is within a Zone 1 of a public well.
Any portion of a cesspool or ivy is within 50 feet of a private water supply well.
Any portion of a cesspool privy is less than 100 feet but greater than 50 feet from a private water
supply well with no ac ptable water quality analysis. [This system passes if the well water analysis,
performed at a DE certified laboratory, for coliform bacteria and volatile organic compounds
indicates that th ell is free from pollution from that facility and the presence of ammonia
nitrogen and n' rate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggere .A copy of the analysis must be attached to this form.]
(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 d ' n 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 c ' eria above)
yes no
the system is within 400 feet of a surface dr' mg water supply
_ the system is within 200 feet of a trib to a surface drinking water supply
the system is located in a nitro€ sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water su yy 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.
4
Page 5 of 1 l
OFFICIAL INSPECTION FORM®NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART I3
CHECKLIST
Property Address:
Owner:
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 ?
T Has the system received normal flows in the previous two week period?
_Z _ Have large volumes of water been introduced to the system recently or as part of this inspection
m ?
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 he 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:
Yes no
/,,` _ Existing information.For example,a plan at the Board of Health.
I/ _ Determined in the field(if any of the failure criteria related to Part.0 is at issue approximation of distance
is unacceptable)[3 10 CMR 15.302(3)(b)J
5
Page 6 of I I
OFFICIAL INSPECTION F® —NOT FOR VOLUNTARY ASSESSMENTS
S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: /S �ii dtr rc
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): —41'10`/I Sunti¢
Number of current residents: 'Y
Does residence have a garbage grinder(yes or no):X__5yS,4e1m rt/Dl" 6ccc:�v»m�vt d r '� ° --'s-e 'Na,,
Is laundry on a separate sewage system (yes or no : / [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):A/
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):LYA.41�_,-„,
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes no):
Non-sanitary waste discharged to the T' e 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: f�'lDS
Was system pumped as part of the inspection(yes 6r no):
If yes, volume pumped: allons--How was quantity pumped determined?
Reason for pumping: `t ta-
TYyE 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/Altemative 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): /i,/
6
Page`?of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: C
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: ,
Materials of construction:_cast iron _40 PVC_other explain):
Distance from private water supply well or suction line: /v /fi
Comments(on condition of joints,venting, evidence of leakage,etc.):
/U c3 L®/Ykr1y¢ Q l��ehyQCl.
I
SEPTIC TANK: /(locate on site plan)
Depth below grade: /..S
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) wK
Dimensions: `/(Z X 1,v-SS_X_ l ' 00 DZ"�
Sludge depth: t ''
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:f_d '_
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: - G
Comments (on pumping recommendations, ifllet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leaka e,etc.):
r ev °
o i►
`v
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass olyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or b e:
Distance from bottom of scum to bottom of ou t 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 age,etc.):
a
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /S8 1z
Owner
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal erglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallon ay
Alarm present(yes or no):
Alarm level: Alarm in king order(yes or no):
Date of last pumping:
Comments(condition of al and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:///,OY
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)
3ak J W✓ .L
v v —
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, con ' on of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ISW ��c
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): /(locate on site plan,excavation not required)
If SAS not located explain why:
i
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions: In )( �
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.):
tr✓ j'+
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: ZZ
Indication of groundwater inflow(yes Comment s(note condition of soil,siydraulic 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 f ' ure, level of ponding,condition of vegetation,etc.):
XX
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /S-cg�w 4ril✓t�
Owner:
Date of Inspection:
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.
G •
rs'
d
sy
3[.'
10
Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: / C-A ����•�%C
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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:
�G 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:
' -
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11
Bill Date: 01/06/99 Account #: 01-4638000-0
TOWN OF NORTH ANDOVER
Bill #: 0011279 Due Dat . 02/05/99
Water and Sewer Bill
Svc Addr: 158 OLYMPI N
s>< >:iz>izzz: i::::;:;_;:«:«<:���.1C.�d11�1 ..�B..��O..���'....................... ................... .........
................................. .......
b Mtr Previous Present Bill Usage Water Sewer
ID Date Reading Date Reading Code
001 8/28/98 3264 12/02/98 3302 EST. 38 $103 .74 0.00 $103 .74
,t
1; NEW WATER RATE IS $2.73 PER 100 CF. Previous Balance $0.00
,l SEWER RATE REMAINS $2.75 PER 100 CF. Penalty Charge $0 .00
UNPAID BALANCES WILL BE SUBJECT TO 14% INTEREST Interest
..� 10 3 .74
Kann t6ic nnrtinn fnr..n...ro�n.ic
Bill Date: 09/15/98 Account#: 01-4638000-0
TOWN OF NORTH ANDOV
D
Bill #: 0011279 ue Date: 10/15/98
Water and Sewer Bill
Svc Addr: 158 OLYMPIC LN
Jfeteir:Rafi t >
Mtr Previous Present Bill Usage Water Sewer - 0
ID Date Reading Date Reading Code
001 5/14/98 3166 8/28/98 3264 ACT. 98 $254.80 0.00 254.80
CURRENT WATER RATE$2.60 PER 100 CF. Previous Balance $0. 0 0
CURRENT SEWER RATE$2.75 PER 100 CF. Penalty Charge $0. 00
Interest 0 . 00
254 . 80
—_xeeD tbt L¢MAMIR For.Your record,-
Bill Date: 05/22/98 Account#: 01-4638000-0
TOWN OF NORTH ANDOVER
Bill#: 0011279 Due Date: 06/22/98
Water and Sewer Bill
Svc Addr: 158 OLYMPIC LN
::::::::::.:::::...::::: Rd S.qty.. 0. ?...........:..:.:::.::::::::.::.:...:...:::.:........:::.
Mtr Previous Present Bill Usage Water Sewer
ID Date Reading Date Reading Code
001 3/12/98 3132 5/14/98 3166 EST. 34 $84.66 $0.00 $84.66
CURRENT WATER RATE$2.49 PER 100 CF. Previous Balance $0.00
CURRENT SEWER RATE$2.55 PER 100 CF. Penalty Charge $0. 00
Bill Date: 06/15/99 Account#: 01-4638000-0
TOWN OF NORTH ANDOVER
Bill #: 0011279 Due Date: 07/15/99
Water and Sewer Bill
Svc Addr: 158 OLYMPIC LN
z ..... <: ii:
::;:::<:>::>::>:;:>:<:>::>::>::::>::>::>::>;::;:<:;::
Mtr Previous Present Bill Usage Water Sewer
ID Date Reading Date Readina Code
001 3/26/99 3339 4/15/99 3345 ACT. 6 $16.38 $0.00 $16 .38
"Beginning July 1st, a new billing system will Previous Balance $o . 00
be put in place. You will be billed quarterly Penalty Charge $0 . 00
on a 3-month staggered schedule. Your next bill Interest $0.00
will arrive either Aug 5 Se 15 or Oct 1
5
g p , » 16.38
I2
Bill Date: 03/20/98
TOWN OF NORTH ANDOVER count#: 01-4638000-0
Bill #: 0005928
Water and Sewer Bill Due Date: 04/20/98
Svc Addr: 158 OLYMPIC LN
Mtr Previous
Present Bill::::.:::::::;:.:
ID Date Readin Date Readin Code Usage Water Sewer
001 12 08 97 3099 3 12 98 3132 EST.
33 82.17 0. 00 82 .17
Previous Balance $0 . 00
Penalty Charge $0. 00
Interest o . 00
l.Due 8 z .17