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HomeMy WebLinkAboutTitle V Inspection Report - 36 SHANNON LANE 6/30/2006 006 COMmONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVTRCNVE N TAL AFFAIRS ............. DEPARTMENT OF ENVIRONMENTAL lU'�M SyQv A 1.1 Ll.� 5 NTARY ASSESSMENTS OFFICIAL INSPECTION FORM NO V- DISPOSAL AS� �® � PART A CERTIFICATION Property Address:_36 Shannon Lane_ North Andover_ Owner's Name: Bobby Lie Owner's Address: 36 Shannon Lane 011I45 _forth Andover, _ Date of Inspection; 6/30/2006_ Name of inspector:_Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_1.11 Argilla Road_ _Andover,Ma.01510 Telephone Number:J978)475-4706_ 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 ance of an site sewage disposal systems.I am a training and experience in the proper function and mainten 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 Date. _6/30/2006® Inspector's Signature°. — 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 systern 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, Page 2 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Shannon Lane_ �I _North Andover- Owner: _Lie_ Date of Inspection:_6/30/2006_ 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"Conditional as Pass"section need to be replaced or repaired.The system,upon completion of the replacement he or repair,the approved by the Board of Health,will pass.Answer yes,no or not determined(Y,N,ND)in following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the ,exhibits substantial in septic tank(whether metal or not)is structurally unsound filtration fitraetpion or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying s tic 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 M TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART A CERTIFICATION(continued) Property Address: 36 Shannon Lane_ North Andover- Owner: Lie_ Date of Inspection:_6/30/2006_ 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: 36 Shannon Lane_ _North Andover- Owner:_Lie_ Date of Inspection:_6/30/2006_ 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 _No_ Liquid depth in cesspool is less than 6"below invert or available volume is'/2 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 welt. _ _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 ASS SSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CHECKLIST Property Address: 36 Shannon Lane_ _North Andover_ Owner:_Lie_ Date of Inspection:_6/30/2006_ i 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 of construction,dimensions depthtof liquid,depth of s udg and depth of condition of the baffles or tees,material 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 INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 36 Shannon Lane_ —North Andover_ Owner:_Lie_ Date of Inspection:_6/30/2006_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):4_ DESIGN flow based on 310 CMR 15.203_600_ Number of current residents: Does residence have a garbage grinder(yes or no): Yes_ Is laundry on a separate sewage system(yes or no):_No Laundry system inspected(yes or no): Seasonal use: (yes or no): No_ Water meter reading:Yes_ Sump pump(yes or no):—Nom- Last date of occupancy:— Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.):e Grease trap present(yes or no):e 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 occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped four years ago,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped: 1500®gallons--How was quantity pumped determined?_Measured tank_ Reason for pumping: _Inspect tank&tees_ TYPE OF SYSTEM _X 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:-12 Years old,10/3/1994, 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: 36 Shannon Lane_ _North Andover_ Owner:_Lie_ Date of Inspection:_6/30/2006_ BUILDING SEWER_X_ (locate on site plan) Depth below grade:_36" 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"PVC thru floor,3"PVC in house with no leaks visible SEPTIC TANKS: % Depth below grade:_24"_ 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):e(attach a copy of certificate) Dimensions:_10'x 5'x 4' Sludge depth —411_ Distance from top of sludge to bottom of outlet tee or battle: 23"_ Scum thickness:_6" Distance from top of scum to top of outlet tee or baffie:_811 _ Distance from bottom of scum to bottom of outlet tee or baffle:_15"_ 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 septic tank leaking in or out. GREASE TRAP:_(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: 36 Shannon Lane_ _North Andover_ Owner:_Lie_ Date of Inspection:_6/30/2006_ TIGHT or HOLDING 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 BOXS:_X_ Depth below grade _4"_ 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 1 is used as drop box.Vent is out of this box.No carryover.No leakage.D-Box 2 is level&distribution equal.No carryover.No leakage._ PUMP CHAMBER: X (locate on site plan) Pump in working order(yes or no):—Yes_ Alarm in working order(yes or no):Yes_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pump chamber ok. Pump cycled on then off.Alarm has both audible&visual Page 10 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_36 Shannon Lane —North Andover_ Owner:_Lie_ Date of Inspection:_6/30/2006_ 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, Driveway Septic Tank ® A to D-Box 1 =108'3" House Water Meter A to D-Box 2=105'10" —� C Pump Tank B to D-Box 1=82'4" ® B to D-Box 2=82'2" A B B to Septic Tank=46'4" B to Pump Tank=48'5" C to Septic Tank=27'10" C to Pump Tank=36110" Vent D Box D-Box #2 #1 Page 11 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_6 Shannon Lane— —North Andover- Owner:_Lie_ Date of Inspection:_6/30/2006_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4'_ 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:_2/9/1990_ 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_ Summary Record Card generated on 6/27/2006 9:50:57 AM by Elaine Barclay Page t Town of North Andover Tax Map # 210-107.A-0228-0000.0 36 SHANNON LANE LIE, BOBBY 36 SHANNON LN NO. ANDOVER, MA 01845 - — 1 Residential Class 101 Single Family Property Type Size Total 1.28 Acres FY 2006 U8 Mailing Index Name/Address Type Loan Number Active/Inact. From Until LIE, BOBBY Payor 36 SHANNON LN NO. ANDOVER, MA 01845 U6 Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14223.0-36 SHANNON LANE Last Billing Date 6/13/2006 2100219 02 Cycle 02 Active U8 Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE 67.80 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 39977015 a Active ENC F.L. METE METE w Water 0.63 0.63 0 Date Reading Code Consumption Posted Date Variance 5/4/2006 854 m Manual estimate 20 6/20/2006 33% MSG 2/2/2006 834 m Manual estimate 15 3/13/2006 0% MSG 11/3/2005 819 a Actual 14 12/14/2005 50% Trouble Code:13 8/10/2005 805 a Actual 10 9/12/2005, 27% Trouble Code:13 5/11/2005 795 a Actual 13 6/8/2005 15% Trouble Code:13 2/14/2005 782 a Actual 16 3/15/2005 44% Trouble Code:13 11/16/2004 766 a Actual 12 12/17/2004 -47% Trouble Code:13 8/11/2004 754 a Actual 20 9/20/2004 319% Trouble Code:09 5/17/2004 734 a Actual 5 6/14/2004 -70% Trouble Code:13 2/17/2004 729 a Actual 19 4/16/2004 0% 11/6/2003 710 n New Meter 0 11/6/2003 0% Commonwealth of Massachusetts City/Town Of I Pumping System c Form DEP has provided this form for use by local Boards-of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When filling out 1. Sy m Locatio ,ter _ forms on the °1 computer,use t� E�L �+ c� ' only the tab key Address to move your cursor-do not use the return Cityrrown tat, Zip Code .key. 2., System Owner: ` Name " Address(if different from location) City/Town Stat Zipde i Telephone Number u in' c r 1. .Date-of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight.Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No - 5. Condition of Syste (4�cA \ V.". +b- U 6. Syst m Pun1ped By t _ LD Name Vehicle License Number Company 7. Locat there contents were Aspose d: SigrKture df H uler Date http://www.mass.gqvidep/water/approval8/t5forms.htrn#inspect t5form4.doc<06/03 System Pumping Record o Page 1 of 1 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: 36 Shannon Dane, North Andover Owner: Lie Date of Inspection: 6/30/2006 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. Bateson Bateson Enterprises, Inc.