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HomeMy WebLinkAboutTitle V Inspection Report - 55 SHERWOOD DRIVE 10/5/2006 577 MAIN STREET HUDSON,MA 01749 800-499-16132 WINDRIVER ' " OCT 2 3 2006 �IEALI DEPARTMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: GINNY & SAL,ANDRONICO PROPERTY ADDRESS: 55 SHERWOOD DRIVE NORTH ANDOVER, MA 01848 ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: OCTOBER 5,,2006 NAME OF INSPECTOR: IIANIEL IIECOSTA Commonwealth of Massachusetts Title iii Inspection Form Not for Voluntary Assessment6 Subsurface Sewage Disposal System Form Inspection wits must be submitted on this fotnit or on the r}ffir:ial TWe 6 Inspection Form dated 61161200D. Inspection forme may not be alter ei itt anyway. A. Ceirtif i+:glition Important: When filling out 1. Properlf`^`orrrmatlon., forms to the o6rnputQr,use only the tab Kay p ertY Mdrej n to moves your <r►v -�- hirV�� v+i _ curaor-do not Owner's Name ose the retunl key, ok At Cttylt vwn ;'^A�^ Ip Cads Data of Inspection: V ���r J l 2.� 2. uUmadot (ctY A Comnany.Name ; Camp ahXA 1d ress ' 6(aco.. MA 01749 C t own , State Zip Code Tolophone NumberNumber i Certifloatlon 3 ted'P iM: I certify that 1 have porsonrally inspected the swage disposal system at this addross and that the information reported,billow Is true,accurate nil complete as of the time of the inspection.The-inspection was performed based on fny training and ex erience in the proper function and maintenance of on site sewage disposal systems. I am a DEP app ved syat6m iftiepactorpursulknt to$eotion l$. of Title 5(310 CIVIR 15000):The system: Passes �] t onditionslly Passes Fails urther lion e I A roA Authority Inopedoes gnatute bate The system Inspector shall suWWt a cop Of thla Inspection report to the Approving Authority(Sward of Health or DI=P)within-30 days.bf corn teting this inspection_ If the system is a shared system or has a design flow of 10,000 gpd or great r;the inspector and the system owner shall submit the report to the appropriate regional office the DER The original should be sent to the system owner and copies sent to the buyer, if applicabl , and the approving authority. ****'This report only deacdbes+ixmdltlons Fddrmm the time of inspection and undar the conditions of use at that tirne.This ittspetation does not how the"tam will Perform In the fuWm under the same or dif�rerent condittaps of us 72 Nfekarson Rd Aahland.doc•1112604 ! Title 6 QM 041 Irlepeatron Form:Subsurface Sewage Disposal System. Page 1 of 113 i Comtnbr wealth of Massachusefts Title 5 Official Inspection Not for Voluntary Aslse ssmont subsurface Sewage Disposal System Form A. Certification (cant.) propertyAddM& '- CFY,—rr wt St&tey Zip Code ownef's Name Date of Inspsction Inspection Summary. Check A,B,C,D or E I always oomplate aft of Section D A) Systom Passe; 1 have not found any information which indictites that any of the failure criteria described in 31.0 CMR 15.303 or in 310 CMR 16.304 exist.Any failure criteria not evaluated are indioated below, Comments: / ,q Get Zw _4� • ~ i � U � 1t9 +E�Md �u151.4CCd o t, i f ! r o C 8) System Conditionally Pasaea: 11 One or more system components as described in the"Conditional mass°sdction need to be replaced or repalred.The system, upon completion of the reply ment or repair, as approved by the Board of Health,will pass. Answer yes, no or not determines!(Y, N,ND)in the E]for the following statements. If"not determined," please explain. C� The septic tank is metal and over 20 years old"or the septic tank(whothor metal or not)is structurally unsound, exhibits$ubstantiai infiltration or exfiltration or tank failure is Imminent. System will pass inspection If the existing tank Is replaced with a complying septic tank as approved by the Board of Health. "eA metal septlo tank will pass inspection If It is structurally sound, not leaking and if a Cerfiflrate of Compifance indicating that the tank Is less than 20 years old Is available. ND Explain: 72 Nickerson Rd Ashiand.doc d 11/2404 TO 5 t7f eW Inspeclton Form,.Subsurfece Se wove Disposal System d Page2cf16 Commonwealth of Massachusetts lugTitle 5 Official. Inspection Form, Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. ertificatlon (cant.) Property AddrQ$s Ci#yR own. �}t�ta — - zip Code OwnWa Name Data of Inspection B) System Conditionally Passes(000): (J Q 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 it(with approval of Board of Health): ® broken plpe(s)are replaced El obstruction is removed Q distribution box Is leveled or replaced NOD Explain: Q The system required pumping more than 4 fnfres a year due to broken or obstructed pipe(s).The system will pass lnspeetion if(with approval of the,Board of Health): broken plpe(s)are replaced obstruction is removed NO Explain: C) Further Evaluatlion Is Required by the Board of Health; to� ® Condttlons exist which require further evaluation by the Board of Health In order to determine if the system is falling to protect publio haalth, safety or the environment. 1. System Mill pats unless Board of Health determines In accordance WM 310 CMR 15.303(1)(b)that the sysom is not functioning In a manner which will protect public heal`t@-i, .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 72 Nickerson Rd Arrhiand.daa•1112044 TMe 5 Omoiai Inspeotion Form:Subeurfeco sewage Enspow system a Pogo 3 of 16 Cornmonwoalth of assachuse ' I Inspection Form Title 5 Offida Not.for Voluntary Asaessm6nte Subsurface Sewage Disposal System Form An Cortification (coat.) PropeM Address . Vp Cade Owner's Name Date of inspection O) Furaier Evatuatlon is Required by the Board of Health (Cont): 2., System will fail unl the Soard of Wealth (and Public Water Supplier,if any) detarrrtlnes that the eystam is func-tloning In A manner that prote the Public health, safety and environment* ❑ The-system has a septic tank and soil absorption system (SAS)and the SAS is within loo feet of a surface water supply or tributary to-a surfer$water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 7 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. ❑ Th6 system has a septic.tank anti 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 booteda 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 foilurs criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. 72 Nlaker'&art Rd Ashlsrid.doo-9 W004 'title 5 offklel Inspection Farm;Subsurface Sewage mtposel system P Pages 4 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Parch A. Certification (coot.) S'atif �vio Proderw Address r.,sfv�i'awn Std �4, ZlpGodaa Owner's Nam; — Dote of rnspeotlan 0)Syetenr Failure Critorlacr Applicable to All Systems: 'You moat Indl "Yes"or"No"to each of the follomAng for All Inspsaagons: Yes No D Backup of sewage into facility or system component due to overloaded or clogged S,AS or rasspool C� 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 outset invert due to an overtoaaded or clogged SAS or cpool ® Liquid depth in cesspool Is less than 6"below invert or available volume Is less than%day flow Qr Required pumping,more than 4 times in the last year N01rdue to clogged or obstruoW pipe(a). Number of tithes pumped, ® TV Any,portion of the SAS,cesspool or privy Is below high ground water elevation. El Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface watar supply. [] -Any portion of a cesspool or privy is within a Zone 1 of a public well, 0 L, Any portion of a cesspool or privy is within 60 feet of a private water supply wall. Any portion of a cesspool or privy is less than 100 feat but greater than SO feet from a private water supply well with no acceptable water quality analysis. RThIs system passes if the well ulster analysloy performed at a DEP cer liflod laboratory;for colfform bacteria and volatile organic C*Mpounds Indicates that the well Is free from pollution from#tit faellittr and the presence of ammonia*nitragen and*nitrao nitre is equal to or loss; than 6 ppm,provided that.no other failure cMeriart Ana triggered.A copy of the analysis must be attached tas this form.] . Yes No ® The system hft.I have determined that one or more of the above failure critoria exist as described in 310 GMR 15.303, therefore the system fails.The system owner should oontact-the Board of Health to determine what will be necessary to correct the failure. 72 Nickerson Rd Aanfand.doa 11!2004 Me 6 OfFraral Inspeaon Farm:Stxbaurfsaca Sawago Dlaposal System° Page,$d 16 Commonwealth of Massachusetts itle 5 Officimal Inspection Not for Voluntary Assessments iubsurfaGe Sewage Disposal System Form A. Dex41t1cation (rant.) C Sf. p Zip Code Owner's Name Qate of 1"11PG(WUF) IMj -Large,Syaftme: T4i be Considered a Largo system the system must salve a facility with a ds>rign ftowof 10,000 gpd to 1&004gpd. For large systdm!�, you must indicate either'yes"or"no"to each of the following, In addition to the questions in Section D. YES NO 0 0 the system is within 400 feet of a surface drinking water supply E] [j the system-is within 200feet of a tributary to a Surface drinking water supply D the system is tooted in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zane if of a public water supply well If you have answered`yefa"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 they. system in m=rdance with 310 CMR 15.304.The system owner should contact the appropriate regional offlco of the Department. A Title V inspection is often misunderstood to suggest that we are conducting a complete inspection of your system. A Title V inspection is limited to determining if, at the time of the inspection,the existing septic system is functioning. The State of Massachusetts has outlined specific tests that are to be performed,which will be completed during your Title V inspection. However, a Title V inspection, and the inspection that Wind River Environmental is performing hereunder,does not evaluate if the system was installed correctly,has been engineered in accordance with state and local regulations, or whether the system will continue to function in the future. It also does not evaluate whether the system would meet the past, current,or future Board of Health or State DEP regulations. A system can pass Title V but still not meet state or local requirements or be suitable for continued use. If the customer would like a complete inspection of their system, including an evaluation as to the design and suitability of your system,Wind River Environmental can provide a quote as to the cost of such services. As well,Wind River Environmental strongly recommends persons interested in buying a home to have a full and complete system evaluation before purchasing a new home. A new home buyer should not rely on a Title V inspection in determining if the system will function in the future, and instead should commission a complete system inspection. 72 Nlckatson Rd A$hland.doc•11/2004 Tide 6 Officio!Inspedtion Pdrr�;Subaurfine Sewage D18potW System Rage 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Not for Voluntary Assessments Subsurface Sewage Disposal System Form Checklist Property Address Cily/rawn State by bode Owr►or's Name Date of Inspection Check if the following have been done.You mint indicate"yes°or"no"us to each of the following; YES NO . ❑ Pumping,information was provided by the owner, occupant, or Board of Health ❑ �+ Wore any of the system components pumped out In the previous two weeka? ;, ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? © Were as buRt plans of the system obtained and examined?(If they were not available oote as WA) i�v' ❑ Was the faddy or dwelling inspected for signs of sewage back up? ❑ Was-the site inspected for signs of break out? ( Were all system components, excluding the SAS,located on site? ❑ Were the wilo tank manholes wnoovered, opened, and the interior of the tank Inspected for the condition of the baffles or tees, material of construction, d1mensions, depth of liquid, depth-of sludge and depth of scum? ❑ Was the facility owner(and occupants If different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The.sire and location of the SolI Absorption Systom(SAS)on the site has been getermined.based on. ❑ Exiating•Information. For example,a plan at.'the Board of Health. ❑ Determined in the Meld(it any of the failure criteria related to Part-C is at Issue approximation of distance is unarceptablo)[S10 CMR 15.302(3)(b)) 72 N1ckemon_Rd A$h1and,doa•111004 Tltle•6 Olffcial Inspection Form:Subsurface Sewage Disposal System Page.7 of 16 Commonwealth-of Nlassaahusetts AI ' ial Inspection Not for Voluntary Assessthents Subsurface Sewags Disposal System Form C. System Inform attWn r.i+- pyyrj Stale ZIP Code Owner's Name Oat*of IniFWtion RtmIdential Flow Conditions: Number of bedrooms(design): Number of bedrooms(sctuai): �t DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#ref bedrooms): Num ber of current residents: Does residence have a garbage grinder? Yes E� No Is laundry on a separate sewage system?[if y0a separate Inspection required) fj Yes 1 C No Laundry dystem Inspected? Ll Yes M--"'No Seasonal E}se? fifes ff No Water meter readings, If available(last 2 years usage(gpd)): -- sump pump? Yes [d No Last date of occupancy: os� CommewAalllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): GaH ,s per day(spd) Oasis of design flow(seats/persons/sq.ft., etc.): Cruse trap presont? Yes No Industrial waste holding.tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? © Yes No Wafer-meter readings, If available: Last-date of occupancy/use: irate Other(describe): 72 Nickerson Rd Ashland.doo•I U2004 Title 5 OffldW inspection Fafm:Subsurface Sewage Disposal Systain Fags a of 1s Commonwealth of Massachusetts Title i l Inspection Not for Voluntary.Assessments Subsurface Sewage Disposal System Form C. System Information (cant.) Property Address v'.itytr45Wn . Bute - - — Zip Code Owner's Nartle 03te of lnepoctron Gonaral information Pumping Records, Source of Information: . �t1 Was system pumped as part of the inspection? ,G/Yes. [I No If yes,volume Pumped: sit �U Wow was quantity pumped determined? Reason for pumping: Ce Type of Syetarn- Septic tank, distribution box,soil absorption system Q Single cesspool El ovlergow cesspooll rl Privy Shared system (yes or no)(if yes, attach previous inspection records, if any) tnnovativedAlternative 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(desodbe): Approximate pga of all components, date/Inatailed(N known/) and source of infOrrmation: eer Were sewage odors detected when arriving at the site? Yee ' No 72 Nickersw Rd Mhland.doo•1112004 Me 5 OfgOial inspaGtlon Forth:Subsurface Sewave Disposal Syntex»o Page 0 of 46 Commonwealth of ilVlausvchusetts -WT1xHe 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property Addr"M C State Zip Code Owner's Name Date of Inspection 6uiiding Sewer(locate on site plan): Depth below,grade: feat Material of construction: cast iron f'40 PVC town water Distance from private water supply well or suction line: -- feet Comments(on ndition df jointaf,venting,evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: [concrete 0 metal El ftberglasa ❑ polyethylone other(explain) If tank is matai, list age; year Is age confirmed by a Certificate of Compliance?(attach a copy of ® Ye* No rertirloate) Dimensions: E O i 1. X�r-j x7`f r Mudge depth: • �i1 ! Distance from top of sludge Jo bottom of outlet too or baffle Soum thickness Distance from top of scum to tap of outlet tee or baffle (distance from bottom of scum to bottom of outlet tee or baffle — How were dimensions determined? 72 Mckpreon Rd Ashland.doc•11/2004 Me 5 Of Wal Inspection Form;Subsurface Sewage Dieposal System Page 10 of 10 Commonwealth of Massochusetts Title ffi 1 Inspection Not for Voluntary Assessments Sobsurface Sewage Disposal System Form S. System, Inforrnaltlon (cont.) Cvfrawn State Zip code owners Name oete of Inspection Comments(on pumping recommendations, inlet and outlet toe or baffle condition, structural integrity, Ilquid levels as related to outlet.invert, evidence of leakage, etc.): . Recommend annual pumping Inlet and outlet tee in good condition structural integrity is good, ligVid` level to outlet invert no evidence of leakage. Grease Trap(locate on Site plan): Depth belowgrade: f�$t Material-of construction: El concrete Q metal C1 fiberglass (] polyethylene other("sin): Dimensions: Scm thickness Ristancer from top of scum to top of outlet ted or beffla Distance from bottom of mum to bottom of outlet tea or baffle note of last pumping: Date Commenta(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Fight*r Holding Tank(tank must be pumped at time of in ction)(locate on site plan): Depth below grade: Material of Construction: d concrete o metai Cl fiberglass polyethylene ll other (ex0ain); 72 Nickerson Rd Ashland.dct•1112004 Tillo&Official Inspection Form:Subsurface Sewage olsposal System page 11 of 10 Commonw0alth of Masssahugotts Title i In' spection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cant.) Rmperty.Addras0 gltyaown 5fata Zip Code OwnW&Name date ofinspecttan Tight or Holding Tank(Wnt-) Dimensions, Capacity: gallons Design Flow: gallons per day Alarm present: Yes No Alarm level: Alarms in working order, Yes© No Date of last pumping: ,Date Comments(condition of alarm and float switches, etc.): Ctstributlon Box(if present must be opened)(locate on site plan):y e Depth of liquid level above outlet invert Comments(note If box Is laval and distribution to Outlet#equal, any evidence of solids carryover, any evid�nc�of la,akaq�first dr��t of box.e#r�• . � _ _ -� -. L46. Pump Chamber(locata on site plan): Pumps in working order. El Yes Ll No Alarms In working order: (] yes Q No 72 Nickerson Rd Ashland.doo•1112004 Title 5 dial Inepe MOM FOM Subistirt8cd Sewage Dlapos'al System Page 12 of 16 Commonwealth of Massachusetts "I"'itle 5 Official Inspection Not for Voluntary Assessmertts Subsurface Sewage Disposal System Form C. System Information (c*nt.) Propartv.Address Zip Cade Owner's Namev Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: Cl leaching chambers number. Q leoohing galfades number: leaching trenches number, length: leaching fields number,dimensions: ❑ overflow cesspool number: innovative/aitemative system Type/name of technology- Comments (note condition of soil;signs of hydraulic failure, level of ponding,damp soil, Gondition.of r,.5.1.4� �?•, �1... frt�j �Lgre �A dt e� 72 Nickerson Rd Ash[and.doo+11/2004 TMe 5 pfnciai Inspection Parm:subsurraco Sewage t)Iapvsat system Page 13 of 16 Commonwealth of Massachusetts Title i c i Inspection Not for Voluntary Assessments Subsurface Sewage Disposal System Fdrm G. System Information (cunt,) Properiv Address Cf y/Town State Zip Code - Ciwner's Name oato of inspection CGespools(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 - - Dimensiono of cesspool —-Material's of of Construction - Indication of groundwater inflow 0 Yes No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, Privy(locate can sito plan): Materlsia of construction: Dimensions Depth of solid$ Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc_): 72 N1ckar8On ad Ashland.doc•11!2.004 7 the 5 afficiat Inspection rmn;subsurface sewage!deposal system Page 14 of 16 Commonweatth of Massachusetts Title xl ,I i N-ot f6y Voluntary Assessments $ubsurfam sewage Dlspbsal System Form. Ca System Info ation (cant.) P(oss4*A re## W►/X owri Meta �� Ztp Gbds owner's Namr Data pe4tlon 'Skstoh,Of 8ev090 ti'tsposai System;Provide a.skdtolh s)f the aowege'dleposal sy.6tem fholudln3g flea o at least two pennonent reifeuence lgndmafks or benchmarkv. Locate all watts wlthln 100 fist, Locate where pubtic water supply enters IN bulldfnq. 145 iq Lt Vt-o D j 1 1 t d�c.�v\—\ 4 h 1 • ter a,d�q.a��soda 17984©M0141lnspeages Fbft:ftbsuffaa i�wmge Dltjp fiystbm t twee 16 Pf 1b Commonwealth of Massachusetts Title Inspection Form Not for Volulntary•Assessmieints Subsurface Sewage Disposal System Form C. System Information (cunt.) Pro0aft Address gWTuwn Stata , , 7Jp Code Owner's Name data of Inspection Site ftam: Slope ' Surface water Check cellar Shallow wells Eatir►tatr3ri depth to ground water: Please indicate all methods used to determine the high ground water elevation, Obtained from system design plans on record If checked, date of design plea reviewed: Dote Observed site(abultJng property/observation hole within 150 feet of SAS) Checked with local Board of Wealth-oxplaln: (� Cheeked'with local excavators, instaliers=(attach documentation) Q Aoomed USGS database k explain: You must desoribo how you+eatabllahed the high ground water elevation: 72 Nickerson Rd Ashtend.doc• 111$004 Tlile 5 OfICial Inspection Form:Subeurrace Salvage Disposal System Page 16 of 10 t' o coo 191" 00 Kam "' a g kn o E 4 O cn pq fA G NN C4 G1 1 Moo w tn M c+> c 69 fr! C D p o w .. lid �o N �. ZO � b CJ a1 o to ►d yx rfy O...4. 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