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Home My WebLink AboutTitle V Inspection Report - 67 VEST WAY 7/18/2016 Commonwealth of Massachusethi Inspection Title 5 Official Subsurface Sewage Disposall.System Form -Not for Voluntary Assessments"' ssessments 61x _ 4 m4 O Pro rty dclress - 6! if l( � c��f � Gamer Vfty&ow_n V�&infiyrmati fo is V Q rrxluired for eln3ry page, state Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Irnipoltant: General Information When filing out fonris on the wrnputer,use 1. Inspector: 1 only the tab key t tai move your use the m do not Name of Inspector ---— _ u:eE►the return p° koy. -----��I r j j ij N JAQ Company Name Company Address r�ara L CI !7n n e4 r1 Zip Code releph ne NumbetJ License Number" B. Certification 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 d Conditionally Passes E] Fails El Needs Further Evaluation by the Local Approving Authority Ins is Signature r Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Wealth 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. This report only describes conditions at the time of inspection and under the conditions of use at that tune.This inspection does not address how the system will perform in the future under the same or different conditions of use. tSin;•03/13 TNt S orfidel inspection pot":Subsurfeoa Sevrege Disposal System•page 1 0117 Commonwealth of Massachusetts Title i i l Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address _ Owner Information is Owner's Name _ required for every page. City/Town State Zip Code Date of Inspection v B. Certification (cont.) -- 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: k zJ m I C o Val vv � G 5 �� rA �i YI 13)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. Check the box for"yes", "no"ter"not determined"(Y, N, ND)for the lowing statyements. If"not determined, " please explain. �J The septic tank is metal and over 20 years old*or the seyt(c tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or,eScfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced�arl1h a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspectio ' it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank i es s than 20 years old is available. ® Y ® N ND (Explain below): i — i Title 5 Official Inspection Form Subsurface Sewage Disposal system- Page 2 of 17 Commonwealth of Massachusetts Title i i l Inspection Form aSubsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Information is Owner's Name required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cost.) B) System Conditionally Passes (cont.); ❑ 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 ❑ Y ❑ N ❑ ND ( xplain below): ❑ obstruction is removed ❑ Y ❑ N ❑ (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ ND (Explain below): ❑ The System required pumping m e than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if�wllth approval of the Board of Health): ❑ broken pipe(s)ar, replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction ' removed ❑ Y ❑ N ❑ ND (Explain below): 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. I. System will pass unless Board of Health le mines in accordance with 310 CMR 15.303(1)(b)that the system is not function gin a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within eet of a surface water ❑ Cesspool or privy is w i In 50 feet of a bordering vegetated wetland or a salt march t5ins•03/13 Title 5 Official Inspection Form Subsurface sewage Disposal posal System•Page 3 or 17 '.. Commonwealth of Massachusetts Title i i l Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Vps ytj� Property Address — — — Owner Information is Owner's Name required for every page. City/Town State Zip Code bate of Inspection B. Certification (cunt.) - - — 2. System will fail unless the Board of Health (and Public Water Supplier, if any) deterimes 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 'AS is within 100 feet of a surface water supply or tributary to a surface water supp ❑ The system has a septic tank and SAS and the SAS is within a Zo supply well. 1 of a public water supply. El The system has a septic tank and SAS and the SAS is with 50 feet of a private water ❑ The system has a septic tank and SAS and the SA 46 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 anal s performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presen of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no othe. allure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No, ® d Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 12/ 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 outlet invert due to an overloaded or clogged SAS or cesspool ® ® Liquid depth in cesspool is less than 6"below invert or available volume is less than % day flow t5ins-03/13 - - ---- Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title Official Inspection t subsurface Sewage Disposal System Form - Not for Voluntary Assessments a = UPS Property Address Owner Information is Owner's Name required for Every page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ Required pumping more than 4 times in the last year NOT due 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 water supply. ❑ EY' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Ek' 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 passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ Q This system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 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 bey 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. / Yes No / ❑ ❑ the system is within 400 feet of a fface drinkiing water supply ❑ ❑ the system is within 200 fee a tributary to a surface drinking ater supply g PP Y ❑ ❑ the system is locate a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA or appedZ_one II of a public water supply well If you have answered "yes"to question in Section E the system is condidered a significant threat, or answered"yes"in Sec above the large system has failed. The owner or operator of any large system considered a s' rSificant threat under Section E or failed under Section D shall upgrade the system in accord�heDet ith 310 CMR 15.304. The systern owner should contact the appropriate regional officero art ment. t5ins-03113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of V Commonwealth of Massachusetts Title ffi i I' Ins pection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments VPs Property Address - -- Owner Information is Owner's Name �. required for every page. City/Town State Zip Code Date of Inspection C Checklist y �- 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 ❑ 0 Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ E Have large volumes of water been introduced to the system recently or as part of this inspection? Ex ❑ 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? 2" ❑ Were all system components, excluding the SAS, located on site? D"' ❑ 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? 2 ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? This size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ 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) [310 CMR 15.302(5)] D. System Information --Y-- Residential Flow Conditions: 1 Number of bedrooms (design): _ �/ Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): J l5ins OJ/13 Title 5 official Inspection Form Subsurface sewage Disposal System•Pape 6 of 17 • Commonwealth of Massachusetts Title i i I Inspection morm a' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments VO4( Property Address - -- Owner Information Is Owner's Name --- required for every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: _ �{ Does residence have a garbage grinder? lu,: (�F� (�'w�� (� V e 0 Yes ❑ No Is laundry on a separate sewage system? [if es separate inoction required] ❑ Yes 1!J No Laundry system inspected'? ❑ Yes ❑ No Seasonal use? ❑ Yes E3" No Water meter readings, if available(last 2 years usage(gpd)): (D IU ,v Detail: Sump pump? E3 Yes G] No Last date of occupancy: Commercial/Industrial Flow Cohditions:. Date Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) —� Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes Cl No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Tit 5 system? ❑ Yes ❑ No Water meter readings, if available: *N• -• a Title 5 Official Inspection Form Subsurface Sevrege Disposal System•Pape 7 of 17 '.... Commonwealth of Massachusetts Title i i I Inspection Form a lip Subsurface Sewage Disposal System Form Not for Voluntary Assessments p Property Address — Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ---�--f— ❑ Yes No If yes, volume pumped: How was quantity pumped determined? gallons Reason for um in p p 9 Type of System: 1 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval ❑ Other(describe): Bins-03I13 Tllle 5 Official Inspection Porte Subsurface Sewage Disposal System•Pape 8 of 17 Commonwealth of Massachusetts Title ffi i t Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r` 6 0 6::h�Jq I) Property Address Owner Information is Owner's Name — required for every page. City/Town State Zip Code Date of Inspection D. System Information (coot.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: Material of construction: feet ❑ cast iron 12 40 PVC ❑ other(explain) Distance from private water supply well or suction line: F6—et --� _- Comments (on condition of joints, venting, evidence of leakage, etc.): /42 �- :q L L Septic Tank(locate on site plan): Depth below grade: S feet Material of construction: concrete ❑ metal ❑ fiberglass % ❑ polyethylene ❑ other(explain) If tank is metal, list age: Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: / 06 Wl- Sludge depth tsins•03/13 Title 6 Official Inspection form Subsurface sewage Disposal system•papa 9 of 17 Commonwealth of Massachusetts oritle 5 Official Inspection a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 05 Property Address ----- Owner Information is Owner's Name — --_ required for every page. City/Town Slate dip Code Date of Inspection -- D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 . How were dimensions determined? �- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): C rY- -k r � 1r° o-'ae Yr ✓1 U a n I I� t?P I L4e _I Grease Trap(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ® fibergla � ❑ of �� Polyethylene ❑ other(explain) E Dimensions: Scum thickness Distance from top of scum to to�of outlet tee or baffle Distance from bottom of scuft`i to bottom of outlet tee or baffle Date of last pumping: f t5ins•03113 Date Title 5 Official Inspection Form Subsurface Sewage oisposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form C�` Subsurface Sewage Disposal System [Corm - Not for Voluntary Assessments � C 54 Property Address Owner Information is Owner's Name —_ required for every page. CiryRown State Zip Code Date of Inspection — D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee orb We condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 17Z Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ poll Y ylene ❑ other(explain) Dimensions: Capacity: e Ilons Design Flow: gallons per day -- Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Comments (condition of ;rm n d float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•03/13 Title 5 OPociel Inspection Form Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title ffi i l Inspection r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address - Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): Z) 15 � P I-D � rdy� bq� Pump Chamber (locate on site plan): Pumps in working order: Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n t 4-1 A �-e� Soil Absorption System (SAS)(locate on site plan, excava k5n not required): If SAS not located, explain why: r' y tsins-03173 'tile 5 official Inspection Form Subsurface Sewage Disposal system Page 12 of 17 '.. Commonwealth of Massachusetts Title ffi ial Inspection Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Information is Owner's Name required for every page. Cityfrown _ State Zip Code Date of Inspection D. System Information (cant.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: _ ❑ leaching trenches number, length: 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.): b l 1x - (-i-i)] C. J WC --P" 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 / r Indication of groundwater inflow ❑ Yes ❑ No e ""'d Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address -- __ Owner Information is Owner's Name required for every page. CitylTown State Zip Code Date of Inspection r D. System Information (cont.) Comments (note condition of soil, 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 hydraulic ft J�e, level of ponding, condition of vegetation, etc.): t5ins-03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal system•Page 14 of 17 Commonwealth of Massachusetts Title Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N 67 Vest Way Propertv Address -- Owner Owner's Name. information is required for North Andover MA 01845 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 0 � � I L4 a car 6 t5ins-11/10 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•page 15 of 17 Commonwealth of Massachusetts Title ffi i l Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r Property Address �- Owner Information is Owner's Name .required for every page. City/Town — State Zip Code Date of Inspection D. System Information (cost.) - _-- Site Exam: ® Check Slope ❑ Surface water / ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: dObtained from system design plans on record If checked, date of design plan reviewed: (j a-Fe I -- ❑ 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 USG$ databaso-explain: You must describe how you established the high ground water elevation: r` Before filling this Inspection Report, please see Report Completeness Checklist on next page. t5ins-03/13 Me s official Inspection Form Subsurface sewage Disposal system•page 18 of 17 Commonwealth of Massachusetts LWM�� Title 5 Official Inspection° l n r ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11,��zr V� Property Address owner Owner's Name — Inform ation is — requinad for every page. City/Town _ State Zip Code Date of Inspection E. Report Completeness Checklist 2- Inspection Summary:A, B, C, D, or E checked Er Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information - Estimated depth to high groundwater L+�J Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-0:1/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 711812016 2:15:55 PM by Karen Hanlon Page 1 '.... Town of North Andover Tax Map # 210-104.B-0162-0000.0 Parcel Id 16484 67 VEST WAY GLEN & PATRICIA SCHMIDT 67 VEST WAY NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential 7oning3 1 Residential Size Total 1.03 Acres FY 2016 UB Mailing Index Name/Address Type Loan Number Activellnact. From Until GLEN&PATRICIA SCHMIDT Owner 67 VEST WAY NORTHANDOVER MA 01845 PALLONE,JOHN Previous Customer Inactive 11/16/2012 67 VEST WAY N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/inactive Bldg Id. 17812.0-67 VEST WAY Last Billing Date 4/14/2016 3170477 03 Cycle 03 Active UB Services Maint. Account No.3170477 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 0.63518 7.82 1/ WTR WATER 01 ALL METER SIZE 57.00 /1 UB Meter Maintenance Account No,3170477 Serial No Status Location Brand Type Size YTD Cons 36185549 a Active ERT HH b Badger w Water 0.63 0.63 1191 Date Reading Code Consumption Posted Date Variance 6/13/2016 1246 a Actual 47 207% 3/11/2016 1199 aActual 15 4/22/2016 -52% 12/10/2015 1184 a Actual 31 1/2012016 -64% 9/9/2015 1153 a Actual 85 10/16/2015 250% 6/10/2015 1068 a Actual 24 7/24/2015 71% 3/12/2015 1044 a Actual 14 4/28/2015 -42% 12/12/2014 1030 a Actual 25 1/15/2015 -74% 9/10/2014 1005 a Actual 97 10/15/2014 224% 6/9/2014 908 a Actual 29 7/16/2014 105% 3/11/2014 879 a Actual 14 4/11/2014 -16% 12/1212013 865 aActual 17 1/17/2014 -77% 9/12/2013 848 aActual 76 1D/15/2013 55% 6/11/2013 772 a Actual 47 7/24/2013 305% 3/14/2013 725 a Actual 12 4/22/2013 22% 12/12/2012 713 aActual 3 1/9/2013 -73% 11/14/2012 710 f Final Bill 25 11/14/2012 -71% 9/12/2012 685 a Actual 124 10/1512012 179% 6/12/2012 561 a Actual 44 7/16/2012 78% 3/13/2012 517 a Actual 25 4/14/2012 -46% 12/12/2011 492 a Actual 45 1/17/2012 -70% 9/13/2011 447 aActual 164 10/13/2011 541% 6/7/2011 283 a Actual 24 7/20/2011 -3% 3/7/2011 259 a Actual 24 4/13/2011 1% 12/8/2010 235 aActual 24 1/12/2011 -84% 9/9/2010 211 a Actual 155 10/15/2010 552% 6/812010 56 a Actual 23 7/15/2010 -9% I I