HomeMy WebLinkAboutTitle V Inspection Report - 73 CARLTON LANE 6/9/2001 -'� COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: �73 �'A+2z-7bA1 I..el
�lL77 A-)Oda
Owner's Name:
Owner's Address: y Cf�`21-7bN' L t}/
Date of Inspection:
Name of Inspector: (please print)
Company Name:�Cy-1
Mailing Address:_( rt ,Glsc/-! GcJac !?rcJi.
J/012-22e 8,v oa clO /Y1 f)
Telephone Number:_q 7 R_ &VC-_ Z2
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 ex
perience 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:
asses.
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this in ion 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 ;
a� JFJ�j(
""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.
1
Page 2 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
PROPERTY ADDRESS:73 Carlton Lane rrRTIFICATION(continued)
North Andover
OWNER Karl Pessinis
DATE OF INSPECTION: 619101
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 I5.304 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 exfittration 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)
'ROPERTY ADDRESS:73 Carlton Lane.
North Andover
OWNER Karl Pessinis
DATE OF INSPECTION: 619/01
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of He/awiht, T ine if the system
is failin to protect public health,safety or the environment.
1. Syst will pass unless Board of Health determines in accordanc 15.303(1)(b)that the
system ' not functioning in a manner which will protect public hthe environment:
____, Cesspo or privy is within 50 feet of a surface water
— Cesspool rivy is within 50 feet of a bordering vegetated wet h
2. System will fail unless the Bo d of Health(and i blic Water Supplier,if any)determines that the
system is functioning in a manner t t protects th public health,safety and environment:
The system has aseptic tank and it sorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a s water supply.
The system has a septic tank SAS an e SAS is within a Zone 1 of a public water supply.
The system has a septic and SAS and the S is within 50 feet of a private water supply well.
The system has a se tic tank and SAS and the SAS less than 100 feet but 50 feet or more from a
private water supply ll**.Method used to determine di ce
**This system p ses if the well water analysis,performed at a P certified laboratory,for coliform
bacteria and volatile organic compounds indicates thgt the well is ee from pollution from that facility and
the presen 'f ammonia nitrogen and nitrate nitrogen is equal to or than 5 ppm,provided that no other'
failure cr' is are triggered_A copy of the analysis must be attached to is form.
Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PROPERTY ADDRESS:73 Carlton Lane.
North Andover
OWNER Karl Pessinis
DATE OF INSPECTION: 6/9 101
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or`no"to each of the following for all inspections:
Yes No
Z Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_L Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
1� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
V1^ Liquid depth in cesspool is less than 6"below invert or available volume is Iess than I/z day flow
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.
_V1. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
V Any portion of a cesspool or privy is within a Zone I of a public well.
V' 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 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.]
N(Yes/No)The system falls.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 co idered a large system the system must serve a facility with a design flow o 10,000 gpd to 15,000
gpd.
You must indr either"ye:?'or"no"to each of the following:
(The following Grit apply to large systems in addition to the criteria e)
yes no
the system is within 40 of a surface dr' g water supply
the system is within 200 feet of Lary to a surface drinking water supply
r the system is located' nitrogen sensitive ar terim Wellhead Protection Area—IWPA)or a mapped
Zone Il of publ' ter supply well
If you have ans ."yes"to any question in Section E the system is sidered a significant threat,or answered
"yes"in S 'on D above the large system has failed.The owner or operato any Iarge system considered a
significant threat under Section E or failed under Section D shall upgrade the sys ' accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
�T
Page 5 of I I
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
ROPERTY ADDRESS:73 Carlton Lane.
North Andover
OWNER Karl Pessinis
DATE OF INSPECTION: 619101
Check if the following have been done.You must indicate"yes"or"n0'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 7
✓� 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 built plans of the system obtained and examined?(If they were not available note as NIA)
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 7
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles br 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.
_ v""D etermined 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(3)(b)j
"r .
Page 6 of 11 ,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'ROPERTY ADDRESS:73 Carlton Lane,
North Andover
OWNER Karl Pessinis
DATE OF INSPECTION: 6/9/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4/ Number of bedrooms(actuaI):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:4_
Does residence have a garbage grinder(yes or no):&0
Is laundry on a separate sewage system(yes or no):N' [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):AV
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):„,4e'-0
Last date of occupancy: c?.v e i
C0MMERCL4L1INDUS'TRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):. gpd
Basis of design flow(seats/persons/sgft,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 meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: e A Pe a– o
Was system pumped as part of the inspection(yes or no):"
If yes,volume pumped: gallon --How was quantity pumped determined?
Reason for pumping:
TYPE 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/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:
Were sewage odors detected when arriving at the site(yes or no):AL
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'ROPERTY ADDRESS:73 Carlton Lane.
North Andover
OWNER Karl Pessinis
DATE OF INSPECTION: 6/9101
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: /VA
Comments(on condition of joints,venting,evidence of leakage,etc.):
z
SEPTIC TANK:_(locate on site plan)
Depth below grade:
Material of construction:Z ncrete 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:
Sludge depth: y"
Distance from top of sludge to bottom of outlet tee or baffle: 3 0
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: /4,„
How were dimensions determined: /hA S (L sr7c K
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
N K �• ca.,v a 00 c rf Pis i n1 c c," I
iJ c v c
PvC;
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 1 i
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS �M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _
PART C a
SYSTEM INFORMATION(continued)
pROpIRTY ADDRESS:73 Carlton bane.
North Andover
OWNER Karl Pessinis
DATE OF INSPECTION: 619101
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. Aolyethylene 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 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
Ieakage into or out of box,etc/ :
r o« bL a Cloy. G n7 �7J iaa`
e
ao •v yip ?i c7 3err,
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,condition of pumps and appurtenances,etc.):
Page 9 of 11 �
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'ROPERTY ADDRESS:73 Carlton Lane,
North Andover
OWNER Karl Pessinis
DATE OF INSPECTION: 6/9/01
SOIL ABSORP'T'ION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
Teaching fields,number,dimensions: / rCUn _/ P�`K 3c XG ;-&
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
o
z C- o NR rY] « n
O7 Z
CESSPOOLS:a(cesspool must be pumped as part of inspectionxlocate 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:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: N (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
y
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PROPER'T'Y ADDRESS:73 Carlton Lane.
North Andover
OWNER Karl Pessinis
DATE OF INSPECTION: 619/01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference Iandmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page 11 of 11 �� '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
PROPERTY ADDRESS:73 Carlton Dane, SYSTEM INFORMATION(continued)
North Andover
OWNER Karl Pessinis
DATE OF INSPECTION: 6/9/01
SITE EXAM
Slope
Surface water
Check cellar Aiu 50 —a
Shallow wells ,e
Estimated depth to ground water & feet
1�
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:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with Iocal 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:
" Cca 1 tr -5 I N 77 y(I i c" cs n
Z e'- —1- w t:
47
s e c d—
f?N 17 v-11
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