HomeMy WebLinkAboutTitle V Inspection Report - 67 STONECLEAVE ROAD 4/7/2000 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON,MA 02108 (617)292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL S'Y'STEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 67 Stoneeleave Rd.
N. Andover, MA 01845
Property Owner: Steve Casey
Date of Inspection: April 7, 2000
Name of Inspector: (Please Print) Paul G. Jenner
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3 10 CMR 15.000)
Company Name: PAUL G. JENNER ASSOCIATES, Inc.
Mailing Address: 31 RILEY AVENUE
Telephone Number: EAST WEYMOUTH, MA 02189
(781) 337-8617 Fax (781) 3371802
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 inspection.The inspection was performed based on my training and experience
in the proper function and maintenance of on-site sewage disposal systems.The system:
X Passes
Conditionally Passes
Needs Further Ev, ation y the Lo ppro ng Authority
Fails
Inspector's Signature: Date: April 8, 2000
The System Inspector shall submit a copy of this i Zctio_n� o rt to the Approving Authority(Board of Health or DEP)
within thirty(30) days of completing this inspect' If 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 Department of
Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and
the approving authority.
NOTES AND COMMENTS
PAUL G. JENNER,ASSOCIATES (Revised 9/2/98) -Page 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION.(continued)
Property Address: 67 Stonecleave Rd.
N. Andover, MA 01845
Property Owner: Steve Casey
Date of Inspection: April 7,2000
INSPECTION SUMMARY: Check A,B,C,or D:
A. SYSTEM PASSES: YES
X I have not found any information within indicates that any of the failure conditions described in 310 CMR 15.303
exist. Any failure criteria not evaluated are indicated below.
B. SYSTEM CONDITIONALLY PASSES: N/A
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.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances.If"not determined",
explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a
Certificate of Compliance(attached)indicating that the tank was installed twenty(20)years prior to the
date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows
substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the
existing septic tank is replaced with a conforming septic tank as approved by the Board of Health.
! Sewage backup or breakout or high static water level observed in the distribution box is due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection
o:
if(with approval of the Board of Health).
n
broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
z
PAUL G. JENNER:,ASSOCIATES (Revised 912198) -Page
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 67 Stonecleave Rd.
N. Andover, MA 01845
Property Owner: Steve Casey
Date of Inspection: April 7, 2000
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: NO
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect the public health,safety and 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 THE PUBLIC HEALTH AND 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.
I
2) SYSTEM WELL FAIL UNLESS THE BOARD OF HEALTH(AND THE PUBLIC WATER SUPPLIER,
IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT
THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water
supply Wei I.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water
supply well.
' The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or
more from a private water supply well,unless a well water analysis 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. Method used to determine distance
(approximation not valid).
3) OTHER:
3
PAUL G. JENNER ASSOCIATES . (Revised 912198) -Page
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 67 Stonecleave Rd.
N. Andover, MA 01845
Property Owner: Steve Casey
Date of Inspection: April 7, 2000
D] SYSTEM FAILS: NO
You must indicate either"Yes"or"No"to each of the following:
_ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303.The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to
correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground 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 In day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped:
i
Any portion of the Soil Absorption system,cesspool or privy is below the high groundwater elevation.
Y
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
0
8 — Any portion of a cesspool or privy is witbin a Zone I of a public well.
a
Any portion of a cesspool or privy is within 50 feet of private water supply well.
u
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.If the well has been analyzed to be acceptable,attach copy ofwell water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS: N/A
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the above criteria:
The system serves a facility with a design flow of system is 10,000 gpd or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or moreofthe following conditions exist:
Yes No
is
The system is within 400 feet of a surface drinking water supply
-__ — The system is within 200 feet ofa 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
The owner or operator of any such system shall bring the system in accordance with 310 CMR 15.304(2).Please consult the
local regional office of the Department for further information.
PAUL G. JENNER ASSOCI[A.TES (Revised 912198) -Page 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 67 Stonecleave Rd.
N. Andover, MA 01845
Property Owner: Steve Casey
Date of Inspection: April 7, 2000
Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following:
Yes No
Y - Pumping information was requested of the owner,occupant,and Board of Health.
Y _ None of the system components have been pumped for at least two weeks and the system has been
receiving normal flow rates during that period. Large volumesof water have not been introduced into the
system recently or as part of this inspection.
Y _ As built plans have been obtained and examined. Note if they are not available with NIA.
Y _ The facility or dwelling was inspected for signs of sewage back-up.
Y _ The system does not receive non-sanitary or industrial waste flow.
Y _ The site was inspected for signs of breakout.
Y All system components,excluding the Soil Absorption System,have been located on the site.
Y __ The septic tank manholes were uncovered,opened,and the interior of the tank was inspected for condition
of baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
i .
Y Existing information.Ex.Plan at B.O:H. i
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N Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance
p is unacceptable) [15.302(3)(b)a
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Y _ The facility owner(and occupants,if different from owner)were provided with information on the proper
maintenance of Sub-Surface Disposal System.
0
PAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 67 Stoneeleave Rd.
N. Andover, MA 01845
Property Owner: Steve Casey
Date of Inspection: April 7, 2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow 110 g.p.d./bedroom
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
Total DESIGN flow: 440
Number of current residents: 5
Garbage grinder(yes or no): Yes-Recommend Disconnect
Laundry(separate system)(yes or no):No If yes,separate inspection required
Laundry system inspected(yes or no) N/A
Seasonal use(yes or no): No
Water meter readings,if available(last two(2)year usage(gpd);Well->100' from SAS
Sump Pump(yes of no):No
Last date of occupancy: Current
COMMERCIAL/INDUSTRIAL: NO
Type of establishment:
Design flow: gallons/day(Based on 15.203)
Basis of design flow
Grease trap present(yes or no)
Industrial Waste Holding Tank present(yes or no):
3
Non-sanitary waste discharged to the Title 5 System(yes or no):
Water meter readings,if available: Last dale of occupancy:
OTHER(Describe);
3 Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS(and source of information)99/Owner
System pumped as part of inspection(yes or no) NO If yes,volume pumped gallons
Reason for pumping: Not pumped at time of inspection,System on yearly maintenance schedule
TYPE OF SYSTEM:
X Septic tank/distribution box/soil absorption system
' Single cesspool
-- Overflow cesspool
_ Privy
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_ Shared system(yes or no),if yes,attach previous inspection records,if any.
- i/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: 78/BOH records
Sewage odors detected when arriving at the site: (yes or no} NO .
PAUL G. JENNER ASSOCIATES (Revised 9/2/98) -]Page 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 67 Stonecleave Rd.
N. Andover, MA 01845
Property Owner: Steve Casey
Date of Inspection: April 7,2000
BUILDING SEWER
(Locate on site plan)
Depth below grade: 15"
Material of construction: cast iron X 40 pvc other(explain)
Distance from private water supply well or suction line:NIA
Diameter-:6"
Comments:(condition of joints,venting,evidence of leakage,etc.)No abnormal signs observed
'g SEPTIC TANK: YES
(Locate on Site Plan)
' Depth below grade:
Material of Construction: X Concrete _ Metal _ Fiberglass _ Polyethylene _ Other(explain):
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 8'L x 4'W x 4'6"D
I Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How dimensions.were determined: measuring stick
Comments(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to
outlet invert, structural integrity, evidence of leakage, etc) No abnormal signs observed at time of inspection,
all tees and baffles in place. Liquid levels, structural integrity OK . No leakage
GREASE TRAP: NO
(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(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to
outlet invert, structural integrity, evidence of leakage, etc):
PAUL G. JENNER ASSOCIATES (Revised 912198) -Page 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 67 Stoneeleave Rd.
N. Andover, MA 01545
Property Owner: Steve Casey
Date of Inspection: April 7, 2000
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or 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:
Alarm level: Alarm in working order: (Yes/No)
Date of previous pumping:
Comments(condition of inlet tee, condition of alarm and floal switches, etc)
i
3
9
j
DISTRIBUTION BOX: YES
(Locate on Site Plan)
Depth of liquid level above outlet invert: 0
Comments(note if level and distribution is equal evidence of solids carryover, evidence of leakage into or out of box, etc)
D-Box was level with no signs of solids carryover,no signs of leakage in or out of box
PUMP CHAMBER: NO
(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.)
8
PAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 67 Stonecleave Rd.
N. Andover, MA 01845
Property Owner: Steve Casey
Date of Inspection: April 7,2000
SOIL ABSORPTION SYSTEM(SAS): YES
(locate on site plan, ifpossible; excavation not required, but may be approximated by non-intrusive methods)
If not located,explain:
TYPE:
leaching pits and number
leaching chambers and number
leaching galleries and number
X leaching trenches,number,length —GO' each
leaching fields,number,dimensions
overflow cesspool,number
Alternative system:
Name of Technology:
Comments(note condition o f soil, si g ns o f hydraullefallure, level ofponding, condition o f vegetation,etc.)No abnormal signs
! observed at time of inspection, no ponding, abnormal vegetation or hydraulic failure observed.
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CESSPOOLS: NO
(Locate on Site Plan):
number and configuration:
depth-top of liquid to inlet invert:
depth of solids layer:
depth of scum layer:
is dimensions of cesspool:
materials of construction:
indication of groundwater:
inflow(cesspool must be pumped as part of inspection):
Comments(note condition ofsoil,signs ofhydraulie failure,level ofponding, condition of vegetation,etc.)
PRIVY: NO
(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.):
PAUL G. JENNER ASSOCIATES (Revised 912198) -Page 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 67 Stonecleave Rd.
N. Andover, MA 01845
Property Owner: Steve Casey
Date of Inspection: April 7, 2000
SKETCH OF SEWAGE DISPOSAL SYSTEM:
(include ties to at least two permanent references landmarks or benchmarks)
(locate all wells within 100)(Locate where public water supply comes into house)
`SEE ATTACHED AS-BUILT DRAWING'
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PAUL G. 3ENNER ASSOCIATES (Revised 912198) -Page 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 67 Stonecleave Rd.
N. Andover, MA 01845
Property Owner: Steve Casey
Date of Inspection: April 7, 2000
DEPTH TO GROUNDWATER
NRCS Report name:
Soil Type:
Typical depth to groundwater:
USGS Date website visited:
Observation Wells checked:
Groundwater depth. Shallow Moderate Deep
SITE EXAM Slope none
Surface water none
Check Cellar dry
Shallow wells n/a
Estimated Depth to Groundwater >7.5 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
X Obtained from Design Plans on record
_Observation of Site(Abutting property,observation hole,basement sump,etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
_Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
Design plans and perk test results on rile @ Board of Health
PAUL G. JENNER ASSOCLITES (Revised 912198) -Page I 1
ATTENTION
THIS REPORT DOES NOT CONSTITUTE A
GUARANTEE, WARRANTY OR REPRESENTATION
THAT THE SYSTEM WILL CONTINUE TO OPERATE
AND FUNCTION IN GOOD WORKING ORDER. THIS
REPORT IS SOLELY LIMITED TO REPORTING
WHETHER THE SYSTEM MEETS THE CRITERIA SET
FORTH IN 310 CMR 15.303; THERE MAY BE LOCAL
LAWS OR REGULATIONS APPLICABLE TO THE
SYSTEM WHICH THIS REPORT DOES NOT ADDRESS.
THIS REPORT CONSTITUTES THE ENTIRE REPORT.
THIS REPORT WAS PREPARED ON BEHALF OF THE
PERSON NAMED ON THE FRONT PAGE OF THE
REPORT AND THE ONLY PERSON AUTHORIZED TO
RELY UPON THE CONTENTS OF THIS REPORT IS
SAID PERSON; ANY MATTERS WHICH SAID PERSON
INTENDS TO RELY UPON MUST BE CONTAINED IN
WRITING IN THIS REPORT AND SAID PERSON
ACKNOWLEDGES THAT THEY ARE NOT RELYING
UPON ANY ORAL COMMUNICATIONS OR
DISCUSSIONS CONCERNING THIS REPORT.
PAUL G.:JENNER ASSOCIATES (Revised 912198) =Page 12