HomeMy WebLinkAboutTitle V Inspection Report - 11 STONECLEAVE ROAD 7/16/2007 Commonwealth of M�assahusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Rhonda Scher�f
Owner
Owner's Name
information is No. Andover MA 01845 7116107
required for
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Benjamin C. Osgood Jr.
cursor-do not Name of Inspector
use the return
key. New England Engineering Services, Inc.
Company Name
f� 1600 Osgood Street Suite 2-64
Company Address
No. Andover MA 01845
�
City/Town _ State Zip Code
978-686-1768
Telephone Number 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 ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspect/s Signature Date
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 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 time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
11 Stonecleave Rd No Andover.DOC•08106 Tit}e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page i of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
..._ `Y 11 Stonecleave Road
Property Address
Rhonda Sche�rpf
Owner Owner's Name
information is No. Andover MA 01845 7116107
required for —
every page. City/Town State Zip Cade Cate of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D
A) System Passes:
WI 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 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 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.
*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
Page 2 of 15
S 1 Sionecleave Rd No Andover.DOC•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
Commonwealth of Massachusetts '.....
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
° 11 Stonecleave Road _
Property Address
Rhonda Scherpf
Owner Owner's Name
information is N Andover MA 01845 7116107
No.required for
every page. City]Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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:
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.
11 Stonedeave Rd No Andover.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
y.__. Title 5 official Inspection Form
..._ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Rhonda Scherpf
Owner Owners Name
information is No. Andover MA 01845 7116107
required for
every page. Cityffown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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 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
❑ �. Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ 2` Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ [P- Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
El Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
E] E9' 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.
11 Slonecleave Rd No Andover.[DOC•OWS Title 5 Official Inspection norm:Subsurface Sewage disposal System•Page 4 of 15
Commonwealth of Massachusetts
Y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Rhonda Sch erpf —..
Owner Owner's Name
information its No. Andover MA 01845 7116/07
required for — .. — — —
every page. Cityirown State Zip Code Date of Inspection
B. Certification {cant.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ®`" Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Eg-'- 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.]
El The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
El ®� The system fails. 1 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.
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 surface drinking water supply
❑ ®-- the system is within 200 feet of a tributary to a surface drinking water supply
❑ E4--' the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area- IWPA) or a mapped Zone 11 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.
11 Stonecteave Rd No Andover.00C•0i Title 6 Official Inspection FormT Su6surrace Sewage Disposal system Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'x 11 Stonecleave Road
Property Address
Rhonda Scherpf
Owner Owner's Name
information is No. Andover MA 01845 7116107
required for _ _ _ —....
every page. CitylTown State Zip Code Date of Inspection
C. Checklist
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
❑ 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?
❑ Q/ Have large volumes of water been introduced to the system recently or as part of
this inspection?
El Were as built plans of the system obtained and examined?(If they were not
available note as NIA)
Ed ❑ Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
[d ❑ Were all system components, excluding the SAS, located on site?
❑ 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?
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:
❑ 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)]
f 1 Stonecleave Rd No Andover.DOC•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Rhonda Scherpf
Owner Owner's Name
information is No. Andover MA 01845 7116107 _
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
L
Number of bedrooms (design): — Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number-of current residents:
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system? [if yes separate inspection required] El Yes ® No
Laundry system inspected? E] Yes No
Seasonal use? El Yes N No
LLa Water meter readings, if available (last 2 years usage (gpd)): �'
Sump pump? ❑ Yes No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment: -
Design flow(based on 310 CMR 15,203): Gallons per day(gpd)
Basis of design flow (seatslpersonslsq.ft., etc.): — _......
Grease trap present? El Yes ❑ No
Industrial waste holding tank present? ❑ Yes El
Non-sanitary waste discharged to the Title 5 system? ❑ Yes E] No
Water meter readings, if available:
Last date of occupancy/use: Date
Other (describe): _
1 1 Slonecleave Rd No Andover.DOC 01013 Title 5 Official tnspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
F Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11_Stonecleave Road
Property Address
Rhonda Scherpf
Owner _ ._. _. _...._ ... _
Owner's Name
information is No, Andover MA 01845 7116107
required for _ _ _ _
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
9N vy,t, A5. P� y-v v�-
Source of information: _.
Was system pumped as part of the inspection? ❑ Yes (A No
If yes, volume pumped: gallons
How was quantity pumped determined? T
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 r No
11 Stonecleave Rd No Andover.DOC-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road W.._
Property Address
Rhonda Scherpf
Owner Owner's Name
information is No. Andover MA 01845 7/16107
required for _ _ _._ _ _.
every page. Gityfrown State Zip Code Date of Inspection
D. System Information (cons.)
Building Sewer(locate on site plan):
Depth below grade: feet_
Material of construction:
( cast iron ❑ 40 PVC ❑ other (explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
El concrete El metal ❑ fiberglass El polyethylene ❑ other(explain)
If tank is metal, fist age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
�• I
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle — �11
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? ��
11 Stonccleave Rd No Andover.DOC•MW Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
x Title 5 Official Inspection Form
6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Rhonda Scherpf -
Owner Owner's Name
information is No. Andover MA 01845 7116107
required for — _ -_.—
every page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: feet
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: Date W..
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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 ❑ polyethylene ❑ other(explain):
11 Stonecleave ltd No Andover.DOC•08/06 Title 5Off6al Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System f=orm - Not for Voluntary Assessments
_ 11 Stonecleave Road ^
Property Address
Rhonda ;che
Owner Owner's Name
information is N Andover MA 01845 7116107
No.required for no _. _
every P 9 a e. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(coat.)
Dimensions:
Capacity: gallons W
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: -- Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date T
Comments (condition of alarm and float switches, etc.):
i
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
3 Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
C> .
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.):
C e- �, a �. Ada AL,_. _... 'mac
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
11 Stonecleave Rd No Andover.DOC•08!06 Title 5 Official Inspection rorm:Subsurface Sewage Disposal system•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Rhonda Scherpf
Owner Owner's Name
information is No. Andover MA 01845 7116107
required for _. __ _
every page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
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,
❑ 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.):
L-0 li a tA r L-- A.)0 j;.0r0 G-
E. 11 Slonecleave Rd No Andover.DOC•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Rhonda Scherpf __ ....�.....
Owner Owners Name
information is No. Andover MA 01845 7116107
required for — —...
.....m.__.._ _.._ .._ ...�......
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
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
Indication of groundwater inflow ❑ Yes ❑ No
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 failure, level of ponding, condition of vegetation,
etc.):
I;
11 Stonecleave Rd No Andover.DOC•08166 Title 5 OfFdal Inspection Farm:Subsurface Sewage Disposal System•Page 13 of 15
I.
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Rhonda Scherpf
Owner Owner's Name
information is
required for No. Andover MA 01845 7116107_........__.__.__.
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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.
l e 1t :;--o
W C1,L
c�I
k
11 Slonecleave Rd No Andovef.DOC.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Rhonda Scherpf
Owner Owner's Name
information is No. Andover MA 01845 7/16/07
required for .�...... _..... . �..._ �... ..
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
Surface water Ajaai�"
® Check cellar p ( "o
(� Shallow wells AJ n t�i
Estimated depth to ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:
' Date
[0 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:
11 Stonecleave Rd No Andover.DOC•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
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