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HomeMy WebLinkAboutTitle V Inspection Report - 1980 TURNPIKE STREET 3/10/2017 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 1980 Turnpike Street ` Property Address John Guisto Owner Owner's Name information is required for North Andover MA 01845 March 2, 2017 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. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Dean G. Luscomb II cursor-do not Name of Inspector use the return key. Dean G. Luscomb II & Sons Company Name 288 Maple Street Company Address Middleton MA 01949 e°0 City/Town State Zip Code 978-774-4065 S1848 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 March 2, 2017 Inspec is 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. t5ins•3/13 N Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r f t_ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is required for North Andover MA 01845 March 2, 2017 _ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: ChevB,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 5 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. /4 The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is AIV 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is required for Noith Andover MA 01845 March 2, 2017 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): brokenpipe(s) are re laced Y N ND (Explain below): ❑ ❑ P ❑ ❑ ❑ ( P ) ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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): f� ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): �J ❑ obstruction is 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR d 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is required for North Andover MA 01845 March 2 2017 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: U ❑ 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. ❑ 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 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 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 ❑ ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is required for North Andover MA 01845 March 2, 2017 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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. ❑ ® 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. ❑ ® 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.] ❑ ® The 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 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 followin addition to the questions in Section D'- Yes No �. U ❑ ❑ the system is within 4'OQ feet of asurface drinking water supply ❑ ❑ the system is within 2009 f f o - tributary to a sun`ace drinking water supply ❑ ❑ the system is locatd"d in a nitrogen se tive area (Interim Wellhead Protection Area—IIWPora mapped Zone II of a p) blip water supply well If you have answered "to any question in Section E the system is co sidered a significant threat, or answered "yes;riri"Section D above the large system has failed. The owne operator of any large system considi ed a significant threat under Section E or failed under Section D s al.l upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is required for North Andover MA 01845 March 2, 2017 every page. City/Town 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? ❑ ® Have large volumes of water been introduced to the system recently or ac; part of this inspection? Were as built plans of the system obtained and examined? (if they were not WIA 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? ® ❑ 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)] D. em Information Residential Flow Con D Number of bedrooms (design): �— of bedrooms(actual): DESIG e on 310 CMR 15.203 (for e)(ample: 110 gpd x' ef drooms): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is required for North Andover MA 01845 March 2, 2017 every page. City/Town State Zip Code Date of Inspection D. System Information Description: owner.and town ___7Z W w� t. {� Number of current residence, U � Does residence have a garbage gender? f/'f ❑ Yes ❑ No Is laundry on a separate sewage syst mdl? (Include laup ry system inspection ❑ Yes ❑ No information in this report.) �� Laundry system inspected? ❑ Yes ❑ No Seasonal use? '"^ ❑ Yes ❑ No Water meter readings, if availgb'le (last 2 years usage (gpd) . Detail: r Sump mp? Yes ❑ No L/stdate of occupancy:p y Date Commercial/Industrial Flow Conditions: Type of Establishment: Industrial buildings Design flow(based on 310 CMR 15.203): /�;J�erRer'sa,h Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 0W S'f Ue`E 2,f141340.5F Llod &,,4005; 31,7 e.o S.F. r 1 Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes 0 No Water meter readings, if available: �` 2Z da y do" Ay&&,u 42d l t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is North Andover MA 01845 March 2, 2017 required for - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: current Date Other(describe below): p4Arrlih4 LuiSSh�SS UL�� General Information Pumping Records: Source of information: Last pumped approx 4 weeks ago-Wind River Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: Zero gallons How was quantity pumped determined? Reason for pumping: No need at this time 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) 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): t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1980 Turnpike Street Property Address John Guisto Ownf,ner Owner's Name requir required is North Andover MA 01845 March 2 2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System is from 1986-31 years old -town records Were sewage odors detected when arriving at the site? ❑ Yes ® No ( Building Sewer(locate on site plan): Depth below grade: 5 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.): Main line and joints are in good condition. Septic Tank(locate on site plan): 4' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Precast rectangular concrete-3500 gallons B C'Uvso_�_( 12,01AC16' i rr�aleS lf tank is me a, Is age: m � .. m F< ears Is�iSfirmed by a Certificate of Compliance? (a=tach copy of certificate) ❑ Yes No Dimensions: 66"deep x 5'wide x 14' long Sludge depth: 1 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is required for North Andover MA 01845 March 2, 2017 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) �} Distance from top of sludge to bottom of outlet tee or baffle 44" / Scum thickness 6° Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 24.. — How were dimensions determined? by measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank and baffle are in very good shape. The solids are light and do not require pumping at this time. The liquid is running at it's correct working heigth. ease Trap (locate on site plan): Depth b w grade: Leet ( Material of constru n: l.i ❑ concrete ❑ meta ❑ fiberglass ❑ pol ene ❑ other(explain): Dimensions: Scum thickness — Distance from to scum to top of outlet tee or baffle Dista from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is required for North Andover MA 01845 March 2, 2017 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Com is (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels elated to outlet invert, evidence of leakage, etc.): �µ Ti ht or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth low grade: Material of co truction: ❑ concrete metal ❑ fiberglass ❑ polyethylene other(explain): Dimensions: Capacity: ` gallons Design Flow: aeons per day Alarm present: Yes ❑ No Alarm level: Alar working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of al m and float switches, etc.): — t r` *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form IA' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 1980 Turnpike Street .Property Address John Guisto _ Owner Owner's Name information is required for North Andover MA 01845 March 2, 2017 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): �l Depth of liquid level above outlet invert Zero 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.): The d-box is 16"x 16" and is 11" below grade. The d-box is in very good shape. 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.): Pumps and alarm are in very good condition. They were replaced in 2009 and are in very good working condition today. 7� or * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: SAS was located by asbuilt drawings. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1980 Turnpike Street _ Property Address John Guisto Owner Owner's Name information is required for North Andover MA 01845 March 2, 2017 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 -40'x60' ❑ 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.): TheSASis in good condition. There are no signs of ponding or breakout. �f d�.- GL�'G '7 "�lnGS [�Q /_onq Q,�1G'/� A vein C Gi►^t pools (cesspool must be pumped as part of inspection) (locate on site plan): Number an figuration Depth —top of liquid to I invert Depth of solids layer a''t Depth of scum layer Dimensions of ces of Material construction ,I,a ication of groundwater inflow Yes �1119 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is required for North Andover MA 01845 March 2, 2017 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Com (note condition of soil, signs of hydraulic failure, level of ponding r ttrr n of vegetation, etc.): ri locate on site plan): Materials of con ction: Dimensions Depth of solids - Comments (note condition of soil, signs of raulic level of ponding, condition of vegetation, etc.): J' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is required for North Andover MA 01845 March 2, 2017 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 d 7" �itop .273Es Abyy74 131 V " 361�� td T �4 aE�x= 43 �e,i fl y /5,680 S.F. 400 S tF. 14-rin BOK t5ins•3/13 Title 5 Offic I Insp k Form: ubsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is required for North Andover MA 01845 March 2, 2017 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: / ® Check Slope ® Surface water dve,- Z41' are, , fl ® Check cellar DcK)o ® Shallow wells lQ0r%4L-� Estimated depth to high ground water: 6' +/- 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 ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Proposed, pumping records and previous title v(from 11/7/08). ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: USGS Maps showed water at approx 6' in this area. The d-box is 11" below grade, bottom of field would be approx 24"to 30" below grade. Before filiirrg this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1980 Turnpike Street Property Address John Guisto Owner Owner's Name information is North Andover MA 01845 March 2 2017 required for , every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t FILE#_� � TITLE V INSPECTION Dean G. Luscomb H & Sons P.O. Box 135 Middleton, MA 01949 978..-774-4065 Licensed Plumber# 20285 SUBSURFACE SEWAGE DISPOSAL SYSTEM IN FORM PROPERTY OWNERS NAMEy i PROPERTY ADDRESS I u` t f° Irv, _ LQA DATE OF INSPECTION cz_.r NAME OF INSPECTOR i LLA ,5 QUALITY IS NUMBER ONE TO US