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Home My WebLink AboutTitle V Inspection Report - 67 STONECLEAVE ROAD 4/18/2017 (2) � ` Commonwealth of Massachusetts Title 5 Official Inspection — orm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owners Name information is O184� eqvimuxxmm� -MA '-"— ' Inspection results must be submitted on this form. Inspection forms ma tered jl�any way. Please see completeness checklist at the end of the form. Important:Whenfilling out forms A. General Information r' ` an the computer, use only othe tab 1Inspector: �~ key mmove your cursor-do not John J. Soucy use the return m,v. Name ofInspector Souc 's Sewer Service Inc. Company Name `---� North Company Address Salem NH 03079 ------' City/Town State Zip Code 603-898-9339 13397 Telephone Number License Number B. Certification | uerthy 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. }oma DEP approved system inspector pursuant tmSection 15.34Dof Title 6(31OCMR 15.O0O). The system: 0 Poeoeo Conditionally Passes Fl Fails 'U ion by the Local Approving Authority 3/20/17 ------------- inspect s--Sign re Date The ystem 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 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 ufuse at that time.This inspection does not address how the system will perform in the future under the same ordifferent conditions ofuse. Commonwealth of Massachusetts r Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4113117 page. Cityrrown State ,Zip Code 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: ® 1 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: 8) 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. 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 17 n urt R i I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w, 67 Stonecleave Road Properly Address Theresa Petrie Owner Owner's Name i information is North Andover MA 01845 4113117 required for every page. City/Town 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 Fusses (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 (Explain below): ❑ 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): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed El ❑ N [IND (Explain below): a 6 V 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 15ins•3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 j 3' i' Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie _ Owner Owner's Name information is North Andover MA 01845 4113117 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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, ❑ 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 El ® 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 ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow I l5ins•3l13 Title 5 Official Inspection Farm,Subsurface Sewage Disposal System•Page 4 of 17 I ti n 0 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Adomnn Theresa Petrie Owner Owner's Name information is MA 01845 �pu|�omr�e� '" ' page. txv[Tomm State Zip Code Date v,Inspection B. Certification (cont.) Yes No �� Required pumping more than 4times inthe |o��year NOT due hndoggedor �� ~ obstructed pipe(m). Number oftimes pumped: ____ AnyporUonoftheSAQ. c000poo|orphvyiobe|mwhiQhgnuundvwatorm|evmtion. Fl �� Any po�imnofcesspool orprivy imvvithin1OUfeet ofanv�aoowater supply or �� tributary tuasurface water supply. El Z Any portion nfacesspool orprivy iowithin eZone 1 ufopublic well. F� �O Any portion of a cesspool or privy is within 50 feet of a private water supply well, Fl EJ Any portion of a cesspool or privy is |000 than 100 feet but greater than 50 feet from u phvmho water supply well with no acceptable water quality analysis. [This system passes ifthe well water analysis, performed atmDEP certified laboratory,for fecal coliform bacteria indicates absent and the presence ofammonia nitrogen and nitrate nitrogen imequal hoorless than Sppm, provided that no other failure criteria are triggered.A copy of the analysis and chain ofcustody must beattached tothis forno.] �� Theayotemiwa0000poo\aemingofa�|dyvv�hadeuign8ovvof2O0Ogpd- ^� �° 10.000gpd. The system fails. | have determined that one ormore ofthe above failure criteria exist aadescribed in 210 CMR 1D.3O8.therefore the system falls. The system owner should contact the Board ofHealth todetermine what will bo necessary tocorrect the failure. E) Large Systems: 7obaconsidered mlarge system the system must serve mfacility with a design flow of1&,OUOgpdtu15.000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions inSection D. Yee No Fl E7 the system iuwithin 4OOfeet ofosurface drinking water supply El D the system is within 200 feet of a tributary to a surface drinking water supply F� �7 the ny�emis |oo�edinandrogansensitive ama (Interim VVe||heodPn»b*oUon | �� ~ Area—|VVPA)ormmapped Zone || nfapublic 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 CIVIR 15.304. The system owner should contact the appropriate � regional office ofthe Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4113117 page. City/Town State Zip Cade 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 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? ® ❑ 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. I Determined in the field (if any of the failure criteria related to Part C is at issue u ® ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins 3713 Tire 5 Offidal Inspection Form:subsurface Sewage Disposal system•Page s of 97 is Commonwealth of Massachusetts r Title 5 Official Inspection Form LL Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information Is required for every North Andover .... – MA 01845 4113117 page City/Town §tate Zip Code Date of Inspection D. System Information Description: 5 ; Number of current residents: VDoes residence have a garbage grinder? ❑ Yes ❑ No ,❑� ,❑ Is laundry on a separate sewage system? (Include laundry system inspection [� Yes E No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail Well 100' + Sump pump?...._ ® Yes ❑ No Last date of occupancy: Current _..... Dake Commercial/industrial Flow Conditions: 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 ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: { ---------- f5irs•3113 Tille 5 Official Inspectuon Forth;Subsurface Sewage Disposal Syslem•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner _ Owner's Name information is North Andover MA 01845 4113117 required for every page. CitylFown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Current Date Other(describe below): General Information Pumping Records: Source of information: Soucy's Sewer Service Inc Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Gauge an truck Reason forum in Maintenance and Inspection p p 9� 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) ElInnovative/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 IIA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): (51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage nlsposaf System•Page 8 of 17 i i 3 i i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owners Name information is North Andover MA 01845 4113117 required for every page. CityfTown State Zip Code date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 22" 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.): No evidence of leakage Septic Tank(locate on site plan): 12" Depth below grade: feet m _..... Material of construction: ®concrete EImetal El fiberglass Elpolyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 8'6'x 4'8" Dimensions: 3" Sludge depth: t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 'u u: V 0 3 l: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 67 Stonecleave Road Property ddress Theresa Petrie Owner Owner's Name information is North Andover MA 01845 4113117 required for every page. Cityfrown State Zip Code Date of inspection D. System Information (cant.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 35 3'1 Scum thickness 6 Distance from top of scum to top of outlet tee or baffle 1161 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape &Sludge tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet baffle, outlet tee good, tank structure is sound, no apparent leaks, pump tank annually due to age of leachin 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 151as 3143 Title 5 Official Inspection From:Subsurtace Sewage Disposal System Page 10 of 17 i s 3 1 I I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage disposal System Form -Not for Voluntary Assessments M 67 Stonecleave Road Property Address Theresa Petrie i Owner Owner's Name information is North Andover MA 01845 4113117 required for every page Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required), is copy attached? ❑ Yes ❑ No 15ins-3713 Title 5 Official lnspecton Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Properly Address Theresa Petrie Owner Owners Name information is North Andover MA 01845 4/13117 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): Oil 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.): "D" Box replaced prior to inspection. See attached permit 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,): * 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: t5ins-3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 u t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner _ _._. �... _. .._ —�...._m. Owner's Name information is North Andover MA 01845 4113197 required for 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: (2)3'x 60' ❑ 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.): No signs of hydraulic failure 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 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Uisposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 67 Stonecleave Road Property Address Theresa Petrie I Owner Owner's Name information is North Andover MA 01845 4113117 required for every page. city/Town State Zip Code Date of Inspection D. System Information (cant.) 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.): t5ins•3113 Title 5 Offrlal Inspection Fotm:Subsurface Sewage Disposal System•Page 14 of 17 I Y 3 d i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13117 page. CityFTown 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 a. (/w• N9_a ILEA_ C. A4 7d' EXISVIIVG ! - 1 !-�uv r� SGNIF•'/L IF35' APPRd X Ar snn1A' GEx dr 4�•4' 1'.3 ov t r •� - LE ,g - U Y EAaanG61 bhp '. �/FSSIUM ' S��SH Of 44S�C� - 0 305EPr N � g,1pBaGPItU nn d6f O � �oRFGlsraa`.�o-s °3sroat sr."` I O/V. l (sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 ^ Commonwealth mfMassachusetts ��°��N�� n��Q��°��N N��°�� N�� NN�N~= �� "�NN0�*N�=0 Inspection �—�~� �� Subsurface Sewage Q|mpoem| System Form 'Not for Voluntary Annnnomanto 67 Stonecleave Road Property Address Theresa mmoo, Owner's Name information is required for every North Andover1yyA01846 4/13/17 page. cxVmowm State Zip Code Date o,Inspection D. System Information (cont.) Site Exam: Z Check Slope Z Surface water Check cellar Fl Shallow wells 5' Estimated depth bohigh ground water: feet Please indicate all methods used todetermine the high ground water elevation: F� Obtained from system design plans unrecord If checked, date. Date Observed site (abutting property/observation hole within 150feet ofSAS) [] Checked with local Board ufHealth 'explain: Fl Checked with local excavators, installers' (attach documentation) Accessed US8Sdatabase-exp|a|n: You must describe how you established the high ground water elevation: Dug hole in low drop off area, left of driveway, no water at 4', 18"elevation difference from SAS location. i Before filing this Inspection Report, please see Report Completeness Checklist on next page. � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Stonecleave Road Property Address Theresa Petrie Owner Owners Name information is required for every North Andover MA 01845 4113117 page. City/Town State Zip Code Dale 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 f5ins•3l13 Title 5 Official Inspection Form:Subsurfaoe Sewage Disposal System•Page 17 of 17 i i COMMONWEALTH OF MASSACHUSETTS NUMBER BHP-2017-0340 North Andover FEE BOARD OF HEALTH $175.00 John Soucy Y ,�c>v NAME j 67 STONECLEAVE ROAD .......... ------- -----------------------------------__................................. ........ ADDRESS 1S HEREBY GRANTED A PERMIT I D-box repair i This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires ---------------June 28, 2017 unless sooner suspended or revoked. -------------- - ----- ---------------- ----- March 28, 2017 BOARD OF . ---------------- ----- HEALTH ------- ---- ---------- ----------- 1 BOARD OF HEALTH CHAIRMAN ----y