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Home My WebLink AboutTitle V Inspection Report - 46 LIBERTY STREET 5/15/2017 Commonwealth of Massachusetts mmya Titlei ri Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Liberty Street Property Address Maryline Bellosguardo ------ Owner _ . _..._—_. __- _ ___.._. .--Owner Owner's Name information is North Andover MA 01845 04/17/2017 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, Please see completeness checklist at the end of the form. Important:WhenA. G neral Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Gerardo Valentin use the return Name of Inspector key. Wind River Environmental --- -_ -_---- -- ab Company Name 46 Lizotte Drive Suite 1000 Company Address Marlboroulr h MA 01752 - . _.._.. City/Town State Zip Code 800-499-1682 S113834 _ 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 (Inspecto's Signature Date Th. 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 1 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. i — 1 ****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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 '..... Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Liberty Street .......... Property Address MarvIine Bellosguardo Owner Owner's Name information is North Andover MA 0184504/17/2017 required for every ----.".- -- i page. Cjjy� State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: F-1 I 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: Z 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. E -1 Y F N ❑ ND (Explain below): t5ins.cloc•rev.6116 Title 5 Oficial Inspection Form,Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts ' ��"��N�� ~��N N��~�� 0°N�� Title �� ~�� N��N Nmm��N��mm Form Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments 46LibertyStreet __��_______��_------_��------__��-----'--��-------�� ------' � pmp*nyAdumoo Marylino 8e|oouu�rd?______��_____........_��_----_��_---_ ��_-______��__ Owner Owner's Name information i's No�hAndnvor MA 01845 U4/17/2017 �qvimufor eve� --------��-------��--- —��-- --�� -- ------�� Stam Zip Code Date mInspection o City/TownPao � B. Certification (cont.) 0 Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumpo/o|armnare repaired. B) System Conditionally Passes (oonL): �� Obnenxxionofsewage backup orbreak out orhigh sbabovvatar|ev� inthe d��ibut�nbox due �� tobroken urobstructed pipe(m) ordue �oa broken, settled orunevendistribution box. System will pass inspection if(with approval n[Board ofHwaKh): ' El broken pipo(o) are replaced [l Y El N 0 N[) (Explain bn|ow): Fl obstruction ioremoved 0 Y O N E] ND (Explain be|nvv): � [A distribution box ioleveled nrreplaced 0 Y 0 N ND (Explain Ue|ovv): D-box has heavy deterioration d corrosion. Needs to be replaced. �� The system required pumping more than 4timen a year due to broken or obstructed pipe(s). The -- system will pass inspection if(with approval ofthe Board ofHom|th): Fl broken pipe(o)are replaced �� Y ElN �� NO (Exp|ninbe|ow\� �l obotruntinniaremoved F� Y N [| N[} (Explain be|ovv : C) Further Evaluation )sRequired bythe Board ofHealth: Conditions exist which require further evaluation by the Board of Health in order to determine if the system iafailing toprotect public health, safety orthe environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: 0 Cesspool orprivy inwithin 50feet ofusurface water 0 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt Marsh Commonwealth of Massachusetts ' ��~��N�� ~��~��N 0��°�� 0°0�� m�� N Nmm��*��N��mm N—��mmmm Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments 46Liberty Street Property Address Mary,ine Bellosquardo Owner Owner's Name information is North Andover MA 01845 04/17/�O17 nmvi��mrovmry page. City/Town State Zip Code Date u*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 m manner that protects the public health, safety and environment: El The system has a septic tank and soil absorption system (SAS) and the SAS is within 100feet ufesurface water supply ortributary boasurface water supply. El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. F-1 The system has a septic tank and SAS and the SAS is within 50feet ofe private water supply well. F� The system has o septic tank and 8A8 and the 8A8 is |ouu than 100 feet but S0feet or more from u private water supply woU°° Method used todetermine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence ofammonia nitrogen and nitrate nitrogen imequal tnprless than 5ppm. provided that no other failure criteria are triggered. A copy of the analysis must beattached Vothis form. 3. Other: D\ System Failure Criteria Applicable to All Systems: You must indicate 'Yes" or"Nm" toeach ofthe following for all inspections: Yon No �� Backup ofnovvagainto facility orsystem component due tuoverloaded or �� clogged SAS orcesspool F� �� Discharge orponding ofnfOuent tothe uu�anoofthe ground nrnu�aoevvetera �� due toanoverloaded orclogged SAS nrcesspool �l �� Static liquid level inthe diohibuUonbox above outlet invert due toanoverloaded �~ �� orclogged SAS orcesspool �� Liquid depth in oeaapnn| is less than O'' below inva�oravailable volume is |ena �~ �� than >6day flow Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 40 LibertvStnaet______��________��______�� __---__ � Property Address K8B U nd -_----'_��________��--- Owner Owner's Name information is required for every North Andover MA 01845 04/17C2017 State Zip Code Date of Inspection page. City/Town B. Certification (cont.) Yes No �� Required pumping more than 4dmeninthe |ao year NOT due tno�gQeUcx �� obstructed pipe(n). Number oftimes pumped: _____. El E Any portion of the SAS, cesspool or privy is below high ground water elevation. �� Any portion of cesspool or privy in within 100 foo(of o surface water supply or �� tributary to a surface water supply. Fl E Any portion ofacesspool nrprivy iowithin aZone 1ofapublic well. El E Any portion of a cesspool or privy is within 50 feet of a private water supply well. � � El E Any portion of ceompnn| or privy is |nos than 108 feet but greater than 50 feet from a private vvotor supply well with no acceptable water quality analysis. [This system pammmm |fthe well water mna|yois, performed ata DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or|eoe than 5 ppnn, provided that noother failure criteria are triggered. Acopy mfthe analysis and chain ofcustody must beattached tothis fprno.] The system iaecesspool serving afacility with adesign flow of200Ugpd- [� [� 10.000gpd. The system fails. | have determined that one or more of the above failure criteria exist as described in3i0CMR 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: Tobmconsidered alarge system the system must serve afacility with a design flow of1O'O80 gpdto15.00Dgpd. For large oystems, you must indicate either°yee" or"no" to each of the fo||ovving, in addition to the questions |nSection D. Yen No El Fl the system is within 400 feet of surface drinking water supply Fl the system is within 200 feet ofatributary bo a surfacewater �l �� the system is located in nitrogen oenoiUvearea (interim VVe||hemd Protection �~ �� Area— |VVPA)nramapped Zone || ofapublic water supply well If you have answered ^yes'`hoany question in Section E the ayntorn is considered o significant threat, or answered "yes" in Section D above the large system has failed. The nvvna/or operator of any |sq@e system considered a significant threat under Section E or failed under Section O shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office ofthe Department. Commonwealth of Massachusetts ' 5 Official Inspection Fom Title Subsurface Sewage Disposal SyetmmFprnm - Nn(hzrVo|untaryAnnesumente 46 Liberty Stroet_��_______��_________��_-----__��-_--_'��_________��_______ Property Address K8 B U d umm*, Owner's Name information is NorhAndnver MA 01845 04/17/2017 ,oquiedforvv°� --__��_'�----__��_---__��---- ��-- ---��-- — page. CitylTown State Zip Code Date wInspection C. Checklist Check |fthe following have been done. You must indicate "yes" or"no" as to each of the following: Yes No Pumping information was provided by the ovvner, occupant, or Board of Health El E Were any ofthe system components pumped out |nthe previous two weeks? �� [l Has the system received normal flows in the previous two week period? Have |erQo volumes of water been introduced to the system recently or as port of [� [� �� this inspection? Were wabuilt plans nfthe system obtained and examined? (if they were not [� [� �= �� available note moN64) �� Was the � �� El Was the site inspected for signs ofbreak out? � Were all system components, excluding the SAS. located on site? 0 Fl Were the septic tank manholes uncovered, opened, and the interior ofthe tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth nfliquid, depth ofsludge and depth ofscum? Was the fnoi|ityowner (andoouUp�nbsi�dUTer�n�fr�mo�nndprovided vvith �� ` ' �� information on the proper maintenance of subsurface sewage disposal systems? The size and location ofthe Soil Absorption System (SAS) nnthe site has been determined based on: F] Existing information. For example, o plan at the Board of Health. Determined in the field Ufany of the failure criteria related to Part C is at issue �� ` �� approximation ofdistance iuunanoeptmb|e) [810CMR 15.3O2(5)] D, System Information Residential Flow Conditions: 44 Number ofbedrooms (desiQn): Number nfbedrooms (aotua|): -------�� DESIGN flow based on31UCMR 15.2O3 (for example: 110qpdx#ofbgdrooms). wmpx""'rev.m`o Title^Official m.pecx""Form Subsurface Sewage v..povalSystem^Page vof,, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 LibertV Street Property Address Marviine Bellosguardo Owner Owner's Name information is North Andover MA 01845 04/17/2017 required for every page. cityrrown State Zip Code Date of Inspection D. System Information Description: . ........... 5 Number of current residents: Does residence have a garbage grinder? Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection El Yes H No information in this report.) Laundry system inspected? El Yes 0 No Seasonal use? El Yes 0 No Private well Water meter readings, if available(last 2 years usage (gpd)): Detail: -S..Ump pump? El Yes F) No Current 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 (seats/persons/sq.ft,, etc.): Grease trap present? 0 Yes El No Industrial waste holding tank present? El Yes El No Non-sanitary waste discharged to the Title 5 system? EJ Yes E] No Water meter readings, if available: t5ins.dDc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Liberty Street Property Address Maryline Bello ardo U a .......... .......... Owner Owner's Name information is required for every North Andover MA 01845 04/17/2017 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: The home owner and Wind River Environmental are Source of information: the sources of the information. Was system pumped as part of the inspection? ® Yes E] No If yes, volume pumped: 150 gallon0 s How was quantity pumped determined? The quantity was determined by the pump truck and it was measured. Reason for pumping: To check the structural integrity of the septic tank. Type of System: Septic tank, distribution box, soil absorption system El Single cesspool ❑ Overflow cesspool El Privy El 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 El Tight tank. Attach a copy of the DEP approval. El Other(describe): t5ins.doc-rev.6176 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is North Andover MA 01845 04117/2017 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: 1986 per plans at the Board of Health. Were sewage odors detected when arriving at the site? El Yes 0 No Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: El cast iron Z 40 PVC other(explain): Private well over 100' Distance from private water supply well or Suction line. feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints look ok, venting is good, no leakage. Septic Tank(locate on site plan): 12" o Depth below grade: feet Material of construction: Z concrete El metal El fiberglass El polyethylene ❑ other(explain) .. ......... .......... .................... ........... ................. If tank is metal, list age: year - Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes El No 1 0'-x 5' x 5' Dimensions: 7" Sludge depth: 15hrir.doc•rev.6116 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46Libertv Street .......... Property Address M a ry-Lime -Pellosguardo Owner Owner's Name information is MA 01845 04/17/2017 required for every North Andover ....... 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 2 " ,9- 2" Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1411 Distance from bottom of scum to bottom of outlet tee or baffle The dimensions were determined How were dimensions determined? by sludge judge, rod, and ruler. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend yearly service. Inlet and outlet tees are in good condition. Structural integrity of the tank is good. Liquid level to the outlet invert is good. No leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: F❑-1 concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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 15TTis.doc•rev.6116 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Liberty Street ....... Property Address MarVline Bellosguardo Owner Owner's Name information is North Andover MA 01846 04117/2017 required for every page. City/Town 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: F concrete D metal El fiberglass El polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: E] Yes Ej Na -1 Yes El No Alarm level: Alarm in working order: E Date of last pumping: Date is Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? Yes ❑ No ffilns.doc rev.6116 Title 5 Official Inspection 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 46 Liberty Street Property Address Mary Line Bellosguardo Owner Owner's Name information is North Andover MA 01846 04�/l 7/201,.7 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): @ 0 _(Box_is 33" below grade) _ 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.): Box is level and distribution to outlets is equal. Some solids carryover, but no leakage. Box has heavy corrosion and deterioration. ............. ............ ........... Pump Chamber(locate on site plan): Pumps in working order: El Yes El No * Alarms in working order: El Yes El 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: .......... �sposal System•-Page 12 of 17 15ins clor-rev.Wri Title 5 Official Inspection Form:Subsurface Sewage D Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Liberty Street ....... Property Address Maryline Bellosc pardo Owner Owner's Name information is required for every North Andover MA 01845 04/17/2017 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Type: El leaching pits number: E] leaching chambers number: El leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: 4 @L20'w x 461 El overflow cesspool number: El 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.): Sandy soil with no signs of hydraulic failure. No ponding and normal vegetation. 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 El Yes El No 15ins.doc-rev.6116 Title 5 Official inspection Forn Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Liberty Street Property Address Marviine Bellosguardo Owner Owner's Name information is required for every North Andover MA 01845 04/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): ............ 15ins.dor-rev.6116 Tille 5 Official InspLclion Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Liberty Street Property Address Mar)�Hne Bellosquardo Owner Owner's Name information is required for every North Andover MA 01845 04/17/2017 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 77 drawing attached separately V3.f Y 0 l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage DisPosel system-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Liberty Street ......................... Property Address Maryline Bellosguardo Owner Owner's Name information is required for every North Andover MA 01845 04/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Z Check Slope Z Surface water Z Check cellar Z Shallow wells 81 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: z Obtained from system design plans on record If checked, date of design plan reviewed: —.- 5/1/1985 Date F-1 Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ..........——----- El Checked with local excavators, installers - (attach documentation) El Accessed USGS database -explain: You must describe how you established the high ground water elevation: Design plans at the Board of Health. .......... Before filing this Inspection Report, please see Report Completeness Checklist on next page. tbins.doc-rev.6116 Title 5 Official Inspection Form Subsurface Sewage Oisposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Liberty Street --- Property Address Maryline Bellosguardo —............. -_--—---------- Owner Owner's Name information is required for every North Andover MA .01-8,45 04/17/2017 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.doc;-rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 17 of 17