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HomeMy WebLinkAboutTitle V Inspection Report - 231 FOREST STREET 5/17/2017 Commonwealth of Massachusetts Title 5 Offidal Inspection Form k, Subsurface Sewage Disposal System Forma Not for Voluntary Assessments 0 231 Forest Street Property Address Robert Sevard owner owner's Name ,.,_.._.__....._._._... information is required for every North Andover MA 01845 04-08-2017 .._ 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. ,4 AL Ito Important:When General Information filling out forms on the computer, use only the tab 1. Inspector, key to move your cursor-do use the returns Name orfInspector©sgood Jr _ _.-- -......,._..,....... key. none r� Company Name 157 Bluff Street Company Address rn Salem NH 03079 City/Town State Zip Code 978-435-1324 870 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: ED Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority _.. 04-10-2017 Inspector's gnature 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 j 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. l5ins-3113 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 231 Forest Street Property Address Robert Sevard Owner Owners Name information is North Andover MA 01845 04-08-2017 i required for every page CitylTown 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: ® 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: ❑ 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 oid*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): NIA ISMS•3113 T€Sle 5 Official Inspection Form:Subsurface Sewage disposal System-Page 2 of 17 Commonwealth of Massachusetts _ _ F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 231 Forest Street Property Address Robert Sevard Owner Owner's Name information is North Andover MA 01845 04-08-2017 required far every .W._ .-- page, Cityrrown State Zip Code date of fnspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cant.): ❑ 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): NIA ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): N/A 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 Wine-3113 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 231 Forest Street Property Address Robert Sevard Owner Owner's Name information is North Andover MA 01845 04-08-2017 required for every _ page_ CityTTown State Zip Code Date of inspection D. System Information Description: 1,000 gallon septic tank, and leach field Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes No information in this report.) El Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water teeter readings, if available (last 2 years usage (gpd))� well Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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? ❑ 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: _- l5ins•3h3 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 7 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System f=orm -Not for Voluntary Assessments 239 f=orest Street Property Address Robert Sevard Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 �.._..___ page. cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date ---- Other(describe below): General Information Pumping Records: Source of information: 7 years per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons Mow was quantity pumped determined? - - --- -- -- - _- 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) ❑ InnovativelAlternative 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): 15ins•3113 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 231 Forest Street Property Address Robert Sevard Owner Owner's Name information is required for every North Andover MA 01846 04-08-2017 i 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: House built in 1965. System is original Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: NIA feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe OK in basement. Septic Tank(locate on site plan): 2,t Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,500 gallons Sludge depth: 2" t5ins•3113 Title 6 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 231 Forest Street Property Address — Robert Sevard Owner Owner's Name -information is is North Andover MA 01845 04-08-2017 required for every _ -----_-- page. cityFrown 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 26" --- -- Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measure stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition. SCH 40 PVC outlet tee missing at inspection but was in the possession of the owner so it was re-installed. 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 Mns•3113 Title 6 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 kn. 231 Forest Street Property Address Robert Sevard Owner Owner's!Name information is j required for every North Andover MA 01845 04-08-2017 page. Cityrrown 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 t5ins•3113 Title 6 Official Inspection Foran: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 231 Forest Street Property Address Robert Sevard _ Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cant.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 -- 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 in good condition. Liquid levels normal, no indication of leakage in or out.Some indication of carryover 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 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �„ •''v 231 Forest Street Property Add fess Robert Sevard Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 page- Cityrrown 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 field 20 x 40 ❑ 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.): Stone in leach field dry and clean. Noponding, damp soil, or breakout observed 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 l5ins-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts x Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 231 Forest Street Property Address Robert Sevard Owner Owner's Name information is required for every North Andover MA 01845 04-08-2017 _-- -�. page. CitytT'own 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•3113 Title 6 Oficial Inspection Form:Subsurface Sewage nisposel System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J 231 Forest Street Property Address Robert Sevard Owner Owners Name information is North Andover MA 01845 04-08-2017 required for every �_ page. Cityfrown 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 ta�L� I _ t z 3it �Ut � o 6-14LLVN _j ��� FFI , Wins-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ., _231 Forest Street Property Address Robert Sevard Owner owner's Name information is North Andover MA 0184_5 04-08-2017 required for eery _ .. page. Cityfrown State Zip Code Date of Inspection D. System information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 3'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: bate -- ® 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: Canton soil You must describe how you established the high ground water elevation: Experience of this inspector is that the ESHVVT in this area is 30 to 40 inches below grade. This system was constructed in a low area that was filled and the bottom is only 2' below grade which places the system Before filing this Inspection Report, please see Report Completeness Checklist on next page. Wins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - , Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 231 Forest Street Property Address Robert Sevard Owner Owner's Name information is North Andover MA 01845 04-08-2017 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 0 System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•3113 Title 5 Qfiiciaf Inspection Form:Subsurface Sewage Disposal System-Page 17 or 17