HomeMy WebLinkAboutTitle V Inspection Report - 1180 TURNPIKE STREET 5/30/2017 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
rK
1180 Turnpike Street
Property-Address
—------
Jennifer and Robert__Keeq.an
Owner Owner's Name ------------
information is
required for every North Andover MA 01845 5/30/2017
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be a n any
way. Please see completeness checklist at the end of the form.
GO
�,N
Important:When
filling out forms A. General Information
on the computer,
use only the tab
1. Inspector:
key to move your
cursor-do not James D Aquiar Jr.
use the return
key. Name of Inspector
Tri-Spec Corporation
tYQ Company Name
PO Box 1549
Company Address
Westport MA 02790
City/Town State Zip Code
508-676-77844332
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 Z Conditionally Passes El Fails
❑ Needs Further Evaluation by the Local Approving Authority
,,
--------------
5/31/2017
-Fnsp� S 19 tdk Date
The system inspectot-sh I 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 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 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.doc-rev.6t16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page I of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t
r 1180 Turnpike Street _
Property Address
Jennifer and Robert Keegan
Owner Owner's Name --
information is
required for every North Andover MA 01845 5/30/2017
_. .- ------ ----
page. City/Town State Zip Code Date of inspection
B. Certification (cont)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates tha y of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. y 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 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.
El Y ❑ N ❑ ND (Explain below):
*System is functioning as designed, No Back-ups or High-Liquid Levels have been detected.
However, the Septic Tank and Dbox Inspection covers were both cracked and broken (they were both
haphazardly repaired by a previous Inspector in July of 2016' using landscape blocks from a stockpile
located at the home)Additionally, deterioration and structural cracking was found in both the Septic
Tank and the Dbox, both of these System components need to be replaced, both covers were
temporarily replaced and sealed with plastic to prevent collapse and water infiltration. Both
components should be replaced expediently to prevent damage to the Systems
t5ins,doc-rev.6116 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
v'•Y 1180 Turnpike Street
Property Address
Jennifer and Robert Keegan_
Owner Owner's Name
information is North Andover MA 01845 5/30/2017
required for every — —
page. oityrrown 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.
13) 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):
*see above notation...The liquid levels were all normal with no signs of back-up or hydraulic failure.
The Septic Tank and Dbox need to be replaced to prevent any permanent damage from occuring to
this System.
❑ 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):
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 determ" s"In accordance with 310 CMR
15.303(1)(b)that the system is not functioning)'n a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 5e�f"et of a surface water
❑ Cesspool or privy is wi#fhin 50 feet of a bordering vegetated wetland or a salt marsh
l5ins.doc-rev.6716 Title 5 Official inspection Form,Subsurface Sewage Disposal System•Pago 3 of 17
i
j
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
tltr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c«, r 1180 Turnpike Street
Property Address
Jennifer and Robert Keegan _—__—
Owner Owner's Name
information is
required for every North Andover MA_ 01845 513012017
— --
page, CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Wealth (and Public Water'Supplier, if any)
determines that the system is functioning in a manner that�pfotects the public health,
safety and environment; //
E] The system has a septic tank and soil absorption syptem (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a su face water supply.
❑ The system has a septic tank and SAS andth AS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SZndt
d the SAS is within 50 feet of a private water
supply well.
F1
The system has a 'septic tank and SAS, e SASis less than 100 feet but 50 feet or
more from a private water supply w 11
Method used to/eean.�
**This system pasater analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria innd the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppt no other failure criteria are triggered. A copy of the analysis must
be attached to this
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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page A of 17
Uns.doc•rev.6116
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1180 Turnpike Street _ _ --
Property Address
Jennifer and Robert Keegan
n
Owner Owner's Name --
information is North Andover MA 01845 5/30/2017
required for every -- — — ----- --- -
page. City/Town State Zip Code late of Inspection
B. Certification (cont)
Yes No
❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or
obstructed pipe(s). Number of times pumped: .
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ to Any portion of cesspool or privy is within 104 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 following, in addition to the
3 questions in Section D.
0
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
El Elthe system is within 200 feet-e a tributary to a surface drinking water supply
E-1 El the system is located itnitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any a stion in Section E the system is considered a significant threat,
or answered "yes" in Section D atsove the large system has failed. The owner or operator of any large
system considered a significarfthreat under Section E or failed under Section D shall upgrade the
system in accordance with310 CMR 15.304. The system owner should contact the appropriate
3 regional office of the Department.
t5ins,doc-rev.6116 Title 6 Official Inspection Form:Subsurface Sewage Disposa$System•Page 5 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
o-
v r 1180 Turnpike Street
Property Address
Jennifer and Robert Keegan
Owner Owner's Name
requir on is North Andover MA 01845 5/30/2017
requireddfor every _ ------- -- --------- mm
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 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 Soit 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. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 — Number of bedrooms (actual):
4
440 GPD per
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): BOH
ji [5ins.dcse rev.Wit) Tide 5 official tnspeclion Form:Subsurface Sewage Disposal System•Page 6 of 17
i
Commonwealth of Massachusetts
U
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
IV 1180 Turnpike Street
Property Address
Jennifer and Robert Keegan _
Owner Owner's Name
information is North Andover' MA 01845 5/30/2017
required far every __.�...
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
4
Number of current residents:
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.)
Laundry system inspected? ❑ Yes -] No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): 215 GPD
Detail:
Sump pump? ❑ Yes ® No
current
Last date of occupancy: Date
Commercialllndustriai Flow Conditions:
Type of Establishment: nq __
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 dischargedto t Title 5 system? ❑ Yes E] No
Water meter readings, if avails ie: - -
Oins.doc•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
,
6V.,r 1180 Turnpike_Street
Property Address _
Jennifer and Robert Keegan
Owner Owner's Name
information is North Andover MA 01845 5/30/2017
required for every
page, City/Town State Zip Code Date of Inspection
D. System Information (coat,)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: last pumped 2015'-per BOH records
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How 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)
❑ 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 IIA system by system operator under contract
❑ Tight tank, Attach a copy of the DEP approval.
❑ Other(describe):
f5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
3
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w, 1180 Turnpike Street
Property Address
Jennifer and Robert Keegan
Owner Owner's Name
information is North Andover MA 01845 5/30/2017
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:
20 years -system installeded in 1997`
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1,5
Depth belowrade: �-
g 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.):
'"appears functional
Septic Tank (locate on site plan):
*less than 12"
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
1500 Gal
Dimensions: —
211
Sludge depth:
i 15ins.doe•rev.6116 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 9 of 17
a
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r''~ 1180 Turnpike Street - ----- ___. -- - --�
Property Address
Jennifer and Robert Keegan_
Owner Owners Name
information is North Andover MA 01845 5/30/2017
required far every -- ---
page. CitylTown 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 18" --
Scum thickness
3"
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 12"
How were dimensions determined? fieldolp a visual
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
*System is functioning as designed, No Back-ups or High-Liquid Levels have been detected.
However, the Septic Tank Inspection cover was cracked and broken (it was haphazardly repaired by
a previous Inspector in July of 2016' using landscape blocks from a stockpile located at the home)
Additionally, deterioration and structural cracking was found in the Septic Tank top and sidewalls
above the water line, The Tank appears liquid tight below the water line with normal liquid levels. The
cover was temporarily replaced and sealed with plastic to prevent collapse and water infiltration.
"When the current homeowner was discussing the location of the Septic System in the yard with me -
he was quick to indicate that the previous inspector damaged the Tank cover when he was removing
it and did not replace it."
Grease Trap (locate on site plan):
Depth below grade: � --��
Material of construction:
El concrete El Elfibergl zsrn olyethylene r_1 other(explain):
Dimensions:
Scum thickness - — - -� -
Distance from top of scum to op of outlet tee or baffle
Distance from bottom o cum to bottom of outlet tee or baffle
Date of last pumping: Date
15ins.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
1180 Turnpike Street
Property Address
Jennifer and Robert Keegan
Owner Owner's Name -�
information is North Andover MA 01845 5/30/2017
required for every -. -- -- -----
page, Cit-y 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: _ --"—
f
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: bate
Comments (condition of darm and float switches, etc.):
r�
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
lslns.doc•rev.6716 Tide s official inspection Form:Subsurfeco Sewage Disposal System Page 11 of 17
Commonwealth of Massachusetts
N Title 5 Official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t
,•` 1180 Turnpike Street
Property Address —
Jennifer and Robert Keegan
Owner Owner's Name
information is North Andover MA 01845 5/30/2017
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):
Depth of liquid level above outlet invert normal
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.):
*DBox liquid level was normal, No Back-ups or High-Liquid Levels have been detected. However, the
DBox cover was cracked and broken (it was haphazardly repaired by a previous Inspector in July of
2016' using landscape blocks from a stockpile located at the home) Additionally, deterioration and
structural cracking was found in the DBox top and sidewalls above the water line, The DBox is liquid
tight below the water line with normal liquid levels present. The cover was temporarily repaired,
shared with wood and sealed withIp astie t�revent colla sp e_and water infiltration.
Pump Chamber (locate on site plan):
Pumps in working order: E]--Yes ❑ No*
Alarms in working order: ❑ Yes ❑ Na*
�r
Comments (note condition of pump chamber, condition oPOumps and appurtenances, etc.);
--_ _ 7
f
l
* 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:
• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
l5ins.doc rev,6116
I
{
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
_ 1180 Turnpike Street
Property Address
Jennifer and Robert Keegan
Owner Owner's Name
information is North Andover MA 01845 5/30/2017
required for every _ ..__.__ _.._ ----------_..._� -_.--- - _
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Type:
❑ leaching pits number: --
❑ leaching chambers number:
❑ leaching galleries number: _-_.
® leaching trenches number, length: 3 5 �-
❑ leaching fields number, dimensions:
❑ I 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 are present-a Garbage Disposal is present in this home and it does not
appear that the System was designed for a Garbage Grinder...It should be removed from the home to
_prevent any System damage.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration ------- --_�..-- --._-
Depth -top of liquid to inlet invert Z
Depth of solids layer
Depth of scum layer
Dimensions of cesspool -
Materials of const 'on -
Indication of groundwater inflow ❑ Yes ❑ No
l5insdoc-rev.6116 Tllle 5 Official inspecllon f=orm:subsurface sewage t7isposa4 system•Page 13 of 17
Commonwealth of Massachusetts
u Title 5 Official inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�, SYgr 1180 Turnpike Street
Property Address
Jennifer and Robert Keegan
Owner owner's Name
information is North Andover MA 01845 5/30/2017
required for every -.--..- -- - ---- – —
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.):
0
Privy (locate on site plan):
Materials of construction: - ----
Dimensions
Depth of solids -- -� u --
Comments (note condition of soil, signs hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc rev.6116 Title 5 otrrciai Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
"s Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1180 Turnpike Street
Property Address
Jennifer and Robert Keegan
Owner Owner's Name
information is
required for every {North Andover MA 0_1845 5/30/2017
---
page. City/Town §late 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
i
it5ins.doc-rev.6116 Title 5 Official Inspection FOM Subsurface Sewage Disposal System•Page 15 of 17
'i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1180 Turnpike Street --
Property Address
Jennifer and Robert Keegan -- _
Owner Owner's Name
information is North Andover MA 01845 5/30/2017
required far every — -------T-�
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high round water: greater than 4' from bottom of system
p g g 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: 1997
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation;
Board of Health documents -groundwater does not appear to be a concern at this location - leaching
area is elevated to ensure proper_groundwater separation _
Before filing this Inspection Report, {Tease see Report Completeness Checklist on next page.
Tille 5 Official Inspection form:subsurface Sewage Uisposat System-Page 16 of t7
151ns.doc•rev:6116
u
Commonwealth of Massachusetts
u A Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1180 Turnpike Street
Property Address
Jennifer and Robert Kee a
Owner Owner's Name
information is North Andover MA 01845 5/30/2017
required for every --- -
page, City£rown 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
u
u
Y.
'r l5ins.doc•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal system Page 17 of 17
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TOP VIEW n
G' COMPACTED CRUSHED - - �-
NO1r• ALL INLETS, OUTLETS. JOINT$, AND COVERS STONE GRAVEL SI1R-RAS[
SNAIL OF SEALED AND MADE WATER 7rC?rT, NOTE: ALL THEE rS.& OUTLETS SHALL RL SEALED
WITH HYDRAULIC CEMENT
{
SEPTIC TANK DETAILS
D—80X DETAILS, DESIGN CALCULATIONS
NOT TO Sr.ALt-
NOT TO SCALE
DESIGN FLOW = 4 SEDROOMS x 1 0 GAL./DAY/gBRM
DESIGN PERC RATE:—6— MIN.JIN.
DESIGN FOR LEACHING TRENCHES (SEE DETAIL)
DEEP TEST RESULTS EFFECTIVE WIDTH = 3fi" - EFFECTIVE DEPTH
F'FRC TEST RESULTS
SOIL CLASS:
CSP�� ��'Z+ ® TRENCH C*PACITY = OS.F./F7 r CAL./S.F. =.0 GAL.,
�C?i� EL.x Ic[2,o P' �J�fJGAL./ t7GAL./FT. = It'+rT. OF TRENCH REQUIRED
A P 5 4 ,I nY 'i3 6-" DEPTH DEPTH USE I TRENCHES AT�FT. =0E2 FT- OF TRENCH PROVIDED,
SOAK rIME
L Lr `�-r'I DROP SOAK TIME
r2'-9' !2"-9,• DROP
i'1rdL l`. ::L �5 2iLF_ 9'-6" DROP _.
- s'-6" arrnP I CERTIFY Tk
PERC RATE f - - AT QN MAY g, f99Ei, 1 PASSED THE EXAMINATION APS
2.�;�/ �`�` G I f N.P,r PERC RATE M,P,I• Sr THE DEPARTMENT OF ENVIRONMENTAL PROTECTION AND THAT T.
ANALYSIS WAS PERFORMED BY ME CONSISTENT WITH THE REQUIREI
�' 1,S Y�T f EXPERTISE AND EXPERIENCE DESCRIBED IN 3W CMR T5.017.
?SE�Ik r ' Zfr i ! GI zEsr aATE: _- �--�= �' - - - -
(Cd t`1L3.rp� SS', ENGINEER: Cc ti x5[ �_LwL�S�3. SIONATrJRE
,IV r c I�cnu� INSPECTOR:
71
Ir 1`t�.u, astYr e' 14'; tcYr.q;. rfa
PLAN OF
rVhrrrAMR, ,�,. - SUBSURFACE ,SEWAGE DISPOSAL S
AS PREPARED FOR
foe-vr_
a '•"m SCALE. AS SHOWN ' G I
T NO- OATS DATE:
9Y REVISIONS: ASSESSORS MAP _I G 7G LOT
r � SURf1fV/S/QN:iOT
rl
CK EN
wc
GINEERNG SER.
UR
11' PARK STRFRT