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Home My WebLink AboutTitle V Inspection Report - 164 MILL ROAD 8/14/2017 RECEIVED Commonwealth of Massachusetts n7 AN T7 Title 5 Official Inspection Form WN OF NORTH ANDOVER Subsurface SexxageDispoma| SystemnPorm - NntfnrVo|untaryAseemommnbs `-��_ ��ARTMENT 104Mill Road Property Address Langston Owner Owner's Name information is required for North Andover MA 01845 July 29 2017 every page. Q$vTuwu State Zip Code Date nfInspection Inspection results must be submitted on this form. Inspection forms may not bealtered in any way. Please see completeness checklist atthe end ofthe form. Important: A. K��U U��00��~��n �NenmUnguu1 ^ ~~ General Information = forms onthe computer, use 1. Inspector: only the tab key tomove your Dean G. Lunoomb || cursor-do not Name~'^~~''~~~~~~ key. Dean G. LVscnnnb || & Sons Company Name 288Maple Street Company Address Middleton MA 01949 City/Town State Zip Code A78-7744065S1848 Telephone Number License Number B. Certification | certify that| have personally inspected the sewage disposal system edthis 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 16'340 of Title 5 (31UCMR 16.VD0). The system: E Passes Fl Conditionally Passes Fl Fails Fl Needs Further Evaluation bythe Local Approving Authority July 29 2017 |napoCtor'm8ignmtuie — 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 in a shared system or has Gdesign flow of1O,OOOgpdorgreater, 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, ifapplicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use otthat time.This inspection does not address how the system will perform inthe future under the same mrdifferent conditions ofuse. Commonwealth of Massachusetts v r Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Mill Road Property Address Langston Owner Owner's Name information is required for North Andover MA 01845 July 29, 2017 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Checf 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 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 Titte 5 Official Inspection Form:Subsurface Sewage€Nsposal System•Page 2 of 17 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Mill Road Property Address Langston Owner Owner's Name information is required for North Andover MA 01845 July 29, 2017 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ rump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 6 Official Inspection Fotm: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 164 Mill Road Property Address Langston Owner Owner's Name information is required forNorth Andover MA 01845 July 29, 2017 -�---- every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ 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 6 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: i Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 '/day flow 15ins•3113 Title 5 OtficEal Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 164 Mill Road Property Address Langston Owner Owner's Name information is required for North Andover MA 01845 July 29, 2017 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] El ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,0009pd. ❑ ® 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) rge Systems: To be considered a large system the system must serve a facility with a des i flow of 10,000 gpd to 15,000 gpd. For large syste , ou must indicate either"yes" or"no"to each of the folio in addition to the questions in Section Yes No ❑ ❑ the system is with 400 fee a surface drinking water supply ❑ ❑ the system is wit ' 00 fee a tributary to a surface drinking water supply ❑ ❑ the syst s located in a nitrogen sitive area (Interim Wellhead Protection Are WPA) or a mapped Zone 11 of a blic water supply well If you have ans d"yes"to any question in Section E the system I onsidered a significant threat, or answere ' es" in Section D above the large system has failed. The o r or operator of any large system�.ed"n'sidered a significant threat under Section E or failed under Section hall upgrade the syste'fil in accordance with 310 CMR 15.304. The system owner should contact the ropriate regional office of the Department. t5ins•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title '5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Mill Road Property Address Langston _ Owner Owner's Name information is North Andover MA 01845 July 29, 2017 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Pealth ❑ ® 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Z ❑ 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)1 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 gpd l5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164 Mill Road Property Address Langston_.. Owner —------------ Owner Owner's Name information is required for North Andover MA 01845 jW�9, 2017 every page. City/Town State Zip Code Date of Inspection D. System Information Description: owner and town ------------ ---_--------- ............. Number of current residents: -3 Does residence have a garbage grinder? ❑ Yes JE No Is laundry on a separate sewage system? (include laundry system inspection El Yes 0 No information in this report.) Laundry system inspected? 0 Yes 0 No Seasonal use? ❑ Yes 0 No Water meter readings, if available (last 2 years usage (gpd)): Detail: e;7w grZ_7 Z 3 0 dew x -i,&g� ----------- Sump pump? n Yes No Last date of occupancy: current Date C mercial/Industrial Flow Conditions: Type of Esta i ment: _.w_.._...... merc'a"m"usra' Type of Esta ment' Design flow(based<on 3 QMR 15,203): Gallons per day.. pd)—�— Basis of design flow(seats/persons tt , etc.): Grease trap present? El Yes El No E Industrial waste holding tank,pr-e*96nt? D Yes El No Non-sanitary X,asrrcrischarged to the Title 5 system? F] Yes E] No Water meter readings, if available: (Sins•3113 'ritie 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 164 Mill Road Property Address Langston Owner Owner's Name information is required for North Andover MA 01845 July 29, 2017 _.. every page. City/Town State Zip Code Date of Inspection D. System-information (cont.) Last date of occupancylus Date Other(describe.below): General Information Pumping Records: Source of information: Last pumped March 2017 and pumped every yr. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: Zero gallons How was quantity pumped determined? Reason for pumping: No need at this time Type of System: ® Septic tank, distribution box, soil absorption system td1pa1hp o�? ❑ 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): 15€ns-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 164 Mill Road Property Address Langston Owner Owner's Name information is required for North Andover MA 01845 July 29, 2017 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: Asbuilt is from 8/9/1985- 32 years old. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 / feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Main line and joints are in good condition. Septic Tank(locate on site plan): 3' Depth below grade: reef V` Material of construction; ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast rectangular concrete- 1500 gallons it tank Is metal, list age: Is, �oompfi�iance?=attach7=copy�ofcer�fificate) �� Dimensions: 5'x 5' x 10' - 1500 gallons Sludge depth: 1" l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts RUGMEME Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 184 Mill Road Property Address Langston Owner Owner's Name requinform r don is for North Andover MA 01845 July 29, 2017 required every page. Cityrrown 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 34" a 1,, Scum thickness 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 15 How were dimensions determined? by measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank and baffle are in very good shape. The solids are light and do not require pumping at this time. The liquid is running at it's correct workin hei th. ease Trap (locate on site plan): Depth bel o rade: feet Material of construct) ❑ concrete ❑ metal ❑ fiberglass ❑ po ylene ❑ other(explain): Dimensions: Scum thickness Distance from tf scum to top of outlet tee or baffle Dist a from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 official Inspection Form " Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Mill Road Property Address Langston Owner Owner's Name information is required for North Andover MA 01845 July 29, 2017 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cisqments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid is related to outlet invert, evidence of leakage, etc.): Ti t or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth b w grade: � ~ Material of con action: ❑ concrete metal ❑ fiberglass ❑ polyethyle ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: es ❑ No Alarm level: Alarm in w king order: ❑ Yes ❑ No Date of last pum i e-9Z Date Comment (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3l13 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 164 Mill Road Property Address Langston Owner Owner's Name information is required for North Andover MA 01845 July 29, 2017 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): fDepth of liquid level above outlet invert Zero / Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box is 20"x 30" and is 11" below qrade. The d-box is in very good shape. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): The cover is 9" below rade and measure 3'3" x 3'3". Pum and alarms ail in good working order. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): ` If SAS not located, explain why: SAS was located by asbuilt drawings. l5ins-3113 Title 5 Official lospection Form:Subsurface Sewage Nsposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .y 164 MITI Road Property Address Langston _.._. Owner Owner's Name information is required for North Andover MA 01845 July 29, 2017 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 5-61long ,renes( ❑ 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.): The SAS is in goad condition. There are no si ns of ponding or breakout. ools (cesspool must be pumped as part of inspection) (locate on site plan): Number and co ration Depth —top of liquid to inlet I " Depth of solids layer Depth of scum layer Dimensions,Qf esspool 9 Ma ert"ials of construction Indication of groundwater inflow ❑ Yes No a t5ins•3113 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Pag €17 I 9 3 0 Commonwealth of Massachusetts s Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments u 184 Mill Road Property Address Langstop Owner Owner's Name information is required for North Andover MA 01845 July 29 2017 every page. CityFrown State Zip Code Date of Inspection D. Sy--stem Information (cont.) Comments(n a condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ivy (locate on site plan): Materials o struction: Dimensions r Depth of solids o✓''J' Comments (note condition of soil, signs of 'lure, level of ponding, condition of vegetation, etc.): R�. Ohs 3113 Title 6 Official Inspection Form:Subsurface Sewage DIsposal System•Page 14 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Mill Road " Property Address Langston Owner Owner's Name information is North Andover MA 01845 July 29, 2017 required for every page. CitylTown State Zig Code Date of Inspection D. System Information cont. Sketch Of Sewage Disposal System: Provide a view oft a sews a disposal system, including ties to at least two permanent reference landmarks or benchmarks.Loc ate all wells within 100 feet. Locate where public water supply enters the building. Check on B of the doxes below: ® hand-sketch in the area below El drawing attached separately Z E"krf �arr.,�yc. G r AA Ando H,-Yge,- p '751 0b GZ f6 a tai ' q7 CSDr 5 `� D 'Sox 15Ens•3113 T'stte 5 O€dal Inspection Form:Subsurface Sewage Dsposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Mill Road Property Address Langston Owner Owner's Name information is required for North Andover MA 01845 July 29, 2017 every page. Gitylfown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope (;e ICV, ® Surface water kbll L ® Check cellars ® Shallow wells C)n-� 5' Estimated depth to high ground water: 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: 618183 Date ® Observed site (abutting propertylobservation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Permit, proposed, asbuilt and previous title v (1117/03) on file. ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole# 1 -5'to ground water. Test hole#2 -6' to ground water. By Richard F. Kaminski 618183. Before filing this Inspection Report, please see Report Completeness Checklist on next page. f5ins•3113 Title 5 official inspection f=orm: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 •` 164 Mill Road I'fopefty Address Langston Owner Owner's Name information is North Andover MA 01845 July 29, 2017 required for every page. Cityfiown 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 ti 151ps•3113 Title 5 Official Inspection Form:Subsurface Sewage€7isposal System•Page 17 of 17