HomeMy WebLinkAboutTitle V Inspection Report - 62 FARNUM STREET 4/8/2006 Commonwealth .ssachusetts
Title 5 G Ficial Inspection Form
_ X Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
Important:
When filling out 1. Property Information:
forms on the
computer, use 62 Farnum St.
only the tab key Property Address
to move your John Good
cursor-do not Owners Name
use the return
key. 62 Farnum
Owner's Address
N. Andover ma 01845
Cityrrown State Zip Code
Date of inspection: 4-8-06
Date
2. Inspector:
Robert Kimball
Name of Inspector
R. Kimball Excavation LLC
21 Clifton Ave
Company Address
Salem NH 03079
Cityfrown State .Zip Code
978-375-1011
Telephone Number
Certification Statement:
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
❑ ed urtheIu I by�tie oc pproving Authority
Insp c# s Signature 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
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.
9
"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.
Title 5 Inspection Forms John Good.doc•1112044 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
62 Farnum St.
Property Address
N. Andover MA 01845
CitylTown State Zip Code
John Good 4-8-06
Owner's Name Date of Inspection
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.
Answer yes, no or not determined (Y, N, ND) in the ❑ 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.
ND Explain'.
Title 5 Inspection Forms John Good.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
621=arnum at.
Property Address
N. Andover MA 01845
Cityfrown State Zip Code
John Good 4-8-06
Owner's Name Date of Inspection
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
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
❑ 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
❑ obstruction is removed
ND Explain:
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
15.3030)(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
Title 5 Inspection Forms John Good.doc•1112004 Title 5 Official inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection f=orm
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
62 Farnum St.
PropertyAddress
N. Andover MA 01845
Citylrown State Zip Code
John Good 4-8.06
Owners Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont,):
2. System will fail unless the Board of Health(acrd Public Water Supplier,N 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
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached
to this form.
3. Other:
Title 5 Inspection Forms John Good.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
? Subsurface Sewage Disposal System Form
A. Certification (cant.)
62 Farnum St.
Property Address
N.Andover MA 01845
Cityrrown State ZipCode
John Good 4-8-06
Ownees Name Date of Inspection
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 %day flow
❑ ® 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. (Phis
system passes If the well water analysis,performed at a DEP certified
laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm, provided that no other failure criteria are triggered.A copy of
the analysis must be attached to this form.)
Yes No
® ❑ The system falls.l 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 Wealth to determine what will be
necessary to correct the failure.
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Commonwealth of Massachusetts
R N Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
62 Farnum St.
Property Address
N. Andover MA 01845
Cityrrown � State Zip Code
John Good 4-8-06
Owner's Name Date of Inspection
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" es" or"no"to each of the following, in addition to the
questions in Section D.
YES NO
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area-- IWPA)or a mapped Zone 11 of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
u
Title 5 Inspection Forms John Good.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
} Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
62 Farnum St.
Property Address
N. Andover MA 01845
Cityrr wn State Zip Code _
JohnGood4-8-06
m �.... _....
Owner's Name Date of Inspection
Check if the following have been done. You must indicate"yes" or"no" as to each of the following;
YES NO
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (if they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on.
® Existing information. For example, a plan at the Board of Health.
® ❑ 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(3)(b)J
Title 5 Inspection Forms John Good.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7of16
Commonwealth of Massachusetts
EA
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
62 Farnum St.
Properly Address
N. Andover MA 01845
City/Town State Zip Code
John Good 4-8-06
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Sump pump? ❑ Yes ® No
ocupied
Last date of occupancy: Date
Commerciallindustrial 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: -- -
Last date of occupancy/use: — —
Dale
Other(describe):
Title 5 Inspection Forms John Good-dor•1112G04 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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Apr 19 OG 02: 55p p• 1
Summary Record Card generated an 411912006 2:07:03 PM 6y Liss Warren Page 1
Town of North Andover
Tax Map # 210-107.A-0086-0000.0
62 FARNUM STREET
GOOD, JOHN J.
62 FARNUM STREET
N. ANDOVER, MA
01845
Cies 101 Single Family Property Type 1 Residential
Size Total 1.12 Acres
Fy 2006
UB Mailing Index
Name/Address Type Loan Number Active/tnact. From Until
GOOD, JOHN J. Payor
62 FARNUM STREET
N. ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Activetinactive
Bldg Id. 14287.0- 62 FARNUM STREET Last Billing Date 3/7/2006
2100282 02 Cycle 02 Active
U8 Services Maint.
Service Code Rate Charge MultipPer/Users
MISCFEE ADMIN FEE 0.63 518 7.82 1/
WTR WATER 01 ALL METER SIZE 64.41 /1
UB Motor Maintenance
Serial No Status Location Brand Type Size YTD Cons
16335864 a Active ERT METE METE w Water 0.63 0.63 0
Date Reading Code Consumption Posted Date Variance
2/8/2006 369 a Actual 19 3/13/2006 -3%
11/4/2005 350 a Actual 18 12/1412005 -20%
8/8/2005 332 a Actual 23 9/12/2005 55%
5/10/2005 309 a Actual 14 6/8/2005 -17%
2/14/2005 295 a Actual 18 3/15/2005 5%
1111512004 277 a Actual 18 12/17/2004 1%
8/11/2004 259 a Actual 16 9/20/2004 20%
5/17/2004 243 a Actual 14 6/14/2004 -12%
2/17/2004 229 a Actual 18 4/16/2004 0%
11/7/2003 211 n New Meter 0 11/7/2003 0%
I
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Not for Voluntary Assessments
.r Subsurface Sewage Disposal System Form
C. System Information (cont.)
62 Farnum St.
Property Address
N. Andover MA 01845
Cityfrown State Zip Code
John Good _ 4-8-06 _
Owner's Name Date of inspection
General Information
Pumping Records:
Source of information: owner
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
40+1-
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Title 5 Inspection Forms John Good.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
u U Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cant.)
62 Farnum St.
Property Address
N. Andover MA 01845
City/Town State Zip Code
John Good 4-8-06
Owners Name Date of Inspection
Building Sewer(locate on site plan):
2_.
Depth below rade: _ ---
g feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain): - -
Distance from private water supply well or suction line. city
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan).
2,
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 ❑ Yes ❑ No
certificate)
Dimensions: 1500 gal -round
6„
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 4$" --.........
2"
Scum thickness _
1"
Distance from top of scum to top of Outlet tee or baffle
A�FI
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? field observation u
Title 5 Inspection f=orms John Good.doc•1912004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
62 Farnum St.
Property Address
Andover _ MA 01845
CityrYown State Zip Code
John Good 4-8-06
Owner's Name Date of Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan): 0-0
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: nate -
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: 0 }
Iv
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Title 5 Inspection Fors John Good.doc-1112004 Title 5 Official Inspection Form.Subsurface Sewage Disposal System
Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System information (cont.)
62 Farnum St.
Property Address
N. Andover MA 01845
Cityrrown State Zip Cade
John Good 4-8-06
Owner's Name Date of Inspection
Tight or Holding Tank (cont.)
Dimensions: m..
Capacity: �, f gallons �..
Design Flow: w _..m
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: --- Alarm in working order: ❑ Yes❑ No
Date of last pumping: gate —. ..--
Comments (condition of alarm and float switches, etc.):
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 5„— - - - m
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.):
Distribution Box was flooded
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Title 5 Inspection Forms John Good.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 112 of 16
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
62 1=arnum St.
Property Address
N. Andover MA 01845
city/Town State Zip Code
,John Good4-8-06
Owner's Name __. Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length: 2-30
❑ 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.):
Dug hole next to trench and determined hydraulic failure w
Title 5 Inspection Forms John Good.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Tide 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
62 Farnum
Property Address
N. Andover MA 01845
CitylTawn State Zip Code
John Good 4-8-06
Owner's Name Date of Inspection
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 lV
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
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 W_._........._ _.._�
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Title 5 Inspection Forms John Good.doc-1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cant.)
62 Farnum St.
Property Address
N. Andover MA 01845
Citylrown State Zip Code
John Good 4-8-06
Owner's Name Date of Inspection
Sketch Of Sewage Disposal System: Provide a sketch 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.
E
{
c
AU l � �
'-'90=
Title 5 Inspection Forms Jotln Good.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
Commonwealth of Massachusetts
IN
Title 5 Official Inspection Form
Not for Voluntary Assessments
9•'V
Subsurface Sewage Disposal System Form
C. System Information (cont.)
62 Farnum St.
Property Address
N. AndoverMA 01845_
City/Town State -_..._� Zip Code ....__..__.
John Good 4-8-06
Owner's Name Date of Inspection
Site Exam:
Slope 0- 30
Surface water npnP
Check cellar Oc'/
Shallow wells ala n e
Estimated depth to ground water:
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: --
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:
USDA Northern Essex soil maps
You must describe how you established the high ground water elevation:
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