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HomeMy WebLinkAboutTitle V Inspection Report - 62 FARNUM STREET 10/8/2008 ' Commonwealth ofrMassachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Farnum Street Property Address Chris Gattis Owner Owners Name requinform r on Is No Andover MA 01845 1018108 requireddfor every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. ImporWhenfllin A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Benjamin C. Osgood, Jr. cursor-do not Name of Inspector use the return key. New England Engineering Services, Inc. Company Name 1600 Osgood Street Suite 2-64 Company Address No.Andover MA 01845 Cityrrown State Zip Code 978-686-1768 Telephone Number License Number B. Certification I certify that 1 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 (310 CMR 15.000).The system: R Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority o 0- A irsspector' ignature 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. ****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 FORM MASTER.00C•08108 Title 5 Olficlal Inspacgon Form:Subsurface Sewage€31sposai System•Page 1 of 15 ' Commonwealth of,MassFachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Farnum Street Property Address Chris Gattis Owner Owners Name information is required for No Andover MA 01845 1018/08 every page. City/Town 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. 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: ❑ 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 TITLE 5 FORM MASTER.DOC•08106 Title 6 Of clal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 16 ` Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Farnum Street Property Address Chris Gattis Owner Owners Name information is required for No Andover MA 01845 1018108 every page. City[Town State Zip Code Date of inspection B. Certification (cont) B) System Conditionally Passes(cont.): ❑ 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 15.303(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 2. System will fall 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. TITLE 5 FORM MASTERMOC•08106 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Farnum Street Property Address Chris Gattis Owner Owner's Name information is required for No Andover MA 01845 1018108 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cant.): ❑ 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 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 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: Yes No ❑ d Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ [�r, 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 ❑ [3.,- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/ day flow ❑ ED/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ET 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 E] Q/ tributary to a surface water supply. TITLE 5 FORM MASTERBOC•68106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 1 3 Commonwealth of Massachusetts r Title 5 official Inspection Form Y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments err 62 Farnum Street Property Address Chris Gattis Owner Owner's Name, Information is required for No Andover MA 01845 10!8108 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ R Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0/ Any portion of a cesspool or privy is within 50 feet of a private water supply well. El 1..3/ 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 than 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.] ❑ Eg/ The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ©/ 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 questions in Section D. Yes No ❑ [0" 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 ❑ E3/ the system is located in a nitrogen 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 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. TITLE 5 FORM MASTERBOC•08106 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts a Tine 5 official Inspection Form n o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 62 Farnum Street Property Address Chris Gattis Owner Owner's Name information is required for No Andover MA 01845 1018108 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 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? ❑ 2/ 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) g, ❑ 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? I--I/ ❑ 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(5)] TE7LE 5 FORM MASTER-DOC•08/06 Title 5 Official inspec6on.Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 62 Farnum Street Property Address Chris Gattis Owner Owner's Name information is No Andover MA 01845 1018108 required for every page. CitylTown State Zip Code Date of inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 3a Number of current residents: -3 Does residence have a garbage grinder? CR Yes ❑ No Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ❑ Yes [R No Seasonal use? ❑ Yes © No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ® Yes ❑ No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersonslsq.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: Date Other(describe): TITLE 5 FORM MASTER.DOC•09!08 Title 5 Ofticlsl Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 62 Farnum Street Property Address Chris Gattis Owner Owner's Name information is required for No Andover MA 01845 1018108 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: /Vol' �rV W p.rJ yI".) 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: Q 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) ❑ Tight tank. Attach a copy of the DEP approval. Other(describe): rl>AA E(L. Approximate age of all components, date installed (if known)and source of information: G 61�5;-- 9-01 LT L -j s Were sewage odors detected when arriving at the site? ❑ Yes 9 No TITLE 6 FORM MASTER.DOC-08106 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts EQOS�x Title 5 official Inspection Form d Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 62 Farnum Street Property Address Chris Gattis Owner Owner's Name information is required for No Andover MA 01845 1018108 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: Z 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.): Septic Tank(locate on site plan): Depth below grade: Z feet Material of construction: 13 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: l 64c c�•i1s Sludge depth: L Z Distance from top of sludge to bottom of outlet tee or baffle 3'7 Scum thickness �" 2 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? TITLE 5 FORM MASTER.DOC•08106 Title 5 ONidal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 62 Farnum Street Property Address Chris Gattis Owner Owner's Name information is required for No Andover MA 01845 108108 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Oo G n!a�j7 d o cJGZ x 1,v 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 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): TITLE 6 FORM MASTER.DOC-08106 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Farnum Street Property Address Chris Gattis Owner Owner's Name information is required for No Andover MA 01845 1018108 every page. City/Town State Zip Cade Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): OL aa wi7 c 17—( vat a j?,.rA Pump Chamber(locate on site plan): Pumps in working order: Yes ❑ No Alarms in working order: Yes ❑ No TITLE 5 FORM MASTER.DOC•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 62 Farnum Street Property Address Chris Gattis Owner Owner's Name information is required for No Andover MA 01845 1018108 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): vNe-P AN/P P—f/Ad 64ftfM. 0Q c -fid 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: leaching fields number, dimensions: k3 ew ❑ 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.): to c L� D n 1?7 N .ti 012,TITLE 5 FORM MASTER.DOC 011106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y ' 82 Farnum Street Property Address Chris Gattis Owner Owner's Name Inforrequired is No Andover MA 01845 1018!08 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cant.) 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 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.): TITLE 5 FORM MASTER.DOC-06106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 16 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Farnum Street Property Address Chris Gattis Owner Owner's Name information is required for No Andover MA 01845 1018108 every page. Cityfrown State Zip Code Date of Inspection D, System Information (cont.) 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. 91 SfRN( S �- AA)IL Oj-j7v rnQ ��.a 1-Mf �� . 15� C�Lta�� ,moo &4u" Go M Fro -T ISN TITLE 5 FORM MASTER.POC•08106 TIUe 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 15 Commonwealth of Massachusetts MURRim Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "r 62 Farnum Street Property Address Chris Gattis Owner Owner's Name information is required for No Andover MA 01845 1018!08 every page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: [T Check Slope [Surface water nvyv,-1- [+Check cellar p [Shallow wells kvo&,7' Estimated depth to ground water: teat 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: Z� 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: HI 6,H TITLE 5 FORM MASTER.DOC•08l06 Title 5 4ffieial Inspection For n:Subsurface Sewage Disposal System•Page 16 of 16 tAORT gab 0 Arms) "V CINU PUBLIC HEALTH DEPARTMENT Community Development Division TTIC4TE OE COMPLI rV r'(rRT, -31 CE As of: October 2, 2006 Tfiis is to cenify that the individualsubsurface disposa[system received a: Euff Septic System Repair by Joseph (Duddy) Wats®n At: 62 Tarnum Street worth,4ndover, gwq 01845 Tfie Issuance of this certijicate shall not 6e construed as a guarantee that the system will function sat4qfactofify. Sus T',Sawyer, WREXS19 U Pu6fic-Veafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978,688.9540 Fox 97808.8476 Web www.townofnorthandover.com �{OnYhr ,.. O�yiw.ru b"�•10 t. r"i4 4� �Y °y4io.Fr� 45 �+1C 4dU'�'� PUBLIC HEALTH DEPARTMENT Community Development Division TOWN OF NORTH ANDOVER " s t SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System( )constructed;( )repaired By: r�%L1 'I� F �� A �� ��j � � � f �aP)t�kf��f(�Irk iri'I ikr�i� 'Pr�i,lf�t1�4 (Print Name) Located at: (�tl 'A te-pi.Ll I'l (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan,originally dated " and last revised on 7. / ~ ,with a design flow of gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 310.CMR 1.5.000,Title 5 and local regulations,and the final grading agrees substantially with the approved plan.All work is accurately represented on the As-built which has been submitted to the Board of Health. Bottom of Tied Inspection Date: "ACS � - Engineer Representative(Signature) i t.L And-Print Name �- Final Construction.Inspection Date: �C%' t '� C f Engineer Representative(Signature) And-Print Name Installer: Jx'� Signature) Date: And_Print Name Enginer: ����1�G� �ilr,2lC�( a/C1 (Signature) Date: 9-2Y- ;� And--Print Name 1600 Osgood Street, North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com