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Home My WebLink AboutTitle V Inspection Report - 59 NORTH CROSS ROAD 10/27/2017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner information is required for every page. City/Town State Zip Code Date of TriispecfiDn-- Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. important:When filling out forms A.-General Information on the computer, use only the tab 1. Inspector: goo key to move your cursor-do not use the return .-•.- key. Name AofInspector l rfr L 0 mpang-Wa�m e jCpC � Ad-dress- Ci own StateZip Code 4 Tel Njr;-be—r 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 ❑ Conditionally Passes ❑ Fails F] Needs Further Evaluaj n by the Local Approving Authority Lj Needs Further e r Fvalua ure Date *nspe�ctor`s n T system S13 r , or all s The system 4inspec or all 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 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. t5tm•3173 Titit.,5 Official Inspection Form Subsurface Sewage Disposal System.page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments -all Property Address Owner Owners Name, information Is required for every A- 44 CRV/Town Zip Code Date of Inspection page. &It.le B. Certification (cont.) Inspection Summary: Check A,B,C,D or E always complete all of Section D A) System Passes: XI 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: Q�k LA- _Y e_91,fYt1k B) System Conditionally Passes: E] 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 th ox for"yes", "no" or"not determined" (Y, N, ND) for the following statements, If"not determined,"please explain. The septic tank is"me and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substaft I-infiltration or exfiltration or tank failure is imminent, System will pass inspection if the existing tank I keplaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection !I structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than tQyears old is available. Cl Y F] N ND (Explain below): t5ins 3113 Title 5 Official tnspection Foam Subsurface Sewage Disposal System Page 2 0117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's_Nam P',,,, information is required for every own page. State Zip Code Date of Inspection B. Certification (cont.) D Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. "S)—System Conditionally Passes (cont.): F-1 Observation of__s'dwagbackup or break out or high static water level in the distribution box due to broken or obstructed p or due to a broken, settled or uneven distribution box. System will pass inspection if(with approvall- oard of Health): ❑ broken pipe(s) are replaced Y El N El ND (Explain below): b 0 r ❑ ed a of Health}: Y El E' ND (Explain obstruction is removed El Y N ❑ ND (Explain below): 0 ji F] distribution box is leveled or replaced F� Y E[] 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): �R broken pipe(s) are replaced FI Y El N El ND (Explain below): Olbktruction is removed El Y El N n ND (Explain below): C) Further Evaluation is Required by the Board of *#a the ❑ Conditions exist which require further evaluation by the Board,44fHealth in order to determine if .0 �m the system is failing to protect public health, safety or the environ ,ent. 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 5 Officiat Inspection Form Subsurface Sewage Disposal system-Page 3 at iT Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address H- Owner Owner' N information is required for every page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) 2 System will fail unless the Board of Health (and Public Water Supplier, if any) -d y ,�,termines that the system is functioning in a manner that protects the public health, fe safend-'Onv'rcinment: Sys m as s ti [:1 The t e has r.=nk and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supe % ibutary to a surface water supply. R The system has a septic tank and SA d the SAS is within a Zone 1 of a public water supply- 'a d the SAS is within a Zone The system has a septic tank and SAS and the S within 50 feet of a private water I c supply well, El The system has a septic tank and SAS and the SAS is less tha 00 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 laborat for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nit en is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the an sis 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 Backup of sewage into facility or system component due to overloaded or F� 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 o Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ,Sins-3113 Title 5 Official Inspection Form Subsurface Sewage[)isposai System.page 4 of 97 Commonwealth of Massachusetts Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Addr s ' V1 V11 "1 Owner r Owner's Ma a information Is �-Y �3 VI required for every "� _ `�"'!�*�. _ r_ { r ?. ', page, Cityfrown 'State Zip Code Date of Inspection _ B. Certification (cont.) _ Yes No ❑ N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 21 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. ❑ 5� 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. ❑ VX 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 90,000 gpd to 15,000 gpd. large systems, you must indica ither"yes" or"'no"' to each of the following, in addition to the que . ns in section D. Yes ❑ ❑ e system is within 400 feet of a su a drinking water supply (� ❑ the sys is within 200 feet of a tributary to a s ce drinking water suPPIY the system is ated in a nitrogen sensitive area (Interi �ellhead Protection ❑ Area — IWPA) or a apped Zane II of a public water supply If you have answered "yes" to any question in tion E the system is considered a significa hreat, or answered "yes" in Section D above the large sys has failed. The owner or operatorof any e system considered a significant threat under section E o iled under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system ow should contact the appropriate regional office of the Department. I5ins-3113 Title 5 Official hspertion Form'Subsurface Sewage Disposa!System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syste arm Not for Voluntary Assessments 6-5 /V611- Property Addr31' 1 vOwner Owner' N information is required for every &C r0— a page. CitytTown 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 yq R Pumping information was provided by the owner, occupant, or Board of Health El 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? F-1 Were as built plans of the system obtained and examined? (If they were not available note as N/A) El Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? El 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: QExisting information, For example, a plan at the Board of Healtr E] ok 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): Number of bedrooms (actual): -------- 4/ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x*of bedrooms): d-1 & 15ins-3113 11116 5 Official Inspection Form.Subsurface Sewage Disposal System�Page 6 of 17 Commonwealth of Massachusefts Title 5 Official Inspection Form Subsurface sewage Disposal System Form - Not for Voluntary Assessments ZVO Property Address Owner Owner's Na information is ,ry I�p„ r required for every /._.s��k,, �° ___ . ,`v C k;,,--- /" /t __ �1-(,, page, Cityfrown — ___.,_ State Zip Code Date of Inspection D. System Information _ Description: Number of current residents: Does residence have a garbage grinder? 1W, Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) �, Laundry system inspected? ❑ Yes Na Seasonal use? ❑ Yes No K Water meter readings, if available (last 2 years usage (gpd)): Ai Detail: Sump pump? ❑ Yes y(K No Last date of occupancy: ` Date Commercial/industrial Flow Conditions: Type of Establishment: D rgn_fl w(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats s/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes F-1No Non-sanitary waste discharged to the Title 5 system? F] Yes ❑ No Water meter readings, if available: 151ns 303 Title 5 Ofrmtal Inspectw 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 t:'T Property Address da(I 1,6'1 i7pt( Owner Owne' N information Is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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: KSeptic tank, distribution box, soil absorption system El Single cesspool 1:1 Overflow cesspool El Privy Shared system (yes ct(2oj) ( yes, attach previous inspection records, if any) E] 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 I/A system by system operator under contract F] Tight tank, Attach a copy of the DEP approval, El Other (describe): !Bins-3113 Title 5 Official Inspection Form Subsurlacf Sewage Disposal Systery,,page 6 of 17 Commonwealth of Massachusetts Title 5 Official In. Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Na information is required for every page. City/Town State Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: ------- Were sewage odors detected when arriving at the site? Q Yes No Building Sewer(locate on site plan): Depth below grade: -L�- — feet Material of construction: Z-cast iron 440 PVC Q other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): lu (< Septic Tank (locate on site plan): Depth below grade: feet Material of construction: Kconcrete E) metal M fiberglass F-1 polyethylene [] other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No Dimensions: A Sludge depth: t5ins-9113 Title 5 Official Inspection Pow Subsufface Sewage Disposal System,Page 9 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w y 5 / Property Address A Owner's wner's Na -- — information Is / required for every "� "� •�'y"'� / c7" '� �_" f — .�_._w page. '6 ty Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cant.) Distance from top of sludge to bottom of outlet tee or baffle r� Scum thickness e rl 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? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n let Grease Trap (locate on site plan): Depth below grade: feet MatedaT a construction: F� ❑ 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 t5ins•3113 Tula 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner &A Owne. s .a information is �� '`� required for every _�`"�, �''_"�-- "_`� ^�-''�°'"�;m.. _ "� ,Ab._"r�� 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.): Tight or Holding Tank (tank must be pumped at tim inspection) (locate on site plan): Depth below grade: -- -------- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimic;tns: Capacity: gallons Design Flow. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: — — -__ .__. ___ Alarm in working order: ❑ Yes ❑ No Date of last pumping: Da Comments (condition of alarm and float switches, etc.): i Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 151ns-3l13 Title 5 Official Inspection Forme Subsurface Smvage Disposal System Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 451 Property Addres OwnerOwn information is required for every Z4> page, Cfty[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 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.): Cs C�—W'e 7-kz.'k.CAL Pump Chamber(locate on site plan): '?uT ,psin working order: M Yes El No* '4-Wor Alarms -king, order: M Yes F� No* Comments (note condition o�p-uMp�icfj_�mber, condition of pumps and appurtenances, etc,): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: f5irn-3113 Title 5 Official Inspection Form:S"I"t)'"face Sewage DiulJO$31 SYMP171-Pape 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments T-6) %S Property Addr"s Owner OUCr S N information is Gti required for every O�4 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number leaching trenches number, length: ❑ leaching fields number, dimensions: 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, et- 1 1 7 -A' 14- (�z t Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Dep ,top of liquid to inlet invert Depth of solids lay Depth of scum layer —----- Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes 0 No 1.5ins•9113 Title 5 Official inspection Form Subsurface Sewage Disposal System.page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syst;prQ Form - Not for Voluntary Assessments Property Address (tilt Y�' V) j Owner Owner' N e information is I A required for every AL6 City/Tl� page, wn 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, e Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of Pon g, condition of vegetation, et1:0< usint•3113 Title 5 Official inspection Form:Subsurface Sewage Nsposat System page 14 of 17 Commonwealth of Massachusetts 7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Fotr7,; Not for Voluntary Assessments Property Address- Owner Owners ' , information is A61A required for every zs�l page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks, Locate all wells within 100 feet. Locate where public water supply enters the building, Check one of the boxes below: El hand-sketch in the area below ��drawing attached separately be, t5ins 3193 Title 5 Official inspection Form:Subsurface Sewage[)jsposel system-Page 15 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ko'c� Property Address/ owner Owners Information is required for every page. cityfrown State YIP Code Date of Inspection _ D. System Information (cont.) Site Exam: El Check Slope F-1 Surface water Aj&,k..4'Q_ F-1 Check cellar " ❑ Shallow wells 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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: EJ Checked with local excavators, installers - (attach documentation) D Accessed USGS database - explain: must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page, (bins•3113 TO),)5 Officiaf Inspection Form Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System FOM . Not for Voluntary Assessments Property Address OwnerOwner information is required for every page. CityfTown State Zip Code Date of Inspection E. Report Completeness Chec-klist - 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 15ins 3113 Title 5 OfficAa9 inspection Form.Subsurface Sewage DsPOsal System-Page 17 of 17 a OFFICIAL INSPECTION FO --NOT FOR"VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ;SYSTEM INFORMATION(continued) Property Address: 59 North Cross Road_ _North Andover Owner. McDonald Date of Inspection; 10/5/2002 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. House DriiveWay Water Line Garage A B Deck Septic Tank 2 1 $1' D-Bax A to 1=30'5" Ato2=23' A to D-Bax=4915" Bto1=32'9" B to 2=40'5" B to D-Box=63'6" I