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Home My WebLink AboutTitle V Inspection Report - 193 LACY STREET 11/6/2017 ^ . K��0M00��nVVealth of Massachusetts ° �� °�"N��0�� °�� ^�� 0�01�� m��/w~��I,�E�� Title �� *�� w� Inspection �-��mmmm Subsu�aceSovxegeDisposal Syatwmn � rmn - NntforVo|untaryAsueaementa NOV @6 7017 193 Lacy Street TOWN OF NORTH ANDOVR Property Address �,° ea ��/pu '`'~—'- 8coM8tannand u*mw Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. Qyirown State Zip Code Date ofInspection Inspection results must be submitted onthis form. Inspection forms may not be altered in any way. Please see completeness checklist atthe end ofthe form. Important:When A. ��k8��U UU��K��00Bk�~��K� filling out�nnn ^ ^~ General Information ~^ onthe computer, use only the tab 1. Inspector: key tomove your cursor'dmnot Robert Herrick use the return Name ofinspector key. Wind River Environmental Company Name Q 1O3Western Axenu� - -- —' - Company Address Gloucester MA 01930 _ CityfTown State Zip Code Tm|ophonoNumbe, License Number B. Certification | certify that | 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. | am o DEP approved system inspector pursuant to Section 15.340 of Title 5 (31OCMR 15.00Q). The system: M Poaoeo El Conditionally Passes [l Fails | | Needs Further Evaluation bythe Local Approving Authority ' 10X03/2017 �,lnopedo/eSignatuna' oah* The system inspector shall submit o copy ofthis inspection report hothe Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has o 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. °°°°Th|sreport 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 ordifferent conditions mfuse. ' Commonwealth of Massachusetts Title 5 Official Inspection nspe= t=onF o °m � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 103 Lacy Street Pm[mny��ex Scott Stannard Owner Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. City7nwn State Zip Code Date ofInspection B. Certification (cont.) Inspection Summary: Check A.B.C'OorE/ complete � . � A\ System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CK8Fl 15.303 or in 318 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good workingorder. 13) System Conditionally Passes: D 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 dmternnined.^ please explain, ThexnpUotankisme(a| ondover20yemreo|d^orthesepUutonk(vvhedhermetm| ornot) immtruoturoUy unenund, exhibits substantial infiltration ormxfi|tnst(on ortank failure is imminent. System will pooe 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 isless than 2Oyears old iaavailable. El y Fl N Fl ND (Explain bo|uvv): Commonwealth of Massachusetts "��N� � ��N 0�� Title �� y� � ��w� Inspection Form Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 193 Lacy Street --------- PropertyAddmoe Scott Stannard Owner Owner's Name information is North Andover K4A01845 10/03C2017 required for every ----' --��---- pogo. Stam Zip Code Date ofInspection B. Certification (cont.) El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 0\ System Conditionally Passes (oonL): �l 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 bruken, settled or uneven distribution box. System will pass inspection if(with approval ofBoard ufHaa|th): El broken pice(a)are replaced E] Y E] N D ND (Explain below): R obstruction isremoved 0 Y [l N E] ND (Explain El distribution box ialeveled orreplaced El Y F1 N ND (Explain beluw): � The system required pumping more than 4 times a year due tobroken orobstructed pipe(s). The system will pass inspection if(with approval ofthe Board ufHeoKh>: El broken pipe(o)am replaced El Y 0 N R ND (Explain below): [� obstruction is removed Y N [l ND (Explain bedow): C\ Further Evaluation kmRequired bythe Board ofHealth: Fl 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 imnot functioning |nmmanner which will protect public health, safety and the environment: El Cesspool orprivy iewithin 5Qfeet ofusurface water F-1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh C��NMK�K»�V��lth of Massachusetts � � Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1g3Lan Street Property Address --- � Scott Stannard Owner Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. City/Town Stam Zip Code Date ofInspection B. Certification (cont.) � 2. System will fail unless the Board nfHealth (and Public Water Supplier, |fany) dsdsnn|nem that the system is functioning in a manner that protects the puh||o health, safety and environment: [l The system has a septic tank and soil absorption system (SAS) and the SAS is within 10Ofeet ofasurface water supply ortributary toasurface water supply. F-1 The system has oseptic tank and SAS and the SAS iswithin aZone 1 ufapublic water supply. [l The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. [l The system has o septic tank and 3A8 and the SAS is |emo than 100 feet but 5Ofeet or more from o private water supply we/|m* Method used todetermine distance: *^ This aym(om passes ifthe well water analysis, performed at a [)EP 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 must be attached tothis form. 3. Other: [% System Failure Criteria Applicable taAll m: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup nfsewage into facility Vrsystem component due tooverloaded or clogged SAS orcesspool � � �� Discharge orponding ofeffluent tnthe so�aceofthe ground oreu�moevvatorm �� due tognoverloaded orclogged SAS orcesspool Static liquid level in the distribution box above outlet invert due to an overloaded orclogged SAS orcesspool �� Liquid depth in cesspool is less than G" below invert oravailable volume is less �� —_than 1/2 day flow Commonwealth of Massachusetts ��N�� b��N ��^�� h�/ Title �� q��N � �� Inspection 0-��mmmm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1Q3Lao Street Property Address Scott Stannard Owner Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. Qi�/foW» State Zip Code Date ofInspection B. Certification (cont.) � Yes No Fl �� Required pumping more than 4times inthe last year NOT due toclogged or obstructed pipe(s). Number oftimes pumped: _____ [l E Any portion of the SAS, cesspool or privy is below high ground water elevation. [l �� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary tnasurface water supply. Fl �� Any portion ofacesspool orprivy|ewithin a Zone ofapublic well. Fl 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. El M Any portion ofmcesspool nrprivy imless than 1OOfeet but greater than 5Ofeet from o private water supply well with no acceptable water quality analysis. [This system passes |fthe well water analysis, performed ataDEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppmn, provided that no other failure criteria are triggered. A copy ofthe analysis and chain mfcustody must baattached tothis fornn.] The system ismcesspool serving afacility with adesign flow of2000gpd' 10.000gpd. �� The aymtemnfaUe. | have determined that one or more of the above failure �� criteria exist aadescribed in310CMR 15.303. therefore the system fails. The system owner should contact the Board of Health tndetermine what will be necessary to correct the failure. E) Large Systems: To beconsidered alarge system the system must serve efacility with m design flow mf10,go0gpdtm15.00Ogpd. For large systems, you must indicate either"yes" or"no" to each ofthe following, in addition to the questions inSection D. Yes No El R the system is within 400 feet ofa surface drinking water supply El [l the system is within 200 feet ufatributary hnm surface drinking water supply �l �l thesymtemio |noabedinonitrogeneennibveoreo (|ntarimVVe||hoodProtootinn Area- |VVPA)oramapped Zone || ufa public water supply well If you have answered "yen" to any question in Section E the system is considered e 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 ofthe Department. 15my.«no'rev.06 Title:Official Inspection Form:Subsurface Sewage Disposal System'Page om,, ' Commonwealth of Massachusetts ��0�� 0�� Title �� ~�� N�� Inspection N—��mmm � Subau�mcwSevuageDisposal SymtenmFormm - NotforVu|un�aryA��eaem*nta 103Loo Street Property Address SnottSkann�rd ___ ----—------ __-��____ uwnor Owner's Name information is MA 01845 10/O3C�U17 mqukod�xeve� ,,ey' ,~'"",°' ------ ------��- i page. City/Town State Zip Code Date mInspection � C. Checklist CheokifUhefoUuwinqhevebmandone. Ynumnuotimdiceha"vam^ or"no" astomaohofthgfoUnwing: Yon No Pumping information was provided by the owner, occupant, or Board of Health Were any nfthe system components pumped out inthe previous two weeks? E El Has the system received normal flows inthe previous two week period? �� Have large vV|ucnemofwater been introduced hothe system nmcenUyoraopadof �� this inspection? �� Fl ` VVeremabuilt p|anoofthe systemobtained and examined? (|fthmyvvnrnnot �� available note amN/4) E El Was the facility ordwelling inspected for signs ofsewage back up? E El Was the site inspected for signs ofbreak out? • El Were all system components, excluding the SAS, located onsite? • El 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 o[liquid, depth ofsludge and depth cfscum? �� Was the facility uvvnmr(and occupants ifdifferent from owner) provided with �� information on the proper maintenance of subsurface sewage disposal systems? The size and |onnd|on of the Soil Absorption System (SAS) on the site has been determined based on: M E] Existing information. For example, a plan at the Board of Health. �� ` �� De{erminedinthe field (ifany nfthe failure criteria related toPart(� imatissue �� approximation mfdistance inunacceptable) [31QCK8R1S.302(5)] D. System Information Residential Flow Conditions: 44 Number ofbedrooms (design): Number of bedrooms (actual): ------��-- DESIGN flow based nn31OCIVIR15.203 (for example: 11Ogpdx#ofbedroome): �-�-�=�---- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments `p 193 Lacv Street _ Property Address Scott Stannard Owner Owner's Name Information is North Andover MA 01845 10/03/2017 required for every _....... _ - _.... __.. .__ __..__.--- _- ._ _._ page, City/Town State Zip Code Date of Inspection D. System Information Description: This system is made up of a septic tank, pump chamber and distribution box and soil absorption stem. I 2 Number of current residents: — Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? 0 Yes ® No Water meter readings, if available last 2 years usage d Well Water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date ied Commercial/industrial Flow Conditions: Type of Establishment: ---.-. - _........ Design flow(based on 310 CMR 15.203): CaVlons 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: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts ��=��N�� ^J��°��0 N�� 0�� Title �� Inspection N—��mmmm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1g3Leo Strent Property Address Scott Stannard Owner Owner's Qwnnr'nNamn information is North Andover MA 01845 1O/O3/2O17 mquiredh*ro*o� ---- page, City/Town8wt* Zip Code Date ofInspection D. System Information (cont.) Last date o[occwpanoykue: oam Other(describe be|ovv : General Information Pumping Records: Homo Owner Source of information: Was system pumped an part of the inspection? El Yes M No |fyes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type ofSystem: Septic tank, distribution box, soil absorption system Fl Single cesspool �l Overflow cesspool �l Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) [l Innovative/Alternative technology. Attach a copy of the current operation and maintonannenontro(t/tobeobtminodfrnmsyabamovvnor\ondanopyof|ateot inspection nfthe |8\system bysystem operator under contract Tight tank. Attach ocopy ofthe DEP approval. Other(describe): P mh mber ts""uoc'rev.m1p Title oOfficial Inspection Form,Subsurface Sewage Disposal System'Page aw/r ' Commonwealth of Massachusetts ��N�� ^��N N��=�� N� Title �� y� � ��mN Inspection �-�� mmm Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 103Lacy Street Property Address Scott Stannard Owner Owner's Name information is NorUlAndoverMA 01845 10/03/2017 mquimUyor�m� page. City[Tmwo State Zip Code Date o/Inspection D~ System Information /C0Of.\ Approximate age of all components, date installed (if known) and source of information: 2005; Plans onFile Were sewage odors detected when arriving aithe site? El Yes 0 No Building Sewer(locate on site plan): 2' Depth below grade: fee Material of construction: Flcast iron 40 PVC [lother(emp\ain): Over 100' Distance from private water supply well or suction line: feet Comments (on condition of'ointo, venUOg, evidence of leakage, etc.): look to be solid, There are n osi ns of leakage and venting tng h the b i|di Septic Tank(locate mnsite p|on): � Depth below grade: fee K8atyrin| nfoonmtruoUnn: Nnnnnrete El metal El fiberglass El polyethylene E] other(expiain) |ftank iemetal, list age: *um ---��------ |oage confirmed byaCertificate ofCompliance?(attach acopy ofcertificate) El Yes El No 10'6" x68"x68" Dimensions: 3" Sludge depth: ' Commonwealth of Massachusetts =�'��N�� ^��°��N 0��=�� n�! Title �� @ ��0 Inspection Form Subsurface Sevvagm ��iepwsm| System Fornm - MotforVo|untaryAounaamen�o 193 Lacy Street Scott StaProperty Address nnard Sbennard Owner Owner's Name information is North Andover MA O1845 18/03/2017 mquimdfor eve� ________- -___-� _____� -___-��- page� Ci�Towm S*�m Zip Code Date of|nopm�inn D. System Information (cont.) Septic Tank(cont.) 31" D|m�mmhfrom top of sludge to bottom �ouU�tee m baffle 1" Scum thickness �.. Distance from top of scum to top of outlet tee orbaffle Distance from bottom nfscum hnbottom ufoutlet tee orbaffle 14" T �W gur� & �|ud oJudgo Hovvvveredimensions determined? -==-�=� -------- Comments (on pumping recommendations, inlet and outlet tee orbaffle condition, structural integrity, liquid |eva|a as related to outlet invert, evidence of leakage, etc]: Recommend lyTheinlet and outletbaffl |id There are no siqnsleakefge and the liquid level is (]Kin relation tnthe inverts. Grease Trap (locate unsite cdan): Depth below grade: feet Material ofconstruction: El concrete F-1 metal fiberglass polyethylene other(explain): Dimensions: Scum thickness Distance from top ofscum tutop ofoutlet tee orbaffle - - D|otenoafrombuttomofscumtobottomofuut|ot tee mrbaffle --� Date oflast pumping: Date---�--- ---- t5ins.m*'rev.6/16 Title oOfficial Inspection m^uSubsurface Sewage Disposal System'Page mof,r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments j9_q_Lacy Street' ' Property Address Scott Stannard Owner - Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. dtyfTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): . ........... Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: n concrete El metal n fiberglass El polyethylene El other(explain): ............. Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: n Yes E] No Alarm level: Alarm in working order: El Yes n No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? El Yes ❑ No 15ins.doc-rev.6116 Title 5 Official Inspection Form Subsurface Sewage Disposal Systern-Page 11 of 17 ' Commonwealth of Massachusetts ��,�� ~��0 0��~�� N��N Title �� lNQ �� Inspection N—��wmmm Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 193L o Street - ------- Property __ PmportyAddnsn Scott Stannard Owner Owner's Nomo informaUunio North Andover &1A 01845 10/U3/2O17 mquimdfor every page. City/Town State Zip Code Date ofInspection D. System Information (cont.) Distribution Box (if present must beopened) (locate onsite p|an): Depth ofliquid 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 nfbox, etc.): The distribution box is |W There are no siqnsof carrvover or leakaqe inorout ofthe box. The liquid level is {}K in relation to the inverts. Pump Chamber(locate onsite p|mn): Pumps in working order: E Yee Fl No* Alarms in working order: 0 Yea n No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): The pump chamberin ood workinq conditionat the time ofinspection. ^ If pumps or alarms are not inworking order, eyabym is onnnditiono| pass. Soil Absorption System (SAS) (locate on site p|an, excavation not required): If SAS not located, explain why: Commonwealth of Massachusetts "��0� � ��"�� 0�� ^�� »� N �� Inspection �-�pmmmm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1Q3Lacy Street PmpenyAddmeo Scott Stannard Owner Owner's Name information is North A d MA 01845 10/O3�017 mquimUk,revmY '' "^~' -------------�� -----' ----�---- page. State Zip Code Date mInspection D. System Information (cont.) Type: � El leaching pits numbor � 3U � E leaching chambers number: El leaching galleries number: � -- leaching trenches number, length: leaching fields numbor, dimensions: El overflow cesspool number: �] |nnovotive/e|turnat|veoyntom Type/name of technology: Comments (note(noto uondition of soil, signs of hydraulic failure, level of ponding' damp soi|, condition of vegetation, etc.): The soil is dry and there are no si ns ofh f�| di Th vegetation i normal for— the area. Cesspools (cesspool must bepumped as part nfinspection) (locate onsite p|en): Number and configuration Depth-tnp of liquid to inlet invert Depth ofsolids layer Depth ofscum layer � Dimensions ufcesspool Materials ofconstruction Indication ofgroundwater inflow Yea [l No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 193 Lacy Street . ........ Property Address Scott Stannard OwnerOwner's Name information is required for every North Andover MA 01845 10/03/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): –——------- 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.): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts .7 Title 5 Official Inspection Form ai Subsurface Sewage Disposal System Form Not for Voluntary Assessments r4i 193 Lacy Street Property Address Scott Stannard______-____. Owner Owner's Name information is North Andover MA 01845 10/03/2017 required for every Date of Inspection page. Ciiyr_Gvn______ State Zip Code 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: F-1 hand-sketch in the area below Z drawing attached separately c 23,Z J3- 13—ze 13 RIX 0 0 Title 5 Officiat Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 (5ins.doc•rev.6116 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 193 Lacy Street Property Address Scott Stannard Owner Owner's Name information is required for every North Andover MA 01845 10/03/2017 page. City/Town State Zip Code Date of Inspection ------------ ------- D. System Information (cont.) Site Exam: Z Check Slope Z Surface water Z Check cellar Z Shallow wells 4' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: z Obtained from system design plans on record If checked, date of design plan reviewed: .'2004 Date El Observed site(abutting property/observation hole within 150 feet of SAS) F-1 Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) El Accessed USGS database- explain: You must describe how you established the high ground water elevation: Obtained the estimated ground water using the 2004 desIgnptan on record with the Board of Health. ............ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins,cloc,-rev.6/16 Title 5 Official inspection Form: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 193LacyStreet Property Address Scott Stannard OwnerOwner's Name information is required for every North Andover MA 01845 10/03/2017 ............ page. City[Town StateZip 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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17