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Home My WebLink AboutTitle V Inspection Report - 456 SALEM STREET 11/7/2017 (2) RECEIVED Commonwealth of Massachusetts APR 2 3 2009 Title 5 Official Inspection Form row 44 oi I'il I ��VFR ��:nke i «�q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 456 Salem Street. Property Address Dan and Debbie Luciano Owner Owner's Name information is North Andover MA 01845 — 4-13-09 required for — o every page. Cityrrown State Zip Code Date of Inspection p 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: 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 _�..... use the return Name of Inspector key. Company Name P.O Bax 932 Company Address Newb_uryport _ MA 01950 CitylTown mm State Zip Code - - 508-32_ _8-4633 870 Telephone_ Number 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: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority - _ 4-1509 spector' 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. ****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. Commonwealth of Massachusetts ------------ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owners Name information is required for North Andover MA 01845 4-13-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Posses: 1 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: El One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. F-1 Y n N ❑ ND (Explain below): ------------- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano ------ Owner Owners Name information is required for North Andover MA 01845 .4-13-09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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): El broken pipe(s) are replaced El Y Ej N El ND (Explain below): F1 obstruction is removed El Y El N R ND (Explain below): ❑ distribution box is leveled or replaced R Y El N F1 ND (Explain below): ----------- ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced R Y El N ❑ ND (Explain below): ❑ obstruction is removed 0 Y E] N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning In a manner which will protect public health, safety and the environment: El Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano OwnerOwners Name information is required for North Andover --————--------- MA 01845 4-13-09 every page. '671ty/Town State Zip Code Date of Inspection B. Certification (cont.) 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: n 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. E] The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. R The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. F-1 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 El 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El E Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ z Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 1:1 z Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is required for North Andover MA 01845 4-13-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. n z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Ej Z Any portion of a cesspool or privy is within a Zone 1 of a public well. E-1 E Any portion of a cesspool or privy is within 50 feet of a private water supply well. Ej 0 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.] E-1 Z The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El z The system falls. 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 g pd to 15,000 g pd. 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 ❑ 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owners Name information is required for North Andover MA 01845 4-13-09 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 E El Pumping information was provided by the owner, occupant, or Board of Health El E Were any of the system components pumped out in the previous two weeks? E 1-1 Has the system received normal flows in the previous two week period? El 0 Have large volumes of water been introduced to the system recently or as part of this inspection? 0 E] 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? El El Was the site inspected for signs of break out? El El Were all system components, excluding the SAS, located on site? M 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 of liquid, depth of sludge and depth of scum? E 0 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: E El 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)] 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): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owners Name information is required for North Andover MA 01845 4-13-09 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 3 Number of current residents: Does residence have a garbage grinder? El Yes 0 No Is laundry on a separate sewage system? [if yes separate inspection required] El Yes 0 No Laundry system inspected?. n Yes N No Seasonal use? ❑ Yes ED No Water meter readings, if available(last 2 years usage(gpd)): -------- Detail: ----------- Sump pump? El Yes 0 No -current 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? M Yes ❑ No Industrial waste holding tank present? F1 Yes ❑ No Non-sanitary waste discharged to the Title 5 system? n Yes El No Water meter readings, if available: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 456 Salem Street-- —----- Property Address Dan and Debbie Luciano Owner Owner's Name Information is required for North Andover MA 01845 4-13-09 every page. Cityfrown 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: 2008 per owner Was system pumped as part of the inspection? El 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 El Privy F1 Shared system (yes or no) (if yes, attach previous inspection records, if any) El 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 [/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is required for North Andover MA 01845 4-13-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Built 1976 per owner - Were sewage odors detected when arriving at the site? R Yes Z No Building Sewer(locate on site plan): 2 Depth below grade: feet-'-"-- Material of construction: 2 cast iron r-1 40 PVC M other(explain): Distance from private water supply well or suction line: 'feet---- Comments (on condition of joints, venting, evidence of leakage, etc.): -Pipe looks good in basement Septic Tank(locate on site plan): 611 Depth below grade: feet _ Material of construction: concrete ❑ metal F-1 fiberglass F] polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) n Yes El No 1500 Gallons Dimensions: Sludge depth: <211 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is North Andover MA 01845 4-13-09 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 211 Distance from top of scum to top of outlet tee or baffle 1211 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? -Measure Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition. Concrete tees in good condition ——-------------- ............. —-------- ----------___------------ ------------- Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El metal El 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 466 Salem Street Property Address Dan and Debbie Luciano ---- Owner Owner's information is required for North Andover -MA 01845 4-13-09 every page. Cityrrown 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: F-1 concrete ❑ metal F-1 fiberglass n polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day ------- Alarm present: El Yes El No Alarm level: Alarm in working order: F-1 Yes E] No Date of last pumping: Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? El Yes El No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owners Name information is required for North Andover MA 01845 4-13-09 every page. Cityrrown 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.): ---------------- --------------- -----------------------...... Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is required for North Andover MA 0.1845 4-13-09 every 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: E hand-sketch in the area below El drawing attached separately _'Tcjrjjic' 3C). (C. Afjfi� 10--7 —P LA j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner _. .__._._. ...___.._._ ._.___ Owner's Name information is required for North Andover MA 01845 4-13-09 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Z Check Slope Z Surface water Check cellar Shallow wells 5 Estimated depth to high ground water: ....feet ........ Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date z Observed site (abutting property/observation hole within 160 feet of SAS) R Checked with local Board of Health -explain: El Checked with local excavators, installers-(attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: Basement dry with no sump pump. USGS soil maps indicate water> 6.0 feet below ground. Leach field only 3 feet below ground. Leach field area is raised above surrounding area by 3 to 4 feet. Yard slopes away in the rear with no observable wetlands within 100 feet. ----—--------—------— —-----------—-—--------- Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owners Name information is North Andover MA 01845 4-13-09 required for every page. CityfTown State Zip Code Date of Inspection E. Report Completeness Checklist • Inspection Summary: A, B, C, D, or E checked • Inspection Summary D (System Failure Criteria Applicable to All Systems)completed Ej System Information— Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file