HomeMy WebLinkAboutTitle V Inspection Report - 456 SALEM STREET 11/7/2017 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON,AIA 02108 617-292-5500
TRUDYCOXE
ARGEO PAIL CELLUCCI
SECRETARY
GOVERNOR DAVID 8.
STRUTIIS
COMINIISSIONER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM(
PART A
CERTIFICATION
PROPERTY ADDRESS:456 SALEM ST-NO ANDOVER,MA
NAME OF OWNER:DAN LUCIANO
DATE OF INSPECTION-A-11-99
ADDRESS OF OWNER:_.!5aApr-_
NAME OF INSPECTOR:(PLEASE PRINT) FRANCIS KING III
I AM A DEP APPROVED SYSTEM INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5(310 CMR 15.000)
COMPANY NAME: ACTION-KING ENTERPRISES,INC.
MAILING ADDRESS: 26 LIVINGSTON STREET LOWELL.MA 01852
TELEPHONE NUMBER: (978)452-7750 FAX: 97U 459
-0770
CERTIFICATION STATEMENT
I CERTIFY THATI 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 INSPECTION. THE INSPECTION WAS PERFORMED BASED ON MY TRAINING AND EXPERIENCE IN THE
PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEMS. THE SYSTEM.
PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
*SPECTOR'S SIGNATURE: ""wil_,-Ay DATE: 8-12-99
IE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIS INSPECTION REPORT TO THE APPROVING AUTHORITY(BOARD OF
1EALTH OR DEP)(WITHIN THIRTY(30)DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR
[AS A DESIGN FLOW OF 10,000 GPD OR GREATER,THE INSPECTOR AND THE SYSTEM OWNER SHALL.suBvirr THE REPORT
'0 THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION. THE ORIGINAL
HOULD BE SENT TO THE SYSTEM OWNER AND COPIES SENT TO THE BUYER,IF APPLICABLE AND THE APPl1tOVING
,UTHORITY.
)TES AND COMMENTS
kNK LEVEL APPROXIMATELY 4 BELOW OUTLET PIPE TO LEACHING AREA
PAGE I
SUBSURFACE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
tOPERTV ADDRESS: 456 SALEM ST N ANDOVER MA 41845
INNER:DAN LUCIANO
kTE OF INSPECTION:8-12-99
'SPECTION SUMMARY: CHECK A,B,C OR D
SYSTEM PASSES:
I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT ANY OF THE FAILURE CONDNTIONS
DESCRIBED IN 310 CMR 15.303 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW.
JMM ENTS: -•-
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.
DILATE YES,OR NO,OR NOT DETERMINED(Y,N,OR ND). DESCRIBE BASIS OF DETERMINATION IN ALI,WrSTA.NCES. IF
NOT DETERMINED" EXPLAIN WHY NOT.
THE SEPTIC TANK IS METAL,UNLESS THE OWNER OR OPERATOR HAS PROVIDED THE SYSTEM IiNSPEC:TOR
WITH A COPY OF A CERTIFICATE OF COMPLIANCE(ATTACHED)INDICATING THAT THE TANK WAS
INSTALLED WITHIN(20)YEARS PRIOR TO THE DATE OF THE INSPECTION;OR THE SEPTIC TANK,WHETHER
OR NOT METAL,IS CRACKED,STRUCTURALLY UNSOUND,SHOWS SUBSTANTIAL INFII.TRA,TION OR
EXFILTRATION,OR TANK FAILURE IS IMMINENT. THE SYSTEM WILL PASS INSPECTION IF THE EXISTING
SEPTIC TANK IS REPLACED WITH A COMPLYING SEPTIC TANK AS APPROVED BY THE BOARD OF HEALTH.
SEWAGE BACKUP OR BREAKOUT OR HIGH STATIC WATER LEVEL OBSERVED IN THE
DISTRIBUTION BOX IS DUE TO BROKEN OR OBSTRUCTED PIPE(S)OR DUE TO A BROKEN,
SETTLED OR UNEVEN DISTRIBUTION BOX. THE SYSTEM WILL PASS INSPECTION IF(WITH
APPROVAL OF THE BOARD OF HEALTH).
BROKEN PIPE(S)ARE REPLACED
OBSTRUCTION IS REMOVED
DISTRIBUTION BOX IS LEVELED OR REPLACED
THE SYSTEM REQUIRED PUMPING MORE THAN FOUR 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
PAGE 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
tOPERTY ADDRESS:456 SALEM ST NO ANDOVER MA 01845
WNERMAN LUCIANO
kTE OF INSPECTION:8-12-99
1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
X CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH
IN ORDER TO DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH,
SAFETY AND 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 THE PUBLIC
HEALTH AND SAFETY AND THE ENFIRONMENT:
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 FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF
ANY)DETERMINES THAT THE SYSTEM IF FUNCTIONING IN A MANNER THAT
PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM(SAS)AND T14E SAS IS
WITHIN 100 FEET TO A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER
SUPPLY.
THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND THE SAS IS WITHIN
A ZONE I OF A PUBLIC WATER SUPPLY WELL.
THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND IS WITHIN
50 FEET OF A PRIVATE WATER SUPPLY WELL.
THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND IS LESS
THAN 100 FEET BUT 50 FEET OR MORE FROM A PRIVATE WATER SUPPLY WELL,
UNLESS A WELL WA'T'ER ANALYSIS FOR COLIFORM BACTERIA AND VOLATILE:
ORGANIC COMPOUNDS INDICATES THAT THE WELL IS FREE FROM POLLUTION
FROM THAT FACILITY AND THE PRESENCE OF AMMONIA NITROGEN AND
NITRATE NITROGEN IS EQUAL TO OR LESS THE 5PPM. METHOD USED TO DETERMINE
DISTANCE (APPROXIMATION NOT VALID)
OTHER: ---- ------ ------
kNK IS EXFILTRATING BY SOME OTHER MEANS. THE LINE LEADING TO THE D-BOX AND S.A.S LOOKS FINE;
D NOT PUMP TANK FOR INSPECTION.
PAGE 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
tOPERTY ADDRESS:456 SALEM ST NO ANDOVER MA 01845
WNER:DAN LUCIANO
kTE OF INSPECTION:8-12-99
SYSTEM FAILS:
)U MUST INDICATE"YES"OR"NO"TO EACH OF THE FOLLOWING:
/A 1 HAVE DETERMINED THAT ONE OR MORE OF THE FOLLOWING FAILURE CONDITIONS EXIST AS
DESCRIBED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS IDENTIFIED BELOW. THE BOARD OF
HEALTH SHOULD BE CONTACCTED TO DETERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE,
'SNO
BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN
OVERLOADED OR CLOGGED SAS OR CESSPOOL.
_ DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR
SURFACE WATERS DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL.
_ STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE INVERT DUE TO
AN OVERLOADED OR CLOGGED SAS OR CESSPOOL.
LIQUID DEPTH IN CESSPOOL IS LESS THAN 6"BELOW INVERT OR AVAILABLE
VOLUME IS LESS THAN 112 DAY FLOW.
_ REQUIRED PUMPING MORE THAN 4 TIMES IN THE LAST YEAR NOT DUE TO
CLOGGED OR OBSTRUCTED PIPE(S). NUMBER OF TIMES PUMPED
_ ANY PORTION OF THE SOIL ABSORPTION SYSTEM,CESSPOOL OR PRIVY IS BELOW
THE HIGH GROUNDWATER ELEVATION.
_ ANY PORTION OF A 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 I OF A PUBLIC.WELL.
_ ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE
WATER SUPPLY WELL.
_ ANY PORTION OF A CESSPOOL OR PRIVY IS LESS THAN 100 FEET BUT GREATER
THAN 50 FEET FROM A PRIVATE WATER SUPPLY WELL WITH NO ACCEPTABLE
WATER QUALITY ANALYSIS. IF THE WELL HAS BEEN ANALYZED TO BE
ACCEPTABLE, ATTACH COPY OF WELL WATER ANALYSIS FOR COLIFORM
BACTERIA,VOLATILE ORGANIC COMPOUNDS,AMMONIA NITROGEN AND
NITRATE NITROGEN.
LARGE SYSTEM FAILS:
)U MUST INDICATE"YES"OR"NO"TO EACH OF THE FOLLOWING:
THE FOLLOWING CRITERIA APPLY TO LARGE SYSTEMS IN ADDITION TO THE CRITERIA
ABOVE.
THE SYSTEM SERVES A FACILITY WITH A DESIGN FLOW OF 10,000 GPD OR GREATER(LARGE SYSTEM)
AND THE SYSTEM IS A SIGNIFICANT THREAT TO PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT
BECAUSE ONE OR MORE OF THE FOLLOWING CONDITIONS EXIST:
:S 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.
THE OWNER OR OPERATOR OF ANY SUCH SYSTEM SHALL UPGRADE THE SYSTEM 1NACC:ORDANCE WITH
310 CMR 15,304(2). PLEASE CONSULT THE LOCAL REGIONAL OFFICE OF THE DEPARTMENT FOR FURTHER
information.
PAGE
ACTION-KING ENTERPRISES,INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
ZOPERTY ADDRESS: 456 SALEM ST NO ANDOVER MA 01845
WNER:DAN LUCIANO
ATE OF INSPECTION:8-12-99
NECK IF THE FOLLOWING HAVE BEEN DONE.YOU MUST INDICATE"YES"OR"NO"AS TO EACH OF THE FOLLOWING:
NO
PUMPING INFORMATION WAS PROVIDED OF THE OWNER,OCCUPANT,AND BOARD OF
HEALTH.
NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND
THE SYSTEM HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE
VOLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYSTEM RECENTLY OR AS
PART OF THIS INSPECTION.
AS BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT
AVAILABLE WITH NIA.
THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACKUP.
THE SYSTEM DOES NOT RECEIVE NON-SANITARY OR INDUSTRIAL WASTE FLOW.
THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT,
ALL SYSTEM COMPONENTS,EXCLUDING THE SOIL ABSORPTION SYSTEM,HAVE BEEN
LOCATED ON THE SITE.
_ THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF'TIiE
SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEE,MATERIAL OF
CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE,DEP'T'H OF SCUM.
THE SIZE AND LOCATION OF THE SOIL ABSORPTION SYSTEM ON THE SITE HAS BEEN
DETERMINED BASED ON:
EXISTING INFORMATION. FOR EXAMPLE,PLAN AT B.O.H.
DETERMINED IN THE FIELD(IF ANY OF THE FAILURE CRITERIA RELATED TO PART C IS AT ISSUE,
APPROXIMATION OF DISTANCE IS UNACCEPTABLE) (15.302(3)(b)
_ THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH
INFORMATION ON THE PROPER MAINTENANCE OF SUBSURFACE DISPOSAL SYSTEMS.
PAGE 5
ACTION-KING ENTERPRISES, INC.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C
SYSTEM INFORMATION
IOPERTY ADDRESS: 456 SALEM ST NO ANDOVER,MA 01845
WNER:DAN LUCIANO
4,TE OF INSPECTION: 8-12-99
ESIDENTIAL:
.SIGN FLOW: 440 p.d./BEDROOM
JMBER OF BEDROOMS:(DESIGN): 4 NUMBER OF BEDROOMS(ACTUAL): 4
)TAL DESIGN FLOW: 440
JMBER OF CURRENT RESIDENTS: 2 ADULTS I CHILD
kRBAGE GRINDER(YES OR NO)-----PLO-
kUNDRY(SEPARATE SYSTEM)(YES OR NO): NO IF YES,SEPARATE INSPECTION REQUIRED
kUNDRY SYSTEM INSPECTED(YES OR NO) YES
'ASONAL USE(YES OR N )
ATER METER READINGS,SIF AVAILABLE: (LAST TWO(2)YEAR USAGE(rpol—
JMP PUMP(YES OR NO) NO
kST DATE OF OCCUPANCY: OCCUPIED
3MMERCIAL/INDUSTRIAL:
ePE OF ESTABLISHMENT: N/A
],SIGN FLOW: GPD(BASED ON 15.203)
kSIS OF DESIGN FLOW
REASE TRAP PRESENT,(YES OR NO)
'DUSTRIAL WASTE HOLDING TANK PRESENT: (YES OR NO)_
3N-SANITARY WASTE DISCHARGED TO THE TITLE 5 SYSTEM: (YES OR NO)--.
ATER METER READINGS,IF AVAILABLE:
kST DAY OF OCCUPANCY:
fHER: (DESCRIBE)
kST DAY OF OCCUPANCY:
GENERAL INFORMATION
JMPING RECORDS AND SOURCE OF INFORMATION.
2 YHEARS-(HOMEOWNE
SYSTEM PUMPED AS PART OF INSPECTION(YES OR NO) YES
IF YES,VOLUME PUMPED GALLONS.
REASON FOR PUMPING— INSPECTION OF TANK AND BAFFLES
ePE OF SYSTEM
—Z SEPTIC TANKMISTRIBUTION BOX/SOIL ABSORPTION SYSTEM
SINGLE CESSPOOL
OVERFLOW CESSPOOL
PRIVY
SHARED SYSTEM(YES OR NO)(IF YES,ATTACH PREVIOUS INSPECTION RECORDS,IF ANY)
I/A TECHNOLOGY ETC. ATTACH COPY OF UP TO DATE OPERATION AND MAINTENANCE CONTRACT.
FHER:
"PROXIMATE AGE OF ALL COMPONENTS,DATE INSTALLED(IF KNOWN)AND SOURCE OF INFORMATION:
12 YEARS OLD
'WAGE ODORS DETECTED WHEN ARRIVING AT THE SITE.(YES OR NO)__ NO
PAGE
ACTION-KING ENTERPRISES,INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
1OPERTY ADDRESS: 456 SALEM ST NO ANDOVER MA 01845
NNER:DAN LUCIANO
#TE OF INSPECTION:8-12-99
JILDING SEWER: NIA
OCATE ON SITE PLAN)
'PTH BELOW GRADE:
ATERIAL OF CONSTRUCTION: CAST IRON 40 PVC OTHER (EXPLAIN)
:STANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE
AMETER
3MMENTS(CONDITION OF JOINTS,VENTING,EVIDENCE OF LEAKAGE,ETC.)
TTIC TANK: X
OCATE ON SITE PLAN)
'PTH BELOW GRADE:
ATERIAL OF CONSTRUCTION: X CONCRETE METAL-FIBERGLASS _POLYETHYLENE_ OTHER(EXPLAIN)
TANK IS METAL,LIST AGE-IS AGE CONFIRMED BY CERTIFICATE OF COMPLIANCE- (YES,NO)
MENSIONS: 10'X 5'X 6'
,UDGE DEPTH:
:STANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE:_
:UM THICKNESS:
:STANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: _
.STANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE:
3W DIMENSIONS WERE DETERMINED: TAPE MEASUREMENT
JMMENTS:
ECOMMENDATION FOR PUMPING,CONDITION OF INLET AND OUTLET TEES OR RAFFLES,DEPTH OF LIQUID LEVEL IN
'ELATION TO OUTLET INVERT,STRUCTURAL INTEGRITY,EVIDENCE OF LEAKAGE,ETC.) _
DID NOT PUMP TANK DUE TO TAK LEVEL BEING 4"LOWER THAN OUTLET PIPE
ItEASE TRAP: NIA
OCATE ON SITE PLAN)
'PTH BELOW GRADE:
ATERIAL OF CONSTRUCTION:-CONCRETE-METAL-FIBERGLASS-POLY ETHYLENE_OTITER(EXPLAIN)
.MENSIONS:
:UM THICKNESS:
:STANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE:
:STANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE:
kTE OF LAST PUMPING:
:)MMENTS:
ECOMMENDATION FOR PUMPING,CONDITION OF INLET AND OUTLET TEES OR BAFFLES,DEPTH OF LIQUID LEVEL IN
'ELATION TO OUTLET INVERT,STRUCTURAL INTEGRITY,EVIDENCE OF LEAKAGE.
:TC.) ---
PAGE 7
ACTION-KING ENTERPRISES,INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
IOPERTY ADDRESS: 456 SALEM STREET NO ANDOVER MA 01845
WNER: DAN LUCIANO
4TE OF INSPECTION: 8-12-99
IGHT OR HOLDING TANK: NIA (TANK MUST BE PUMPED PRIOR TO,OR AT I iME OF INSPE TION)i
OCATE ON SITE PLAN)
,PTH BELOW GRADE:
ATERIAL OF CONSTRUCTION: CONCRETE-METAL_FIBERGLASS-POLYETHYLENE--_„OTHER(EXPLAIN)
MENSIONS:
kPACITY: GALLONS
?SIGN FLOW: GALLONS/DAY
:.ARM PRESENT
:.ARM LEVEL: ALARM IN WORKING ORDER: YES_-NO J
!TE OF PREVIOUS PUMPING
)MMENTS:
ONDITION OF INLET TEE,CONDITION OF ALARM AND FLOAT SWITCHES,ETC.)
STRIBUTION BOX: X
OCATE ON SITE PLAN)
?PTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 0"
3MMENTS:
OTE IF LEVEL AND DISTRIBUTION IS EQUAL,EVIDENCE OF SOLIDS CARRY OVER,EVIDENCE OF LEAKAGE INTO OR OUT OF
iOX,ETC.)
D-BOX LOOKED GOODAT TIME OF INSPECTION. WATER LEVEL WAS BELOW OUT rT FROMLANK DUE
'O EXFILTRATION.
1MP CHAMBER: N/A
OCATE ON SITE,PLAN)
JMPS IN WORKING ORDER(YES OR NO)
.ARMS IN WORKING ORDER(YES OR NO
3MMENTS:
OTE CONDITION OF PUMP CHAMBER,CONDITION OF PUMPS AND APPURTENANCES,ETC.)_, _
PAGE 8
ACTION-KING ENTERPRISES,INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
SYSTEM INFORMATION(CONTINUED)
ZOPERTY ADDRESS: 456 SALEM ST NO ANDOVER MA 01845
WNER: DAN LUCIANO
ATE OF INSPECTION: 8-12-99
)IL ABSORPTION SYSTEM(SAS): X
OCATE ON SITE PLAN,IF POSSIBLE,EXCAVATION NOT REQUIRED,BUT MAY BE APPROXIMATED BY NON-[INTRUSIVE ME-TVIODS).
NOT LOCATED,EXPLAIN:
fPE:
LEACHING PITS,NUMBER:
LEACHING CHAMBERS,NUMBER:
LEACHING GALLERIES,NUMBER:
LEACHING TRENCHES,NUMBER LENGTH.4 X 4-01-
LEACHING FIELDS,NUMBER,DIMENSIONS:
OVERFLOW CESSPOOL.NUMBER:
ALTERNATIVE SYSTEM: -
NAME OF TECHNOLOGY
)MMENTS:
+TOTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGETATION,
;TC.) _ --- - -------AREA OF LEACHING AREA LOOKED GOOD - - -
-SSPOOLS: NIA
OCATE ON SITE PLAN)
JMBER AND CONFIGURATION:
-PTH-TOP OF LIQUID TO INLET INVERT:
:PTH OF SOLIDS LAYER:
:PTH OF SCUM LAYER:
MENSIONS OF CESSPOOL:
ATERIALS OF CONSTRUCTION:
'DICATION OF GROUNDWATER:
INFLOW(CESSPOOL MUST BE PUMPED AS PART OF INSPECTION:
)MMENTS:
+TOTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGE'T'ATION,ETC.)
ZIVY: NIA
OCATE ON SITE PLAN)
ATERIALS OF CONSTRUCTION: DIMENSIONS:-__...-.,.-._.-
1PTH OF SOLIDS:
)MMENTS:
OTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGETATION,ETC.),
PAGE 9
ACTION-KING ENTERPRISES,INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
IOPERTY ADDRESS: 456 SALEM ST NO ANDOVER MA 01845
WNER: DAN LUCIANO
ATE OF INSPECTION: 8-12-99
CETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES LANDMARKS OR BENCHMARKS
COAT ALL WELLS WITHIN 100'(LOCATE WHERE PUBLIC WATER SUPPLY COMES INTO HOUSE)
ti
PAGE 10
ACTION-KING ENTERPRISES,INC.
SUBSURVACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
tOPERTY ADDRESS:456 SALEM ST NO ANDOVER MA 41845
WNER:DAN LUCIANO
ATE OF INSPECTION:8-12-99
ICS REPORT NAME
SOIL TYPE
TYPICAL DEPTH TO GROUNDWATER
;GS DATE WEBSITE VISITED
OBSERVATION WELLS CHECKED
GROUNDWATER DEPTH: SHALLOW MODERATE-DEEP-
TE
ODERATEDEEP_TE EXAM SLOPE
SURFACE WATER
CHECK CELLAR
SHALLOW WELLS
;TIMATED DEPTH TO GROUNDWATER: 6+ FEET
EASE INDICATE ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION.
OBTAINED FROM DESIGN PLANS ON RECORD
_OBSERVATION OF SITE(ABUTTING PROPERTY,OBSERVATION HOLE,BASEMENT SUMP ETC.)
DETERMINE IT FROM LOCAL CONDITIONS
CHECKED WITH LOCAL BOARD OF HEALTH
_CHECKED FEMA MAPS
V/ CHECKED PUMPING RECORDS
CHECKED LOCAL EXCAVATORS,INSTALLERS
_USED USGS DATA
?SCRIBE HOW YOU ESTABLISHED THE HIGH GROUNDWATER ELEVATION.(MUST BE COMPLETED)
NECKED SURROUNDING AREA. WAS INFORMED BY THE BOARD OF HEALTH'THAT A GROUND WA'T'ER AND SOIL
;URVEY WAS PERFORMED IN THIS AREA IN 1997 AND SUPPORTED MY EVALUATION OF WATER DDEPTH_6-+'
PAGE 11
ACTION-KING ENTERPRISES,INC.
26 LIVINGSTON STREET
LOWELL,MA 01852
TEL: (508)452-7750
FAX: (508)459-0770
20PERTY ADDRESS: 456 SALEM ST NO ANDOVER MA 01845
INNER: DAN LUCIANO
ATE OF INSPECTION: 8-12-99
CTION KING ENTERPRISES,INC.HAS BEEN RETAINED BY THE OWNER TO PROVIDE AN INSPECTION OF THE ON-SITE
EWERAGE DISPOSAL SYSTEM AS DEFINED BY 310 CMR 15.303.D.E.P.GUIDANCE INSTRUCTS THE INSPECTOR TO MAKE AN
;VALUATION OF THE SYSTEMS PERFORMANCE ON THE DAY OF THE INSPECTION. THE TITLE 5 INSPECTION IS NOT
1ESIGNED TO PROVIDE INFORMATION TO DEMONSTRATE,THAT THE SYSTEM WILL ADEQUATELY SERVE THE USE TO BE
'LACED UPON IT BY THE NEW OWNER AS STATED IN 15.302. THIS INSPECTION IS NOT A WARRANTEE OR GUARANTEE OF
'HE SYSTEM FUTURE PERFORMANCE,AND DOES NOT EITHER EXPRESS OR IMPLY IT.
PAGE 12