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Home My WebLink AboutTitle V Inspection Report - 89 GRAY STREET 1/9/2018 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: a re Owner's Name: l 1q Al hJ G-0(ZD0kv,i r Q, )r,1 1 AND 1V Owner's Address: C�-{2► Si f� c,r MOOT)OF VIEPAT14 1�_v0tzn r he acsux-a- P Date of Inspection: t, u Name of Inspector:(please print) n� , ,A+,t 0s(,-o� c-lL „ �. Company Name: Nt Pn-&LAta p Crwtr t/1Ic`c 21+V G- Mailing Address: G, D t , NO 1d`rlt ern!D b olcz2 ti+/i Telephone Number: q 7 S- Caw - /7 G� CERTIFICATION STATEMENT 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 15340 of Title 5(314 CMR 15.000 The system; V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature; n Date: 6L66:D The system inspector shall submit a copy of this insp n 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 10,004 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,ifapplicable,and the approving authority. Notes and Comments ****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. Page 2 of i I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:i S9 GRAY STREET NORTH ANDOVER,MA Owner: DIANNA GORDON Date of Inspection:� 6/6/02 Inspection Summary: Check A, s,t;,u yr a�, ...r.�y.._ ,.__.e allofSection D A. System Passes: Vi 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: or more system components as described in the"Conditional Pass"section need to be rep or :. repaired.The em,upon completion:of the°replacement or repair,as approved by the Board of th,will pass. Answer yes,no or not ermined(Y,N,ND)in the . - for the fallowing statements.I of determined"please explain. The septio tank is metal d over 20 years old*or the septic tank( er metal or not)is structurally unsound,exhibits;substantial infil tion or exfiltration or tank failure is' l=ent.System will pass inspection if the existing tank is.replaced with a comp g septic tank as approved b e Board of Health. "A metal septic tank will pass iitspecti if it is structurally soon of leaking and if a Certificate of Compliance indicating that the tank is less than 20 old is available. ND explain: Observation of sewage backup or br or ' static water level in the distribution box due to broken or obstructed pipe(s)or due to,a broken,settl or uneven di bution box. System will pass inspection if(with approval of Board of-Health): oken pipe(s)are repla obstruction is Iemoved distribution box is leveled or rep cod ND explain: The 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 89 GRAY STREET " NORTH ANDOVER,MA Owner: D]ANNA GORDON Date of Inspection:_ 616102 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 icing to protect public health,safety or the environment. 1. em will pass:unless Board of Health determines in accordance with 310 CMR 15.303(4(6)that the syste ' not functioning in a manner which will protect public health,safety and the 'ronment, — Cesspoo privy is within 50 feet of a surface water — Cesspool or 'ry is within 50 feet of a bordering vegetated wetland or a sal arch 2. System will fail unless the Board of. lth(and Public ater Suppliek,-if any)determiues that the system is functioning in a manner that prot the pub ' ealth,safety and environment: The system has a septic tank and soil a co system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surfa ter su ly. The system has a septic tank AS and the SAS is w1 ` a Zone 1 of a public water supply. The system has a septi and SAS and the SAS is within 50 of a private water supply well. The system has tic tank and SAS and the SAS is less than 100 feet t 50 feet or more from a private water sup well**.Method used to determine distance **This passes if the well water analysis,performed at a DEP certified laborat or coliform bacteria d volatile:organic compounds indicates that the well is free from pollution from that facility and. the ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other ure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ 89 GRAY STREET NORTH ANDOVER,MA Owner. DIANNA GORDON Date of Inspection:__ 6/6/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or`5no"to each of the following for ail inspections: Yes No Backup of sewage into facility or system component due to 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 outlet 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%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 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. 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. ['ibis system passes if the well water analysis, performed at a DEP.certifed laboratory,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 than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.[ No (YeslNo)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. rge Systems: To be co red a large.system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "or`ono"to each of the following: (The following criteria apply to a systems in addition to the criteria above) yes no the system is within 400 feet of a surface g supply the system is within 200 feet of a tribu o a surface g water supply the system is located in a ' ogen sensitive area(Interim Welth otection Area—IWPA)or a mapped Zone II of a public er supply well If you have answ 0d Eyes"to any question in Section E the system is considered a signifi threat,or answered "yes"in S D above the large system has failed.The owner or operator of any large system sidered a signifi t 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. .T; Page 5 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART R CHECKLIST Property Address: 89 GRAY STREET -- NORTH ANDOVER,MA Owner: DIANNA GORDON Date of Inspection: 6/6/02 Check if the following have been done.You must indicate es"or"no"as to each of the following- Yes ollowin :Yes No 1�� Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out is the previous two weeks? Has,the system received normal flows in the previous two week period? ✓r 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) V Was the facility or dwelling inspected for signs of sewage back up? V Was the site inspected for signs of break out? fWere 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 br 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: Yeso Existing information.For example,a plan at the Board of Health. ZDetermined in the field(if any of the failure criteria related to'Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(3)(b)] Page 6 of l I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_ 89 GRAY STREET NORTH ANDOVER,MA Owners MANNA GORDON Date of Inspection:_ 616102 RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual):AL DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 3 Does residence have a garbage grinder(yes or no):U!!-5 Is laundry on a separate:sewage system(yes or no):ALQ [if yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use:(yes or no): , p Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(yes or no):4�5 Last date of occupancy: C CONEAERCIALlINDUSTRU L Type of establishment: Design flow(based on 310 CMR 15.203):- �d Basis of design flow(seats/persons/sgtt,etd.): Grease trap present(yes or no):_ Industrial waste bolding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_/y pv/K p! p„,,, Was system pumped as part of the inspection(yes or no): t = 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 Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative 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): Approximate age of all componen date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): /VO 3\ Page 7 of 11 - OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ 89 GRAY STREET NORTH ANDOVER,MA 0,%mer: DLANNA GORDON Date of Inspection:. 6/6102 BUILDING SEWER(locate on site plan) Depth below grade:_ /2-"— Materials of construction:-tZcast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: J 2 T Material of construction: concrete metal`fiberglass,_polyethylene _other(explain) If tank is meta!list age:T Is age confirmed by a Certificate of Compliance{yes or no): (attach a copy of certificate) Dimensions. loco c.p N C� G v►�, Sludge depth: 21, Distance from top of sludge to bottom of outlet tee or baffle: 3 Z" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: (�f Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: 114o 717 w2eg 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 ca y 01-+aN_ vc. Z 4v c�NDkT)6(1 GREASE TRAP:AL&locate on site plan) Depth below grade: Material of construction: concrete_metal (explain): fiberglass polyethylene other 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: Comments(on pumping recommendations;inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 �' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS x. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ 89 GRAY STREET - NORTH ANDOVER,MA Owner:_ DIANNA GORDON Date of bspectiow., 616102 TIGHT or HOLDING TANK:b1i (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other{explain): Dimensions: Capacity:_ gallons Design FIow: ---gallons/day Alarm present(yes or no): Alarm level:- Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): .DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: f?" ,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.): JA, Olt, D. f EBJ i� �N EQJ 1.�•� �Jt LNC C Ll�' So �• P > C PUMP CHAMBER:My�- (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): p E � Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ 89 GRAY STREET NORTH ANDOVER,MA Owner: DIANNA GORDON Date of Inspection: 616142 SOIL ARSORP Ii01r 5 a x.�.,�� . L.�..... ........ r_e,excavation not required) If SAS not located explain why: Type w-'-leaching pits,number:_v 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, etc.): /t",> G-0;Duc cam t'i)NDV(�� R6 e,t na lr- S i d`oJ,z IN D,c r4S T1-LrftT s�i S R _ CESSPOOLS:0(cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth-top of liquid to inlet'inert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:LAI (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_ 89 GRAY STREET NORTH ANDOVER,MA Owner: DIANNA GORDON Date of Inspection:. 616102 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. 1)� A v v1 ' � V .7' R }tiz- Page l I of 11 rr . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 GRAY STREET NORTH ANDOVER,MA Owner: DIANNA GORDON Date of Inspection.-, 6/6/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 0 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: -a' Observed site(abutting propertylobservation hole within 150 feet of SAS) Checked with local Hoard 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: //�� O F 5 S�'C�..1_ F lL, l�l� P /�- U 1"� A-a EAS. '',