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HomeMy WebLinkAboutTitle V Inspection Report - 50 STONECLEAVE ROAD 2/7/2018 Commonwealth of Massachusetts PtEcEIVED Title 5 Official Inspection Form 0 K Subsurface Sewage Disposal System Form Not for Voluntary Assessments or NAN OWN 60 Stonecleave Road ORT�4 DMIER, Property Address JJE-ALI M MTN N ME MarilynJoyce Owner Owner's--- Name information Is req u ired for every North Andover MA 01845 12/1/2017 page. City/Town State Zip Code Date of Inspection 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: key to move your cursor-do not Anthop R use the return _y Mottolo key, Name of Inspector John Zanni Pumping Co. V6:1 Company Name PO Box 407 Company Address retwn North Reading MA 01864 City/Town State Zip Code (781) 944-0149 515018 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 16.000). The system: ❑ Passes Conditionally Passes El Fails ❑ Needs Further Evaluation by the Local Approving Authority -- lm- - 12/14/17 Inspector --------------------------------------------------------------------------------- nature t u r 9 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 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. t5ins.doc-rev.6116 Title 6 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 50 Stonecleave Road Property Address Marilyn..Joyce Owner Owner's Name information is required for every North Andover MA 01845 1211/2017 ----------- page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E always complete all of Section D A) System Passes: ❑ I 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: ...........- —------ 13) System Conditionally Passes: Z 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. El Y n N F1 ND (Explain below): .............- t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts tr Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 50 Stonecleave Road Property Address Marilyn Joyce ...................... Owner Owner's Name information is required for every North Andover MA -00 _._...-85 12/1/2017 page. City/Town State Zip CodeDate of Inspection B. Certification (cont.) F-1 Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): ❑ broken pipe(s) are replaced n Y [I N 0 ND (Explain below): ❑ obstruction is removed El Y F N 0 ND (Explain below): Z distribution box is leveled or replaced Z Y F N F] ND (Explain below): Determined that d-box has been leaking for a long time. Filled box with water to check flow going into leaching trenches. Found all 4 lines working well. No sluggishness. -------------- ❑ .............. .......... 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): F-1 broken pipe(s) are replaced El Y F-1 N F1 ND (Explain below): F] obstruction is removed FY n N R ND (Explain below): .......... .. ..... ---------- C) Further Evaluation Is Required by the Board of Health: 0 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 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 (5ins,doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts $31) Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments . ..... 50 Stonecleave Road Property Address Marilyn Joyce Owner Owner's Name information is North Andover MA 01845 12/1/2017 required for every page. City/Town State Zip Code Date of lnspe�-6`n-------- B. Certification (cont.) 2. System will fail 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: F] 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. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. El 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 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 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 E Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool E-1 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool EJ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool D E Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2day flow t5ins.cloc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 50 Stonecleave Road Property Address Marilyn Joyce­ ....................... OwnerOwner's Name information is North Andover MA 01845 12/1/2017 required for every City/Town Zip Code -Date-41"n-spection page. State B. Certification (cont.) Yes No El E Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El M Any portion of the SAS, cesspool or privy is below high ground water elevation, El 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El E Any portion of a cesspool or privy is within a Zone I of a public well. R E Any portion of a cesspool or privy is within 50 feet of a private water supply well. El 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 6 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. 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 10,000 gpd to 15,000 gpd. 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 1:1 F1 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 El R Area—IWPA) or a mapped Zone I I 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. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 <LNN Commonwealth of Massachusetts Title 5 Official Inspection Form W. Subsurface Sewage Disposal System Form Not for Voluntary Assessments 50 Stonecleave Road .......... Property Address Marilyn Joyce. Owner Owner's Name information is North Andover MA 01845 12/11/20117 every required for eve 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 Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Z ❑ 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? 11 El Were as built plans of the system obtained and examined? (if they were not available note as N/A) H El Was the facility or dwelling inspected for signs of sewage back up? 0 n Was the site inspected for signs of break out? * 1:1 Were all system components, excluding the SAS, located on site? * 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? Z ❑ 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: 0 El Existing information. For example, a plan at the Board of Health. 1-1 Z 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): -3 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 50 Stonecleave Road Property Address Marilyn 4_qyq _.._....__- Owner Owner's Name information is required for every North Andover MA 0_1_845.....__ 1211/2017 page. CityfTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? M Yes El No Is laundry on a separate sewage system? (include laundry system inspection El Yes 0 No information in this report.) Laundry system inspected? El Yes M No Seasonal use? El Yes 0 No Water meter readings, if available(last 2 years usage (gpd)): PRIVATE WELL Detail: ----------- Sump pump? Yes ❑ No Last date of occupancy: current Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes El No Industrial waste holding tank present? EJ Yes Ej No Non-sanitary waste discharged to the Title 5 system? El Yes El No Water meter readings, if available: t5ins,doc•rev.6116 Title 5 Official Inspection 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 50 Stonecleave Road Property Address Marilyn Joyce — Owner Owner's Name information is required for every North Andover MA 01845 12/1/2017 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: owner ....... Was system pumped as part of the inspection? 0 Yes n No If yes, volume pumped: 1000-- gallons upr trucke m How was quantity pumped determined? gauge on P- .— ................ Reason for pumping: maintenance Type of System: H Septic tank, distribution box, soil absorption system n Single cesspool E] Overflow cesspool n Privy n Shared system (yes or no) (if yes, attach previous inspection records, if any) n 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 n Tight tank, Attach a copy of the DEP approval. n Other(describe): t5ins.doo-rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Stonecleave Road - Property Address Marilyn Jorce OwnerOwner's Name _..____..._.._. _ _._...._.......__ .__.....__ Information is North Andover MA 01845 12/1/2017 required for every ._......�. �. ......._ _ ..____..... page. CltyFrown State Zip Code Date of Insp11 ection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1978, ep r as-built plan provided by owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): -....._ __ ._. ......_._..___.-. Distance from private water supply well or suction line: +100 _................... feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints and and venting ok. No visible leakage. Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon single compartment tank If tank is metal, list age: Years - Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 81 x 4'6"W x 5'H 6" Sludge depth: _.___....... __-- i l6ins.doc•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 50 Stonecleave Road Property Address Marilyn Joyce OwnerOwner's Name information is required for every North Andover MA 01845 12/1/2017 page. ciij own 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 1411 Scum thickness 1/4"--.- 1 of; Distance from top of scum to top of outlet tee or baffle --- Distance from bottom of scum to bottom of outlet tee or baffle 2811 .................. How were dimensions determined? Sludge--------Judge-------- 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 should be pumped every 1-2 years, depending on number of occupants and usage. Inlet and outlet baffles are intact and in good working condition. Structural integrity of tank is good. Liquid level is at outlet invert, No visible leakage into or out of tank. ---------- Grease Trap(locate on site plan): Depth below grade: feet Material of construction: El concrete F1 metal R fiberglass F1 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: -Data.._..._ t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form ....._. subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Stonecleave Road Property Address Marilyn Joyce Owner owner's Flame l information is North Andover MA 01845 12/1/2017 required for every _.. ___..__...._.__ ___.__ _ 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.): i Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: _................- ___ww Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: .....-. . Capacity: gallons Design Flow: ._......_.. _.. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: —.-.---.-.._._......_..............__ Alarm in working order: ❑ Yes ❑ No Date of last pumping: - __.__w __.. _... _._. -__-- Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Stonecleave Road Property Address Marilyn Joyce Owner Owner's Name Information is North Andover MA 01845 12/1/2017 required for every --- -- --- page. City/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 below inverts 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.): D_box needs to be replaced One wall is completely disintegrated. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, 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: t5ins.doc rev.6116 Tllle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 50 Stonecleave Road Property Address Marilyn,,Joyce .............. Owner Owner's Name information is required for every North Andover 01845 11211-/ZO-17 page. City/Town State Zip Code Date of Inspection --------------...... D. System Information (cont.) Type: ❑ leaching pits number: ------------------------ E-1 leaching chambers number: E-1 leaching galleries number: El leaching trenches number, length: ❑ leaching fields number, dimensions: 1. 900 sq. ft. ❑ 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.): Soil is dry and vegetation is normal grass. No ponding. No visible signs of failure. Water test showed that leaching pipes still drain properly. ........... ........... ------------------ Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert .............— Depth of solids layer ------------------- Depth of scum layer Dimensions of cesspool Materials of construction -----_--_-- Indication of groundwater inflow El Yes F1 No t5ins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 50 Stonecleave Road ............. Property Address Marilyn Joyce Owner Owner's Name information is required for every North Andover MA 01845 12/1/2017 ............ 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.): ------------ ------------------ 15ins.doe-rev.6116 'rifle 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title x __ fficil Inspection Dorm - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Stonecleave Road Property Address Marilyn Joyce.._. ___ .._..,. Owner Owner's Name information Is required for every North... t _ 5 12/1/2017 zi Ctt !Town State .—..._ ..... Andover page. Y p 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: © hand-sketch in the area below ® drawing attached separately i I 15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments .5,0 Stonecleave Road Property Address Marilyn J9Y9em- OwnerOwner's Name information is MA 01845 12/1/2017 required for every North Andover page. State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water Check cellar Shallow wells Estimated depth to high ground water: 6+ ............. feet Please indicate all methods used to determine the high ground water elevation: El 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) El Checked with local Board of Health -explain: ................. El Checked with local excavators, installers-(attach documentation) El Accessed USGS database-explain: .......... You must describe how you established the high ground water elevation: Property has a high elevation. No evidence of high groundwater. Checked sump pump in basement and found it to be dry. Owner says that pump has never turned on. ---------- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc rev.6116 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 .'° 50 Stonecleave Road Property Address Marilyn Joyce ------- --- - -- --- Owner owner's Name -- - - information is required for every North Andover-.-,..-. MA 01845 12/1/2017 __._._.__..._.._...._...__- page. City%Town 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 ® System Information —Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I i t5ins.doo•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 + CQ "Ica tv 0 1-1 q 7-Z c 6e S-- 47 LA. L4 r.— ly! - -------------- two AIX 1ST v is 0; I Tlft MIL IL I've