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HomeMy WebLinkAboutTitle V Inspection Report - 49 PADDOCK LANE 4/13/2018 Commonwealth of Massachusetts RECEIVED .�� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments APR 1 ` 01 !',14C)i T6I NOOVE Prppe y Addr 65 LR.l D I""�aR� I ®f._...._. Owner O n r s Name ,�} infprrnation is //��� y (� (� `-- --- 1 0( p requfrt d for avely _.L._�_1 ._..�.... _...—.__ __-- ......_. �—.. ._.._ page, city/TownState 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, Imoutfarms When filling out fA. General Information on the computer, use only the tab 1. Inspector: key to move your Charles .-�t y_�]ar l e s J. Roux. use the return cursor-do not {�, ,J key, Narne of Inspector Charles J Roux, LLC ra Gornpany Narne 1 3 Patten broad Tewkshur— E,ompany Address m _ _ State Zip Code. 978_..640--9984 - ...w _._.. . S1891 l"elephone 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: [� Passes Cl Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority InspectUf s 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional Off icE;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. f i t5ins.doc rev.6116 Title 5 official Inspection Form:subsurface Sawage Disposal System•Page 1 of 17 '....... C<>rrrrrlonwaalth of Massachusetts I Tillak 5 Official Inspection Form w Subsurface Sewage Disposal System Form Not for Voluntary Assessments J Property Address J Owner Owner's Name information is required for every _ __---___. __ _ —..— _ _ — page cttylTowr St�lte Lata Code Date of Inspection B. Certification (cont._-__._ Inspection Summary: Check A,B,C,C or E 1 always complete all of Section D A,) System Passes: [,J� I have not found any information which indicates that any of the failure criteria described in 310 CMR 15,303 or in 310 CMR 15.301 exist. Any failure criteria not evaluated are indicated below. Comments-. i� f'Jv ✓l..___. . '�`�' C._bV�'1 v'Y�~P..1/1C�:��"l._�4.`�_�.��'�_r_�11 _��t�!�_.�.�!�_��_�.:�-- B) System Conditionally Passes; [� one or more systern 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, NQ)For the following statements. If"not determined," please explain. ` i The septic tank is metal and over 20 years old* or�h septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfV1complying tion or tank failure is imminent. System will pass inspection if the existing tank is replaced with 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�/h:ss than 20 years old is available. a' C_) Y ❑ N 11 Nb (Explain below); r 'ride S Offk9al Inspection Foam:Subsurface Sawap taisposal system rage 2 cf 17 1!5lns.doc rev.5118 s Commonwealth of Massachusetts Mew if a 5 Official Inspection 1=orrn Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address i -W- Owner ownes Name information is requirod for every !Town state Zip(<>de [lake of inspectionCot page. Y __. B. Certification (coni) Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 13) System Conditionally Passes (cont.): I� Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipcf(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 Y ND (Explain below): [ ] obstruction is removed ❑ Y N [ ] ND (Explain below): [� distribution box is leveled or replaced E] N [] ND (Explain below): i r' F] The system required pumping more than 4 times a year due to broken or obstructed pipe(s), The system will pass inspection if(aV°ith approval of the Board of Health): E] broken pipe(s)are/(eplaced [_ Y [] N L] Nth (Explain below): [_] obstruction is Pemoved Y [A N Ll 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 H alth determines in accordance with 310 CMR 15.303(1)(b)that the system is not f ctioning in a manner which will protect public; health, safety and the environment: [ ] Cesspool or privy is with7— 50 feet of a surface water f [j Cesspool or privy isyWithin 50 feet of a bordering vegetated wetland or a salt marsh t5tns.doc•rev.6116 'title 5 Ofrwtal Inspection Farm:Subsurface Sewage t)Isposal SYstam•Page 3 of 1 Gornririonwealth of Massai llusetts wLm. l(: {official Inc pcctia�r� Farm Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every _ ate lip f`ode Date of Inspection j page. CityrTown 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: The system has a septic tank and soil absorption system (S ) and the SAS is within 100 feet of a surface water supply or tributary to a surface wa r supply. [_] The system has a septic tank and SAS and the SAS is ithin a Zone 1 of a public:water supply. The system has a septic tank and SAS and the Sf 8 is within 50 feet of a private water supply well. f El The system has a septic:tank and SAS and the SA;S is less than 100 feet but 50 feet or more from a private water supply well**. i i Mothod used to determine distance: **This system passes if the:well water analysis, performed at a DLP certified laboratory,for fecal coliform bacteria indicates absent and thq�bresonce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that na 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 Na Backup of sewage into facility or system component due to overloaded or � ) U`_1 / 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 1 Liquid depth in cesspool is less than 6" below invort or available volume, is less .l than 1/2 day flow ltilns.doc•rev.6116 1 itlo 5 Official Insporllun Form:.Subswraco Sowago Disposal Syslom•I'aa{le 4 of 17 Cornmonwealth of Massachusetts Title 5 Official llrispecti©n Form Subsurface Sewage Disposal System Form - blot for Voluntary Assessments Property Address Owner, Qwnor's blame information is required for evol — Cit fT"own State 71p Code Date of Intif>artron Pape. y B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or obstrt.icted pipe(s). Number of times pumped: _.. _• [4;�,, 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 sulfiace water supply. (�J ] Any portion of a cesspool or privy is within a Zone 1 of a public well. [_] [Ty Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ (f.! Any portion of a cesspool or privy is less than 100 feet but greater than :)0 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the 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 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. LJ 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 systerr1 fails. Thr system owner should contact the Board of Health to determine what will be necessary to correct the failure. P) 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 o f the following, in addition to the questions in Section D. Yes No o' ❑ ❑ the system is within 400 fee. f a surface drinking water supply (� (� the system is within 20 feet of a tributary to a surface drinking water supply the system is loca�ed in a nitrogen sensitive area (interim Wellhead Protection ❑ [•-1 Area---IWPA)or . mapped Zone it of a public water supply well If you have answered"yes"to an ,,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 signifiom/ht threat under Section f� or failed tinder 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. ISlns.doe^rev.6116 rifle 5 official Inspection Fenn:subsurface Sewage i)ispo:arl Systern•page 5 of 17 commonwealth of Massachusetts =, Title 5 Official lin, peetion Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner -._._ __ Owner's Name information is required for every page. City/Town State Zip code [date of Inspection C-. �Ihet:kllst Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No [ Ll Pumping information was provided by the owner, occupant, or Board of Health [J ( ] Were any of the system components pumped out in the: previous two weeks? Has the system received normal flows in the previous two week period? El FX" Have large volumes of water been introduced to the system recently or as part of this inspection? Lr i Were as built plans of the system obtained and examined? (If they were not available note as NIA) tJ [❑ Was the facility or dwelling inspected for signs of sewage back up? F] Was the site inspected for signs of break out? �! [ Were all system components, excluding the SAS, located on site? ' U Were the septic,tank manholes uncovered, opened, and the interior of the tache inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? El 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: I E=xisting 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 El approximation of distance is unacceptable) [310 CMFi 15,302(5)] D System Information Residential Flow Conditions; -S Number of bedrooms(design): Number of bedrooms (actual): --_ DESIGN flow based on 310 CIVIR 15.203 (for example: 110 gpd x#of bedrooms): ( -/ t6lns.doc•rev.6116 1 itio 5 bffidal Inspection Form;Subsurface.Sewaga ralsposal System-Page 6 of 17 Commonwealth of Massachusetts Title Official Inc) f=orm Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address owner Owner's Name information is required for every page. CltyfTawn state lip c ode Date of Inspection A. System Information Description: Number of current residents: Does residence have a garbage grinder? L] Yes [ ] Na Is laundry on a separate sewage system? (Include laundry system inspection [-1 Yes 0 No information in this report) Laundry system inspected? j,(� �� Yes (_] No use? //`l E] Yes [, No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? /� �, 0 Yes r] No Last date of occupancy: date Commercial/industrial Flaw Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): / __ali _.__ GcSns r)er day t4tpd) Basis of design flow(seatsfpersonslsq.ft., e Grease trap present? 0 Yes U No Industrial waste holding tank presTat? [.j Yes [] No t� Non-sanitary waste dischargecoo the Title 5 system? ❑ Yes [_r] No Water meter readings, if ay ilable: ffilmdoc-rev.6116 Title 5 Official Inspection Farm:Sul mudace Sewage Olwposnl Sysiam•Pago 7 or 17 j Commonwealth of Nlassachtisetts F Titin. 5 ""Mic.ial iii,�pe�ctior� Form Subsurface Sewage Disposal :'system Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every _.....__... page elty/Tawn — State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use:: elate Cather(describe below): General Information Pumping Records: Source of information: ..._.--.._ Was systern pumped as part of the inspection? [ ] Yeas [. No If Yes, volume pumped: gallons How was quantity pumped determined? — Reason for pumping: Type of System: [ Septic tank, distribution box, soil absorption system C. 1 Single cesspool U Overflow cesspool ] Privy D Shared system (yes or no) (if yes, attach previous inspection records, if any) } 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 [� Tight tank. Attach a copy of the CEP approval. [� Other(describe:): Wns.doc•rev.6/16 Title 5 C7fficlat tnspection Form:Subsurface Sewage Disposal System•page 8 of 17 lz-�L� Commonwealth of Massachusetts Title 5 Official Inspection d=orm 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w r Property Address Owner Owners Name information is required for every .m.. _ Lip Cade [)ate of Inspection pane. Gity/Town .__,_ --- _.._...__.. . .. U. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? Yec, [ ] Na Building Sewer(locate on site plan): Depth below grade: feet Material of construction: cast iron 40 PV(, other(explain): r Distance from private water supply well or suction line: feet Comments (on Condition of joints, venting, evidence of leakage, etc.): � AILt +C E Septic"tank (locate on site plan): F } Depth below grade: feet Material of construction: concrete metal [N..j fiberglass [ polyethylene other(explain) If tank is metal, list age: years Is age confirmed by a Certificate;of Compliance? (attach a copy of certificate) [..� Yes [ No 4 I Dimensions: ry ._o Sludge depth: 15hs.efoc rev..6115 Title 5 Official la,spection Fore:subsurface sewage Disposal system•Page 9 of 17 UOMM011wealth of { 53,1ohUsotte A- Title 5 Official Inspection Form a q Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner owner"s Name Information is required for every — -- — — t to Zip(cafe Date of Inspection S page. city/Tawn U. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottorn of outlet tee or baff le Scum thickness Distance front top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle —...... _..._ How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, strtfcturl integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): V. Al1 .... , ....- � eUC Grease Trap (locate on site plan): Depth below grade: ,% feet r'd Material of construction: ,/ o� J �� polyethylene [ other(explain): concrete LI metal /EJ fiberglass I o Dimensions: f Scum thickness Distance from top ofsc/In to top of outlet tee or baffle Distance tance from taottorrf of scum to bottom of outlet tee or baffle Date of last pumping: Date tbins.dec•rev.6116 1'ille 5 q(ticlarl Inspectknr F°nmr.Suhsurlaca Sewage Disc«sal System rade 10 rd 17 Cornmonweatth of Massachtas�;tts E v Title 5 official Inspection Form ' Subsurface Sewage Disposal laystem Form Not for Voluntary Assessments _ rr Property Address Owner Owner's Name information is required for every — _�.f. Cit Ctown State Zip Code [date of Inspection page. D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet te9,6r baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage ,,etc.): r r r Tight or Molding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: CI concrete [mI meatal El fiberglass/ El polyethylene [ .� other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: r [] Yes (� No j Alarm level: _ — f .._. _ _..— ._ Alarm in working order: [ Yes 0 No r" ' Date of Inst purr#ping: �� i7ate__..._—.._.—._----...____.._.__.______ Comments (condition of a�drrn and float switches, etc.): f,f *Attach copy of current pumping contract(required), Is copy attached? El Yes ❑ No t5lns.doc rev.6.116 1 KIL 5 Official tnspudlon Foran:&Ibsuface Sewage Dlsposal Syclem Page'ti of 17 Comimonwealth of Massai�husatts Tille 5 official Inspection Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owlier Owner's Name information is i required for every _—... .,_ mage CltylTown — -- tete Zip Code Date of Inspection D. System Information (cant.) Distribution sox (if present must be opened) (locate on site plan): Depth of liquid 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 of box, etc.): _-------- -4— w_-.._Lei Pump Chamber(locate on site plan): / Yes No* Pumps in working order: ] (.7 Yes �,..� No* Alarms in working order: -� Comments (note condition of pump chamber, con0i'lion of pumps and appurtenances, etc.): i' * If pumps or alarms are not in working order, systerfr is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: tfiins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage r)Isposal System•Page 12 of 17 Gotntnotmealth of Massachusetts E si Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ZUT _.5 Property Address ©wrier owners Name information is required for everyDate Cit (Town State Zip Code D ste of Inspection page. Y .. . D. System Information (cont.) Type: leaching pits number: [� leaching chambers number: �] leaching galleries Ejleaching trenches number, length: m leaching fields number, dimensions: �-_.- - nur�rber: -_.-- .....__.._..__ overflow cesspool 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.): VC�. P't ,} i ih •...,� ti," ,_%..: '.-._1!_l. �1� i _"__..._._ ,Xt-.... .._ C�)_. FK �a,._....._.. .. ... "y ti . . ( f \ Cesspools (cesspool must be pumped as part of inspection)(locat 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 ❑ Yes ❑ No 15ins.doc•rev.6/16 Tllle 5 Official Inspection Form:Subsurface Sewage Disposal System•Palle 13 of 1*1 Commonwealth of Massai;husetts = Title 5 Official Inspection Form Subsurface Sewage Disposal11 >ystem Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every -State Zip Code bate of Inspection page. CltylTown __.._ D. System Information (Cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f, r Privy (locate on site plan). Materials of c:onstructian: Dimensions Depth of solids ..--- Comments (note condition of soil, signs of h raulic failure, level of ponding, condition of vegetation, etc.): -------------- t5ins.doc•rev.606 Yrlie 5 Official inspection(Form:Subsurface Sewage Disposal System-Page 14 of 17 | ' ---` Title 5 Official Inspection Form SUhsurfacoSevvage Disposa| SystemForm -NVtforVo|unioryAsoessmontn ' Property Address Owner Owner's Name , information is=9uimofor every V��~ Information -S—tat-0~ mp G- mu, um,mmnwpn page. Q�U�wn --------- System _ �~��� � K�� �� ���XK � (��DT.) dheAl - Sketch Of Sewage D|opnyo| Syabpm: Prov|d*o view ofthe sewage disposal aym�em, including Ueo to � at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet, Locate where public water supply enters the building. Chock one of the boxes below: hand-sketch \nthe area below [l drawing attached separately ,~~ �� *� mwsommmun"*w,w�.**mm�"o�°�p*�" o�"m''�"^,*v m=^�'°°ons commonwealth of Massachusetts a m re Title 5 official Inspection Form r a Subsurface Sewage Dis osal System Form -trot for Voluntary Assessments Property Address Owner owner's Name information is required for every C_y.l_awwn—......�— -state --Zip(adr--.-_ LitE of I_n.spn.—ution pago —..—.. D. System Information (cont.) Site Exam: FCheck Slope _ Surface water r El Check cellar f Shallow wells / Estimated depth to high gr"o"und water: eat f 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 Ian reviewed: .3 p Date C� Observed site (abutting property/observation hole within 150 feet of SAS) [� Checked with local Board of Health-"explain: [?� Checked with local excavators, installers-(attach documentation) F1 Accessed USGS database- explain: You must describe how you established the high ground water elevation: C, �¢��,.�_E. -�i{_�v�....��._.._� _.L,t.,.-5�/�-4.��-�:--. —4-«��— r �4_�.'_lf_*...�5..�._"��,.,`,u •��� ��=..t�......i-_�!, Before filing this Inspection Report, please see Report Completeness Checklist on next page. L5Ins.dnr,-rev.6116 f ItJe 5(711'iriel Inspert1nn Purm::3uhsudace$4wa6a Glsp�sal Sysltrm F'�t1n 16 of 17 ,C,>m,"Onwealth of Massachusetts IriAlc 5 official Inspection Form $ ' n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J o C --- Property Address Owner Owner`s Marna t information is _ raquirad for every -..--.—_— — - — State Zip Code to of knsrrPctiori page, CItylTown E . Report Completeness Checklist Inspection Summary: A, C3, C, D, or E checked v�Inspection Summary D (System Failure Criteria Applicable to All Systems) completed LL�/System Information -Estimated depth to high groundwater [O/Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 'Titin:1 officlat Inspection Form:Subsurface Sewage Olsposal System•Page 17 of 17 tJlns.doc•rev.6116 8r„,. 4�cinrer,� �' o � Toxon of North Andover HEALTH DEPARTMENT sACHUS CHECK #: DATE °f LOCATION: H/O NAME; CONTRACTOR NAME: /,)n(,,) � Type� of Permit or License: (Check box) ❑ Animal $ -- ❑ Body Art Establishment $ ❑ Bode Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Su s� tuns: ❑ Septic-Soil Testing $ ❑ Septic--Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ Cl Title 5 Inspector $ Title 5 Report �' , ' ” $ � ❑ Other:(Indicate) $ Hea'Ith Agent Initials White-Applicant Yellow-Health Pink-Treasurer