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Home My WebLink AboutTitle V Inspection Report - 615 BOXFORD STREET 4/17/2018 . . . Commonwealth of Massachusetts � m�� 0°�Q�� ^��'��°�� 0��~�� U��h �a�, N ��N�� m ��/0 � N��Q�mN Inspection �- �� mm �p� mmw �w�~_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments -property Address 100 yk DIE' . , Owner Owner's Rame information is �,��\~ mq��dkxevu� / °�v , page. C'`p'"=' State Zip Code Date ofInspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end ofthe form. Important:When A. ��K�4��U UD��^��K� filling out forms ^^~ General Information ~^~" unthe computer, use only the tab 1 | ��mmmmyou, � n cursor do not -Ael, ( � 0 C use the return le o Inspector key. ., Mny Address City/Town State Zip Telephone Number License Number B. Certification | certify thmt | have pereonaUyinopec�/dthe disposaloy�emat�hioaddnmaoandthmdthe inhzmnationrepodedbelow imtrue, ocourabaand oomp�be aowfthe time ofthe inspmctiVn. The inopeotion vvaope�o,medbased onmytreiningand mxpmrienoeinthe proper func(iPnand maintenonceofonsite aewaQedinposa|systems. � ammmDEP approved aystemminspector pursuant boSection 1S.348of Title 5(31OCMR 15.0OO). The system. �l Passes Conditionally Passes Fl Fails ~ Fl Needs Further Evaluation Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)withln'�O 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. °°°°Th|sreport only describes oond|tionaatthe timneofinspection and under the conditions oyuse atthat t|nme.This inspection does not address how the system will perform inthe future under the same ordifferent conditions ofuse. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 36 -Property Address Owner Owner's Na information Is -_ _ a 4 required for every page, City/Town 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: AJ� 13) 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. 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 aver"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 witfi"a,qo,mp lying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurall not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is aVaitable. 0 Y F] N El ND (Explain below): 7- t5ins.doc rev,6116 Title 5 Official Inspection FonoSubsurface Sewage Disposal Systern-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Information is Owner's Na J required for every APS k& (T page. City/Town State Zip Code Date of Inspection B. Certification (cont.) El 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 "&kqken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will I pass iNnspection if(with approval of Board of Health): ❑ broken pipe(*-aye replaced [:1 Y F❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y n N n ND (Explain below): ❑ distribution box is leveled or replaced Y El N El ND (Explain below): ----------- -------------- F] 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): El broken pipe(s) are replaced F1 Y El N 0 ND (Explain below): obstruction is removed El Y n N n ND (Explain below): --------------- C) Further Evaluation is Required by the Boar -of Health: -1 F❑ 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 en tronment. 1. System will pass unless Board of Health determines in accor accord aQce with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will, otect public health, safety and the environment: p17 Fj Cesspool or privy is within 50 feet of a surface water F-1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts ��°��N�� /~��~�� 0��^��~�� U��h 0N�N�� yNNN�~N��N Inspection 0—�� m � m Subsurface Sewage Disposal System Form ~Not for Voluntary Assessments Owner CA information is mquimdmrevmry page, City/Town State Zip Code ~~~`' ^'`~~''~^ B. Certification (OODt.) 2. System will fall unless the Board ofHealth (and Public Water Supplier, ifany) \'determines that tht is functioning in that protectsth b|ihealth, saiety-and environment: F� The system hasp septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a su rfacewater"supply or tributary to a surface water supply. F� The system has a septic'tankand SAS and the SAS is within a Zone 1 of a public water El The system has a septic tank and S d the SAS is within 50 feet of a private water supply well. Ej The system has a septic tank and SAS an=! I th n 100 feet but 50 feet or more from a private water supply well". Method used todetermine distance: ** This ayebam passes ifthe well water analysis, performed ata DEP certified ca| iuo|iform bacteria indicates absent and the presence of ammonia nitrogen and n� nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of aiomuot boattached (othis form. 3. Other: D) System Failure Criteria Applicable toAll Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yeo No Backup ofsewage into facility orsystem component due tooverloaded or clogged SAS orcesspool [� ` Discharge orpon�ingofe�uenttothe au�mceofthe ground orau�acewaters [� ^~ duetoenoverloaded orclogged SAS orcesspool �l �f� Static liquid level inthe distribution box above outlet inve�due ioan overloaded^^ �-� or clogged SAS or cesspool �� l�| Liquid depth incesspool |aless than 6" below invo�oravailable volume imless �� ^��- than 1/2da flow , ' ' Commonwealth of Massachusetts ' Title 5 Official Inspection nspetionF orm Subsurface Sewage Disposal SymtemFunn -NotforVm|unteryAsseaementa Property Address Owner Owner IsNa� information is required for every d page. City/Town State Zip Code action B. Certification (cont.) Yes No �� Required pumping more than 4Umeminthe last year/V[)Tduatodoggedor �� obstructed pipe(o). Number oftimes pumped: ____. |l �� Anyportion ofthe G8S �emopoo| orprivyinbe|mwhigh �round��ber�|wvaUon . . �l Any portion of cesspool or privy is within 100 feed of a surface water supply or �� tributary haasurface water supply. [l Any portion ofacesspool orprivy iowithin mZone 1ofapublic well. El Any portion of cesspool or privy is within SO feet of private water supply well. [l /�J Any portion of a oeaopno|or privy is |eom than 100 feet but greater than 50 feet ^� ~� from e private water supply well with no acceptable water quality analysis. [This system posses if the well water analysis, performed at m DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence ^ of ammonia nitrogen and nitrate nitrogen is equal to orless than S ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain nfcustody must beattached tothis formn.] �� The system is a cesspool serving a facility with a design f|mm of2DO0gpd' �� ' 10'000gpd. [l �� The system fails. | have determined that one or more of the above h*i|una criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board mfHealth todetermine what will be necessary tocorrect the failure. E) Large Systems: To he considered e large system the system must serve ofacility with m design flow of10,OOUQpdto15,DO0gpd. For,,Iarge systems, you must indicate either"yes" or"no"to each of the following, in addition to the Commonwealth of Massachusetts ��N�� `�:��~��0 0��°�� 0��0� Title �� *�0NN��N��N Inspection Form Subsurface Sewage Disposal System orm -Not for V | t Assessments Property Address uvno, information is , mqtjiredfor every »000 City/Town State- Zip Code --------n C. Checklist Check ifthe following have been done. You must indicate"yea^or"no^aahoeach ofthe following: Yea No Fl Pumping information was provided bythe owner, occupant, orBoard ofHealth [l �f Were any ofthe system components pumped out|nthe previous two weeks. Has the system received normal flows inthe previous two week period? [l Have large volumes of water been introduced to the system recently or as part of this inspection? Were mmbuilt plans ofthe system obtained and examined? (If they were not available note amNAV Was the facility ordwelling inspected for signs ofsewage back up? Was the site inspected for signs ofbreak out? �l Were excluding the SAS, located onsite? �� Fl VVerethe septic tank manholes uncovered, opened, and the interior ofthe tank ={ ^� ` inspected for the condition of the baffles or tees, material of construction, dimensions, depth ofliquid, depth ofsludge and depth ofscum? ' Fl VVasthe facility owner(and occupants ifdi�eront�nmowner) provided with �< �� informat|onontheprnpermainbonenceofsubourfaoemmwag*dioposa|myntema7 The size and location ofthe Soil Absorption System (SAS) onthe site has been determined based on: Fl Existing For example, eplan atthe Board cfHealth. �� Determined in the field (if any of the failure criteria related to Part C is at issue approximation ofdistance iounacceptable) [31DCMR 15.3U2(5)] \ D. System Information Residential Flow Conditions: �f Number ofbedrooms (design): ---z---- Number of bedrooms(actual). --------- � DESIGN flow based on31OCMR 15.283(for example: 11O8pdx#ofbedroomo): -'�-�----- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner, a Sj Its U information is ee required for every ZU&' _ . page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection ❑ YesNo information in this report.) ❑ Laundry system inspected? El Yes tq No Seasonal use? 1 f El Yes Q No Water meter readings, if available(last 2 years usage(gpd)): Detail: ------------------------- Sump pump? ❑ YesNo 41 Last date of occupancy: v,--e Date Commer611alftdustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203y----__ Gallons per day(gpd) j Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes [:1 No Industrial waste holding tank present? El Yes [_1 No Non-sanitary waste discharged to the Title 5 system? E] s ❑ No Water meter readings, if available: ----------7___ 15ins,doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts °�~�N� � ��~�N N��~�� Title �� /NN0��0��N Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ----------------------- Property Address Owner Ow information is required for every page. °'`r''""'' State Zip Code ~~^~`''''~~`~'~' D. System Information (cont.) Last date ofoccupancy/ume: Date Other(describe be|ow): Genera| |nfonmmUon �6�'�� Pumping Records: c~ J " 8ource of information: I8 VVaxsystem pumped aupart ofthe inspection? Yea [l No ' If yes, volume` ' gunvnn How was quantity pumped determined? Reason for pumping: Type ofSystem: Septic tank, distribution box, soil absorption system �l Fl Single cesspool Fl Overflow cesspool El Privy Shared system (yes or no V(if yes, attach previous inspection records, if any) �l |nnovoiveA\|ternativetechno|ogy. Attach acopy ofthe current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection ofthe |6Asystem bysystem operator under contract �l Tight tank. Attach acopy ofthe DEP approval, El Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ............... Property Address Ae Owner Owner's Name information is required for every ay� 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: .Cts -;)C V�, (S<:-Q ,o 0 0 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: El cast iron k40 PVC ❑ other(explain): Distance from private water supply well or suction line: Id-0 feet Comments(on condition of joints, venting, evidence of leakage, etc.): LC Septic Tank (locate on site plan): C2 Il Depth below grade: feet Material of construction: ,concrete [] metal EJ fiberglass El polyethylene F-1 other(explain) ---------- If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes E] No Dimensions: ............... Mfr Sludge depth: tbins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ------------- Property Address OwnerOwner's Narm information is Aj , -T'--,,-- required for every j, page. City/Town State Zip Code Dat b of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle G-) 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 How were dimensions determined? V Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc,): ------------ VA V�- (Ye Grease Trap (locate on site plan): " De below grade: feet 11 "' Material Of c'bnstruction: ❑ concrete ❑ metal n fiberglass E] 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 t6ins.doc•rev.6716 Title 5 Official inspection Form:Subsurface Sewage Disposal Sys tbT'l-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ---------- Zo I Property Address Owner Owner's N information isry ❑'b required for eveZip Code page. City/Town State Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid lev I s as related to outlet invert, evidence of leakage, etc.): ........ Tight or Holding Tank(tank must be pumped at time of�ins ction) (locate on site plan): ,�,ct.ion, Depth below grade: -c_ate on site plan): Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene other(explain): D17 risions, Capacity: gallons Design gallons per day -----_— Alarm ------- Alarm present: n Yes E] No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: : Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 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 <3 Property Address Owner Owners Na information is /11 )es required for every VC —-----!LC........J-1, page, Xity/Town State Zip Code Date of Inspection--- D. nspectionD. System Information (cont.) Distribution Box (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.): -------------------------------- x-5------------- A-> IJ j P'lo"— ........... -------------------- ..................... ------------ ........... Pump Chamber(locate on site plan): Pumps in working order: F-1 Yes 0 No* Alarms in working order: F-1 Yes El No* Comments n s (note condition of pump chamber, condition of pumps and appurtenances, etc.): ----------------- If pumps or alarms are not in working order, sys is a conditional pass. Soil Absorption System (SAS) (locate on site plan, exca 7�� ion not required): If SAS not located, explain why: -------- t5ins.doc-rev.6116 Title 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 Property Address Owner Owner's N /0 �: Information is required for every 6 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: 0 leaching pits number: 0 leaching chambers number: D leaching galleries number: pp leaching trenches number, length: 0 leaching fields number, dimensions: El overflow cesspool number: .......---.._-....._......._....__....__....m. EJ 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.): lt u C"je, /zt,- .......... ............ ....................... -------------------- Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration ---------------- Depfh-r,t9p of liquid to inlet invert Depth of solids layer Depth of scum layer --❑----------- Dimensions of cesspool ------------- Materials of construction Indication of groundwater inflow EEI Yes-,,, El No 15ins.doc rev,6/16 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 Property Address Owner Owner's-�e information is required for every /VA- 61 f 4 page. 'City/Town State Zip Code Date of inspection D. System Information (cont.) Comm nts (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 ition veget Comments (note condition of soil, signs of hydraulic failure, level of ponding, cond��7 ation, etc.): ...............---------------------- - ----------- t6ins.doc-rev.6/16 1 itle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments S7 —--------------- Property Address JJ Owner Owner's information is required for every A) Aj 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: ❑ hand-sketch in the area below drawing attached separately cc? cr 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 99- ---------------- -------------- Property Address Owner Owner' Information is ' required for every page. City/Town 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: feet Please indicate all methods used to determine the high ground water elevation: F-1 Obtained from system design plans on record If checked, date of design plan reviewed: z � Date El Observed site (abutting property/observation hole within 150 feet of SAS) El Checked with local Board of Health -explain: R Checked with local excavators, installers-(attach documentation) 0 Accessed USGS database-explain: You must describe how u established the high ground water elevation: 4S Ll ------------ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doe-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts L W = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments c-- Property Address Owner -.- _ __.__...._._.. Owner's Na information is required for every A. page. 6iti/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 t5ins,doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern-Page 17 of 17 02h'4 ystem ria cl .. Sketch Of Sewage Cis sal System: Provide a wield of the sewage disposal system, including ties to at least two permanent reference landmarks orbenchmarks. Locate all Wells within 100 feet. Locate where public water sauppC,-r enters the bu iding. Check one of the boxes below: p ,d.sketch in the area below drav,,ing attaclhed separately Su�I.D�NC RES ELI,!DING CORNER A SEPTIC TANK 1 15.333.7 0 PUMP TANK _ DIST, BOX _ 36.Ct 5 OUTLET CORN. LEACH FIELD 1 52.3 85.6 k CORN. LEACH FIE B 2 131,2 91.0 4 CC1RN. LEACH FIE L!? 3 7 44.3 , rnRI. I EACH I 'Q A4 47,9' 2OT � her IN RT E EV Tl Aa , s,�. -� W TE ERViCE 4" PIP TN ,e�� ^«s SEPTIC TANK IN 123.28 _ ! 30' � E U = 12�� ti 3G° MIN. rARR U PW--Our- (UNDER CONSTRUCTION 4 BORM. Cq D1,131, BOX OUT 122.5 T.��-x��" c'v NCD LEACH Ll = 122.0 A 9 (D - , p t1 chd N . 5 1 2 0t3 SEPTIC-- c14 (D TANK Q O Q CRAVEL DRIVEWAY (N01 CON SVO �21Or LEACHING 143.63' gOPTYMI Town of North Andover HEALTH DEPARTMENT SACH% tg CHECK#: DATE: LOCATION: H/ONAME: _.,_ CONTRACTOR NAME: Z"Y"? lype of j"ermit or License: (Check box) 0 Animal 0 Body Art Establishment 0 Body Art Practitioner 0 Dumpster 0 Food Service-,Type:—. 0 .Funeral Directors 0 Massage Establishment 0 Massage Practice 0 Offal(Septic)Hauler 0 Recreational Camp El Sun tanning El Swimming Pool 0 Tobacco 0 Trash/Solid'Waste Hauler 11 Well Construction SEPTIC S,t�sterns: 13 Septic-Soil Testing 0 Septic-Design Approval 0 Septic Disposal Works Construction(DWC) 0 Septic Disposal Works Installers(DWI) 0 Title 5 Inspector $ Title 5 Report 0 Other. (Indicate) Health Agent Initials White-Applicant Yellow--Health Pink-Treasurer