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Home My WebLink AboutMiscellaneous - 10 JERAD PLACE 4/30/2018 (2)Z-�� 0 O o 'p2 Dd b? aaj� o w� IDR ; � ID 03 0C DR Ort 06/27/2017 Address: 10 Jerad Place North Andover Health Department Community and Economic Development Division All North Andover Residents with Septic Systems and Garbage Disposals Please note that due to a recent review of a Title 5 Report, your property has been identified as maintaining a working garbage disposal that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. I Garbage disposals are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this disposal could quickly cause a pre -mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to: healthdept@northandoverma. gov. Thank you for taking the time to consider the impact that your current setup has on your septic system and the environment. Sincerely, Brian LGrasse, CEHT Director of Public Health 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor -do not use the return key. VQ GA t5ins - 3113 RECEIVED Commonwealth of Massachusetts Title 5 Official Inspection Form JUN 2 2 2017 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments TOWN OF NORTH ANDOVER HEALTH, DEPARTMENT Property Address - 'x e1 Owner's N City[T°Wn 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. A. General Information 1. Inspector. Z) Telephone Number B. Certification State _ Zip Code License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reporte?d 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 DEA approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes ❑ Fails ❑ Needs Further Evalytion by the Local Approving Authority Date The system inspectbrAhall 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 is a shared system or 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 DEP. 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. Title 5 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 Address Ti Owner's s Na information ie required for every page. CityfTown: 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: 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: as B) System Conditionally Passes: L ❑ 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 th oard of Health, will pass. Check the�plgxplain. es",. "no" or "not determined" (Y, N, ND) for the following statements. If "not determine The septic tank is metal "aover 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial Itration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is re ced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 2kyears old is available. ❑ ly ❑ N ❑ ND (Explain below): t5ins • 3113 Title 5 Official Inspection form. Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner owners Nam a 401V information is / required for every '. V �fj� _ G� �(J _1 Z �� 3 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Cham Limps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are d. B) System Conditionally Passes (co ❑ Observation- ewage backup, or break out or high static water level in the distribution box due to broken or obs ed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (wit rovai of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ ND (Explain below): ❑ The syste quired pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pas " ection if (with approval of,the Board of Health): ❑ broken pipe(s) are 'ced E]Y ElN ❑ ND (Explain below): ❑ obstruction is removed Y ❑ N ❑ ND (Explain below): C) Further Eval 'on is Required by the Board of Health: ❑ Conditions exist which ire further evaluation by the Board of Health in order to determine if the system is failing to protec lic health, safety or the environment. 1. System will pass unless Board o th determines in accordance with 310 CMR 15.303(1)(b) that the system is not function a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins • 3113 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal Systam - Page 3 of 17 Owner information Is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Owner's N e 9Cityfrown Sta� Zip Date of Inspection 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, safely , environment: ❑ The system a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface _ r supply or tributary to a surface water supply. ❑ The system has a -sep nk and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank an S and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the, A 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 1 story, for fecal co iform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to dr4ess 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 ❑ 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 . t5ins • 3113 Title 6 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts ' Title 5 official Inspection Form f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Own es Narr)g information is ��"'-� required for every d ( S Z p page. Cttyffown State Zi Code Date of Inspection n B. Certification (cont.) Yes No ❑ 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. ElAny 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. [This system passes if the well water analysis, performed at a DEP certified laboratary, for fecal, coliform bacteria Indicates absent and the presence of ammonia nlirogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other fallure, 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- 10,0009pd.; a The system fails. l 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 larges stems; you must indicate either "yes" or "no" to each of the following, in addition to the questions inSection D. Yes No ❑ ❑ the system Mthin 400 feet of a surface drinking water supply ❑ ❑ the system is within 20 t of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitroge nsitive area (Interim Wellhead Protection Area— IWPA) ora mapped Zone II ofa' blic water supply well If you have answered "yes" to any question in Section E the system is nsidered a significant threat, or answered "yes" in Section D above the large system has failed. The o or operator of any large system considered a significant threat under Section E or failed under Section hall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact th ppropriate regional office of the Department. (Sins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Owner Information is required for every page. t5ins - 3113 Commonwealth of Massachusetts " Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 <yCk ti, L P/Alt'16-11 City/rown 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 D. System Information Residential Flow Conditions: Number of bedrooms (design): L _ _ Number of bedrooms (actual): ` t DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): �� u Tide 6 Official inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ j�] Wereany of the system components pumped out in the previous two weeks? ❑\ 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? Were as built plans of the system obtained and examined? (if they were not available note as NIA) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were 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 or 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: El Existing 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 approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): L _ _ Number of bedrooms (actual): ` t DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): �� u Tide 6 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 e.�CIL- Property Address Owner Ovines N information e QIy required for every Civ [ � 3 '3 page. Ciry(tovvn State Zip Code Date of Inspection D. System Information T GAI t5ins • M3 Description: Number of current residents: 01 Does residence have a garbage grinder? K Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection information in this report) ❑ Yes AQ No Laundry system inspected? ❑ Yes (( No Seasonal use? ❑ Yes ( No Water meter readings, if available] (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes C No Last date of occupancy: eun rt�tit Date Commmerciallindustrial Flow Conditions: Type b�Establ ishment: Design flow (based on 310 CMR 15.203): Basis of design flow(se ersohs/sq:ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: GM s per day (gpd) es ❑ No ❑ Yes ❑ o. \ ❑ Yes ❑ No 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 B&I c Property Address Owner Owner's _ N.:a v - — — Information Is required for every CLll� page. itylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Date Pumping Records: Source of information: U Was system pumped as part of the inspection? [i Yes No 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 o 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): 15ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required'for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ohti5J & Cal 122.--a 3 —14 Cityfrown State Zip Code Date of Inspection D. 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? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron 0x.40 PVC ❑ other (explain): Distance from private water supply well or suction line: ❑ Yes OL No 'd , c feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): -�) 6 1"ks 0 Septic Tank (locate on site plan): Depth below grade: Material of construction: concrete ❑ metal ❑ fiberglass If tank is metal, list age: 4 1 f, feet ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5, X/ C� Sludge depth: 67 11 t5ins - 3113 Title 5 Official Inspection Form: Subswface Sewage Disposal System • page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Na _ ham. Information is required for every page. Cityfrown D. System Information (cont.) state Zip Code Date of Inspection Septic Tank (cont) Distance from top of sludge to bottom of outlet tee or baffle �N 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 !p How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence'of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: Material f construction: ❑ concrete ❑ metal ❑ fiberglass 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: t5ins • M3 feet ❑ polyethylene ❑ other (explain): Date Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address _ ._ �CS r1 •�J 5��\ Owner Owner's Na information is A , �� Jct 1c� S— Z 3 required for every � lam"'` Cityrrown - — - - - page. State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid s as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of Depth below grade: Material of construction: [] concrete ❑ metal ❑ fiberglass Dimensions: ) (locate on site plan): ❑ polyethylene ❑ other (explain): Capacity: gallons Design Flow: gallons per day Alarm present: \ ❑ Yes ❑ 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 Mns • 3/13 Title 5 Official Inspection Forth: 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 Property Address ation is Owner Owner's N inform required for every // "� `' �� B s a3 —�/t7 page. City/Town State Tarp 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 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.): Pump Chamber (locate on site plan):. Pumps in ing order. Alarms in working or, Comments (note condition ❑ Yes ❑ No* ❑ Yes ❑ No* chamber, condition of pumps and appurtenances, etc.): * I=Absorpti arms are not in working order, system is a conditional p;� SSystem (SAS) (locate on site plan, excavation not required): . If SAS not located, expla hv: t5ins • 3113 Tide 5 Oficial In lon Form: Subsurface Sma a Disposal g po System •Page 12 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address /- - Owner O is -Na infortnation is p r L required for every page. tityrTown - State Zip Code Date of Inspection D. System information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system j C.. Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site pian): and configuration Depth —top of IigAtid-to inlet invert „ Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes \ ❑ No [sins - 3113 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 Pmnnrry Brrrrroce Owner Owner's Na information is required for every 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 r%--A.r...s .,,.r.�. !Sine • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Pape 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments AL CL Property Address Owner Owner's Na information is required 'A A required for every r�u �- atie�� SLOt Y� l -_7 33-64 page. Cny/ I own 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: R -hand -sketch in the area below ❑ drawing attached seaarately t5ins • 3113 Title 5 Official Inspection Forrn: 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 16 Property Address Owner Inform' is Ow�ers 4`requiredfor every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope 0 Surface water N iti Check cellar' J' e � ❑ Shallow wells Estimated depth to high ground water. U' z l feet Please indicate all methods used to determine the high ground water elevation: ❑ - Obtained from system design plans on record qr,� If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - .gxplaim Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: ,%" 11� W1 DMI= Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins - 3113 Title 6 official Inspection Form Subsurface Sewage Disposal System - Page 16 of 17 .t Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address \( \� Owner Ownee information is p ,,, �n� / required for every !`jam' A& QU46 page. City7own 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 4 t5ins - 3/13 Title 5 Official inspection Forth: Subsurface Sewage Disposal System - Page 17 of 17