HomeMy WebLinkAboutMiscellaneous - 10 LIBERTY STREET 4/30/2018N
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Town of North Andover
HEALTH DEPARTMENT
C 'I, DAT4E:,5W3
CHECK#: (26 1 o
LOCATION: h / I NAA
H/O NAME:
CONTRACTOR N
Type
of Permit 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
$
•
Offal (Septic) Hauler
$
•
Recreational Camp
$
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
$
0
TrashlSolid Waste Hauler
$
0
Well Construction
$
SEPTIC Systems
0
Septic - Soil Testing
$
0
Septic - Design Approval
$
13
Septic Disposal Works Construction (DWC)
$
11
Septic Disposal Works Installers (DWI)
$-
0
Title 5 Inspector
$
Title 5 Report
$ 4
0
Other (Indicate)
$
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Health,kg'ent Initials
White - Applicant Yellow - Health Pink - Treasurer
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Town of North Andover
HEALTH DEPARTMENT
C U
CHECK#: DATE:,
c
LOCATION:
H/ONAME:
CONTRACTOR NAME-Tnhn1i�ACanzjj
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TyRe of Permit 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
$-
0 Sun tanning
$
0 Swimming Pool
$
0 Tobacco
$
0 TrashlSolid Waste Hauler
$-
0 Well Construction
$
SEPTIC Systems
• Septic - Soil Testing
$
• Septic - Design Approval
$
0 Septic Disposal Works Construction (DWQ
$
0 Septic Disposal Works Installers (DWl)
$
0 Title 5 Inspector
$
'1�6 Title 5 Report
0 Other (Indicate)
$
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HealthA-jg'anitials
White - Applicant Yellow - Health Pink - Treasurer
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Asses:
10 Liberty street
Property Address
Paul Galante
Owner's Name
North Andover
City/Town
ma 01886
State Zip Code
MAR 2 2 2013
OF NORTH ANDOVER
March 6, 2013
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:
John DiVincenzo
Name of Inspector
Stewart Septic Service
Company Name
58 South Kimball _
Company Address
Bradford
City/Town
978-372-7471
Telephone Number
B. Certification
Ma
State
S113386
License Number
01835
Zip Code
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 ❑ Conditionally Passes ❑ Fails
ruing Authority
Date
nspection report to the Approving Authority (Board
is inspection. If the system is a shared system or
spector and the system owner shall submit the
P. 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 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
10 Liberty street
Property Address
Paul Galante
Owner's Name
North Andover
City/Town
B. Certification (cont.)
ma 01886 March 6, 2013
State Zip Code Date of Inspection
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:
B) 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 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.
❑ Y ❑ N ❑ ND (Explain below):
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
viE
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Liberty street
Property Address
Paul Galante
Owner's Name
North Andover ma 01886 March 6, 2013
CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
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
❑ obstruction is removed
❑ Y ❑ N ❑ ND (Explain below):
❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ 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 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:
❑ 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
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Liberty street
Property Address
Paul Galante
Owner Owner's Name
tiis
equine fo
d for every North Andover _ ma 01886 March 6, 2013
require
page. City/Town State Zip Code 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,
safety and environment:
t5ins • 11110
❑ 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.
❑ 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
❑ ® 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 Y2 day flow
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
i
t5ins • 11110
❑ 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.
❑ 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
❑ ® 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 Y2 day flow
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
❑ ® 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
❑ ❑ 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
Area — IWPA) or a mapped Zone II 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 • 11110
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
W
Title 5
Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Liberty street
Property Address
Paul Galante
Owner
isrequired
Owner's Name
--
for every
very
North Andover
ma 01886 March 6, 2013
page.
City/Town
State Zip Code Date of Inspection
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.
❑
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑
® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑
® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
®
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [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
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
❑ ❑ 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
Area — IWPA) or a mapped Zone II 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 • 11110
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Insp
Subsurface Sewage Disposal System For
10 Liberty street
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
ection
Form
® ❑
m - Not for Voluntary
Assessments
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
Property Address
available note as N/A)
-
Was the facility or dwelling inspected for signs of sewage back up?
Paul Galante
Was the site inspected for signs of break out?
® ❑
Owner
Owner's Name
Were the septic tank manholes uncovered, opened, and the interior of the tank
information is
required for every
North Andover
ma
01886 March 6, 2013
page.
Cityrrown
_
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?
® ❑
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 N/A)
® ❑
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:
® ❑
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): 4 - Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 864
t5ins • 11/10
Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Liberty street
Property Address
Paul Galante
Owner Owner's Name - - --" -
information is
required for every North Andover _ ma 01886 March 6, 2013
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? [if yes separate inspection required]
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
see analytical
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/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:
Gallons per day (gpd)
❑ Yes
®
No
❑ Yes
®
No
❑ Yes
❑
No
❑ Yes
®
No
Well
❑ Yes ® No
occupied
Date
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
t5ins • 11/10 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
10 Liberty street
Property Address
Paul Galante
Owner Owner's Name
information is
required for every North Andover
page. CitylTown
t5ins - 11/10
ma 01886 March 6, 2013
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: Andover septic
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity Site guage on truck
q y pumped determined? -- ---
Reason for pumping: inspect tank
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/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 DEP approval.
❑ Other (describe):
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Liberty street _
Property Address --
Paul Galante
Owner Owner's Name - - --
information is
required for every North Andover _ _ ma 01886 March 6, 2013
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:
28 years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan)
Depth below grade: 22'
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: 91
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan)
Depth below grade:
10"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene
❑other (explain)
Tank in good condition
If tank is metal, list age
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions:
Sludge depth:
❑ Yes ❑ No
t5ins • 11/10
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17
Commonwealth of Massachusetts
-� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Liberty street
D. System Information (cont.)
State
01886 _ _March 6, 2013
Zip Code Date of Inspection
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
30"
0
7.3"
14"
How were dimensions determined? Sludge judge and tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
both baffles in place structurly sound, no leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction.-
El
onstruction:❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
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 • 11110
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Property Address
Paul Galante
Owner
Owner's Name
information is
required for every
North Andover
page.
City/Town
D. System Information (cont.)
State
01886 _ _March 6, 2013
Zip Code Date of Inspection
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
30"
0
7.3"
14"
How were dimensions determined? Sludge judge and tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
both baffles in place structurly sound, no leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction.-
El
onstruction:❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
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 • 11110
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
_W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Liberty street _
Property Address
Paul Galante
Owner Owner's Name
information is North Andover ma 01886 March 6 2013
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.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: --
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Capacity: -
gallons
Design 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
t5ins - 11/10 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
10 Liberty street
Property Address
Paul Galante _
Owner Owner's Name
information is
required for every North Andover
page. Cityrrown
D. System Information (cont.)
ma
State
n144G
Distribution Box (if present must be opened) (locate on site plan)
March 6, 2013
Date of Inspection
Depth of liquid level above outlet invert 0 -
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.):
Dist. box equal, no leakage, very little carryover.
Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
® Yes ❑ No
® Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pumps are in good working order ran pumps by bringing floats to operating position all in working
order
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why.-
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Liberty street
Property Address
Paul Galante
Owner Owner's Name
information is
required for every North Andover
page. City/Town
D. System Information (cont.)
State
01886 March 6, 2013
Zip Code Date of Inspection
Type:
®
leaching pits
number: 3 pits— ----
❑
leaching chambers
number:
❑
leaching galleries
number:
❑
leaching trenches
number, length.-
❑
leaching fields
number, dimensions: —
❑
overflow cesspool
number:
❑
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
no hydraulic failure, no ponding pits dry
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
t5ins • 11/10
❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Liberty street
Property Address
Paul Galante
Owner Owner's Name
information is North Andover ma 01886 March 6 2013
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
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal; System Form - Not for Voluntary Assessments
H .+
10 Liberty street
Property Address
Paul Galante
OwnerOwner's Name -------- --------------.. __ _----- ------------------- -
information is
required for every North Andover ma 01886 March 6, 2013
---------------------------- ----- ---------..._. _
page. CltylTown 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:
M/hand-sketch in the area below
❑ drawing attached separately
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Liberty street
Property Address
Paul Galante
Owner Owner's Name
information is
required for every North Andover ma— 01886 _ March 6, 2013
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: 4' B.o.p 119 S.h.w. 114.20
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 plan reviewed: 11/18/86
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain.-
pulled
xplain:pulled files
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain.-
You
xplain:
You must describe how you established the high ground water elevation:
Plans drawn by joe Barbagano water table 4"+ seperation to bottom of pits 11/18/86
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 11/10
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
' M 10 Liberty street
Property Address
Paul Galante _
Owner Owner's Name --
information is
required for every North Andover ma 01886 March 6, 2013
page. Cityrrown 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 • 11/10
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
. LA M -
�rSx 0L -L -f 41 �G L�-C 17°
v
i
i'
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Nashoba Analytical, LLC Tel: 978-391-4428 Fax: 978-391-4643 LabNumber: 134923
31A Willow Road, Ayer MA 01432 Website: http://www.NashobaAnalytical.com Use this number with all correspondence
Client:
Still River Home Inspections, Inc. Dan Jones
18 Jacob Gates Road
Havard, MA 01451
Certificate of Analysis
Chris Langford, 10 Liberty Street, North Andover MA
Parameter Method
- Kitchen Sink
Sampled: 2/252013 7:15:00 PM by Dan Jones
Total Coliform Bacteria, /100ml ENZ. SUB. SM9223
Arsenic, Total, MG/L
SM 3113B
Calcium, MG/L
EPA 200.7
Copper, MG/L
EPA 200.7
Iron, MG/L
EPA 200.7
Lead, MG/L
SM 3113B
Magnesium, MG/L
EPA 200.7
Manganese, MG/L
EPA 200.7
Potassium, MG/L
EPA 200.7
Sodium, MG/L
EPA 200.7
Alkalinity, MG/L
SM 2320B
Ammonia, MG/L
SM 4500-NH3-D
Chloride, MG/L
EPA 300.0
Chlorine, Free Residual, MG/L
SM 4500 -CL -G
Color Apparent, CU
SM 2120B
Conductivity, UMHOS/CM
SM 2510B
Fluoride, MG/L
EPA 300.0
Hardness, Total, MG/L
SM 2340B
Nitrate as N, MG/L
EPA 300.0
Nitrite as N, MG/L
EPA 300.0
Odor, TON
SM 2150B
pH, PH AT 25C
SM 4500 -H -B
Sediment, pos/neg
— — -----
Sulfate, MG/L
EPA 300.0
Turbidity, NTLI
EPA 180.1
ReportDate: 2/28/2013
Result MCL MRL Date of Analysis Analyst
Absent
Absent
Absent
2/26/2013 9:15:00 AM
M-MA1118
ND
0.01
0.001
2/27/2013
M-MA1118
ND
Not Spec
1
2/27/2013
M-MA1118
ND
1.3
0.01
2/27/2013
M-MA1118
ND
0.3
0.01
2/27/2013
M-MA1118
ND
0.015
0.001
2/28/2013
M-MA1118
ND
Not Spec
1
2/27/2013
M-MA1118
ND
0.05
0.005
2/27/2013
M-MAI118
ND
Not Spec
1
2/27/2013
M-MA1118
61
See Note
1
2/27/2013
M-MA1118
84
Not Spec
1
2/26/2013
M-MA1118
ND
Not Spec
0.1
2/27/2013
M-MA1118
36.6
250
1
2/26/2013
M-MA1118
ND
Not Spec
0.02
2/26/2013
M-MA1118
ND
15
1
2/26/2013
M-MA1118
310
Not Spec
1
2/26/2013
M-MA1118
0.2
4
0.1
2/26/2013
M-MA1118
ND
Not Spec
2
2/27/2013
M-MAI118
ND
10
0.05
2/26/2013
M-MA1118
ND
1
0.01
2/26/2013
M-MA1118
0
3
0
2/26/2013
PN
8.1
6.5-8.5
NA
2/26/2013
M-MAI118
NEG
------
NEG
2/26/2013
PN
10.6
250
1
2/26/2013
M-MA1118
0.3
Not Spec
0.1
2/26/2013
M-MA1118
MCL=Maximum Contaminant Level (EPA Limit), MRL = Minimum Reporting Level
Sodium Guidelines- Mass 20, EPA 250, # = Result Exceeds Limit or Guideline
ND = None Detected (<MRL), * = Background Bacteria Noted
Massachusetts Certified
Laboratory #MA1118
David L. Knowlton
Laboratory Director Page 1 of 1
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Reg 9.1
9.6
Page 2 -
Leaching
-
Leaching Pits
Leaching pits are preferred where the installation is possible
a) calculations of leaching area -minimum 500 sq ft
b) spacing
c) surface drainage 2%
d) cover material
'e) I W I aro" splash pad
f) tee at elbow
g) no bends in pipe from d -box to pipe
L eacMn Fields
al nc greater t 20 minutes/inch
b area -minimum 900 eq ft
c construction of field
A) surface drainage 2 %
e) 201 from cellar will or inground mtdudng pool
Leaching Weenches
a) calculations or leaching area -min 500 sq ft
b) spacing -4 ft min 6 ft with reserve betwen
c) dimensions
d) construction
e) stone :--
f) surface drainage 2%
Downhill Slope
a) sloopeT=-oto be s1wv
b) ylx Z 150 - (to be shown
Ems
a) approval
b) stand-by power
IN
A•
BOARD OF HEALTH
No.Andover, 'Mass., '
A
SUBSURFACE DISPOSAL DESIGN CMK LIST
APPROVED DATE 12-1
Provided:
kfIL t04 15 1U pn)
GA&V FaW
Title V FAIL I Ob
Reg 2.5
Reg 6
Reg 10.2
Reg 10.4
LOT #
DISAPPROVED DATE
Reasons:
The submitted plan must show as a minimum:
,a) the lot to be served-area,dimensions lot #..abutters
location and log deep observation hoes -distance to ties
c location and results percolation tests -distance to ties
d design calculations & calculations showing required leaching area
(e) location and dimensions of system -including reserve area
(f) existing and proposed contours
(g) location any wet areas within 100' of sei*ge disposal system or
disclaimer -check wetlands mapping
(h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i) location any drainage easements within 1001 of sewage disposal
system or disclaimer -Planning Board files
(j) known sources of water supply within 2001 of sewage disposal e
system or disclaimer
(k) location of any. proposed well to serve lot -1001 from leaching facility
(1) location of water lines on property -101 from leachipg facility
(m) location of benchmark
(n) driveways
(o) gage disposals
(p) no PVC to be used in construction
(q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
other elevations
(r) maximum ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Septic Tanks
(a) capacities -15U of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground swimming pool
(d) 251 from subsurface drains
Distribution Boxes
a) slope greater 0.06
b) sump
Department of Environmental Management/ Division of Water Resources
WATER WELL COMPLETION REPORT
WELL LOCATION
Address/d 7,
City/Town 1114.
G.S. Quadrangle Map
Grid Location
-- /.? - / r /, — , e --t /�` - - , J, � -- ;4.4 1
Domestic
Other
WELL USE
Public [] Industrial
Method Drilled Rowq
j
Date Drilled 4 - 15 - K12
CASING
Length 40' Diameter- 4
Type S i e -If 1 /6 1��
CONSOLIDATED WELL
Type of Water -bearing Rock 4A :1 $,r,
Water -bearing Zones
1) From 1�0 To 960
2) From—To-
3) From—To
4) From To—
Depth to Bedrock
UNCONSOLIDATED WELL
STATIC WATER LEVEL
Water -bearing Materials
Feet below land surface
Sand: fine[] medium[]
coarseM
Date measured -lc;- Z4
Gravel: fine[] medium[]
coarseE)
Screen:
GRAVEL PACK WELL
Slot length rorn_to_
Yes El No X
_f
Split Screen (or 2nd screen)
WATER QUALITY TESTS MADE
S lot # lenqth_from_tQ_
Chemical El Biological
Depth To Bedrock
PUMP TEST
Drawdown feet after pumping_ days_hours at GPM. 1.
How measured Recovery— feet after hours.
LOG of FORMATIONS COMMENTS: (On well or water)
Materials From To
M I tbrs a /0
r,le, -or k, /6 00 DRILLER
Firm 4
Address t t
City -? .� A, .
Registration No.
41- ) I
C - Operator's 6ignature
(—wo of HE"OL-m
Nol�TH Aupnoel'�, MA,
y
nor 1�3 f� ST WAS) i
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APRWING AUThoi�ITy
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
A& �
SYSTEM LOCATION
(example: left front of house)
,VV OF NORTH ariDk,
BOARD OF HEALTH
- 4 2002
DATE OF PUMPING: %16-0@— QUANTITY PUMPED GALLONS
CESSPOOL: NO -,,I SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE _,_ EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
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47 RAIIROAD STREET
BRADFORD, MAL 01835
978-372-7471
M39r(iI.Y REPORT FOR TOWN OF
P-G�RD oF'
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BOARD CF IiEALTH
No.Andover, Mass. v(i
• SUBSORFACE'DISPOSAL DESIGN CHECK LIST
w�S lD�f,E➢ ��1�, �'w�vi� �- X y
APPROVED DATE DISAPPROVED DATE!„
Provided: Reasons:
to
Title V FAIL OK
Reg 2.5
Reg 6
Reg 10.2
Reg 10.1
t 11 emy 5
LOT � -z�
15 a �, v o� 6 6
v
The submitted plan must show as a minimum:
a) the lot to be served-area,dimensions lot #, tters
b location and log deep observation hoes -distance to ties
c location and results percolation tests -distance to ties
d design calculations & calculations showing required leaching area
e) location and dimensions of system -including reserve area
f) existing and proposed contours
g) location any wet areas within 100' of sewage disposal system or
disclaimer -check wetlands mapping
h) surface and subsurface drains within 100' of sewage disposal
system or disclaimer
;i) location any drainage easements within 1001 of sewage disposal
system or disclaimer -Planning Board files
j) known sources of water supply within 200' of sewage disposal d
system or disclaimer
k) location of any proposed well to serve lot -1001 from leaching facility
;1) location of water lines on property -3.01 from leaching facilitjr-
;m) location of benchmark
;n) driveways '
;o) garbage disposals
p) no PVC to be used in construction
,q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r) maximum ground water elevation in area sewage disposal system
;s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Septic Tanks
a) capacities -15M6 of flow, water table, tees, depth of tees,
access, pumping
b) cleanout
c) 10, Brom cellar wall or inground swimming pool
d) 251 from subsurface drains
Distribution Boxes
a) slope greater UMM 0.08
b) sump '
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Department of Environmental Management/ Division of Water Resources
WATER WELL COMPLETION REPORT
WELL LOCATION
Address ."?, ( V -
—1 of /, 1, 1 1), ( V
City/Town /%4i-
G.S. Quadrangle Map
Grid Location
Owner IVr , 141),;
Address 1Z SIL. Ar,
WELL USE
Domestic g PublicE] Industrial E]
Other
Method Drilled —Rata
Date Drilled
CASING
Length Diameter -
Type V, -d Ir, //,.
STATIC WATER LEVEL
Feet below land surface
Date measured W
GRAVEL PACK WELL
Yes n . No to I
WATER QUALITY TESTS MADE
Chemical El Biological 1:1
CONtOLIDATED WELL
Type of Water -bearing Rock Cn? �,l
Water -bearing Zoryps
11 From J4 A To
2� From 0 1) To
3) From—Tq
4) From To
Depth to Bedrock
UNCONSOLIDATED WELL
Water -bearing Materials
Sand:
fine medium [I
coarse[]
Gravel:
fine medium[]
coarse[]
Screen:
Slot #
length_from_to_
Split Screen (or 2nd screen)
slot#
lenqth—from—to
Depth To Bedrock
PUMP TEST
Drawdown —feet after pumping_ days_hours at GPM.
How measured Recovery—feet after hours.
0
LOG of FORMATIONS COMMENTS: (On well or water)
Materials From To
1 1, A
DRILLER
Firm A --C� ("r
Adclress--2�
City ::h- , !- �-*,,,A,
Registration No- U -�
n-4 --" -
Operator's _Signature
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: lot►
S+,
D. 14AL6kil
Owner's Name:
Owner's Address:
Date of Inspection:
—/o -,o Z --
Name of Inspector: (please print) ,1L)hil L l Voireum
Company Name: S
Mailing Address: 2.0 5o. i
�r
Telephone Number: q 7 & - 3,72
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
t/ Passes
Conditionallv Passes
Inspector's Signature:
by the Local Approving Authority
Date: -1G o z
The system inspector shallfsubmit a copy of this inspection report fb the Approving Authority (Board of Health or
DEP) within 30 days of mpleting 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.
Notes and Comments
tiT::da'd 0 q iN AN>�
pOp.;xrW 0� ALT
****This report only describes conditions at the time of inspection and under the coLerlFeBF-salmetor
* at
time. This inspection does not address how the system will perform in the future un differe t
conditions of use.
d
Title 5 Inspection Form 6/15/2000
page I
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection: —
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
V r1have not found any information which indicates that
any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
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.
Answer yes, no or not determined (Y,N,ND) in the
explain.
for the following statements. If "not determined" please
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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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):
broken pipe(s) are replaced
obstruction is removed -
ND explain:
1�I
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /to CIkrlv 67'.
o. �i e.
Owner:
Date of Inspection: — — 0,7
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 Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect pudic healih, 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
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 (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.
_ 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 coliform
bacteria and volatile organic compounds indicates that the well is. free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
}
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate "ye4" or "no" to each of the following for all inspections:
Yes No
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
1 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
c''/s
cesspool
Riquid depth in cesspool is less than 6" below invert or available volume is less than day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
— � water supply.
ratty portion of a cesspool or privy is within a Zone 1 of a public well.
ny 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 laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No) 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: , _ . V
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to.each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
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 Area — IWPA) or a mapped
Zone II of a public water supply well 4.
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: A9 6 —416, ,
Owner: Lo//��
Date of Inspection:
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
_ 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 ?
t/— Were as built plans of the system obtained and examined? (If they were not available note as N/A)
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 ?
_4_ 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 ?
6he_ 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:
. _ ._. .. .. _ .F ..., I _.
Yes �o '
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) (3 10 CMR 15.302(3)(b)]
n y
Page 6 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: % 6 het ' '.
Owner: k1_160
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): __ Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents: -A--
Does residence have a garbage grinder (yes or no)NO
Is laundry on a separate sewage system (yes or no) [if [if yes separate inspection required]
Laundry system inspected (yes orno):
Seasonal use: (yes or no)Ha 11
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no) -IV 0
Last date of occupancy: 0 e(,, n t -r C4
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no): _
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: 2 D U D iia +-,t 2
Was system pumped as part of the inspection (yes or no):
If yes, volume pumped:/ -00 -- How was quant ty pumped determined? 1 } C
Reason for pumping: N SV -Q C j'��(N 1L
r
TYP F SYSTEM
_ySeptic tank, distribution box, soil absorption system
_ Single cesspool
Overflow cesspool
— Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
_ Tight tank _ Attach a copy of the DEP approval
Other (describe):
Approximate age of a compo ent date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no)�%�
6
tt 4
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Z -/h v f;
Owner:
Date of Inspection: T -la 7 --
BUILDING SEWER (locate on site plan)
�i
Depth below grade:
Materials of construct "ion: t iron _40 PVC _other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: _ (locate on site plan)
/l
Depth below grader
Material of construction: _concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions:.- .5' X 5 � y- 16,6
Sludge depth: u
Distance from top of� Judge to bottom of outlet tee or baffle:.)-
Scum
affle:Scum thickness: /—
Distance from top of scum to top of outlet tee or baffle: n
Distance from bottom of scum to bottto of outlet tee or baffle -7-9
How were dimensions determined: I etd2e- iM45y ✓` L
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as relat�e to outlet invert, evi ence le a e, etc.):
� �rU c� , . 7� e5 6 tC NO STU uc r C�ctL 18Q rn&� t.L
GREASE TRAP: _(locate on site plan) r i
Depth below grade:
Material of construction: _concrete _metal _fiberglass 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:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of I 1
4
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: D L,,
0. t
Owner:
Date of Inspecti r : —
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions: U
Capacity: gallons )
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: I/ (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 o,of box, etc::
1)a Sail ( irk Utter & vaL- dlCT-
PUMP CHAMBER: l/ (locate on site plan)
Pumps in working order (yes or no): tis
Alarms in working order (yes or no.
Comments `note condition of p p chamber, condition of
o r4T S �}�v ,!/v rx�0 1,0
poo act lea -1 e0wP
8
C�nm oat
r
. •4,
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
/D
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not -required)
If SAS not located explain why:
Tvme
leaching pits, number:
G
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
0 f -Y v1 W a'j t C- Gt t tr U
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
N i2l f f
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 or no):
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.):
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: / U
Owner
, Z19AI6 1-2
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
(-9
qJ '7'6 SeTl�
P r4N IC
o vei\ 1D00 ' 'from P1 tS
10
00L3
(-9
qJ '7'6 SeTl�
P r4N IC
o vei\ 1D00 ' 'from P1 tS
10
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: Ii(/
.76
Date of Inspection: Z_
fF
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet'{
Please indicate (check) all methods used to determine the high ground water elevation:
_j,e'6btained from system design plans on record - If checked, date of design plan reviewed:
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)
Accessed USGS database -explain:
You,mmust describe how you establi ed\the high ground w tgY elevation:1 4C N,66ZAV le -AQ
i