HomeMy WebLinkAboutMiscellaneous - 1072 JOHNSON STREET 4/30/2018 (3) 1 �
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TOWN OF N RTH ANDOVEP,
U^rt �� . �".(� SYSTEM P P1Np RP.COFZD JAN
SYSTEM OWNER dt ADDRESS
SYSTEM LOCATION
I
DATE OF PUWNQ:_ , -'. _.._QUANTITY PUMPED;
CtSSPOOL: NO__..._.....YES„ ...... Soptic Tank: NU, YDS L!
NA rVKE OF SERV 4
It,6. KUU'flNk„._ _ �MRRUEaN( 1'
UkiSBRVA('1ONS, ,
GOOD CONDITION FULL To COVER �
HEAVY ORBASB BAPFL83 IN PLACC.
ROOTS LEA.CF{RBLD RUNBACK
6XCUSiVE SOLIDS—. FLOODED
SOUDCARRYOYER,_.._,OTHER EXPLAIN
Sy.t.m Pump,d by _. ...... bG,.. ,. ..
_�Q.._.cSa r'vic�
VUMMENTS.
,-:VN PEN'I'S rKANSF'ERRBL) I't)
RECEIVED
........
FEB 0 2 2005
TOWN OF NORTH ANDOV R HEALTH DEEPARTMETOWN 05 NORTH �NTER
uA 1�r.
SYSTEM PUMPING} RI~COR .
SYSTEM OWNER M ADDRESS SYSTEM LOCATION
A9 7a -
DATE OF PUMPiNQ; IaANTITY P
_._..._..__,.........__.._....___..._Q LIMPED:
CtsSPOOL: NYES.. ....... Snptic 1'enk: NU
YES'
NA rURE OF SERVICE: ROU'fI.NE _ _ EMI✓RUENC'1'
OBSERVATIONS:
GOOD CONDITION PULL.'T`U COVER
FBAVY ORF.1ISE w BAPFLBS 1N PLACE.
ROOTS
LWMELD RUNBACK
BXCESSiVE SOLIDS— -- FLOODED
SOLID CARRYOVER._....._.OTKER EXPLAIN
Sy.tfm Pumpcd by
q7/ 177a.
VUMMENTS.
'-'UN I t~N I'J fKANSF'ERRfiD 11)
Jvlly Uh i ANL' /
it 0r 'AEALT
TOWN OF NORTH ANDOVER NU. .. 4 20,
SYSTEM PUMPING R_EC0U
I E Y7 UwNER & ADDRESS SYSTEM LOC.aTION
��CsCf (`x�mPle cfl front of hn
E OF PUMPINC:J % — (QUANTITY PUMPF /o�i `- - - -
�')I'OOL. NO
YES SEF'TIC' TANK : NO YE
J`.
A-I*URE OF SERVICE: ROUTINE �� EMERCENCY
C;OOD CONDITION I,'ULI TO CU `,,
HFAVY CREASE �AFFLES IN
ROOTS LEACHFIEL D
EXCESSIVE SOLIDS FLOODED -
SOLIDS CARRYOVER O.;HFR (EXPLAIN ;
I LM PUMPED BY 77
TS
� �, I l.'-N I'S TIZANSFEIZIZLD TO
Town of North Andover
Health Department Date:
Location: 1 /�I
(Indicate Address, if Resi,,4 tial,or Name o sine`s
Check#.
Type of Permit or License:(Circle)
➢ Animal $
➢ Dumpster $
➢ Food Service-Type: $
➢ Funeral Directors $
➢ Massage Establishment $
➢ Massage Practice $
➢ Offal(Septic)Hauler $
➢ Recreational Camp $
➢ SEPTIC PERMITS:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC)$
❑ Septic Disposal Works Installers(DWI) $
➢ Sun tanning $
➢ Swimming Pool $
➢ Tobacco $
➢ Trash/Solid Waste Hauler $
➢ Well Construction $
➢ OTHER:(Indicate)
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
Commonwealth of Massachusetts RECEIVc:D
W Title 5 Official Inspecti®n Form MAY 2
° Not for Voluntary Assessments 2006
r� Subsurface Sewage Disposal System Form TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Inspection results must be submitted on this form or on the official Title 5 Inspection Form date
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
Important:
When filling out 1. Property Information:
forms on the
computer,use 1072 Johnson St.
only the tab key Property Address
to move your Linda Soucy
cursor-do not Owner's Name
use the return
key. 1072 Johnson St.
Owner's Address
N. Andover ma 01845
r1A� Cityrrown State Zip Code
IIS Date of Inspection: Date 6
Date
2. Inspector:
Robert Kimball
Name of Inspector
R. Kimball Excavation LLC
21 Clifton Ave
Company Address
Salem NH 03079
City/Town State Zip Code
978-375-1011
Telephone Number
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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Fu hervaluti , t Local . Ing Authority
fR�&Z 4 a G0
Inspec is Signature Date /
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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 Inspection Forms Soucy.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
N. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
1072 Johnson St.
Property Address
N. Andover MA 01845
City/Town State Zip Code
Linda Soucy 4-29-06
Owner's Name 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.
Answer yes, no or not determined (Y, N, ND) in the ❑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.
ND Explain:
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
. Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
1072 Johnson St.
Property Address
N.Andover MA 01845
Citylrown State Zip Code
Linda Soucy 4-29-06
Owner's Name Date of Inspection
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
❑ 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:
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
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
. Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
1072 Johnson St.
Property Address
N. Andover MA 01845
City/Town State Zip Code
Linda Soucy 4-29-06
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (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:
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
. Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
1072 Johnson St.
Property Address
N. Andover MA 01845
City/Town State ZipCode
Linda Soucy 4-29-06
Owner's Name Date of Inspection
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
❑ ® 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 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.
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5of16
. Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Not for Voluntary Assessments
y` Subsurface Sewage Disposal System Form
A. Certification (cont.)
1072 Johnson St.
Property Address
N.Andover MA 01845
City/Town State Zip Code
Linda Soucy 4-29-06
Owner's Name Date of Inspection
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 I5rotection
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.
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposat System
Page 6 of 16
. Commonwealth of Massachusetts
a Title 5 Official Inspection Form
a Not for Voluntary Assessments
y` Subsurface Sewage Disposal System Form
B. Checklist
1072 Johnson St.
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Linda Soucy 4-29-06
Owner's Name 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?
❑ ® 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(3)(b)]
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
. Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
1072 Johnson St.
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Linda Soucy 4-29-06
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents:
1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? `•®.'Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: ocupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Not for Voluntary Assessments
` Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
1072 Johnson St.
Property Address
N. Andover MA 01845
City/Town State Zip Code
Linda Soucy 4-29-06
Owners Name Date of Inspection
General Information
Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ❑ 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 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):
Septic tank, one leacing trench, no distrubution Box
Approximate age of all components, date installed (if known)and source of information:
40+/-
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
`a Subsurface Sewage Disposal System Form
p Y
C. System Information (cont.)
1072 Johnson St.
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Linda Soucy 4-29-06
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: city
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: 750 gal round
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle
48"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
1"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? field observafron
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspecif6A f=orm:Subsurface Sewage Disposal System
Page 10 of 16
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
r` Subsurface Sewage Disposal System Form
C. System Information (cont.)
1072 Johnson St.
Property Address
Andover MA 01845
City/Town State Zip Code
Linda Soucy 4-29-06
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
System is in fair condition
Grease Trap(locate on site plan):
Depth below grade:
feet
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:
Date
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):
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
1072 Johnson St.
Property Address
N. Andover MA 01845
City/Town State Zip Code
Linda Soucy 4-29-06
Owner's Name Date of Inspection
Tight or Holding Tank(cont.)
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.):
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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 working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
_ Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
1072 Johnson St.
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Linda Soucy 4-29-06
Owner's Name Date of Inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1/30'
❑ 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.):
Dug hole next to trench stone and soil dry.
Title 5 Inspection Forms Soucy.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
1072 Johnson St.
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Linda Soucy 4-29-06
Owner's Name Date of Inspection
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 ❑ Yes ❑ 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.):
Title 5 Inspection Forms Soucy.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 14 of 16
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
1072 Johnson St.
Property Address
N. Andover MA 01845
City/Town State Zip Code
Linda Soucy 4-29-06
Owner's Name 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.
0�-c
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 15 of 16
,. Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: -S/
✓C��/lun2� `S/
Owner: ;Sc�"/C,�
,d/CJ�i"7Y
Date of Inspection: L 'D cy
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.
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DAM NO MMER 11, 2004
10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
a` Subsurface Sewage Disposal System Form
C. System Information (cont.)
1072 Johnson St.
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Linda Soucy 4-29-06
Owner's Name Date of Inspection
Site Exam:
Slope O- 3�,
Surface water J S r
Check cellar (��y -Np
Shallow wells N3QYo-__
Estimated depth to ground water:
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: Date
❑ 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:
USDA Northern Essex
You must describe how you established the high ground water elevation:
Set up Laser and took elevations of pond and botom of SAS. N)a "o le V")V_Cr
Ory W iA\, Eav'A� 4, Ccjo cg . S6 k
Title 5 Inspection Forms Soucy.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
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.ober-t E.' Minbal-I Sri.
ma,s smisfied, the Depar4iient's .qualificatioas• as required- and is hereby
authorized to use the, .tide
CERTIFIED TITLE S SYSTE t• INSPECTOR
as provided' 3 100 C—MR J 5 340• and Section 13 of Ch,ptet 21 A of the
iin
General Laws.. ZSsued by '1' e Departinerat of Enviiroxuezatl Protection.
June 12, 1995
0611& Direc6r•of the. -,Uri U,t Wme'r Polliitioll Control
' r
R. COMMONWEALTH OF MASSACHUSETTS
4ID EXECUTIVE OFF OF ENVIRONMENTAL AFFAIRS
DEPARTMEN OF ENVIRONMEN punmr�IV
° RECEIVE
JARS 97
2005
.)F NORTH ANDOVER
HEALTH DEPARTMENT
TITLE 5
OFFICIAL INSPECTION RM-NOT FOR(VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: /07A T7-o& sney S T
,LlOA,?Zf Aay�Ioy��
Owner's Name: So!>C.y
Owner's Address:
Date of Inspection: /2 3[9 ZO-V
Name of Inspector: (please print) ,62wfW Fi4l2M�'
Company Name: ItVI! 57,01•
Mailing Address: G(,rs=S TZJst/ 5 T
Telephone Number:
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:
1,-'Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: //7-
The
zThe system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system 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
****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 Inspection Form 6/15/2000 page I
' %94 of 11. _
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OFFICIAL INSPECTION FORM—N0T FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
DART A
CERTIFICATION (continued)
Property Address: TDPl$AVS L ST
d 7f
Owner: SCJ L y
Date of Inspection: /L j
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
1
A. Sy tem Passes:
r
]^have not found any information which indicates that any of the failure criteria described in 310 CMR
1537 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
omments:
s YS r�/Y) /A/ T70&
B. Syst m 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 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 infiltrdtion 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:
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: /19Z2 % 0/// 900) Sl
/UlJ/L� ,Od?11�2.
Owner• so
Date of Inspection: 1A 3
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
I--
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:
3
!S
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: �702 S(`)I�/G�SO�II S
Owner:
Date of Inspection: U p�
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
_A�//9 Liquid depth in cesspool is less than 6"below invertor available volume is less than'/s day flow
_ _✓Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped .
_ y"'� portion of the SAS,cesspool or privy is below high ground water elevation.
_�l/ 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 coliform bacteria and volatile organic compoaeds
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.]
�v v(Ye o)o) he system fails. I have determined that one or more of the above failure criteria exist as
Uest ibed 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: //tstem
To be considered a large syste 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 11 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.
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1072 U-e?& SOA) ! /
Owner: sc)
Date of Inspection: i� 3 (�
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 C$j�wrr�y'S
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?
I1 Have large volumes of water been introduced to the system recently or as part of this inspection?
A11-4' Were as built plans of the system obtained and examined?(If they were not available note as N/A)
V_ Was the facility or dwelling inspected for signs of sewage back up
V0000' 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:
Yes no
!�/+G 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)]
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: S'O 0 r V
Date of Inspection: /L O
FLOW CONDITIONS
RESIDENTIAL
.Number of bedrooms(design): Number of bedrooms(actual): .3 7 'x3 _ / 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): / / T/
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yep or no):W [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): W
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy: 2 /T'
COMMERCIAL/INDUSTRIAL AV1j4
Type of establishment:
Design flow(based on.310 CMR 15.203):_ gpd
Basis of design flow(seats/persons/sgft,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: ST WA449-7'5
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: gallons--How was quantity pumped determined? ,Ui9-tiF � 11S7� i9-�
Reason for pumping: 'A1 n4"/.y L i/V SAE
TYPE OF SYSTEM
OF
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 all components,date installed(if known)and source of information:
06 2!KS
Were sewage odors detected when arriving at the site(yes or no): Y
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* A I�age 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /r32,2 nolflUSenV ST
Owner: Sa t/G y.
Date of Inspection: le-V
BUILDING SEWER(locate on site plan)
Depth below grade: /8
Materials of construction: vcfast 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:V(locate on site plan)
Depth below grade: /Z 1(
Material of construction:_ crete_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: '4(0p'('o 1 X
Sludge depth: 12 A
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: " A
Distance from top of scum to top of outlet tee or baffle:—q n
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan) N�
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.):
7
•Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: (/
Date of Inspection: L O4
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/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: !/ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: d it
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
D LZ D-,60X -- /--L-oW Q(//¢t-/ 7-,f- oy1�
PUMP CHAMBER: ocate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
'Page 9 of I 1
/ P �
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ IQ; v'01VX4r6WST
Owner: C L/
Date of Inspection: L a
JF
SOIL ABSORPTION SYSTEM(SAS):A61ocate on site plan,excavation not required)
If SAS not located explain why:
Type
- leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
_k/-Teaching trenches,number, length: Z 7
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.):
CESSPOOLS:xil `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(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: ocate 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.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DLSPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ /e;)') ✓�� iL�n21 �/
Owner:
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.
A0 — '
34.2'
IIF. CAR 15.6
072 PORT
22.2
JOHNS
STREET
PL" of Lr AIVD
1N
NORTH AJ00 VER, MASS.
PREPARED MR OF Ad--
MMA soUcY
1072 JOHNSON STREET �' 1-4
NORTH ANDOVER MASSACHUSE77S 01845
DATE: NOVEMBER 11, 2004
10
3
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /6 7,�2 7,)/
Owner: SOUC t/
Date of Inspection: 2 O
SITE EXAM
Slope O 3 0
Surface water 3, !
Check cellar v— aO PUMP
Shallow wells > S--�
Estimated depth to ground water Y,,5 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained 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)
_L.-Accessed USGS database-explain: 4
You must describe how you established the high ground water elevation:
))o � i �f d z Zr-z- �_ A%.�/4Gr/A//, �5AAn.//. .5'OZ L h A
Ra-_1 1(/i T` C`ne_0"ZS SOT L_ S !_'*44261VIV C-6C ;>C 5�A.
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