HomeMy WebLinkAboutMiscellaneous - 1213 SALEM STREET 4/30/2018 (2) 1213 SALEM STREET
210/106.A-0119-0000.0
The o
�epNc Guys, HiQ.
P.O. Box 959
Westborough, MA 01581
Tel: (800) 240-2400 • Fax: (508) 366-6568
•.CC3JF�/ '
SGA^�GF HFF1i H
July 18, 2003
Town of No. Andover
Board of Health
27 Charles
No. Andover, Ma. 01845
Re: 1213 Salem Street,North Andover.
Dear Sir or Madam:
Enclosed please find a passing Title 5 Inspection for the property located at 1213 Salem
Street,North Andover, MA.
If you should have any questions regarding the enclosed please feel free to contact the
Title 5 Inspector, Garry Harmon, at 1-800-240-2400.
Thank Y/,
ricia a ovitz
he Se is G nc.
Encl: Title 5
A FULL SERVICE SEPTIC COMPANY
4li� N
COMMONWEALTH OF MASSACHUSETTS -
�'` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
V `
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:_/ Z l3 5,94 es) 5
Owner's Name:
Owner's Address: /!s
Date of Inspection:
Name of Inspector: (please print) f,q 12 7 G
Company Name:
Mailing Address
Telephone Number: Q(Z
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:
/,-�c Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fans
-Inspector's Signature:
Date:—2 7_�49 0—
The system inspector shall submit a copy this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this ' pection.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 officeDEP.The original should be sent to the system owner and copies sent to the buyer,iapplicable, and the app ovling
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 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: / ,5 h G z
rt f�/(i Do C',z t
Owner: w e dL l S L/9/d Sl�N
Date of Inspection: 7 - - G
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
1 303 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.septictank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than20 years old is available.
ND explain:
Observation of sewage backup'or breakout or high staticwater 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 inspecii6i if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
r
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:
2
•Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: ! Z! S ,,Py Lr/-t S
/V 01 i,/yn 44 A /-4
Owner: i- /e-L I S , L,q oe5oly-
Date of Inspection: 7 ;7- Zoo 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(l)(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
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 watersupply 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 indicatesthat the well is.free from pollution 5 'that facility gnd
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 s must b
e
attache
d to this form.
3. Other:
3
'Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: .ln. !G e- !S 4 2
Date of Inspection: - :!�:o 3
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 %2 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:l.of a public well.
Any portion of a cesspool or privy is within 50 feet ofa.private water supply well.
-re Any portion of a cesspool or privy is less than 100 feet but eater th
gr an.50.feet from a private
supply well with no acceptable w l water
p water quality analysis.{This system passes if the well water analysis,
performed ata 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 t 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 thefatlure
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,0.00 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
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:_) Z 13 L r2 5 T
Owner: -IV 2s&o"'
Date of Inspection: 7 - G 3
Check if the following have been done.You must indicate`yes" or"no"as to each of the following:
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 s
— _ ystem 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?
Jll�4 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 ?
_ 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 r
maintenance of subsurface sewage disposal systems?
The size and location of the-Soi1 Absorption System(SAS)on the,i6 has been determine s based otu u~ T xk
Yes
IV/nehxisting 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)]
I
5
Page 6.of 11
A
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION
Property Address: Z 13 `$4/ •
Al - 19/,eO v "-,09 -
Owner:
-i9 -
Owner: L.i/LL!S L f9/Z„5
Date of Inspection: ?- 7- Zp03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): `7
DESIGN flow based on 310 CI 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):,W [if yes separate inspection required]
Laundry system inspected(yes or no):—
Seasonal use: (yes or no):A/0
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):_,A10
Last date of occupancy:
COMMERCIAIJINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease
trap present es(Y or no):_,
Industrial waste holding tank presentes or no):
(Y _
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 /E ✓e-2 2 e A/ls O.ti G --.."V"e
Was system pumpedAs.partof the:inspection;(yes or no): G 5
If yes,volume pumped:.:.?S G allons—How was quantitypumped:determined? 00c., --t /0 T/?_lvGn
Reason forpumping:
WE OF SYSTEM
Septic tank,distribution box,soil absorption system
_
Single cesspool
� P
_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 a e of all components,date insta}ed(if known) and source of in rmation:
Were sewage odors detected when arriving at the site(yes or no):LV115
6
Page 7of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:- ZZ- / 3 S,9L C/-i S i'
Owner: /y/1 S o
AC
Date of Inspection: '?- 7- 71,d j
BUILDING SEWER(locate on site plan)
rc
Depth below grade: z
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SOs.v�S /y248!:�a.r �=Q dt '5- D vG ^e CS 00)0 /✓D G 4`"'49
SEPTIC TANK:_(locate on site plan)
Depth below grade: I �1
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) % I i
Dimensions: L 'k S c,. X-5-- P
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 3 �q
Distance from top of scum to.top of outlet tee or baffle: _
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:. TA176 /%1eog 5 44f e, ,y, J SL L'4o Z-C- i01
Comments(on
pumping recommendations,inlet and outlet.tee or baffle condition;structural integrity,liquid levels
as related to outlet invert,evidence of leaks e,etc.): _
//"Z-, T i/L/TRG S7,241LTv-24
44 Q a, TU O v X L'.T
GREASE TRAP::.(locate on site plan)
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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: I Z 13 s /5' LC e- -5 i
Owner:
Date of Inspection:—7_2- Z UG F
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: IAlarm in working order(yes or no):
Date of last pumping'.
Comments(condition of alarin and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site pian)
Depth of liquid level above outlet invert: d
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.): _
t'lle-1 f-
100,
PUMP CHAMBER: (locate on site plan)
` .umps;,in working order(yes or no);_
Alarms in working order es or no)::_
Comments_(not e condWon:of pump°chamber,condition of pumps and appurtenances,etc.):
8
v
Poue.9 of I i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: I Z/3 ,S 4 G eft Si
/Y - /9/v QG vC"C
Owner: 5 444,SoN
Date of Inspection: 2. 7 - ZUG
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type /> ,y ( R G "0"
leaching pits,number: �
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
'LC leaching fields,number,dimensions: 5-0 LGlvL X w'overflowcesspool,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.):
O /yYU•2C,�t� Lc/2�
SG/� a of n AT
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:.
Depthof 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.):
=s. 9
f
Page10of11 ..
OFFICIAL INSPECTION.FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /Z /
Owner:
Date of Inspection: 7- ZOO 3
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.
S T 2e��c /
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3I J
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10
1}aaellofll
' OFFICIAL INSPECTION FORM_—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: I Z !.3 S fi G,6/1 5 T_
Owner: S
Date of Inspection: 7 - ? - 76t,-i
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water G 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)
Accessed USGS database-explain:
You must describe.how you established the high ground water elevation:
f x"o 0_5 D /Z e_" • 7-0 i3 0/i li 17
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WATERBILLINC' HISTORY 3160400-LARSON� WILLISA. MET
ER #1. 3160400 Copy
1213 SALEM ST dhdl
0
CYCLE SERUICf PRIOR CURRENT USE WATER SEWER FEES TOTALAng
4�
1 2000-13 09/13/1499 472 494 22 60.06 0.00 0.00 60.06
E2 2800-23 01/10/2000 494 517 23 62.79 0.00 0.00 62.79 L'
xec 3 2000-33 03/29/2000 517 539 22 60-06 0.00
4 2000-43 06/13/2000 539 561 22 60.06 0.00 0.00 b0.0686 60.96rE32
S 2001-13 09/11/2000 561 585 24 65.52 O.AO 11.00 76.52
6 2007-23 01/18/200-1 0 12 12 32.76 0.00 11.00 43.76
r r 7 2001-33 A3/22/2001 12
Shortc 28 16 43.68 0.00 11.00 54.68
Pr"I 8 2001-43 06/18/2001 28 47 19 51.87 0.00 11.00 62.87 =� `N
9 2002-13 08/28/2001 4'7 b4 17 41.99 0.00 5.5S 47.54 .
Ile 10 2002-23 01/251200?_ 64 OWN
98 34 83.48 0.00 5.55 88.53
11 2002-33 04/08/2002 98 116 18 44_46 0.00 5.55 50.01
ouch 2002-43 06/13/2002 116 127 11 27.17 0.00 5.55 32.72
Expr11 2003-13 09/30/2002 127 145 18 42.84 0.00 5.97 48.81 . ..
;. 14 2003-23 12/14/2002 145 158 13 30.94 A_00 5.97
15 2003-33 03/1O/2OA3 36.91 osoll
I 158 180 22 S5.20 0.00 S.97 61.17 ord
16 2003-43 116/09/2003 180 202 22 SS.20 0.00 S.97 61.17
Netw
Nriyhl"REVIEW CHOICE. 8 01' <FNTER> FIORE HISTORY:
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Start 2U Telnet- 10.1.71.55
l�`� .AN14 9:37 AM
('rnnntonw All uXMassachusetts
Massachuscits
"F stem Pumping Record
System Uwner System Location
L
)ate of Pumping: ' f i Quantity Pumped: 16 gallons
Cesspool: No 1.4 Yes L.) Septic Tank: No Yes
#
Pumped �d
License
System ! upped Uy. t5at'eQo�t
Contents transferrred to : areater Lawrence Sanitary District
Date: _ Inspector:
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