HomeMy WebLinkAboutMiscellaneous - 1423 SALEM STREET 4/30/2018 (31) Commonwealth of Massachusetts
- W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 1423 Salem Street
Property Address
Courtney Scruggs
Owner Owner's Name
information is North Andover MA 01845 May 1 2017
required for ,
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El ® 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.
b 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.]
El ® The system is a cesspool serving a facility with a designfl
ow 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 followi , in addition to the
questions in Section D.
Yes No
❑ ❑ the system is wi to-400 feet of a su a drinking water supply
❑ ❑ the system is within 200 fee a_tributary to a surface drinking water supply
❑ ❑ the system is located " a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or apped Zone II of a publi6water supply well
If you have answered "yes"to a question in Section E the system is considered a significant threat,
or answered "yes" in Sectio above the large system has failed. The owner or operator of any large
system considered a sig ' cant threat under Section E or failed under Section D shall upgrade the
system in accordant ith 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage ge Disposal
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