HomeMy WebLinkAboutMiscellaneous - 1423 SALEM STREET 4/30/2018 (19) OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (continued)
Property Address: 1423 SALEM STREET, N. ANDOVER, MA 01845
Owner: MICHAEL & ELAINE MORGILLO,
Date of Inspection: SEPTEMBER 24, 2001
D. System Failure Criteria applicable to all systems:
You must indicate"Yes"or"No" to each of the following for all inspections:
Yes NO
X _ , Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
X _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
X------ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X__ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
X----- Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X----- Any portion of a cesspool or privy is within a Zone I of a public well.
X----- Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X----- 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.]
Y (Yes/No) The system fails. I have determined that one or more of the above failure criteria exists 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
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)
The design flow of system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
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 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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