HomeMy WebLinkAboutMiscellaneous - 1469 SALEM STREET 4/30/2018 (2) J
TOWN OF NORTH ANDOVEP,
/1 11 SYSTEM PUMPINQ Rl?CoR.D
SYSTEM 0 IER;& A�DDRIE35S SYSTEM LOCA 1 JUN
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COMUION OWEALTH OF MASSACHUSETTS
I EXECUTIVE OFFICE"bF.ENVIRONMENTAL AFFAIRS
Gly; 5-,PEPARTI 1" T OF.:ENVIRONMENTAL PROTECTION
O�.E �11'�TER STREET BOSTOtv.. MA 0?108 61.i '92 i.500
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ARGEO_PAUL CELLUCCI __ DAVID B.STRUHS
Lf.Gov'emor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
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CERTIFICATION
r Property Address:` Address of OwnerOL" (` /
Date of Inspection: (If different)
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Name of Inspector: t%
' I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: ` ?"ct-? ,
Mailing Address: "� (KA 14 ' }� S �*e�a�..<
Telephone Number: 'y .~, 7 ? ,
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes .
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails �t
Inspector's Signature: Date: /
The System Inspector shall submit a-copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure..criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS: d
y�
B] SYSTEM CONDITIONALLY PASSES: _
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. h'e system, upon
F ! completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination.in all instances. If"not determined", explain why-not.
The septic tank is metal,.unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septiwtank is replaced with a conforming septic tank,-
as approved by the Board of Health. A,
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web http:/twww.magnet.state.ma.us/dep
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)'
Property Address:. Q► ,,r7 ® � ° -
Owner: �(
Date of Inspection:
q B].SYSTEM CONDITIONALLY PASSES(continued)
r Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
or due to a-broken settled or uneven pipe(s) u e en distnbuUon box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
P PPe are re
broken i (s) laced
�•
t' obstruction is removed
distribution box is levelled or replaced
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The system required pumping more than four times ayear 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 .-
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obstruction is removed
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 the
t; public health, safety and the environment.
SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
•s WHICH.WILL PROTECTTHE PUBLIC HEALTH AND SAFETY,AND THE ENVIRONMENT:
f+
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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
x;—The system has a septic tank and soil absorption system (SAS) and the SAS is within,100 feet to a surface water supply or
tributary to a surface water supply.
y — ;The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
<The system has a septic tank and'soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
pnvatewater supply-well unless a well:watecnalysis for coliformacteriaand volatile:organic compounds=indicates.chat
W ' the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
�rTn
less than 5m. Method used to determine distance
,.... PP (approximation not valid).
3) OTHEV
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1, (revised 04/25/97) '`•
,� Pape 2 of 10
~• A, '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
r Date of Inspection:
DJSYSTEM FAILS:' t
You'rnust indicate either "Yes"' or No as to each'of the following;,.
" I.have determined that'the system violates one or more of the following failure criteria as defined in 310 CMR 15:303. The basis
'for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure:
' Yes No
Backup of sewage into facility or system component:due to an overloaded or clogged SAS or cesspool
_ Discharge or ponding of effluent t0he surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool. -tA
sCr,
Static liqu d'level m the d s ribution 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
I _ _ Any portion of. a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply,
r'
!Any portion of a cesspool'or privy is within a Zone I of al 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
i
E] LARGE SYSTEM FAILS:
t You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The s stem serves a facility with a desi n,flow of_10000
Y f „g pd,or greater (Large System).;and�the system,is a sign ficant_threat to
public health and safety"and the environment.because one 6i 'More of the following conditions exist:
# Yes` No
echesystem is within 400 feet of a surface drinking water supply
E
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 Il of a
public water supply well)
The owner.or operator of any such system shall bring the system and facility into full compliance with the'groundwater treatment program .
requirements of 314 CMR 5.00 and 6:00. Please consult the local regional office.of.the Department for further information. )
taw' 11
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(revised 04/25/97)
.Page 3 of 10
3;_
rlkSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
s PART B ,
. CHECKLIST ,
Property Address: . . .
Owner:
Date of Inspectionj •
l
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: .
Yes No
w, ;l Pumping information was provided'by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water havenot been introduced into the system recently or
as part of this inspection'.
—/' — As built plans have been obtained and examined. Note if they are not available with N/A.
VR — The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
e The site was inspected for signs of breakout.
F All system components, excluding the Soil Absorption System, have been located on the site.
— .—The septic tank manholes were uncovered opened, and the interior of the septic tank was inspected for condition of f
f baffles or tees, material of:construction, dimensions, depth of liquid, depth of'sludge; depth of scum.
[ The size and location of the Soil Absorption System.on the site has.been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
j. Existing information. Ex. Plan at B.O.H.
Determined in the field (if an of the failure criteria related to Part C is at issue, approximation pproximation of distance is
unacceptable)-[l 5.302(3)(b)]
. . ' � fie ` ' `� i. t•, ,,.. ,,.
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(revised 04/25/97) Page 4 .of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r;. .
PART C
SYSTEM INFORMATION
Property Address:
Owner.
Date of Inspection: ,.
} FLOW CONDITIONS
RESIDENTIAL
Design,flow: e p /bedroom for S.A.S.
Number of bedrooms
# ' Number.of current residents: ,
Garbage grir.der (Yes or no).- Q { l
Laundry connected to system 1yes or no) y l
Seasonal use (yes.'or no): °
Water meter readings, if available (last two (2) year usage (gpd): t
Sump Pump (yes or no):
34 ,
Last dA:'of�occupanc};
f
COMMERCI.AUINDUSTRIAL: h;
Type of establishment:
Design flow: gallons/day
x Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: Ives or no)
t' Non-sanitary waste discharged to the Title 5 system: (yes or.no)
Water meter readings, if available:
/ ,o cupancy:
Last,date of
b
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st�' OTHER:;{Descnbe,
t" Last'dat0 of occupancy.'
GENERAL INFORMATION.
PUMPING RECORDS and source of information
i
System pumped as part of inspection: (yes or no)_
If yes,,volume pumped:, allons
y7 Reason<foi:pumping _!"A CCL
TYPE os Eng
Septic tank/distribution tox/soil absorption system h ;
r' Single cesspool
a.. Overflow cesspool
r ,.
Privy :
r Shared system (yes or no) (if yes, attach previous inspection records, if any)
3 I/A Technology etc. Copy of up to date contract?
Other.
{ APPROXIMATE AGE of allcomponents, date installed (if known) and source of information: 2!zt,e/y
i
aSewage odors detected when arriving at the site:.(yes or no):'
F;".
+: (revised 64/2S/97) Page 5 of 10
7^ f
"' t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) 3
'. Property Address:
., 6 � °' ►
f° Owner:
{1, Dateof Inspection
TIGHT OR HOLDING TANK; (Tank must be pumped prior to, or at time; of inspection).
(locate'on-.site plan)
Depth below grade:
Material of construction: concrete - metal Fiberglass _Polyethylene other(explain) 1
I
Dimensions:
Capacity: gallons � f°
DeSlgnlOvr; y. gallons/daV ..s x y r.' �� '14
Alarm level Alarm in working order_Yes; No
Date of.previous pumping: !i
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
3s , DISTRIBUTION B'OX:
P�
(locate on site"plan).:
K Depth of liquid level above outlet invert:- �
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
5 x P .cd O 000-1 t0S
PUMP"CHAMBERi
(locate;on site lar
Pumps in working order, (Yes or No) f
::. nw n r rN
'Alarms 1 ork� g o der (Yes.o o)
Comments: :;
(note condition,of pump chamber, condition of pumps and appurtenances, etc.)
i-
(revised04/25/97) Page 7 of 10
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$ SUBSURFACE SEWAGE DISPOSAL;SYSTEM INSPECTION FORM
PART C'
SYSTEM INFORMATION (continued)
Property Address (
Owner:
� f 4
Date of Impectionc
SKETCH.OFSEWAGE-DISPOSAL:SYSTEM:
include ties to at least two permanent.references landmarks'or benchmarks
locate all wells within .100'
`�, 1. ' .: '• -( - � ` -'!,
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yi . '`t ! - i• 666"',
DEPTH TO GROUNDWATER
Depth to groundwater: feet'
method of determination or approximation:
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(revised 8/15/9.5) : 9
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address . eA
Owner: _.
Date of.Inspects n: 7
Depth to Groundwater Feet E.
a Please indicate all'the methods,used to determine High Groundwater Elevation:
Obtained from Design,Plans.on record .
! Observation of Site (Abutting property,observation hole, basement sump etc.)
fLof Determine it from local conditions
�w V.
Check with loc4l"Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
-
Use USGS Data "n
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' DescnbYe in'�our own words how you establishedhe'High Groundwater,Elevationy'(Must be completed) •.;
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SYOhfteiPumping Record
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DEP,.has provided thts form for use by local Boards of Health. Thtqeee SS
be submitted to the local Board of Health or other approving authorit�y,r l ecor must
A. Facility Information
JUN
4. 2007
�-lmgortant.
out
forjns On 1' System t.ocation i�,gFTH ANDOVER
COrrlputer,USAEALT _. ARTI�ENT
only the tab key Address
to move your ��. t �2.�f�,�✓
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usa th CI /Town
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Fr. Name
Addreaa(If different from location)
�� Clty/Town.
Y State Zip Code
Telephone Number
',t g,'PgMp,ng Repord.
r•� Data of Pumping ' oats - 2. Quantity Pumped; d�U
Gallons
3, Typo 4f system, ❑ Cesspool(s) eptic Tank ❑ Tight Tank
/
:Other des I
( cr be); .
4 Effluent Tee Fliter present?..❑ Ye o' If yes, was It cleaned? ❑ Yes ❑ No
f yr
N r 6 ;Condition of Systgm;`
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