HomeMy WebLinkAboutMiscellaneous - 164 MILL ROAD 4/30/2018 (3) '�
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` COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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DEPARTMENT OF ENVIRONMENTA_ L P_RO_T_E_CTI_ON
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NOV 2 6 2003
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TITLE 5 --
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:_164 Mill Road_✓ _
_North Andover_ L
Owner's Name:_Derek Rhodes_
Owner's Address:_164 Mill Road_ _ .L
_North Andover,MA 01845_ ��
Date of Inspection:11/8/2003_
Name of Inspector: Neil J.Bateson
Company Name: Bateson Enterprises Inc._
Mailing Address:_111 Argilla Road_
_Andover,Ma.01810_
Telephone Number:_(978)4754786_
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:
X_ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fai
Inspector's Signature: Date: _11/7/2003_
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.
Notes and Comments:Septic Tank Riser Needs Replaced,Cover Broken.
****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.
• Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_164 Mill Road_
_North Andover—
Owner:_Rhodes_
Date of Inspection:_11/8/2003_
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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 ass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
P P Y g
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 stem required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass
sY �1 P P g Y
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_164 Mill Road_
• _North Andover
—
Owner:_Rhodes_
Date of Inspection:_11/8/2003_
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
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 dual 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:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_164 Mill Road_
North Andover
—
Owner:_Rhodes_— —
Date of Inspection:_11/8/2003_
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_No_Liquid depth in cesspool is less than 6"below invert or available volume is'h day flow.
_No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_No_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_No_ 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.]
No (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.
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)
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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_164 Mill Road_
_North Andover—
Owner:_Rhodes_
Date of Inspection:_11/8/2003_
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Yes_ _ Pumping information was provided by the owner,occupant,or Board of Health
— _No Were any of the system components pumped out in the previous two weeks?
Yes _ Has the system received normal flows in the previous two week period?
No_ Have large volumes of water been introduced to the system recently or as part of this inspection?
Yes Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Yes Was the facility or dwelling inspected for signs of sewage back up?
Yes_ — Was the site inspected for signs of break out?
_Yes_ _ Were all system components,excluding the SAS,located on site?
_Yes_ _ 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?
_Yes _ 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
_Yes_ _ Existing information.
_No_ 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)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_164 Mill Road_
_North Andover_
Owner:_Rhodes_
Date of Inspection:_11/8/2003_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_600_
Number of current residents:_4_
Does residence have a garbage _
g g 1 der(Yes or no): No
Is laundry on a separate sewage system(yes or no):_No_
Laundry system inspected(yes or no):
Seasonal use:(yes or no):_No_
Water meter readings: Yes_
Sump pumps(yes or no):_No_
Last date of occupancy:_Current_
COMMERCIAL/INDUSTRIAL
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:_Pumped last year,owner_
Was system pumped as part of the inspection(yes or no): Yes_
If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank_
Reason for pumping: Inspect tank&tees_
TYPE OF SYSTEM
X 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
Approximate age of all components,date installed(if known)and source of information:_18 Years Old, 8/9/1985,
As built plan_
Were sewage odors detected when arriving at the site(yes or no):_No
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_164 Mill Road_
_North Andover—
Owner:_Rhodes_
Date of Inspection:_11/8/2003_
BUILDING SEWER(locate on site plan)X
Depth below grade:_4'_
Materials of construction: _cast iron _X_40 PVC_X other
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast iron thru wall. 3"PVC in house,
no leaks._
SEPTIC TANK: X locate on site plan)
Depth below grade:_31
_
Material of construction:—X—concrete_metal_fiberglass polyethylene
j _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:_10'z 5'x 4'
Sludge depth: 8"_
Distance from top of sludge to bottom of outlet tee or baffle:_17"_
Scum thickness:_10"
Distance from top of scum to top of outlet tee or baffle:_8"
Distance from bottom of scum to bottom of outlet tee or baffle:_15"_
How were dimensions determined:_Difference in sludge&scum depth to tee length_
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): Pumped septic tank.Inlet tee ok.Outlet tee ok.Depth of
liquid at outlet invert.No evidence of leakage._
i
I
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
related to outlet invert evidence of leaks ,etc.)::
as g )
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_164 Mill Road_
_North Andover
Owner•_Rhodes_
Date of Inspection:_11/8/2003
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 olyethylene 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: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: _0"_
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-Box level&distribution equal.No evidence of carryover.No evidence of
leakage._
PUMP CHAMBER: X (locate on site plan)
Pump in working order(yes or no): Yes_
Alarm in working order(yes or no): Yes_
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):_Pump cycled on then
off. Alarm has both audible buzzer&visual light._
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_164 Mill Road_
_North Andover—
Owner:_Rhodes_
Date of Inspection:_11/8/2003_
SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
_X leaching trenches,number,length:_5 trenches 61'long_
_ 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.):_Soil ok.Vegetation ok.No sign of ponding to surface._
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 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.):
Page 1.0 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_164 Mill Road_
_North Andover—
Owner:_Rhodes_
Date of Inspection:_11/8/2003_
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.
Driveway
A to Septic Tank=13'7"
A to Pump Tank=2213"
A to D-Boz=62'3"
B to Septic Tank=6016"
B to Pump Tank=7515"
B to D-Boz=97'6"
Water Meter
House
B A
Porch
Septic Tank Pump Tank
D-Boz
61' 01
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_164 Mill Road_
—North Andover—
Owner:_Rhodes_
Date of Inspection:_11/8/2003_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 4'_
Please indicate(check)all methods used to determine the high ground water elevation:
X Obtained from system design plans on record-If checked,date of design plan reviewed:_5/23/1983_
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: As per design plan._
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Connect Edit Terminal Help (�1, :--r-
NATER BILLING HISTORY 2100320-DR. DEREK RHODES METER #1 : 2100320 ;
--------------------- 164 MILL RD Microsoft m
# CYCLE SERVICE PRIOR SE WATER SEWER FEES TOTAL outlook
1 2000-12 08/04/1999 768 833 65 177.45 0.00 0.00 177.45
2 2000-22 12/10/1999 833 865 32 87.36 0.00 0.00 87.36,
; . 3 2000-32 03/15/2000 865 886 21 57.33 0.00 0.00 57.33
s
4 2000-42 05/22/2000 886 912 26 70.98 0.00 0.00 70.98 5om- .0` ;_`"-'` =? =""''
__ r
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5 2001-12 08/09/2000 912 947 35 95.55 0.00 11.00 106.55 .xF,..C6r>.±° o
py
6 2001-22 11/15/2000 947 980 33 90.09 0.00 111 .00 101.09 download.hdl
7 2001-3202/20/2001 980 997 17 46.41 0.00 11.00 57.41
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8 2001-42 05/22/2001 997 1020 23 62.79 0.00 11 .00 73.79 Q_
9 2002-22 12/06/2001 1086 1132 46 130.42 0.00 5.55 135.97
10 2002-32 03/19/2002 1132 1151 19 46.93 0.00 5.55 52.48
11 2002-42 05/21/2002 1151 1163 12 29.64 0.00 5.55 35.19 .
12 2002-12A 08/09/2001 1020 1086 66 214.54 0.00 5.55 220.09 . :
13 2003-12 08/09/2002 1163 1188 25 66.60 0.00 5.97 72.57 :fir
14 2003-22 11/07/2002 1188 1206 18 42.84 0.00 5.97 48.81
115 2003-32 02/12/2003 1206 1222 16 38.08 0.00 5.97 44-051overn32 2 EMS
16 2003-42 05/07/2003 1222 1237 15 35.70 0.00 5.97 41-67 ..,-LIVE - =_
17 2004-12 08/14/2003 1237 1277 40 113.44 0.00 7.42 120.86
REUIEW CHOICE # or <ENTER> MORE HISTORY:
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Tel: (978) 475-4786
Fax: (978) 475-5451
B ATE S ON ENTERPRISES, INC.
Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service
�I
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 164 Mill Road, North Andover
Owner: Rhodes
Date of Inspection: 11/8/2003
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Ne' J. B eson
Bateson Enterprises, Inc.
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ELEVATIONS
description design as built " "
INV. PIPE OUT OF HSE. 2Co2.50 AS �`
INV. PIPE INTO TANK 2co2.30 ?60.59 B B LT ., "
INV. PIPE OUT OF TANK 2G2.05 2lo0.2ln SUB - SURFACE D ISPO.SI� L
INV. PIPE INTO PUMP 202,05 Z59. 88
INV. PIPE OUT OF PUMP 259.co4
INV. PIPE INTO DIST. BbX,. 2&09.50 Z<o9.U2 SYSTEM
INV. PIPE OUT OF DIST BOX 2ea9.I5 IN
INV. END OF PIPE # I 2CO5.00 Z6OB �O�T1-1 AIJC�O�/Et2 MA.
2 Z000o.00 2<0 5.28
q ' 3 2CoT.00 Zlolo.24 ,
4 2 08.00 z�Y.ss FOR • STEPHEN M . UP—OWE
5 Scale: I " = 4d Date: ,4uG. 9,I9as
RICHARD F. KAMINSKI AND /-ASSOCIATES , 'INC. .
ENGINEERS ARCHITECT • SURVEYORS • LAND PLANNERS
NORTH ANDOVER , MASS .
8/9/85
To: North Andover, Mass.
Board of Health
From: Design Engineer Re: Soil Absorption
Sewage Dispoal
System
This is to certify that I have reviewed the construction
materials of said disposal system at Lot 7B Mill Road
Site Location
North Andover, Massachusetts.
The grades and construction materials are in General Conformance
to my plans and specifications dated Nov. 3, 1984 and
As-Built Aug. 9, 1985
Reg. f.P. gi
cis CIVIL `
No.31012
�FSSIONALnn
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