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HomeMy WebLinkAboutMiscellaneous - 178 GRANVILLE LANE 4/30/2018 (2)�.ao�r4�cl� Owner information is required for every page. ,Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses; 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner's Name North Andover Cityrrown MA 01845 State Zip Code i v t G 9/31/10 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Benjamin C. Osgood, Jr. cursor - do not use the return Name of Inspector key. none Company Name 16 Hillside Ave, Unit 3 Company Address Amesbury City/Town 978-255-2261 Telephone Number B. Certification OCT 19 laic TOWN ®P NMH AMVER HEAM DEPARTMENT MA State 870 License Number 01913 Zip Code 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-5-10 -A, (f- 2 Inspector ignature Date 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. ****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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner Owner's Name information is required for North Andover MA 01845 9/31/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete atl of Section D A) System Passes: ® 1 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. Check the box for "yes", "no" or "not determined" (Y, N, ND) 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 pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Owner information is required for every page. . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner's Name North Andover MA 01845 9/31/10 Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner's Name North Andover MA 01845 9/31/10 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 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 must be attached to this form. 3. Other: 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 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner Owner's Name information is required for North Andover MA 01845 9/31/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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.] ❑ ® The system is a cesspool serving a facility with a design flow 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 following, in addition to the questions in Section D. 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 11 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. M Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner's Name North Andover MA 01845 9/31/10 Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes 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 system 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? ® ❑ 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 site? ® ❑ 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 maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner Owner's Name information is required for North Andover MA 01845 9/31/10 every page. Cityrrown D. System Information Description: Number of current residents: State Zip Code Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) 3 ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Commonwealth of Massachusetts , uVi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner Owners Name information is required for North Andover MA 01845 9/31/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date pumped last year per owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane 9/31/10 Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Built 1979 Der Board of Health records (as built) Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 15 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe ok in basement Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal at grade feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 1000 Gallons Sludge depth: 2" El Yes ❑ No Property Address Joseph and Valerie Cinseruli Owner Owner's Name information is required for North Andover MA 01845 every page. Cityfrown State Zip Code 9/31/10 Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Built 1979 Der Board of Health records (as built) Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 15 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe ok in basement Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal at grade feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 1000 Gallons Sludge depth: 2" El Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ 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: Date Property Address Joseph and Valerie Cinseruli Owner Owner's Name information is required for North Andover MA 01845 9/31/10 every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" 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 16" How were dimensions determined? Measure Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition. PVC outlet tee in good condition Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ 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: Date Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane ,p Property Address Joseph and Valerie Cinseruli Owner Owner's Name information is required for North Andover MA 01845 9/31/10 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 D FI UO UH ow. gallons per day Alarm present: El Yes F1 No Alarm level: Alarm in working order: El Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 9/31/10 Date of Inspection 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.): System contains three d -boxes. First box splits flow to two separate systems and is in OK condition. Flow levelers installed and gaps between pipes and wall of box repaired with cement. 2"d box in ok condition. distribution equal, no evidence of carryover or leakage in or out. 3rd box cover was replaced because it was broken and colapsed in to box. gaps between pipe and box wall repaired with cement. distribution equal. new cover installed. No evidence of solids carryover or leakage in or out. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 4N , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner Owner's Name information is required for North Andover MA 01845 9/31/10 every page. City lTown D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ® leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/alternative system State Zip Code Date of Inspection number: number: number: number, length: number, dimensions: number: 8 36' LONG Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of leach field looks normal. No evidence of ponding, damp soil, or unusual vegetation. Distribution feeder pipe on south east comer exposed upon initial inspection was covered with soil. 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 ❑ No • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Owner information is required for every page. 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owners Name North Andover MA 01845 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9/31/10 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.): • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner Owner's Name information is required for North Andover MA 01845 9/31/10 every page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner owner's Name information is required for North Andover MA 01845 every page. Cityfrown State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high round water• 2 9/31/10 Date of Inspection g feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record IN If checked, date of design plan reviewed: Date 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: usgs maps You must describe how you established the high ground water elevation: System built in an area which was raised approx 2 feet above old existing grade. Water table in the area bewteen 2 and 4 feet below existing grade (from inspector experience and knowledge of the area) USGS maps indicate water table > 6 feet below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. a f ' . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Lane Property Address Joseph and Valerie Cinseruli Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code E. Report Completeness Checklist 9/31/10 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file NEW ENGLAND ENGINEERING INC North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 178 Granville Lane, North Andover, MA Dear Sirs: . SERVICES NOV 2 6 202 November 25, 2002 Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely J�_c D� m BenjamC. Osgood, J 60 BEECHWOOD DRIVE -NORTH ANDOVER, MA 01845 - (978) 686-1768- (888) 359-7645- FAX (978) 685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION_..Tf-oiN OF NORTH AN,)G 7/ BOARD OF HEALT H I Z 6W TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A Property Addm, Owner's Name: Owner's Addre: Date of Inspecti CERTIFICATION Name of Inspector: (please print) Q .. C -Do S � 2 Company Name: M acv ) AAS -L .4 Q ERVC, I v (Z 1 Mailing Address: (cfl 8 EEt' hl w� o b bt2�t �vor�n-t AN ri .Pbec^4A Telephone Number R 1z — (- 86 - 1768 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: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: / 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 ****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: )-lb N1) 5L11-1 �Nuc»e 2 ivLA Owner: At. E l l c: C 1 AJ e Z QJ4-% Date of Inspection: 1112S/ o Z — Inspection Summary: Check A,B,C,D or E /ALWAYS complete all of Section D A. Syst m Passes: 7I 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 beeplaced or repair The system, upon completion of the replacement or repair, as approved by the Boar f Health, will pass. Answer yes, no not determined (Y,N,ND) in the for the following .statem . If "not determined" please explain. The septic tank is etal and over 20 years old* or the septic ether metal or not) is structurally unsound, exhibits substantia ' filtration or exfiltration or tank fail is imminent. System will pass inspection if the existing tank is replaced with a mplying septic tank as appro by the Board of Health. *A metal septic tank will pass ins ion if it is structural l d, not leaking and if a Certificate of Compliance indicating that the tank is less than 2 ears old is avai e. ND explain: Observation of sewage ba break or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a br , settled or un distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are r cod obstruction is removed distribution box is leveled o eplaced ND expl The system required pumping more than 4 times a year due to broken obstructed pipc(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: i -i s (TRA Ny i t. LZ L� N ry0 (ZIV i.N oojtE 2 Owner: _ V P Vr%21 C, (tvi-I Date of Inspection: _ilk j az 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 sys&m is not functioning in a manner which will protect public health, safety and the environment: — CeSSOW1 or privy is within 50 feet of a surface water — Cesspoo privy is within 50 feet of a bordering vegetated wetland or a salt m 2. System will fail unless the Boa of Health (and Public Wa Supplier, if any) determines that the system is functioning in a manner tha""rotects the public h th, safety and environment: _ The system has a septic tank and soil orption em (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface pply. — The s/organiccompotmds a septic tank and SAS d the SA ' within a Zone 1 of a public water supply. — The sa septic tank AS and the SAS is wi 0 feet of a private water supply well. The sa septic and SAS and the SAS is less than 1 eet but 50 feet or more from a private wawell**. ethod used to determine is **This sysf the well water analysis, performed at a DEP certified la ratory, for coliform bacteria an'organic compounds indicates that the well is free from poU from that facility anl the presenonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, ovided that no other failure critiggered. 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; 178 6-g4N o."% 1..N p o g�rH A0j 9 pJ C- .2 MA Owner:__ ��,e}���2►ty c►NsE2�V► Date of Inspection: t. -j_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or `Sao" 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 %z day flow i 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 fed 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 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 ropy of the analysis must be attached to 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 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 1;Pd- You must indicate e' er `Wes" or "no!' to each of the following: (The following criteria a to large systems in addition to the criteria above) yes no "I,, — _ the system is within 400 feet _ — the system is within 200 feet of a >r' a surface drinking water supply _ —the system is located ' nitrogen sensitive area (Int ' Wellhead Protection Area - IWPA) or a mapped Zone II of a pub ' ter supply well If you have answered "yes" to any question in Section E the system is considered a ' ificant threat, or answered "Wes" in Section D above the large system has failed. The owner or operator of any lartem considered a significant threat under Section E or failed under Section D shall upgrade the system in acro ce 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: 1'7g Cr2Aojvj4-LC t_W POfLTR AODoO 2 MA Owner: u A lrE2lE CtNSt:l2uLi Date of Inspection: : I ! Z'0 eZ Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes 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 system 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 ? ✓_ 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 site ? �_ 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 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 ✓ _ Existing 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) [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: )'79 Cr 2 A M 1 L LE L N tJofL►li 1�N1)CJis iL M1�} Owner: C1r0C*1L0L% Date of Inspection: 1 k 1 i.-1 o z FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): !' Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: q ^ Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system (yes or no):IV [if yes separate inspection required] Laundry system inspected (yes or no)r Seasonal use: (yes or no): i Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): AL Last date of occupancy: r. y 1r r �T COMMERCIALIMUSTRIAL 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 meta readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: 17 i l A Z)17 -7-f Vey eq �P.c- O&VIVC k Was system pumped as part of the inspection (yes or no): If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: TYPPF SYSTEM W'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) _ InnovativetAltemative 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: $,-It 1�1'7`1 -?e2 As - 21 Were sewage odors detected when arriving at the site (yes or no): LVO Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I? 4 G!LO Nc1I LLE- t_N W O (m4 A N fl pj�s %z nnR Owner:y * L -C- k21 C; G I N s.E R oi- ► Date of Inspection: i it Z5 1-.> Z. BUILDING SEWER (locate on site plan) Depth below grade: j 2 Materials of construction: ✓cast iron 40 PVC other (explain): Distance from private water supply well or suction line: ti #I' Comments (on condition of joints, venting, evidence of leakage, etc.): f, Pi; 1'o- 'A's �a� '-.j i3P's e'1"'5 JT— SEPTIC T SEPTIC TANK: — (locate on site plan) Depth below grade: D 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) Dimensions: IkS�a o C,,A j_ N s Sludge depth: L V, w Distance from top of sludge to bottom of outlet tee or baffle: Z 2 Scum thickness; G. I " Distance from top of scum to top of outlet tee or baffle: (' Distance from bottom of scum to bottom of outlet tee or baffle: 15 •' How were dimensions determined: 1A 6^ rK ., R s 7n e K Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TA -k ,.J 60a0 GOasa Mo 0. S' Poe- %fC /N G-od, "AVD IlOn. GREASE TRAP -.N4 (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.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1,7 8 &-RAA1 J j L6% L_N Wo2TH �tNDamti2 Owner: v+�►.E�2�E ciNsG �2ut,� Date of Inspection: TIGHT or HOLDING TANK: A/vf (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: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (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.): __.BD I, 6-z.a; wnP,T7DA- P -67'/2,J u7?6^ Cavetj N� c✓�a� NGS arm sc/}44V0jZ�P. PUMP CHAMBER: Aff (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17$ Crt2 R N u i t t r.IJ Ne R.TK ANDa,ji,2 Owner: Vkw;tt.1e L1NS;"1� 1 Date of Inspection: 1 tJ� ?, i 1 -,.z. SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers., number: leaching galleries, number: ✓ leaching trenches, number, length: 3 1 re At H F -s 3 (o` Imo Al 6- Z V -wk p (7 e p* leaching fields, number, dimensions: overflow cesspool, number: innovativelalternative system Typetname of technology: Comments (note edition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ►j:t,a 4 OF S. s rt M b o ��. ► .�1 o Ny E✓ �.a r �L L� v F Pb N P N (T DA,r�. P SQ« n 2yaJ,cYL V r &G 7Y,Ljaa M CESSPOOLS;NA (cesspool must be pumped as part of inspectionxlocate 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.): PRIVYyj[,- (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 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _ l -116 6414-NuiI LE L-1\3 No 2T R A N D e 12 Owner: V AL,621 E C tAJS E allLJ Date of Inspection: t o 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. (flue g -E (.1 Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 178 GRRNoILLE L.N M6 a:n4 /kIJ>0) j X Owner:_ V14L_E21E GI"F12VUL Date of Inspection: _ III a j SITE EXAM Slope tv 61, Surface water 34* o i4. a.. RE S,Oc o f X20 �• Check cellar ,s r Shallow wells r�� C Estimated depth to ground water Y 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: 'Tee hGM6s "^AT t- cTea ` e;aLD. - 6->2:op tJ LIJM-e2 -r,s GLE FboAjp 0r Js' _6" k3iftZv- et4Z #40J- !Y7 6 us v-5 c.j D . c. A- r) s u.) A-rg-2 ` .Recd Gid -,ASD e T-& n D fl ✓t F. Ay I H L 3 k^., S A CT Gia IZ jN iia A- Y(L L�o C p wA-7g-R Tt+a L_e p r 36 is 'Z 1-6. 1 NC -HC -S 4 William F. Weld Gowmor Trudy Coxa Set:retary, EDEA David B. Struhs Commissioner ,bA Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a PART A fJs 1 7 CERTIFICATION Property Address:Address of Owner: Date of Inspection: t3 . i 1 (If different) Name of Inspector: �?Te'ep Company Name, Address one Number: 9,1400L) - So,,//C_ t"a. y� �� Fr CERTIFICATION STATEMENT �t/pv�j� , /Pj, o 1 F3 r 3 7 2--7 `;-/-7 / 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 Inspector's Sig ure: Date:�—�� _'_041attl - The S. tem 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: ig 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. B] SYSTEM CONDITIONALLY PASSES: One or mores stem components InAt be r IY Preplaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street a Boston, Massachusetts 02108 a FAX (617) 556-1049 a Telephone (617) 292 -SM 4160 Printed on Recycled Paper Cd Property Address: Owner: Date of Inspection: r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ..y PART A CERTIFICATION (continued) �lg h / a q 2✓1,—r94 B] SYSTEM CONDITIONALLY PASSES (continued) y, 04r Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or de to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Boyd - p7 tealth): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 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 public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL -PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 fee! to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. D] SYSTEM FAILS: 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. Backup of sewage into facility or system component due to an overloaded or dogged 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. 10 (revised 8/15/95r 2 r '("o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: G� R'dt �' '4' ,"/ 'A'1, �4'64 Do U Owner: Date of Inspection: DI SYSTEM FAILS (continued): /V Static liquid level level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liqui-7 pth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Requfeimping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped I _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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 bdt 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. E] LARGE SYSTEM FAILS: P. , - 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: 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) 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. p. � (revised 8/15/95) 3 r, if r" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j PART B CHECKLIST Property Address: Owner:ilfC� !—• Date of Inspection: Check if the following have been done: — Putnping information was requested of the owner, occupant, and 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 wring that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ A� built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ T e system does not receive non -sanitary or industrial waste flow _ The site was inspected for signs of breakout. II 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 baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. 1/ t• _ The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. _ The facility o•,�ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 8/15/95) 4 Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION �vG �r G jq, 4."00r -e✓ RESIDENTIAL: Design flow:�d u ealllons Number of bedrooms: Number of current resident's: Garbage grinder (yes or no): Laundry connected to system yes or no):_ Seasonal use (yes or no):. Water meter readings, if available:_ Last date of occupancy: UC CLP/ e FLOW CONDITIONS COMMERCIAUINDUSTRIAL: � Type of establishment: Design flow:_gallons/day 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 OTHER: (Describe) Last date of occupancy: PUMPING RECORDS and source of form ion: u M GENERAL INFORMATION System pumped as part of inspection: (yes or no) -ye -7 - If o) e7'If yes, volume pumped J06-'> eallons Reason for pumping. r1A e c rL RA-rFi el 4- 157J A(,rT U 09 L TYPE gVSYSTEM 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) Other (explain) 57tt V C 7-%jA K k APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected wheniarriving at the site: (yes or no) ' e (revised 8/15/95) 5 • r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SEPTIC TANK:�P S (locate on site plan) t Depth below grade: " lr Material of construction: _Le=concrete _metal _FRP _other(explain) Sludge depth: of V i/ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: ; ,r Distance from top of scum to top of outlet tee or baffle: � it Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of. liquid level in relation to outlet invert, structural intaarihi avirfanra of lanlrnaa atr 1 . GREASE TRAP:_ 144. (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum in bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: G� Date of Inspection: ` r �� �� ��'1✓ TIGHT OR HOLDING TANKJt (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOde " (locate on site plan) Depth of liquid level above outlet invert: 'f Comments: (note if level and distribution is equal, evidence of sohd5 carryover, evidence of leakage into or out of box, etc.) 10uNM N' !ten C S / u n 6e i9L-CC v M4 U / 4L?-ecf 14, A- C r L -C, 4- K p d_ 0 u l— A-0 rva-f Co V rr f At 9 PUMP CHAMBER:_ J� F r (locate on site plan) Pumps in working order:(yes or no)_ Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) r (revised 8/15/95) 7 r .� 01 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):— (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: 3>; (00 overflow cesspool, number: { Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) IIfU %'/ :2 Ca t6" y'e'A-feov ` 4ZzC c -y t o •-f !-f u 2 nitA t.. CESSPOOLS: _ (locate on site plan) r 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 (cesspool must be pumped as part of inspection) k 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.) at (revised 8/15/95) 8 �;. . _ —1 , .. , . . _% , . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,,ry Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER jq,v eljiN' Depth to groundwater:_2 (0 feet method of determination or approximation: Jif (revised 8/15/95) 9 'tv TgNS t ip � 6eA 1 — I 0 r1, L.1r!/A -r 147 f4 �5._ _ 1 -MV DIPE OUT OF N5E- I KI SL PIPE I NTO T,4, ky- v PIPE.OUMOP M t,, t7 - N' -V- i - tN�! PIKE lNTa D. q=E a t 1 I NL 1?tP-E—O.11T .71 �I Ore !�JVrs ry- of fiwL7t'S til � �y'4> s w L—r 4O0Y-r iN �\\ o, 4WD c a\,tE.R.- )+ S CA LE I " _ A-0 moo., -E, 6q �' 2A. ►11C G C� >_�� N o.S �. A s Svc ti .o'�`� �' S �4 �i �.N t�G�.l�.i2 �3-T' ;'� ta. L1l�t C���lE•Q , 0 J FRANK C. GELINAS l REGISTERED PROFESSIONAL ENGINEER REGISTERED LAND SURVEYOR NORTH ANDOVER OFFICE PARK 451 ANDOVER STREET NORTH ANDOVER, MASS. 01845 TELEPHONE 687.1483 December 27, 1978 Mr. Thomas Murphy North Andover Board of Health North Andover Town Hall North Andover, MA 01845 Reference: Lot 32 Granville Lane Dear Mr. Murphy: Enclosed you will find a revision of the subsurface disposal system design for lot 32 Granville Lane. The revisions are two: 1. Reduction in the size of the house 2. Term culvert change to ditch As you can see, neither of these changes effect the disposal system. If you have any questions please do not hesitate to contact me. Yours truly, If oseph B. Cushing /scp enclosure cc: Mr. Ralph Ciardello • ENVIRONMENTAL ENGINEERING • STRUCTURAL ENGINEERING • CIVIL ENGINEERING • PROPERTY AND TOPOGRAPHICAL SURVEYING I IM Teo -.10.2 Rog. 10.4 Reg. 11 .2 Reg. 11.4 Reg. I . i C eg.11 .11 Reg. 15.1 Reg.15.1 Reg.15.4 Reg.15.8 reg. 3.7 Reg.14.1 Reg.14.3 Aeg.14.4 14.5 neg.14.6 g. 14. ;ego14.1C Reg. 9.1 LIK(,a)Slope greater than 0.08 (b Sump Leachl.n� P1ts Leaching pits are prefer l:here the installation is possible (a) Calculatio of leaching area (minimum 500 S.F.) (b) Spacing (c) Surf drainage 2% d) COv r material Lea in Fields 1 / (a)N Greater t n 20 minutes/inch (b) Area ('` imum 900 S.F.) (c) Cons- uction of field (d) Sace drainage 2% (e) -`0' from -cellar wall or inground swimming pool reaching Trenches (a) Calc-olations of leaching area (min. 500 S.F.) , Spacing (4 ft. min. 6 ft. v�ith reserve between) M Dir,.jensions d). Cons true tion' 0 Stone f) Surface drainage 2% Downhill Slope (a) Slope y/x = (to be shoran) (b) y/x X 150 = (to be shown) PuL� a (a) Approval (b) S',and-by pc"Jer. I I '0 '_7) _F, C E 1- R 0 V 1 D E D Title 5 Reg. 2.5 IFail R A JV R G 1,11 The submitted plan must show as a minumum: (a) the lot to be served (area,dimensions'lot ,-,abutters) 111/' / (Planning Board files) --'(b) location and log of deep observation holes -distance to ties location and results of percolation tests -distance to ties (fd) design calculations-& calculations showing required leaching area (e) location and dimensions Gf system (including reserve area) "(;_)---existing and proposed contours location of any wet areas within loot of the sc D disposal system or disclaimer (check -vl'etl;�nds map -ping surface and subsurface drains within loot of disposal system or discla--I.mer location of any ea.13pments within 100I of sewage disposal system or disclaimer (pl_an--Jing boa-od fit -es) 1,,no�-.,n sources of -v.,a-'L-Ier supply within 2001 of disposal system or disclaii.,ger location of any proposed well to serve the lot (1001 from leaching facility) location of water lines on property (10, from. '116facilities) (m-)- location of benchmark d.riveways garbage disposers no PVC is -'L-,o be used in construction ,q) a profile of -LL-Ihe system (-elevations of basetneiit, pipe septic tank, distribution box inlet,s and outle-s distribution field piping and any other eIeVa-G.-J_r,?i.S) lilaxilDul-II ground --.1ater elevation in area of system plan 1;iust be prepared by a 17-1_-ofessional or other professional authorized by law to prepare :;-.-,(-,h plans Sex-tic_T a n s (aa)�-'CaiDcacitbies - 150% of flow, of tees, access, pulping., �C1eo.?iOUL c 0 fr o m cellar -.,-.,all or lnground s,...: i. Poo 25 from subsurface draills Lti VL "t trcauv �.w� fs.:waw us v t�R DATE FAIL OK TN`,f 4LL",' ICK CKS40K LT 87 LOT 'F.CArAfl Nd OK FAIL 1. Distance To: a. wetlands b. Drains c. Wen 2. Water Line Location -3. _No PPC Pipe:_ - septic Tank ---..- a.- - ank _a. Tees- --]Length k -To Clean Out Covars -- -- b. Cement Pipe to Tank - On Bath Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. Ali. Lines Fio;4.ng Equal Anounts c..No Back now 6. Leach Field or Trench-- - - a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone: 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Csnient Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. - Final Grading inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location -4th Regards -to Pere Test d. Elevations e: Water Table •.� `' SOIL PROFILE & PERCOLATION TEST DATA r' Board of Health -North Andover, Mass, Street R Lot No. Subdivision' ,.��-� Owner Investigator 1 a...�.-Wo Observer— 1. Date Elev. Feet Inches 0 0 1C 01 2. Date Elev. SOIL PROFILES 3. Date Elev. 4. Date -Elev. Ties to Test Pits 1. . 2. 3. 4. 5. Note: Top & subsoil depth; depths of other soil types; depth of water table; depth of refusal. PERCOLATION TESTS nai-P L,_11A.1t nat-P nn+ - P nm -Fa 'nn -Fin Pit Number 1 2 3 4 5 Start Saturation , Soak -Mins. Start Test -Time r4 Drop of 3" -Time �o Drop of 6" -Time ?� Mins. 1 st 311 Drop Mins. 2nd 3" Drop Rate Ein. In. TOWN' OF. NORTH ANDOVER NORTH ANDGVER BOARD OF HEALTH REPCR.T OF PERC TEST ADDRESS OF SYSTEM(J /�� NAME OF PROFESSIONAL INGINEFR CR SANITARIAN CONDUCTING TESTS /�ACL aa -//o NAME OF LOT OWNFR. DATE & 76 ADDRESS � �r-i-, lJ' , moi!-,0/0ue� /yfG SHOW APPROXIMATE LOCATION OF PITS ON SKETCH ON REAR OF PIIS SHEET Soil Log:T soil ka Subsoil - LE44,20—/ .�D th & Tomes FA, PC Total Water Level Pit D th Perc Tests Depth Saturation Time to Time Drop 1211 - 911 Time to Drop 9f1_._ 61, Other Considerations:_O�C..' / C1�//�r✓ %E'[��'' ��� Recommendations; ' e toi/ / Signature I �4 ���oticel 3 % /4- 461 /7 p r", " -)