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HomeMy WebLinkAboutMiscellaneous - 1925 GREAT POND ROAD 4/30/2018 1925 GREAT POND ROAD pad 210/035.0-0058-0000:0 J E W E R _ _ 1 i t r` i r Of AOR f i N©� Commonwealth.of, Massachusetts ©��cr�R°° Executive Office of .Environmental Affairs Department of Environmental Protection William F.Weld Go`ema TrudyCoxe Secntuy,EOEA David B. Struhs Comm ssioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 1925 Great Pond Rd -N . Andove�dess of Owner: Date of Inspection: 6-4-96 f t event) Name of Inspector: T Company Name, Address an2ife}leph ne k f}A RLI Corp. 475 Bostob Rd . Billerica , Ma . CERTIFICATION STATEMENT 1 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 Fais Inspector's Signature: Dates_5-96 The System Inspector shall submit,a 'copy of this inspection report to the Approving Authority within thirty (301•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 authori7. 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. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced 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 ail 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. (revise3 8/15/35; 1 i One Winter Street a Boston, Massachusetts 02108 a FAX(617) 556-1049 a Telephone(617)292-5500 `�! Pnnted on ReCVCied Pax* ,w r4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1925 Great Pond Rd . N. Andover Ma . Owner: Date of Inspection: 6-4-96 BJ SYSTEM CONDITIONALLY PASSES (continued) , Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): 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 seotic tank and sod absorption system and is within 100 feet to a surface water supp j of tributary to a surface rater 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 waver;;. 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 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. .revised E/.5/5.; 2 i y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1925 Great Pond Rd . N . Andover , Ma . Owner: Date of Inspection: „ 6—4—9 6 D] SYSTEM FAILS (continued): . Y-es 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 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. 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 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. E] LARGE SYSTEM FAILS: 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 11 of a public water supply wells •. 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. c_.aea E/.5/55 3 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) rropertyAddress- 1925 Great Pond Rd . N. Andovdr, Ma. Owner: Peter Bouffard Date of Inspection: 6-4-96 TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: eallons Design flow: eallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of.liquid level above outlet invert: v 6 Comments: inote ,f level and distribution is equal, e\idence of solids car-yover, evidence of leakage into or out of box, etc.) Fff 1 iipnt- i c over t-n= of Tl Rnx{ Ahcorh+i nn arca i c cA+iira+cri PUMP CHAMBER: /a (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) irevcse6 E!.5/35; 7 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1925 Great Pnnd Rd . N. Andover , Ma . Owner' Peter Bouffard Date of Inspection: 6-4-96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: o 0 irev:sed S/.5/9Si 9 f