HomeMy WebLinkAboutMiscellaneous - 234 DALE STREET 4/30/2018 234 DALE STREET
j 210/064.0-002&.0000.0
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 234 Dale Street_ FtE\iEl1/ED
North Andover
Owner's Name:_Lisa Gabriel_
Owner's Address: 234 Dale Street NOV 1'8 2005
North Andover,Ma 01845_
Date of Inspection 11/1/2005_ TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Name of Inspector: Neil J Bateson_
Company Name: Bateson Enterprises Inc._
Mailing Address:_111 Argilla Road_
_Andover,Ma.01810_
Telephone Number:_(978)475-4786_
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
Fail
��Inspector's Signature: Date: _11/1/2005_
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: 234 Dale Street_
_North Andover-
Owner:_Gabriel
Date of Inspection:_11/1/2005_
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 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.
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 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
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:_234 Dale Street
_North Andover—
Owner:_Gabriel_
Date of Inspection:_11/1/2005_
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 I 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 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:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_234 Dale Street_
—North Andover
—
Owner:_Gabriel_
Date of Inspection:_11/1/2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
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'/z 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
lfld-
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: 234 Dale Street
_North Andover__
Owner:_Gabriel
Date of Inspection:_11/1/2005
Check if the following have been done.You mast 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?
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.
_Yes _ 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: 234 Dale Street
_North Andover–
Owner: Gabriel_
Date of Inspection:_11/1/2005_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2_
DESIGN flow based on 310 CMR 15.203_220
Number of current residents:_2
Does residence have a garbage grinder(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 reading: Yes_
Sump pump(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.): i
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 two years ago,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&baffles
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:_13 years old,4/30/1992,
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:_234 Dale Street_
_North Andover_
Owner:_Gabriel_
Date of Inspection:_1111/2005_
BUILDING SEWER_X_ (locate on site plan)
Depth below grade:_28"
Materials of construction: X cast iron _X 40 PVC____other
supp
Distance from private water ly well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.) 4"Cast iron thru floor.4"Cast iron in
house,no leaks visible
SEPTIC TANKS: X
Depth below grade:_6"_
Material of construction: X 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: 10'x 5'x 4'_
Sludge depth: 2"_
Distance from top of sludge to bottom of outlet tee or baffle: 25"_
Scum thickness:_311
_
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:_18"`
How were dimensions determined:_Tape Measure_
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._
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
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: 234 Dale Street
_North Andover
Owner:_Gabriel
Date of Inspection:_11/1/2005_
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
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 BOXES: X
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 leakage. Evidence of
carryover,pumped d-box to clean_
PUMP CHAMBER:—(locate on site plan)
Pump in working order(yes or no):_
Alarm in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_234 Dale Street_
_North Andover_
Owner:_Gabriel_
Date of Inspection:_11/1/2005_
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 35'long_
leaching field,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:
Number and configuration:
Depth—top of liquid to inlet invert:_
Depth of sludge 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 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 234 Dale Street
_ North Andover_
Owner:_Gabriel_
Date of Inspection:_11/1/2005_
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
Water Meter
House
A B
Septic Tank
1 2
A to 1 =31'8"
Ato2=23'4"
A to D-Bog=369"
B to 1=11'5"
Bto2=5'7"
D-Bog B to D-Bog=2013"
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 234 Dale Street_
_North Andover_
Owner:_Gabriel_
Date of Inspection:_11/1/2005_
SM EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water _>6'_
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)
X Accessed USGS database-explain: Essex County Soil Map
You must describe how you established the high ground water elevation:_Essex County Soil Map,Sheet#30,
Canton Soil,Water>6'Deep_
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Summary Record Card generated on 11/1/2005 11:20:50 AM by Elaine Barclay Page 1
Town of North Andover
Tax Map # 210-064.0-0028-0000.0
234 DALE STREET
GABRIEL, LISA
234 DALE STREET
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 0.27 Acres
FY 2006
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
GABRIEL, LISA Payor
234 DALE STREET
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 2548.0- 234 DALE ST Last Billing Date 10/6/2005
3180438 03 Cycle 03 Active
UB Services Maint.
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 126.78 /1
UB Meter Maintenance
Serial No Status Location Brand Type Size YTD Cons
0010608099 a Active ENC F.L. ? w Water 0.63 0.63 0
Date Reading Code Consumption Posted Date Variance
9/26/2005 2312 a Actual 32 10/14/2005 -9%
6/16/2005 2280 a Actual 27 7/15/2005 70%
3/30/2005 2253 a Actual 20 4/5/2005 -29%
12/22/2004 2233 a Actual 24. 1/14/2005 227%
9/29/2004 2209 m Manual estimate 9 10/8/2004 -36%
6/18/2004 2200 a Actual 7 7/30/2004 104%
4/28/2004 2193 a Actual 8 5/17/2004 0%
12/31/2003 2185 n New Meter 0 12/31/2003 0%
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service
1 I I Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 234 Dale Street, North Andover
Owner: Gabriel
Date of Inspection: 11/1/2005
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.
Neil J. Bateson
Bateson Enterprises, Inc.
TOWN OF /1,/, ,1
SYSTEM PUMPING RECO7RECEIVED
DATE:^" NOV - 9 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
- j-
DATE OF PUMPING: l l -e°42 _ QUANTITY PUMPED : O� GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
BulLo,*a� t1 All 11 �tl
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---
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AS BU I LT PLAN
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SUBSURFACE DISPOSAL SYSTEMREPAIR -
--A
LOCATEDIN �
AS PREPARED FOR
5T uL'S
E RC ERT C.
DATE: _A_�l3_i L.�--3_0_ 1 �_2_ Q.�VIL �..
SCALE: NO.31Eso
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MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 TEL (617) 475-3553. 973-5721
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE::
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
� c"
i
ll:.�TE OF PUMPING: QUANTITY PUMPED GALLO'N'S
CE SSPOOL: NO v YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE "EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS ACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYS"I'EM PUMPED BY: VA
CO'1I.NIENTS:
C:ONTE NTS TRANSFERRED TO:
!-address , �lL� ST Title of Hie
P.age —_ of
Date File Open:
---_ Date file Closed:--
Doc
Document/Action Title Date of _
action 6tefer to other Purpose of Document/jAct-ion and notes
Num. Document/ docurruent/
Action De Department
------------------------------
Board of Appeals — Board of Heal h Planning Board _ Co
nseruatiion commission — Building Departnlen;t —'�—�
TN ANDOVER/
TOW aOARp OF NEAUSN
Commonwealth of Massachusetts V 2 1995
Executive Office of Environmental Affairs NO
Department of
Environmental Protection
William F.Weld
Gowmor
Trudy t^,oxe
Secretary,EOEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: G3 '11 D ct lc S t M c t Address of O r:ner: 1 c. F .,s T F_ CZ s i a C- is T
Date of Inspection: I),t� �q Ll nn (If different) s—
Name of Inspector: Z
Company Name, Address and Telephone Number
N c w G �C. .� E inch
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and .
.maintenance of on-site sewage disposal systems. The system:
✓Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: �2 Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
u::,nect ori. 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'
ti•i. report to the appropriate regional office of the Department of Environmental Protection..
I hi, original 5hould be sen; to the syslern owner and copies sent to the buyer, if applicable and the ahpro�ing authormj'.
i�SPECTION SUMMARY:
Check A, B, C, or D:
A) S=ot
ES:
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.
Bl 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 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) 1
One Vfttar lqtreet • Boston, Ma�3*chusett3 02108 0 FAX(617)556-1049 • Telephone(617)292-55W
.r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address; Z3 t-1 D,Ic S+ ti c';il, Iq AN ,✓t2 AA
Owner: L.k N a 01 /31..13 r9N 0
Date of Inspection:
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
CJ 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.
t! SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING INA 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 PUBLTC !NATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM 15 FUNCTIONING IN_A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
EN1'IR0NMENT:
_ The system nay a septic tank ano soli absorption system and is within 100 feet to watt:, swpp:� of tributary to a
surface water supply.
The svqem ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. .
The system has aseptic tank and soil absorption system and is within 50 feet of a private water supply well.
The system ha> a septic tank and soil absorption system and is less than 100 feet.but 50 feet or more from a private water
T 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.
(rev,sed 8/15195) 2
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Z 3 H Da le St. j. lute. Ct b y j
Owner: :
Date of Inspection:
tl�,y1ys •
D1 SYSTEM FAILS (continued):
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($).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation,
T 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 l of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well,
Anv 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 floe, 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
pubic 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.
(revised B/is/95) 3
r
r
f•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: ?3 zf 0,:71 I c S1' N. A c elt M
Owner: L1'1 oR 14 L BANG
Date of Inspection:
i 117
Check if the following have been done:.
✓Pumping information was requested of the owner, occupant, and Board of Health.
VCX cc �
None of the system components have been pumped for at least two weeks and the system has been receivine normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
VThe facility or dwelling was inspected for signs of sewage back-up.
ZThe system does not receive non-sanitary or industrial waste flow
/The site was inspected for signs of breakout.
_ZA11 system components, excluding the Soil Absorption System, have been located on the site.
_JThe 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.
/The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated b�• non-intrusive methods
/The facility, ov.ncr land occupants, if differe.nt frcm owner? were provided with information on the proper maintenance of Sub-
Surface Disposal System.
i.evised 8115195) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2.3 `f U ccic Stree f AJ AN Us c5�2i- /'Acs J
Owner: ti V'Octi A l lean O
Date of Inspection:
It ` t7{ cis
FLOW CONDITIONS
RESIDENTIAL:
Design flow: >;allons
Number of bedrooms:-3—
Number
edrooms:Number of current residents: G�
Garbage grinder (yes or no): 'A-) t
laundry connected to system (yes or no)-
Seasonal use(yes or no):,
Vvater meter readings, if available:
Last date of occupancy,
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design floc+�; gallons/day
Cease trap present; (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Tide S system: (yes or no)_
Veater meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy.:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
7 -I1, G—L-F C3 v a L I
System pumped as pan of inspection: (yes or no)_
If yes, volume pumped ealions
Reason for pumping:
TYPE OF SYSTEM
^_ 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)
APPROXIMATE AGE of all components, date installed (if known) and source of information: -3 yrcr r~S
Sewage odors detected when arriving at the site: (yes or no)
;revised 8/15/95) 5
'F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Dale S'1 , ti. r� /vt C.
Owner:
Date of Inspection:
SEPTIC TANK:_
(locate on site plan)
Depth below grader
Material of construction: _zconcrete metal FRP —other(explain)
Dimensions6 1-4-0!V
Sludge depth:
Distance from top.of sludge to bottom of outlet tee or baffle:,, 3 y r
Scum thickness: 0
D aW6
stance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: /!o
Comments:
irccomntendation 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,) r9,viA r j ('0 D «v Dr T7 C1 Arc» ✓EK `r' C'"4
GREASE TRAP:_
locate on site plan)
Death below grade.
Material of conStruC ion: _„concrete _,_,metal —FRP —other(explain)
f�;rnensions:
�:,rm IhiCkr'tN�S.
Distance from top of scum to top of outlet tee or baffle:
n;Sta^.ce from bottom n cit t^ hottom of nude! tee o, 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
r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2 3 q OAbC $7� �7" N• ,4NOn�`c 2, ivy i yy
Owner: /,tti3OA Al 6A/yc•
Date of Inspection: _
TIGHT OR HOLDING TANK:
(locate on site plan) T
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 BOX:
(locate on site plan)
.r
Deoth of liquid level above outlet invert;
Comments:
(:c"c :f !C%el and d:s!.. b;c eq-,j; e`,;donee of solids car,r)\e•, evidence of leakage into or out of hox. etc 1
ii' e` 's 0 �✓
PUMP CHAMBER:_
(locate on site plan)
Pumps in working ordec(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
4:ev;sed 8/15/95) 7.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Z 3 H 0 X41 s'T. ,� ,q,u 0 o i y _
Owner: L-1 A; 0 r9 Aw Q/jNJ
Date of Inspection:
/,7115=
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: 67
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
` S sats! Si ti F FA/.c 11,QC.
CESSPOOLS: _
f ocate on site plan)
"'umber and configuration;
Depth-top of liquid to inlet invert:
Depth of solids layer,
Depth of scum layer:
Dimensions of cesspool! .
'.taterials of construction:
-,d cation of groundwater:
inflow (cesspool must be pumped as part of inspection)
(.omments: (note conduion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: _
;locate on site plan)
�'aterials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,)
sed 6/15/9.5) 8
,f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Z 3 O 11r;E S T.• -V,
i
Owner: � '9N/,J Gvc 2 A4 -4 car
Date of Inspection: �rA,1�� r4r�E3Avc�
l i/i7�SJ
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
L-Xrs'TtvC,
VV F. D
77S
< 27,5
3b•��
a ig o i�
DEPTH TO GROUNDWATER
f
Depth to groundwater:. y`� feet
rr:ethod of determination or approximation: 1Al-,n 49 e4 G.v
1z+°vied BflS/9S1 9
�-- #ZE►'A1R I eRENOVaTiotit ��at..l
FOR SM)T, SEPTIC 5YSTr=vl
• h►�t
_ NORTIA &v I00VEf2 , Mei - - -
- PaR
(�! 0T(PAUI:S EPISCOPAL. CHuv�c,N
.-- i(i� ME1gRIMbC►C E�16'G SERVIC£5�1��-
��,
�y
- SATE t DEC
p �? y a 20 g-o foo
f
rKor I Soo
C.4LL�WA
P,c SSFTI C
�� +O1C o ��1 _ Ccs SNkC�afG (T'i r
V ;, ,ve ISR�� gol2 �ot� ST6CCPil-In�G�
FOP, PERFOW-M&I-ICS ICEFEIZ
` b Td sKEEIs Iz
0
c6co .,. RC:sECRT C.
_DALEY--_-
CIVIL
No.a zfl
F.,
5 k e-WT 3 o r 3
i
DOT Of
wrl -
1 of 3
ILAI
L a =J
PROJECT: REPAIR/RENOVATE SEPTIC SYSTEM
OWNER: ST. PAUL ' S EPISCOPAL CHURCH
LOCATION : 234 DALE STREET , NORTH ANDOVER Tk%A G4 f TL 23
SUBJECT: OUTLINE OF CONSTRUCTION SPECIFICATIONS
DATE: DECEMBER 9 , 1991
Based on a two bedroom house , and using 165 GPD per bedroom . . .
Total Design Flow = 330 GPD
Based on a Percolation Rate of 20 min/in , use "Trenches " for
leaching facility .
Test Pits on the site , taken on November 26 , 1991 , are as
follows :
TP #1 TP #2 TP #3
0"-24" Top & 0"-24" Top & 0"-24 " Top &
Subsoil Subsoil Subsoil
24 "-84" Brown Silty 24 "-84" Brown Silty 24"-72 " Brown
Till w/ Bones Till w/ Bones Silty Till w/
Bones
Refusal @ 84" Refusal @ 84 " Refusal @ 72 "
No Water Water @ 66 " Water @ 66 "
From these results , the bottom of the new trenches should be set
by the contractor at 12" below what is now the existing ground
surface. Board of Health shall be notified for "Bed Inspection"
There shall be 5 trenches , each trench being 3 ' wide , spaced
apart 9 ' on center , 33 feet long, so as to achieve the required
amount of leaching area (using 12 " sidewall @ 0. 50 GPD/SF and 36 "
Bottom @ 0.33 GPD/SF) .
Existing tank and pit shall be disconnected , pumped out, removed
and lawfully disposed of.
MERRIMACK ENGINEERING SERVICES,INC. - 66 PARK STREET - ANDOVER,MASSACHUSETTS 01810
2 of 3
Proposed 1 ,500 gallon precast concrete septic tank and 9-hole
distribution box shall be installed , as shown on the schematic
site plan or as directed in the field by the Town of North
Andover Board of Health .
All fill for the leaching facility shall be clean sand or gravel .
All top and subsoil shall be stripped between property sidelines
within 10 ' of the proposed leaching facility and stockpiled
on-site at least 100 ' from the wetlands or removed from the site .
Upon completion of septic system and prior to backfilling , the
contractor shall contact the design engineer and the Board of
Health for a final inspection and "As-built" survey.
MERRIMACK ENGINEERING SERVICES,INC. 66 PARK STREET • ANDOVER,MASSACHUSETTS 01810
SEPTIC SYSTEM INSPECTION FORM
ADDRESS 2 `t
DATE INSPECTED '
PROPERLY FUNCTIONING? N
WEATHER CONDITIONS
COMMENTS :
a
WATER QUALITY TES i tb n ReSoL-?S?
DYE TEST PERFORMED? Y N
DATE?
SKETCI�
ro 00
""""\-E_S1D_LNT5 QTLTESTIONNAIRE
W11Z
11-511Y
2. Street Address t'
3. uv, many members are in your household?
4. What type of sewage disposal system do you have?
—1i
cesspool
septic tank and leaching area
connection to municipal sewerf.
L-1 other (describe)
,__1 do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health?
yes ❑ no F1 do not know
15. 11pw old is your sewage disposal system? 0 0-5 years El 6-10 years El 11-20 years
over 20 years F1 do not know
7. Has your sewage disposal system been rebuilt or repaired?
El yes no F] do not know
If ves, approximately how long ago? years. What was done?
S. How frequently is your sewage disposal system pumped out? El annually
❑ every 2-4 years Lq every 5-10 years El over 10 years El never
9. Have you had any problems with your sewage disposal system? 0 yes no
If yes, what problems?
El repeated pump-outs needed
El system clogs, backs up, or drains slowly
F odors
El sewage surfaces through ground
10. 'How many of each appliance are connected to.your sewage disposal system?
washing machine dishwasher garbage disposal
dehumidifier drain sump pump toilet
roofJ/pavernent drains showerlbathtub L/
brand and type (liquid or
11. '';ease state the powder) of detergent you use for:
diEhivasher kdz1=5' j7o/ 6-7,11"?
clotheswasher X e
12. Does your property have a lawn? El yes [Vn 0
I
,f yes, approximately what size? -1 M 3/4 acre El 1 acre
1 1
17 less than 1/4 acre El 1/4 acre F 2acre El
71❑ more than 1 acre (Specify) — acres
13. --Iow often do you fertilize your lawn?
4o. of applications per year
of the year —
14. 21--ase stto the brand and type (liquid or granular) of lawn fertilizer you use:
AZO7,/ e
C_j� -ck here if your lawn is maintained by a professional landscape contractor.
MERRIMACK ENGI klG�IERIVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL.(508)475-3555, 373-5721 • FAX(508)475-1448
May 6 , 1992
Town of North Andover
Board of Health
Town Hall - Main Street
North Andover , MA 01845
RE: #234 Dale Street - Septic Repair
Dear Mr. Rosati :
As of this date , we have completed our inspection of the
installation of the new septic system in place of the original
cesspool .
The system is installed correctly and the few minor changes have
been done to my satisfaction .
In order to expedite the process , I have told Steve Breen to back
fill the system and to ensure that the piping to the trenches
from the distribution box are properly "haunched " to prevent any
settlement.
Should you have any questions or comments , please feel free to
contact me .
Very truly yours ,
MERRIMACK ENGINEERING SERVICES
o ert C . Daley , PE
Project Engineer
sh
cc : St. Paul ' s Church
E r �
is
COMMONWEALTH OF MASSACHUSETTSID
D l-cS
lopEXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:aj Y O A L I :�-7-
AJ D Tli N PO y i a,
Owner's Name: C 1.1 R 15 TI,v F .M ELV I V
Owner's Address: Z 3 V Oft LE ST
tii e an-( Ar/v D Do -12 iyt A
Date of Inspection: /�/TTS
Name of Inspector:(please print)__
Company Name: /Vee IUL,.j.Ayj) CiVL�1g9t��/1��t�
Mailing Address: &ooizcv
Telephone Number. 1'7,9— 6 0 G- j 7 6 g
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 eicperience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.004 The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: b 0 oi
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. t. ori,» GF
Notes and Comments
NOV 2 6 2001
****This report only describes conditions at the time of inspection and underconditions of use at that
time.This inspection does not address how the system will&MM-iwthe 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: 2 3 DFI-t_r 5T-02 r�
N C� tLTI-I A N Doo is(L iYl 4
Owner: 6M21 Ni:' 114 ELVl.A!
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sy em Passes:
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. Syste Conditionally Passes:
One or a system components as described in the"Conditional Pass"section needto be replaced or
repaired The cyst. ,upon completion of the'replacement or repair,as approved by the d of Health,will pass.
Answer yes,no or not det ined(Y,N,ND)in the for the following stat ents.If"not determined"please
explain.
The septic tank is metal an over 20 years old* or the septic (whether metal or not)is structurally
unsound,exhibits substantial infiltra•on or exfiltration or tank fa' a is imminent.System will pass inspection if the
existing tank is replaced with a compl • g septic tank as appr ed by the Board of Health.
*A metal septic tank will pass inspection• it is structu call sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years d is avail e.
ND explain:
Observation of sewage backup or out or • static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, ed or uneven di button box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are repla
obstruction is removed
distribution box is leveled or r laced
ND explain:
The em required pumping more than 4 times a year due to broken obstructed pipe(s).The system will
pass in on if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
i
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Z 3) PPLe
Owner: C N 2iST[A.'C" MEt-VI'v
Date of Inspection:- i i/t aI&
C. Further Evaluation is Required by the Board of Health:
ditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to otect public health,safety or the environment.
1. System I pass unless Board of Health determines in accordance with 310 C 5.303(1)(b)that the
system is no unctioning in a manner which will protect public health,safety d the environment:
_ Cesspool or ivy is within 50 feet of a surface water
_ Cesspool or pri is within 50 feet of a bordering vegetated wetland a salt marsh
i
i"
2. System will fail unless the Board o ealth(and Public4ater Supplier,if any)determines that the
system is functioning in a manner that pr ects the publit/health,safety and environment:
The system has a septic tank and soil a on system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface J supply.
_ The system has a septic tank and Si and the S is within a Zone 1 of a public water supply.
_ The system has a septic tank d SAS and the SAS is 'thin 50 feet of a private water supply well.
The system has a septi and SAS and the SAS is less 100 feet but 50 feet or more from a
private water supply we'
.Method used to determine distance
**This system p if the well water analysis,performed at a DEP ed laboratory,for coliform
bacteria and vol ile organic compounds indicates that the well is free fro llution from that facility and
the presence ammonia nitrogen and nitrate nitrogen is equal to or less than ppm,provided that no other
failure a'eria are triggered.A copy of the analysis must be attached to this fo
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: Z3 1i C�,.t-i:, S-TtEi;
' _Mi7 fZl�l-/ t�lllD�v�� �btl4 i
Owner: C s" AJ
Date of Inspection:J s o
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
_Z Liquid depth in cesspool is less than 6"below invert or available volume is less than''/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 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 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.]
-JVD(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.
F- a Systems:
To be co red a large system the system must serve a facility with a design flow of 10 gpd to 15,000
gpd•
You must indicate either "or"no"to each of the following:
(The following criteria apply to a systems in addition to the criteria a
yes no
— _ the system is within 400 feet of a surfa water supply
the system is within 200 feet of a tri ary to a s drinking water supply
— _ the system is located in ' ogen sensitive area(Interim a ead Protection Area-IWPA)or a mapped
Zone II of a public er supply well
If you have answ "yes"to any question in Section E the system is considered a s ificant threat,or answered
"yes"in S n D above the large system has failed.The owner or operator of any large em considered a
si ' cant threat under Section E or failed under Section D shall upgrade the system in actor ce with 310 CMR
5.304.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: _ r34 DAL-C-'
-]V 0 12.1-H Ay Oct F 12 ,,K f}
Owner: E M R i r Tw[ iU _1..v t il' `
Date of Inspection: I I 10to t
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
W
ere any of the system components pumped out in the previous two weeks? '
Has the system received normal flows in the previous two weekP eriod?
v" 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 br 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.
'Z 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 I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2 3 4 D O L sT-(t E:rr
NOrzTH A,-j DO uC--Q ./vi A
Owner: C f-C(z t S.-n IV F M E L-t/Iw
Date of Inspection: "4)0
/ r
FLOW CONDTITONS
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: 11
Does residence have a garbage grinder(yes or no): !L0
Is laundry on a separate sewage system(yes or no):_At2 [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):_, /C ,
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): n/z
Last date of occupancy: (-J r,•t,ci
CONIIMIERCIAL(MUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): Qnd
Basis of design flow(seats/persons/sgft,ete.):
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):
GENERAi.INFORMATION
Pumping Records
Source of information: - S Yrs 01-0 A-T
Was system pumped as part of the inspection(yes or no):A
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
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:
C,
Were sewage odors detected when arriving at the site(yes or no): IV
Page 7 of I I :F
s
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Z 3 9 DOL` _'�,f2 t
PnTLT{•f Pte:Uou Q
Owner: C R(ztkil A; &V(4/
Date of Inspection: i/b o ky
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade:_
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: J O 0
Sludge depth: '3..
Distance from top of sludge to bottom of outlet tee or baffle: 2S
Scum thickness: _
Distance from top of scum to top of outlet tee or baffle: t3"
Distance from bottom of scum to bottom of outlet tee or baffle: 19
How were dimensions determined: Ir
Pc iA
Comments(on Pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
iAtiK r� G—c�a � ( �•,� �uu (` N�kti ! � s t�✓
GREASE TRAP:t&(locate on site plan)
Depth below grade:_
Material of construction:_concrete metal fiberglass
(explain): _--polyethylene_other
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 baffie:
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 ASSESSMENTSY�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Z 3 4 D rtt•E .STS Ec-T
W6 RTR Arm Dove R n.A
Owner: CHaisnev�-=
Date of Inspection: n i4pl
TIGHT or HOLDING TANK:.1V-A-(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.):
DLSTRIBUTION BOX: (if present must be openWocate on site plan)
Depth of liquid level above outlet invert: ]
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.):
O PL. x {ti 6-6 0 i� C.c V iJ Tl G•V.
PUMP CHAMBERW lc� (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 l
tuL �
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 ?5 y nAI— ,—
N o R-T-H Afv i0"' g- 11A#4
Owner: CK(Zlsi.A rVEW 14
Date of Inspection: i 11)of o 1
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: y -rxertclves FkpyAo r 7
leaching fields,number,dimensions:
overflow cesspool,number:
innovativetalternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
Ft2Er'� a� Sy.s�'m c-oc���s �i2mAt� stf� �8/vDi�y(� Df1n�P
tam 02 Cls?rsSU14 L— yELr-moi 7'?0ta
CESSPOOLS: (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.):
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 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 31 p A iE .Sfi7LE,—T
wo a7'N A A-)9 L)a
Owner: N -)s N' Chill%
Date of Inspection: // i�
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.
OfLI�� •
Ixa�e
�.b
-3;
z
Page 11 of 11
r 4�
Y'�r?'tf
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 234 DAl-
__NO,2TH A-,j7tpy[=0-, stn9
Owner:_ cHt2i5TjNE' /VIELVov
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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, (attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation: