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HomeMy WebLinkAboutMiscellaneous - 29 WILDWOOD CIRCLE 4/30/2018 (2)F.P. REILLY AND SONS, INC. 206 ANDOVER STREET, SUITE 11 ANDOVER, MA 01810 (508) 475-1237 SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION r 1997 Property Address: 29 Wildwood Circle, North Andover, MA 01845 Address of Owner (if different): N/A Name of Inspector: Peter F. Reilly (I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name, Address, Phone #: F. P. Reilly & Sons, 206 Andover St., Suite 11 Andover, MA 01810 (508) 475-1237 / (508) 475-4370 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information is true, accurate and complete as of the time ofinspection. 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 N/A Conditionally Passes N/A Needs Further Evaluation By the Local Approving Authority N/A Fails r Inspector's Signature: Date: September 20, 1997 P ter F. Re llyr The system inspector shall submit a copy of this inspection report to the approving authority within thirty (30) days of completing this inspection. If the system is a shared system d has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the 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: A. SYSTEM PASSES: Check A, B, C or D ✓ I have not found any information which indicates that thesystem violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 B. SYSTEM CONDITIONALLY PASSES: N/A 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, ND). Describe basis of determination in all irstances. If "not determined", explain why not) N The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfrltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is repla(ed with a conforming septic tank as approved by the Board of Health. N Sewage backup or breakout or static high 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 (withapproval of the Board of Health): N/A broken pipe(s) are replaced N/A obstruction is removed N/A distribution box is leveled 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): N/A broken pipe(s) are replaced N/A 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 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: N/A Cesspool of privy is within 50 feet of a surface water N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh. 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: N/A The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. N/A The system has a septic tank and soil absorption and is within a Zone I of a public water supply well. N/A The system has a septic tank and soil absorption and is less than 100 feet but 50 feet or more from a private water supply well, unless a water 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 nitratenitrogen is equal to or less than 5 ppm. Method used to determine distance N/A (approximation not valid). SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 D. SYSTEM FAILS: N/A 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. N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N/A Liquid depth in cesspool <6" below invert or available volume < 1/2 day flow. N required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: none N Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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 a large system in addition to the criteria above. N/A The design flow of system is 10,000 gpd orgreater (Large System) and the system is a significant threat to pubk health and safety and the environment because one or more of the following conditions exist: N The system is within 400 feet of a surface drinking water supply N The system is within 200 feet of a tributary to a surface drinking water supply N The system is located in a nitrogen sensitive area (Interim Wellhead 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 DEP for further information. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART B - CHECKLIST Property Address: 29 Wildwood Circle, Lane, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 Check if the following have been done: ✓ Pumping 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 during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. N/A As built plans have been obtained and examined. Note they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage backup. ✓ The system does not receive non -sanitary or industrial waste flow. ✓ The site was inspected for signs of breakout. ✓ All system components, excluding the SAS, 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. ✓ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. The size and location of the SAS on the site has been determined based on: N/A Existing information (Example: Plan at BOH). N/A Determined in the field if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable [15.302(3)(b)]. PART C - SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design Flow (gpd/bedroom for SAS): 440 gallons (110 gpd/bedroom) Number of bedrooms: 4 Current residents: 5 Garbage grinder: no Laundry connected to system: yes Seasonal use: no Water meter readings, if available: not available - private well Sump Pump (yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of Establishment: N/A Design Flow: N/A Grease trap present: N/A Industrial waste holding tank N/A Non -sanitary waste discharged the Title 5 system N/A Water meter readings, if available: N/A Last date of occupancy: N/A OTHER: Describe: N/A Last date of occupancy: N/A SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 GENERAL INFORMATION PUMPING RECORDS and source of information: last pumping: April 1997 according to owner System pumped as part of inspection: no if yes, volume pumped: N/A gallons Reason for pumping: N/A TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy NO Shared system (yes or no - if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: System installed in 1984 when house was constructed. Sewage odors detected when arriving at the site NO BUILDING SEWER: (locate on site plan) Depth below grade: 24" material of construction: ✓ cast iron 40 PVC other (explain) Distance from private water supply well or suction line about 100 feet Diameter: 4" Comments: Condition of joints, venting, evidence of leakage, etc.) Building sewer was watertight and appeared sound. SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 24" material of construction: ✓ concrete metal FRP other (explain) Dimensions: rectangular - 1,500 gallons < 1 " sludge depth 28" distance from top of sludge to bottom of outlet tee or baffle < 1" scum thickness 6" distance from top of scum to top of outlet tee or baffle 14" 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 integrity, evidence of leakage, recommendations for repairs, etc.) Tank was watertight, baffles were in good condition and tank was operating properly. Property Address: Owner's Name: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) 29 Wildwood Circle, North Andover, MA David Tremblay 9/20/97 GREASE TRAP: N/A (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 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 integrity, evidence of leakage, recommendations for repairs, etc.) N/A TIGHT OR HOLDING TANK: N/A (locate on site plan) Depth below grade: material of construction: concrete metal FRP other (explain) Dimensions: N/A Capacity: N/A gallons per day Design Flow: N/A gallons per day Alarm level: N/A Alarm in working order N/A Date of previous pumping: N/A Comments: (condition of inlet tee, condition of alarm and float switches, etc.) N/A DISTRIBUTION BOX: ✓ (locate on site plan) 0" depth of liquid above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) The d -box was watertight, level and functioning properly. There was no evidence of solids carryover. PUMP CHAMBER: N/A (locate on site plan) N/A Pumps in working order (yes or no) N/A Alarms in working order (yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenames, recommendations for maintenance or repairs, etc.) N/A SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 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: not applicable Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number alternative system (name of technology)N/A N/A N/A N/A two (2) trenches estimated 40 to 50 feet long N/A N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommmdations for maintenance, repairs, etc.) Soils over leaching area were good, no evidence of breakout. CESSPOOLS: N/A (locate on site plan) number and configuration N/A depth -top of liquid to inlet invert N/A depth of solids layer N/A depth of scum layer N/A dimensions of cesspool N/A materials of construction N/A indication of groundwater inflow (cesspool must be pumped as part of inspection) N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable PRIVY: N/A (locate on site plan) materials of construction N/A dimensions N/A depth of solids N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: _ 9/20/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: indicate at least two permanent references, landmarks, or benchmarks, locate where public water system enters house locate all wells within 100' N/A 1,500 /20 / /t -M. Srpir C. t4ik Screen Pore 2 - -5""7 ___ _4- C O Do%ht54-i L we I 1 710' SEPTIC TANK TIES: A to Inlet (I) 2511" B to Inlet 1414" A to Center (C) 28'0" B to Center 1310" A to Outlet (0) 3114" B to Outlet 1311" D -BOX TIES: B to Box 291810 B to Box 3 7 110 NOTE: The septic tank is in the side yard and the leaching area is in the front yard. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 DEPTH TO GROUNDWATER Depth to Groundwater 2'-4' (below bottom of SAS) Indicate all methods used to determine High Groundwater Elevation: N Obtained from Design Plans on record Y Observation of Site (abutting property, observation hole, basement sump, etc.) Y Determined from local conditions N Check with Local BOH N Check FEMA Maps N Check pumping records Y Check local excavators, installers N Use USGS Data Describe in words how High Groundwater Elevation was established: Grade changes in the area indicated no groundwater in the SAS. Nearby wetland area is substantially downgradient of SAS. SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No (,c�� �Q�(,cJ0c7rl Lot No Loc/Subdiv. Pland Owner Investigator j*'�F'r� Observer [ll1TT T)DALITT L1 r%AML Q l.'Elev V n 3.Elev 3 4 4 5 6 7 3 5 6 7 8 Benchmark Elevation 11 DATES 9 010 Location Datum PERCO;,ATION TESTS 0 1 2 3 5 6 7 8 9 10 4.Elev Ties Pills est Pit Number 1 2 3 �+ Start Saturation Soak -Minutes Start e Drop of 3" -Time Drop of 6" -Time M6ms.lst 3" drop Mins.2nd " Drop Percolation Board of Health W. BEFTIC SISTEK North Anc_overzMaas. ` ,. INSTALLATIGK CMg LIST 1l e FAIL OK LOT G 1&D UJMP 1EXCAVATICIN ,y L eaa_ cl p,v6UT- A - /1 50 oe 1. Distance Tot a. Wetlands b. Drains c. Well � 2. Water Line Location 3. No PPC Pipe $. Septic Tank ,, r_ t►,sl 1�--�iE� a. _Tess -_Length & To Clean Ont Covers. b. Cement Pipe to Tank Oa Both Sides of Tank 5• Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach s a* cions b. ne Depth c. lash Pads d. Tees Cement 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 -with Regard -to Perc Test d. Elevations % e: Water Table Board of Health ` No rt):: -n do ve r, ?Sas s APPROVED DATE Provide r xo SUBSURFACE DISPOSAL DFMGN CHECK LIST DISAPPROU,D DATE Reasons;. --ee T.4.. CZE LOT 1 3 w1��woc�p Title V FAIL OK Reg 2.5 The submitted plan wast show as a mini '- a) the lot to be served-area,dimensions lot #,abutters location and log deep observation hoes -distance to ties C location and results percolation tests- di. stance to ties d design calculations & calculations showing required leaching area e location and dimensions of system -including reserve area f) existing and proposed contours g) location any wet areas Athin 100' of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 100111 of sewage disposal system or disclaimer (i) location any drainage easements utthin 7D01 of serge disposal system or disclaimer -Planning Board files (j) kno= sources of water sLrply within 2001 of sage disposal e _ system or discl_siner ✓ k) location of any proposed well to serve lot -1001 from leaching facilit. (1) location of Iter lines on prope+'ty-101 from leaching facility --, Am) location of benchmark n) driveways - - n/n e44 e,Fr,,E garbage disposals no PVC to be used in construction i e septic tank.., q) profile of system -elevations of basement, plumb, p p , ep distribution box inlets and outlets, distribution field piping and ®cher elevations rs) may{mSSm ground S,aterelevation in area se-6-agedisxos81 system plan must be prepared by a Professional Eagineer or other I professional authorized by lax to prepare such plans Reg 6 I Septic Tanks a) capacit� ies 150% of flog, vater table, tees, depth of tees, access, pu-ming cleanout eq lot from cellar wall or inground s � ng Pool d) 251 from subsurface drains Reg 10.2 I Distribution Boxes a) s ope greater than 0.08 Reg 10.4 I b) stamp .�y face pD={ =i Chi^ List Pape 2 IFI.I, I CKI Leaching Pits Leaching pits are preferred mere the installation is possible tog 3-1.2 I a) calculations ofil�eaching area-niLni=m 500 sq ft u.4b) spacing 11.10 c surface a 2% u.11, d� cover tenial e) splash pad f) at elbow g) bends in .pipe from d -box to pipe Leaching Fields ` ;eg 15.1 a no greater t an'20 adnutes/inch b area- J Bq ft X5.4 c construc of field 15.8 d) surfac irainage 2 % 3,7 e) 20� m cellar wall or inground swing pool Leaching Trmchss C) tag 14.1 a) calculations of leaching area -n n 500 sq ft 14.3.3 ) spacing -4 ft tadn 6 ft with reserve between .4 dimensions 14.6 construction 14.7 a stone 1410 surface dra, a 2% Dounhill Slone a) slope -y7x ---Ito be shown) b) y/x Z 150 - (to be shown) Pumas leg 9.1 a) =d-by 9.6 b) power �EA�t , N ►N n 1 S(� D.R iEa v �.t �.res S 'VG5I 4rJ Foil ti at��►�►w t 30 Co " ro J e— 10' Flt4 -' r-3 -U 014— l.0 r" 4 i?o"J►.3 P, L . L M -u -k 3 SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No lJl_J AW(16 �l�a-c-� P Lot No Loc/Subdiv. Pland Owner Investigator ef1',A A-ct<- Observer ✓mac KCS SOIL PROFILE DATES 1.Elev 2.Elev 3.Elev 4.Elev Benchmark Elevation 0 1 0 21 I 2 31 1 3 41 1 4 5 5 6 6 71 1 7 81 1 8 9 9 10 10 0 1 2 3 4 5 6 7 8 9 10 Ties tp Test Pits U� I\ Location Datum PERCO;,ATION TESTS 0-1, 1 r VAUZZ Vx c cmc? Pit Number 2 3 4 c. 5 Start Saturation Soak -Minutes s Start e Drop of 3" -Time 1 Drop of 6" -Time Mmms.lst 3" drop Mins.2nd " Drop 5 Percolation '? L-�RA mL 1 r F.P. REILLY AND SONS, INC. 206 ANDOVER STREET, SUITE I1 ANDOVER, MA 01810 (508) 475-1237 SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION Property Address: 29 Wildwood Circle, North Andover, MA 01845 Address of Owner (if different): N/A Name of Inspector: Peter F. Reilly 0 am a DEP approved system inspector pursuant to Section 15.340 or Title 5 (310 CMR 15.000) Company Name, Address, Phone #: F.P. Reilly & Sons, 206 Andover St., Suite 11 Andover, MA 01810 (508) 475-1237 / (508) 475-4370 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information is true, accurate and complete as of the time ofinspection. 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 N/A Conditionally Passes NIA Needs Further Evaluation By the Local Approving Authority N/A Fails Inspector's Signature: , Date: September 20, 1997 Peter F. Reill The system inspector shall submit a copy of this inspection report to the approving authority within thirty (30) days of completing this inspection. If the system is a shared system d has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the 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: A. SYSTEM PASSES: Check A, B, C or D ✓ I have not found any information which indicates that thesystem violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. [4 SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 B. SYSTEM CONDITIONALLY PASSES: N/A 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, ND). Describe basis of determination in all instances. If "not determined", explain why not) N 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. N Sewage backup or breakout or static high 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 (withapproval of the Board of Health): N/A broken pipe(s) are replaced N/A obstruction is removed N/A distribution box is leveled 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): N/A broken pipe(s) are replaced N/A 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 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: N/A Cesspool of privy is within 50 feet of a surface water N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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: N/A The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. N/A The system has a septic tank and soil absorption and is within a Zone I of a public water supply well. N/A The system has a septic tank and soil absorption and is less than 100 feet but 50 feet or more from a private water supply well, unless a water well water analysis for coliform bacteria and volatile oganic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitratenitrogen is equal to or less than 5 ppm. Method used to determine distance N/A (approximation not valid). SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 D. SYSTEM FAILS: N/A 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 Niall be necessary to correct the failure. N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N/A Liquid depth in cesspool <6" below invert or available volume <'/z day flow. N required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: none N Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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 a large system in addition to the criteria above. N/A The design flow of system is 10,000 gpd orgreater (Large System) and the system is a significant threat to pubk health and safety and the environment because one or more of the following conditions exist: N The system is within 400 feet of a surface drinking water supply N The system is within 200 feet of a tributary to a surface drinking water supply N The system is located in a nitrog water supply well) en sensitive area (Interim Wellhead Area (IWPA) or a mapped Zone 11 of a public 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 DEP for further information. ir SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART B - CHECKLIST Property Address: 29 Wildwood Circle, Lane, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 Check if the following have been done: ✓ Pumping 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 during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. N/A As built plans have been obtained and examined. Note they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage backup. ✓ The system does not receive non -sanitary or industrial waste flow. ✓ The site was inspected for signs of breakout. ✓ All system components, excluding the SAS, 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. ✓ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. The size and location of the SAS on the site has been determined based on: N/A Existing information (Example: Plan at BOH). N/A Determined in the field if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable (15.302(3)(b)] . PART C - SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design Flow (gpd/bedroom for SAS): 440 gallons 010 gpd/bedroom) Number of bedrooms: 4 Current residents: 5 Garbage grinder: no Laundry connected to system: yes Seasonal use: no Water meter readings, if available: Sump Pump (yes or no): not available - private well Last date of occupancy: no current COMMERCIAL/INDUSTRIAL: Type of Establishment: N/A Design Flow: N/A Grease trap present: N/A Industrial waste holding tank N/A Non -sanitary waste discharged the Title 5 system N/A Water meter readings, if available: N/A Last date of occupancy: N/A OTHER: Describe: N/A Last date of occupancy: N/A .e SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 GENERAL INFORMATION PUMPING RECORDS and source of information: last pumping: April 1997 according to owner System pumped as part of inspection: no if yes, volume pumped: N/A gallons Reason for pumping: N/A TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy NO Shared system (yes or no - if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: System installed in 1984 when house was constructed. Sewage odors detected when arriving at the site NO BUILDING SEWER: (locate on site plan) Depth below grade: 2-4" material of construction: ✓ cast iron 40 PVC other (explain) Distance from private water supply well or suction line about 100 feet Diameter: 4" Comments: Condition of joints, venting, evidence of leakage, etc.) Building sewer was watertight and appeared sound. SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 2-4" material of construction: ✓ concrete metal FRP other (explain) Dimensions: rectangular - 1,500 gallons <1" sludge depth 28" distance from top of sludge to bottom of outlet tee or baffle < 1 " scum thickness 6" distance from top of scum to top of outlet tee or baffle 14" 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 integrity, evidence of leakage, recommendations for repairs, etc.) Tank was watertight, baffles were in good condition and tank was operating properly. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 GREASE TRAP: N/A (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 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 integrity, evidence of leakage, recommendations for repairs, etc.) N/A TIGHT OR HOLDING TANK: N/A (locate on site plan) Depth below grade: material of construction: concrete metal FRP other (explain) Dimensions: N/A Capacity: N/A gallons per day Design Flow: N/A gallons per day Alarm level: N/A Alarm in working order N/A Date of previous pumping: N/A Comments: (condition of inlet tee, condition of alarm and float switches, etc.) N/A DISTRIBUTION BOX: ✓ (locate on site plan) 0" depth of liquid above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) The d -box was watertight, level and functioning properly. There was no evidence of solids carryover. PUMP CHAMBER: N/A (locate on site plan) N/A Pumps in working order (yes or no) NIA Alarms in working order (yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenarces, recommendations for maintenance or repairs, etc.) N/A .B r SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address_: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 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: not applicable Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number alternative system (name of technology)N/A N/A N/A N/A two (2) trenches estimated 40 to 50 feet long N/A N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recomm®dations for maintenance, repairs, etc.) Soils over leaching area were good, no evidence of breakout. CESSPOOLS: N/A (locate on site plan) number and configuration N/A depth -top of liquid to inlet invert N/A depth of solids layer N/A depth of scum layer N/A dimensions of cesspool N/A materials of construction N/A indication of groundwater inflow (cesspool must be pumped as part of inspection) N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recomn ,lotions for maintenance or repairs, etc.) not applicable PRIVY: N/A (locate on site plan) materials of construction N/A dimensions N/A depth of solids N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommtlations for maintenance or repairs, etc.) not applicable ,a SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: indicate at least two permanent references, landmarks, or benchmarks, locate where public water system enters house locate all wells within 100' N/A Scrce-n Pore R 2 - 54ar7 C O DoN,5frL we I I 71 °O SEPTIC TANK TIES: A to Inlet (I) 25111, B to Inlet 14 '4 " A to Center (C) 2810" B to Center 1310" A to Outlet (0) 3114" B to Outlet 1311" D -BOX TIES: B to Box 19' 8" to Box 371101, NOTE: The septic tank is in the side yard and the leaching area is in the front yard. AS - .s f r SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 29 Wildwood Circle, North Andover, MA Owner's Name: David Tremblay Date of Inspection: 9/20/97 DEPTH TO GROUNDWATER Depth to Groundwater 2'-4' (below bottom of SAS) Indicate all methods used to determine High Groundwater Elevation: N Obtained from Design Plans on record Y Observation of Site (abutting property, observation hole, basement sump, etc.) Y Determined from local conditions N Check with Local BOH N Check FEMA Maps N Check pumping records Y Check local excavators, installers N Use USGS Data Describe in words how High Groundwater Elevation was established: Grade changes in the area indicated no groundwater in the SAS. Nearby wetland area is substantially downgradient of SAS.