HomeMy WebLinkAboutMiscellaneous - 370 SALEM STREET 4/30/2018 (3)WILLIAM F WELD
Governor
ARGEO PAUL CELLUCCI
Lt. Govcmor
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CO.MMON�1'EALTWOf MASSACHUSETTS
FJUNEXECUTIVE OFFICE OF ENVIRONMENTALAFFAIil
--
DEPARTMENT OF ENVIRONMENTAL PROT
ONE WINTER STREET. BOSTON. ht.4 02108 6I1-:92.5500
TRUDY C0)
Secreu
DA%ID 8 STRW
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissior
PART A
CERTIFICATION
Property Address: 3 `?O 541e-- <D1 ,4J- Q VC, 0, Address of Owner:
Dale of Inspection: 5 /6 - y S (If different)
Nome of Inspector: t k l� n
W! -Ft d�
I am a DEP a proved system inspect pursuant to Section 15.340 of Title S (310 CMR 13.000)
Company Name: -
Mailing Address: L '(4 �rC
Telephone Number: c4O 4 7 co c.
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 (unction and
maintenance of on-site sewage disposal systems. The system:
te
' \ passes
_ Conditionally Passes
_ reeds Further E%aluation 8v the Local Approving Authority
Fads
Ih4pecto0 Signa Date:
The S%•stem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (301 days of completing this
Inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system own
end copies sent to the buyer, if applicable. and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
Al SYSTEM PASSES:
I have not found any intormaiioh which Indicates that the system violates any of the failure criteria as defined in 310 CMR
Any failure criteria not evaluated are indicated below.
COMMENTS:
15.30'
III SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass- section need to be replaced or repaired. The system, up
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N. or NO). Describe basis of determination in all instances. If "not determined', explain why not.
_ The septic tank Is metal, unless the owner or operator has provided the system inspectdr with a copy of a Certificate of
Compliance tattachedl indicating that the tank was installed within twenty (201 years prior to the date of the inspection:
the septic tank, whether or not metal, is cracked. structurally unsound, shows substantial, infiltration or exfiltration, or taf
failure is imminent. The system will pass inspection it the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised Os/lS/stl page i of to
DEP an CN WOM WifeWOO' h"O" "W magna soft nr.uMOae
A pf"ed ." Fteew re Parr -
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
3
-2d �3/1"
K ti L -L tp (),c
81 SYSTEM CONDITIONALLY PASSES (continuedi
Sewage backup or breakout or high static water level' observed in the distribution box is due to broken or obstructed
pipels) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Healthl. Describe observations:
broken pipels) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken nr obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipelst are replaced
obstruction is removed
Cl 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.
i) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply,
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supn'v well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well. unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and thB presenctD of ammonia nitrogen and nitrate nitrogen is equal to or
less than S ppm: Method used to determine distance (approximation not valid).
3) OTHER
tteoisad 04/25//71 rap ! a! it
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3 �O Sei1e*—,
Owner: e. I(e \
Date of Inspection: P
D) SYSTEM FAILS: /&
You must indicate ether "Yes- or "No' as to each of a following:
I have determined that the system violates o e or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. T e Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
_ Backupof sewage. into facility or sy em component due to an overfoaded or clogged SAS or cesspool.
Discharge or ponding of effluent to t e surface of the ground or surface waters due to an overloaded or clogged W or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is les, thin " below invert or available volume is less than 1/2 day flow..
_ Required pumping more than 4 times in the last year NQT due to dogged or obstructed pipets),
Number of times pumped _
Any portion of the Soil Absorption Stem, cesspool or privy is below the high groundwater elevation
Anv porton of a cesspool or privy is ithin 100 feet of a surface water supply or tributary to a surface water suppl%..
Any porton of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy IS within 50 feet of a private water supply well.
Anv portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well wills no
acceotable water quality analysis. If the well has been analyzed to be acceptable. attach copy of well water analysis for
coliform bacteria, volatile organic c pounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No- as to each of thit following:
The following criteria apply to large systems ir addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment cause one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surf ice drinking water supply
the system is within 200 feet of a tribi tary to a surface drinking water supply
the system is located in a nitrogen ser 0tive area (Interim Wellhead Protection Area - IWPAI or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 0*/15/971 Prase 3 of 16
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3 ?d �� j e i v` 37- A
Owner: iC� ffit`pfe-
Date of Inspection: d
L6 - il��
Check if the following have been done: You must indicate either "Yes" or 'No" as to ew-+ of rho following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
✓ None of the system components have been Dumped _ ped 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 pan of this inspection
N_ As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non -sanitary or industrial waste flow.
The site �%as inspected for signs of breakout.
✓ _ All s%stem components. excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tuck was inspected for condition of
barites or tees. material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/ The size and location of the 50d Absorption System on the site has been determined based on:
✓ _ The facit ry owner (and occupants, if different from owner were provided with information on the proper maintenance of
Sub -Surface Disposal System.
/ v111A _ Existine information. Ex. Plan at B.O.H.
_ Determined in the field ttf any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptabtei (15.301(3)(b)(
(re.feed 04/36/971 1 rage 4 e! 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 3 76 w, �4e�%avec�
Owner-
Date
c,' n�e�—l�✓v�t�% K/V 4-e,0�G�r
Date of Inspection: i/ /v�_
FLOW CONDITIONS
RESIDENTIAL:
Design flow it.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents:
Garbage girder (yes or no!:
Laundry corrected to systees or no):
Seasonal use Lyes or no►:_L�/ Y -
Water meter readings. if available (last two Ili year usage Igpd):/T--Qo50 1 0 Cf 454(0711- �T12-
Sump Pump Ives or no).
Last date of occupann• IW 2 A, f—
COMMERCI,UINOUSTRIAL:
Type of establishment:
Design flow-gallons+dav
Grease trap present: Ives or not_
Industrial Waste Holdmit Tank Present: Ives or not_
Nori-sanitary waste dtscnarged to the Title 5 system (yes or no)_
Water meter readings. ii available
Last date of oe:uaanc\
OTHER: (Describe!
Last date of occuoann-
GENERAL INFORMATION
PUMPING RECORDS, and
System pumped as part of inspection: (yes or no)
If yes, volume pumped: gallons
Reason for pumping
TYP Of SYSTEM
Septic tank/distribution box/soil absorpttnn system
Single cesspool
Overflow cesspool
Privy
, VIO Shared system (yes or no) (if yes. attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: Fi z lJ e—,\. -
Sewage
,\.
Sewage odors detected when arriving at the site: lyes or not �
(sNlsed 04/23/97)
Page 9 69 to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Property Address: 3 7o :5,11 ei„` S
Owner:
Date of Inspection: ��
BUILDING SEWER:
(locate on site plan)
PART C
SYSTEM INFORMATION (continued)
kA
1=Al
Depth below grade:
Material of construction: _ cast iron'_ 40 PVC _ other (explain)
Distance from private water supply well or suction hr,
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:'
(locate on site plant
Depth below grader /'1 S
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explainl
If tank is metal, Inst age _ Is age confirmed by Cenificate of Compliance _ (YeVNol
Dimensions 2Oy� .� 1)
Sludge depth eS
Distance from top ot.sludgee to bottom of outlet tee or baffle: 2-3
Scum thickness: IwCIne.S
Distance from top of scum to top of outlet tee or barite: /
Distance from bottom of scum to bottom of outlet tee or baste: /
Mow dimensions were determined:
Comments:
(recommendation for pumping, condition of gni t and let t s or kaffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) e (pte-T 1 ,A4 7-4cT
GREASE TRAP!
(locate on site plant
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:
(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 111/75/97) page i of 10
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
n / SYSTEM INFORMATION (continued)
Property Address: 396 / U �� 1 e e,,- C.-) J,4_ / v L1 , If
Owner: re r
Date of Inspection: sem_ _ c� G�
TIGHT OR HOLDING TANK: sank must be pumped prior to, or at time. of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacitvr gallons
Design flow gailons/da%
Alarm level Alarm in working order _ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee. condition of alarm and float switches. etc.)
DISTRIBUTION BOX:
(locate on site plane
Depth of liquid level above outlet mien:
Comments:
(note if- level and distri
PUMP CHAMBER:_
(locate on cite plan)
is equal, evidence of solids nrryovef, evidence ofIt
kage into or out o_f box, etc.)
Pumps in wonting order. (Yes or Not
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 00/25/171 Oen 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7v S�(�, 5 J
Owner: �J TC,(J li` k,-4- ► `t K/U Li.. e� �C
Date of Inspection: t/ S
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. ength-
leaching fields, number, dimensions.
overflow cesspool, number
Alternative system:
Name of Technology:
Comments:
(note con
iition ql-fQil signs of hydraulfailure, level of pond ing,,condition of vegetation, etc.)
CESSPOOLS: _
(locate on site plant
Number and configuration
Deoth-top of liquid to inlet invert.
Depth of solids laver:
Depth of scum laver:
Dimensions of cesspool
Materials of construction:
Indication of groundwater
inflow (cesspool must be pumped as pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: _
(locate on site plan)
Materials of construction:
Depth of solids:
Comments:
(note condition oHoil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/23/97) page I of 30
Dimensions:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3176 c A -(e.., 5l /� 0 . •� '�G VC t�-�
Owner: XN
Date of Inspection:
)-- /o/ — CSC
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
• (r*vi.Od 04/35/971 s.r 9 of 30
Is
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Ptoperty Address: 3 90 S l ( Aj � „c
Owner: �/ �/7
Date of Inspection: Klu t4- -e PCL t.,
Depth to Groundwater G Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local'Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe .n %-our own words how you established the High Groundwater Elevation. (Must be completed)
'b613
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A PL(6 6
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(s.'V!•w 04/35/97) P•e• 10 of 10
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( 76 1,
APPLICATION FOR SEWAGE DISMAL IMIALIATIA a��t�
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
SAI Pm Street . I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank where the grade shall not exceed 2%. I will install a con-
crete septic tank of 1600 Gal in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of 180 • -lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel.or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches /100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE Apri1,'3.1962
Signat ��of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
Signapre of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
a
Signature o pecting Officer
Percolation Test 5 min Soil Clay
Garbage Grinder No
BOARD OF HEALTH
TOWN OF NORTH ANDOiTER, MASS.
/600 ,
S
1. NAME DATE
2. ADDRESS 3�.. �''�: "� . LOT N0. �I TEL.6pn/4-u .
3. NO. OF BEDROOMS .3 DEN YES �. N0. .
Q. GARBAGE GRINDER YES N0. .�. .
SHOW DIhERTSIONS OF HOUSE
t/b. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
✓ 7. SHOW DIbENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE- OF WELL FROM SEWERAGE SYSTEM
10. SHGW LOCATION OF BROOKS., STREAKS, DITCHES.. LEDGE OUTCROPt ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
I
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