HomeMy WebLinkAboutMiscellaneous - 378 SALEM STREET 4/30/2018 (2)Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department off,
Environment l `OF
n r r
r 7.417L,
Wllllam F. Weld f'
Gc.emor
Argeo Paul CellucclLDISPOSAtLftS?7SW1&$PECTI0
a s1 2 gr
U. Govemor
SUBSURFACE SEWAGE NFORM
Trudy Cox@
Secretary
David S. Struhs
Commissioner
PART A
CEP N
PropertyAddress: � �
3 V `e- "s� N �
_ � Address of Owner.
Date of Inspection: (If different)
Name of Inspector. N let, N
Company Name, Address and jT�e-l7ephone Number. BATESON ENTERPRISES, INC. TEL: i30811 -i -t 171
5_Qg P ' ! S_ L 1 (�—% FAX:13081.473-3.4-11
CSO E.cavating • W'ater S Sewer Lines - Septic Systems & Pumping Service
CERTIFICATION STATEMENT I I 1 Argilla Road Andover, Mass. 0 18 10
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:
asses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
F
r _—
Inspector's Signature: Date: a O
The System Inspector shall lit a y of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector, and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A) SY9 SES: .
I have not found any information which indicates that the system.violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B1 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 yea, 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
irri inent. The system will pass inspection if the existing septic tank is replaced with a Fonfortniitg septic tank as approved
by the Board of Health.
(revised 11/03/95)
1
a
One Winter Street a Boston, Massachusetts 02108 a FAX (617) 556-1049 6 Telephone (617) 292-5500
A
" Pnnted on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION ((continued)
Property Address:
Owner.
Date of Inspection:
B1 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 .;f (with approval of the Board of
Health):
broken pipes) 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 wi l pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced ,
obstruction is removed s ( , i ?
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 etn-ironment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT
Cesspool or privy is within 50 feet of a surface water < i
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:' .
The system has a septic tank and soil absorption system and is within 100 feet to it surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95) 2
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
p—� l CE�RjTIFICATI N (continued)
Property Address:
Owner.
Date of Inspection: Ll _8ka—C?(,n
Dl 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.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
.�,. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface. water supply or tributary, to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
,f
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 1
El LARGE SYSTEM FAILS:
The following criteria apply to large syatems in 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 because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95)
a
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST,
Property Address.
Owner.
Date of Inspection t4
Check if the following a been done
_ Pump ormation was requested of the owner, occupant, and Board of Health.
_
one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
,� I /during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
,v/! ' As plans have been obtained and examined. Note if they are not available with N/A. .
_ The or dwelling was inspected for signs of sewage back-up.
y The m does not receive non -sanitary or industrial waste flow
The si was inspected for signs of breakout.
_f/ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, terial 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 by non -intrusive methods.
LThe facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
{S�Y'STE`MI, I-N,FOOR,M^ATION
i�rOp�,rty��dipesi 3' I�
Owner.,1�21��h%4:.,�•
Mr�
Date of Inspection: 14r--�3 X -
FLOW CONDITIONS
RESIDENTIAL:'
Design flow:'aay gallons
Number of bedrooms: a
Number of current residents: I
Garbage grinder (yes or no):
Laundry connected to eyslem (yes or no)`:__
Seasonal use (yes or no): o ops r s (/ 7
Water meter readings, it available: S � G1p f}3 x � � � _ � 01� � � o�a,t � � ,,,,,�
Last date of occupancy:cV(M-4�
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_d + y=
Non.&wdtary waste discharged to the.Title 5 system: (yes or,no)
Water meter readings, if available:
Last date of occupancy: f
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informations
System pumped as part of inion: (yes or no)Q5
If yes, volume pumped: gallom
Reason for pumping:IkC_
r
TYPE OF�4XSTEM
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: ` . t �g6y-s 01, ` — oyye4—
Sewage odors detected when arriving at the site: (yes or no) PC>
(revised 11/03/95)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C. }
SYSTEM INFORMATION (continued)
18�Property Address: • lid. �' • I V • 0�� �l.t�C.QA—
Owner. S , 't ' e'e—V\.
Date of Inspection. / j 11
`( — p' 6?
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: t__.-ncrete _metal—FRP, other(expjain)
Dimensions: l Ut'1�
Sludge depth:_
Distance from top of s �4dge to bottom of outlet tee or baffle:
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: `7
Comments:
(recommendation for pump �°nditio of inlet and outl t tees or baffles,epth of uid level in relation to tlet invert, ��
ctu�ral int grit
evidence.of leakame. of c.) _ V� V %X' G ` t'�i�L1z . IU V U Z<_- Z/
GREASE TRAP.
(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, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
r, y Adtl"681
Owner. 6'kc' yc ' r'
Date of Inspection �y aa_4
TIGHT OR HOLDING TANK: rtCV)P
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP _other(explain) -
Dimensions:
Capacity: gallons
Design flow: ¢allona;day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION Boy -
(
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if 1ev,
equal, evidence of solids carryover evidence of lea4ge into or gut ofx, etc.)
YNC.�-v- e a, UQ� . LX V P Vl`� ai ;Q-
PUMP CHAMBER: Y\OV\e.
(locate on site plan) V
Pumps in working order:(yes or no)
t
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
1
SYSTEM INFORMATION (continued)
Property Addweaes I S2 `Q�t t L N 4JoL — ! i
�s . 't (ec" CIA
Owner. ,
Date of Inspection: Lf a s —Clf.' t
SOIL ABSORPTION SYSTEM (SAS): v
(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:_ ` C' I
leaching galleries, number: �' t �N
leaching trenches, number length: `T �
leaching Gelds, number, dimensions:
overflow cesspool, number:
Comments: (note cogdition of soil.
CESSPOOLS: InGV\vP
(locate on site plea)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: .
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:1(\C�h�,
(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.)
(revised 11/03/95) g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to graundwater:_6feet
method of determination or avaroxir
(revised 11/03/95) 9
-� o 7 9 ��
WS i f
,C> 't
DEPTH TO GROUNDWATER
Depth to graundwater:_6feet
method of determination or avaroxir
(revised 11/03/95) 9
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
reb
Commonwealth of Massachusetts Zmay
City/Town of A/b l v�
System Pumping Fie ord 005
Y p 9
Form 4
N OF MENT R
DEP has provided this form for use by local Boards of Health. Othed, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
Address
Ah %/Vc1 M
City/Town State
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
'b
State
Telephone Number
Date P J— 2. Quantity Pumped
Cesspool(s) �Keptic Tank
❑ Other (descrl e).
4. Effluent Tee Filter present? ❑ Yes No
5. Condition of System:
6. Systemumped By:
Na e
Company
7. Location where contents were disposed:
of
Zip Code
Zip Code
d
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
Date /
t5form4.doc• 06/03--- System Pumping Record • Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RE CO R4D 1v;AY 2003 a
�1 I'EM OWNER & ADDRESS SYSTEM LOCATION
(example. Icf( iron( of howl))
27 LSA
. apt
UATC OF PUM?INC: QUANTITY PUMPED&WOC'ALLo
NO YES SEPTIC TANK: NO YES
w
�ATUKE OFSERYICE: -ROUTINE EMERGENCY
0I1.>FRVAT IONS:
COOD CONDITION.
HFAYY CREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
>1.>TLM PUMPED BY:
CU M�I FNTS:
tRANSFERRED TO:
NULL TO COVER
0AFFLL;S IN PLACb'
LEACHFIELD RUNBACK..-
FLOODED
UNBACK.FLOODED
Oj�HI~R-(EXPLAIN)
TOWN OF NORTH ANDOVER
SYSTEM Pi7MPING RECORD
DATE
SYSTEM OWNER & ADDRESS SYSTEM LOCATION-
Kahn za c k
3'78 sale l,g S r
N OlUouec, tOa .
DATE OF PUMPING QUANTITY PUMPED -
CESSPOOL NO_,,)� YES SEPTIC TANK NO YES_
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION_ FULL TO COVER
HEAVY GREASE BAFFLES RtLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED ..
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY
Ls
COMMENTS:
CONTENTS TRANSFERRED TO
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