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HomeMy WebLinkAboutMiscellaneous - 62 STONECLEAVE ROAD 4/30/2018 (2) r 61STONECLFAVE fZOAa. 't'C"�'_�' 'X T ♦RR zlS�A�RR h � u f NorthAndoverBoardol:AssessorsPublic Access Page 1 of 1 µOR7M b of�N l'iilifS.ve Of y�o,•,po Rei .o AS`.p'�'i+�'.�. 5 �'g8�es fi' Property Record Card Retum to the Home page click on logo Parcel ID:210/104.13-0120-0000.0 Community:North Andover SKETCH PHOTO New Search Click on Sketch to Enlarge Click on Photo to Enlarge Sales Summary d Residence l "` k Detached Structure Condo Commercial Comparable Sales 62 STONECLEAVE ROAD Location: 62 STONECLEAVE ROAD Owner Name: BARRY,DOUGLAS J PATRICIA M BARRY Owner Address: 62 STONECLEAVE ROAD City:NORTH ANDOVER State:MA ZIP:01845 Neighborhood:7-7 Land Area:1.14 acres Use Code:101-SNGL-FAM-RES Total Finished Area:2035 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 507,600 529,900 Building Value: 281,800 292,200 Land Value: 225,800 237,700 Market Land Value:225,800 Chapter Land Value: LATEST SALE Sale Price:460,000 Sale Date:12/20/2001 Arms Length Sale Code:Y-YES-VALID Grantor:MANUEL APIGIAN Cert Doc: Book:06564 Page:0318 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&LinkId=1180309 2/6/2008 DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Wednesday, February 06, 2008 10:46 AM To: 'patty@matternow.com' Subject: 62 Stonecleave Road Importance: High Hi Patricia, Attached is a copy of the full content of your Health File. There was no Septic As Built, but there are two older Title 5 Reports which will show the location of your system. Please call 978.688.9540 if you have any further questions. Thank you. Pamela Health Department Assistant -----Original Message----- From: noreply@yourcopier.com[mailtomoreply@yourcopier.com] Sent: Wednesday,February 06,2008 11:38 AM To: DelleChiaie, Pamela Subject: Message from KMBT 600 SKMBT_600080206 11370.pdf 1 - PRDPosE1D Pna L _ 1 a,� p W M Ant u F L A P/c_/4 L-_. .•� - G 1 S TUNEC..�f�5�� R a��__.. r. /1/0 . ANnoVEa �'N p g c . oda com4f �Y zU) ro o O T T A � _ X )CIS IMC, CL Ati o - DIckRth fps f #1` 9.2 r n ►„� C09A/ER o� r �u Lk h Ea A N i "7 a .TDP of PoaL 80776A-pod PEEP 5,VO 9� ��7 p VE &-d tg-p - .:� v- __ � J / j w� � ' � y -�.. /�ti-�GG/�-L [. ��aa� D �� _ _ ; z - -- - - - -- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF.ENVIRONMENTAL PROTECTION _ T(�i`VV Cir tl��R E li c}i€' `v cfi/ BOARD OF HEALTH Y 0 5I TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: (OR S-ne Cl Pave f - - pJ ./Vv A uerX0-0 it l o Owner's Name: - I,Ci r'1 �� Owner's Address: j Date of Inspection: F as fid Name of Inspector: (please print)_ }1Y1��y 1Y1CCYl2� Company Name: q o r+ts. Mailing Address: 41 Rci a I#'aril St Rre2A Telephone Number: 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: —/Passes Condition kly Passes Nee s F e)r EvalLtion by the Local Approving Authority Fai Inspector's Signature: Date: The system inspector shall bmit a copy of this inspection report t e Approving Authority(Board of Health or DEP)within 30 days of mpleting 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. Title 5 Inspection Form 6/15/2000 page I Ix.Page 2 of 11 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: (,, 51ne- 06--Aue (j, /Ud AnrJdv er ma 35 s Owner: ./j� I q ti Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System 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: r p 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 yea`r's 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 bf Board of Health)s broken pipes)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: f 2 -J Page 3 of I 1 OFFICIAL- INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: c`eck o- Owner: Date of Inspection! 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. `A f 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that{theme system is-not functioning inja manner which will protect public-health' safe and the environments Y P ,.. 4 . — 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 , u 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 njtraX 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: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Coot C l eta,,-Rl T ND Lh�� Owner: A n15� Date.of Inspection: 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 euent to the surface of the ground or surface waters due to an overloaded or I�;.. . fflclogged SAS or-c6spojl - r' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /Liquid r' ✓ 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 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. _ 3/1�:y Any portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. 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 compomads 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.] /16 (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: Tobe considered a large.system thesystem;gnust-serve a facility with abdesign flow of 10;0009 pd to 15,000 + ' gPd• You must indicate either"yes"or"no"to each of the following: 4 (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 71 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 theappropriate re ional office t Yg e of the Department. 4 a Page 5ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: AJ4 A-710 Owner:— lain Date of Inspe tions / �c 1 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: YNo 7 _ Pumping information was provided by the owner,occupant,or Board of Health A�,ere any of the system Components pumped out in the previ6s two W40-2. J. _ Has the system received normal flows in the previous two week period? — Have large volumes of water been introduced to the system recently or as part of this inspection? e ✓ _ 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 or 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? t! 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. J _ .Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] 5 A Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION s Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): L/ Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinderes r no): $e,5 Y�Co rrMon r�,rwva/ Is laundry on a separate sewage system(yes or.no): nvd [if yes separate inspection required] - Laundry syst m inspected.(.yes or no„): Ad Seasonal use:(yes or no): np Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):J Last date of occupancy: g c t,t,p,c-t,/ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd- Basis pdBasis of design flow(seats/persons/sgft,etc.): 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 n Source of information: At-I Goof r 5-e�-1 IC 9/'3 Ado Was system pumped as part of the inspection(yes or no):-11f5 / If yes, volume pumped: 1�gallons--How was quantity pumped determined? Reason for pumping: ect h I( 1 a T7 OF SYSTEM T/Septic tank,distribution box,soil absorption system i _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: Were sewage odors detected when arriving at the site(yes or no): /V0 6 • • a � Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATION(continued) t Property Address: 60-� 3+ne C l e-r#'v 4 Ab /�}yr✓3 Owner: 14 Yl Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: ak 'o Materials of construction: �/6ast iron o;+040 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) r Dimensions: S—j X Sludge depth: .3 i r-n Distance from top of sludge to bottom of outlet tee or baffle: 31 #n Scum thickness: ! sr) Distance from top of scum to top of outlet tee or baffle: 71 n- Distance from bottom of scum to bottom of outlet tee or baffle: i y irk• How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 13,-1 TT Fie S d -6,) is &,7r 6oyi_ GREASE TRAP:_(locate on site plan) Depth below grade:— 4 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.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: &o� s l c OCY4 e 2j Nn AvO Owner: /}p le IG() Date of Inspection: 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:0 'y —Wons 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 BOX:-106if present must be opened)(locate 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.): rv0 Spt s ootrry dyor ofny PUMP CHAMBER: (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.): it id r� 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property Address: (CA S- ne C1C'%i%.1erj } Nif -)p 1 Owner: A DQ IU n Date of Inspecti n: -,X)rj SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not-required) If SAS not located explain why: 7 Type leaching pits,number: leaching chambers,number: ; leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: 0�br.i cod 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.): �^ All) n Sioo E l�y dwL Jr� tai/�/Y� Q Pit palati CESSPOOLS: /Uh (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: , Depth of scum layer: Dimensions of cesspool: r 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.):' .t. 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.): t 9 ' Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: s4nne ct eo e /Ura /�I✓� Owner: 1�D IGG/1 Date of Inspection: fS -r j 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. • r � I { 14-D 3� —� 'go 6 10 .� Page 11 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 'A 5 cl e4 uei Owner: A 0 G Date of Inspection: J SITE EXAM Slope Surface water Check cellar Shallow wells - pp,, gr 1 4e` et _F t t• Estimated de to oun�l_water� �. 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) Accessed USGS database-explain: You must describe how you established the high ground water elevation: '-b v5 Glow 0 cc -1-165X No Wak r Obs ' ued P 1 Y F 11 - =- COMMONATEALTH OF MASSACHUSETTS l EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION y, ONE WINTER STREET, BOSTON NIA.02108 (617) 292-5500 TRUDY COX.E <. Secretarc t ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner, '- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ¢ / PART A `4 fQ CERTIFICATION Property Address: Ta t-fP � �1v Name of Owner �} Address of Owner: Date of Inspection: / d Name of Inspector:(Please Print) l7 u 50 I am a DEP approved system inspectorpursuant to Section 15.340 of Tide 5(310 CTR 15.000) < Company Name: A#(Oi os., (1--0,7 �r C_ Mailing Address: '2.4 /lit 7 r Telephone Number: 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: 7r.Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 2 • T ff ✓ -Iit The System Inspector shall/submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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. NOTES AND COMMENTS WL 9 1999 revised 9/2/98 Pagel of 11 *v Prmled on Recycled Paper - i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART A CERTIFICATION (continued) 'roperty Address: 62— A j ` ✓-0� 14�f Jwner: • /t P p j Date of Inspection: / ( , t -'INSPECTION SUMMARY: Check A, A C, or D: A. SYSTEM PASSES. I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure r 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 repaii-,'as approved'brthe Board of Health," itl pass." H Indicate yes, no, or not determined IY, N, or ND). 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 inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 complying septic tank as approved by the Board of Health. 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 t _ 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 -a ('l 1 revised 9/2/98 Page 2of11 ` fff SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) � ! / ��. -r /�✓ lir` /fin/ a Property Address: P s Owner: 2,. Date of Inspection: . t C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. r 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply 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 r 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. Method used to determine distance (approximation not valid). 3) OTHER f revised 9/298 Page 3of11 sr� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: . . S TG r (�c.t' s--c '04 n Owner: Date of Inspection: D. SYSTEM FAILS: . You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No _ 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. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: 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 a health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface dunking water supply the system is within 200 feet of a tributary to a surface drinking water supply I — — i 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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. . t revised 9/2/98 Page 4of11 fir SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM } PART B CHECKLIST Property Address: 6.2-- 01, P i6�e p.j 4„1 B41,01 d to Owner: S- Date of Inspection: Check if the-following have been done: You must indicate either "Yes or "No" as to each of the following: Ye No ✓ _ Pumping information was provided by the owner, occupant, or Board of Health. I 1 _ 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. As built plans have been obtained and examined. Note if they are not available with N/A. _ Thee facility o .dwHingwas inspected for sigiiiof sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. Ole, _ 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 size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 11 5.302(3)(b)] The facility owner(and occupants,if diffeient from owner) were provided with information on the proper.maintenance..of Subsurface Disposal Systems. Ic e .3... _..-, �#". ?. S. a.? .. • ,.per ..i .A. .. 34 A�' yg. -E..- -i `7-i _ �.�. _e �, 3. �:-• - revised 9/2/98 Page 5of11 'r r% r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i r PART C b SYSTEM INFORMATION 'roperty Address: Owner: ' i' Date of Inspection: � r��t E FLOW CONDITIONS f. RESIDENTIAL: Design flow: g.p.d.lbedrpom. Number of bedrooms(design): Number of bedrooms(actual):_ Total DESIGN flow Number of current residents: Garbage grinder(yes or no):--YPj . Laundry(separate system) lyes or no): #; If yes, separate.inspection required Laundry system inspected.(yes or no) Seasonal use(yes or no):--y6 `` Water meter readings,if available(last two year's usage(gpd):li&r=. t� Sump Pump lyes or no):�s Last date of occupancy:�CC.�• COMMERCIAUINDJTAIAL• f , Type of establishment: t Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: lyes or no)_ Industrial Waste Holding Tank present: lyes or no)__ Non-sanitary waste discharged to the Title 5 system: lyes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)Yx If yes, volume pumped: a gallons Reason for pumping: TYPE OF SYSTEM LSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system lyes or no) (if yes, attach.previous inspection records,if any) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank, 3 Co of DEP A Poy-alt_ � � { t -.b #� Other APPROXIMATE AGE of all components, date installed{if known)and source of information: .t y Y� — l Sewage odors detected when arriving at the site: (yes or no) / t�► revised 9/2/98 Page 6of11 A t�,T • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: tJ �6 `© `( ,b"! Owner: Date of Inspection: gO BUILDING SEWER: (Locate on site plan) y Depth below grader � �i Material of construction: Ger-ast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,-etc.) C�6 M/1/T/A .-i SEPTIC TANK: (locate on site la Depth below'igrade: )' r Material of construction.4o"concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance— (Yes/No) %G Dimensions: G Sludge depth: Distance from top of sl dge to bottom of outlet tee or baffle: Scum thickness: / / Distance from top of scum to top of outlet tee or baffle:t�'r L. Distance from bottom of scum to bottom of outlet tee or baffle: _y How dimensions were determined: !?'r r 'omments: (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.) GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction: concrete metal Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: i, Distance from topkof scum toop,of`outlet,tee oj,`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 9/2/98 Page 7orti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I,} SYSTEM INFORMATION(continued) h c cc e > 4,-s �` / �n� c• property Address: ` Owner: last 9 -,.,-9 IF Date of Inspection: 1" >i TIGHT OR HOLDING TANK:1�Jank must be pumped prior to, or at time of, inspection) (locate on,site plan) 'It Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes No Date of previous putn in ' Comments: '. r (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: �P (locate on site plan) Depth of liquid level above outlet invert:' Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (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.) c a f i s 3 revised 9/2/98 Page 8ofII � A L � '• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i, 4operty Address: & :S (/7��-/�' C�G�'� e Jwner: Date of Inspection SOIL ABSORPTION SYSTEM(SAS)- y. on site plan,if possible; kcav tion not required,location may be approximated by non-intrusive methods) If not located, explain: I Type: t leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches,number, length: leaching fields, number, dimensions: ��� overflow cesspool,number Alterna4ve system: k f "Name of Technology: r i Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) I'lU /Sef rs 1e YDX 4f1 G /Lu/CA ji d ",d/A, /F CESSPOOLS:_ (locate on site plan) f Number and configuration: Depth-top.of,liquid to inlet.invert: Depth of solids.layer: a )epth of scum layer:. Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) I� Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: tr. (locate ori site plan) , r Materials of construction: Dimensions: Depth ofisolids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) r: i I a. revised 9/2/98 Page 9ofII i 1 ! 6� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)) 'roperty Address: e[, .7 1Q J-1 e CGAL- 61r lwner: Date of Inspection: . Alit ) /a, � f 1 SKETCH OF SEWAGE DISPOSAL SYSTEM: !: include ties to at least two permanent reference landmarks or..benchmarks locate all wells within 100' (Locate where public water supply comes into house) i a r Atl �f �� l ` � 4 -i 1f . ; �' �. � ( ., � 9 ' � • r-'i � �- Try Yf . .. a +o .1 R revised9/2/98 Page toortt i µ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) operty Address: U� tp cL I., t' 1 /ter- 1` it / Jwner: Date of Inspection: I S NRCS. Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep w ' SITE EXAM Slope Surface water Check Cellar E 4, Shallow wells). Estimated Depthto GroundwaterFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) 4 Determined from local conditions Checked with local Board of health Checked FEMA Maps i Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) P0 t! ' 16 •o ,. � wr� n t C1 ,.. C r I revised 9/2/98 Page 11 of 11 1