HomeMy WebLinkAboutMiscellaneous - 75 HAY MEADOW ROAD 4/30/2018IF
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM EORM_
PART A
CERTIFICATION
Property Address: 75 Hay Meadow_
North Andover_
Owner's Name: Kim Cormier_
Owner's Address: _75 Hay Meadow
_ North Andover, MA 01845_
Date of Inspection: _8/10/2005_
Name of Inspector: Neil J. Bateson_
Company Name: Bateson Enterprises Inc._
Mailing Address: _111 Argilla Road_
_Andover, Ma. 01810_
Telephone Number: _( 978 ) 475-4786_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
X Passes
Conditionally Passes
NeqAs Further Evaluation by the Local Approving Authority
41-
ls
4IL;;
Inspector's Signature:tf��Date: _8/10/2005_
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments:
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 75 Hay Meadow_
_ North Andover—
Owner: _Cormier
Date of Inspection: _8/10/2005
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure
criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated
below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,
will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined"
please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or
not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will
pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the
distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System
will pass inspection if (with approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or
obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
. ` I Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 75 Hay Meadow_
—North Andover—
Owner: _Cormier
Date of Inspection: 8/10/2005_
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(i)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
su_rface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance —
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 75 Hay Meadow _
_ North Andover—
Owner: _Cormier
Date of Inspection: _8/10/2005_
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
_ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_No Liquid depth in cesspool is less than 6" below invert or available volume is''/z day flow.
_No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
No Any portion of the SAS, cesspool or privy is below high ground water elevation.
_No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described
in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to
determine what will be necessary to correct the failure
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 75 Hay Meadow _
_ North Andover—
Owner: _Cormier
Date of Inspection: _8/10/2005
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Yes_ _ Pumping information was provided by the owner, occupant, or Board of Health
No Were any of the system components pumped out in the previous two weeks ?
Yes_ — Has the system received normal flows in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this inspection ?
Yes_ _ Were as built plans of the system obtained and examined?
Yes __ Was the facility or dwelling inspected for signs of sewage back up ?
Yes_ _ Was the site inspected for signs of break out ?
Yes _ Were all system components, excluding the SAS, located on site ?
Yes _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the
condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of
scum ?
_Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the
proper maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no
_Yes_ —Existing information.
_Yes_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _75 Hay Meadow
_ North Andover–
Owner: _Cormier
Date of Inspection: 8/10/2005_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_
DESIGN flow based on 310 CMR 15.203 _440_
Number of current residents: _4
Does residence have a garbage grinder (yes or no): No
Is laundry on a separate sewage system (yes or no): _ No_
Laundry system inspected (yes or no): _
Seasonal use: (yes or no): _No
Water meter reading: Yes, 028510_
Sump pump (yes or no): _No
Last date of occupancy: —
Current-COMMERCIAL/INDUSTRIAL
Type of establishment: _ _
Design flow (based on 310 CMR 15.203): ,gpd
Basis of design flow (seats/persons/sgft,etc.): _
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use: _
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: _Pumped last year, owner _
Was system pumped as part of the inspection (yes or no): Yes_
If yes, volume pumped: _1500_ gallons -- How was quantity pumped determined? _Measured tank
Reason for pumping: _Inspect tank & tees_
TYPE OF SYSTEM
X_ Septic tank, distribution box, soil absorption system
Single cesspool _ Overflow cesspool
_ Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank _ Attach a copy of the DEP approval
— Other (describe): _ _
Approximate age of all components, date installed (if known) and source of information: -27 years old, 12/30/1978,
as built plan._
Were sewage odors detected when arriving at the site (yes or no): _No
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 75 Hay Meadow
_ North Andover _
Owner: _Cormier
Date of Inspection: _8/10/2005
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: _5'_
Materials of construction: X cast iron _X_40 PVC ,other
supp
Distance from private water ly well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.)
house, no leaks visible._
SEPTIC TANKS: X
_ 4" Cast iron thru wall to tank. 3" PVC in
Depth below grade: _4' _
Material of construction: X concrete _ metal _fiberglass polyethylene
_other(expiain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: —10'x 5'—x4'
Sludge depth 4"_
Distance from top of sludge to bottom of outlet tee or baffle: _23" _
Scum thickness: _4" _
Distance from top of scum to top of outlet tee or baffle: _8" _
Distance from bottom of scum to bottom of outlet tee or baffle: 19" _
How were dimensions determined: _Tape measure_
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc. _ Pumped septic tank. Outlet tee ok. Depth of liquid at outlet
invert. No evidence of tank leaking. _
GREASE TRAP: _(locate on site plan)
_Depth below grade: _
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of l l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _75 Hay Meadow
_ North Andover_
Owner: _Cormier
Date of Inspection: _8/10/2005
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOXES: X
Depth of liquid level above outlet invert: _0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):_ D -Boz level & distribution equal. No evidence of leakage. Evidence of
carryover. Pumped d -box to clean_
PUMP CHAMBER: _ (locate on site plan)
Pump in working order (yes or no):
Alarm in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): _
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 75 Hay Meadow_
_ North Andover _
Owner: _Cormier
Date of Inspection: _8/10/2005_
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number: _
leaching chambers, number: —
leaching galleries, number:
_ leaching trenches, number, length:
X_ leaching field, number, dimensions: _1 field 20' x 401
_
overflow cesspool, number:
innovative/alternative system Typetname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.): _ Soil ok. Vegetation ok. No sign of ponding to surface. _
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: __
Depth — top of liquid to inlet invert: _
Depth of sludge layer: _
Depth of scum layer: _
Dimensions of cesspool:
Materials of construction: .
Indication of groundwater inflow (yes or no): _
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): _
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _75 Hay Meadow_
_ North Andover—
Owner: _Cormier _
Date of Inspection: 8/10/2005_
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
.6'7"
61'
X2'2"
58'2"
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _75 Hay Meadow _
_ North Andover
—
Owner: _Cormier
Date of Inspection: _8/10/2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater _ >6' _
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed: _
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain: _
Checked with local excavators, installers- (attach documentation)
X Accessed USGS database -explain: Essex County Soil Map
You must describe how you established the high ground water elevation: _Essex County Soil Map, Sheet # 31,
Charlton Soil, Water >6' Deep_
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 75 Hay Meadow, North Andover
Owner: Cormier
Date of Inspection: 8/10/2005
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil 4Btes?on
Bateson Enterprises, Inc.
aDe
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. NIA 02108 617-292-5500
WILLIAI%I F. WELD TRUDY COME
- Sccrctar)
Governor
ARGEO PAUL CELLUCCI --- - -- — — - - DAVID-B.STRUHS
Lt. Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICAT19N
Property Address: ' '"p ` k)0�-\-L� dr� Owner:
Date of Inspection: (1— (If different)
Name of Inspector:
I am a D pro ed system in or aursuant to Section 15.340 of Title S (310 CMR_ 15.000)
Company Name:
Mailing Address: t . exgl 0
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 posal systems. The system:
Passes
Conditionally Passes
_
Neeos Further Evaluation By the Local Approving Authority
i
Inspector's Signature 1/ ""�'��' Date:
��
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 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:
AI SYSTEM SES:
Check A, B, C, or D:
I have not found any information 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:
BI SYSTEM CONDITIONALLY PASSES:
15.303.
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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
_ The septic tank is metal, 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 conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Paye 1 of 10
DEP on the World Wide Web: httpJ/www.mapnet.state.ma.usddeP
^ Printed on Recycled Paper
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
' CERTIFICATION (continued)
Property Address: 1 tCyCSoUIiU .Iy `� ��� `'�'�x
Owner: �*'- -
Date of Inspection:
BJ SYSTEM! CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system_ required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health): ---
broken pipe(s) are replaced
obstruction is removed
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.
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
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
1) 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 1 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
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
(revippd 04/25/97) Paye 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
,, CERTIFICATION (continued)
Property Address: JE" v to+ J�1 Nov -v&
pate of Inspection: '�v,� p,
4e
D) SYSUM FAILS:
You tttut±t indica either "Yes" or "No" as to each of the following:
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.
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
coliiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as 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 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 drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a
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.
a
(rfvf94 Of/35/87) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r PART B
CHECKLIST
prop
grty Address:
Date of Inspection.
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes
Pumping information was provided by the owner, occupant, or 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.
V 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 was inspected for signs of breakout.
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, 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:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub -Surface Disposal System.
r Existing information. Ex. 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) [15.302(3)(b)]
1
is vt.gd Pago ! of 10
V '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
DoleoD
ate of Inspection•
FLOW CONDITIONS
RESIDENTIAL:
Design. flaw: L(C) a. dAwdroom for S.A.S.
Number of bedrooms:
a
Number of current residents:
Garbage (yes
Rr,rder or no):�5•
Laundry connected to system (yes or no):r�3
Seasonal ijw (yes or no): 1.10 9(
=Y3
Water meter readings, if aLvgilable (last two (2) year usage (gpd):
Sump Pu (yes or no): NO
p . , rnp . —
'000
a S '
Last dateQ f occupancy:
P panty:
V3 a •a- sf `{ = 9 �6 /a = 7 �,,Cs
COMMER_CIAUI N DUSTRIAL:
TYPO of establishment:
Design flow:_ jtallons/day
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)_
Vyater meter readings, if available:
Lastlate of occupancy:_
OTFIER: (Describe)
Last date of occupancy:
PUMPING RECORDS and source of information
GENERAL INFORMATION
. ah - CwV\w-
$ysterlr! pumped as part of �iLspection: (yes or no)S
If Yes, volume pum IbCej izalloys
Reason for pumping: NSSC)"•
TYPE O, l��M
Septic tank/distr(bution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
OX TE AGE of II components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) NO
trgvial�d 0{/35/97) Pago 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
y PART C
SYSTEM INFOwR,MAT,ION/ (continued)
Property Address.
Owner
Date of Inspe0ion•
BUILDINCO SEWER:v�J
(Locate on site plan)
Depth below grade:
Material of cortstru^tion: y_ �t iron _ �O�PC other tcRlain)f ,
Distance metprivate water supply well or suction line
Diaer
Comments: (condition of joints, venting, evidence of leakage, etc.)
)0, \v,t�ac'
SEPTIC TA►K:.'.''
(locate on site plan)
Depth below grade:
Material of construction: _ oncrete _metal _Fiberglass _Polyethylene _.other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No)
Dimensions:
Sludge dopth: l `(
Distance from to of sludge to bottom of outlet tee or baffle: f
p !t g h
Scum thickness: a
Distance from top of scum to top of outlet tee or baffle: t-1
� �(
Distance from bottom of scum to bolt let tee o baffle:
How'dimensions were determined: —S -1.^b ��
Comments
(recommendation for pumping, condiY n f inlet d o let tee r fle , deepth of I' uid level in
integrity. exidence of jeakage, etc.), r, ,t
GREASE TRAP300Ae-
(locate on site plan)
Depth below grade:
Material of construction: _.concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Sam 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, structura
integrity, evidence of leakage, etc.)
(roV40 4 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM 114FORMATION (continued)
Property Address:
Owner �Cy
Datp of Inspection:
I
TIGHT AR HOLDING T_ ANK.. Y') (Tank 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:
Capacity: gallons
Design flour: gallons/day
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: t/
(locate on site plan)
Depth of liquid level above outlet invert: E
Comments:
(note if lei
, evidence
PUMP CHAMBER:_
(locate on site plan)
oftleakare into or
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.)
(vavif9d 04/25/87) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' SYSTEM INFORMATION (continued)
Property Address: ►� }�cu ®�
4,'�
Omer; E ��
Dale of Irtspeoion;
SOIL ABSORPTION S. STEM (SAS):jj�'—
(locate on site plan, if possible; excavation phot required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions: C W
overflow cesspool, number:
Alternative system:
Name of Technology:
of sail, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS: `�
(locate on site plan)
Number and configuration:
DepttHop 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 pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY; WIG -
(locate on site plan)
Materials of construction:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(rpviaed 04/25/97) Page 0 of 20
Dimensions:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMAAT`IO,N, (continued)
Property Address:�`'�
ge
Dateof C
of Inspection:
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)
D - l (o''� 4
i�o t -\,)vkkAMXAJ w�� vas t1
(rapippd 04/25/97) Paga 9 of 10
SUBSURFACE 5EWAGI: DISPOSAL SYSTEM INSPECTION FORM
PART C
j—� SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of inspection:Qil1`-
Depth to Groundwater . Lf 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.)
etermin it from local conditions -.
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
110
(revised 94/25/97) Page 10 of 10
,Y TES_: (508) 475-1-17-1
FAX: (508) 475-5451
AA SCAN ENTERPRISES, INC.
x�3Yatltlg - Wdtar tk Spvypr ilnrs - SCptic Systems & Pumping Scivice
111 Argilla Road „ Andover, Mass. 018111
'Title 5 Inspection Report
D7t;o 4f Tospecticlo; -----------------
q report contained herein does not constitute a guarantee
pf future usage and the functionality of the existir►g septic
gy@tegi, Sgch report Issued herewith is merely based upon nay
p14perVattpgpr and I hereby disclaim any Suri -her operation
of ypur cuFrer}t septic system.
AGI
Neil J . HaLoSoll
I3atr:5uu LuLUrprisea IIIc:.
■
Nage I of ll
r
TO: NORTH ANDOVER, MASS 12-L-3 G 19 7F
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
/10 % C/ 6f11 Y MEA:D 0 t /Q -C/. North Andover, Mass.
The grades and construction are as specified in my plans and specifications dated
19
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?_. 1Water Line Location
Ito PVC Pipe
4. Septic Tank
Tees - Length & To Clean Out Covers
Cez:ient Pipe to Tank - On Doth Sides of Tank
Distribution Dox
Cover & Dox - No Cracks
Al! Lines Flo,,.ing Equal Amounts
No Back Flog
` Leach Field .or'Trench
.f Dj.-men's ons
e' D e P.
, h
C -a -peed E-�ds
Clean Double t'ashed S':ane
7. beach Fi.-s
D r;e.`sa_ot�s
Stc� .e'` Depth
a,s h "' s
C,em e n t PI -pe ',o Pit..-----Bo':h Sides
Cle3nD`ou-b1_e, ?-'�'_�ed_ Stone
8. No Ga -'•a, e Disposal
�. Final Tn,pec i.i on
10. Barras - _in C e : -wed Sys' em
11. As - Built Submit ted
Lot Loc -.kion
D mensions of System
1 _Loca�.ion ;rich ?�.RegardJk-"D
o Pere _ .svt-
Elevations
'r?a.ter Table
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<'
-'Distance To:
'/I.
'•:Wetlan(Is
.�'.
Drains
Well
?_. 1Water Line Location
Ito PVC Pipe
4. Septic Tank
Tees - Length & To Clean Out Covers
Cez:ient Pipe to Tank - On Doth Sides of Tank
Distribution Dox
Cover & Dox - No Cracks
Al! Lines Flo,,.ing Equal Amounts
No Back Flog
` Leach Field .or'Trench
.f Dj.-men's ons
e' D e P.
, h
C -a -peed E-�ds
Clean Double t'ashed S':ane
7. beach Fi.-s
D r;e.`sa_ot�s
Stc� .e'` Depth
a,s h "' s
C,em e n t PI -pe ',o Pit..-----Bo':h Sides
Cle3nD`ou-b1_e, ?-'�'_�ed_ Stone
8. No Ga -'•a, e Disposal
�. Final Tn,pec i.i on
10. Barras - _in C e : -wed Sys' em
11. As - Built Submit ted
Lot Loc -.kion
D mensions of System
1 _Loca�.ion ;rich ?�.RegardJk-"D
o Pere _ .svt-
Elevations
'r?a.ter Table
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