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Home My WebLink AboutMiscellaneous - 76 WINTERGREEN DRIVE 4/30/2018i Z m G7 m m z 9 NEW ENGLAND ENGINEERING SERVICES INC tsu/Anu _ NOV 1 41995 November 7, 1995 North Andover Board of Health Town Hall Annex 120 Main Street North Andover, MA 01845 RE: TITLE V REPORT Enclosed is the Title V report for 76 Wintergreen Dr. North Andover, MA If there are any questions please call me at my office, 686-1768. Yours truly, B�aurin C. Osgood Jr. P�'esident 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 William F, Weld Goremor Trudy Coxe Seaetnry, EOEA David B. Struhs Commissioner Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protecti®n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: `��. l,L,'n i4 ,e G S AN 02 g+ 4we, 1I Address of Owner: Date of Inspection: (If different) Name of Inspector: Z3r!7 Company Name, Address and Telephone Number: peu• �NG/.n�►4 ,(trG•.�B<,C,'nF,S�t��cCs, 7"c -41n.0/YVJ 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: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Date: Inspector's Signature: ;" // 3 X The System Inspector shall srmit copy of this inspection report to the Approving Authority within thirty (30) days of completing this nsper(on. if the sN•stem is a shared system or has a des(gn floe,, of 10,000 gpd or greater, the inspector and the system owner shall submit M. report to the appropriate regional office. of the Department of Environmental Protection, ^.e original should he sent w ine s�'sterr, owner and copies se:11 to the buyer, if appl cable and the appro�ing authont}•. INSPECTION SUMMARY: Check . B, C, or D: Aj SYSTEM PASSES: 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, BJ 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 yes, no, or not determined fY, N, or NO). Describe basisof determination in all instances. If "not determined", explain why not) The septic tank is metal cracked, structurally unsound, shows substantial infiltration or eAltration, 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 8!15/55) Dreg`VJIe �r P> �R, r.. .;Rion, M ?.a "LaE•pP?g 70" 0 FAX f617) 55 -1Y.0 c Teiaphorie {617) 232-55M 95-77 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.. A CERTIFICATION (continued) 7G �; tit 6�ee,e4 0e /Gv . ynciavee, 'Wo Property Address: �� Owner: 8 wQ�nGC� /T''G tS Date of Inspections 61 SYSTEM CONDITIONALLY PASSES (continued) due Sewage backup or breakout or high static water levet observed Thein sem wution LI pas box. spettiono broken(h approval of he . pipe(s) or due to a broken, settled or uneven distribution bo Y Board of Health): 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 C1 FURTHER EVALUATION IS REQUIRED BY THE BOARDOF' 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 PASSUNLESS 80ARD 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 saltmarsh UBLIC WATER SUPPLIER, IF APPROPRIATE) DET SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(ANDS T THE PUBLIC HEALTH AND SAFETY AND H�ERMINES THAT THE.SYSTEM•15,FUNCTIONING IN A MANNER THAT PROTECT ENVIRONMENT, The �+'SiPm had a SeOtiC lank ana SOU absorption system and i5 within l0U leer tv d nuifa� c �+atci >uNNi) of tribuibl_y iv d surface water supply. The sysien hay 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 sy>ien) hc� 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 D1 SYSTEM FAILS: 1 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 ofsewage into' facility or system component due to an overloaded or clogged SAS or cesspool surface of the ground or surface waters due to an overloaded or clogged 5A5 Discharge or ponding of effluent to the or cesspool: 2 Ire-.ised 8/15/95)' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner::. Date of Inspection: /a./S 7 15-S/ DJ SYSTEM FAILS (continued): 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 Lof. 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: The following criteria apply to large systems in addition to the criteria above: The design .flow, of system is 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 li of a public water supply welli . 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.consuit the local regional office of the Department for further information. 3 (revised 8%15/95) , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST a'o vGC Property Address. 76o �L%'� �e eGL�� oe , Owner: 6<11 eljt►.0 iZ Date of Inspection: /o /1 7 /ys� Check if the following have been done: Pumping information was requested of the owner, occupant,. and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period, Large volumes of water have not been introduced into the system recently or as part of this inspection, 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. k1The: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. J/ 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 or . approximated by non -intrusive methods. The occ;:pa^:�, if.d.ffvrer7' fres: owner) were provided with information on the proper maintenance of Sub. Surface Disposal System. ti-evised 8/15/'95! 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION Property Address: 76P Owner 41 At /(s Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: Rallons Number of bedrooms; Number of current residents: Garbage grinder (yes or no):_f Laundry connected to system (yes or no);—,V— Seasonal use (yes or no):�Ld water meterreadings, if available Last date of occupancy:6,�A+r, COMMERCIAIIINDUSTRIAL: Type of establishment: Design flow: allonsMay 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 OTHER: (Describe) Last date of occupancy:— GENERAL r ccupancy; GENERAL. INFORMATION PUMPING RECORDS and sourc�jof information %l/u � r"v.riP/sD �•, �' �C,��' � . C�So �ecrz o u -ss �a �) . System pumped as part of inspection: (yes or no) ,to If yes, volume pumped O gallons Reason for pumping._ /jirt4�t7n4k'r/ iLa t`' TYPE OF_SYSTEM. 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: 7 V,V?J Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) - 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 76/ Owner: 444,Q1jyO0, Date of Inspection: /0 417�55� SEPTIC TANK: (locate on site plan) Depth below. grade:' f Material of construction: concrete _ metal `FRP —other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:.17 Scum thickness:49 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: /i,, 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.) 1e' -s Zf��F�`��s �sr oK �;��;� �daG �i / °I GREASE TRAP: (locate on site plant Depth below grade: Material of construction: concrete ,metal _FRP __,_other(explain) r ;mensions: 'kne5 Distance from top of scum to top of outle( tee or baffle: r'-I-ce fro-'. botto- n' croli 1^ hotto^' Of outlet tee or baifle: 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.leakaee. etc.t trevised '8/:5/95) .6 p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART C SYSTEM INFORMATION (continued) Property Address: /7� +'^ �eL6 2��?h De lVo ;Pn Owner: Date of Inspection TIGHT OR HOLDING. TANK:_ (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/da)` Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: floca)e onsite plan; Depth of liquid level above outlet invert: d Comments: (note df level and d st bv!: evidence of �o( df V deuce of leakage into or out of box. etc.) �1J 70 PUMP CHAMBER: (locate on site plan Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 a .3-77. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION (continued) Property Address: - Tee I-ee r/.t Owner: Date of Inspection: 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; r leaching trenches, number, length:.3_____= 33_/rWh leaching fields, number, dimensions; overflow cesspool, number: Comments (note Condition of soil, signs of hydraulic 'failure level .of ponding, condition of yegetation,etc,) G h. S O /Z ,P G Z G - 4iLv e/1 CESSPOOLS: (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, Materials of construction: indication of grouno,wate,: inflow (cessbool must be pumped as part 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: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) $ (revised 8/15/95) (revised 8/15/95) 9 v441irfz c� yu X�^ /So a C—A SEPT/ e 7�-i9A(* \Ab atEgG-,g DA• EELZ FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ***APPLICANT FILLS OUT THIS SECTION*********************** (APPLICANT Og"'Il yl PHONE (097")-3 /LOCATION: Assessor's Map Number 104 Q PARCEL J SUBDIVISION LOT (S) $ (/ STREET W JN P(ZI V I✓ ST. NUMBER 16 ***OFFICIAL USE ONLY 11 RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED / DATE REJECTED INMECTOR-HEALTH DATE APPROVED / 52/zz, / Q` �7 DATE REJECTED If T— COMMENTS PUBLIC WORKS - SEWERMATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE b (5615T/B pastaea) — Of Zo-7 q.V 7 P"o y :uo!IgwjxWdde Jo fleuiu"a fa P°4,Wm aam"nml of 4tdad IRLYMUNnOW) Ul NJA343 x� ,9 .A aoS+ ,DOL uJLuw SlEam 118 aAbo! 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M..:-�.L - , system Pumping Record E e` a. pumping Record f- woe &MMOIng �' Z. Own* PUMpft TM Of ysf m: C cam K%) G-STank 4, ORL4W Tee fftf ;ftftftt7O Yes fj. No # Waskd-aMWd? Yee CINE 1— W JL Facwft womton { ^ n n ^ A� «J3 VER t�ltth0 IVIENT Wt�1�E iODy � - 0,— 1*mmyw AlS *A d �• ZP Code - a T ae MMber a. pumping Record f- woe &MMOIng �' Z. Own* PUMpft TM Of ysf m: C cam K%) G-STank 4, ORL4W Tee fftf ;ftftftt7O Yes fj. No # Waskd-aMWd? Yee CINE 1— W