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HomeMy WebLinkAboutMiscellaneous - 863 DALE STREET 4/30/2018 (4)4 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 FORM PART A CERTIFICATION Property Address: 863 DALE ST N. ANDOVER MA 01845 Owner's Name: MATT MCLENNAN Owner's Address: 863 DALE ST N_ ANDOVER MA 01845 Date of Inspection: ALTGLTST 4 --200 3 Name of Inspector: (please print) TAMES 3n1RIGHT Company Name: R-1, INSPECTIONS INC Mailing Address: ONE ncr•nnD ST METHUEN MA 01844 Telephone Number: 978-681 —8759 -'�&Rl1 OF i 11 AUG 22 T 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 toSection 15.340 of Title 5 (310 CMR 15.000). The system: r/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: _ Date: � The system inspectors submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days 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 t.`.e system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 863 DALE ST N_ ANDOVER MA 01845 Owner: MATT MCLENNAN Date of lnspection: AUGUST 4; 2001 Inspection Summary: Check A,B,C,D or E / ALWAYS complete.all of Section D A. 7Theave Passes: , 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 (w er metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure i ' minent. System will pass inspection if the existing tank is replaced with a complying septic tank as approve the Board of Health. *A metal septic tank will pass inspection if it is structurally so d, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is availab ND explain: Observation of sewage backup or br out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, sett d or uneven distribution box. System will pass inspection if (with approval of Board of Health): roken 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): ND explain; broken pipe(s) are replaced obstruction is removed 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: R h -j T)AT.F ST -M9—ANDMIER MA 01 A4`i Owner: MATT MCLENNAN Date of Inspection: A11Gi1ST 4, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation b oard of Health in order to determine if the system is failing to protect public health, safety or the enviropHrent. 1. System will pass unless Board o ealth determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in manner which will protect public health, safety and the environment: _ Cesspool or pr' is within 50 feet of a surface water Cesspool rivy 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 surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and th is within a Zone 1 of a public water supply. The system has a septic tank and S and the SAS is within 50 feet of a private water supply well. _ The system has a septi and SAS and the SAS is less than 100 feet .but 50 feet or more from a private water supply we * 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 I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 863 DALE ST NO, ANDOVER MA 01845 Owner: MATT MCLENNAN Date of Inspection: AUGUST 4, 2003 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No� c -up of sewage into facility or system component due to 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 ,Oergged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool uid depth in cesspool is less than 6" below invertor available volume is less than % day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number o ones pumped 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 �ter supply. y 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. 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.] /"(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 'th a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the fol mg: (The following criteria apply to large systems in ad ' ion to the criteria above) yes no the system is within 400 f�of a surface drinking water supply — _ the system is with)R'200 feet of a tributary to a surface drinking water supply the system located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II qf 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _863 DALF ST NO- ANDOVER MA 01-845 Owner: MATT MCLENNAN Date of Inspection: AUGUST 4, 2003 Check if the following have been done. You must indicate `yes" or "no" as to each of the following: Yes Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks ? 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 ? 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 f'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 :7Was s or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _e f ili c i'dif a ner rovided with information on the ro er the facility owner (and occupants if different from owner) p 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: 2y__*q— E .fisting information. For example, a plan at the Board of Health. Determined in the field if an of the failure criteria related to Part C is at issue approximation of distance _ ( Y PP is unacceptable) [310 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: 8631 DALE ST NO. ANDOVER MA 01845 Owner: MATT MCLENNAN Date of Inspection: A[jcjS1 T 4., 2 n n 4 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # obedrooms): Number of current residents: Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system. (yes or no): /V[if yes separate inspection required] Laundry system inspected (yes or no): _ Seasonal use: (yes or no): -' 67 S Water meter readings, if ava.1 _le (last 2 years usage (gpd)): Sump pump (yes or no). Last date of occupancy: 0 COMMERCIAL/INDUS TRIAL Type of establishment: Design flow (based on 310 CMR 15 Basis of design flow (seats/perso Grease trap present (yes or no ' gpd Industrial waste holding present (yes or no): _ Non -sanitary waste di arged to the Title 5 system (yes or no): Water meter readin , if available: Last date of occ acv/use: OTHER f46scribe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection (yes or no): _ If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: TYPY,.,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) _ 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): _ Page 7 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 863 DALE ST NO, ANDOVER MA 01845 Owner: MATT MCLENNAN Date of Inspection: AiTC;UsT 41, 2003 BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: _cast iron -3,ZOVC _other (explain): Distance from private water supply well or suction line: Comments (on condi 'on of joints "inevidence of leakage, etc.): c �'//O'�✓ SEPTIC TANK: _ (locate on site plan) Depth below grade: j 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) Dimensions:%� �}(, S—"k- .5 Sludge depth: 3 t _ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: j ; r Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ` How were dimensions determined: �Gj 17 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP: _(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fib ass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top outlet tee or baffle: Distance from bottom of sc to bottom of outlet tee or baffle: Date of last pumping: Comments (on purr ' g recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to out invert, evidence of leakage, etc.): 7 Page 8 of l 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 863 DATE 8T Nn_ ANDOVER MA 01845 Owner. MATT MCLS NAN Date of Inspection: — AUGUST 4,,-2003 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete mai-- fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present es or no): Alarm lev Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX:(�/ if 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.): PUMP CHAMBER:(locate on site plan) Pumps in working order or no): Alarms in workin er (yes or no): Comments (nom condition of pump chamber, condition of pumps and appurtenances, etc.): d Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: $ 6 *3 DALF ST NO_ ANDOVER MA 01845 Owner: MATT MCLENNAN Date of Inspection: AUGUST d 900 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: le • g galleries, number: eaching trenches, number, length: leaching fields, number, dimensions: 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.): 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 solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construe • 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 condX of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page I 1 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 863 DALE ST NO. ANDOVER MA 01845 Owner: MATT MCLENNAN Date of inspection: A 1(; 1ST 4, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet 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: Clitecked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: 71 11 Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 863 DALE -,T NIL ANDOVER MA 01845 Owner: MATT MCLENNAN Date of Inspection: AUGUST A, 2003 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. 10 . Aug 15 03 01:47p V! Zs O', N V �y m CT V1 .�4]NJm'+I O. U'I 4r0N�k !c -I NNNNNNNNNNNNNNNN C7 a' m ocmor�o©w=C=mmQQd -e i m , ww�u�� '3�POO m���m0gnm i? m Ell I mN i ,I: w N W W W W O W W w W Cd w W w w W W W r r w P W N iYO CIV �O y NnPwJ© c� I C7I� � - .A,JNJJ JN W Npp NpNwNp �'7 I S-� CD :..O WOO�ODOOJ1d®AfPN©dfi-+. 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