HomeMy WebLinkAboutMiscellaneous - 871 FOREST STREET 4/30/2018 (2)N
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Commonwealth of Massachusetts
City/Town of .
System Pumping. Record
.� Form 4
DEP has provided this form for use -by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left / Right front of house, Left / i ret a of ho ,Left /right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear df building, Under deck
Address
C'ity/Town State Zip Code
2. System Owner.
Name
Address Cd different from locafi _
Cityrrown ' JUN Stat
N 0� NORTH AN®OVER
yEtLTH DEPARTMENT � Telephone Number
B. Pumping Record
1. Date of Pumping o2. Qu ty Pumped:
Gallons y
3. Type -of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Ly'No If yes, was it cleaned? ❑Yes ❑ No,
"
S. Condition of System:
6. System Pumped By. -
Nell
y:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Loca'ton where contents were disposed:
Waste Water
F5821
Vehicle License Number
Co
Date
t5form4.doc 06/03 System Pumping Record • Page 1 of 1
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COMMONWEALTH OF MASSACHUSETTS
EXECUTNE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF EwmoNMENTAL PROTECTION
ONE MNTER STREET, BOSTON MA 02108 (617) 292-5500
�;, 0. bf,
TRUDY COXE
Semtfty
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commimioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM BIISPEOM FOM
PART A
CERTI U 10N
Property Address: 871 Forest Street, North Andover Name of Owner: Janos Kovacs
Address of Owner: 871 Forest Street, North Andover, MA. 01845
Date of Inspection: 712912000
Name of Inspector: Neil J. Bateson
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
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 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:
—X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: 7/29/2000
The System Inspectorsefthe
ita cop this inspection report to the Approving Authority (Board of Health or DEP)wfthin thirty (30) days of
completing this inspectioystem isa 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
revised 9/2/98
Page I of 11
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 871 Forest Street
Owner: Kovacs
Date of Inspection: 7/29/2000
INSPECTION SUMMARY: Check A, B, C, or D.
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS: Replaced D -box cover, installed flow levelers In D -box, & replaced outlet tee with gas baffle.
B. SYSTEM CONDITIONALLY PASSES:
One or move 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 NO). 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 leveled 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
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 871 Forest Street, North Andover
Owner. Kovacs
Date of Inspection: 7/29/2000
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 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 sal absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and sal 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
revised 912198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 871 Forest Street, North Andover
Owner: Kovacs
Date of Inspection: 7/29/2000
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
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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 871 Forest Street, North Andover
Owner: Kovacs
Date of Inspection: 7/29/2000
Check if the following have been done: You must indicate either "Yes" or "No` as to each of the following:
Yes No
_X Pumping information was provided by the owner, occupant, or Board of Health.
X 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.
_N/A_ As built plans have been obtained and examined. Note if they are not available with NIA.
_X The facility or dwelling was inspected for signs of sewage back-up.
_X The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout.
_X Al system components, excluding the Soil Absorption System, have been located on the site.
X_ 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:
_X Existing information. For example, Plan at B.O.H. Design plan no as built plan.
_X Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[I 5.302(3)(b)]
_X The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 912198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 871 Forest Street, North Andover
Owner: Kovacs
Date of Inspection: 7/29/200
FLOW CONDITIONS
RESIDENTIAL:
Design flow 150 _ .g.p.d./bedroom.
Number of bedrooms (design):—4 _ Number of bedrooms (actual) 4_
Total DESIGN flow _600 _
Number of current residents: 5
Garbage grinder (yes or no): _ No_
Laundry (separate system) (yes or no):_ No_ If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):_ No_
Water meter readings. 53,100 ft3 x 7.5 = 398,250 Gals. / 730 Days = 545 Gals. / Day
Sump Pump (yes or no): _ Yes_
Last date of occupancy: Current
COM M ERCIALII NDUSTRIAL:
Type of establishment:
Design flow: 9pd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no) _
Non -sanitary waste discharged to the Title 5 system:
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe) _
Last date of occupancy:
(yes or no)
GENERAL INFORMATION
PUMPING RECORDS and source of information: Pumped three years ago, Owner.
System pumped as part of inspection: (yes or no)_Yes _
If yes, volume pumped: _1500_gallons
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)
VA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 12 years old. 4-11-1988. As per info at B.O.H.
Sewage odors detected when arriving at the site: (yes or no)_No
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 871 Forest Street, North Andover
Owner: Kovacs
Date of Inspection: 7/29/2000
BUILDING SEWER: X
(Locate on site plan)
Depth below grade: 16"
Material of construction: _X cast iron _X_ 40 PVC _ other (explain)
Distance from private water supply well or suction line:
Diameter :4"
Comments: 4" cast iron thru wall. 3" PVC in house.
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 4"
Material of construction: _X concrete _metal _Fiberglass _Polyethylene _other (explain)
If tank is metal, list age _Is age confirmed by Certificate of Compliance _ (Yes/No)
Dimensions: 10' x 5'x 4'
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: N/A
Scum thickness: 10"
Distance from top of scum to top of outlet tee or baffle: N/A N/A = outlet tee corroded off.
Distance from bottom of scum to bottom of outlet tee or baffle:N/A
How dimensions were determined: Measure depth of scum & sludge.
Comments: Pumped septic tank. Inlet tee ok. Outlet tee corroded off. Replaced with plastic tee with gas baffle. Depth of liquid at outlet invert. No evidence of
leakage.
GREASE TRAP: None
(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:
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 871 Forest Street, North Andover
Owner. Kovacs
Date of Inspection: 7/29/2000
TIGHT OR HOLDING TANK: _None (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 flow:_gallons/day
Alarm present
Alarm level: Alarm in working order: Yes_ No
Date of previous pumping:
Comments:
DISTRIBUTION BOX.:_X_
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments: D -box cover broken . Replaced same. D -box level , distribution not equal. Installed flow levelers. Evidence of carryover, pumped d -box to clean. No
leakage.
PUMP CHAMBER: —None, gravity system_
(locate on site plan)
Pumps in working order. (Yes or No)
Alarms in working order (Yes or No)
Comments:
Revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued))
Property Address: 871 Forest Street, North Andover
Owner: Kovacs
Date of Inspection: 7/29/2000
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods)
If not located, explain:
Type:
leaching pits, number.
leaching chambers, number:
leaching galleries, number
leaching trenches, number, length:
leaching fields, number, dimensions: 1 Field 20'x 45'
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments: Soil ok. Vegetation ok. No sign of ponding to surface.
CESSPOOLS: None
(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 groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
PRIVY: None
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
revised 912198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 871 Forest Street, North Andover
Owner: Kovacs
Date of Inspection: 7/29/2000
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)
A to 1 = 39'3"
•to2=48'
A to D -Box = 53'5"
B to 1 = 31'
Bto2=22'
B to D -Box = 26'
revised 9/2/98 Page 10 of 11cccccc
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 871 forest Street, North Andover
Owner: Kovacs
Date of inspection: 7/29/2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 5 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_X Obtained from Design Plans on record
_X Observed Site (Abutting property, observation hole, basement sump etc.)
—X—Determined from local conditions
—X—Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed) As per design plan.
revised 912198 Page 11 of 11
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: 871 Forest Street, North Andover
Owner: Kovacs
Date of Inspection: 7/29/2000
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.
i
L
Neil J. Bateson
Bateson Enterprises, Inc.
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
�1 STEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
:�'1'E OF PUMPINC: 7 ���� QUANTITY PUMPED �S�CUGALLO
U
NO t1l YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE L,� EMERGENCY
c�H.SFRVATIONS: /
GOOD CONDITION ✓ FULL TO COVER
HFAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER �JJHER (EXPLAIN)
>1' "PLM. PUMPED BY:
c'U.1I IyI ENTS:
� UN"I ENT' TRANSFERRED To:
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WELL DATABASE
ADDRESS: !% p T N ,� ,� G •
AGE OF WELL: WELL DRILLER:
WELL PER�v= n: WELL LOCATION: j/,
_WELL PERMIT DATE: DEPTH OF WELL:
a
TYPE OF WELL: a.. DRILLED b. DUG c. OWN
TYPE OF WATER BEARING ROCK -
WATER ANALYSIS DATE: I3IGH MANGANESE: Y N
HIGH IRON: Y N OTHER CONTA ENANTS: Y N
WELL DATABASE
ADDRESS: ?l / I—D /��t1[.oi► y�
AGE OF WELL: WEL DRILLER:
WELL PERMIT 4: WELL L CATION.f�
WELL PERMIT DATE: DEPTH OF WELL.
TYPE OF WELL: a.. DRILLED b. DUG c. UNKNOWN
TYPE OF WATER BEARING ROCK:
WATER ANALYSIS DATE: HIGH MANGANESE: Y
HIGH IRON: Yn/^' N OTHER CONTANIINAINTS: Y N
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