HomeMy WebLinkAboutMiscellaneous - Exception (326)COMMONWEALTH OF
EXECUTIVE OFFICE (
DEPARTMENT OF
ENVIRONMENTAL AFFAIRS
[RONMENTAL PROTECTION
IgTLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: _138 Old Cart Way-
— North Andover_
Owner's Name: _Gerald Eisen_
Owner's Address: _138 Old Cart Way_
_ North Andover, MA 01845_
Date of Inspection: _5/18/2005_
Name of Inspector: Neil J. Bateson_
Company Name: Bateson Enterprises Inc._
Mailing Address: _111 Argilla Road_
Andover, Ma. 01810_
Telephone Number: _( 978 ) 475-4786_
RECEIVED
MAY 2 5 2005
TOWN OF rvUlt i H ANDOVER
HEALTH DEPARTMENT
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
Needs Further Evaluation by the Local Approving Authority
ail Rp�
t ; �
Inspector's Signature: .! Date: _5/18/2005_
The system inspector shall submit a copy of is 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: _138 Old Cart Way_
_ North Andover_
Owner: _Eisen
Date of Inspection: _5/18/2005_
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:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _138 Old Cart Way_
_ North Andover—
Owner: _Eisen
Date of Inspection: 5/18/2005_
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(1)(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
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 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: _138 Old Cart Way _
_ North Andover—
Owner: _Eisen
Date of Inspection: _5/18/2005_
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
—No7 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.
—No7 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.
_NoAny 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
gld-
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: _138 Old Cart Way _
_North Andover—
Owner: _Eisen
Date of Inspection: 5/18/2005_
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 ?
N/A 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
_N/A_ _ 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: _138 Old Cart Way _
_ North Andover_
Owner: _Eisen _
Date of Inspection: _5/18/2005_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): _N/A_ Number of bedrooms (actual): _4_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _N/A_
Number of current residents: _2
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 _
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/sqft,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: _Never pumped, 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: -10 Years old, owner _
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: _138 Old Cart Way_
_ North Andover _
Owner: _Eisen
Date of Inspection: 5118/2005_
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: _24"_
Materials of construction:_ _ cast iron _X 40 PVC _other
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANKS: X
4" PVC thru wall, 3" PVC in house _
Depth below grade: _12"_
Material of construction: X 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: 10'x 5' x 4'
Sludge depth —10" _
Distance from top of sludge to bottom of outlet tee or baffle: _11"_
Scum thickness: _12" _
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: 9" _
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. Inlet tee ok. Outlet tee ok. Depth of
liquid at outlet invert. _
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 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _138 Old Cart Way-
- North Andover -
Owner: _Eisen
Date of Inspection: 5/18/2005_
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 BOX: 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 -box 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 ofpumps 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: _138 Old Cart Way_
_ North Andover _
Owner: _Eisen
Date of Inspection: _5/18/2005_
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required)
If SAS not located explain why:
Type
_ leaching pits, number: _
leaching chambers, number:
leaching galleries, number:
_X leaching trenches, number, length: _2 trenches 56' long_
_leaching fields, number, dimensions:
overflow cesspool, number:
innovativelalternative system Type/name 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
UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _138 Old Cart Way_
_ North Andover—
Owner: _Eisen _
Date of Inspection: _5/18/2005_
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.
Water
House
B
A to Tank = 54'
A to D -Bog = 76'
B to Tank = 29'3"
B to D -Bog = 53'6"
Driveway
D -
Septic Tank Bog
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _138 Old Cart Way_
—North Andover—
Owner: _Eisen
Date of Inspection: 5/18/2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater —>6'—
Please
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 #36,
Canton Soil, Water > 6'Deep_
Summary Record Card generated on 5/17/2005 12:47:04 PM by Lisa Warren
Town of North Andover
Tax Map # 210-1073-0120-0000.0
138 OLD CART WAY
EISEN, GERALD
138 OLD CART WAY
NO. ANDOVER, MA
01845
Class 101 Single Family
Size Total 1.09 Acres
FY 2005
UB Mailing Index
Name/Address Type Loan Number
EISEN, GERALD Payor
138 OLD CART WAY
NO. ANDOVER, MA
01845
UB Account Maint.
Property Type
Active/Inact. From
Account No Cycle
Occupant Name
Active/Inactive
Bldg Id. 7394.0 - 138 OLD CART WA
Last Billing Date 5/3/2005
1090436 01 Cycle 01
Active
UB Services Maint.
Service Code
Rate
Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8
7.82
1/
WTR WATER
01 ALL METER SIZE
25.20
/1
UB Meter Maintenance
Serial No Status
Location
Brand
Type Size
39766675 a Active
Y ENC F.L.
METE METE
w Water 0.63 0.63
Date Reading
Code
Consumption
Posted Date
4/21/2005 1650
a Actual
9
5/13/2005
2/1/2005 1641
a Actual
11
2/15/2005
MSG
10/27/2004 1630
a Actual
60
11/15/2004
Trouble Code: 13
8/3/2004 1570
a Actual
61
8/25/2004
5/10/2004 1509
m Manual estimate
15
6/8/2004
2/4/2004 1494
a Actual
15
2/24/2004
11/3/2003 1479
n New Meter
0
11/3/2003
Page 1
1 Residential
Until
YTD Cons
0
Variance
-84%
-2%
359%
-3%
0%
0%
1;4,I r T
a
-
�f
.$ U/S ACCOUNT HISTORY
1090436-FISEN, GERALD
METER 01: 1090436
-------------------
811:138
OLD
CART UA
8 CYCLE
SERUICE PRIOR CURRENT
USE
UATER
SEUER
FEES
TOTAL
1
1 '10H0 1
07/01/199'1
651
7111
100
273.00
0.00
0.00
273.08
2 211H0-21
11,16/1999
7111
904
53
144.69
0.00
0.00
144.69
3 211110 3.1
03/0"!. 20011
H114
819
1b
40.9!,
0.00
11.00
40.95
4 2HH0 41
H:/I1/7.000
819
037.
13
35.49
0.00
0.00
35.49
b 2110111
07/27/7.1,11)
H32
872
40
1119.7.0
0.610
11.00
120.211
6 2001-7.1
11/112/7.000
8?2
908
36
98.2R
0.00
11.00
109.28
7 2001-31
02/17./2001
908
1211
1?
46.41
0.00
1.1.00
57.41
H 200.1-41
0S/07/2001
925
9S2
27
73.71
0.00
11.00
84.71
9 2002-11
07/7.6/20111
9112
1038
86
290.18
0.00
5.S5
295.73
10 2002-21
11/19/7.001
1038
1154
116
417.08
0.00
S.S5
422.63
11 2007.-31
03/11/2002
1154
1176
21
S1.87
0.00
5.55
S7.42
17. 2002-41
05/14/2.002
11'75
1183
8
19.76
0.00
5.55
25.31
t3 7.002 -CRI) 11/20/7.001
1154
1154
0
-30.40
0.00
0.00
-38.48
1.4 2003-11
07/26/2002
.1183
1228
45
1.42. 60
0.00
5.9?
148.57
2003 7.1
10/29/2007.
127.8
1.322
94
323.12
0.00
5.97
329.09
16 2003-31
01/28/2003
1322
133?
1.11
35.'70
0.00
5.97
41.67
11,S
1? 2003-41
04/23/2003
1.337
1350
13
30.94
0.00
5.9?
36.91
IS 20H4-11
0'J/'l.1 /'7.011:1
1350
1.390
40
119.00
0.00
7.42
126.47.
HEUIFU CHOICE
A or <ENTER> MORE HISTORY:
1;4,I r T
a
lelnet 10.1.71.55
U/S ACCOUNT HISTORY 1$390436-E1SEH, GERALD ME:TF.R III: 1HYH436
------------------- RR:1.38 OLD CART WR
11 CYCLE SERUICE PRIOR CURRENT USE UA'IER SEDER FEES TOTAL
1 2004-21 11/03/2003 1390 14'79 89 282.15 0.00 7.42 289.5
2 2004-31 02/04/2004 1479 L4Y4 1S 34.2H 11.00 7.42 41.6
Etl CHOICE U or <ENi'ER> MORE HISTORY:
40.
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mll�w i�s-
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: 138 Old Cart Way, North Andover
Owner: Eisen
Date of Inspection: 5/18/2005
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.
Bateson Enterprises, Inc.