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Home My WebLink AboutTitle V Inspection Report - 530 FOSTER STREET 7/30/2018 Commonwealth of Massachusetts ...... ----------- Title 5 Official Inspection Form 1: Subsurface Sewage Disposal System Form Not for Voluntary Assessments 03 530 Foster St ti slo Property Address Jeffrey OwnerOwner's Name information is required for every No. Andover MA 01845 05-23-2018 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A filling out forms General Information on the computer, use only the tab 1 Inspector: key to move your cursor-do not John DiVincenzo use the return ......................... key. Name of Inspector J and S.Development Stewarts Septic Service ............ VQ Company Name 58 South Kimball St Company Address Bradford MA 01835 City/Town liy/Tow n State Zip Code 978-372-7471S113386 ..-...................... Telephone Number License Number B. Certification 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: Passes ❑ Conditionally Passes F-1 Fails El e s F0 er Evalu n by the Local Approving Authority re / F spect AII e tor's Signature Date The system inspects H"submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) 1fiin 30 days of completing this inspection. If the system 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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. t5ins,doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts ~�� "�Q 0�� Title �� v�� @N��@�m� Inspection �~��uomw Subsurface Sewage Disposal System Form Not for Voluntary Assessments 530 Foster Property Address Jeff re Owner Owner's Name information is Andover N1A01845 -2018 required for every No. ---- ------ page. CityfTmwn State Zip Code Date ofInspection B. Certification (cont.) | Inspection Summary: Check A,B.C.[J or E/always complete all of Section O A) System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303orin 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Removed sphinnkler rine that ran over center cover B) System Conditionally Passes: F1 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 ofHealth, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank ismetal and over 20years old* orthe septic tank (whether metal urnot) imstructurally unsound, exhibits substantial infiltration or exfi|t/ation or tank failure is imminent. System will pass / inspection ifthe existing tank is replaced with a complying septic tank as approved by the Board of | Health. *Ametal septic tank will pass inspection if it is structurally sound, not leaking and if Certificate of Compliance indicating that the tank ieless than 2Uyears old iaavailable. R Y F-1 N Fl ND (Explain be|ow): | Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface SwvxaBeQisposm| SystemmFprmn -NotforVm|untoryAsaenemnnto 30 Foster S Property Address J��re Owner Owner's Name information is required for every No. Andover MA 0184505-23-2018 page. Cityrrmwn State Zip Code Date ofInspection B. Certification /c0U[.\ [l Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. � B) System Conditionally Passes (oont.): |l Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)ordue bz u broken, settled or uneven distribution box. System will pass inspection if(with approval ofBoard VfHeu/th): [l broken pipe(s) are msp|aood F] Y [l N [l ND (Explain below): obstruction iaremoved F] Y R N n ND (Explain be|ow): distribution box ieleveled orreplaced [l Y F-1 N El ND (Explain below): M 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 nfthe Board ofHaa|th): R broken pipe(a) are replaced [l Y Fl N [l ND (Explain be|ovv : F-1 obstruction is removed D Y 0 N F-1 ND (Explain be|ow): C\ Further Evaluation boRequired bythe Board ofHealth: Fl Conditions exist which require further evaluation by the Board of Health in order to determine if the eyebern is failing to protect public hoa|(h, safety orthe environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 1S.3U3(1)(b>that the system is not functioning in a manner which will protect public health, safety and the environment: F1 Cesspool orprivy iawithin 5Ofeet ofa surface water Fl Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts ' Title 5 ur�N�" i aQ Inspection nspe= t" n F orm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 530 Foster St ---------- Property Address Jeffrey Owner Owner's Name information is required for every No. Andover MA 01845 05-23-2018 page. Cityrrmn State Zip Code Date nfInspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system |sfunctioning |mmmanner that protects the public health, safety and environment: Fl The system has aseptic tank and soil absorption system (SAS) and the SAS iswithin 1O0feet ofesurface water supply ortributary toasurface water supply. F-1 The system has a septic tank and SAS and the SAS is within e Zone 1 of public water supply, [l The system has a septic tank and SAS and the SAG is within 50 feet of private vvab*r supply well. �] The system has a septic tank and GAS and the GAS in less than 100 feet but 5Ofeet or more from a private water supply we|l** Method used todetermine distance: ** This system passes ifthe well water analysis, performed ata DEP certified |aborabzry, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or|eaa than 5 ppm, provided that no other failure odb»ha are triggered. A copy of the analysis must be attached to this form. 3. C)Uler D) System Failure Criteria Applicable toAll Systems: You must indicate'^"/es" or"No"tpeach ofthe following for all inspections: Yen No �� Backup ofsewage into facility orayotenncomponent due hoovedoadador �� clogged SAS orcesspool �� Discharge orponding ofeffluent tothe su� � waters �� due toanoverloaded orclogged SAS nrcesspool [l �� Static liquid level in the distribution box above outlet invert due to on overloaded orclogged SAS orcesspool Liquid depth in cesspool is less than S" below invert or available volume is |emm �� than 1/2day flow ,mno.uoo'rev.em Title*Official Inspection Form:Subsurface Sewage Disposal System^Page 4m,, � � Commonwealth of Massachusetts � ` Title 5 Official Inspection nspec =onF rm Subsurface SaxVageDigponn| SysbarnFormn - NotforVu|untaryAaeeyementS � � 53OFoster St PmpenyAddrems Jeffrey Owner Owner's Name information is required for every No. Andover MA 01845 018 pag*. City7own State Zip Code Date oiInspection B. Certification (cont.) Yes No �l �� Required pumping more than 4times inthe last year NOT due boclogged or �� obstructed pipe(s). Number oftimes pumped: _____. 0 Z Any portion of the SAS, cesspool or privy is below high ground water elevation. [� �� Any pn�ionofcesspool nrprivy iswithin 1OOfeet ofaau�aoewater supply or �� tributary b)usurface water supply. Z Any portion of a cesspool orprivy iswithin aZone 1 ofapublic well. El Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. El Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from e private water supply well with no acceptable water quality analysis, [This system passes ifthe well water analysis, performed mta DEP certified laboratory, for fecal coliform bacteria indicates absent 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 and chain o7custody must be attached tnthis fmvnm.] The system iaacesspool serving 8facility with adesign flow of2OOOgpd- 10.000gpd. [l �� The system fails. | have determined that one nrmore ofthe above failure criteria exist aadescribed in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board ofHealth todetermine what will ba necessary Locorrect the failure. E> Large Systems: Tobeconsidered olarge system the system must serve afacility with a design flow pf10'00O gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions inSection D. Yen No n [l the system is within 4DOfeet ofa surface drinking water supply El [l the eyehnm is within 200 feet ofatributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—|VVP/\) oramapped Zone || ufapublic water supply well |fyou have answered "yee" toany question inSection Ethe system iaconsidered a significant threat, or answered "yes" in Section O above the large system has failed. The owner o[operator ofany large system considered osignificant threat under Section E orfailed under Section Oshall upgrade the system inaccordance with 318CMR 15.3O4. The system owner should contact the appropriate regional office ofthe Department. Commonwealth of Massachusetts itle 5 uff icial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 530 Foster St ---------------- .............. ........... Property Address Jeffre K- .......... ------------ Owner Owner's Name information is No. Andover MA 01845 05-23-2018 required for every ................... page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No E ❑ Pumping information was provided by the owner, occupant, or Board of Health El H 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? 0 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? Was the site inspected for signs of break out? N El Were all system components, excluding the SAS, located on site? Z 0 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? • El 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: • EJ Existing information. For example, a plan at the Board of Health. • El Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 4 Number of bedrooms (actual): .................. DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doo-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 530 Foster St Property Address Jeffrey ..................... Owner Owner's Name information is required for every No. Andover MA 01845 05-23-2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: ----------- --------------- ........ ---------_--------- ........................... . ..... ---------- 2 Number of current residents: Does residence have a garbage grinder? Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection 0 Yes [E No information in this report.) Laundry system inspected? El Yes El No Seasonal use? El Yes H No Water meter readings, if available (last 2 years usage(gpd)): Detail: Recommend to remove garbage disposal ..........- Sump pump? ❑ Yes No Occupied Last date of occupancy: Date PJ ....................... Commercial/industrial Flow Conditions: Type of Establishment: ............ Design flow(based on 310 CMR 15.203): Gallon,s_per day(gpd) Basis of design flow(seats/persons/sq.ft,, etc.): Grease trap present? R Yes El No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 n�, Commonwealth of Massachusetts ---------- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 530 Foster St Property Address Jeffrey.. ---------------- --- Owner Owner's Name information is required for every No. Andover MA 01845 05-23-2018 ------------ ---------- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) as date of occupancy use: —------------ Date Other(describe below): ---- .............. .......... General Information Pumping Records: Source of information: Stewart's Was system pumped as part of the inspection? 0 Yes E-1 No 1500 If yes, volume pumped: -gallons. . site gauge on truck Now was quantity pumped determined? ....... Reason for pumping: inspect tank Type of System: z Septic tank, distribution box, soil absorption system 0 Single cesspool R Overflow cesspool E-1 Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology, Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract 0 Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.8116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts 2 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 530 Foster St Property Address JeffTy_,,,_,,,...................................... Owner Owners Name information is required for every No. Andover MA 01845 05-23-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1998 Were sewage odors detected when arriving at the site? E-1 Yes E No Building Sewer(locate on site plan): 301V Depth below grade: .feet fe.et Material of construction: 2 cast iron E]40 PVC El other(explain): Distance from private water supply well or suction line: -fee.t... Comments (on condition of joints, venting, evidence of leakage, etc.): ............ ---------------- .......... ................. Septic Tank (locate on site plan): Depth below grade: 12" feet Material of construction: Z concrete El metal F-1 fiberglass n polyethylene E] other(explain) .......................... ................ -------------- If tank is metal, list age: years .............. Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) F-1 Yes F No Dimensions: ---------------------------------- Sludge depth: 111-11.11.._....._._...... 15ins.doc-rev,6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts its 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 530 Foster St ............... Property Address Jeffrey ..................... Owner Owner's Name information is required for every No. Andover MA 01845 05-23-2018 page. City/Town.......................................... ---- State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 3011 Distance from top of sludge to bottom of outlet tee or baffle ---------- Scum thickness 511 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1611 How were dimensions determined? Tape measure/sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both baffles are in good shape, no leakage and liquid leves are good ------------ ---------------------- ....... .....................................- .................. ............ Grease Trap (locate on site plan): Depth below grade: ................_._----- feet -------- feet Material of construction: 0 concrete ❑ metal El fiberglass F-1 polyethylene F-1 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: -[late--- __............-. t5ins.doc-rev,6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 (f� Commonwealth of Massachusetts it 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 530 Foster St Property Address Jeffrey Owner Owner's Name information is required for every No. Andover --------..................................................................................... MA 01845 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ---------------------------- ............. ...................................- .......... -1-.------.......................... Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depthbelow grade: ..................11...............------------------ _..........._.-------- Material ..............-----------Material of construction: El concrete El metal El fiberglass F-1 polyethylene El other(explain): Dimensions: ........................................................................................................ Capacity: gallons Design Flow: gallons per day Alarm present: E-1 Yes E-1 No Alarm level: Alarm in working order: E] Yes El No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ------ ........... ---------------- ---------------------- ------------- Attach copy of current pumping contract(required). Is copy attached? El Yes E-1 No t5insAoc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts --- Title Official Inspection r - H Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 530 Foster St �4 ......._..._.v................._------------ .__....,_.. .....�..._ Property Address Jeffrey,-""".--.. __._.__. .. Owner Owner's name information is required for every No Andover MA 01845 05-23-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 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.): Equal distribution,no leakage, no solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes No* Alarms in working order: ❑ Yes [J No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan„ excavation not required): If SAS not located, explain why: l5ins.doc rev.6116 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 <L Commonwealth of Massachusetts - - ---- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 530 Foster St Property Address Jeffrey OwnerOwner's Name information is required for every No. Andover 01845 05-23-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 0 leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: 2 - 50' 0 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.): No hydraulic failure, no ponding and no damp soils ...................... ------------------------------ ............... ........................ 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 construction Indication of groundwater inflow El Yes El No t5ins.doc-rev,6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments . ..... 530 Foster St ------------------- Property Address Jeffre Owner Owner's Name information is required for every No. Andover MA 01845 05-23-2018 .............. ----------- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 w........._ .......... Depth of solids ............ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): .. ............. .... ....... ............ t5ins.doc-rev.6/16 Title 6 Official Inspection Forn Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Ti I fiiil Inspect on orm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 530 Foster St Property Address Jeffrey Owner Owner's Name information is No. Andover MA 01845 06-23-2018 required for every _,_a........__.....-_.___ _..._......_ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below Z drawing attached separately 16ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 530 Foster St Property Address J effrey Owner Owner's Name information is No Andover MA 01845 05-23-2018 required for every ---- ---. _.........__. - page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 130 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 01-09-1998 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: pulled files ® Checked with local excavators, installers- (attach documentation) El Accessed USGS database -explain: You must describe how you established the high ground water elevation: Taken from plans on record BOH _... _...... ..._._ _—..__..._ ....._ -.. . ----_...._.. _...._. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doe•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 530 Foster St ----------- Property Address Jeffrey ffrey OwnerOwner's Name information is required for every No. Andover MA 01845 05-23-2018 page. d71ty -/-r -o,`wn-- State Zip Code Date of Inspection E. Report Completeness Checklist Z inspection Summary: A, B, C, D, or E checked Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Z System Information — Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 1 4 , , 0 1 tk"T 8 "'5 Town o North Andover HEALTH DEPARTMENT CHECK DATE: " ............... ...................... LOCATION: HBO NAME: �X� NAME: CQNTRACT Type of Permit or Licens,e: (Check box) 0 Animal $ • Body Art Establishment • Body Art Practitioner $ 0 Dumpster $ 0 Food Service- $ • Funeral Directors $ • Massage Establishment $ • Massage Practice • Offal(Septic)Hauler • Recreational Camp IJ Suit tanning 0 Swimming Pool 0 Tobacco 0 TrasIVSolid Waste Hauler $ 0 Well Construction SEPTIC Systems- * Septic-Soil Testing $ * Septic-Design Approval $ * Septic Disposal Works Construction(DWQ $ * Septic Disposal Works Installers(DW[) $ * Title 5 Inspector $ Title 5 Report $ 0 Other. (Indicate).--,--- $ ........... Health-Agent Initials White-Applicant Yellow--Health Pink-Treasurer