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HomeMy WebLinkAboutTitle V Inspection Report - 121 RALEIGH TAVERN LANE 8/15/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form RECEIVED Subsurface Sewage Disposal System Form Not for Voluntary Assessments AUG 15 121 Raleigh Tavern Lane _15'roperty Address �I'ME HEA1,11H DUIPJK Megan Glennon —---------- Owner's Name infCrm'ration is required for every North Andover —------------- MA 01845 8-8-2018 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. Inspector Information fillingout forms on the computer, use only the tab Neil James Bateson key to move your Name of Inspector cursor-do not Bateson Enterprises Inc. use the return Company Name key. 111 Argilla Road VQ Company Address Andover MA 01810 Cityrrown Sfafe– Zip Code nn 978-475-4786 SI-15 Telephone Number License Number B. Certification I certify that: I am a DEP approved system Inspector In full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. E Passes 2. ❑ Conditionally Passes 3. n Needs Further Evaluation by the Local Approving Authority 4. E01 F s 8-8-2018 ns ect r s ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 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 DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. i5insp,doe-rev.712612018 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 1 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property Address Megan Glennon Ow owner's Name inf=eration is MA 01845 8-8-2018 required for every North Andover page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: 1 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: 2) System Conditionally Passes: El 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): i5j 1 psp.doe•rev.7/213/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property Address Megan Glennon ----------- _m.___ Owner Owner's Name information is required uired for every North Andover MA 01845 8-8-2018 -- - page. di—tyffown — State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): F-1 Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. R 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): El broken pipe(s)are replaced M Y n N F-1 ND (Explain below): ❑ obstruction is removed El Y F1 N El ND (Explain below): ❑ distribution box is leveled or replaced E] Y M N n ND (Explain below): El 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 E] Y r-1 N Ej ND (Explain below): F1 obstruction is removed Y E] N El ND (Explain below): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system Is not functioning in a manner which will protect public health, safety and the environment: t5lirsp.doc-rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property Address Megan Glennon —--—--------- Owner Owners Name information is required for every North Andover MA 01845 8-8-2018 -—---------.......... page. �jityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) I determines that the system is functioning in a manner that protects the public health, safety and environment: R 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. R The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. R The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. n 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 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 must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or El 2 clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters El 0 due to an overloaded or clogged SAS or cesspool l5rsp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts - - - Title 5 Official Inspection Form -------- Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property Address Megan Glemon Owner Owner's Name information Is required for every North Andover MA 01845 8-8-2018 pa6e. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El M Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El z Liquid depth in cesspool is less than 6" below invert or available volume is less than '12 day flow n z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: 1:1 z Any 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 water supply. El E Any portion of a cesspool or privy is within a Zone I of a public water supply well. E z 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. [This system passes if the well water analysis, performed at a 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 of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 pd- 0 10,000 gpd. El ED The system falls. 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. 6) 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 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No El ❑ the system is within 400 feet of a surface drinking water supply 0 El 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 ProtTction 11 F1 Area—IWPA) or a mapped Zone 11 of a public water supply well t5lrisp.doc•rev.712612018 "rifle 5 Official Inspeclimi Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property Address Megan Glennon OX"" Owner's Owners Name inf'rm tion is MA 01845 8-8-2018 required for every North Andover pa0e. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.6 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for an inspections: Yes No Pumping information was provided by the owner, occupant, or Board of Health El E Were any of the system components pumped out in the previous two weeks? 0 M Has the system received normal flows in the previous two week period? 0 E Have large volumes of water been introduced to the system recently or as part of this inspection? Z 1:1 Were as built plans of the system obtained and examined? (if they were not available note as N/A) • El Was the facility or dwelling inspected for signs of sewage back up? • El Was the site inspected for signs of break out? F Were all system components, excluding the SAS, located on site? El 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? Was the facility owner(and occupants if different from owner) provided with N El 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: Z Ej Existing information. For example, a plan at the Board of Health. 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)] t6insp.doc-rev,7126/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 121 Raleigh Tavern Lane —------------------- Property Address Megan Glennon Owner Owner's Name information is reqfor every North AndMA 01845 8-8-2018 page, Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: 4 Number of current residents: Does residence have a garbage grinder? F Yes No Does residence have a water treatment unit? El Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection 0 Yes [D No information in this report.) Laundry system inspected? El Yes n No Seasonal use? El Yes E No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? E Yes El No Last date of occupancy: Current Date t6i psp,doo rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 121 Raleigh Tavern Lane Property Address Megan Glennon Owner Owner's Name i rmation is information MA 01845 8-8-2018 req I uired for every North Andover _._._.__----- page. ------- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(g_pd) _ Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? n Yes F] No Water treatment unit present? El Yes El No If yes, discharges to: Industrial waste holding tank present? El Yes 0 No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date – Other(describe below): 3. Pumping Records. Pumped 2017,owner Source of information: Was system pumped as part of the inspection? Yes ❑ No I� 1500 If yes, volume pumped: gallons Measured tank How was quantity pumped determined? _._..-_— Inspect tank&tees. Reason for pumping: iw�sp.doc-rev.7/26/2018 Title 5 official inspection Form:Subsurface Sewage Disposal system-Page 8 of 18 i Commonwealth of Massachusetts -—---------- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane ........ -—----- Property Address Megan Glennon Owner at,on,s Owners Name re ,Wired for every North Andover_-,-__,_ MA 01845 8-8-2018 ---------- page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 4. 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) 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 El Tight tank, Attach a copy of the DEP approval. Other(describe): Approximate age of all components, date installed (if known) and source of information: 1years old, 4-27-2005, as built plan Were sewage odors detected when arriving at the site? El Yes H No 5, Building Sewer(locate on site plan): 2 Depth below grade: Material of construction: cast iron E 40 PVC E] other(explain): —------ Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4"Cast Iron through wall, 3" PVC in house, no leaks visible t5insp.doc•rov.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern-Pago 9 of 18 Commonwealth of Massachusetts ---------------­-- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property-Address- Megan Glennon Owner Owner's information is required for every North Andover MA 01845 8-8-2018 page. Cityrrown State Zip Code -bate of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: Material of construction: E concrete F] metal 0 fiberglass El polyethylene ❑ other(explain) 1500 Gallon Micro Fast Septic Tank .............. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) n Yes El No Dimensions: 10'x 5'x 4' Sludge depth: 32" Distance I from top of sludge to bottom of outlet tee or baffle Scum thickness --------- Distance from top of scum to top of outlet tee or baffle 8'w Distance from bottom of scum to bottom of outlet tee or baffle 18-1 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.): Inlet tee ok. Outlet baffle ok. Depth of liquid at outlet invert. No evidence of leakage. Pumped septic tank. Inlet cover, center cover&fast cover are all to grade. 15ihsp.doc-rev.7126t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane ------ Property Address Megan Glennon Owner Owner's Name information is req6ired for every North Andover MA 01845 8-8-2018 pa6e. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: 'feet Material of construction: El concrete El metal El fiberglass El polyethylene F1 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: ate Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete E-1 metal El fiberglass ❑ polyethylene n other(explain): Dimensions: Capacity: Design Flow: ga-11onis—per day­---"­ t5i s Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Pago 11 of 18 n p.doc-rev.712612018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property Address Megan Gle�nnon Owner Owners Name information is required for every North Andover MA 01845 8-8-2018 ----------— page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: El Yes El No Alarm level: Alarm in working order: El Yes F1 No Date of last pumping: I ...... Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). is copy attached? El Yes El No 9. 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.): ---—------- t5insp,doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts rp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property Address Megan Glennon -------- owner Owner's Name inf8rmation is req I pfired for every North Andover MA 01845 8-8-2018 pae. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: E Yes 0 No* Alarms in working order: Yes © No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump Tank ok. Pump ok. Alarm ok.Alarm has both audible &visual, tested both ok. __------- --------- ---------- ------ ---------- If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: E] leaching pits number: 0 leaching chambers number: 50 El leaching galleries number: n leaching trenches number, length: E-1 leaching fields number, dimensions: ❑ overflow cesspool number: innovative/alternative system Type/name of technology: (5ihsp.doc-rev.7126/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 13 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property Address Megan Glennon ------------ owner �W Name information is re�uired for every North Andover ------------ MA 01845 8-8-2018 I,e. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) 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. 10 rows of five infiltrator chambers per row. Opened up inspection ports X&Y no water present. ----------- 12. 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 F-1 Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5i i nsp.doc-rev.7/26/2018 Title 5 Official Inspection Farm.Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property Address Megan Glennon Owner Owner's Name information is required for every North Andover MA 01845 8-8-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids __.__......_a._-.. _...__...__ Comments ---------- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ---------- t51nsp.doc rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sy-stern-Page 15 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form .I..... Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property Address Megan Glennon Owner Owners Name information is required for every North Andover MA 01845 8-8-2018 page. State Zip Code Date of Inspection D. System Information (cont.) 14, 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: ,M hand-sketch in the area below El drawing attached separately 440 1 L4 0 Li 0 X C-)�5 C) I PcLe 14 `3 U %,4 0 t5lnsp.doc iev.7!.26/20118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property—Address —------ Megan Glennon Owner Owner's Name information is North Andover MA 01845 8-8-2018 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Z Check Slope Z Surface water ED Check cellar Z Shallow wells Estimated depth to high ground water: 2 ....... feet Please indicate all methods used to determine the high ground water elevation: z Obtained from system design plans on record 9-21-2004 If checked, date of design plan reviewed: b`a-tW,-----,--"" --.1------------- El Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: design Plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: -------------- You must describe how you established the high ground water elevation: As per test pit data on design plan. Local upgrade allowed Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc-rev.712612018 'rille 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts - ---------- Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Raleigh Tavern Lane Property Address Ow Megan Glennon �erfOwner's Name rn rmeq6iration is ed for every North Andover MA 01845 8-8-2018 pa6e. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. inspector information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, oro checked Z C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.712612018 Title 5 Official Inspection Foran:Subsurface Sewage Disposal System•Page 18 of 18 "Wastewater Treatment Services, nc. 44 Commercial Street Raynham,MA 02767 Tel: (508)880-0233 Fax: (508)880-7232 August 6, 2018 Ms. Megan Glciuion 121 Raleigh`Tavern Lane North Andover, MA 01845 Reference: FAST'Wastewater Treatment System- Serial Number: 24747 Dear Ms, Glennon: Attached please find the Field Inspection & Service Report with.field test results for services perfori-ned on 7/10/18 at your property located at 121 Raleigh`Tavern Lane, North Andover, MA. Please call if you have any questions or require additional information. Sincerely, `Wastewater(Treatment,Services Wastewater Treaftnent Services, Inc. Service Dcparbrient Enclosures Cc: Massachusetts DEP id /I IrrrJI 8450 Cole Parkway, Shawnee, KS 66227,Phone 913-422-0707, Fax 913-422-0808 e-mail.,onsite@bigMicro,bics.com,www.biornicrobios.com,800-753-FAST(3278) MASSACHUSETTS FIELD INSPECTION & SERVICE REPORT , For Bio-Micr•obics FAS7'Systems 30754 INSTALLATION AUTHORIZED SERVICE PROVIDER Installation Address: 121 Raleigh Tavern Lanc Name: WastewaterTreatment Services,Inc. North Andover,MA 01845 Owner Name: Megan Glennon j ---------- - -- - ------- Mail Address: 121 Raleigh Tavern lane Mail Address: 44 Commercial Street North Andover,MA 01845 Raynham,MA 02767 Phone: 478-975-3101 lax: a-mail: Phonc: (508)880-0233 Fax: (508)880-7232 e-mail: r INSTALLATION INFORMATION Startup Date Date of last taramp out ---- MicroFAST.5 24747 5/24/2005 Approval Tyne O Gencral O Provisional O Piloting (x)Remedial O Gencral Denite Seasonal Rcsidencc ()Yes (x) No EQUIPMENT YES NO MAIN'T'ENANCE PERFORMED AND COMMENTS Electrical Pancl(s) Visual Alarm Operating x Audio Alarm Operating x (if present) Blowe►•(s) Air htlet Filter Clean x Blower flood Vents Clear x Excessive Noise x Excessive Vibration x 'L eatmerrl nnit(s) Unusual Odor x Settleable Solids'1•est Performed Pump out Required X f� Primary Settling Zone Sludge Depth 14" Aerobic Treatment Zone Sludge Depth 14" -- Thickness of Scum Layer I" Sludge Level Distance to Outlet Depth of Ponding Within SAS Visual Observation Comments: Measurement Conmteals: RItT+AJENT LIMIT RFStif 1 Fstimated Daily Flow 440 Bpd ..-_-•.-- pH(Standard lJnils).—A____._ 6109 7 Tarbidiiy c 40 ITI'tJ 5.41 Dissolved Oxygen >2 Mg/L 2.9 — --- � _... ..... .. Color Clear Clear Icmperaturu Odor Not Septic Farthy Effluent Solids (x)None ()Some Ellltrenl Sanrpics'1'akcn: Influent: ()pH ()BOD OCBOD O+i'SS OTKN ()Nitrate ()Nitrite O Total Nitrogen OPhosphums()Spec.Ccnd, OAnnuoniu ()Alkalinity ().OillOreasc ()VOC ()Fecal Collrornt ) ERluent: Opl3 ()DOD OCI30D ()TSS OTISN ()Nitrate ()Nitrite O1'olal Nitrogen()Phosphorus()Sped.Coad. ()Ammonia ()Alkalinity ti ()Of/Grease ()VOC ()Fecal Coliform t Dascri tion Oran ntaintenauae erPot+rated since previous hts ptetlon Rc thn 1a this ins tertiorp.p Y p l 1 ' g i Cleaned Filter,Checked S lash Recycle,Prat (s) Inspected,Float(s)inspected _.......... _.,. ,_._ _...._.-_., __.... __--... . Notes and Comments: I CERTIFIED OPERATOR NAME CERTIFICATION NUMBER SERVICE DATE Jared Kelley 16387 7/10/18 OPER I'OR S1GNNI*URE p� r h i e ffA P. e 2 gig f i 09-FEB-05 00:31AM FROM-JRENGPRC' +15008807232 i)' T-293 P.02/03 F-5T0 `Wluletenimv, 44 Cornmerclal Street Raynham,MA please tanVlola all ilmm Marked• 02767 including Throe signatures, Moil signed OTI$iffil COMM W, .Wfiat�aftr TrcaMxAL&M49aJuj4 Tel,(508)880-0233 Ratan44 r,9M=aW-S1M Fax:(508)880-7232 An EFFLUENT TESTING AG�REEMUNT Agreement entered into by and between Wastewater Treatment Services,Inc.(herein called WTS)and the FAST"System OWNER(herein called OWNER)for the inspection by WTS of certain equipment of OWNER which is described below, o in Upon acceptance of this agreement at WTS's office,WTS will render the f llow g services ces only. Equipment will be inspected at leaqt 4 times per year that this Agreement remains in effect,with the first inspections beginning J� �u'''. These inspections will include: 1) Testing of the sludge depth in the septic U& -2) Inspeotion,power testing and clean/replace intake filter of the air blower. 3) Inspeaion of the alarm system. 4) Inspect overall condition of FASP System. 5) Notification to OWNER of any problems oncountered. $6) Inspection of Septic Tank and pump Chamber *7) Inspection of pump and pump cycle *8) Inspect/Clean floats 9) Service other than routine maintenance will be billed at an hourly rate,plus travel and parts. fl WTS shall notify the local Board of Health and Department of Environmental Protection in writing within 24 hours of a system failure or alarm event including corrective measures that have been taken. OWNER will be billed standard WTS charges for any parts used in repairs or maintenance. Any additional labor time will be billed to the OWNER at standard labor rates of$74.00 per hour. is Emergency service between regular inspections will be provided at standard labor rates during normal business hours;at time and one-half after 5:00 PM and On Saturdays;and at double time on Sundays and holidays. Emergency service charges will include a minimum four(4)hours of labor, plus standard WTS charges for parts,plus mileage and travel charges. The annual rate includes routine maintenance, but does not include repairs required for damages caused by abuse,accident,theft,acts of third persons, forces of nature,or alterations made to the equipment. WTS shall not be responsible for failure to render the agreed services if caused by strikes,Tabor disputes,non-cooperation by OVMR,or other factors beyond the control of WTS. OWNER understands and agrees that WTS is not responsible for special,incidental or consequential damages,including loss of time,injury to person or property,or equipment failure. OWNER agrees that WTS may enter OWNER's properry mid have acceptable access to il areas its duties hereunder. deemed by WTS to be necessary or appropriate for WTS to perform 00-FEB-05 09:31AM FROM-JRENGPR( +16008807232( 1-293 P-03/03 F-670 This is a two-year contract which will be billed annuallY. All payments are non-reflandable, OVMIR'Sfailurc to pay invoices promptly or to otherwise comply with this contract may result in suspension of service, cancellation of contract and/or nullification orwarranties,at The election of WTS. This agreement Is not assignable without the consent of WTS and will remain in force until canceled by either party through written -notice. MAMA93—U-M MODEL NO. SIAL NOLQqAT_T0N AMWAL RATF Bio-Microbics //, 0' WoroFAST 7 North Andover,MA $390.00 5 EQaENT ME Wastewater Treatment—S—er—V-1ee.,s Inc. *Signed by OWNER.. Michelle Harrison Signed: L-�— *Address, 121 Raleigh Tavern Lane 44 Commercial Street Raynhara,MA 02767 Tole, (508)823-9566 *City; state. —Zip:— Pax- (508)880-7232 North,Andover MA 018451)'13 T e I e ph o ill-_7 24- 2 Effective Date of Agreement Daytime Telephone, OWNER understands that(1)ANNUAL RATE payment is for one year only of this two-year agreement and is non-refundable;and(2)Current DEP Regulations require OWNER to maintain a service agreement for the life of the PAST"System. I HAVE U AD AND UNDERSTAND TIM, FOREGOING. *SignedbyOWNER: {ffluentTesti Effluent sample taken 4 times per year and delivered to a qualified testing lab for eValuation. Results sent to State and local Agencies as well as the OWNER. OWNER is responsible for providing acceptable access to effluent To enable a grab sample to be taken for laboratory testing performed. PERMIT. *(PLEASF,CHECK ONE) )GENERAL ( X)REMEDIAL PROVISIONAL *SpECIAL CONDITIONS PER LOCAL BOARD OF HEALTH(Y)or(N)if yES,please attach copy of perrnit (X)PH,BOD5,TSS )Total Nitrogen X Other per Local Board of�Jealth: *Distal Pressure&Inspection of pump,floats,septic&punV chamber. Cost for Testing-, $180.04/Visit Testing of Distal Pressure U-50-00/vigit Total $330.00Nisit Operator assigned., William Everett Telephone: 908)400-3868 *Engineer, New *Approval for Effluent TestmLli�-� $' Homeowner Signature Town of North Andover Tax Map # 210-107.A-0113-0000.0 Parcel Id 17938 121 RALEIGH TAVERN LANE MEGAN & DAMIEN GLENNON 121 RALEIGH TAVERN LANE NORTH ANDOVER, MA 01846 Class: 101 Single Family Property Type I Residential Zonin 62 1 Residential Zonlng3 I Residential Size Total 1,01 Acres FY 2019 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until MEGAN&DAMIEN GLENNON Owner Active 121 RALEIGH TAVERN LANE NORTH ANDOVER,MA 01845 HARRISON, RICHARD Previous Customer Inactive 4/21/2005 121 RALEIGH TAVERN LANE N.ANDOVER,MA 01845 UB Account Maint. Accou,Int No Cycle Occupant Name Active/Inactive Bldg Id. 14138.0-121 RALEIGH TAVERN LANE Last Billing Date 6/1212018 2100121 02 Cycle 02 Active UB Services Maint. Account No, 2100121 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0k3 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE 125.95 /1 UB Meter Maintenance i Account No, 2100121 Serial No Status Location Brand Type Size YTD Cons 16335640 a Active ERT METE METE w Water 0.630.63 990 Date Reading Code Consumption Posted Date Variance 5/3/2018 1573 a Actual 29 6/20/2018 13% 2/1/2018 1544 a Actual 26 3/28/2018 -55% 11/1/2017 1518 a Actual 57 12/29/2017 -31% 8/2/2017 1461 a Actual 85 9/20/2017 168% 5/1/2017 1376 a Actual 30 6/26/2017 22% 2/2/2017 1346 a Actual 26 3/14/2017 190% 11/1/2016 1320 a Actual 8 12/19/2016 -68% 8/10/2016 1312 m Manual estimate 30 9/21/2016 25% MSG 5/`3/2016 1282 a Actual 22 6/21/2016 11% 202016 1260 a Actual 20 3/28/2016 -39% 11/2/2015 1240 a Actual 32 12/30/2015 152% 8/4/2015 1208 a Actual 13 9/14/2015 -39% 5/4/2015 1195 a Actual 21 6/22/2015 -17% 2/3/2015 1174 a Actual 26 3/20/2015 48% 111/3/2014 1148 a Actual 18 12/15/2014 -11% 8h/2014 1130 a Actual 19 9/11/2014 3% 5/5/2014 1111 a Actual 19 6/12/2014 -17% 2/3/2014 1092 a Actual 24 3/17/2014 4% 10/31/2013 1068 a Actual 22 12120/2013 -18% 8/112013 1046 a Actual 27 9/18/2013 1% 5/112013 1019 a Actual 24 6/18/2013 70% i 217/2013 995 a Actual 17 3/13/2013 1% 10/30/2012 978 a Actual 15 12113/2012 3% 8/212012 963 a Actual 15 9/26/2012 -8% 5/212012 948 a Actual 16 6/20/2012 3% Common wealth of Massachusetts City/Town of . S*em Pumping.record Form 4 DEP has provided this form for use-by local Boards of Health. Other form's 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. Fact ty rnforMi ation' 1. System Locatio , e ig fr lit 5tf ' e, Left/Right rear of house, Left/right side of house, Left Right side of bu , Left/Right ront of buildirig, Left/Right rear df building, Under deck Address CityfTown state Zip Code 2. System Owner. Name' Address(if different from location) City/Town ' Stater d Telephone Number w ` ftiR - .B. Pumping RR cord 011 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Other(describe): � 4. Effluent Tee Filter present? ❑ Y" I r __Mo If yes, was it Cleaned? ❑ Yes ❑ No, S. Condition of System: 6; System Pumped By: Nell.Bateson F5821 Name Vehicle License Number Bateson nterprises Inc' Company 7. Lo ontent&were disposed: L S: Lowell WasteWater Sign a Hbul Date t6form4.dne*06/03 System Pumping Record•Page 1 of 1 r Town of North Andover HEALTH DEPARTMENT CHECK 4: H/0 NAME: CONTRACTOR NAME: Type If permit,qKjLc!?.nse_:(Check box) El Animal • Body Art Establishment • Body Ail Practitioner El Dumpster 0 Food Service O Funeral Directors • Massage Establishment • Massage Practice • Offal(Septic)Hauler • Recreational Camp • Sun tanning • Swimming Pool 0 Tobacco 0 Trash/Solid Waste Hauler 0 Well Construction • Septic-Soil Testing ~ septic Design— ' '