HomeMy WebLinkAbout- Title V Inspection Report - 59 WILLOW RIDGE ROAD 10/11/2018 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: Re)
IV o 97H A,-a o u t R , M k
Owner's Name: -FR\.GkA A R A - L
Owner's Address: 6-1 W.ilo..—
Date of Inspection:
Name of Inspector:(please print)1-at Any,•� � (�Goy p �2
Company Name: 'New 1 C,I.AN 1) i^tiG i.4,EL=Rt u c
Mailing Address: to o
Telephone Number.
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 gperience in the proper fimction and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system:
asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 3 a
'The system inspector shall submit a copy of this in "on 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:,_ TRICIA WA.R.R.ANGER
-- 59 WILLOW RIDGE ROAD
der'' NORTH ANDOVER,MA 01845
Date of Inspection:_ ll,�10 2,
Inspection Summary: all of Section D
A. System Passes:
V I have not found any information which indicates that any of the failure criteria described in 310 CUR
15.303 or in 310 CMR:15304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. tern Conditionally Passes:
On more system components.as described in the"Conditional Pass"section need to be oed or
repaired.The iem,upon completion:of the
'replacement or repair,as approved by the Board o ealth,will pass.
Answer yes,no or not ermined(Y,N,ND)in the for the following statements "not determined"please
explain
The septic tank is metal over 20 years old*or the septic tank( er metal or not)is structurally
unsound,exhibits,-substantial infil 'on or.exfiltration or tank failure is' inent.System will pass inspection if the
existing tank is.replaced with a compl ' g septic tank as approved by a Board of Health.
*A metal septic tank will pass inspection' it is structurally noun of leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years d is available.
ND explain:
Observation of sewage backup or break hi static water level in the distribution box due to broken or
obstructed pipe(s)or due-to°a broken,settled or even 'on box.System will pass inspection if(with
approval of Board of Health):
br0 pipes)are replaced
o 'on is removed
distribution box is leveled or reply
ND explain:
The system r it pumping more than 4 times a year due to broken or o cted pipe(s).The system will
pass inspection if th 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:_ TRICIA WARRANGER
Owner, 59 WILLOW RIDGE ROAD
Date of Inspection:_ NORTH ANDOVER, MA 01845
tlOh Z.
C. Farther Evaluati_ ._._. . ........ .... ......a.,va uCutcn:
Conditions exist which require further evaluation by the Board of Health in order to determ' if the system
is fa ` g to protect public health,safety or the environment.
1. Sys m will pass;unless Board of Health determines in accordance with 310 C 15.303(1)(b)that the
syste nott functioning in a manner which will protect public health,safety nd the environment:
or privy is within 50 feet of a surface water
Cesspool privy is within 50 feet of a bordering vegetated wetland a salt marsh
Z. System will fail unless the B of Health(and Pub' Water Supplier,4f any)determines that the
system is functioning in a manner t protects the p health,safety and.environment:
The system has a septic tank and '1 on system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a ter supply.
j The system has a septic tank and an a SAS is within a Zone I.of a public water supply.
The system has a septic d SAS and the is within 50 feet of a private water supply well.
The system has a sep ' tank and SAS and the SAS' ess than 100 feet but 50 feet or more from a
private water supply we *.Method used to determine d' ce
**This system p if the well water analysis,performed at a D certified laboratory,for coliform
bacteria and v atile.;organic compounds indicates that the well is fr from pollution from that facility and
the presen of ammonia nitrogen and nitrate nitrogen is equal to or 1 than 5 ppm,provided that no other
failure teria are triggered.A copy of the analysis must be attached to 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;_ TRICIA WARRANGER
Owner: 59 WILLOW RIDGE ROAD
Date of Inspection:.' NORTH ANDOVER,MA 01845
D: 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 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
f Liquid depth in cesspool is less than 6"below invert or available volume is less than'/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 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.
LLL� / Any portion of a cesspool or privy is within a Zone 1 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. [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 mast 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
descxr'bed 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, rge Systems:
To be co . ered a.large system the system must serve a facility with a design flow of 10 gpd to 15,000
You must indicate e' er"yes"or"no"to each of the following:
(The following criteria ap to large systems in addition to the criteria abo
yes no
the system is within 400 feet o ce ter supply
the system is within 200 feet of a tri surface drinking water supply
the system is located in ogen sensitive area(Int ellhead Protection Area—IWPA)or a mapped:
Zone II of a publ' ter supply well
If you have eyed"yes"to any question in Section E the system is considered ificant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any larg em considered a
significant threat under Section E or failed under Section D shall upgrade the system in acco ce 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: _
TRICIA WARRANGER
Owner: -" 59 WILLOW RIDGE ROAD
Date of Inspection:_ NORTH ANDOVER,MA 41845
Check if-the following have been.done.You must indicate es"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
jZWere any of the system components pumped out in the previous two weeks?
f 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?
Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles br 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 information on the proper
intenan mace 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
Existing information.For example,a plann 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(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:_ MC1A WARRANGER
59 WILLOW RIDGE ROAD
Owner: NORTI ANDOVER,MA 01845
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):6,y�-o &,P D
Number of current residents:
Does residence have a garbage gender(yes or no): p
Is laundry on a separate�sewage system(yes or no):t)c> [if yes separate inspection required]
Laundry system inspected.(yes or no):
Seasonal use:(yes or no): N 0
Water meter readings,if available(last 2 years usage(gpd)): e L
Sump pump(yes or no): Nc,
Last date of occupancy: c
COMMERCUUINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): pd
Basis of design flow,(seats/persons/sgft,etd.):
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: f...f}5 r P o rk-P v N A nJ G, Al
Was system pumped as part of the inspection(yes or no):,tl v
If yes,volume pumped: gallons-How was quantity pumped determined?
Reason for pumping:.
3 YP OF SYSTEM
eptic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system.(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): IV O
W.
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
TRICIA WARRANGER
Owner: 59 WILLOW RIDGE ROAD
Date of Inspection; NORTH ANDOVIIR,MA 01845
BUILDING SEWER(locate on site plan)
Depth below grade: 0'
Materials of construction: ✓cast iron 40 PVC other(explain):
Distance from private<watc r supply well or suction line: �9zx5 l
Comments(on condition of joints,venting,evidence of leakage,etc.):
F,14-SC-, e ev
SEPTIC TANK:_(locate on site plan)
Depth below grade: (�
Material of construction: concrete metal fiberglass`polyethylene
other(explain) V
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions: (r--o v
Sludge depth: l L'`
Distance from top of sludge to bottom of outlet tee or bale: <L
Scum thickness: !Z
Distance from top of scum to top of outlet tee or baffle: ?`
Distance from bottom of scum to bottom of outlet tee or baffle: !C-
How were dimensions determined: c t►C K
Comments(on pumping recommendations,inlet and outlet tee or bale condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc):
n1011, Ins ()it, C0N1'), c fLosS Of r-CLe IA.1 0141 coNi7, (.eC-c>AA �
GREASE TRAP:N (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethyleneather
(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 ;fr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address
TRICIA WARRANGER
Owner: 59 WILLOW RIDGE ROAD
Date of Inspection NORTH ANDOVER,MA 01845
11GHT 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 gallonslday
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: (if present must be opened)(Iocate 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.):
PUMP CHAMBER:/V rq (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
In
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
TRUA WARRANGER
Owner; 59 WILLOW RIDGE ROAD
Date of Inspection: NORTH ANDOVER, MA 01845
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers.,number:
leaching galleries,number:
Teaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool;number:
innovativetalternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
j,i l�!q o f— 1�I(.L p t o�,�as �c.s� r2-M✓-I'C.. ',
CESSPOOLS:N 4 (cesspool must be pumped as part of inspectionXlocate 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(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: tJ±(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
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:.
TRICIA WA12.R.ANGER
Owner: 59 WILLOW RIDGE ROAD
Date of Inspection: NORTH ANDOVER,MA 01845
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,
Aq-1
a
Page 11 of 11 _>
N x
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
TRICIA WARRANGER
Owner: 59 WILLOW RIDGE ROAD
Date of Inspection NORTH ANDOVER,MA 01845
Li 0
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water (,3 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
t 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)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
O LC.}i.-
V S t �;So{I- G vvt&CR-soG.,on m�i'5 1 D{C_a--�