HomeMy WebLinkAbout- Title V Inspection Report - 804 FOREST STREET 4/16/2019 1 . s commonwealth of Massachusetts ' I'lVE Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y V MRY�WPi�°k F'r party Address 1 Owner Ow e1's am information Is ( � required for every -date—of - �� -� '��- ZIp Cads Date of Inspection 71tvy Town — _.___• . page. 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. General Information filling out forms on the computer, use only the tab 1, Inspector: key to move your �`� J Charles Char . Rom cursor-do not 4 1 use the return ke . Name of Inspeatar Charles J. Roux r LC _..._____....__L._—.. - ___� ........ — __ ... � Company Name _ _ 213 Patten Road__.___.________ Company Address Tewksbura____.___ --_ A -_ - 0187 CitylTawn o Zip Code tat IB 1 978-6 40 99.-84 Telephone i4umber 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority DateIn spector's Signature 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 CEP.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. t6lne.doc rev.6116 Tile s ofkwi Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Information is required for every page. City/Town State Zip Code Date(if Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E always complete all of Section D A) System Passes: 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: re B) 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 r pair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y,, N, ND)for the f owing statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic nk(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or to failure is imminent. System will pass inspection If the existing tank is replaced with a comply! septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is ructurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less t n 20 years old is available. El Y E] N El ND (E lain below): ---------- tSins.doc-rev.6116 Title 5 Offitial Inspection Form:Subsurface Sewage Disposal System-page 2 of 17 <LN\ Commonwealth of Massachusetts VV Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is required for every page. City[Town State _.nrvZip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ND (Explain below): ❑ obstruction is removed ❑ Y N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ ❑ N ❑ ND (Explain below): ❑ The system required pumpi more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspecti if(with approval of the Board of Health): ❑ broken pipe(s are replaced ❑ Y ® N E] ND(Explain below): ❑ obstruct' is removed ❑ Y ❑ N ❑ ND (Explain below): 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 o . e environment. 1. System will pass unless Board of Healt etermines in accordance with 310 CMR 15.303(1)(b)that the system is not funs ping in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is wit ' 50 feet of a surface water ❑ Cesspool or priv ' within 50 feet of a bordering vegetated wetland or a salt marsh t5lns,doc•rav,f/Iff Title 5 official inspection Form:Subsurface Sewage Disposal Systom•Page 3 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 0 Property Address Owner Owners Name information is required for every page, City/Town State Zip Code Date of Inspection d.-beriffica't-ion (cont.) 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: [I 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 Z e 1 of a public water supply. ❑ it�' 50 feet The system has a septic tank and SAS and the SAS is wit 1 50 feet of a private water supply well. a 100 E- SAS The system has a septic tank and SAS and the SAS is I s 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 analysi , performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the pr ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no of r failure criteria are triggered. A copy of the analysis must be attached to this form, 3. Other: D) System Failure Criteria Applicable to All Systems: You must Indicate"Yes" or"No" to each of the following for all Inspections: Yes No El 1z Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Ej [A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El Liquid depth in cesspool is less than 6"below invert or available volume is less than X!day flow t5lns.doo-rev,6/16 Tito 5(Micial fnspe(,*n Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - r Property Address Owner i Owner's Name information is required for every -- — ....._-.._-_...------- ..__-------— -- page, CityfTown State Zip Code Data of Inspection B. Certification (cant.) Yes No ❑ �/ 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, ❑ 2' Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ [ Any portion of a cesspool or privy is within a Zone 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 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.] ❑ [�f The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. 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 gpd. For large systems, you must indicate either"yes"or"no"to each the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet a surface drinking water supply ❑ ❑ the system is within 20 eet of a tributary to a surface drinking water supply ❑ ❑ the system is locat in a nitrogen sensitive area (Interim Wellhead Protection Area--IWPA)or mapped Zone II of a public water supply well If you have answered"yes"to any uestion in Section E the system is considered a significant threat, or answered "yes"in Section D ove the large system has failed. The owner or operator of any large system considered a signific threat under Section E or failed under Section D shall upgrade the system in accordance with 10 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 151ns.doc-rev.6f16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts CA fv ��m��0�� �� �������~��N N��������°������� ����U���� Title �� ��V� �������� Nmm���������N��mw N���mpwm Subsurface ScwxagmDispqaa| SystemnFornm -NotforVm|untaryAomeoonnanko Property Address Owner owner's Name Information is required for every page. Cityrrown State Zip Code Date of Inspection C, CheckU~st Check if the following have been done. You must indicate"yes"or"wƒas to each of the following: Yes No Pumping information was provided by the owner,occupant, mr Board cfHealth 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? A |� --// Have large vo|u,noaof water been in�nducedUo the system nammnUycveopa�of ^� �� this inspection? Were os built plans of the system obtained and examined? (if they were not [� available note omN/A) Fl Was the facility ur dwelling inspected for signs of sewage back Up? El Was the site inspected for signs of break out? r� [l Were all system components, excluding the SAS, located onsite? '�/ �� VVerethe septic tank manholes uncovered, opened, and the interior of the tank -- inspected for the condition of the baffles or tees, material ofconstruction, dimensions,depth of liquid, depth of sludge and depth ufscum? [_y' F� VVmethe fuoU||yowner(andoccupants ifdU��nenthnm owner)prov�odvvith �= �� information on the proper maintenance of subsurface sewage disposal systerns? The size and location wf the Soil Absorption System/SAS>on the site has been determined based on: 2/ El Existing information. For example, a plan ot the Board ufHealth. —~/ �� ` Determined in the 8e|d (Kany of the failure criteria related to PudC is at issue �] �� approximation uf distance iu unacceptable) {31OCKAR15.8O2(5)] D. System Information Residential Flow Conditions: Number pf bedrooms(deaign): Number of bedrooms(mcbua|): --------- DESIGN flow based on 310 CW1R 15,203 (for 11OQpd x#ufbedrooma)� . ` . ' / Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name information Is required for every page. CityrTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? 0 Yes R No Is laundry on a separate sewage system? (Include laundry system inspection El Yes Z No information in this report.) Laundry system inspected? P� 1:1 Yes [j No Seasonal use? El Ye 3 No Water meter readings, if available(last 2 years usage(gpd)): ?v-i vla a S Detail: ------------ Sump pump*? El Yes [� No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: —-------- __._.-.-__-----...-----------_-- Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/scift, etc.): ——------- Grease trap present? D Yes ❑ No pe M r� R'o r /s 203 q.ft)*'- etc.): Industrial waste holding tank present? 0 Yes E] No tank to 0 Tit am?Non-sanitary waste discharged t e Title 5)system? E] Yes F] No Water meter readings, if ava'/ble: LSIns.dor-rev.6116 Title 5 Of"I Inspection Form:Subsurface Sewugo Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a" Property Address Owner Owner's Name information is required for every ---_-_. page. City/Town State lip Code mate of Inspection t D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records. / Source of information: Was system pumped as part of the inspection? Yes ❑] No If yes, volume pumped: ��'. .__.C7._ �..------ gallons ,,�yI How was quantity pumped determined? f` - -� 7 Reason for pumping: - � ! _� Cld�_ ��� Type of System: l� 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 Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5lns.doc•rev.6146 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page, CitylTawn S �-J.^ tote �Zip Cade pate of Inspecllan D. System Information (cant.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? u Yes Rl' No Building Sewer(locate on site plan): Depth below grade: Material of construction: 0 cast iron El 40 PVC El other(explain): - — -- �✓ ___.....___.—..— Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: fret .__-- Material of construction: 0 concrete D metal ❑fiberglass [l polyethylene ❑ other(explain) If tank is metal, list age: years .._..._...._ Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes n No Dimensions: Sludge depth: � t5fns.doc•rev.6/16 We 5 afiiclul Inspedlon Form:Subsurface Sewage afsposal System•Page 9 of 17 I Commonwealth of Massachusetts _ Title 5 Official Inspection 1"orm a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every - page. Cityfrown State Zip Code pate of inspection i i D. System Information (cunt.) Septic Tank(coat.) Distance 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 � � U Distance from bottom of scum to bottom of outlet tee or baffle ------ —------—— Mow were dimensions determined? __� � _..._._ _—e Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): d Grease Trap(locate on site plan): Depth below grade: fe Material of construction: [l concrete ® metal [.®]fiberglass ❑ polyethylene E] other(explain): Dimensions: ._..._-.. Scum thickness - Distance from top of scum to to f outlet tee or baffle -- - - Distance from bottom of s ' to bottom of outlet tee or baffle — - Date of last pumping: t5lns.doc rov.6116 lltla 5 CNtidal'Inspection Form:Subsurface Sewage Disposal System•Pago 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Q(4F- I Property AddressOwner i Owner's Name information Is required for every _ ------.----- page. City/Town Slate Zip Code hate 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.): Tight or Molding Tank(tank must be p/atinspection) (locate on site plan): Depth below grade: -------------__ Material of construction: ❑ concrete E] metal ❑fiberglass /En] olyethylene ❑ other(explain): Dimensions: __..._..w._._...w.. Capacity: -------- gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ .No Alarm level: — — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Laato _ ..._------____._,,_...____.m.__..._____ _--- Comments(condition of arm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 151ne.doc-rev.6116 We 5 ofllcial Inspection Fumy:Subsurface Sewage Disposal System flags 11 of 17 4, Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � P e - r ra 6 Owner owner's Name information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cant.) Distribution Box(if present must be opened)(locate Vsitplan): Depth of liquid level above outlet invert ---- "'7J----- 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(locate on site plan): Pumps in working order: Yes No* Alarms in working order: ❑ Yes 0 No" Comments(note condition of pump chamber, condition o umps 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: t5ins.doo+rev.6116 Title 5 offWal Inspection Form:Subsurtew Sewage Disposal System+Flags 12 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page, City[Town State Zip Code Date of Inspection D. System Information (cons.) Type: ❑ leaching pits number: ❑ leaching chambers number: -- ❑ leaching galleries number: ___... 11 leaching trenches number, length: — -- 16 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.): ~ r wd�1 Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration �. ...__.._w.__.._..._.w.. Depth-top of liquid to inlet invert - Depth of solids layer Depth of scum layer - - -- - - --- -- Dimensions of cesspool -_.---- Materials of construction --- Indication of groundw er inflow [ Yes ❑ No t6lns.doc rev,6116 We 6 Official Inspection Form:Subsurface Savage Disposal System-Page 13 of 17 <� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address --- ------.._ Owner owner's Name _ information is required for every �__ page, cityfrown State _ Zip Code __.__.. Date of Inspection D. System Information (cost.) 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 ponding, condition of vegetation, etc.): t5lns.doc•rev.C416 Title 5 offlr:lal Inspection Form;Subsurface Sewage Disposal System Page 14 of I Commonwealth of Massachusetts Title 5 Official Inspection Farm a Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments x Property Address — ....._------ -----------------. Owner Owner's Name _.._. Information is required for every _ page, City/Town cont State Zip Code Date of Inspection D. System Information ( .j _._ 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 0 drawing attached separately a�a o'�' t i i i 15tns.doc-rov.W6 Title 5 Qfroclat Inspection Form:Subsuifaw Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name Information is required for every __ _ _...__._ __ s ----,_.____ page, City/Town _.._. _ State Zit Cade Date of Inspection D. System Information (cant,) Site Exam: ❑ Check Slope ❑ Surface water / ❑ Check cellar j ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: E( Obtained from system design plans on record If checked, date of design plan reviewed: �- - — -- Date [� Observed site(abutting property/observation hole within 150 feet of SAS) El 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lns.doc•rov,5/16 TlUo 5 Of5dat Inspectlon Forth:Subsurface Sewage Disposal System•flags 16 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11-jv- o b Property Address Owner Owner's Name information is required for every page. CitylTown State-^ Zip Code Dale of Inspection E. Report Completeness Checklist [✓"Inspection Summary:A, B, C, D, or E checked [' Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information--Estimated depth to high groundwater [Sketch of Sewage.Disposal System either drawn on page 15 or attached in separate file Wns.doc•rev.6/16 Me 6 Official leA s{rectbn Form:Subsurface Sewage ntspaaai System•Page 4'/rrf 17 "'agORTe{ 0,*v.4s4.is AMO O A . ^ Town of North Andover HEALTH DEPARTMENT is aC US CHECK#. DATE: . ° H/O NAME. CONTRACTOR NAME: Type of Permit or License: (Check box) 0 Animal � m • Body Art Establishment ® Body Art Practitioner • Dumpster - 0 Food Service • Funeral Directors _ — ® Massage Establishment © Massage Practice ❑ Offal(Septic)Hauler _.--.---. ® Recreational Camp _- • Sun tanning -- ❑ Swimming Pool ❑ Tobacco $ Trash/Solid Waste,Haulier � 0 Well Construction SEPTIC Systems: © Septic-Soil Testing * Septic-Design Approval $ ® Septic Disposal Woi°ks Construction(DWC) $ ® Septic Disposal Works Installers(DWI) $_ * Title 5 Inspector Title 5 Report a - $ ❑ Other:(Indicate). —._.......____ — � altl-Agent Initials` White-Applicant Yellow-health Pink- Treasurer