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HomeMy WebLinkAboutPass - Title V Inspection Report - 393 SALEM STREET 9/30/2019 Commonwealth of Massachusetts Title 5 official Inspection Form M51) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 0 2419 '� SEp Ar��vER Ply Add - �,Our,, �PP9�__. 71) Owner Owner's Na - •-- (� r egou red ion for eis ve � '"` i.-�._ -_ / _ 7. ��.. l Page City/Town State Zip Code Date of trtspedion 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 filling out forms on the computer, _._. use only the tact ___l _ t-1--k key to move your Name oLinspector cursor-do not ���yJ--`� ( �l.` use the return Compapy key. C_0� dress own State Zip Code -- _�?. _ 2- 3Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector In full compliance with Section 15.340 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. WPasses 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by 0te Local Approving Authority 4. ❑ Fails 14 Date The system inspector shall su 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. t.5arrsrr tw-rev 7I26M18 Abe 5 Qrfi0a-PvAwAmn Form Sr*AXf0ce Se**Q*DMO"SYstem•Pip®1 of" Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Vo4un ry Assessments Property Address Owner 0.wrier's N I a I rniy�_)­­ ­N information is //U required for every page City[Town Iswe Zip Code Date of Inspection C. Inspeclion 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: "S 2) System Conditionally Passes: ❑ One or more system components as described in the'Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 5 o C e box for'yes", 'no'or"not determined'(Y, N, ND)for the following statements. If"not dete:rmin please explain. .c ' tat and The septic tar ' metal and over 20 years old* or the septic tank(whether metal or not)is structurally t t4 c unsound,exhibits tantial infiltration or eAltration or tank failure is imminent. System will pass inspection if the k is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass in n if it is structurally sound, not leaking and ifa Certificate of Compliance indicating that the tank is le n 20 years old is available. n Y ❑ N 0 ND(Explain be t5onsp doc-rev 7re6rM18 Title 8 0111cW kopecbm Form Subststwe Sewage Dmpos*4 Sysim-Pop 2 d 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fon-n -Not for Voluntary Assessments -3 Property Address Owner Owner's information im, 71- required for every page. City own State Zip ode Date of tnspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): Pump Chamber pumpsialarms not operational. System will pass with Board of Health approval K pumps/alarms are repaired. Observation of sewage backup or break out or high static water level in the distribution box due n of sewage backup W oken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will if wit approval ion if(with approval of Board of Health): pass ( ova 0 0 broken pi r r ❑ Y ❑ N ❑ ND(Explain below). broken pi are replaced ❑ obstruction r strucho is r mov pi" bstruction is remove ❑ Y ❑ N ❑ ND(Explain below): El distribution box is leveled or repl 0 Y 0 N El ND(Explain below), ❑ The system required pumping more than 4 times a year due to broken or obstructed 'pe(4). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced E] Y 0 N E] ND(Explain below). E] obstruction is removed n Y E] N 0 ND(Explain below): ---------- 3) Further Evaluation its Required by the of Health: ❑ Conditions exist which require further evaluatio the Board of Health in order to determine if Board r 1c IL the system is failing to protect public health, safety or environment. a. System will pass unless Board of Health determines in-AccQrdance with 310 CMR 15.303(9)(b)that the system is not functioning in a manner which-'Will protect public health, safety and the environment: Ls4r1GPC10C-rev 71.16WIS Tide 5 OMaa Ins char,Fcxm subsunaw sewsve Disposwsyswn-Pap 3 of 18 ti Commonwealth of Massachusetts _.___ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner'S� information is nn �� required for every ) page city/Town State Zip code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water [WI Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unles a Board of Health (and Public Water Supplier, if any) determines that the system is ctioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil ab tion system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a rface water supply. ❑ The system has a septic tank and SAS and the SA ' within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within eet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 f 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 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 LINnv. .am•rev 70wol6 ',tit•w 01wa r F(Xm SubSutfac8 SevMtW t-iSr70 System•PagO 4 W,15 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 GityrTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No F-1 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6'below invert or available volume is less than 1/2 day flow E] Required pumping more than 4 ir m espiun'1ped'last year NOT due to clogged or obstructed pipe(s). Number of times EJ Any portion of the SAS, cesspool or privy is below high ground water elevation. E] Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El M Any portion of a cesspool or privy is within a Zone 1 of a public water supply "IN well. ❑ 146/ 4 Any portion of a cesspool or privy is within 50 feet of a private water supply well 0 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 gpd C] 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. 5) Large Systems�'`'l;gbe considered a large system the system must serve a facility with a design flow of I 0,000'gpo to 15,000 gpd, For large systems. you must intricate either-yes' or"no'to ea of the,following, in addition to the- questions in Section CA Yes No ❑ E] the system is within 400 feet d surface drinking water s ly feet 0 s urface drinking water u a F c the system is within 200 feet of a tribu to a surface drinking water supply It the system is located in a nitrogen sensitive a (interim Wellhead Protection El n Area—IWPA)or a mapped Zone 11 of a public er supply well L-*Wdm-row 7r2WO18 7 ft 5 offioai vor*cwxi form subs�aiam Sewage wo"syskom-Pap 5 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form W Subsurface Sewage Disposal System Form Not for Voluntary Assqsments -I .. Property Addre&-5 OWMr s Nar2 information is 7;___[ ?� required for every '. . - J_ __ __ - Page. CityfTovvn state C. Inspection Summary (cont.) - zip code Date of ) 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.5 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 all inspections: Yes No Pumping information was provided by the owner, occupant. or Board of Health Were any of the system components pumped out in the previous two weeks? fur) N 0 Has the system received normal flows in the previous two week period? Ej Have large volumes of water been introduced to the system recently or as part of this inspection? 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? 0 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 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 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: 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 CC4,44 approximation of distance is unacceptable)1310 CMR 15.302(5)]1� is atfstue 15,,Kc dm-rev its 5O�UW MSPOOM Form Sxmyjac*Spwagt,Ehspo,'A SYSNM.page C W to Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ' Owner C+wrver' N m�►infoation is s required for every page City/Town State Zip Code daft of kWee ion D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): --- - - DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: Number of current residents: _. Does residence have a garbage grinder? ❑ Yes �No Does residence have a water treatment unit? ❑ Yes No If yes,discharges to: Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) El Yes No Laundry system inspected? ❑ Yes j No Seasonal use? ❑ Y s No Water meter readings, if available last 2 ears usage �VIA - ate 9 , { Y 9 (gid))• Detail: Sump pump? K Yes ❑ No Last date of occupancy: CLLV� Date t-nK dor,•My M614618 Title 6 OMW kwPoeban Farm Subw m 5ewar Omposw System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Property Address ownel information is required for every page, city[Tow" State Zip Code Date of kv;pection 6_._Si;tem Information (cont.) 2. Commerciallindustrial Flow Conditions: Typed blishment: Design flow( on 310 CMR 15.203): Gabom per day(gpd) Basis of design flow(sea ns/sq.ft,etc.): Grease trap present? 0 Yes E] No Water treatment unit present? El Yes 0 No ` f Yes, discharges to: Industrial was�hdldi"nk present? El Yes 0 No Non-sanitary waste dischargett the Title 5 system? Yes El No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 4f 3. Pumping Pecords: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gaRons How was quantity pumped determined? Reason for pumping: t&nsp clot-my MAM18 Tfl*!,OMaW kq*CW Pam&bwtsw Sw&vV DApm*SW -Pqpsol" Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address owner Owner's Uvrner's N information is required for every 4vev page Ciiytfown State .Tap code Dde of kepecion D. System Information (cont.) 4, Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool F1 Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (d 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 E) 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? El Yes k, No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: 9 cast iron n 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 ttqnsvom-mv 71W2016 I dic 5 Orhaa hrAwmw Form 5,0wri"Sever UtWoW Sys*m Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Systerri Form -Not for Voluntary Assessments Property Address'--- IL Owner owner's—Na�rne information is C�L�� � required for every T-wn AIA OA-4 page 41�1� State ZiP QWS DOU!of kepackin D. System Information {cant.) 6. Septic Tank(locate on site plan),- Depth below grade: feet Material of construction.- concrete 0 metal 0 fiberglass E3 polyethylene 0 offm(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) 0 Yes 0 No Dimensions: Sludge depth: 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 Distance from bottom of scum to bottom of outlet tee or baffle 1 -2 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 4c Q t5nsp doc-rev 7r4%M% Tibe 5 omog Inspacbm Form SubagMs Sw*"Dapa"SYSWM.pop 10 of to 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3_ S 3 � I _ Property Address Owner trey s Names, information is required for every page_ &IT4vun Stale zip Code Date tnspiedion D. System Information (cont.) i 6Wtse Trap(locate on site plan): Depth below grade: Material of construction:' ❑concrete ❑meta! ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum_to,.top of outlet tee or baffle Distance from bottom of scum to bottom utlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or ba a tertian,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 gra Material of construction: 0 concrete ❑r'W" lass ❑ polyethylene ❑other(explain): Dimensions: Capacity: Pill" Design Flow: 9 par day t&rsr oxc-rev,7126P* TM&6 oft*k"60 +Form suu«+rao. •Pop 1i d IS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, Property Address Owner Owner's Nan)e,, information is re0red for every a Inspection page city/Toin State zip code D. System Information (cont.) 8. Tight or Holding Tank(cont) Ada present: El Yes El No Alarm level: Alarm in working order. El Yes El No Date of last pumping: Comments(condition of alarm and float swft c,): Attach copy of current pumping contract(required). is copy attached? C3 Yes 0 No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 4- Gornments(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.): t5mw 00C-rev 7126MIS Tit*5 offioai inspecoon Form SWAAAsw Sewsp DMPOS91 SYSIM•PWO 12 Of U Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pwperty6AddressOwner Owner's , information is - " required for every ©a l b✓Ci.� � page City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, rondi amps and appurtenances, etc.): *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: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ( leaching trenches number, length: C=;? � ❑ leaching fields number,dimensions ❑ overflow cesspool number: _ ❑ innovativelatternative system Typeiname of technology: t°nnsp a=•rev 7f1rM1& i1*5 Otfiaaj inspection Form Su"ace Sewage Disposal System•Pape 13 of 18 Commonwealth of Massachusetts Tine 5 Official inspection Farm Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments Property Address Owner Owner's information is - - required for everyQ 0 paQL- State Zip Code Date of 1 D. System information (cont.) 11. Soil Absorption System (SAS) (cunt.) mments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of 7�* etc.): 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): N ber and configuration Depth- of liquid to inlet invert Depth of solids W*. Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of sail,signs of hydraulic failure, le f ponding, condition of vegetation, etc.): tN,isp cioc•tev 7PIWO16 Tale--Or6aa kiwrtrofs Form Stbsuvlace Sewage Dispose,,,systtem•page 14 or ie Commonwealth of Massachusetts Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form Not for Voluntary Assessments Oroperty__ Owner Owneei�COMW, information is required for every page own fate Zip Code Date of Inspection D. System Information (cont.) 13, Privy (locate on site plan)-. Materials of construction: Dimensions Depth of solids Comments (note condition o�fsigns of hydraulic failure, level of ponding, condition of vegetation, etc-): 6wmdw.rev 7*6=0 lit*'60MOO ITISPOMM,fWrn SUDSUIKA Se*agL L45POSW SYS*M'Page 15&16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address 4 A- Owner owr►ersr Narnq!��- information is , -Z d V4 1 required for every , Y je�-�Z- 9--,—7��--,/ ..-. ---- -6, -- — -D-a-te—of page. 'tvy own t fate ii�b&w 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 ❑ hand-sketch in the area below ❑ drawing attached separately A-c- 09 32: :3 3S3 ----------- emw am•few -nft 6 OM"WWP*CWn Farrar&AXO*M SM"s D"Oft%%6W•ftp a 16 Commonwealth of Massachusetts v : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner -- -- Owners tU /�/_ (�L C'_information is I JL,� 44 - _� 1� aired for y� a req every 1-1.1-- - - page. City/Town tate Zp Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water `—� Check cellar �J Shallow wells fUr,N1R_ _._ Estimated depth to high ground water. 7feet 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: ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with kcal excavators,installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you wed the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. tS W ooc-rev 7/2GW18 roW 5 Offloai wspewon Form Subsudace Sewage Dtsposa System•Page 17 d 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Addnit Owner Owners N kwommoon is required for every Page Cityrrown _ State Zip Code Hate 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, or 4 checked [� 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 L5mg dm•rev.7l1 MIS Tot 5 0owas Mwomon forth&bSUrt"Sewape Dr4MM SYMM•Pp®16 Of 18 r 4 t NOIITH, 8 7 E t... or', - • °i ti p Town of North Andover �' HEALTH DEPARTMENT F ,JS CHUSE� CHECK DATE: LOCATION: 393 4-/e.(n S� H/O NAME: ! CONTRACTOR NAME: �e- f Type of Permit or License:(Check box) i ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ k ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ w SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ j c c} 1 Title 5 Report 1 (}�`� $ ❑ Other. (Indicate) $ HealtTi Xgent Initials White-Applicant Yellow-Health Pink-Treasurer