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HomeMy WebLinkAboutPass - Title V Inspection Report - 197 CAMPBELL ROAD 11/16/2020 ~~ Commonwealth of Massachusetts Recelvea Title 5 Official Inspection Form NOV j Subsurface Sewage Disposal Syste Form -Not for Voluntary Assessments 2020 TOftOFNO HE4LTH �HANaGV Property Address Owner Owner's Na information is �1 4 �y� q— �� U — 2� required for every /� 1 / `�� 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 filling out forms on the computer, 44 t ill use only the tab key to move your Name of Spector cursor-do not use the return mp�gy Nam key. f, o c3 �- Co Address Ci /Town State Zip Code Telephone 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. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails I spector's Sign ture Date The system inspector shal 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9e�r v Property Address Owner Owners Nam information is g 11ti � - Zo required for every i page. Citylrown 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: 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: U L-L te Cf 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 Board of Health, will pass. Check th ox for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined,"pie Iase 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 inspecti h,yf 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 belobu): t5insp-doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address _ Owner Owners Name �L j 1 information is dy ,11 A�t���yim, FJ required for every " page. City[Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) 2) System Conditionally Passes (cont.): ❑ Pu Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps s are repaired. ❑ Observation of sewage kup or break out or high static water level in the distribution box due to broken or obstructed pipe or due to a broken, settled or uneven distribution box. System will pass inspection if(with approva 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 ❑ Y N ❑ ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The tem will pass inspection if(with approval of the Board of Health): Elbroken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruct n is removed ❑ Y ❑ N ❑ 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 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5msp.doc•rev.7/26/2018 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is q ��� (/ �� required for every _ Y, �- j'`7' «..11��� P _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) ❑ Cesspool or privy is within 50 feet of a surface water ❑.,, Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. Systerri will fail unless the Board of Health (and Public Water Supplier, if any) -determines+talt-theSjst@i Is fu ctiSn sg hn � my no that protects the rublic health, safety and environm4nt. p ❑ The system has a septic ta k-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 Zone 1 of a public water supply. �'- ❑ The system has a septic tank and SAS and the,,5H,S is within 50 feet of a private water supply well. ❑ 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 ltitrogen 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 Rar_.kup of sewage into facility or system component due to overloaded or U '\ clogged SAS or cesspool 11 il�crF�argn nr rnnnyiinny of effl� Pnf to the clYrfara of the grniinri nr ci,irfare u/atcrc [J /`l�j due to an overloaded or, clogged SAS or cesspool t5insp.doc•rev.7126t2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System.Page 4 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 ���-►� e Property Address Owner Owner's Name information is / required for every page. ityffown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 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 %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. El tributary 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 water supply well. ❑ J� 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 gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 S tems: To be considered a large system the system must serve a facility with a design flo of 10,000 gpd to 15,000 gpd. For large sys s, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Secti CA. Yes No ❑ ❑ the system is in 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 t of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitro sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone I a public water supply well 6msp.doc•rev.726/2018 Title 5 Offidal Inspection Form_Subsurface SewageDi sposal System•Page 5 of 18 Commonwealth of Massachusetts I9 Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address - ----- 1 Owner Owner's Name ) information is �� 5 required for every t--�-'�- —P— page. CI !Town 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.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 aU 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? ❑ Has the system received normal flows in the previous two week period? F-1 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 NIA) ( ❑ 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 or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Z 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. a Determined in the field (if any of the failure criteria related to Part C is at issue ❑ approximation of distance is unacceptable) [31 J C"rlR 15.30215)) t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth: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 Property Address {� — Owner er's Name information is required for every f page. Cityrrown State Zip Code Date of Inspection 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 K No If yes, discharges to: — - --- Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes r No information in this report.) Laundry system inspected? ❑ Yes ( No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): —A' - - Detail: A.)6 <6 Sump pump? Yes ❑ No c: Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Fio Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `J Property Address Owner Owner's N m information is 1 � AM-- —6 �l required for every /V 1 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: c Type bf Establishment: Design flow( d on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(sea rsons/sq.ft., etc.): Grease trap present? '�.,� ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: -,Industrial waste holding tank present? ``�� El Yes ❑ No Non-s'anitary, waste discharged to to Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use:-,,. Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form r io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Na information is required for every ;L page. Cityrrown tate 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 4Nif yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: Ncast iron ❑40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 9 of 18 Commonwealth of Massachusetts �o Title 5 Official Inspection Form -, Subsurface Sewage Disposal System Fo -Not for Voluntary Assessments Property Address Owner Own r s Nam information is / '}e t required for every f v $I{!a_! T page. CltylTown to Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): b Depth below grade: -- — -- feet Material of construction: �) concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: - years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: X S— — f( Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 11 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 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.): (2, t5insp-doc.rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 10 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner—Name _ information is � �Y1, required for every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 7. grease Trap(locate on site plan): Depth below grade: feet Material of bon truction: ❑concrete ❑ me ❑fiberglass ❑polyethylene ❑ 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: Date 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 p ed at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyp ylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: — -- — - gallons per day t5insp_doc•rev.7/26/2018 Title 5 Official inspection Forms Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts ' r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's NW)llp information is 1 a C.� required for every ��-' page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 8. Tight r Holding Tank(cont.) Alarm pre nt: El Yes El No Alarm level: Alarm in working order: ❑ Yes ElNo Date of last pumping: Date Comments (condition of alarm and float swi etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ 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.): -L, ILI f t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 12 of 18 AN, Commonwealth of Massachusetts Title 5 official Inspection Form w� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Nam information is ��� required for every � � page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps ' working order: ❑ Yes ❑ No* Alarms in working o?d ❑ Yes ❑ No* Comments (note condition of pu chamber, condition of pumps 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: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: - — - ---- ----- t5insp.doc•rev.712612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ' p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �s Owner information is Owne16 /Vj� -- � �— required for every � /�J page. C'ityrTown State Zip Code Date of Inspection D. System Information (cost.) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration De h—top of liquid to inlet invert Depth of so' layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failureXlevef ding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments d Property Address Owner Owner's N information is L / required for every page. Cltyffown fate Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Mated of construction: Dimensions - Depth of solids — Comments (note condition of soil, si of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/262018 Title 5 Official Ins pection Form;Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts s Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments d Properly Address Owner Own is Nam information is C' T required for every page. City[Town 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: ❑ hand-sketch in the area below ❑ drawing attached separately ' ff !1 a24' A I a tsinsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / � � � �7 Property Address Owner Owners Nam information is © \ 1 V �� �/�i►fF- c 1l — required for every � � - page. ityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells _ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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 y established the high ground water elevation: o Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/262018 Title 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 Property Address Owner OW s information is required for every TZ;1OZA page. ity/Town 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 R 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 Q 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 Form:Subsurface Sews Disp osal posal System-Page 18 0118 3 g � w Town of North Andover `ti •,,..o.� .� HEALTH DEPARTMENT CHECK #:3 500/L',9 � DATE: LOCATION: H/O NAME: ��-. CONTRACTOR NAME: CL1 U Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ _ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ _ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ _ ❑ Title 5 Inspector $ ❑ Title 5 Report �0.' '� $ ' ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer