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Home My WebLink AboutTitle V Inspection Report - 159 FOREST STREET 7/24/2015 u�^ ' Commonwealth of Massachusetts Title=�'=��N�� `J��~��0 0��=^�"�� U�� /� 0N��0�mN Qmx��N��mm �-��mmum Subsurface Sewage Disposal System Form Not for Voluntary Assessments 159 Forest Street Property Address Brett G ioin er Owner Owner's Name information is North Andover MA 01845 7/24/15 required for City/Town State -- Date nfInspection every page. . Inspection results must hesubmitted on this form. Inspection forms may not he altered in any way. Please see completeness checklist at the end of the form. Important: A. ��U U��K��t'��n VVhenfiUingout ^ ^^ General Information - �� s�� RECEIVED computer,use 1 Inspector: on�the�Ukey ' �U� '17 0o move your Jonathan Gnanz '`°� oumor-dnnut �sa�en�um Name»f|nnPm�or 7DVVNOFNORTHAND[VBR key. Preventative Septic and Drain L.L.C. ComponyNamo 327 Asbury Street ----- Company Address South Hamilton [NA 01082 City/Town State Zip Code 078-468-9001 S113405 Telephone Number License Number B. Certification ' | certify that| have personally inspected the sewage disposal aysbam 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. | am a OEP approved eYotmnn inspector pursuant to Section 15.340 of Title 5(310 CK8R1S'0O0). The system: Passes El Conditionally Passes E7 Fails [l Needs Further Evaluation by the Local Approving Authority 8/12/15 tu�re -- Date Th tern inspector shall eubmita copy of this inspection 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 DER The original should be sent to the system owner | and copies sent to the buyor, if applicable, and the approving authority. � °^°^Thia 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 mr different conditions ofuse. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 i Commonwealth of Massachusetts _ - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City/Town State Zip Code Date of Inspection B. Certification (coot.) 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: System is in good condition, B) 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisin r Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City[Tnwn State Zip Code Date ufInspection B. Certification (cont.) F-1 Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if | pumps/a|armsona repaired. � � B) System Conditionally Passes (uont]: E] 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 ufHma|th): El broken pipe(e) one replaced [l Y R N 0 ND (Explain below): F1 obstruction is removed Y 0 N R ND (Explain below): E] distribution box ie leveled orreplaced El Y 0 N R ND (Explain be|Vw): F] The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval nf the Board ofHeo0h): �] broken pipe(s) are replaced Fl Y R N R ND (Explain be|ow): �] obstruction isremoved El Y El N R ND (Explain be|ow): 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 or the environment. 1' System will pass unless Board of Health determines in accordance with 310 CK0Fk 15.3U3(1)(b)that the system is not functioning ina manner which will protect public health, safety and the environment: El Cesspool or privy in within 5O feet ofa surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 x�^ Commonwealth of Massachusetts Title 5 Official Inspection F orm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 159 Forest Street Property Address Brett G iein Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City/Town State Zip Code Date nfInspection B. Certification (cont.) 2. System will fail un|wam 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: The system has a septic tank and soil absorption system (SAS) and the SAS is within 1OO feet ofa surface water supply or tributary toa surface water supply. F-1 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. Fl The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. F] The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from o private water supply we||°° Method used tn 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|wae than 5 ppm, provided that no other failure criteria are triggered. A copy of the one|yoia must � be attached to this form. / 3. Other 0) System Failure Criteria Applicable toAll : You must indicate "Yes" or"No"to each of the following for all inspections: Yea No � Backup of sewage into facility or system component due to overloaded or clogged SAS orcesspool Discharge or ponding of effluent to the surface of the ground or surface waters due toan overloaded or clogged SAS orcesspool �l �� Staboliquid level in the diatribudonbox above ouUetinve�due tnanoverloaded �� ur clogged SAS orcesspool [l �� Liquid depth in cesspool ia less than 8" be|ovvinv*�or available volume ialess �� than 1/2day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 159 Forest Street Property Address 1 Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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. ` ❑ ® 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. I ❑ ® 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.] El ® 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. I For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for every page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: 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? ❑ ® 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) ® ❑ 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? ® ❑ 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. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] I D. System Information l Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 500 GPD per plan t5ins-3t13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15Q Forest Street Property Address Brett Guisinger Owner Owner's Name information is North MA 01845 7/24/15 required for ��— ��-- ou�o�n�u�ion | every page. City/Town ' } D. System Information . Description: � tank,System is composed of 1500 Gallon septic distribution box and fo 34' leaching trenches. 2 Number of current residents: ---------- Does residence have ogarbage grinder? El Yes 0 No |o laundry ona separate sewage system? (include laundry system inspection yen H No information in this report.) � Laundry system inspected? H Yea Fl No ��Yes No Semeona| uoe? �� n/a Water meter readings, if available (last 2 years usage (gpd)>: / Detail: Private non-metered well. � l Yes �� No Sump pump? �� ~ Currant Last date ofoccupancy: �Dame --�� Commercial/industrial Flow Conditions: � � Type ofEstablishment: � Design flow(based on310CyWR152O3): Gallons per day(gpd) Basis cfdesign flow( renno/ao,fL' etc.): Grease trap �� Yee [l No pprmson[/ �� Industrial waste holding bank present? El Yes F1 No Non-sanitary waste discharged to the Title 5 system? 0 Yes El No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J i 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for every page. City own State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): I General Information Pumping Records: Source of information: Last pumped two years ago per homeowner. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I <L\, Commonwealth of Massachusetts X� R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: The As-built is dated 5/1/90, per BOH records. Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): 2011 Depth below grade: feet Material of construction: F-1 cast iron M 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer is in good condition with no signs of leakage, backup or any other problems. Septic Tank(locate on site plan): 61' 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 101 x 5'W x 4'D effective Dimensions: 611 Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts -_ Title ®ffiicial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27° 4" Scum thickness Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? SludgeJudge/Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The 1500 gallon septic tank is in good condition, structurally sound, no leakage in or out, liquid level at outlet invert, inlet has a concrete baffle in good condition, outlet has a PVC T in good condition. **this tank does not require pumping at this time** Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 u�^ Commonwealth 0fMassachusetts =M=~��N�� 'J��"��U 0��=��~�� 1��| Title �� /� � N��Q Inspection %—��nmmm SubsurfammSexvageDimpome| SystunnFnnn -NntforVo|untaryAeaeaemento 159 Forest Street Property Address Brett G iain er Owner Owner's Name information is No�hAnd�ver MA 01846 7/24/15 mquied�r ____ ____-�_' every page. City/Town State Zip Code Date ufInspection D. System Information (cont.) Comments (on pumping recnmmendotiona, inlet and outlet tee or baffle uondiUon, structural integrity. liquid levels as related to outlet invart, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: [l concrete El metal R fiberglass El polyethylene Fl other(explain): \ Dimensions: | Capacity: gallon Design Flow: gallons per day Alarm present: Yee El No Alarm |ava|: Alarm in working order: El Yea E] No Date of last pump[ng� � Date Comments (condition of alarm and float switches, etc.): °Attach copy of current pumping contract/required\. |a copy attached? E] Yes [:1 No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 i i Commonwealth of Massachusetts W T"Itle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ♦iA 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for — every page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate 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.): Distribution box is in new condition (replaced due to inspection, see BOH records), no signs of solids carryover, no leakage in or out level, distributiing equally. The cover is 13" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i * 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: l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form o Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4 @ 341 I ❑ 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.): Soil over system is dry,grassy and consistant with surounding yard with no signs of ponding, breakout or abnormal vegetation. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title=�'=��N�� `J��"��°��0 0��=�� N~0�� /@ � ��H �wn��0��mm Form Subsurface SoxvagmDiappsm| SyetennFormn - NotforVo|untaryAeeeaemente 158 Forest Street Property Address Brett G i in r Owner Owner's Name information is North Andover MA 01845 7/24/15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level ofponding. condition of vegetation, etc]: Privy (locate on site p|an\: Materials ofconstruction: Dimensions Depth ofsolids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official inspection Form�Subsurface Sewage Disposal System-Page 14 of 17 / Commonwealth of Massachusetts It e 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: F-1 hand-sketch in the area below Z drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 1 i Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Forme Not for Voluntary Assessments I 159 Forest Street j Property Address Brett Guisinger Owner Owner's Name I information is required for North Andover MA 01845 7/24/15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: fe Below SAS 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: 4/8/86 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Plan on file for the design of this system. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Soil testing was performed for the design of this system on May, 8-9, 1984 by Dan O'Connell &Steve Durso, witnessed by Mike Graf& Mike Rosati, no groundwater was found at 108" & 96" (two deep holes) below grade. This system was installed in an elevated area with a 4' seperation from groundwater, it is not interfacing with groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 159 Forest Street J Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City/Town State Zip Code Date 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 1 i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17 771r� 4 V6 1,1A �' Th�K oly .0 0 v� A N7ffl— lot# pjot-t P� rollor ;r/Kf"b--r