HomeMy WebLinkAboutTitle V Inspection Report - 850 WINTER STREET 11/7/2000 COMMONWEALTH'OF MASSACHUSETTS
ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION YORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: °
Owner's Name: ,i v H Ay M C H Rb i-C
Owner's Address: 06D W (N j?= s'71E4
/VV tZVY Ai P4
Date of Inspection: / / 7/0d
Name of Inspector:(please print) 1 FA);HNL Company Name: IVtG&Ii
Mailing Address: hca 3QEc14Lv )r> platu
42 2ny A/,j oyER ..kl►4
Telephone Number: jqZ j? - LB6—/7-60
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed Missed on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspec tor pursuant too Section 15340 of Title 5(310 CMR 15.000). The system:
V Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date. jl/7A)0 _
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 is a shared'system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original shouldfbe sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the Mime 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,theisame or different
conditions of use. ;
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PROPERTY ADDRESS.850 Winter Street
North Andover,MA
OWNER:John McArdle
' DATE OF INSPECTION: 11/7/00
1
Inspection Summary: Check A,B,C,D or E/ALWAYS complete'all of Section D
A. System Passes:
—V-,/I have not found any information which indicates that any of the failure criteria described in 310'CMR
15:303 or in 310 CMR 15.304 exist.Any failure; riteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as descri bed in the"Conditional Pass"section ne to be replaced or
repa d.The system,upon completion of the replacement er repair,as approved by th oard cf Health,will pass.
Answer yes,n r not determined(Y,N,ND)in the for the following st ments.If"not determined"please
explain.
the septic tank is etal and over 20 years old*or the septi nk(whether metal or not)is structurally
unsound,exhibits substantia ' filtration or exfiltration or tank i ure is imminent. System will pass inspection if the
existing tank is replaced with a plying septic tank as ap oved by the Board of Health.
*A metal septic tank will pass inspe 'on if it is structur sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 rs old is av ' able.
ND explain:
Observation of sewage backup o reak out or h static water level in the distribution box due to broken or
obstructed pipe(s),or due to a broken ettled or uneven is tion box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The stem required pumping more than 4 times a year due to broken or obstructed pi s).The system will
pass insp on if(with approval of the Board of Health):
broken pipe(s)'are replaced
obstruction is removed
ND-explain: ;
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Title 5 Inspection Form 6/15/2000
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Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
PART A
CERTIFICATION(continued)
PROPERTY ADDRESS.850 Winter Street
North Andover,MA
OWNER:John McArdle
DATE OF INSPECTION: 11/7/00
Further Ev*luation is Required:by the Board of Health:
nditions exist which require further evaluation by the Board of Health in order to dete if the system
is failing to otect public health,safety or the environment.
1. System v Ii ass unless Board of Health determines in accordance with,P10 C 15303(1)(b)that the
system is not etioning in a manner which will protect public health,safe and the environment:
Cesspool or pri is within 50 feet of a surface water
Cesspool or privy is ithin 50 feet of a bordering vegetated wetlanr a salt marsh
2. System will fail unless the Board of Heal (and Publ' Water Supplier;if any)determines that the
system is functioning in a manner that protects a pu tc health,safety and environment:
_ The system has a septic tank and soil abso o ystem(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface ater sup
— The system has a septic tank and S and the SAS is in a Zone 1 of a public water supply.
The system has a septic tank SAS and the SAS is within 0'feet of a private water supply well.
The system has a septic t and SAS and the SAS is less than 1 feet but 50 feet or more from a
private water supply well". ethod used to determine distance
"This system passes ' the well water analysis,performed at a DEP certified oratory,for coliform
bacteria and volati} .organic compounds indicates that the well is fret from pollu ' n from that facility and
the,presence of fnmonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, rovided that no other
failure criteri are;triggered.A copy of the anilysis must be attached'to this form.
3. ther:
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Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ;
CERTIFICATION(continued) �
'ROPERTY ADDRESS.850 Winter Street
North Andover,MA
OWNER:John McArdle
DATE OF INSPECTION: 11/7/00
i
D. System.Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
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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 tAS or cesspool
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 V2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or'obstructed pipe(s).Number
of times pumped
_ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ _✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacte?ia and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen.and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
AtQ (Yes/No)The system fails.I have determined that one or mbre 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. Lar stems: `
To be con side a large system the system imust serve a facility with a design flo 10,000 gpd to 15,0001
gpd•
You must indicate either "or"no"to each of the following:
(The following criteria apply to a systems in addition to the crite ' ove)
i
yes no
— — the system is within 400 feet of a s a g water supply
the system is within 200 feet of utary to a s e drinking water supply
! — the system is located ' nitrogen sensitive area(Interim We d Protection Area—IWPA)or a mapped
Zone II of a pub ' ater supply well
If you have ans ed"yes"to any question in Section E the system is.considered a signi is threat,or answered
"Yes"in Se ' n D above the large system has failed.The owner or operator of any I system idered a
signifi t threat under Section E or failed under Section D shall upgrade the system in accordance wi 310 CMR
15 The system owner should contact the appropriate regional office of the Department.
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Title 5 Inspection Form 6/15/2000
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Page 5 of 11
OFFICIAL INSPECTION, FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PROPERTY ADDRESS.850 Winter Street!
North Andover,MA
OWNER:John McArdle
DATE OF INSPECTION: 11/7/00
Check if the following have been done.You must indicate`yes"or"no"as to.each of the following:
Yes No, i
Pumping information was provided by the owner,occupant,or Board of Health
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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?
f 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?
f Was the site inspected for signs of break out?
f _ Were all system components,excluding the SAS,located on site?
1 _ 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:
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Yes no .
f _ 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 glyM 15.302(3)(6)] i
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Title 5 Inspection Form 6/15/2000
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PROPERTY ADDRESS.850 Winter Street
North Andover,MA
OWNER:John McArdle
DATE OF INSPECTION: 11/7/00
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): — Number of bedrooms(actual):A r
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms).
Number of current residents:
Does residence.h4ve a garbage grinder(yes or no):ALD
i Is laundry on a separate sewage system(yes or no):ALO [if des separate inspection required]
Laundry system inspected(yes or no):=
Seasonal use: (yes or no):X0
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):ALO
Last date of occupancy: l,c.+22�Ar
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):—
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: E a Z5 1�E P— O w AJ cs 12,
Was system pumped as part of the inspection(yes or no):,D
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)
—Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age df all components,date installe r d(if known)and source of information:
,
Were sewage odors detected when arriving at the site(yes or no):
Title 5 Inspection Form 6/15/2000 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
'PART C ,,
SYSTEM INFORMATION(continued)
PROPERTY ADDRESS.850 Winter Street
North Andover,MA
OWNER:John McArdle
DATE OF INSPECTION: 11/7/00
i
BUILDING SEWER(locate on site plan)
Depth below grade: 12
—
Materials of construction: cast iron —40 PVC other(explain): i
Distance from private water supply well or suction!'I ne: AI A
Comments(on condition of joints,venting,evidence of leakage,etc.):
PI /15 j5 -U CAI I
SEPTIC TANK:_(locate on site plan)
Depth below grade: 2 1
Material of construction:✓ concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: /000 6'141-1-oN>
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3
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: 14CtT RE 57l P
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
/9,t)//. /.V rat)n e6,AJ P 7'70,y eup o,-R-GA S f N
V C0N o ITtON
GREASE TRAP:IVw"(locate on site plan)
Depth below grade:_
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:
Comments(on pumping recommendations,inlet and outlet teell or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Title 5 Inspection Form 6/15/2000
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PROPERTY ADDRESS.850 Winter Street
North Andover,MA
OWNER:John McArdle i
DATE OF INSPECTION: 11/7/00 _
TIGHT or HOLDING TANK: IV (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain): i
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: O
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.)-.
IN 01" 60"jp I'D 0N /V,;, Ey 1 06NCL^ OT l-'Fd i i/11
r2 o`T( D!Z [S E-OU i4L
PUMP CHAMBER:(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
j
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Title 5 Inspection Form 6/15/2000
Page 9,of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;
PART C
cv"IEM INFORMATION(continued)
PROPERTY ADDRESS.850 Winter Street
North Andover,MA
OWNER:Johp McArdle
DATE OF INSPECTION: 11/7/00
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:
T leaching trenches,number,length:
leaching fields,number,dimensions: G(,P •_
T 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.):
A)
Am o1 012 '9N VS0 f)1-- 0aCE :Vt-n9,v
CESSPOOLS:/yA (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 or no):
Comments(note condition of soil,signs d,�hydraulic failure,level of ponding,condition of vegetation,etc.);
i
PRIVY: (locate on site plan) t
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of-vegetation;etc.):
Title 5 Inspection Form 6/15/2000 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PROPERTY ADDRESS.850 Winter Street
North Andover,MA
OWNER:John McArdle
DATE OF INSPECTION: 11/7/00
i
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all well within 100 feet.Locate where public water supply enters the building.
I
P 21 uE W&:;0 5 e,
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Title 5 Inspection.Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART C ;
SYSTEM INFORMATION(continhed)
PROPERTY ADDRESS.850 Winter Street
North Andover,MA
OWNER:John McArdle
BATE OF INSPECTION: 11/7/00
SITE EXAM
Slope
Surface water
Check cellar
i Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting propertyrobservation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
t �
Title 5 Inspection Form 6/15/2000 11