HomeMy WebLinkAboutMiscellaneous - 25 ABBOTT STREET 8/25/2015 f t%ORT#1
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PUBLIC HEALTH DEPARTMENT
Community Development Division
E RT "�C AXCE
As of:
Way 26, 2006
This is to certify that
the indiv>idualsu6surface dsposafsystem was
Repaired— -ooh Tank Repfacement
enja in C. Osgood, Jr., P.E.
.fit:
25-Abbott Street
Xorth Andover, 9W"A 01845
The Issuance of this cent 'cate shaff not 6e construed as a guarantee that the system wiff
Junction satisfactorify.
Susan T Sawyer, REAS/RS` ti
Pu6fic Yfeafth Director
1600 Osgood Street,North Andover,Massachusetts 01645
Phone 976.666.9540 Fox 978.688.0476 Web www.townofnorthandover.com
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TOWN OF NORTH ANDOVER NORTH
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Office of COMMUNITY DEVELOPMENT AND SERVICES '.0 "'.
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845 4T.D
ACHU
978.688.9540 - Phone
Susan Y. Sawyer, REHS/RS 978.688.9542-FAX
Public Health Director healflidept a_( tq)Nnofnorthandovet%coni -e-mail
www.townoffiorthandover.corn -website
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE:
LOCATION:
LICENSED INSTALLER NAME: Oe,4740A,, 05-rIOZ
PLEASE PRINT
SIGNATURE: TELEPHONE4 27b,- 686-1768
CHECK ONE:
FULL SYSTEM REPAIR: ($250)
OMPONENT REPAIR (indicate what parts): PJ�ox T&,iA ke, ($125)
• NEW CONSTRUCTION:
• If NEW CONSTRUCTION, please attach the Foundation As-Built Plan.
$250.00(g12:53ee Attached? Yes No
Project Manager Obligation From Attached? Yes r No
Foundation As-Built? Yes No
Floor Plans? Yes No
Approval of Health Agent Date:
I
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INSTALLER PROJECT MANAGEMENT OBLIGATIONS
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As the North Andover licensed installer for the construction of the septic system for the
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property at 6" H .&- t eT relative to the application
of dated for plans by and
dated with revisions dated X Re-p( t
I understand the following obligations for management of this project:
I. As the installer I am obligated to obtain all permits and Board of Health approved plans prior
to performing any work on a site. I must have the approved plans and the permit on site
when any work is being done.
2. As the installer I must call for any and all inspections. If homeowner, contractor, project
manger, or any other person not associated with my company schedules an inspection and the
system is not ready then item three shall be applicable.
3. As the installer I am required to have the necessary work completed prior to the applicable
inspections as indicated below. I understand that requesting an inspection, without
completion of the items in accordance with Tile 5 and the Board of Health Regulations may
result in a$50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first. Installer must request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or
verbal OK from engineer must be submitted to Board of Health, after which installer calls for
inspection time. Installer must be present for this inspection. With pump system all electrical
work must be ready and able to cause pump to work and alarm to function.
c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be
on site.
4. As the installer I understand that only I may perform the work (other than simple excavation)
required to complete the installation of the system identified in the attached application for
installation. I further understand that work by others unlicensed to install septic systems in
North Andover can constitute reasons for denial of the system, and/or revocation or
suspension of my license to operate in the Town of North Andover; significant fines to all
persons involved are also possible.
5. As the Installer I understand that I must be on site during the performance of the following
construction steps:
a) Determination that the proper elevation of the excavation has been reached.
b) Inspection of the sand and stone to be used.
c) Final inspection by Board of Health staff or consultant.
d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other
components.
6. As the installer I understand that I am solely responsible for the installation of the system as
per the approved plans. No instructions by the homeowner, general contractor, or any other
persons shall absolve me of this obligation.
Undersigned Licensed Septic Installer
C/ Date: 4 �6®(�
Disposal Works Construction Permit#
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COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
b
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 25 Abbott St.
N.Andover MA.
Owners Name: Marcia Gremmell&Jason Carlson '
Owners Address: 25 Abbott St. NED
N. Andover MA.
Date of Inspection: May 1,2006 MAY J 0 OOG
Name of Inspector: (please print) John B.Nicholas
Company Name:Mail a Drains Mailing Address: Box 298 h u� ,���.�I[�� e I���. i
y
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Wilmington MA 01887
Telephone Number: 781-272-3100
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 based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
X Conditionally Passes
Needs;tw by the Local Approving Authority
Fails
Inspector's Signature: ! Date:
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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 should be 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 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.
Title 5 Inspection Form 6/15/2000 page 1
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'Page 2 of I 1
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 25 Abbott St.
N.Andover MA.
Owner: Marcia Gemmell&Jason Carlson
Date of Inspection: May 1,2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
No 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:
B. System Conditionally Passes:
Yes 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
No 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.
ND explain:
Yes Observation of sewage backup or break out or high static water level in the distribution box due to broken
or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
X distribution box is leveled or replaced
ND explain:
No 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 of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 25 Abbott St.
N.Andover MA.
Owner: Marcia Gemmell&Jason Carlson
Date of Inspection: May 1,2006
C. Further Evaluation is Required by the Board of Health:
No 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 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS 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 coliform
bacteria and volatile organic compounds indicates that the well is free fi•om 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.
3. Other:
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 25 Abbott St.
N.Andover MA.
Owner: Marcia Gemmel]&Jason Carlson
Date of Inspection: May 1,2006
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public we]I.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 bacteria 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.)
No (Yes/No)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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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—I WPA)or a
mapped Zone It 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.
'Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 25 Abbott St.
N.Andover MA.
Owner: Marcia Gemmell&Jason Carlson
Date of Inspection: May 1,2006
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X 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)
X _ Was the facility or dwelling inspected for signs of sewage back up
X — Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site?
X 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?
X 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:
Yes No
X Existing information.For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [3 10 CMR 15.302(3)(b)]
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,Page 6 of 11
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 25 Abbott St.
N. Andover MA.
Owner: Marcia Gemmell&Jason Carlson
Date of Inspection: May 1,2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): N/A
Seasonal use:(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): No
Last date of occupancy: Occupied
COMMERCIALAN DUSTRIAL
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: Last pumped in 2004 per owner
Was system pumped as part of the inspection(yes or no): Yes
If yes,volume pumped: 1,500 gallons--How was quantity pumped determined? Gage on truck
Reason for pumping: Inspection
TYPE OF SYSTEM
X 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 of all components,date installed(if known)and source of information:
1986 per owner.
Were sewage odors detected when arriving at the site(yes or no): No
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'Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 25 Abbott St.
N.Andover MA.
Owner: Marcia Gemmell&Jason Carlson
Date of Inspection: May 1,2006
BUILDING SEWER(locate on site plan)
Depth below grade: 14"
Materials of construction: cast iron X 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
Pipe okay
SEPTIC TANK: Yes (locate on site plan)
Depth below grade: 3"
Material of construction: X 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: 10'x 5'x 5'
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: >2'
Scum thickness: %Z"
Distance from top of scum to top of outlet tee or baffle: I"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tank is water tight, liquid at proper level.Outlet baffle corroded and needs to be replaced.
GREASE TRAP: No (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 tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
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Page 8 of I 1 t
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 25 Abbott St.
N.Andover MA.
Owner: Marcia Gemmel)&Jason Carlson
Date of Inspection: May 1,2006
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other
(explain)
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; Yes (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.):
Level is good;box is completely corroded above water line and need to be replaced.
PUMP CHAMBER: No (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.):
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Page 9 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 25 Abbott St.
N.Andover MA.
Owner: Marcia Gemmel]&Jason Carlson
Date of Inspection: May 1,2006
SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers,number:
leaching galleries,number:
X leaching trenches,number, length:@ 30'
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.):
No visible signs of failure sand and soil dry and clean.
CESSPOOLS: No (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 of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: No (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Page 10 of I 1
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 25 Abbott St.
N.Andover MA.
Owner: Marcia Gemmell&Jason Carlson
Date of Inspection: May 1,2006
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 wells within 100 feet. Locate where public water supply enters the building.
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) l
Property Address: 25 Abbott St.
N.Andover MA.
Owner: Marcia Gemmell&Jason Carlson
Date of Inspection: May 1,2006
SITE EXAM
Slope Yes
Surface water No
Check cellar Yes
Shallow wells No
Estimated depth to ground water 7 feet
Please indicate(check)all methods used to determine the high ground water elevation:
X 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 local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Topographical layout of area and previous inspection on file at B O H.
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL .AFFAIRS
t DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Names
Owner's Address:
Date of Inspection:
Name of Inspector: (please print) -g 6W,-y 4 D 5,"o (-,C6('rl
Company Name:
tilailing Address, 0, 73 M / 8-
4S N, �_9
Telephone .Number:
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 based on my
framing and experience in the proper function and maintenance of on site sewage disposal systems I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15,000). The system
Passes
_ Conditionally Passes
Needs Further Evaluation by the Loca; Appro�ing Authon�v
Fails/
Inspector's Signature: �—s / Z-1— Date: S-
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
pd or greater. the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority
'Votes and Comments
ALTHOUGH THIS REPORT MAY BE DEEMED RELIABLE , NO WARRANT-1--';
OR GUARANTIES ARE EXPRESSED OR IMPLIED.
""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,
Title 5 Inspection Form 6/15/2000 page
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Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: �' !>
Owner: A-11l
Date of Inspectf/onn '
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A., System Passes:
// 1 have not found any information which indicates that any of the failure criteria described in 3 10 C%1R
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated belo\�
Comments:
B, System Conditionall` 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, \,ill pass
Answer yes, no or not determined (Y,N,ND) in the 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 structural!v
unsound. exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspecti on 1f the
existing tan-k 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 Comcl ante
indicating that the tank is less than 20 years old is available.
ND explain:
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(%�tth
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system ill
pass inspection if(with approval of the Board of Health);
broken pipe(s) are replaced
obstruction is removed
ND explain
2
Pa�ze 3 n[ | I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-M
PART
CERTIFICATION (continued)
Property Address: 2-
Owncr: �
Date nfInspection: /
C. Further Evaluation is Required by the Board of Health:
Conditions exist which requi-re further evaluation by Lhe Board ofHealth u-i order to deter-mine /(the �)a�m
is !'a/!m� m protect public health, sa�/yorthe cnv�onmcnt
\ 5>uem oiU pass unless Board of Health determines in accordance with 3}0C&1R }5,]U3(l)(b) that the
System is not functioning in u manner which will protect public health, sa6tvand the cn`irooment:
Cesspool o/ pn,} is ^ithm5O feet o[a surface water
Cesspool o, privy is within 50 feet ofobnrdcnngvegetated wetland orosalt marsh
2, S�oem will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
sN'm,m is functioning in u manner that protects the public health, safety and environment: �
�
The system has asrpoc umkand soil absorption system (SAS) and the SAS is «xhm 100 feet o[u
,ur�cc �oter supply ornikutar7mosurface water supply. �
The system has a septic tank and SAS and the SAS is within aZone l n[o public vatermppi�
The system has u septic taok and SAS and the SAS u within 5O feet o[aprivate xme, surp!! «e|'
Txe s\,orm has aseptic tank and SAS and the SAS is less that) 100 6u but 50 reu m oo,,
nn`au "uc, mpp|� well*^ Method used m determine distance
____________________
~*This system passes i[the well water analysis, performed atuDEPccmficd bboraor., |b, cp|/iom`
000c'ound volatile organic compounds indicates that the well is free from pollution from that faoht> and
the presence o[ammonia nitrogen and niomtoniougcn ix equal morless than 5 ppm, provided that no other
:'aUure m/rnu are uirod. 6 copy o[the analysis must be attached to this form
l Other: �
�
3 |
�
�
Page 4 of I I
I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1
PART A
CERTIFICATION (continued)
Property Address: 2 CiiL G
Owner
Date of Inspect n E2-4
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no" to each of the following for all inspections:
Yes No
Z-1 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 overloadec or
clogged SAS or cesspool
V 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 'i, day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets) Numoer
of times pumped
d� Any portion of the SAS, cesspool or privy is below high ground eater 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 I 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 s+ater
supply well with no acceptable water quality analysis. IThis system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria 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 forma
/✓ C )Yes'�o) The system fails. I have determined that one or more of the above failure criteria e\i,t a
described in 310 CMR 15 301, therefore the system fails The system m rer should conrnc! the Board or
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
You must indicate either"yes" or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 — I WPA) or a mapper:
Zone 11 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 ans\�ered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
signiicant tlueat under Section E or failed under Section D shall upgrade the system in accordance with 310 CNIP
5 304 The system owner should contact the appropriate regional office of the Depanment
4
Pace 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: r7�— "--et
Owner:
Date of Inspect on:
Check if the following have been done. You must indicate "yes" or"no" as to each of the followine
Yes \'o
_, Pumping information was provided by the owner, occupant, or Board of Health
",ere,ere any of the system components pumped out in the previous nvo weeks
Has the system received normal flows in the previous two week period ?
Have large volumes of seater been introduced to the system recently or as pan of this inspection "
Were as built plans of the system obtained and examined? (If they were not available note as ti A)
G� 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 th,,°
of thhe '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 vs ith infonnation on the prone-
maintenance of subsurface sewage disposal systems
l Ise size and location of the Soil Absorption System (SAS) on the site has been determined based on
ti n�o/
IJ 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 distan
is unacceptable) (3 10 CMR 15 302(3)(b)J
5
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Page 6 of I 1
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1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2S d6e'
Owner: 7�
Date of Inspection: 5"`--22--o
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): a Number of bedrooms (actual);
DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x H of bedrooms):
Number of current residents: 0
Does residence have a garbage grinder �} or no):/'V()
Is laundn on a separate sewage system (yes or,=):jll�r (if yes separate inspection required)
Laundry system inspected (yes or-ffo,):�—/E$
Seasonal use: (yes or-rye-): /'VO
Water meter readings, if available (last 2 years usaee (gpd)) S
2 )q-3 �
Sump pump (.)a~s or no): /4/0
Last date of occupancy: .2 00,2,
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgh,etc.):
Grease crap present (yes or no): _
Industrial waste holding tank present (yes or no): _
ion-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
So-rce of information.
\l as s,,stem pumped as pan of the inspection (yes or no).
I; es, volume pumped: gallons -- How was quantiry pumped determined' _
Reason for pumping:
Tl'PS OF SYSTEM
Septic tanl:, distribution box, soil absorption system
_ Single cesspool
_ Overflow cesspool
_ Prn'\
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ lnnovative/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):
4prroN imate aee of all components, date installed (if known) and source of information
Were sewage odors detected when arriving at the site (ys or no): /VO
6
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Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: 7 --'-
Date of lnspectio — 2 Z— 0
BUILDING SEWER (locate on site plan)
Depth below grade
Materials of construction: _cast iron _40 PVC _other (explain):
Distance from private water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of leakage ,etc.):
SEPTIC TANK: ____ (locate on site plan)
Depth below grade:
.Material of construct—Jon-61/concrete_metal _fiberglass_polyethylene
—other(explain)
If tank is metal list age: ---- is age confirmed by a Cenificate of Compliance (yes or no) (artach a copy of
certificate)
Dimensions y t1n lT ar
Sludge depth
Distance from top of sl 4.j-
Distance de to bottom of outlet tee or baffle: �.o
Scum thickness: �
from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bono i of outlet tee far baffle
H,,\, .,ere dimensions determined
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integnt`, liquid levels
as related to outlet invert, evidence of leakage, etc )
GREASE TRAP: _(locate on site plan)
Depin beiol� grade: _
.41aterial of construction: _concrete_metal _fiberglass _polyethylene_other
(explain)
Dimensions
Scu m thickness:
Distance From top of scum to top of'outlet tee or baffle;
Distance from bottom of scum to bottorn of outlet tee or baffle:
Date of last pumping
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integnn, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
1
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Page 8 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSNIEXTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-N1
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: t ,
Date of lnspectio
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain)
Dimensions
Capac ir\ gallons
Design Flow: eallons/dav
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 invent
Comments (note if box is level and distribution to outlets equal, any evidence of solids camover. an% ev idence of
leakage into or out of box, etc.):
PU11P CHA%1BER (locate on site plan)
Pumps in working order (�,es or no):
Alarms in -vorking order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc ).
8
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Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspectio . _�-^
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
if SAS not located explain why:.
Type
leaching pits, number: _
leaching chambers, number:
T leaching galleries, number:
leaching trenches, number, length,:
leaching fields, number, dimensions:
o�erflo�{ cesspool, number
tnnovative'altemative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of�egetation.
etc.).
CESSPOOLS: (cesspool must be pumped as pan of inspection)(locate on site plan)
\umbe,- and conflaurauon:
Depth - top of liquid to inlet invert
Depth of solids layer
D�pt,n o sour-, layer _
Dimensions of cesspool
Materials of construction:
Indication ol'Lrroundwarer inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetauon, etc i
PRIVY: (locate on site plan)
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation. etc i
9
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Page 10 of" I I `
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OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSNIENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) t
Property Address:
Owner: f
Date of Inspect' n: 37 02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmar'Ks or
benchmarks Locate all wells within 100 feet. Locate where public water supply enters the building
r
i
30
i S i i_ vy G-
15'00 _
57 �Ii
to
i
Paee I I of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2
Owner: % 7�
Date of Inspectio : S " 0.3
S EXAM
I
Surface water
eck liar
al ow wells
Estimated depth to ground water_-Z 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 property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
E Checked with local excavators, installers- (attach documentation)
Accessed USGS database-explain:
Youu must describe how` You established the high ground water elevation:
II