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HomeMy WebLinkAboutTitle V Inspection Report - 2201 SALEM STREET 10/7/2015 Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments (Y"T TOWN OF NORTH ANDOVER 2201 Salem Street HEALTH DER�RTNIENT Property Address 2 Periathamb Owner y — Owner's Name information is required for North Andover MA 01845 October 7, 2015 every 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 filling out A. General Information forms on the computer, use 1. Inspector: only the tab key to move your Dean G. Luscomb 11 cursor-do not Name of Inspector use the return key. Dean G. Luscomb 11 & Sons Company Name VQ P.O. Box 135 11k I& Company Address Middleton MA 01949 City/Town State Zip Code 978-774-4065 S1848 Telephone Number License Number B. Certification 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: N Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Aop. Al. October 7, 2015 Insp ct5,rs Sig-nature Date 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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title i i l Inspection r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7 2015 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: ChecIGB,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: 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. 6 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): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title fi i I Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7 2015 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. (� B) System Conditionally Passes (cont.): V ❑ 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 ❑ 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 t1 system will pass inspection if(with approval of the Board of Health): `IJ ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title i i l Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7 2015 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: O ❑ 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. O3. Other: i I I D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No v E] N Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title i i l Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 2201 Salem Street Property Address Periathamby Owner Owners Name information is required for North Andover MA 01845 October 7, 2015 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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. v ❑ ® 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 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 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 de ' n flow of 10,000 gpd to 15,000 gpd. For large s ms, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Se n D. Yes No V ❑ ❑ the syste is within 400 feet of a su drinking water supply ❑ ❑ the system is with) 00 fee f a tributary to a surface drinking water supply ❑ ❑ the system is locat In a . rogen sensitive area (Interim Wellhead Protection Area—IWPA a mapped Zo II of a public water supply well If you have answered "yes" any question in Section E the stem is considered a significant threat, or answered "yes" inSe�ion D above the large system has fail e The owner or operator of any large system considers �significant threat under Section E or failed and ection D shall upgrade the system in�ccordance with 310 CMR 15.304. The system owner should tact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °w 2201 Salem Street M Property Address Periathamby Owner Owner's Name information is No'th Andover MA 01845 October 7, 2015 required for every page. City/Town 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)] D. System Information 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): 440 gpd a taL Ds A6DO �, t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 6 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.� 2201 Salem Street Property Address Periathamb Owner Owner's Name information is North Andover MA 01845 October 7, 2015 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: owner and town 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: I l' / n / lan Sump pump? ❑ Yes ® No current Last date of occupancy: Date C mercial/Industrial Flow Conditions: Type of Esta * ment: el Design flow(based on 3 R 15.203 : ) Gallons per da pW Basis of design flow(seats/persons/s etc.): Grease trap present? ❑ Yes ❑ No Industrial waste hold' nk present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title i i l Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 every page. City/Town State Zip Code Date of Inspection D. System I—n�f�ormation (cont.) Last date of'occupancy' Date Other(describe below): General Information Pumping Records: Source of information: Pumped every year Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: Zero gallons How was quantity pumped determined? Reason for pumping: No need at this time 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page B of 17 Commonwealth of Massachusetts F Title 5 Official Inspection- Subsurface Sewage Disposal System Forma Not for Voluntary Assessments �M 2201 Salem Street Property Address Periathamby Owner Owner's Name information is North Andover MA 01845 October 7, 2015 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: SAS is from 1986. Tank and D-box from 2008 Were sewage odors detected when arriving at the site? El Yes ® No Building Sewer(locate on site plan): 22" Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Cast iron to PVC Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Main line and joints are in very good condition Septic Tank(locate on site plan): 12" W74 X lee, 6-k'�� Depth below grade: feet ={ ma,,4ole Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast rectangular concrete- 1500 gallons If tank is me a, I years Is a med by a Certificate cop y of certificate) o 5'x 5'x 10' - 1500 gallons Dimensions: 1" Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2201 Salem Street Property Address i Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Lj Distance from top of sludge to bottom of outlet tee or baffle 34" 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? by measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank and baffle is in very good shape. The solids are light and do not require pumping at this time The liquid is running at it's correct working heigth rease Trap (locate on site plan): Depth be grade: feet Material of constru n: ❑ concrete ❑ me ❑ fiberglass ❑ -plyo1hylene ❑ other(explain): Dimensions: Scum thickness Distance from top of sc- to top of outlet tee or baffle Distance from,bo ottott m of scum to bottom of outlet tee or baffle t Date of'last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title i i I Inspection r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 2201 Salem Street Property Address Periathamb Owner Owner's Name information is MA 01845 October 7, 2015 required for North Andover every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Co nts (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid leve related to outlet invert, evidence of leakage, etc.): Tig t or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): (, Depth �grade: v Material of construction: ❑ concrete . ❑ metal ❑ fiberglass ❑ polyethylene ❑ ot1-1 (explain): Dimensions: Capacity: gallons Design Flow: `°Zfloatswitches, ns per day Alarm present: Yes ❑ No Alarm level: arm in workin g order: ❑ Yes ❑ No Date of last pumping:Comments (condition of : "., 5, r l *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts F Title Official In, spection Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 2201 Salem Street Property Address Periathamb Owner Owner's Name information is North Andover MA 01845 October 7, 2015 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Zero 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.): The d-box is 16"x 16" and is 36" below grade with cover built to 6" below grade. The d-box is in very good shape with no signs of any problems The d-box has speed levels. P mp Chamber(locate on site plan): Pumps in ng order: ❑ Yes ❑ No* u �..._ Alarms in working order: es ❑ No* e condition of um ch er, conditio umps and appurtenances, etc.): Comments (not pump * 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: f SAS was located by asbuilt drawings and previous title v. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 t5ins•3/13 Commonwealth of Massachusetts Title i i I Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: I ❑ leaching galleries number: ® leaching trenches number, length: 2 -50' x3`W ❑ 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.): The SAS is in good condition. There are no signs of ponding or breakout. Ce ools (cesspool must be pumped as part of inspection) (locate on site plan): Number and c ' uration U Depth—top of liquid to inlet in Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication'of groundwater inflow ❑ Yes ❑Flo_._ t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title i i l Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Co ents (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): P V vy (locate on site plan): Materials o struction: Dimensions �. Depth of solids Comments (note condition of soil, signs of hyd,a�H` 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 Title Official Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2201 Salem Street Property Address Periathamby Owner Owner's Name information is North Andover MA 01845 October 7 2015 required for , every page. City/Town State Zip Code Date of Inspection U. Sys em n orma ion 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: ® hand-sketJh in the area below ❑ drawing at ached separately J\ F�0'1 W r-(I< c o3 X / Sa leM S�. B T Se�kc, pol"CIN Tan k x r � r "SOX u AWr- A fa X :� y� I 31x ZVI 3'6" U10 AID-bf53 ` Q� 36 ` w +� D = q4 ` t5ins•3//1.3 A Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title fi i I Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope �cc ® Surface water GJe a,n ® Check cellar b I No Ell""►' P"P ® Shallow wells f Jo n-e- 7' +/- 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: 10/16/85 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Proposed, asbuilt and previous title v on file. ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: The basement is 7' below grade with no sump pump. 5/13/85-no water found at 9' and at 10' by: Thomas J. Murphy. Salem Street is 10' + below the grade of the yard. Wetland area is 10'+ below the grade of the yard where is the system is located. 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 Commonwealth of Massachusetts F Title 5 Official Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 2201 Salem Street Property Address Periathamby Owner Owner's Name information is North Andover MA 01845 October 7, 2015 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 FILE d) c) '716, 11 f rrr i�j/% rrr TIT : V INSPECTION 1 ► r« I.�l�sotb TI & Sons P«0« SOX. 13 MA 01949 978-774-4065 is/ fir/ rr Licensed Plumber # 20285 ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � /,�� C►PER'TY OWNERS N l ADDRESS PROPERTY AD q a 0 `--� ry) DATE OF IN C C-f C> �OF,INSPECTOR QUALITY IS NUMBER ONE TO US r rrrr,/ o�