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HomeMy WebLinkAboutTitle V Inspection Report - 290 BARKER STREET 5/23/2011 -P\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 290 Barker St Property Address._— Amy Lindyvist Owner Own.sNmme nfor red on s North Andover __._ _ Core 5/23/2011 eve page. Ci(y/TOwn Stale OpB ode pate 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. Import ,,,or nlnp.ut A.General Information computer,use 1. Inspector. only the tab key '.. to move your John DlVincenzo _ cursor-d.not Name of Inspector use the return key. Stewart Septic Service Company Name 58 South K mobil _ C p ny Address _— Bradford me 01830 Zip aw" C ty/TOwn _ State 01 Code _ 978-372-7471 S113386 _ 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.1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system ® Passes ❑ Conditionally Passes ❑ Fails ❑,N eds Fur I17 Evalua ion by the Local Approving Authority / 1 5/23/2011 t rs 51 al 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 DEP.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 wil erfmm in the future under the same or different conditions of use. j (ft T111.I Commonwealth of Massachusetts Title 5 Official Inspection Forma Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 290 Barker St Properly Address Amy Lindgvist Owner Owners Name 'n(orm lion is requ'red r" North Andover_ _.. Ma. 01845 5123/2011 every page Oityn own _... State Zip code_.. Dale of Inspection __... B.Certification(cont.) — 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: 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,NO)for the following statements.If"net 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 exfiltratlon 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): .........._... commonwealth of Massachusetts '.. Title 5 Official Inspection Form / Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 200 Barker St Property Address Amy Lindqvist Owner Owners Name. "m—ton�e North Andover requred for Ma 01845 5/23/2011 —_ every page. Gity/TOwn State Zip Code Dale of Inspect on B.Certification(Cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage residue or break out or high static water level in the distribution box due to broken or obstructed pipes)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 system will pass inspection if(with approval of the Board of Health)', ❑ broken pipes)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,safely 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 commonwealth of Massachusetts !� Title Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 5, 290 Barker St Propetly Address Amy Lindgvist owner ownera Name r1,r rord r or orAndover Is Nth Andd f ty _ Ma every page Clty/TOwn Stale Op8'otle 5/23/2011 Date 0/Inspectio1 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: ❑ 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or pending of effluent to the surface of the ground of 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 Y day flow Commonwealth of Massachusetts 6 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 290 Barker St Praper(Y Address Amy Undgvist wn mo,m t n is u, red L,, North Andover_ Ma 01845 5/23/2011 every page. Cityl r— State_. Zip Coda Date of Inspect on 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 ❑ ® 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 pp., 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- I 0,000g ad ❑ The system tails.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 grunt to 15,000 gpd. 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 fiber im Wellhead Protection Area-IWPA)or a mapped Zone I I 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. ? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foram-Not for Voluntary Assessments 290 Barker St Property Atltlress- Amy Lindgvist '.. Owner Owners Name i tlon is r,equ'r etlfor North Andover _ Ma 01845 5/23/2011 _ every page. CitylTOwI State Zip Gotle 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? X ❑ 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 ;mow'\ Commonwealth of Massachusetts I... RTitle Official Inspection Form f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 290 Barker St Property Address Amy.Lindgvist OwnerOwners Name qured r,, an to r North Andover is tor -_- -_ _ Ma 01845_ 5/23/2011 every page City/TO.' State 7rp Code Uate of Inspection _-- D.System Information Description: Number of current residents 5 Does residence have a garbage grinder? ❑ Yes 0 No '.. Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes® No Laundry system inspected? ❑ Yes Z No Seasonal use? ❑ Yes® No Water meter readings,if available(last 2 years usage(gpd)): 74 GPD.-_ __.. Detail. Water meter readings Sump pump? ❑ Yes© No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): --- ---- __--. Gellans per day cpd) Basis of design flow(seats/persons/sq.f.,etc.): --- --- --.-__- Grease trap present? ❑ Yes❑ No Industrial waste holding tank present? ❑ Yes❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes❑ No Water meter readings,if available: --- -- -___- 1 Commonwealth of Massachusetts Title 5 Official Inspection For S� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 290 Barker St ProPedy Address Am�Lindgvist_ Owner Owners Name requtred d, No rid Andover _. Ma 01845 5/23/2011 every page. City/Town Slate Zip Code Dade of Inspect on D.System Information(cont.) Last date of occupa ncy/use: are Other(describe below): General Information Pumping Records: Source of information: Andover Septic _._. Was system pumped as part of the inspection? ® Yes❑ No If yes,volume pumped: 1500 How was quantity pumped determined? Site guage on truck. __.. Reason for pumping: inspect tank _. 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), n,, Commonwealth of Massachusetts qilm o Title 5 Official Inspection Form ,V Subswfiace Sewage Disposal System Form-Not for Voluntary Assessments 290 Barker St _.. ......._-_ PropedY Add owner Amy Lintlgvk" information is owners Name- required for North Andover Me 01845 5/23/2011 every Page ciwfTOwn __ -. _.-_ state ZIP code— Date of lnspechon D.System Information(cont.) Approximate age of all components,date installed(if(mown)and source of information. Were sewage odors detected when arriving at the site? ❑ Yes® No Building Sewer(locate on site plan): Depth below grade: 23" '.. Material of construction X 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 construction Z concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal,list age' years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes❑ No Dimensions: _. _._.. Sludge depth: S.1\ commonwealth of Massachusetts Title 5 Official Inspection Form k5 Subsurface r7 ..e Disposal System Form Not for Voluntary Assessments 290 Barker St Property Address. Amy Lindqvist Owner Owner s Name information is - --- regdrod for North Andover Me 01845 5/23/2011 every page. city/Tawn _— __. - Stale Z P Code Date of Inspect on D.System Information(cont.) — — Septic Tank(cant.) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7 Distance from bottom of scum to bottom of outlet tee or baffle 14 Flow were dimensions determined? Slugejudge,_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.): Inlet and outlet baffles are in good condition no structual damage no leakage Grease Trap(locate on site plan): Depth below grade: —.. feel 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 ---- --- -.. Data of last pumping: __. Date Iy\ commonwealth of Massachusetts q� 4 �� "Title 5 fificial Inspection For l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M � 290 Barker St Property Address Amy Lirdgvist owner owners Name .qa,r, t on s North Andover renu'red for _ Ma 01845 _ 5123/2011 Y page y - Slate Zip Code Date of Inspect on ever Clt ITOwn — ---- — D.System Information(cont.) — Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,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: ❑concrete ❑metal ❑fiberglass ❑polyethylene El other(explain): Dimensions: Capacity: gallons __- Design Flow: - _... ga eons per day Alarm present: ❑ Yes ❑ No Alarm level: -- - - -- -- Alarm in working order. ❑Yes ❑ No Date of last pumping'. Date Comments(condition of alarm and float switches,etc.): Attach copy of current pumping contract(required).Is copy attached? ❑Yes ❑ No "Ill-\ Commonwealth of Massachusetts jTitle 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 290 Barker St Amy Lmdqvist Owner Owner's Name nfornation Is North Andover �nutedfor _ _ _ Ma _ 01845 5/23/7011 _ every page Cityao.' slate Zip code Date of Inspect on D.System Information(Cont.) 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): Replaced cover,no solids carryover,.no leakage D-box level good 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.): Soil Absorption System(SAS)(locate on site plan,excavation not required) If SAS not located,explain why. Commonwealth of Massachusetts '.. Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °�y./ 280 Barker St W Property Address Amy Lindgvist. -�torman in is North Andover requ red ror ---. __.. Ma 01845 5/23/2011 every page. CitylTown_ slate Zip Code Oahe of Inspection -- --- D.System Information(cont.) Type: ❑ leaching pits number --- - --- ❑ leaching chambers number - ------ ---- ❑ leaching galleries number. - - ❑ leaching trenches number,length: ---- ❑ leaching fields number,dimensions 1-18 X 60 ❑ overflow cesspool number'. ---- ------- ❑ innovative/alternative system Type/name of technology: ---- - - --- -- __. Comments(note condition of soil,signs of hydraulic failure,level of pending,damp soil,condition of vegetation,etc.): No hydrolic failure nomonding no damp soils no 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 a,", Commonwealth of Massachusetts '.. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments q, 290 Barker St Pro pery t Addvi" Amy Lindgvist '.. owner owners led— feq,,,edife s North Andover gryPer,r -... -. Se M. 01845 Date every page. chvrrown s(eie - z�P code o�e or ni,peuron ___... D.System Information(cent) Comments(note condition of loll,signs of hydraulic failure,level of pending,condition of vegetation, etc.): Privy(locate on site plan), Materials of construction: --- --- --- -..- Dimensions - - - --- -- Depth of solids --- ---- --- Comments(note condition of soil,signs of hydraulic failure,level of pending,condition of vegetation, etc.): P\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5/ 290 Barker St Property Atltlress Amy Lindqvist owner own.is Name rnmrmation" North Andover Ma 01845 5/23/2011 .'ary d or _.. everypage. City/TOwn Stale 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, ❑ hand-sketch in the area below ® drawing attached separately T'\ Commonwealth of Massachusetts �2 Title 5 Official Inspection Ferry' J\ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments q- 290 Barker St Propene nddreea Amy Lindgvist Ow,,er owners Name. ru'_,on is Nalh Antlover requred ror _._ Ma 01845 5/23/2011 every page. cltyrrown _- state_. zip code Date o/Inspection D.System Information(cont) Site Exam: M Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water teei— --- _. 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: f3-24-1994 _. Date Observed site(abutting properly/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain. Went threw file ❑ Checked with local excavators,installers-(attach documentation) '.. ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Checked.plans on file at the No.Andover B.O.H Before filing this Inspection Report,please see Report Completeness Checklist on next page. Commonwealth of Massachusetts 1... Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 290 Barker St Propehy Add ress Amy Lindquist '... Owner Owners Name -nformat"'s North Andover rom,ror . Me 01845 5/23/2011 every page. Clly/TOw i State Zip God, Dale of lnspeotw E.Report Completeness Checklist Z 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 Wnre:rs 6 91F R—orsn rvn E .Ra ey Contractors - Engineers, Inc. Ronus Ear 1-1 RENTAL Ervc rvcen rvc 33 OAK KNOLL.ROAD METH—N. MASSACHUSETTS y D� LJ GLI^llt l J L IV'i�i GJ / 2�o Bar I i V�� a p) ee 5 ' _ — ___ r 9r3,o N J:�s