HomeMy WebLinkAboutTitle V Inspection Report - 38 WHITE BIRCH LANE 12/15/2015 I
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NEW ENGLAND ENGINEERING SERVICES
1
April 24, 2000
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 01845
RE: TITLE V REPORT: 38 White Birch,North Andover
Dear Sirs:
Enclosed is a copy of the Title V report for the above referenced property. The system ap ssed our
inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
Benjann C. Osgood Jr.,
President
60 BEECHWOOD DRIVE-NO R TH ANDOVER,MA 01845-(978)686-1768-(888)4189-7848.-FAX(978)888..1090
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• C�MMONMA.LTH OF SACHUSEI TTS <,
EXECUTIVE•OFFICE OF ENvIRONMFNTAL AFFAIRS
DEPARTMENT OF EmmoNMENTAL PRO ON >
I
ONE WINTER STREET,BOSTON MA 02108 (617)292-6500 ;;"
4�s
ARGEO PAUL CELLUCCI �&U �'
DAVID iI,S, HS�,.:
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM * t•.
PART A
` CERTIFICATION
Property Address: �' Lk)Vx,TL Qt K fz SS Name of owner V
A), AN 0010E IZ, AAA Address'of Owner: Do,) '12--
Data of Inspection:
Name of Inspector:(Please Print) Benjamin C. Osgood,Jr.
(am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310•CMR 15.000)
companyNarne: New England -Engineering e s Inc.
MaTmg Address: 60 Beechwood D iye No th Andnmer, MA
Telephone Number: 978-686-1768
CERTIFiCATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the Information.reportad below is true,accurate
and complete as of the•time of Inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
,,/Passes e
® Conditionally Passes
® Needs Further'Evaluation By the Local Approving Authority
_ Falls`
Inspector's Signature: Date: Gt(>
The System Inspector shall submit a copy o this inspection report to the Approving Authority(Board of Health or DEP)whh(n thirty(301-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 Department oVEnvironmental Protection. The original should'be sent to-ft
system owner.and copies sent to the buyer.if applicable,and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page Ioftt
a
i ^..ReURmwSEWAGE DISPOSAL SYSTEM INSPECTION'pORMI
PART'A
Property Address:38 White Birch 'CER . ;;•
North Andover
TtFiCA710RC( � '�4' ` f
Owner:Mary Lacey
Date of Inspection:4/13/00 '
z ,tip
MISPECTiON SUMMARY: or D:A, •B, j . ; •,
Ap SYSTEM PASSES: i 1
,
1 have not found any Information which indicates that any of the failure conditions described In 310 CMR 15:303 exist. Any failure! ,
criteria not oval gated are Indicated below. I
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
I
One or more system components as described in the"Conditional Pass" section need to be'repiaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all Instances. If`not determined",explain why not.
The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of
Compliance(attached)Indicating that the tank was Installed within twenty(20)years prior to the date of the(nspectioh:or
the septic tank,whether or not metal,Is cracked,structurally unsound,shows substantial infiltration or enfiltration,or tank
failure Is imminent,• The system will pass inspection If the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipets)are replaced
obstruction is removed
distribution box is levelled or replaced
_ - The system required pum*g-more than•fourtimes c yeardue to brogan or obstructed pipe(s). The system •
inspection if(with approval of the Board of'Heafth):
broken ptpe(s)are replaced
obstruction is removed
revised 9/2/98 Pate zeftt
any a�
C11fl4 URFACE SEWAGE DISPO$AL SYSTEM INSPECTION FORM
Property Address: 38 White Birch PART A
North Andover CERT1FiCA1ION(continued) ,,',=t:.
� '
Owner:Mary Lacey
Date of Inspection:4/13/00
C. FURTHER EVfiLUAT1ON IS REQUIRED BY THE BOARD OF HEALTH: 1
CoAdidohs exist which require further evaluation by the Board-of Health in order to determine If the system Is f�airng to protecfthe'::
public hielth,safety and the environment.
11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMI1JES IN ACCORDANCE WIT7(31®CMR 16.303(1)(b)-THAT THE SYSTEIJ
IS NOT FUNCTIONING IN A MANNER"ICHMILLP.R07ECT•THE PUBLIC HEALTHAND SAFETY ANTI THE ENVlaONMENL°
_ Cesspool or privy Is within 50 fact=of surface water
Cesspool or privy Is within 50 feet of a bordering vegetated wetland or a sell marsh.
21 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 HEALT4i AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone i of a public water supply well
_ The system has a septic tank and soil absorption system and the SAS is within 60 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS Is I®ss than 100 feet but 60 feet or more from a
private water supply well,unless a wall water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of-ammonle nitrogen and nitrate nitrogen is equal to or less
then 6 ppm. Method used to determine distance (approximation not vafid)r•
31 OTHER
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SUSSURF CEEWAGE Di5POSAL SYSTEM INSPECTiON,f-0RM
•S
r PART A
CERTIFICATION(continued)
Property Address: 38 White Birch `
,
North Andover `
Owner:Mary Lacey
Date of Inspection:4/13/00 _
r
D. SYSTEM FAILS:
You must Indicate either"fifes"or"No" to each of the following.
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for thls
determination is identified below. The Bpard of Health should be contacted to determine what will be necessary{o:correct the failure.
Yes No
Backup oiocWage into•facility-or-d+stam"mponant•dueao an overloaded or_4aggod•GAS-or�cesspooi.' • w+- «^.�
_ 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 112 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 Soil"Absorption System,cesspool or privy is below the high groundwater elevation.
® Any portion of a cesspool or privy Is within 100 fdet of a surface water supply or tributary to a surface Water supply.
® Any portion of a cesspool or ptivy is-wlthln 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(ess•than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. if the well has been analyzed to be acceptable,attach copy of wall water analysis for
»coliform bacteria,volatile organic•compounds,ammonia nitrogen-and nitrate nitrogen. -
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 1:0,000 grid or greater(Large System)and the system is a significant thrept to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
® the system is within 400 feet of a surface drinking water supply
® the system-Is-within 200�o�t-ofa tai utaryttdaourfaw-danicl+►9 awtor•sury►!Y• ®. -the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mopped Zone 11 of a public
water supply well)
The owner or operator of any such system shall upgrade the System In accordance with 310 CMR 15.304(2). Ploass consult the local regional
office of the Department for further information.
revised 9/2/98 Patt4eru
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' SUBSURFACE SEWAGE DISPOSAL SYSTEM tNSPECTI�,N FORM
PART 0
CHECKUS7
a, t
Property Address:38 White Birch
North Andover
Owner:Mary Lacey !
Date of Inspection:4/13/00
I
Check if the following have been done:Ybu must Indicate either"Yes"or'No"as to each of the totiowing: Y;;•
Yet/ No
PIping information was provided'by the owner,occupant,or Board of Huth.
:None of the systemcompoa4aU-laaua:J>can ptmrR*Uor-atJaast tvco•ureakc suid-the'Wstam liow
rates during that period. large volumes of water have not been introduced Into the system recently or-as part ofthis
inspection.
As built plans have been obtained and examined. Note if they are not available with NIA.
_ 'The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non•si,rdtary br industrial waste flow.
® The site was inspected for signs'of.breakout.
All system components,excluding the Soft Absorption System,have been located on the:ite.
V r _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,mdtariat of construction,dimenstons,depth of liquid,depth of siudgb,depth of scum.
The size and location of the Soil Absorption System orr the site has been determined based on:
Existing information.For example,Plan at B.O.H.
V Determined in the field(if any of the failure criteria related to Part C Is at issue,approximation of distance is unacteptabie) '
®/ (15.302(3)(b)1
�( o The facility owner(and.ocaupaats,.Jf diifleraot 1rooLownej).waraprauidad.wIth Inf°unation on f
® SubSurtace Disposal Systems.
i
revised 9/2/98 Pate serIt
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SUBSURF4CE SEWAGE DtSPOSAgSYSTEM INSPECTION FORM y r
F PART
Property Address:38 White Birch SYSTEM tNFO11MATION
North Andover :
Owner:Mary Lacey ,t `4
Date of Inspection:4/13/00
V.
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FLOW CONDITIONS
RgSIDBIMAL'
Design flow: .&6 g.p.d./bedroorn.
Number of bedrooms kdesign): " Number of Bedrooms(actual): ! c
Total DESIGN flow d
Number of current residents• 1 -
G6rboge grinder(yes*or no):
Laundry(separate system) (yes or no):ALP; if yes,sepamte.inspectlon•required
Launtiry system Inspected (yes or not
Seasonal use(yes or nol:•QW
Water meter readings,if available(last two year's usage (gpd):
Sump Pump(yes or no)._A
Last date of occupancy.--LU-201i I
COM M ERCIAL/TNDUSTRIAL:
Type of establishment:
Design flow: rrpd (Based on 16.205)
Basis of design flow
Grease trap present:(yes or no)®
Industrial Waste Holding Tank present:(yes or no)®
Non•sanitary waste discharged to the Title 6 system:(yes or no)® e
Water meter readings,if available:
Lest date of occupancy:
OjHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION.
PUMPING RECORDS and source of Information:
a0& tag Q PEA i2w. &Jo—Z
System pumped as part of inspection:(yes or no)„A40
If yes,volume pumped: gallons
Reason for pumping:
' I
TYPE OF SYSTEM
_ Septic tank/distribution box/soli absorption system
Single cesspool
Overflow cesspool
Privy
Shaved system(yes or no) (if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other' -
3vIL,T ,D AT t� t�Zifs
APPROXIMATE AGE of all components,date Installed-{(f known)-and source ot•fnformation: -• ^-�—°
Sewage odors detected when arriving at the site:(yes or no)
n
revised 9/2/96 Patt6of11
- SURSJRFACE SEWAGE DISPOSAL SY dNSI`ECTDN FORM
Property Address:38 White Birch PART C ON
North Andover SYSTEM INFORMATION(continued)
Owner:Mary Lacey
Date of Inspection:4/13/00
Date of inspection: 3/3/00
BUILDING SEINER: ''
' (Locate on site plan) + '
Depth below grade. '
Material of construction; cast Iron 40 PVC other(explain) S`,
Distance from`private.water supply.well or su tion lino
Diameter <
Comments:(condition fjoints,verlting,evidence-of taakage,-etc.)
�� v w I AJ 13 /t4 E^✓T
SEPTIC TANK:—
(locate on site plan)
L4 N
Depth below grade: a I
Material of construction:I/concrete_metal_Fiberglass _Polyethylene®other(explain)
If tank Is(petal,list age® 1s.age.confumed by Certificate of Compliance®(Yes/No)
Dimensions: 15"00 641L 5
Sludge depth: 2'''
Distance from top of sludge to bottom of outlet toe orfraffle:
Scum thlckness:lf
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 dimensions were determined: ,t,,fA5 jIze STtCl4
Comments:
(recommendation for pumping,condition of inlet and outlet tees or-baffles,depth of liquid level In relation to outlet Invert,•structur"togr(ty,
evidence of leakage,etc.) li A)JA, I,v AJ. e0AJ D, jc L-7jEs / S r'E'cTrl�
GREASETRAP•
(locate an 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 too or baffle:
Distance from bottom of scum to bottom of outlet toe or baffle;
Date of last pumping:
Comments;
(recommendation for pumping,condition of Inlet and outlet toes or baffles,depth of fiquid.lovel In rotation to outlet invert,structural Integrity,
evidence of leakage,etc.)
revised 92/98 Pate 7oftl
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1 SuasuRFACE SEWAGE WSPOSA[.SYSTEWtNSPECTION FOAM y,
PART C :f
�'• Property Address:38 White Birch SYSTEM INFORMATION(cocrts(pu64111
North Andover
Owner:Mary Lacey
Date of Inspection:4/13/00
TIGHT OR HOLDING TANK;NAtTank must b4 pumped prior to,or at time of,Inspection)
(locate on site plan)
Depth below grade:
Material of construction:®cpncrete®metal®Fiberglass,_POlyethylene®athor(oxplatn)
Dimensions '
Capacity: gallons
Design flow: gallons/day
Alarm present _
Alarm level: Alarm in working order:Yes o NO—
Date of previous pumping: ?
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:,®
(locate on site plan)
Depth of Uquld level above outlet invert: ,
Comments:
(note if level and distributian is equal,evidenee of solid c carryover,evidence of leakage Into or out of box.ate.)
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PUMP CHAMBER:-AZ)4- . .
(locate on site plan)
Pumps In working order.(Yes or No) ”
Alarms In working order(Yes or Noll
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Mgt softt
SUEISURFACE SEWAGE DISPOSAL YSTEMINSPECTICINr ORM �y
• Property Address:38 White Birch PART ;+
SYSTEM INFORMATION(cortti{+uodl .
North Andover •'
Owner:Mary Lacey +
Date of Inspection:4/13/00 '
°
SdtL ABSORPTION SISTEM(SAS);®
(locate on sftq plan,if possible;excavation not required,location may be approximated by non4ntrusive methods)
If not located,explain; '>
.e...�!� gc
Ty e:
leaching pits,number:®
leaching chambers,number:®
leaching galleries,number:® i _ Al
leaching trenches,number,length.--
leaching fields,number,dimensions:
overflow cesspool,number.
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of h tic failure,level of ponding,damp soil,condition of vegetation,etch
�J S
CESSPOOLS•
(locate on site plan)
Number and configuration: ,
Depth•top of liquid to inlet Invert:
Depth of sofio layer:
Depth of scum layer.
Dimenstoh's of Cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil,signs of hydraulic failura,•levei of Votuing,4ondition of vegetation,etc.)
PRIVY: ,
(locate on site plan)
Matedpis of construction Oimonslon:;_
Depth of soUds:
Comments:
(note condition of soil,signs of hydraulic fallure,level of ponding,condition of vegetation;etc.)
revised 9/2/98 Pete 9ofIt
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SUBSURFACE VEYAGE WSPOSAL SYSTEM INSPECTION FORM
• PART C `
i
SYSTEM INFORMATION(oondrwad)
Property Address:38 White Birch
North Andover '
Owner:Mary Lacey
Date of Inspection:4/13/00 '
I
,SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least t*o permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes Into house) '
TKEAA)CH E
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revised 9/2/98 Page 10 of 11
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ON
Property Address: 38 White Birch PAtiT
North Andover sysTEm tNFORMATION(continued)
Owner:Mary Lacey
Date of Inspection:4/13/00
NRCS Report name o t— 'vim Czy ` L 5_Sn
C-
Soil Typo
I Typical depth to groundwater
USGS Date website visit d
Observation Wellf chocked
Groundwater depth: Shallow Moderato Deep „
SITE EXAM Slope "
Surface water
Check Cellar
Shallow wells //
Estimated Depth to Groundwater � Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
JL Obtained from Design Plans on record
Observed.Site(Abutting property,observation hole,basement sump etc.) °
Determined from local conditions
Checked with local Board of health ;
Chocked FEMA Maps-
Chocked pumping records
Checked local excavators,Installers
L Used USGS Data
Describe how you established the High Groundwater Elevation.(,Mast be completed)
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revised 9/2/98 P.c:ttofIt