HomeMy WebLinkAboutTitle V Inspection Report - 1220 SALEM STREET 6/11/1999 i
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PETER F. REILLY
AFFILIATED WITH F.P. REILLY AND SONS, INC.
206 ANDOVER STREET, SUITE 11
ANDOVER, MA 01810
(978) 475-4370
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
Property Address: 1225 Salem Street, North Andover, MA 01845
Name of Owner: Rudolph Koczera
Address of Owner: same
Name of Inspector: Peter F. Reilly
(I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: F.P. Reilly & Sons
Mailing Address: 206 Andover St., Suite 11, Andover, MA 01810
Telephone Number: (978) 475-1237 / (978) 475-4370
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the
information 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
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
Inspector's Signature: June 11, 1999
Peter F. eilly
The system inspector shall submit a copy of this inspection report to the approving authority within
thirty (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 regional
office of the Department of Environmental Protection. The original should be sent to the system
owner and copies sent to the buyer, if applicable and the approving authority.
NOTES AND COMMENTS
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SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C or D
✓ I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
System was functioning properly.
B. SYSTEM CONDITIONALLY PASSES:
N/A 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.
Indicate yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If "not
determined", explain why not)
N 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 tan was installed within twenty (20) years prior
to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound,
shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection
if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health.
N Sewage backup or breakout or static high 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
N/A broken pipe(s) are replaced
N/A obstruction is removed
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
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 the public health, safety and environment.
1. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND
THE ENVIRONMENT:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh.
2. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF
APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT
PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
N/A The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet
to a surface water supply or tributary to a surface water supply.
N/A The system has a septic tank and soil absorption and the SAS is within a Zone I of a public water
supply well.
N/A The system has a septic tank and soil absorption and the SAS is less than 100 feet but 50 feet
or more from a private water supply well, unless a water well water analysis 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. Method
used to determine distance N/A (approximation not valid).
3. OTHER
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
D. SYSTEM FAILS:
You must indicate "Yes" or "No" to each of the following:
N/A I have determined that the system violates one or more of the following failure conditions
exist as defined in 310 CMR 15.303. The basis for this determination is identified below. The
Board of Health should be contacted to determine what will be necessary to correct the
failure.
Yes No
No Backup of sewage into facility or system component due to an overloaded or clogged SAS or
cesspool.
No Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS
or cesspool.
N/A Liquid depth in cesspool <6" below invert or available volume <Y2 day flow.
No required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped: none
No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater
elevation.
N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply.
N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A 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. If the well has been analyzed to
be acceptable, attach copy of well 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 a large system in addition to the criteria above.
N/A The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat
to public health and safety and the environment because one or more of the following conditions exist:
N/A The system is within 400 feet of a surface drinking water supply
N/A The system is within 200 feet of a tributary to a surface drinking water supply
N/A The system is located in a nitrogen sensitive area (Interim Wellhead Area (IWPA) or a mapped
Zone II 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).
Please consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
Check if the following have been done. You must indicate either "Yes" or "No" as to each of the
following:
Yes No
Yes Pumping information was requested of the owner, occupant and Board of Health.
Yes None of the system components have been pumped for at least two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
N/A As built plans have been obtained and examined. Note they are not available with N/A.
Yes The facility or dwelling was inspected for signs of sewage backup.
Yes The system does not receive non-sanitary or industrial waste flow.
Yes The site was inspected for signs of breakout.
Yes All system components, excluding the SAS, have been located on the site.
Yes The septic tank manholes were uncovered, opened and the interior of the septic tank was
inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,
depth of sludge, depth of scum.
N/A Existing information (Example: Plan at BOH).
N/A Determined in the field if any of the failure criteria related to Part C is at issue, approximation of
distance is unacceptable [1 5.302(3)(b)].
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
FLOW CONDITIONS
RESIDENTIAL:
Design Flow: >330 gpd (110 gallons/bedroom/day
Number of bedrooms (design): unknown
Number of bedrooms (actual): 3
Total Design Flow: unknown
Number of Current residents: 2
Garbage grinder (yes or no): yes
Laundry (separate 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 two years usage (gpd): est. 100 gpd past two years
Sump Pump (yes or no): no
Last date of occupancy: current
COMMERCIAL/INDUSTRIAL:
Type of Establishment: N/A
Design Flow gpd (based on 15.203): N/A
Basis of Design Flow: N/A
Grease trap present (yes or no): N/A
Industrial waste holding tank present (yes or no): N/A
Non-sanitary waste discharged to the
Title 5 system (yes or no): N/A
Water meter readings, if available: N/A
Last date of occupancy: N/A
OTHER: (Describe) N/A
Last date of occupancy: N/A
GENERAL INFORMATION
PUMPING RECORDS and source of information:
last pumping: about 4-5 years ago according to owner
System pumped as part of inspection (yes or no): no (pumped following inspection)
if yes, volume pumped: N/A gallons
Reason for pumping: N/A
TYPE OF SYSTEM
✓ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
NO Shared 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 (explain)
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Original system installed in 1972.
Sewage odors detected when arriving at the site (yes or no) NO
BUILDING SEWER: (locate on site plan)
Depth below grade: 8"-12"
material of construction: cast iron ✓ 40 PVC other (explain)
Distance from private water supply well or suction line N/A
Diameter: 4"
Comments: Condition of joints, venting, evidence of leakage, etc.)
Building sewer was watertight and appeared sound.
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 6"-10"
material of construction: ✓ concrete metal Fiberglass Polyethylene other (explain)
If tank is metal, list age N/A Is age confirmed by Certificate of Compliance N/A (Yes/No)
Dimensions: rectangular- 1,000 gallons
1%2" sludge depth
24" distance from top of sludge to bottom of outlet tee or baffle
0"-1" scum thickness
5" distance from top of scum to top of outlet tee or baffle
14" distance from bottom of scum to bottom of outlet tee or baffle
How dimensions were determined: measurement
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in
relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.)
Tank was watertight and functioning properly. Pumping was recommended and done following inspection.
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions:
N/A scum thickness
N/A distance from top of scum to top of outlet tee or baffle
N/A distance from bottom of scum to bottom of outlet tee or baffle
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in
relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.)
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to, or at time of inspection)
(locate on site plan)
Depth below grade:
material of construction: concrete metal Fiberglass Polyethylene other (explain)
Dimensions: N/A
Capacity: N/A gallons per day
Design Flow: N/A gallons per day
Alarm Present: N/A
Alarm level: N/A Alarm in working order N/A (Yes or No)
Date of Previous Pumping: N/A
Date of previous pumping: N/A
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: ✓ (locate on site plan)
0" depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out
of box, recommendation for repairs, etc.)
The d-box was level and functioning properly. Five lines were not distributing equally. Little solids carryover
evident. Box was deteriorated and was replaced following the inspection.
PUMP CHAMBER: N/A (locate on site plan)
N/A Pumps in working order (Yes or No)
N/A Alarms in working order (Yes or No)
Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.)
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, but
may be approximated by non-intrusive methods)
If not determined to be present, explain: not applicable
Type
leaching pits and number N/A
leaching chambers and number N/A
leaching galleries and number N/A
leaching trenches, number, length N/A
leaching fields, number, dimensions five (5) lines - overall size about 800 s.f. (20'x40')
overflow cesspool, number N/A
alternative system (name of technology) N/A
Comments: (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.)
Soils over leaching area were good, no evidence of breakout.
CESSPOOLS: N/A (locate on site plan)
Number and configuration N/A
Depth-top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow (cesspool
must be pumped as part of inspection) N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
PRIVY: N/A (locate on site plan)
Materials of construction N/A
Dimensions N/A
Depth of solids N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indicate at least two permanent references, landmarks, or benchmarks
locate where public water system enters house
locate all wells within 100' N/A
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SEPTIC TANK TIES: A to Inlet (1) 31'1" B to Inlet 36'7"
A to Center (C) 28'9" B to Center 39'2"
A to Outlet (0) 26'8" B to Outlet 42'5"
D-BOX TIES: A to Box 23'0" B to Box 50'2"
NOTE: The system is in the rear yard.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
NRCS Report Name N/A
Soil Type N/A
Typical depth to groundwater N/A
USGS Date website visited 4/1/99
Observation Wells checked Wilmington
Groundwater depth: Shallow Moderate ✓ Deep
SITE EXAM Slope level in area of system
Surface water none observed
Check Cellar dry
Shallow wells none observed
Estimated Depth to Groundwater > 1 ' (below bottom of SAS)
Indicate all methods used to determine High Groundwater Elevation:
N Obtained from Design Plans on record
Y Observation of Site (abutting property, observation hole, basement sump, etc.)
Y Determined from local conditions
N Check with Local BOH
N Check FEMA Maps
N Check pumping records
Y Check local excavators, installers
N Use USGS Data
Describe how you established the High Groundwater Elevation.*
Soils and grade changes in the area appear to confirm adequate groundwater separation.
*Inspector's Note: Soil Evaluation is the currently recognized method for determining or establishing the high
groundwater elevation. Since I am not a licensed or certified soil evaluator, I am not qualified to determine or
establish the high groundwater elevation beyond the public information available, such as recent design plans of the
site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain
all available information both on and off the site and my experience as a certified subsurface disposal system
inspector. (see attached Disclaimer)
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DISCLAIMER
This passing septic inspection under Massachusetts Title V is in no way
a guaranty or warranty of the inspected septic system. The inspection is
a "snapshot in time" and does not constitute a complete assessment of
the quality or potential longevity of the septic system. The pass/fail criteria
are specific and outlined in detail in this report. Under the limited criteria
of a Title V inspection, it is impossible to determine how long any septic
system will last. The inspector made a diligent effort to certify the septic
system based on the criteria required under Title V.
Under Massachusetts Title V, soil evaluation is the accepted method of
determining the high groundwater elevation. This inspector is not a
certified soil evaluator and is therefore not qualified under Title V to
determine or establish the high groundwater elevation. The method used
to estimate the high groundwater for this inspection was based on the
public records and methods of observation described on the previous page.
Groundwater levels can vary greatly from season to season, year to year
and soil evaluation is considered the most reliable method of groundwater
determination under Title V.
Pet r F. Reilly
Inspector
June 11 , 1999