HomeMy WebLinkAboutTitle V Inspection Report - 101 CROSSBOW LANE 6/7/1996 i
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld
Governor
Trudy Coxe
Secretary,EOEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address; ,Q%C(tT:,5 t3X,,_ Address of Owner:
Date of Inspection; CA---7_ct(� (If different)
Name of Inspector: ('(C't1r't�r�, P
Company Name, Address and Telephone Number;
°yp r
CERTIFICATION STATEMENT
i cenify 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 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
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails - ✓
Inspector's Signature; Date; ,t` � ���
1
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspeciion 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 j
the repo- to the appropriate regional office of the Department of Environmental Protection.
Ine original should be senl t0 the nvsten) owner ana copies Sent to Ul(2 UU)'ef, 11 appi1CdUiCa ctliu tiic
INSPECTION SUMMARY:
Check A, B, C, or 1.7
A] SYSTEM PASSES:
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.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired, The system, upon completion of the replacement or repair,
passes inspection.
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, 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.
(revised 8/15/95)
One Winter Street 4 Boston, Massachusetts 02106 Y FAX(617)555-1049 a Telephone (617) 292-5500
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: l Ot C "t
Owner: Ha I`y 1?j2a�l'tey
Date of Inspection:
D) SYSTEM FAILS (continued):
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 1/2 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 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 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:
The following criteria apply to large systems in addition to the criteria above:
Tne design flo\N 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:
the system is within 400 feet of a surface drinking water supply
the sv�tem is within 200 feet of a tributary to a surface drinking water supply
_ the s!cr is located in a nitrogen sensitive area (Interim Wellhead Protection Area (I\VPA) or a mapped Zone II of a
public water supply well;
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 101 C(OSS 6,.
Owner:
Date of Inspection:
Check if the following have been done:
d Pumping information was requested of the owner, occupant, and Board of Health.
/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.
/As As built plans have been obtained and examined. Note if they are not available with N/A.
_The facility or dwelling was inspected for signs of sewage back-up.
/The The system does not receive non-sanitary or industrial waste flow
/The site was inspected for signs of breakout.
_All system components, excluding the Soil Absorption System, have been located on the site.
_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.
—The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated b\ non-intrusive method,
T�.- _ -;I h-„ •, (r!'lip ,;" frnq�. M' nn,) were providefl vJ 0, Informal ion on the proper maintenance Of Sub-
Surface Disposal System.
trevised 8/15/55) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: fC�( CFC= �a�
Owner: Rc,' t
Date of Inspection (C✓y
6-7—(i',
RESIDENTIAL, FLOW CONDITIONS
Design flow:&Qa_gal ions IdW(
Number of bedrooms:
Number of current residents:
` Garbage grinder(yes or no):
Laundry connected to system (yes or no):Y,?—%
Seasonal use (yes or no):
Water meter readings, if available: 3 a
Last date of occupancy: flege �� �CCc)PteJ
COMMERCIAUINDUSTRI.4L:
Type of establishment:
Design flow:___gallons/d ay
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)
"1 ater meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL IIvFORA1ATl0;�
PUMPING RECD S and source of information-
System pumped as pan of ns n b Q
pection: yes or not
I()'es, volume p,,mnr'd�
Reason for pump,nE. gallons
TY�pF 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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: r t
�i 1 e cOr o� (-deal
n ' l � a3
Sewage odors detected when arriving at the site: (yes or no)NO
(revised 8/15/95)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property A Iddress: (
Owner: Haccy kP1e
Date of Inspection: 7- ''10
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
docato on site plani
Depth of liquid level above outlet invert: ek-G GJ t4' TK,,2
Comment_
c GC ` 0:'
. p\C:_a...b: :"„��' v� Cam{ lj^`” e'.�:.�
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: cocySS "J
Owner: Ho ml ( ot,- kc-tey
Date of Inspection: 6 —'T e��
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
o C
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DEPTH TO GROUNDWATER
Depth to groundwater: _feet pvn �I011"!7o'1 I (� _.I
method of determination or approximation: Fmm �( i v1 C', lG N .1 rt'm ill �.hP.`s l'',
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SMUUB04A/CS/VO4/L017 TOWN OF NORTH ANDOVER DATE: 06/04/96
TERMINAL NO: 052 CONSUMER METER F/M TIME: 11 :02^02
Acct : 01-4691000-0 BRAKELEY, HARRY 101 CROSSBOW �N
Meter No: 1 Rev Mtr/#: N Book: 17 Page: 46910. 00000 Meter Flgr 0 [ 1]
Connector: ] Digits: 43 Dim Ed : A] Multiplior: ] Arb #: ]
Manf Cd � ] Units: Pipe Size: ] Len^ ] Type: ]
Req . Inst : Cnct : Disc: Cd : 0]
Wrk Cdv ] Mt Code: ] Met Loc: ] In/Out : ]
Notes: 5/8 TRI-Q,) ] Serial # : 0029220582 �
Bgn: Cur: 1542 E Prev: 1503 A 2nd Prev: 1474 A [2]
From: 02/08/96 To: 05/06/96 Cur2: Prev2:
Next : Cns Cr: Mth Bill : 03 User: ]
-------------------------- Consumption Information -----------------------------
--- First 12 Billing Months ------[3] } ------ Last Ig Billing Months -------[4]
0)G/96 39 E 12/94 35 A 106/93 16 A
��03/96 29 A 09/94 89 A /03/93 28 A
p ' 12/95 — 30 A 06/94 -~20 A 112/92 30 A
09/95 59 A 03/94 31 E 109/92 43 A |
06/95 - 24 A 12/93 � 42 A 106/92 �12 A
03/9536 2 A ��9/93 - 51 A }03/92 25 A
First 12 'Total : 471 | Last 12 Total : 154 |
/
(ESC} to Enter New Meter Number
(M}odify, (D} elete or =ext.
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