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8 CEDARCREST ROAD - SEPTIC RECEIVED JAN 6 E �NN,,.�VI�R�<>NM EN T A L - O 201 " '�1�:! CITY OF SALEM BOARD OF HEALTH Wind River Environmental Title v Inspection Cover Report Name: nt Address (, �J Town: Q em Branch : A14 E. IU• Inspector: J 1Y'1� " bate: ► Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Cedarcrest Road PFO ty Address Virginia Moore Owner Owner's Name information is required for every Salem MA 01974 December 4,2412 pap¢, CiryR'own State Zip code pate of tnspectkn 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 farm. Important:When A. Genera! Information filing out farms on the computer, use only the tab 1, Inspector key to move your . cursor_do not James Gallant use the return key. Name or inspector —. MI��I�I Wind River Environmental Gompany Name Com Western Ave Company Atldress ^aW Gloucester MA 01980 Gity7fown Slate Zip Code 978-282-7315 S113402' 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 i9 true,accurate ang complete as of the time of the inspection.The inspection was performed based on my training and exp fence in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.840 of Title S(310 CMR 15.000).The system: bYPasses ❑ Conditionally Passes ❑ Pails ❑ Needs FgAbeLEyaluation by the Local Approving Authority (", )/1-444 W Inspector's Signature Date The system inspe r 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. tSiro•tttta TIN S Oftal hwwlan Fo :Sub+nece Saxapa ei:posel Sys19Yn•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Cedarcrest Road Properly Address Virginia Moore Owner Owner's Name Informad;on is Salem MA 01970 December 4 2012 required for every page. Cityfrown state Zip Cade Date of inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/a/ways 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.$03 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are Indicated below. Comments: I have not found any information which Indicates that any of the failure criteria described has been met. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined."please explain. The septic tank is metal and over 20 years old`or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Y ❑ N ❑ ND (Explain below): rshs.irpp TiOa 5 ORCIeI NSpettian Foml:SuM.Iam$"a Wpm]SystsM•Daae 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Cedarcrest Road Property Address Virginia Moore Owner Owners Name information Is required for every Salem MA 01970 December 4,2012 page. Cayrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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 D 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 pipe($)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 !sins•11A0 Title 5 Off ual Inepec(im Fenn:Subswfsce GGWQ29 Olspmsl Syelem•Page 3 017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments B Cedarcrest Road Property Address Virginia Moore _ Owner Owner's Name • information is Salem MA 01970 December 4, 2012 required for every page. City/rovm 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: ❑ 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 El ® 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 ''A day flow Mr19.11110 Tele 5 Offidel 118peCbOn FOmI:SubsuAam$pWege pjappeal System•VaAa 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Cedarcrest Road Property Address Virginia Moore Owner Owner's Name inibrmrequire for a Salem MA 01970 December 4, 2012 required for every page. Cityrrown 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. ❑ ® 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 falls. 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 gpd 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 ❑ El Area system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA)or a mapped Zane II 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. (Sins•11110 TWO 5 OOldal Mapadlan F&m;SubwdaW Sewage Dlspgsal Sysleat•Page 5 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form ,Not for Voluntary Assessments 8 Cedarcrest Road Property Address Virginia Moore owner Ownar's Name information is Salem MA 01970 December 4,2012 required for every page. Ctty/Town Slate ip Code Date of Inspection C. Checklist Check 4 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) ® Q 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$AS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with ® ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Sol[Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)1 D. System Information Residential Flow Conditions, Number of bedrooms(design). 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 16.203(for example: 110 gpd x#of bedrooms): 330 gpd (Sins 19HD rNe 5 official Inspedion Form:Suaswfam$awaw Disposal System•Pepe 6 N 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments B Cedarcrest Road Properly Address Virginia Moore Owner Owners Name information fo every�s fermietl for Salem MA 01970 December 4,2012 page. page. Cily/rown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?fif yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 91.02 gpd Detail: I obtained the information from the town water department. Sump pump? 0 Yes ® No Last date of occupancy: 2009 Date commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., 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: r`�na' Ina Tide 5 0MC181 inape iw F=:SOSUftM Searepe oiapoeal Sr"•Pegs 7 0117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Cedarcrest Road Property Address Virginia Moore Owner Owner's Name tiis reequirequired ffor every Salem MA 01970 December 4, 2012 o page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Dare Other(describe below): General Information Pumping Records: Source of information: Wind River Environmental record Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons Wow was quantity pumped determined? The quantity was determined by the pump truck and it was measured. Reason for pumping: To check the structural integrity of thematic 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/Ahernative 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): Istria•11110 Me 5 ORdal Ina apion fOml:SLo urtaca Sexap 0ts9gW System•Papa or 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Cedarcrest Road Property Address Virginia Moore Owner Owners Name Information is required for every Salem MA 01970 December 4, 2012 page. Ckyrrown State 9p Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: The approximate age of all components is 12 years old Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 33" Depth below grade: feet Material of constructiore ®cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: fW Water Comments(on condition of joints,venting, evidence of leakage, etc.): The joints are clean. The venting is good. There is no evidence of any kind of leakage. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® 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 10'x5'x5' Dimensions: 14" Sludge depth: t5ine•i ins Me 5 offtdal inmawm Fm :swevneW sewage 009w srmm•sage 9 Of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Cedarcrest Road Property Address Virginia Moore Owner Owner's Name information is Salem MA 01970 December 4 2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 21" 0" Scum thickness Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 14" The dimensions were determined How were dimensions determined? with a sludge j�e, rod and ruler. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend annual service. Inlet T is in place and in good condition.The outlet T is in place and in good condition.There are no cracks. The structural integrity is good. The liquid level to the outlet invert is good. There is no evidence of leakage into or out of the tank. Grease Trap(locate on site plan): Depth below grade: feet 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 Date of last pumping: Date rsire•11110 rifle 5 Woe]mepectign Form:SubW800 Se ge Dbpoed eyatem•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments 8 Cedarorest Road Property Address Virginia Moore owner owners Name information is required for every Salem MA 01970 December 4,2012 page. citytrown State Zip Code Date of inspection 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 ❑other(explain): Dimensions: Capait:ty. gallons Design Flow: gallons 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 N•1v10 lieeeo Mier IM mFwm:au6aunaca pB4ti SeWeyB Diipasa15re1em•Page 11 0117 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a Cedarcrest Road Property Address ViERinia Moore Owner Owner's Name information is required for every Salem MA 01970 December 4, 2012 page- City/rows State Zip Code pate of Inspection 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.): The distribution box is level.The distribution to all outlets is equal. There is no carryover of solids. The distribution box has no evidence of leakage into or out of the distribution box. 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.): Structure of pump chamber is good, 1 single pump in good working order, all floats are working properly. Alarm is working, Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5im.11110 M 5 OfficW inspotlim Lome:5ubmrr9c9 Sewage Dispostl System•Page 12 of 17 ,gL\� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments B Cedarcrest Road Property Address Virginia Moore Owner Owners Name informatrequired s Salem MA 01970 December 4, 2012 required far every page, City/Town State Zip Code Date 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 at 20'x 30' ❑ overflow cesspool number ❑ innovativelaltemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The soil is clean and dry.There is no sign of hydraulic failure.There is no ponding.The grass is green over the lawn. 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 t5iro•1 V10 Title 5 omclel mepedw rqm:Svt w&x Sewage Disposal System•np913 at 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Cedarcrest Road Property Address Virginia Moore Owner Owners Name information is Salem MA 01970 December 4,2012 regolred for every page. Clty/rown state Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, 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 ponding,condition of vegetation, etc.): sns,nllc Title 5 Dffidal hapecaon Fwm:svwtdace Sewage Diapmai System•Pop 14 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Cedarcrest Road Property Address Virginia Moore ovmor pwnees Name ...� - Information Is Salem MA 01970 December 4,2012 required fpt every dY page. G rrown state Yip 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 p :S� f4- n 0%7 20J q F- G- IF 33 .. 5b' � �I 4rGG1c I� roo p +Prk d � F 1511rc•11110 Me 5pfr ej"pMOW FQM SUWAf,' 6"S oepoW Sy9 Page 15 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Cedarcrest Road Property Address Virginia Moore Owner Owner's Name information is repaired for every Salem MA 01970 December 4, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells, Estimated depth to high ground water: 7 rest Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans an record If checked, date of design plan reviewed: June 14, 1999 Date ❑ Observed site(abutting property/observation hole within 150 feet of$AS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Soil test performed by Charles Ogden, witnessed by Mark Tallman, Beverly BOH. Test pit#1 is 7"to ESHGW. Test pit#2 is 7.5"to ESHGW. Before filing this Inspection Report,please see Report Completeness Checklist on next page. tains•11110 TO 5 prridal Inepedian Farm:Suasunaw Sewage DispoW SyMm•Page 18 M 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Cedarcrest Road Property Address Virginia Moore Owner Owner's Name information is required for every Salem MA 01970 December 4,2012 page. CRyrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® 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 an page 15 or attached in separate file 669•f fno rye 5 ornow irimecdon Forth:S+bwrrace sewage Dlspoeat sprem•Page 17 of 17 r Title 5 Official Inspection Form ?� Subsurface Sewage Disposal System Form-Not fnr Voluntary Assessments 4 r 8 Cediercrest Road Owner Vtr rola Moore intonation or 0w^.ie"i Name _ requiredforevety Salemn MA.._. 01970 December4,2012 _ page. Crtytram slate Zip Cafe [late of Inspection Inspection results must be submitted on this farm. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. hnportan6 when filing oqt forma A. General Infaririatian - 4_ on the cornpaior, use only the tab 1. Inspector. key to move your curscu-donot James Gallant use the return _—._....__.�..�—_.—._.. _...__._.�. _..._-_..._.. ..._...�._._____._._......_ kel/ Name or Inspector t♦�d_.r9 n Wind River Environmental ry Company Neale 103 Western Ave Company Address Gloucester MA .,_.._._M__.._..� 01930 _..._..__. City?rnvn state ZIP Coda 978-282-7315 SI13402 Telephone Number ___...__._......_�...�,..—_. Lkx+nse 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, accurateAnd 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_6(310 CMR 15.000).The system: (-y passes © Conditionally Passes © Fails © Needs Fu valuation by the Local Approving Authority • _ / 7 inspectors Signature were The system Inspe r 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 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 us at that time.This Inspection does not address how the system will perform In the future unde the same or different conditions of use. ISM•f Inc Td's 50f s hapiio an Fv Svcuafue 3w ps avows sMbm•Page I of t Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments 8 Cedarcrest Road Property Address Vir inia Moore ______ —�— e Owner Owner s Name information is Salem MA 0_19_70 December 4, 2012 required for every --- _ _ —_ page Cityrrown State -Zip Code Date of Inspection B. Certification (cant.) — Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: 1 have not found any Information which indicates that any of the failure criteria described has been met. 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. 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 exfiltra6on 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)- ISM-11110 elow):ISM-11110 T.mS01f:'om 6lspYCbnform$uDwrlaw s>+"mnlrpoW Srstsm•Pry 2an - �\ VVIIUIIVIIT 6WIue v, vowrwwe.,..vr.w Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -r 8!.edarcrest Road F'roydy Address � ----- Virginia Moore _ OwnerOwner's —._� _�._....__.._..._.. Name iequiredifo k Salem MA. 01970 December 4,2012 on requited tar every _. page. Ciryfravn Stele Zip Cede Date of Inspection B. Certification (cont.) —� B) System Conditionally Passes(cont.): ❑ 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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(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 pipe(s)are replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): Ct 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 .6w•)Inc T1Ua s orcval4eca[tion rano:SuOear¢®5eweao0lspnaBl SyY�n•PeW 3 of i7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �E ` . itCedarcrast Road _'ro?erty Address Virg n a Move__- OwnerO.vner's Name ----------- ----- ------------- - information Is Salem MA _01970 December 4,2012 required for every - -.— _ _-_.- Paye_ Gty/rown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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 aseptic 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 ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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' day flow t5ma•.1n0 TKa 50ffi"F PWMFx &Lb. =S4obp.0WD0.e1 SyN -PW 4e 17 V'�„"` VVIIIl11V/Ip GalU1 vI urnwwvu..vw.w .r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ti B Cedarcrest Road_ Property Address Owner Owners Name - requiratianis Salem MA 01970 December 4,2012 required for every ___..__.... _. __....---_..._.__.. Page. cityrrovm State Zip Code Data o1lr�spedion 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 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 design flow of 10,000 gpd 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 ❑ 11 Area system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II 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. t5tm-itnC To 50%o hvgc Fa $u'b&Ad MSavapoowwl Sygm-POW 60 17 l Title 5 Official Inspection Form a k , Subsurface:Sewage Disposal System Form-Not for Voluntary Assessments ,•. �� 8 Cedarcrest Road T Prpperty- ITOSS _—_—V--. "—`_.--- Virginia Moore Owner -_ .__..- ---------------------- Chwncrs Name ------ info fs Salem requirediretl for every MA _ 01970 __ December 4 2012 page. cityrrown Slate L Code _._--.-_.:_,-___. p Oats ollnspediun 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 oras part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) R ❑ 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): 3 — -- Number of bedrooms(actual): 3 - DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 qpd _ �a ,v'o nbsomr�i Inspaorx,Fam 3,dIH11(BCB S'!."gi B Dapmel SyWan•Ppe 8 @ 17 ............. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments ' 6 Cedarriest Road Property Address Vi_r all,_Ia2�1 22Le— Ovmer ownel's Name MA 01970 December 4,_M12 required for every Salem page. cdyrr— state Zip Code Date,of inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[if yes separate inspection required] El Yes 0 No Laundry system inspected? 0 Yes [I No Seasonaluse? C3 Yes N No Water meter readings, if available(last 2 years usage(gpd)): 91.02 qpd Detail: I obtained the information from the town water department. Sump pump? ❑ Yes El No 2009 Last date of occupancy: Date Commercialfindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gs_V4ns_ver—day(g;;d)___ Basis of design flow(seats/personr/sq.fL,etc.): Grease trap present? ❑ Yes El No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: is. 11ho TM 5 Moo irzpaotloi Pt:S .t.5"s D.cru,(riy�.-Papa]W 17 - ; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments k _ 8 CcdarcrestRoad Property AddreW Virginio_Moore _ Owner Owner's Name in dfor every n;s teyoiaileied Salem _ MA 01970 December 4.2012 Paye CiryRavm Slate Zip Code Data or Inspection D. System information (cont.) Last date of occupancy/use __. .- _--- ..._. Date Other(describe below): General information Pumping Records: Source of information: Wind River Environmental record Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gellorre How was quantity pumped determined? The quantity was determined by the pump truck and it was measured. Reason for pumping: To check the structural integrity of the septic 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/Altemative 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 IIA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): 19.•1110 Tft 6 Cfncel a OWM Form.SlmWMar,Sewepa USWIld SWW•PP."8 a 11 '. 4Ornrylonwedful Vt Inaaaaa.�ruav�w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t� s Cedarciest Road Property Address Virginia Moore 9wnar OwaafsName intam+atinn is Salem MA 01970 December 4,2012 required tar every _. ______ ..___ Pa ge. Ciryrrmn State Zryf Cotle Oats of tnsoegign d. System information (cont.) Approximate age of all components,date installed(if known)and source of information: The approximate age of all components is,12 years older Were sewage odors detected when arriving at the site? [J Yes ® No Building Sewer(locate on site plan): Depth below grade: fl`------ .— — — tea Material of construction: N cast iron ©40 PVC ❑other(explain): ----- Distance from private water supply well or suction line: Cid Water teat Comments(on condition of joints,venting,evidence of leakage,etc.): Thejoints are-clean The venting is.good. There is no evidence of an kind of leakage_ Septic Tank(locate on site plan): Depth below grade: 2' — t"t Material of construction: ®concrete [ metal ❑fiberglass n polyethylene []other(explain) If tank is metal,list age: is age confirmed by a Certificate of Compliance?(attach a copy of certificate) [] Yes f7 No Dimensions: 10'x 5'x 5' Sludge depth: 14 raa nnn r+u,acrtoa hwxrmFam sa.aunere e:,�e aid sy.� vv.aw u .te Tide 5 Official Inspection Form ry, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Not t>�' 8 Cedarcrest Road _-- ._.--- _�_ -- -- --------___ __ Pmpwty Andreas Virginia Moore Owner ..�._ .m_—..,__-_.........__.�� iintalion is Owrbr's name - required for every Salem ___.__._. MA 01970 December A. 2012 page. Cityrf Slate lip Code— Cate of Impaction D. System information (cont.) Septic Tank(cont) Distance from top of sludge to bottom of outlet tee or baffle 21" – -- — Scum thickness 0" Distance from top of scum to top of outlet tee or bailie 611 --- Distance from bottom of scum to bottom of outlet tee or baffle t`l' ---- How were dimensions determined? The dimensions were determined with a sludge judge._rod and ruler. Comments(on pumping recommendations,Inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Recommend annual service. Inlet T is in place and In good condition.The outlet T is in place and in good condition,There are no cracks.The structural integrity is good.The liquid level to the outlet invert is gocd._There is no evidence of leakage into or out of the tank. Grease Trap(locate on site plan): 6 Depth below grade: feet Material of constructlon: concrete ❑metal ❑fiberglass 0 polyethylene n 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 — – Date of last pumping: Date -- �S�n•ivte Taw 3 OWA h.ragipn Fv eu0 . s�d*�svoe*-vcae1n.n Ir Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments S 8 Cecarcrest Road -.- ------— —----- _... Property Adtlrosa —'-- --_ Virginia Moore _ Ovners flame reformation is required for every Salem MA 01570 December 4, 20.12 _. . Page. City/Town State - TrpCode ._----- Date of inspection 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 ❑uther(explain): Dimensions: — - --------- -------- Capacity: — gallons Design Flow: gallons per day - --- Alarm present: ❑ Yes ❑ No Alarm level' - .Alarm in working order: ❑ Yes ❑ No Dale of last pumping! Date ----- ------ Comments(condition of alarm and float switches, etc.): .Attach copy of current pumping contract(required). Is copy attached? [] Yes ❑ No U`ina t!(14 'D�h 5 SMrwar[,vDvq;tin Forzn S,RUGxs Swope D:.peWi SP�.v•!'Na 1.vt1': Title 5. official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3 C eda;crest Roa_d- _.... -..__�.. 1'-Gpa9y Address vi 19 nla(ypOtB Owner Owner's Name —...... info mqui'a�"' requiSalem M 01970 December 4,2012 red for every lA�_... _.. ._ page. Cfty/Tm State Zip Code Date of Inspection D. System information (cont.) Distribution Box(if present must be opened)(locate on site plan). , Depth of liquid level above outlet invert01 -------__ _.� 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 distribution box is level. The distribution to all outlets is equal.There is no carryover of solids. The distribution box has no evidence of leakage into or out of the distribution box__ 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,): Structure of pump chamber is good, t single pump in good working order, all floats are working properly.Alam!is workino---_—._....__-.._ _ Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: LS,M1A•tutu TP 5 OfB"WpMMM FM suGupS6s 9a'rtlye MWsy*"•Pa"12 a 17 Title 5 Official Inspection Form a Subsurface Sewage[Disposal System Form-Not for Voluntary Assessments 8 Cedarcrest Road R perty Atldrm Virginia Moore Owner Owner's Name requiredifo iv Salem MA 01970 Dzcember 4,_2012 repaired for every - -page City/Town state Tip—Code Date or Irsoectior D. System Information (cont.) Type: ❑ leaching pits number: - ❑ leaching chambers number: -- — ❑ leaching galleries number ❑ leaching trenches number,length' — ® leaching fields number,dimensions: 1 at 20'x 30' — ❑ overflow cesspool number: ❑ innovativelaltemative system Type/name of technology: ---------- -------- Comments (note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The soil is clean and dry. There is no sign of hydraulic failure.There is no ponding.The grass is green over the!awn. 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 15�tw 111+G Tips 5Ofty Msvo Finn S Cwf Swaps Disposal System Papa 13IN 17 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 8 Cedarcrest Read areoem.naaleaa � , Mr inia Moore Qwnw's Name ..... _......_ required is Salem u_, MA 01970 December4, 2692 rage, for every _�..._.-,._ page, CitYiTrnvr: State— -----Cotle Uala of Inspeaian D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of constmotion: Dimensions Depth of solids — -- Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): tsirettno rrcxacxr,�avvuoruton ram;s�w.law sow�a uyaw sr«�.rffyiaary ��\ VVIUIII VIIWGi41N1 VI IKIollP4n uay.v Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Cedarcrest,Road _ Property Address Vi�nia Moore Ovmer Owner's Name required fro is Salem MA 01970 December4,2012 pagerequired ter every __.�— - Gage City/town Stets Zip Code Data oFlnspaUion 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. 0 hand-sketch in the area below ❑ drawing attached separately k- E 191 3 E tar 4 - e�,G 19i G G Sb i f _n GrACX d 0 U O -'Anlf U O F v rrmn t �e-++no Ti6l5Q1iuel nsp¢rt+prFo+m rwbwifaw$e'.'eW Gu{psY SYsumPape 75 oJR -t� r Title 5 Official inspection Form rte Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Addro5S Vi. inia Moore (honer -nees N_,_._._.... _.---- owners Nana informmain dfo `s Salem ...___.,._ MA 01970 _ December 4,2012 ---- pagefor every __,,,_.___„N page. City/To” state Zip Code Data of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar Shallow wells Estimated depth to high ground water. 7 feet Ptease 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: June 14,1995 Date _ - - — ❑ Observed site(abutting propertylobservation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database•explain: You must describe how you established the high ground water elevation: Soil test;performed by Charles Ogden,witnessed by Mark Tallman, Beverly BON.Test pit#1 is 7"to ESHGW,Test. i�_is_7,5'to ESHGW. Before filing this inspection Report,please see Report Completeness Checklist on next page. Sim itn0 TIW506.iNb�fa S=dit*8WMWD0P=d SyIX ,Pop/aWtt a z: Title 5 Official Inspection Form Subsurface r Sewage Disposal System Form-Not for Voluntary Assessments Property Address aad Vir rola Moore �� Cwper's Name inrwmation a Salem MA 01970December 4, 2012 required for every CitYtTown ..-- _-- _ .._. page State Zip codeDate of Icspeaion E. Report Completeness Checklist ® 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 15im-'Mo T&502dd bw,ybn Form&dM0.Sar00e UW,, Ysye •VIXN 17W 17