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0004 PETER ROAD - TITLE 5 INSPEC. Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form I-Not for Voluntary Assessments Q Property Ad c f Owner Owners Name reformations SL=,�Q �}+t9 ;> �-2(0— �S required for every I�NL - �r- –lJl-�-�� page. City/rows tate Zip Code Dateldf Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: IJst1 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: ° P e,,J 5 �-t� -iew, B f l Leve I s i.-a 4At-' K u.l P-0 4e/�&G A ¢- w-rs S kki P 1 A-r m^e 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 exfiftration 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): 'Abe Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Ra Props Owner Owner gams/ information is ( (' 41 o r97G it.. ?-(0 - t s required for every \ uv" AStat page. Cky a Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the forth. Immo out forms A. General Information filling out forms on the computer, use only the tab 1. . Inspector. key to move your cursor-do not use the return key. Na Of or Complirly Name Q Com pan A as t�SSpX�� �A 01770 Cyrown Ste Zip Code � 4 Telephone Number License Number B. Certification Icertify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection el&s performed based on my training and experience in the proper function and maintenance of on site *q age disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of 16N Title 5(310 CMR 15.000).The system: �I ray asses ❑ Conditionally Passes ❑ Fails U CF Needs Further Evaluation by the local Approving Authority Inspector's Sig m Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of Inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Commonwealth of Massachusetts Title 5 Official Inspection Form -1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner !Q✓� . J 4r l ,S _ _. Pxner's Name information i5 required for every � , A^ 0(970 page- City/Town tate Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval K pumps/alarms are repaired. 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 ❑ ND (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): 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Add - Owner Owners Name information is el?7o €- 26— l S required for every ^ page. Citylr `-� 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 ❑ ❑ 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 %day flow Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage D posal System Form - Not for Voluntary Assessments q Property Address Owner Owners Name information is s^� o required for every 0/97.0 ® -2,ro— l r page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) Yes No ❑ ge� 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. ❑ [p,� 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. ❑ yy 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 collforrn 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 ❑ L7 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 ❑ the 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments q Ile Property Address17 / C/ G Owner ownersame information is required for every 6. X;-_Xj— page. city/rSlate Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Y-es/ No [� ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 2/ Were any of the system components pumped out in the previous two weeks? IV ❑ Has the system received normal flows in the previous two week period? ❑ Ep Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? UG/ ❑ Was the site inspected for signs of break out? 6�/ El Were all system components,excluding the SAS, located on site? R ❑ 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? ❑ 03/� 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: ❑ L� Existing information. For example, a pian 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 s r5ins.N13 r..l_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Addre-q �. . Owner Owner's information is Cy c2C required for every Qtttt �(4711 �f page. CrtylTown Ste a 21p 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?(Include laundry system inspection El Yes No information in this report.) Laundry system inspected? E' Yes ❑ No Seasonaluse? ❑ Yes No Water meter readings, if available (last 2 years usage(gpd)): — Detail: (A.) a —ars d w *--k Sump pump? ❑ Yes No Last date of occupancy: S' 2-C— 1, Date CommerciaUlndustrlal 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? ElYes [! No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes No Water meter readings, if available: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dispos I System Form -Not for Voluntary Assessments y 7/&- Property Address Owner Owners N infonnation is required for every page. Cilyrrown State Zip Code Date of Inspection D. System Information (cont.) �- Last date of occupancy/use: Date 26 - IS Other(describe below): General Information Pumping Records: 7l/f�� Source of information: �'� EV " -" eee Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: a50 �R E' o N $ gallons How was quantity q ty pumped determined? Reason for pumping: Type of System: 2L 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth - Not for Voluntary Assessments ad Property Address / , Owner Owners Nameinformation is �— required for every nn -17(1 d Us 4j page. Cityfrown VCitylfown Sfate Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): /l, Depth below grade: ��ii feet Material of construction: f ❑cast iron ❑40 PVC ❑other(explain). O�^Te 'faS- � b�I f a/t Distance from private water supply well or suction Zine: jib ` Comments(on cond'tt ion of joints, venting, evidence of leakage, etc.): M./- - Septic Tank(locate on site plan): Depth below grade: feet Material of construction: Elponcrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 16&1 Icftd, �bHfj¢ef Sludge depth: klRs No Slu�co Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments Pe -el rL PropeAyAddress � A 6 ^ Owner 1 'VAN e l S ; l/ Owners Name information is (� � required for every �i7AA 0— page Cow I ownt5 ate Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 144-5 J VSA W0.4-rAID 5 Scum thickness Al nAe Distance from top of scum to top of outlet tee or baffle /UOriti — Distance from bottom of scum to bottom of outlet tee or baffle / o�0�� How were dimensions determined? /It"U P—L A Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): w'A S l n ar r-r Grease Trap (locate on site plan): Depth below grade: v 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 tam•3/13 �.._..._ . ..__ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y d4v 2j Property Address ^ Owner Owner's Ne r ,✓ information is M //I, (S►R76 S ��'" �J required for every — ,At. � page. City/7own 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.): l U� n' 'L —P0 AA4 Ad tties U 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: Capacity: 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 Lsm¢.3113 =..._ ..a: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P 2 /d Property Address Owner Owner's IV r C t tai information is •/1 required for every page. Cityrrown 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 invert 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: �J ❑ Yes ❑ No' Comments(note condition of pump cham r, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5iv•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments � Property Address (r OwnerOwners Name information is required for every n 7V �9 7U page. citya� � SWM 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: ❑ overflow cesspool number: — ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 6YA- C OAJC> Po ti J Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth-top of liquid to inlet invert / n Depth of solids layer / Y r Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P4er PA Property Address C. I'S C � Owner Owners Nam�/�� J infOrnation required for'every page Cityrrown State Zip Code Date'&Inspeaion 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.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Pe-1 cl 2 j S Property Address 'r— Owner Owners NaLne information is required for everytLl, OtL page. CityrT State Zip Code Date of Tnspection 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: E24 hand-sketch in the area below ❑ drawing attached separately A -�d a a►' 7 ' D C /0 " 3 F C a3�y u kr A +o C I G/,q * - 1 R � c Ar I t6im•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments L/ �N? 4-el— 12 d Property Addresses ,, - ` / �C l 5 .f� /1_(_ .y,L/� Owner t�i2Abw Owner's Name information is required for every — A& 0I ?7Q O 2f. page. Cay/Town state Zip Code We of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water [/],"Check cellar ❑ Shallow wells Estimated depth to high ground water. o7o r e fJ�A" r seat Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: r ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address OwnerC Owners Name information is ^,n'^ required for every S 4LtA , Y .�..� t� page. CitylTOwn State Zip Code late o Irupe t 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 FORN14.SVSMI PLq%IpWG REroRi ., CommEQt�aealth of Afassachusetts v Massachusetts DEC 312003 CITY OF SALEM BOARD OF HEALTH System Pumping Record System Owner }'stem Location CAMPBELL 4 PETER ROAD Estimated Date of Pumping: 8/19/03 Quantity Pumped: 1000 gallons Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes Q RAGGS SEPTIC SERVICE, INC. System Pumped by: d .b.a . E. A. COMEAU SEPTIC License r: Contents transferred to: _ WAYLAND SUDBURY TREATMENT PLAN Date 12/16/03 Inspector RAGGS SEPTIC SERVICE INC. COMMONVJEAT,TH,O&MA.SSACHUSETTS EXECUTIVE'OFFICE''OFr'ENVIRONMENTAL AFFAIRS JUL 8 ` 1999 DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617) 292.5500 CITY OKSALEM,,,•, HEALTH,DEPT.• TRUDY CORE Secretary c. AROEO PAUL CELLUCCI DAVID B STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - . . .: o,,. - ...CFATIRCATION- Propertty Address: y Pe4 er- Rd r 6484 P1 Name or owns h(tH OG K // Address of Owner: Date of Inspection: V(� I QQ . Name of Inspector:(Please Prim1:1��uP /!nI: I am a DEP pro ode i pector pursuart[to Section 16 340 of T1ta�61310 1 CMR 5.0001 Company Nanta: Q 11,711 MaSng Address: eA A ju. y ?I -jw .,.. ..Ji, Telephone Number:' CERTIFICATION STATEMENT I certify that I have personally inspected the seage disposal system et this address and.that the in wformation reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training,andiesperience in.the proper function and maintenance of on-site Seage disposal systems. The system: /Li//Passes Conditionally Passes Needs Further.Evaluation By.the Local Approving A46rrty Pei s Q Inspector's Signature: Date: !( / The System Inspector shell submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30) days of completing this inspection. If the system Is a shared system or has a design flow o1 10,000,gpd or greater,the inspector and the system owner shell submit the report to the appropriate 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 authorlty. NOTES AND COMMENTS ! -A SeP �t� n (� S�IOv�ULePvNtd eu � .Z years , revised 9/2/98 Page t of 11,,:; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ... 1-.is .rar:).PART•A is t ...r\a::;%t,s!i% , n ^'r•.i�l: ';,! 1 CERTIFICATION cgdbped1,T-tfl Property Address: ..t! Date of Inspection: - .. .. . :_T i Ili INSPECTION SUMMARY: Check A, 8, C, or D: A. SYSTEM PASSES: - I have not found any information which Indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are lndiclff d'belowl — 'Oi 7"'':7 aY+, R:;:)4Gt'a:;J1;!'1.,:„i•,iii:rt:{s.,:' COMMENTS: ii 1 �a3t?'y::ri. ts:,yr;rfu waoli B. SYSTEM CONDITIONALLY PASSES: - - -- - . . .:_ .....•y'-"'•t0 le; w , 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'Hebith,'wlil;Vase-:p """+�t,i',,•s••'�^' '+.'': •• '.r., - Indicate yes, no, or not determined(Y,N, or NO). Describe basis of determination Wall.Instagen: If?'not'.delermined%',expldin why not. . The septic tank is metal, unless the owner or operator has provided thesystoro Inspector with•a copy of a Certificate of - Compliance (attached)Indicating that the tank was installed within twenty 120)years prior to the date of the inspection; or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltretlon'or e7iflitiation,'or tank •• ' failure is imminent. The system'will pass inspection lCtfie existlnb septio`tank,ls'replabedvvith a'complying septic tank as approved by the Board'of Health: _:.' , ..` ::'r.r.•t c e.,:t:e•.', t e.. noua:go:t, :.:•: •tnt:.:, :.,: t„ -, , . ,. 1'•1:srLY? 0y .o+n'a7<ye Ioaogtil•':f(je:;ye:. e.,.<,c . . n Sewage backup or breakout or high static water level observed In the distribution box-Is Aue to brokan'or.obstructed pipelsl or due to a broken, settled of uneven distribution box,!'The systemwlllipess ins{iectlon Iflwith approval of the Board of Health). - 1 broken pipelsl•are replaced •�;;; � : ' 1,„ Is ruction isYsmoved distribution box is levelled or replaced ' :. -. 7., C14.•L•i '.•,1?i l;v%. ilnivolgvjA qd,of r1Gra nV1i:W17ai t+til to V,,yC.l a :%:.•.i:. ,.. The system required pumping mors•than foul tima'a year-due 'td brolren'b obstnlctdd'pipe(s)."Tha aystem•wi11'pass Inspection If(with approval'of Me Board of'Heslthli' 7°q'11'7b '` ' ' !o aowa+aw••,rn, >rc^ _ 7: ,: , broken pipe(s)are replaced'1b1•v"`- " -'i+ �' ,': .•or:• - obstruction Is removed A, revised 9/2/98 of 11.1, SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM ,V,..,PART A'i(,' rd;is r... CERTIFICATION(continued) Property Address: Date of Inspection: C. FURTHER EVALUATION IS REOUIRED BY THE BOARD OF HEALTH: Conditions exist which,require further evaluation by the.Board of Health in-ordeetoldetermine If the system is'faiiing.to protect the r, , e x r lru� tnmrn:n:o w, t yrn.'r! : e t.o*r,. to r public health,'Befety end the environment - ,_ u: S [, r': L.lr}�+I:JD tiJ Lil_..:2 dn,'F! C tdv3 e„ +r'.J .,..:f . . 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15,303 11)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privyis within 56 feet of a b'orderingvepefated "wetland or s'salt marsh. A1»;::01 te.l'_o `•:4,1.`. X".5 'C (.1:L Lh: i,t'i .. .. +� .. t.!,� < id:.yr,,ya _.:':^_;. . i br.l �y'.p 1' 'r t'iL •l I . ... .; 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'AND SAFETY AND THE ENVIRONMENT: . _ The system has a septic tank and soil absorptlonoystem'(SASlvnd the SASS is!within.100 feet�of,a surfacemater supply or tributary to a surface water supply. The system has a septic tank'and soil'absorption`iystem'and•tlii$ASds within a Zone'I of a public'.water.supply well. The system hes a-septic tank and soil absorption system and the SAS Is within 50 feet of a privets water supply well. The system has a septic tank end soil etiiorption'gyaUrn eridhhe'SAS WIess'than�t00 feet but 50 feet or more from a private water supply'well;unless a well water analysts for coliform-bacteria and volatile:organiccompounds 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 then 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER 1: . i - .r.. 9 ". tyJ revised 9/2/98 page or If-'! - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM CERTIFICATION 1p"razed) Property Address: Owner: Data of InsPet:don: ?41 ?;1..'i; !. ::':1/J--L:)3i:P'.t,>;, VJS,':U Fi :,. .!�:• . y ..:. D. SYSTEM FAILS: - - You mus@indicate either "Yes" or "No" to each of the following:,, , - - 1 have determined that one or more of the following failure conditions exist as described in 3.10CMRt 15303.. The basis for this determination is identified below. The Board of Health should be contacted to determine what wlll benacessaiy't'o correct the failure. . i A� r..1.4 'P'-' J r.i;;a1 _I.' r :• ej�i ': 1(t11,' .t1 lJTY}} r, i: •.l Yes No . . Jf; .•:�'.. -,'';; ,, . Backup of sewage into facility or system component due to an overloaded orclogged SAS or cesspool. ..: n r. n:. "_ .::Lit. Discharge or ponding of effluent to the surface of t,"ground.or,surface waters due to an overloaded or:,clogged SAS or cesspool. v.. . :......: .. .. :. ,. . . -. 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 Iswithin1001eet cf,a.,sur(ece water supply,or tributary to a'surface water supply.4,1 ' Any portion of a cesspool.orprivy is within a;2pnq I;of pa public weli,.,,J :,J ; r Any portion of a cesspool or privy is within.60;faet of a rlvete water u I well ?• a „ ` -t.. r .P l4 .PPY Any portion of a cesspool or pnvy,is leap than 100 feet 6ut.great0r thpn,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 cofiform bacteria,.volatile.orgenic compounds, ammonia.nitrogen and„nitrate.nitrogen..�J 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 10,000 gpd'or"greater (Large System).and the System is a significant threat to public - Health and safety and the environment because ona*ar mole of the following donditlons exist:-'^" Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply. the System is located in a nitrogen sensitive area(Interim Wellhead Protection Area•IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shell upgrade the system in accordance with 310,CMR 15.30412). Please consult the local regional office of the Department for further information. revised 9/2/98 Paget!oru ,i SUBSURFACESEWAGE,DISPOSAL.SYS.TER-LNSPECTION,FORM:,,-w PARTtB M q ,p�.. - R Address: �..: owner: 5�osnOt (t Date of Inspection- 61311 nspection l/`/� ( 6 ;k'err,,.to asci I'I Check if the following have been done; You must Indicate either "Yes" or "No" asap,each,of the following,;:, .. Yes Noi' .. Yf _ Pumping,information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system hps been receiving normal flow Tates during that period. Large volumes'of water have not been Introduced Into the system recently-or as.•part of.this Inspection: .. . .t ., ,� . » \.�.�''''.., t',.):..._.C�•i:e..'U:.< til 4444 _ ., 'rv'r 1. .: I4 , .. .. ,411,4 As built plans have been obtained and examined. Note if they are not available with NIA A � . es _ The facility or dwelling was inspected for signs of sewage backup. . . t The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. S All system components, excluding the Soil Absorption System,hays,baen locetad�on th},aIle Ye _ The septic tank manholes were uncovered, opened, and the Intortor of the septic tank was Inspected for condition of battles 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 hes been determined based on: , . .. .. _ . _ ILIO Existing information. For example. Plan at B.O.H utl4:s'.r, JAf tics: { roximetion,of,distanee.is unacceptable) Determined in the field lit any o1 the failure criteria related to,Part C 16 atJssue, app_ .a . `�, ♦'t"S` f `3;'t »,t?,ic , ..?•_ ;., ;,'•,4444 115.302131(b)1 . . _. __.. . _ _.._:: 1, . ._ _ The facility owner land occupants,It different from owner) were provided with information on the proper maintenaace.of SubSurface Disposal Systems. Y ?�•.. .o• d:++u r:osm:re c.na ro a,,:cGt 5:a4 �A try to .. _. .__ �'.. _. .. s � ,1n'.;¢':,tar .�.r' il Js ..•.l s b,.L,,t,:: a .. 444,4. . - . . .. 4444, 4444 ., _ .4.,rti .'J::-. . , ..v •r. 4444 ._. . 4_444. revised 9/2/98 Pages or it ,:r; SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM PARVCl''+ SYSTEM INFORMATION Property A"ddress: '`Pealer R' ,(- ! alio '�I + Owner: 5�1 C(,HbG (/' 1' t � - Date of Inapec/ti ROW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedro m. Number of bedrooms(design): Number of (actual):,` Total DESIGN flow 33 0 Number of current residents; Garbage grinder lyes or no):ILIV ''// - Laundry (separate system) (yes or no):,,-(1a1 If yes,separate Jnspectlon required Laundry system Inspected (yes or no) Seasonal use lyes or nol:&fQ0 Water meter readings, If a1v'a/li,e,bIs (last two years usage(gpd):�/lY7t�//// Sump Pump (yes or no): / Lost date of occupancy;JCM f0jed COMMERC(ALANDUSTRIAL: Type of establishment: ' Design flow: apd I Based on 15.203) Basis of design flow Grease trep present: (yes or no)— Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the;Title 5 system: lyes Or-no) .f`iu;e;•• -v�:;,!:':'ca �. .pit �:[;bwPa•.:; .;i+•. u..;:: :;,e::. �.' Water meter readings,if available: +„ Leat dere of occupancy: `e':: ,c � it ,� ..., cs:;,,a+, .:e,=, x,�c,Lw :.i" - r.cr: r.'t r.? ,•� ..' \ d): :.1. •...,..d uy"i: ,:9da;.0 0.nt5 ::. ... ..., OTHER:(Describe) "' :1:• c'zi c. '.est date of occupancy: GENERAL INFORMATION:..".. "c.� r:,.,,+ �.•• •: .. PUMPING KDS end source of rot7ationiA �wv .+ +.i• ',•:+ System pumped as part of inspection: lyes or no) If yes, volume pumped: gallons ' °' - -- - . Reason for pumping: TYPE OF SYSTEM" Septic tank/distribution box/soil absorption system �(L Single cesspool A& Overflow cesspool -Ale Privy ,/n 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 i/O Tight Tank Copy of DEP Approval _ Other APPROXIMATE AGE of all components, date installed III known)end source of information: 414) RerQCd Sawa le odors detected when arriving at the site: lyes or no) L+� revised 9/2/98 Page,6 of 11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM „ .PART C..' / - SY.STEM�INFORMATION,(continued). Property Addlrrress�s: qp ?.r P0 �Cl/!O Y`:l -;� .;.":rl .. ��-� •4 .i .. Owner: s ka pINN�o Gvv�� /�J ,..... Date of ImpactionICJ�K BUILDING SEWER: (Locate on site plan) u� �. :> >a u:'. .:•�C .-`' ... . ., .. Depth below grader Materiel of conatru tg'on:_cast iron_40 PVC other (epplaln) _ ..., 7-7, _ Distance from private water supply well or suction lirle _ Diameter Comments: (condition of joints, venting, evidence of leakage;etc.) - SEPTIC TANK: 0ocate on site plan) - rv' ^'.• b' "'� - " - Depth below grader Material of construction: _concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal.list age_ is age confirmed by Certificateof Compliance'_'IYealNol"'" _ Dimensions: Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle: . Scum thickness:_ // Distance from top of scum to top of outlet tee or bale, 7 /� . . Distance from bottom of scum to bottom of outlet tee or baffler How dimensions ware determined: V44'0- n!'G S!/✓l0 /s'1.6xi�p �� taH'K .. ___.. _. •" ' - Comments: (recommendation for pumpin , condition of'nlet an ou let tees or baffles, depth of liquid level In relation o outlet invert, structural integrity. evidence of leaks e, etc.) w .. ... .. Q._ ... J � GREASE TRAP: (locate on site plan) - 'J qr".'< Depth below grade:_ Material of construction:_concrete._metal_Fiberglass _Polyethylene_otherlexplainl 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 baffler Date of last pumping: Comments: (recommendation for pumping, condition of Inlet and outlet tees or baffles, depth of Ilquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7 ef11, SUBSURFACE SEWAGE DISPOSACSYSTEM WSPECTION FORM'"' PART C_' SYSTEM WFORMATION'Icartinued)"' YP�� r REQ Saev"t •A ' ` Property Ad as: l Owner: $ 0.vtoG�( - •.. . Date of Inspection: TIGHT OR HOLDING TANK:,(Tarik must be pumped prior to, or at time of, inspection) - (locate on site plan) .. ,. .� :: Depth below grade:_ J tl ^f Material of construction:_concrete_metal_Fiberglass Polyethylene=otheilex�taln) Dimensions: Capacity: gallons . . . ,. .. Design flow: gallons/day ' '-- Alarm present Alarm level: Alarm in working order; Yes_ No - Date of previous pumping: - - Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX;A/O - (locate on site plan) " AV Depth of liquid level above outlet invert: ' e Comments: - - (nota if level and distributionls equal, evidence of solids carryover; evidenceso/leakage Into or out of box,'etce) PUMP CHAMBER:, `.. (locate on site plan) Pumps in working order:(Yes or NO)_ " - `"`+"' `� ,l •;,c:; - Alarms in working order(Yes or No) - '- - - --• . _,. . _,__ Comments: Inote condition of pump chamber, condition of pumps and appurtenances, etc.) .. ., .. ., •.+w� .4 . . r.7 Yx67rC J F.i t J:,�'U 4 ✓;ry.0 P. ,i.•. ..,. revised 9/2/98 Page 8 of 11 ' - SUBSURFACE-SEWAGE'DISPO§AL'SYSTEMINSPECTIONFORM%2 PAfif C',I SYSTEWINFORMATION(coiitiim d) I t Property Address: gPefej­ Ad. S 4 40 Owner; shalloca _ .. . Data of Inspection �a SOIL ABSORPTION SYSTEM ISASI:—L/�- (locate on site plan, it possible; excavation not required,location may be approximated by non-intrusive methods) .'.4'JfL14 4, .. ... If not located, explain: Type: leaching pits, number:1 - leaching chambers,number:_ leeching galleries,number:_ leaching trenches, number, length: .- leaching fields, number,.dimensions: - ' overflow cesspool, number:_ Alternative.system: - Name of.Technology: Comments: (note a ndition of soil, signs of hydraulic failure, level of ponding, damp soil, conditon of vegetation, etc.) i O r n t1 n Ma same 5; CESSPOOLS:.dw 'I (locate on site.plan) Number and configuration: Depth-top of liquid to inlet invert: ', ! v Depth of solids layer. Depth of scum layer: - f Dimensions of cesspool: - 4 ' Materials of construction: Indication of groundwater: r' inflow(cesspool must be pumped as part of inspection) w _ Comments: p g; ditlon of-vegetation; etc.)--........-- - ..... .... _ ._._:._._. ._ .. _ .. (note condition of soil, signs of hydraulic failure, level ofondm_ `eon � _ •,-v PRIVY: (locate on site plan) Materials of construction: Dimensions:-- Depth of solids:_ , •J t , , '.1,'. h .. Comments: .- (note condition of soil, signs of hydraulic failure, level ofponding, condition of vegetation, etc.) revised 9/2/98 Psge9 or It 1 SUBSURFACE SEWAGE DISP.,OSAL;SYSTEM,IN�P,ECTION FORM .. SYSTEM.INFORMATIgN (co","). , Property Address: Ll Pe der-RJ 5C4 . owner: S1LanocQ Date of InspecUay .. / 91 .. i�.; . , ;.i,{q., ec xx.n .• r n,nr U tn,.'':i,., r :.n.. ..,re 'i r . . ,. .. . . r': . SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' ILocate where public water supply comes into house] - t �} � c3y I .13 .0 = 2I ,.7 rl T,dr^ _.. . ._ __ _. .. . F-p. 10, a r, C n nF ,E ItLu.,4exdel�rea revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATION(continued) Property Address: 41 Prier P • S a owner: S 6 n o& _ Date of knspection: / NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope S water heck Cellar Sh w wells Estimated Depth to Groundwater_Zest Please indicate all the methods used to determine High Groundwater Elevation: _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 Checked FEMA Maps /Checked pumping records Checked local excavators;installers Used USGS Data - Describe how you established the High Groundwater Elevation. (Must be completed) / P✓h�G� f G�1 in� �J��� 6t/� iGh CUGt S Oh `y c I n� j" 1', c G Of— 'A �4,p 6o f �► Frok �o 4,j,j, "6o Nom L q (r�/, do � L✓� It- I,\ 0a'\ ycn{ !✓1`S��Y' 11/ 7 fp (vlGt� 7. lei OF ¢..A.eI CL/5{0p-ted` bias h Pq Will +�t ��s� �-� � t�f is . esji*Italed t4W, bus 11 +ad WAG,`f�- 6F lzm ¢o too till) 9 Frow 4#, cCC �n iF aF�ei- ��r ;nr p p C . revised 9/2/98 Past 11 Or 11 r FORM 4 - SYSTEM PUNA' �G g� `[U� Commonwealth of Massachusetts �((RFviED Massachusetts MAY 2 4 1999 System Pumping Record ITYoy ALE HEADEPT. System weer System Location SAl If)k yvl-� Type: Emergency Routine F-1 Cesspool: No Yes ❑( " Septic Tank: No ❑ Yes Date of Pumping qQuantity Pumped: lr--klQ gallons System Pumped by (Company): 0 —TEP, Permit k: Contents transferred to: Contents disposed at: Date `S ��Pumper Sim atur no Condition of system/other comments: tJ ( sot)c, E Gtl�4i R PEP APPROVFD FOR\i-12/07/95 FORM 4 - SYSTEM PUMPING RECORD JUUNN 1 55 1998 IMI 1 C OF }{E H SALDEITY PT Commonwealth of Massachusetts Salem ,Massachusetts System P=Pinq Record System Owner: System Location: Mortin Shandk back yard 4 Peter Road Salem Date of Pumping: May 13, 1998 Quantity Pumped: 1500 gallons Cesspool: No /X/ Yes /—/ Septic Tank: No /—/ Yes /—X/ System Pumped by: Service Pumping & Drain Co., Inc. License # Contents transferred to: S.E.S.D Date: May 15, 1998 Pumper: M.F. This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Hoard of Health for regulatory purposes. tm Forest St. N FORM 4-SYSTEM PUMPINTG RECORD y� Middleton, 9 (508)774.27725� 1 ¢v�G Commonwealth of Massachusetts `y:� `�� . sgle-M , Massachusetts 'JUL S 1997 CITY OF:ALEM DEPT. System PUming Record System %%Ter �)C)P)04 l rho rC f o v) ystem ocauon Q�C g of i7gc/�>e n 3s� 6 0E-r- LcFf;Gor�^ �` 7ys� 60$� ZI 'C ° ° FF �5• Date of Pumping: Quantity Pumped:------ gallons Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes System Pumped by: License a;: ---- Contents transferred to: Date (O' cl — � 7 Inspector