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1 ELEANOR ROAD SEPTIC SYSTEM I DISPLAY PERMIT IN A CONSPICUOUS PLACE ON THE PREMISES City of Salem, Massachusetts I r ��. Board of Health 3 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 PublicHealth Iramdin@salem.com P'... P'.Mcl. Kimberley Driscoll pERC TEST PERMIT Larry Ramdin RS/RENS, CHO, CP-FS Mayor Health Agent Date: 8/14/2014 No. PT-14-1 Service Location: 1 ELEANOR ROAD Permit Fee: $225.00 Owner Name: ZALLEN ROY M FRANCES L Owner Phone#: ZALLEN ROY M FRANCES L Type of occupancy: Residential Typeof Work: Title 5 Review Work Description: Disposal System Construction Permit- Replacing Existing Septic Tank Perc Test Test 1 Test 2 Observation Hole No. Depth of Perc 0 0 Start of Pre-Soak ; End of Pre-Soak Time at 12" Time at 9" Time at 6" Time 9"-6" r' Rate Test Result Failed Failed ., Performed By: . Witnessed By: GRANTED WITH THE USUAL CONDITIONS Comments: Health Agent Call (978) 741-1800 For Inspection Commonwealth of Massachusetts City/Town of Salem Certificate of Compliance Form 3 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. This is to Certify that the following work on an On-Site Sewage Disposal System Important:When filling out forms ❑ Construction of a new system on the computer, ❑ Repair or replacement of an existing system use only the tab ® Repair or replacement of an existing system component key to move your cursor-do not use the return Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP): key. 14-1 July 30, 2014 � DSCP Number DSCP Date Roy ler Facilityy Owner 1 Eleanor Road Street Address or Lot# Salem MA 01970 Citylrown State Zip Code Designer Information: Name Name of Company Signature Date Installer Information: Milt Hamilto Preventative Septic and Drain Name Name of Company Signature Date Use of this system is conditioned on compliance with the provisions set forth below: No additional conditions The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. Larry A. Ramdin, Health Agent Approving Authority Signat Date t5form3.doc•06/03 Certificate of Compliance•Page 1 of 1 Commonwealth of Massachusetts City/Town of Salem Certificate of Compliance Form 3 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. This is to Certify that the following work on an On-Site Sewage Disposal System Important:When filling out forms ❑ Construction of a new system on the computer, ❑ Repair or replacement of an existing system use only the tab ® Repair or replacement of an existing system component key to move your cursor-do not use the return Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP): key. 14-1 July 30, 2014 D ffi DSCP Number DSCP Date Roy Zaller Facility Owner 1 Eleanor Road Street Address or Lot# Salem MA 01970 Cityrrown State Zip Code Designer Information: Name Name of Company Signature Date Installer Information: Milt Hamilto Preventative Septic and Drain Name Name of Company Signature Date Use of this system is conditioned on compliance with the provisions set forth below: No additional conditions The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. Larry A. Ramdin Health Agent Apyroving Authority L $ �ylr Signatuf� Date t5fonn3.doc•06/03 Certificate of Compliance-Page 1 of 1 1 Preventative Septic Services Experienced Title 5 Professionals Milton Hamilton Principal 338 Grapevine Road Wenham MA 01984 ] SEPTIC SERVICFB j 978-468-9001 office milton.hamilton@vedzon.net �preventativeseptic.com 978-815-6121 cell /GROUND LEVEL CLfnMoun w r MLET NN SG�E ' EAEFI.E .. SCUM I m ;Q _ OUM1Ef jj" flnFF1E o uQums w' n; SWDGE S TWO COMPARTMENT TANK 1 r� CITY OII SE.M. TNLi ss 1CHUSETTS BOARD()F HEALTH 7 20 WASIIItiGI oa S rRFr,r,4 Fr.00R PnblicFiealth Prevent Plo Hole.ProI¢l. Tna,. (978) 741-1800 FAX (978) 745-0343 ICIMBERLEY DRISCOLL ]tamdin(a,salem.com LARRY R,ANMIN,RS/RI?NS,CHO,CP-I'S MAYOR tAcr,N r Questionnaire for contractor repairing a distribution box On title V subsurface disposal systems: The following information and questions are for contractors asking to do distribution box repairs on Title V subsurface disposal systems: The State Environmental Code Title V: Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, 310 CMR 15.232 "Distribution Boxes", state the following: Trease fill in the blankspaces with the correct answer. 1) For all gravity flow distribution systems, a water tight distribution box designed to equal distribution of septic tank effluent to the distribution lines of the soil absorption system shall be provided between the septic tank and the soil absorption system. 2) The minimum inside dimension of the distribution box, regardless of material, shall be /L inches. The minimum wall thickness for reinforced concrete shall be inches. �ro2--�JY 3) The distribution box shall conform to the following design specifications: a) When the soil absorption system is to be dosed or the slope of the inlet pipe exceeds 0.08 per roa; ' an inlet tee, baffle or splash plate extending to JW / inch(es) above the outlet invert elevation shall be provided to dissipate the velocity of the effluent. b) The invert elevation of all outlets shall be equal to each other and located at least Z inches below the invert elevation of the inlet. The distribution lines leading from the distribution box shall all have the same invert elevation as determined by flooding the distribution box to the height of the distribution line invert after all lines have been sealed in place. If all inverts are not the same elevation, they shall be 's adjusted by filling with durable and non-deformable material permanently fastened to the line or reconstruction the lines until all inverts are the same elevation. c) Outlet distribution lines shall be level for a minimum of the first 2— feet of their length. There shall be at least one outlet for each effluent distribution line. d) Every distribution box shall have watertight cover or in the case of systems with a design flow greater then 2,000 gpd, watertight manhole with cover. e) Every distribution box shall have a minimum sump of (zp,— inches as measured below the outlet invert elevation. 4) 310 CMR 15.221, general construction requirements for al system components states... distribution boxes shall be constructed or set level and true to grade on a level stable base which has been mechanically compacted. If the component is placed in fill, proper compaction is required to ensure stability and to prevent settling; native ground with a CO inch stone base if otherwise adequate. The top of all system components including the septic tank, distribution box or dosing chamber and soil absorption system shall be installed no more than 34 inches below finish grade. Where site restrictions prevent compliance with this provision, a variance may be sought. Name: (print) /t-l/ — Date: Name: (signature) a Score: out of 10 Notes: 5 < Ir_ CITY Ol, SALLM, MASSACHUSETTS lu BOARI>()F.H EA I[1 120 WASHINGTON STREET,4"'FLOOR Public Health Preaenl.Pm nom Promct. T�.z.. (978) 741-1800 FAX (978) 745-0343 IQMBERLEY DRISCOLL ltamdinnsalem.com LARRY KANiDIN,Rti/RF.HS,CHO CP-FS MAYOR I IEAL'I ii AGENT Disposal System Construction Permit Permission is hereby granted to: /"«4-i r` /�P✓�r�fizC�7�c Qtz f� ani, E�� Name Name of Company Address jr City/Town State Zip Code to perform the following work on an on-site sewage disposal sysem: Construction Repair or replacement Repair or replacement of system components Facility Address Nl�'4 6i91?0 City/Town State Zip Code Owner Telephone Number Recrav�® JUL, 8 2014 CITY OF SALEM BOARD OF HEALTH The work to be performed is further described in the Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with the Title 5 and the following local provisions or special conditions: 71 All construction must be completed within three years of the date below. %J Approved by,---_It-.. Date Title ��� PEPIN PRECAST 59 Shaw.Road, Sanford ME 04073 Tel: (207)-324-6125 WWW. RPEPIN.COM A Division of R.Pepin&Sons Inc. 1500 GALLON MONOLITHIC SEPTIC TANK / PUMP CHAMBER 68" {..� 130" 130" 20"'dA 00%CRS O (av�a,�elE wtx is'mwn) _ 20" DIA COVERS TDPI 1 i I (TYP-) 1}A I I i / I 130" 68" L _ J 4' KNOCKOUTS M) PLAN VIEW 130" \\� 64" 67"W\Lid {�-- 130" 130" INLET I { OUTLET \ 68" � 1 tel' 64" LREINFORaING 3.SPECIFICATION4 �1.)CONCRETE 5,000 PSI AFTER 28 DAYS. RIB LEVEL 3'2.)CONSTRUCTION CONFORMS TO DEP TITLE V REGS. 3- LEVEL 3.)JOINT SEALED W\BUTYL RESIN. 4.)REINFORCEMENT PER ASTM C1227-93. 5.)INLET TEE SHALL EXTEND TO MID DEPTH OF THE TANK (TEES BY OTHERS) 130 6.)OUTLET TEE SHALL EXTEND TO 12"TO BOTTOM OF TANK CROSS SECTION A-A (TEES BY OTHERS) crpl,4cl Awl `7a SGA1c 6443 (70 VP L, 1 C: �Guy- ��}•Zo /�D/� D�^'G Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Eleanor Road Property Address Roy Zaller Owner Owner's Name information is Salem MA 01970 Jul 2, 2014 required for every Y page. City/Town State 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 form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Vincent Macdonald use the return Name of Inspector key. Rooter-Man rm Company Name PA, Box 471 Company Address Peabody MA 01960 City/Town State Zip Code 978 532 4744 #2048 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 is true, accurate and 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 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority '4 ✓�/¢< Ct2� July 2, 2014 Inspector's Signature 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. t5ins•3/13 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. w Property Address Roy Zaller Owner Owner's Name required for is Salem MA 01970 7-2-2014 required far every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out - forms on the computer,use 1. Inspector: - only the tab key to move your Vincent MacDonald cursor-do not Name of Inspector use the return key. Rooter-Man 40--h Company Name PO Box 471 Company Address Peabody MA 01960 rsrm City/Town State Zip Code 9785324744 2048 Telephone Number License Number B. Certification 1 certify 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 was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature 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. Rear rRDAae•17/D7 Mlle 5 W,l l Inspection Form:.Subsuff ce Sewage Disposal System•Pepe 1 W 15 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name tia reequirequired for Salem MA 01970 7-2-2014 o every page. City/town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described MR 1 . 03 r in 1 MR 15.304 xi t. n failure criteria nevaluated are in310C 53 0 3 OCexist. Any u e a ot indicated below. Comments: 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. Answer yes, no or not determined (Y, N, ND)in the ❑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. ND Explain: Y" 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 ❑ obstruction is removed EleanorROAm•12107 Title 501ficlal Inspection Form:SW urfaee Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 Eleanor Rd I Property Address Roy Zaller _ Owner - - —._- - Owner's Name informations required for Salem MA 01970 7-2-2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): [� distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: 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 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 EleanorRD.dw•12/07 Title 5 Official InsPat;wn Farm:Subsurface Sewage Disposal system•Page 3 0l 15 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name information is required for Salem MA 01970 7-2-2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 13 ® 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 El or clogged SAS or cesspool EJ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than 1h 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 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. EleanorRDAm•12/07 rtle 5 0Hcial Inspedon Farm:Suhsudane Sewage.Disposal System-Page 4 o115 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 Eleanor Rd. ` Property Address _ f Roy_Zaller.--_ OwnerOwner's Name . -- ---_ - ---- -- --- — -- --- --- - requinforma tifn is red for Salem MA 01970 7-2-2014 require every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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 El 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. Eleaw,RD.dm•12!07 Title 5 Official Inspection Porro;Subsurface Sewage D%poral System•Page 5 0 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments — 1 Eleanor Rd- Property Address owner — -- — -- OwneYs Name information is required for Salem MA 01970 7-2-2014 every page, Cityfrown State 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: 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? ❑ �1 ❑ Were as built plans of the system obtained and examined?(If they were not [Y available note as N/A) ® ❑ 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. ® El approximation 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)] o- Eleana De -12107 rite 5 0111noW Impaction F":Subskdwe sewage Dis wel system•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. P Property Address Roy Zaller Owner Ovmer's Name informations required for Salem MA 01970 7-2-2014 every page. City/Town State Zip Code Date of Inspection 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): 330gpd Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?(if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage not available 9 ( Y 9 (gpd)): Sump pump? ❑ Yes Z No Last date of occupancy: mid June 2014 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: Last date of occupancy/use: Date Other(describe): EloarrorRe.J -1=7 Me 5 Official Inspection Farm'Subsurface Sewage D6Pesal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy taller Owner Owner's Name information s Salem MA 01970 7-2-2014 required for every page. CityfTown Slate Zip Code Date of Inspection. D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: 51 years old. House was built in 1963. Were sewage odors detected when arriving at the site? ❑ Yes ® No EleenorRD.doc•12107 Title 5 Official Inspedon Form:Subsurface Sewage Disposal System•Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd- Property dProperty Address Roy Zeller Owner Owner's Name information is required for Salem MA 01970 7-2-2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): No evidence 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 ager year Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------- Dimensions: 8'x4'x6' Sludge depth: 9 Distance from top of sludge to bottom of outlet tee or baffle 21 Scum thickness 1-1f2" Distance from top of scum to top of outlet tee or baffle 21 Distance from bottom of scum to bottom of outlet tee or baffle 2 How were dimensions determined? Sludge gage and tape measure ElearmvRD.doc-171D7 Title 5 Official Inspection Farm:Subsurface Sewage Deposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zeller_____ Owner Owner's Name informations required for Salem MA 01970 7-2-2014 every page. Cityffown State Zip Code Dale 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.): No inlet Baffle. Tank is completely corroded through around the outlet. Tank is leaking, liquid level is very low. Inlet cover is paved over under the driveway and unaccessible. Tank walls are only 4" thick( H-10). The tank is not H-20 load rated (6"thick) to support vehicle weights. 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 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): Elean0 D.doc•1207 rtle 5 ORmiel1%PWron Fon,SubsuAece Sewage Dispmj System•Page 1D M 15 Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1 Eleanor Rd. Property Address - Roy Zaller Owner Owner's Name information is required for Salem MA 01970 7-2-2014 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 2"BELOW inverts 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.): Box is very corroded and leaking Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No EleanorRD.doc•12/07 Title 5 Ofcisl Inspection Fonn:Subsurface Servage Disposal System•Page 14 of 15 c Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name information is required for Salem MA 01970 7-2-2014 every page. Cttyfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ Teaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2,49' & 10'+ ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativetalternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of any problems. Used camera to view and plot lines. They were clear. Could only get the camera out 10' for one line. It turned to the right and probably runs parallel to the other line. ElearwrRDAoc•12107 Tale 6 Official Impectim Porn:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller. Owner Owners Nemo informarequired for Salem MA 01970 7-2-2014 required for every page. Cityn'own State Zip Code Date of Inspection D. System Information (cont.) 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 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.): EleamrRD.don,•12/07 Title 5 Official Impaction Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name ° quires for Salem MA 01970 7-2-2014 on is req°fired for every page. Cdyfro" State Zip Code Date of InspWion D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. C-LEAXO � Rdl ��1"CtQt 1 g-� PAVED � SEM A,4r/D WAY � 0= 0 - 8ox c 0 A - c = 50 .3 ' A -D = 6-1 `6" FJeMWRD.tloe•1zW 7100 5 Offdel hsps M ram:Subsufxe Sffi' (;e DllpoW System-Page 14 of 15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zeller Owner Owner's Name information is required for Salem MA 01970 7-2-2014 every 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: 6 feet 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: The only information available for this property are pumping records. ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database--explain: Found no information for this area. You must describe how you established the high ground water elevation: The basement does not have a sump pump and shows no signs of ground water entry. Spoke with neighbor across the street at 2 Eleanor Rd. and he states that he does not have a problem with groundwater entering his basement. Checked catch basin in front of the house. Water was 6 1/2' down,with a noticable stain on the side 6down. I ElemmrnDA.•12107 Tine 5 Official Inspection Finn:Subsurface Sewage Dispamal System•Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name information is required for Salem MA 01970 7-2-2014 every page. Clty/rown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always 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 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Answer yes, no or not determined (Y, N, ND) in the ❑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. ND Explain: YObservation 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 ❑ obstruction is removed EleanorRD,doc•12107 Me 5 Otfnal Inspection Fon:Subsurtace Sewage Dspmal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name information is required for Salem MA 01970 7-2-2014 every page. City/town Slate Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): Ydistribution box is leveled or replaced NO Explain: ❑ 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 ❑ obstruction is removed NO Explain: 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 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. EleanorRD.doc•12107 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name informations required for Salem MA 01970 7-2-2014 every page. Cityrrown Stale Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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: Y Pp Y You must indicate "Yes" or "No" to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool E] ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool E] ® 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 ''Y2 day flow E] ® 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. F1 ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. EleanorRD.doc•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 or 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name informations required for Salem MA 01970 7-2-2014 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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 El El 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. EleanorRUcloc•12107 Tile 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. Property Address _Roy Zaller Owner Owner's Name information is required for Salem MA 01970 7-2-2014 every page. Cdy/Town State 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: 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? EJ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑4 1❑ 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? ® ❑ 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)] EleanorRD.doc•12/07 Tdle 5 Offxial Inspectlon Form:Subsurface Sewage Deposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name information is Salem MA 01970 7-2-2014 required for every page. Cltyrrown State Zip Code Date of Inspection 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): 330gpd Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d not available 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: mid June 2014 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: Last date of occupancy/use: Date Other(describe): EleanorRDAoc•12/07 rue 5 Official Ins I>eLdmt Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name information is required for Salem MA 01970 7-2-2014 every page. Clty/rown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 51 years old. House was built in 1963. Were sewage odors detected when arriving at the site? ❑ Yes ® No EleanorRD.dm•12107 Tdle 5 Official Inspection Fonn.Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name information is required for Salem MA 01970 7-2-2014 every page. Cityrrown Slate Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage. Septic Tank(locate on site plan): Depth below grade: 1 feel 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 - --------------------------------------------------------------------------------------------------- ------ Dimensions: 8'x4'x6' Sludge depth: 9 Distance from top of sludge to bottom of outlet tee or baffle 21 Scum thickness 1-1/2" Distance from top of scum to top of outlet tee or baffle 21 Distance from bottom of scum to bottom of outlet tee or baffle 2 How were dimensions determined? Sludge gage and tape measure EleanedtD.doe-12/07 Title 5Ofktal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owners Name informal fo s for Salem MA 01970 7-2-2014 every page. City/Town 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.): No inlet Baffle. Tank is completely corroded through around the outlet. Tank is leaking, liquid level is very low. Inlet cover is paved over under the driveway and unaccessible. Tank walls are only 4" thick( H-10 ). The tank is not H-20 load rated (6"thick) to support vehicle weights 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 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): EleanorRD.doc•12/07 Title 5 Mist Inspection FormSubsurface Sewage Disposal System•Page 10 or 15 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name information is required for Salem MA 01970 7-2-2014 every page. Citynbwn State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 2" BELOW inverts 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.): Box is very corroded and leaking Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No EleanorRD.doc•12107 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owners Name information is required for Salem MA 01970 7-2-2014 every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2, 49' & 10'+ ❑ 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.): No signs of any problems. Used camera to view and plot lines. They were clear. Could only get the camera out 10' for one line. It turned to the right and probably runs parallel to the other line. EleanorRD.doc•12107 Title 5 Official Inspection Fon:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zaller Owner Owner's Name informations required for Salem MA 01970 7-2-2014 every page. City/town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): ElearwrRD.doc•12/07 Title 5 Dffeial Inspection Fonn:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 Eleanor Rd. Properly Address Roy Zeller Owner Owner's Name requiration is Salem MA 01970 7-2-2014 required for every page. Cayfrown State Lp Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. ELEA*OA Rd► �Rrel 1> 3: PAM WE- � crrMeA - PAr/D WAY . C= TA�h G�C9"G�T' h= 0 - 80X c 0 A - c 5-o3A -D = El /6'' a -- 018 '6" 8 _ DA' 18/ MeamrRD.dw-1207 TiOe 5 Oifidd 4opecUur Fam:Suoawreca Sewape Dlsposel Syamnl•Pap 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Eleanor Rd. Property Address Roy Zeller Owner Owner's Name informations required for Salem MA 01970 7-2-2014 every page. City/rown 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: 6 feet 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: The only information available for this property are pumping records. ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database-explain: Found no information for this area. You must describe how you established the high ground water elevation: The basement does not have a sump pump and shows no signs of ground water entry. Spoke with neighbor across the street at 2 Eleanor Rd. and he states that he does not have a problem with ground water entering his basement. Checked catch basin in front of the house. Water was 6 1/2' down, with a noticable stain on the side 6'down. EleanmRD.doc•12/07 Title 5 ficial Inspection Fenn Subsurface Sewage Disposal System•Page 15 or 15 Commonwealth of Massachusetts _ Form 4--.System Pumping Recordt0u FO)d!s AA ° %t: .t Massachusetts . iq.ai3l:r.y •sta t .:- '�' 't( - -. . , System.Pumping'Record a,, ...• rtit ._ .tI >5 chiv.may G➢^tlx L� .at." " •. ->' '+..: . i• . c«. - ;"E icY .a]l•.l V-Irl .• r,. SystemtOwier-T AR (oust reaehedu System Location - Zallen Roy Primary Home 1 Eleanor Rd 1 Eleanor Rd Salem, MA, 01970 Salem, MA, 01970 (978)-745-0752 x (978)-745-0752 x I Zallen Roy Type: Emergen Routine 1 1 FFCesspool: UX Ko �/ Yes !1�? Septic Tank: No � Yes (Date of Pumping. 9.97 �.t7 "•.r ;`'�` iy,:'fig. 6 ..,j rQudntity Pumped:' I SOO 7; Gallons, •' "' ' - System Pumped By: Wind River Environmental,LLL ,,;.F,.,,.,#.., - Permit#: 09/29flilio 4? Contents Transferred to: M• '+ .'t lC _ __... :X,11 �.. •� -� t: ..P r7�j llt tyyl l .. . . • •_,r f ."i ttyrt ` " l r 4 Y Contents Disposed at: - qe Date: Pumper Signature: Condition of System/Other,Comments w' !7E.+iV l(,. �'.Ta w. '�.. � L.:1 1� -T� , `.{S �!«� ♦ w+ Jr r• ��. C• 1 Y -� ® Pom d..=ydM cr - , Dep Approved Form-12/07/95 k ' ,. it � � •. y - J � ,r .. ... .♦ .n .. y .^f • �Y4 .�L • 4� ..ori • $L.�e J . . }i l✓ �l v 7Ofo _ f Commanwealth of Massachusetts:' Form d system Pumping Records a^!ev Lr s. MassachusettsnoMLOF zir. , lit s System Pumping Record 01 System Owner System Location Zallen Roy Primary Home 1 .Eleanor Rd 1 Eleanor Rd Salem, +MA', 01970 Salem, MA, 01970 (978)-745-0752 x (978)-795-0752 x Zallen.Roy Type: `Emergenc Routine Cesspool. •No, Yes Septic Tank: t`�' No Yes 1 Date of Pumping:, - P 9 Q aq O r Quantity Pumped: 1000 Gallons 7• :. . � . z ; 'i.�='` r-7.=fi '-�T' 2�.."^`-^ '-V . :- -:—.a-^,�'.rVr +System Pumped By' Wind River Environmental,LLC 'Permit# !Contents Transferred to �" • " r ' • .j Sy t Puraf y Conte'CCAA- nts'Disposed at: • .t t r t Date: Pumper Signature: r R :Condition of System/Other Comments^ -^-� -t.- - ->^�- _ -�_ -•-- •'-•� -- _- a _ _- y r } a ' Wig . "i` ~ {• �I 0 • SO4 f � r RinlcJonrtgdNpaper , - Dep Approved Form-12/07/95 -. - - _ - - l # ; y3�0222024234 Y 10/15/2001 ie •• Commonwealth of Massachusetts ,r Form 4;-System Pumping Record i s e .t• .� ., MaSSaChu5ett5 r System Pumping•Record •" p System Owner, System Location Zallen Roy Primary Home 1 Eleanor Rd 1 Eleanor Rd Salem, MA, 01970 Salem, MA, 019,70; (978)-745-0752 x - (978)-745-0752 x Zallen Roy .. _.. (TYPe Emergent Rauti'ne� �• a .;:. +s e Cesspool: Na Yes r Septic Tank " ,' No Yes�� ' i I Date of Pumping: + ��- 3-�R` - _ r Quantity Pumped:' .Gallons 1 System Pumped By: Wind River Environmental,LLC . ' ` Permit# Ji r Contents Transferred to: I r . f . ContentsDiPd t: 9C6 [0 VIN sos ea r PSWI C h Water W - a - lurid RMUle -L Ipswich, MA 01938 , ) �. 4 " s f' r ' Dater Pumper Signature x ,r •''' 1 yrCondition of System/Other Comments � - r rpt .•rte r r T `rr �• �. +�._� a 1 �.4 ; . ' a •t'1 Dep Approved Form-%2 07/95 h S I ` a • t � i r li T n -4' '� a..�x• '��-L-�1 Tom+';-f _ ..... . _ . - t sri i tj lef y, a �EVS1:fr8i� . Es�rt . "r AM ,r4:•l�^ 8q.1 cm I N L _ rm: co 5 ^•7 lieu W? '•I�r C� +�7. •.`�aiii ..j: l..""�.1 �',.rfly" .'Nn ' ,,tee o�• ^_ . y.; — - _ a aa11617.0011' Commonwealth of Massachusetts Form a--system Pumping Record,,,.. _ Massachusetts System Pumping Record System Owner - System Location Loca'tion - T.alle+i Roy Primary Home .1 Eleanor Rd I Eleanor Rd ;Salem, MA, 01970 Salem, MA, O'197Q . ;(97k3},745-0952•x (9'/8)-745-0752 'x' Za1-len .Roy. -Type: Emergen 'Routine. •-Cess ool ;'No • e, ,.'Yes - .z ' p �. +� _. ._ Septic Tank: No YesQ Date of Pumping: �. Quantity Pumoed:- S Oa- --Gallons 1 - - -• . ;System Pumped By: ' '.Wind River Environmental,LLC Permit#i Contents Transferred to: + v ` Contents Disposed at. 1 X• .Date: O, Pumper Signature: Condition of System/Other Comments ' ' •i RTCOVEU ' DEC 102007 } CITY OF SALEM SOD ` •BOARD.OF HEALTH, c � Dep Approved Farm-'12/07/95 , •_-Form 4 --System.lko prg Record . CommnmiweaK of Mossachusetss p ' Massadusem • System Pumoim Recoil N {• �� DEC 0-20 10CIT VVV System Omer.. _ System U=twn OF - •SCI Z/a.U, Roy - Primar,r -No:aa HEALTH ,• .. el 1 Ble,.nox Rd 1 Bleaq.oc Rd Salem•, KA, 03970 Salem, 'M., O on r (978)-745--0752 x (978)-745-.0752 x Frances ryPe° m 'Routirc - Cesspool: No - Yes - Septic funk: w , Yes �. Date of Pumping: 13 f Qua" Pumped: 50 ecll'= ' System Pumped By: Wind 0Envuvmm fvl, LLC - - Permit#: - - ,Cmrtorts transferred to: •-r.; •y`. - . i Contorts Disposed at: _ � .✓� . y Date: - —� 1:�� �b,- ..PAW- S : - • - Condition of-Systewother Ca moons Dep Approved Form - 12/07/95 Fara 4 --`Systaln Pumping Retm`d •. :4 - Commonecalth of Mas3aohusetss L - a Massoahusem �• t` + Srstem pumeina Record •'' r ✓ ': f' r c r System 0%mer -!' ' System Location t k' Roy Zallen .r ♦ r Roy_ ,., ' ... i1`•r �� 1 EleaiorRoad 1 EleanorRoad J T; - Salem. 14A 01970 t- r Salam, MA -:01970. (978) 745-0752 (978) 745-0752 F f, •rl ry i Type: Emeryenry Routine • ! .; •. r .,T ♦ r 4 Cesspool: Pb Yes - ♦�_'^' •.` -.. Septic tank _ No Yna't Date Of pumping: �..{ O , t -� '.Qumrtity Pumped:'% O O Gallons System Pumped By: Wind fti r Enrummental•LLC per4wt Jt •'Y Contents transferred to: I. Contents Disposed at: t S ♦ n , ' r . Date: s V 1 Pumw Symtwe:. � Condition of System/Other Comments - " �• - • r , ,- Y\'. ..' +. • • `W 1 -A Dep Apprved from - 12/07/95 i