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4 ELEANOR ROAD - TITLE V INSPECTIONS + SYSTEM PUMPING RECORDS nnnryntnn.e A.r not,l mnol Commonwealth of Massachusetts Form 4--System Pumping Record 6 Massachusetts System Pumping Record System Owner System Location Thomas Kathleen Primary Flome 4 Eleanor Road 4 Eleanor Road Salem, MA, 01970 Salem, MA, 01970 (978)-744-5343 x (978)-744-5343 x Thomas Kathleen Type: Energen Routine Cesspool; No yes Septic Tank: No yesri Date of Pumping: Z - U - Quantity Pumped la6lo Gallons System Pumped By. Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Date: Pumper Signature: / Condition of 5ystem/Other Comments �Y> MA, Deb Aobreved Form-12/07/95 OT/00 39dd ?EAIJQNIM 6990THB9 G 91:EZ VTOZ/6Z/ZT 1 ............... nn,a aennnn Commonwealth of Massachusetts Form 4--System Pumping Record 0% Massachusetts System Pumping Record System Owner System Location Thomas Kathleen Primary Home 4 Eleanor Rd 4 Eleanor Rd Salem, MAA, 01970 Salem, NW, 01970 (978)-744-5343 x (9"18)-744-5343 x Thomas Kathleen Type: Emergenc Routine Cesspool: No Yes Septic Tank: No Yes Date of Pumping: - 0�-1- 10 Quantity Pumped: IC700 Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments ® Primed an recycled parcr Dep Approved Form-12/07/95 Form 4 -- System Pumping Record Commonwealth of Mlassachusetss Mlassachusetts System Pumaing Record system Owner System Location Rose 'Vea:t.te pciiodry Home "> N;" m„rr Rd 4 Bieenor id 5alF--I, M0, 419"7i1 MA, 01970 'M 74' 5458 x 9781 =Q4 -1958 % Type: Emegercy Routine Cesspool: w Yes septic tank: w [::]Yes Date of Pumping: Quantity Pumped: /ek2pSalkms System Pumped By: Wind River Envo w/menta/, LLL' permit A: Contents transferred to: Contents Disposed at: i Date: pumper signature: Condition of system/Other Comments Dep Approved Form - 12/07/95 CommaForm 4 -- Sy mveakh of Mossachuttfss : Massachusetts System Pumaina Record SEP 2 3 2002 CITY OF SALEM BOARD OF HEALTH Sysfem Owner System Location Annette 'rhact 'y Elcznm. vi-anor Fi.i Eleanor Rd MA a"+ a16a MA 01170 9191 -744 59SB t Type: Emergency Routine Cesspool: No Yes Septic tank: No Yes Date of Pumping: O�j— Qua" Pumped: Salons System Pumped By: Wild AMw Envmomental, LLC Permit#: Contents transferred to: Contents Disposed at: �SES— Date: Pu rc: Condition of SysteWOHrr Comments Dep AA"ved From - 12107195 E. FILE#, Q A L O Q A TITLE V INSPECTIONS Dean G. Luscomb II & Sons Y� P.O. Box 135 a Middleton, MA 01949 978-774-4065 Licensed Plumber#20285 b � SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM � i PROPERTY OWNERS NAME D Cl h -' Dnp Q h P_ P( P r C'e PROPERTY ADDRESS 4 E I e Q h o r R d Eal2M MA n 4, ADDRESS OF OWNER(if different) (��VQIIeV Pd JOIDS e.)d MA DATE OF INSPECTION A j, r O ) 0�� 0 07 NAME OF INSPECTOR DE D (3; L US C D h-) h 1L_ I t o QUALITY IS NUMBER ONE TO US RECEIVED APR 132001 d CITY OF SALEM BOARD OF HEATH COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a DEAN G. LUSCOMB II & SONS P.O. BOX 135 MIDDLETON, MA 01949 1-978-774-4065 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:4 E j eO n or Ra Owner's Name:Dg0rne n i�rC RECEIVED Owner's Address: '�MP Date of Inspection: r I t APR 13 2007 Name of Inspector:(please print) Dean G. Luscomb II CITY OF SALEM Company Name:Dean G. Luscomb II & Sons BOARD OF HEALTH Mailing Address:p_0_ Box 135 . MirlAlPtnn, MA 01949 Telephone Number: 978_774-4065 CERTIFICATION STATEMENT I certify that 1 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: V Passes _ Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 49QA Date: rc' 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. Notes and Comments ****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. 1 Dean G. Luscomb II & Sons P.O. Box 135 ' Page 2ofII Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 EI eRhDr !SU QICm, Owner:p l e rCf' Date of Inspection: - I Inspection Summary: Cheek��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. PThe 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: NObservation 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 distribution box is leveled or replaced NOexplain: 0 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 pipets)are replaced obstruction is removed ND explain: 2 Dean G. Luscomb II & Sons Page 3 of I I P.O. Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: l' CQY1CUr rid S(2Ie .MA Owner:.r iGrce Date of Inspection: o. - 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: L 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. A) The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. NThe system has aseptic 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other- 3 Dean G. Luscomb II & Sons P.O. Box 135 ' Page 4ofII Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: q E )e onor Rd n SctlQmt YY1fl Owner: IJ I e Y C Z. Date of Inspection:—4- 1 "] D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No /J 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 A ' cesspool _ 1�e Liquid depth in cesspool is less than 6"below invert or available volume is less than-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. _d 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 I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma CJD (Yes�Noo 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• " You must indicate either"yes"or Ito"to each of the following: (The following criteria apply to large systmPaddition to the criteria above) yes no / the system is within 400 feet of a surface =urfa r supply i the system is within 200 feet of a tributary tri i g water supply _ the system is located in a nitrogen sensitive a nterim Wel d Protection Area-I WPA)or a mapped Zone It of a public water supply well If you have answered"yes"to any qu on in Section E the system is considered a signi�Cthreat,or answered "yes" in Section D above the lar system has failed.The owner or operator of any large system considered a significant threat under See ' n E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system ow r should contact the appropriate regional office of the Department. 4 Dean G. Luscanb II & Sons P.O. Box 135 Page5of11 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 'f 7� CHECKLIST Property Address•'? E I CO nO f Rd Owner: Pic f Ce Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No V _ Pumping information was provided by the owner,occupant,or Board of Health f 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'? Yv' 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? V1 1 _ Was the site inspected for signs of break out'? Were all system components,excluding the SAS,located on site? _jZ _ 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: zYe no _ _ 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)[3 10 CMR 15.302(3)(b)] 5 Dean G.Luscomb II & Sons P.O. Box 135 Page 6 of I I Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:`Y E e.Q h r SCI _ Owner: 1'"I e rce Date of Inspection: FLOW CONDITIONS RESIDENTIAL 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): 3 oq�l Number of current residents: 6) Does residence have a garbage grinder(yes or Qpb Is laundry on a separate sewage system(yes or(o : A-6[if yes separate inspection required] Laundry system inspected(yes or 0106 Seasonal use:(yes or Qo)&)0 Water meter readings, if available(last 2 years usage(gpd)): " Sump pump(yes o mo . IUD Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(6led,on 310 CMR 15.203): Basis of design flow s�"6ats/ ersons/sqft,et Grease trap present(yes or no . Industrial waste holding to resen or no):_ Non-sanitary was ' c arged to the Title tem(yes or no): Water meterfeadings,ifavailable: — Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records /0 Source of information:, t t bpm �e,x .}S G�GiQ Was system pumped as part of the inspection(yes oKgD_ I If yes,volume pumped:_gallons--How was quantity pumped determined? �Y1e45U Q4 1 ;S Reason for pumping: No lLl�rtr c<i {G, S $& v F TYpt 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): Appp5unate age of alt compone s date installed if nown)and source of information: �o4ie �Yb° !/ParS Q� Sit « Ai' C+ t(� trfG Were sewage odors detected when arriving at the site(yes o no A)b 6 Dean G. Luscomb II & Sons P.O. Box 135 Page 7 of I I Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:4 Eleanor Rd nn �Q12rY> hnfl qq� , Owner: I'"i erCe a d 7 Date of Inspection: tv4 I r) -Q BUILDING SEWER(locate on site plan) /E3" >i Depth below grader Materials of construction:.cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(yyn condition ofjoints,venting,evide a of leakage,F ('�,t"t' .Lro� t,✓ N� �4a�tAprrrb�:�tS SEPTIC TANK: /6(locate on site plan) d Depth below grade: � Material of construction: ✓concrete metal fiberglass_polyethylene _other(explain) Pca.r ROitKF ,�HL�,c,k< If tank is metal list age: .)A Is age confirmed by a Certificate of Compliance(yes or no):N-A(attach a copy of certificate) 1 Dimensions: E� Sludge depth �r Distance from top of sludge to bottom of outlet tee or baffle: 33 Scum thickness: <I" ^11 Distance from top of scum to top of outlet tee or baffle: 55 Distance from bottom of scum to bottom of outlet tee or batfle:1 How were dimensions determined: ay A'skS CSra rae% vEG r&tf C Comments(on pumping recommenda�ns,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence pf lgakaptc.): p t Sr�r�tic Ta tC aa �oph Y9crff(n5 CurQ in4ppod .c�rler'a � rloC< 1"u'oh 7�,.• di t�s,�t, in 'r 'A ;s r"iAfnnjA4 c' if-i GREASE TRAP:,0(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other% (explain Dimensions: / ns: Scum thickness: Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet t affle: Date of last pumping: ... , Comments(on pumping recommenn at ns,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, of leakage,etc.): 7 Dean G. Lusoornb II & Sons P.O. Box 135 Page 8 of I I Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:4 u e-Q r) 'r d Owner: ier Date of Inspection: 4- ((7' U?— TIGHT or HOLDING TANK: PO (tank must be pumped at time of inspection)(locate on siteplan) Depth below grade: Material of construction:"_concrete metal_fiberglass o!yetH ene other(explain): Dimensions: "°"^*•.,,,,,+ Capacity: gallons Design Flow: gallons/da Alarm present(yes or no): Alarm level: Alar�m„in orking order(yes or no): Date of last pumping:,,✓` Comments(condition of alarm and float switches,etc.): �! DISTRIBUTION BOX:YES (if present must be opened)(locate onsite plan)`,1J-rya Y, i S 4� Depth of liquid level above outlet invert: Ze'v u 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.): L \ � J�IWQr"I W f Yb-Rol is 1 dyf Sol M Y-/Vs- arEG79 BlGCl+ Zn� f5'0S nw�i✓X; ,O/'�/'C.�'�©Gt� PUMP CHAMBER:t=(locate on site plan) . Pumps in wbTkin&order(yes or no): Alarms in working or er yes Lao.: Comments(note condition of pump cTaltlber ndi�,gf n of�ptffhps and appurtenances,etc.): 8 Dean G. Luscomb II & Sons P.O. Box 135 ' page 9 of I I Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMS INFORMATION(continued) ICA.1 PropertyAddress:7 peanpr JQoJr iiy-, hiA Owner: y-tiz Date of Inspection: r SOIL ABSORPTION SYSTEM(SAS): eS(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: leaching fields,number,dimensions: �,p,roN.. SizQ Sr'ao4.✓+'t overflow cesspool,number:_ ' _innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc. : r sc�� C( �a� u.Al �w d St7 GG - _ CESSPOOLS:N O (cesspool must be pumped as part of inspection)(locate onsite plan) Number and configuration: Depth-top of liquid to inlet invert: �� Depth of solids layer: Depth of scum layer: Dimensions of cesspool: w Materials of construction: Indication of groundwater intleoi(yes or no): Comments(note conditioriof soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: 1,b(locate on site plan) Materials of construction:Dimensions:sol / Depth of solids: ,i/ Comments(note condition of soil,signs-4hy,^d�rauuliicc fajlu�evel of ponding,condition of vegetation,etc.): `... 9' Dean G. Luscomb II & Sons P.O. Box 135 'Page 10 of II Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: '�E leo t-) Y d a 19-bo } 1 Owner: PI rC.e Date of Inspection: q- 10 -07 SKETCH OF SEWAGE DISPOSAL SYSTEM ge disposal s stem includinRties to at least two Pertr,anent refere{ce lapolllarks_oC___.__,..___, Provide a sketch of the sewa __— benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. av A CuYrg A3`I0 T ` 17/ 26 Xz !& a 30 r D 10 Dean G. Luscanb II & Sons P.O. Box 135 Pagellofll Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ele q.nD( Rd a '111 Owner. f e r :p Date of Inspection:T 'ED ITE EXAMp Slope ✓ urface water A)aw.:.. " Check cellar Dr'j h10 5w'p pk, p ✓Shallow wells /Uohc Estimated depth to ground water — feet Please indicate(check)all methods used to determine the high ground water elevation: V/,Obtained from system design plans on record-If checked,date of design plan reviewed: /Ud pcwlz�s- Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: 1W Recor Cf S Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: e?J�Zei4. 04 W, 11