6 ELEANOR ROAD l e a,vo� ��a d
Preventative Septic and Drain, L.L.C.
338 Grapevine Road 978-468-9001 (Office)
Wenham, MA 01984 978-356-9005 (Fax)
December 24, 2012
Salem Board of Health
120 Washington Street.
Salem, MA
To whom it may concern:
Enclosed you will find the completed Title 5 Inspection report for 6 Eleanor Rd, Salem MA.
Dennis Zielski,the owner has requested that all correspondence regarding this report be
mailed to:
Dennis Zielski
29 Grimstone Drive
Belmont,NH
03220
If you have any questions please call me directly at 802-839-8165.
Sincerely,
Jonathan Granz
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
OwnerOwners wme -
Information is Salem MA 01974 12/13/12
required for -
every page. CitylTown 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 A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Jonathan Granz _
cursor-do not
Name of Inspector
use the return
key. Preventative Septic and Drain LLC
-company
327 AsburySt.
Company Address
Hamilton MA 01982 _
CityfTown State Zip Code
978-468-9401 S113405
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
G' 12/24/12
Inspe o i nature Date
Th oil
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.
t51ns•11110 Title 6 Official Inspection Form r Subsurface Sewage Disposal System•Page 1 of 1
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. Cityfrown 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is working properly.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass' section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
Sms•11110 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection FormSubsurface Sewage Disposal System•Page 3 of 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
_ 6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. CitylTown State Zip Code Date of Inspection
B. Certification
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
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
E] ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y:day flow
t5ins•11110 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 4 of 4
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner
I Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. City/Town State Zip Code ate of Inspection
B. Certification (cont.)
Yes No
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.
❑ ® 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.
El ® 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.
El ® 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,9 Y Y Y o g, 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.
t51ns•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name .
information is
required for Salem MA 01970 12/13/12
every page. City[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?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
1:1 El available
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?
® El information
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;he 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): n/a - Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a
(Sins•11/10 Title 5 Official Inspection Form.Subsurface Sewage Dispose System•Page 6 of 6
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
c'
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
System is composed of a 700 gallon septic tank, distribution box and four leaching trenches.
Number of current residents:
2
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 : 75.7 GPD
( Y 9 (gp ))
Detail:
Water meter readings were provided by the Salem Water Department, GPD was averaged from
usage between 10/13/2010 through 11/1/2012 750 days usage (See attached copies).
Sump pump? ❑ Yes ® No
Last date of occupancy: current
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:
t5ins-11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 7
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is Salem MA 01970 12/13/12
required for
everypage. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: last pumped Fall of 2012, per records.
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) 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):
t5ins-11110 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. City/Town State _ Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
House was constructed in 1963, system assumed to be original.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20
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.):
Building sewer is in good condition, no signs of back up, leakage or any other problems. The line is
constructed of cast iron on the interior of the foundation wall and SCH40 PVC at the septic tank.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 7' round, 4' Deep Effective
Sludge depth: 3
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
—„ 6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 31"
Scum thickness 0
11
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 14"
How were dimensions determined? Tape measure/Sludgeoludge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition, structually sound, no signs of leakage in or out, liquid level at outlet invert,
there is a PVC "T" in place on the outlet, no inlet baffle present.
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
t5ins•11110 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 10 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
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.):
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
t5ms•11110 Title 5 Official Inspection Form'.Subsurface Sewage Disposal System-Page 11 of 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. City/Town State Zip Code Date of Inspection
D. System Information
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert o
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.):
Distribution box is new, there are no signs of solids carryover, no leakage in or out. Outlet inverts are
36" below grade, there is a riser bringing the top of box within 12" of grade. Speed levelers are
present in each of the four outlets.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12
Commonwealth of Massachusetts
-r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2 @ 2@ 12'
❑ 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.):
Ground over leach field is dry, grassy and consistant with the surounding yard. There are no signs of
any failure. All four leaching trenches were inspected with a camera to verify length and condition,
there are no signs of failure.
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
t5ins•11110 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 13 of 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. City/Town State Zip Code Date of Inspection
D. System Information
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.):
t5ins•11110 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 14 of 14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
tains•11110 Title 5 Official Inspection Form'.Subsurface Sewage Disposal System•Page 15 of 15
Commonwealth of Massachusetts
_ r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. City/Town 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: feeetet +
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 5
Date '
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Soil testing was performed on 3/2/05 at 1 Peter Road"(abutting property) by Edward Cullen and
witnessed by Martin Fair, there was no ESHGW found at 121" (see attached copies). This
information puts the system at 6 Eleanor Road well above the ESHGW.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Vans•11/10 Title 5 Official Inspection Form'.Subsurface Sewage Disposal System-Page 16 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Rd.
Property Address
Dennis Zielski
Owner Owner's Name
information is
required for Salem MA 01970 12/13/12
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ms-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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EVALUATOR. EDWARD CULLEN
WITNESS.' MAR77N FAIR FAR THE SALEM BOARD OF HEAL TY
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PERFORMED BY ME CONS/Smw Wl7H THE REQUIRED
7RAINING, EXPER77SE, AND EXPERIENCE DESCRIBED IN 310
CMR 15.018 (2).
SEE SOIL SUITABILITY ASSESSMENT REPORT
ON FILE WITH THE BOARD OF HEAL TTI
EDWARD CULLEN, CER77RED SOIL EVALUATOR DATE
VOICE (978) 777-3050, FAX (978) 774-7816
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PROPERTY UNE PfEPARM FOR
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PAW OR TRAIL I PETER ROAD
• • , Q��f�niNG. UGHr, STEPS & OVERHANG SALEM MA 01970
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07 012012 752••343 A 3042400 900 .. 0 92
04!1912012 729115 A 103300 900 n 97
01113/2012 7136119 A 1025ur! 800 0 66
10/1`!,2011 698941 A 101700 IOOA 0 91
0712012011 6P.4040 A 100700 1400 0 92
04/19/2011 669265 A 99300 1000 0 99
O1II/2011 65455^ A 99300 1000 0 90
10/13/2010 - 639951 A 97300 1600 0 92
07113120in 62533! A 957r 1600 0 95
04106120iO 610921 A. 94100 1000 n 32
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Summary AIR 6A-Serfxs-Coneral
account 010-201
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Parcel 3001DIF Name
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Date B111 V Service Spq Type Curr Rd Usage Amount
- 767829 iwq63K I Pmt Pr 0 0 -23.85
1111CII/2012 767529 IVVq63R 1 Disc 0 0 -2.65
1111ni'(1012 75782.9 SUFQ53R I Charas 104900 26,50
,6/1-7/20 12 752943 I1VII)63p, 1 pmtPr 0 L) -23.85
08,104/14012 752913 1lpl'qE.97 I DSc 0 0 -269
08AI2120 12 752143 IVIQ6T, I Charge 1042�rO 900
05/30(2012 729115 !VvQ6 3; 1 Pmt Pr 0 Cl 44,30
os!o: 2012 /--1 103300 Boo 24.30
�Ilc IO/Q63R I Charge
02f17/2012 11 13(y is IWQ63p, 1 pmCFlr 0 0 -24_10
02/01/2012 713618 iWQ63R I Charge 102500 Boo 24,30
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M&YOR HIFZ�UL;IIOOA IIiMif'
October 25, 2012
Dennis Zielski
29 Grimstone Drive
Belmont NH
Dear Mr. Zielski,
RE: Distribution Box Replacement letter of compliance 6 Eleanor road, Salem MA 01970
The Salem Board of Health has reviewed the plans and documentation submitted per replacement of the Distribution
box for your onsite disposal system. Further we have inspected the installed D-Box and have found the replacement
/installation completed and in compliance with the requirements of Title V of the State Sanitary Code 310CMR15.00
Yours very truly,
L.
Larry Ramdin RS/REHS, CHO, CP-FS
Health Agent
A
Commonwealth of Massachusetts
City/Town of Salem Number
Application for Disposal System
Construction Permit Fees
Form 1A
DEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it.
A. Facility Information
Important:When
filling out forms Application is hereby made for a permit to: VRepair
onstruct a new on-site sewage disposal system
on the computer, EJ
or replace an existing on-site sewage disposal system
use only the tab epair or replace an existing system component
key to move your
cursor-do not
use the return 1. Location of Facility:
key.
ot
� Address or Lot#
5;ctLe,,&�
CdYliown Stale Zip Code
imm
2. Owner Information
Name
Add ss(if different from above)
City/Town State Zip Code
(mak
Telephone Number
a
K 3. Installer Information ,L�
*� Name Name of Company '
,.a.
� A,,
• i gjY43..
.f�f Addr ss
CityrTown State Zip Code
Telephone Number
4. Designer Information
; �
Name Name of Company
w Address .
Cityrl"own State Zip Code
" Telephone Number
a l5forn l a.doc•06/0370
/Z,/? Application for Disposal System Construction Permit•Page 1 of 3
A\- Commonwealth of Massachusetts
City/Town of Salem Number
Application for Disposal System $225
Construction Permit Fee
Form 1A
A. Facility Information (continued)
5. Type of Building:
Dwelling ❑ Garbage Grinder(check if present)
Other: Type of Building
Number of Persons Served
❑ Showers Number of showers ❑ Cafeteria ❑ Other fixtures
Specify other fixtures:
6. Design Flow:
Gallons per Day
Calculated Daily Flow: Gallons
7. Plan: Date of Original
/ I
Number of Sheets Revision Date
Title of Plan
8. Description of Soil:
9. Nature of Repairs or Alterations(if applicable): A p
10. Date last inspected: Date
t6form1 a.doc•06103 Application for Disposal System Construction Permit•Page 2 of 3
}
Commonwealth of Massachusetts
City/Town of Salem Number
Application for Disposal System $225
Construction Permit Fee
Form 1A
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and
not to place the system in operatio until a Certificate of Compliance has been issued by this Board of
Health.
Signature Date
Application Approved By:
L - llt_�tk-x� o 1 Z
Nam Date
Application Disapproved for the following reasons:
t5form1 a.doc•06103 Application for Disposal System Construction Permit•Page 3 of 3
Commonwealth of Massachusetts 'Ir �
City of Salem
Kimberley Dnscoll
a Board Health
arof ��' MByOf
$ a 120 Washington Street,4th Floor-
12
$ SALEM MA 01970w* d
DISPOSAL WORKS CONSTRUTION PERMIT
DATE PRINTED: 10/25/2012 N r � "✓
V.
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s
ESTABLISHMENT,NANIE' . Preventatiw'svtic and'Drains LLC `
<,
File Number BHF-2002 000004 ' �` 327 Asbury StrCOt r„ ,,-
Av
' a HAMILTON - MA 01982 ?
LOCATED AT:, : :- �' V. t
All
r .,
SALEM, MA` 01970
Permit Type= Permit No. Permit Issued Permit Expires Fee Restrictions 9 Notes
SEPTIC INSTALLER o6 2012-Os54�Oct 25,2012 Dec 31,2013 $10.00'
Total Fees: $10.00
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PERMIT EXPIRES ecemher 31 2013 1"T, � .
Board of Health ,, -
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KIM131i LMI DRISCOLLv,j.... (978) 74'1-1800
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MAYOR '=»(978)745-0343
hanxlin(til.ilm cgm
LARRY Rr1 Rd DiN,RS�li i5liS,CtrO,CP-RA ,
tIL;;V:I'I I Aci'.N'r '
APPLICATION FOR DISPOSAL SYSTEM INSTALLERS PERMIT Fee: $10.00
In accordance with the provisions of )I O.CMi R 15.00 and the Salem Board of I Iealth regulations an application for a
Disposal Works Installers permit in hereby submitted[: ,
Name of Applicant::_ H1 Lv"j
(Print.name of Applicant) 1
Address: 2✓��3 G e V/^/¢ �� l �Jl— /f'q'tn 4L-e `# Oi 9S'y
print Address of applicant
- — --—
q2�-9zz 3s"�i =- -
Telephone: I�'-Mai L•
Business Name: // PVA 5 \ CGL
Address if Differentfrom applicant:
I certify under penalties of Perjury, that I to the best of my knowledge and belief have tiled all state tax returns and
have paid all state taxes required by law
Signature:
7 For official Use only
Amount Received: � Received by:
Approved By : Permit#
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10/23/2012 TUE 13: 46 FAX 978 388 6959 NOW England Concrete Pr. fZ001/001
INLETT(6) 4" DIA OUTLET
7" O.C- u 1'-4" 1•-5•' p2" _PL PLASTIC PIPE SEAL 1._O.. !
PLAN VIEW 2 OPTIONAL 12" RISER
SECTION VIEW
WEIGHT
6 OUTLET STANDARD ITEM N0. EI-6D6 W COVER 226$
B-6DBC COVER ONLY 1 45#
B-61DBR RISER SECTION 1 117
' ____= _—__
;,._- I —F (6 DIA OUTLET
i O; IOi
it I ii 1 1"
i 92,.
9 OC
v1 TAPER — 3
PLAN VIEW SECTION VIEW
WEIGHT '
I '
6 OUTLET BAFFLE BOX ITEM NO. B-6DBB W COVER 734
B-6DBBC COVER ONLY 184#
i
(1) 4•' INLET (G) 4•' DIA OUTLET
7" 0.VPLANIEW
1 _8" 7— PLASTIC PIPE SEAL
/SEOCTIONVIEW�f
AWEHT
6 OUTLET H-20 IETEM N0. B-6 w COVER 432
B-6DBCH COVER ONLY 151
NOTES:
1. CONCRETE: 4,000 PSI MINIMUM AFTER 28 DAYS.
2. DESIGN CONFORMS WITH 310 CMR 15.000, DEP
TITLE 5 REGS, FOR DISTRIBUTION 10111-
Now
New 800-696. 7432 ( Precosfe� DISTRIBUTION BOX
800-696-7432 (SHEA)
CONCRETE PRODUCTS www.shenconcrete.com 6 OUTLET
773 Salem Street 87 Haverhill Road 160 Old Turnpike Road Page: D2
P.O. Box 520 P.O. Box 807 Nottingham. NH 03290 I
Wilmington, MA 01887 Amesbury, MA 01913 db6out.dw 1/4 2006kp,,� J
SpeclTlc❑tions subject to change without notice,
�P �l ea r��r ,�
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Preventative Septic &Drain --
338 Grapevine Road CNWenham, Ma 01984
k
13
,
Salem City Hail rte(
120 Washington Street
Salem Ma 01970
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Commonwealth of Massachusetts
City/Town of Salem
System Pumping Record
Form 4
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 your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use 6 Ellinor Road
only the tab key Address
to move your Salem Ma 01970
cursor-do not
use the return City/Town - State Zip Code
key. 2 System Owner:
Dennis Zielski
Name
29 Grimstone Drive
Address(if different from location)
Belmont Nh 03220
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 11/17/11 1000
p g Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Good Condition but high liquid levels
6. System Pumped By:
Dustin Prieur K84568
Name Vehicle License Number
PSAD LLC
Company
7. Location where contents were disposed:
Ipswich Waste Water Treatment Plant
" 11121/11
Signature of Hauer Date
Signature of Receiving Facility Date
t5form4.doc•03/06
System Pumping Record•Page 1 of 1
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)AemWATAr rntem on
Toyer Crone Eleanor l�caaa
I)Ift of Pumping: 13101 Qua dw pwwd- Ooo goons
ceqpd: No ® Yes . ❑ Sq* Tea- No ❑ Yes ❑
RAG= SEPTIC SBRYtczo M.
S3'Mn gmwd b.-la..R. 8. A. C-mmu swrc License S.:
COMM budbmed to: FITC®ORG
> 111131 D 9 RA= 38"IC S6RVIC8. INC,
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