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53 INTERVALE ROAD r,1 .,'� lrt�t T�'.+P tlr�lLF �' D . S�PI`ec i I i _.� CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 KIMI3ERLEY DRISCOL.L Fax(978) 745-0343 MAYOR DGREI3NBAUM@SAI.EM.CUM DAVID GREEN13AUM ACTING HEAI.;II-I AGENT WELL CONSTRUCTION PERMIT Location: 53 Intervale Road Owner: Matthew Nichols Address: 53 Intervale Road This permit is granted in conformity with the statutes and ordinances relating to well permits. Well Construction permits are non-transferable. This permit shall be on site at all times that work is taking place. Permit shall expire one (1) year from the date of issuance unless revoked from cause. This permit does not constitute a Water Supply Certificate. Permit#: 001-09 Date Issued: August 4, 2009 (Domestic use well) (TED Inc. — Reg. #560) r ACTING HEALTH A NT I CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOU FAx(978) 745-0343 MAYOR DGREENBAUM2SALEM.COM DAVID GREF_'N BAUM ACTING H rAl;rl-I AG UNT Well Construction Permit Application Fee: $180. Check payable to the City of Salem (no cash. No charge for monitoring wells) Date: June 16, 2009_ Location:_53 Intervale Road Salem, MA. 01970 Owner: Matthew Nichols Address 53 Intervale Road—Tel.-978-335-2250 Type of well:-6" Artesian Well use: Domestic use Well Contractor: C.M. Rollins Pump Contractor: Dave's Well & Pump Address: 129 Depot Road Boxford, MA Address:51 Kenney Road, Middleton, MA Phone: 978-887-2320 Phone: 978-646-9902 Reg. #:305 Have abutters been notified? (y)_ How? ---------------------------------------------------------------------------------------------- In the space provided below(or on back)show the location of the proposed well in relation to existing or proposed above or below ground structures. A description of visible prior and current land use within (200)feet of the proposed well location, which represent a potential source of contamination. There is no fee for monitoring wells but a permit is required for installation. B.O.H. use only. Check#. Check date:/ � Permit#:Cn�)JL-6 Well const permit appl revised 11/25/02 w 4 Loc T/orl .�y CD vi I N 7 � I F�utT m � J 0 l6 f � . pi r 0 � o c Janet Mancini From: Heather Lyons Sent: Thursday, June 18, 2009 12:14 PM To: Janet Mancini Subject: FW: Well water information Attachments: 53 Intervale rd Well location.pdf EWI 1!LAMI 53 Intervale rd Well location.... -----Original Message----- From: dslebel@verizon.net [mailto:dslebel@verizon.net] Sent: Thursday, June 18, 2009 11: 16 AM To: Heather Lyons Subject: Re: Well water information Hello Heather, Janet followed up with me this morning and she requested a drawing of the well location which I have attached to this email. Also, regarding the notification to the neighbors who are located next to 53 Intervale Rd there are roughly 2-3 neighbors who will be contacted by phone today and or will be notified in person if we are not able to reach them by phone. Could you please have Janet approve the well permit ASAP as we would like to get in there tomorrow morning to perform the work? Please let me know if any additional information is required. Thank you, Dave LeBel Dave's Well & Pump 51 Kenney Road Middleton, MA 01949 978-646-9902 Jun 16, 2009 10:07 :58 AM, HLyons@Salem.com wrote: Hello David, I have attached the water quality requirements along with a few other documents for your references. I also attached our construction permit application for future reference. We've been doing some research and will get back to you with an answer about a fee/no fee for the drilling at 53 Intervale Road. Heather Lyons Principal Clerk Salem Board of Health 978-741-1800 1 "The more you praise and celebrate your life the more there is in life to celebrate. " No virus found in this incoming message. Checked by AVG - www.avg.com Version: 8 .5.339 / Virus Database: 270. 12.78/2185 - Release Date: 06/18/09 05:53:00 2 CITY OF SALEM, MASSACHUSETTS BOARD OF H& rrH 120 WASHINGTON STREET,4."FLOOR 1 EL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGREENBAUM&ALEM.COM DAVID GRUYNBAUM ACTING HI-;,ALTN AGi?N'r Salem Board of Health Pumping Test Report Name of well owner: Matt Nichols Address: 53 Intervale Road Well location (referenced to atleast two permanent structures or landmarks): About 24' diagonally off of right front corner of house and 16'from bulk head opening Date pumping test was performed: July 16, 2009 @3:05 PM EST Depth at which pump was set for the test: 200' Location of the discharge line:Well tank Static water level immediately before pumping commenced: 8' Discharge rate: 13 g.p.m._(if applicable, time the discharge rate changed) N/A Pumping water levels and respective times after pumping commenced: Static Water level dropped to 16.9' and remained at this level throughout the entire test Maximum drawdown during the test: 16.9' —8' = 8.9' Duration of test: a) pumping time: 4 Hours b) recovery time during which measurements were taken: Well is producing over 100 gpm and static water level never dropped below 16.9' Recovery water levels and respective times after cessation of pumping: 3:05 Water Level 8' 3:35 water level 16.9' 4:05 water level 16.9' 4:35 water level 16.9' 5:05 water level 16.9' 5:30 water level 16.9' 6:00 water level 16.9' 6:35 water level 16.9' 7:00 water level 16.9' Finished pumped an estimated 3,120 gallons within a 4 hour period Reference point used for all measurements:Well tank Pump test performed by: David LeBel Dave's Well and Pump 51 Kenney Road Middleton, MA 01949 978-646-9902 Matt Nichols(home owner) present Please till out form completely and return to the Salem Board of Health along with the Water Well Completion Report. Pump test report is a requirement prior to issuing a Water Well Supply Certificate CITY OF SALEM, MASSACHUSETTS + BOARD OF HEAL'T'H 120 WASHINGTON STRHE"T,4."FLOOR TEL. (978) 741-1800 KIN BF,RLEY DRISCOLL FAX(978) 745-0343 MAYOR DGREENBAUNIA,SALEAd.COM DAVD GREFNBAUM ACTING H13A].;TH AGrN T Well Water Supply Certificate Application The issuance of a Water Supply Certificate by the Board of Health shall certify that the private well may be used as a drinking water supply. A Water Supply Certificate must be issued for the use of a private well prior to the issuance of an occupancy permit for an existing structure or prior to the issuance of a building permit for new construction which is to be served by the well. The following must be submitted to the Board of Health to obtain a Water Supply Certificate : 'copy of the Well Construction Permit 'copy of the Water Well Completion Report as required by the DEM Office of Water Resources (313 CMR 3.00) 'copy of the Pumping Test Report 'copy of the Water Quality Report ----------------------------------------------------------------------------------------------------------- Location of well: 53 Intervale Road Salem, MA. Owner of property:_Matt Nichols_Tel. 978-335-2250 Owner's address: 53 Intervale Road Number of bedrooms: 3 Date: July 31, 2009 ------------------------------------------------------------------------------------------------------------ B.O.H. use only Permit # Nashoba Analytical, LLC TO:978486-3316 F.:978-486-3319 LabNumber: 106196 29 King Street,Littleton MA 01460 Website:http://www.NwhobaAnalytical.com Use this number with all correspondence Client: ReportDate: 7/28/2009 Dave's Well& Pump 51 Kenney Rd Middleton, MA 01949 Certificate of Analysis Parameter Method Result MCL MRL Date of Analysis Analyst MCL=Maximum Contaminant Level(EPA Limit),MRL=Minimum Reporting Level Sodium Guidelines-Mass 20,EPA 250, #=Result Exceeds Limit or Guideline ND=None Detected(<MRL), '=Background Bacteria Noted Massachusetts Certified David L.Knowlton Laboratory#MA1118 Laboratory Director QTY OF SALEM, MASSACHUSEM BOARD OF HEALTH 120 WASHINGTON STREET,4"4 FLOOR It-L. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGREENBAUM(aSALEM.GOM DAVID GREENBAUM ACTING HEALTH AGENT Salem Board of Health Pumping Test Report Name of well owner: Matt Nichols Address: 53 Intervale Road Well location (referenced to atleast two permanent structures or landmarks): About 24' diagonally off of right front corner of house and 16'from bulk head opening Date pumping test was performed: July 16, 2009 @3:05 PM EST Depth at which pump was set for the test: 200' Location of the discharge line: Well tank Static water level immediately before pumping commenced: 8' Discharge rate: 13 g.p.m._(if applicable, time the discharge rate changed) N/A Pumping water levels and respective times after pumping commenced: Static Water level dropped to 16.9' and remained at this level throughout the entire test Maximum drawdown during the test: 16.9'—8' = 8.9' Duration of test: a) pumping time: 4 Hours b)recovery time during which measurements were taken: Well is producing over 100 gpm and static water level never dropped below 16.9' Recovery water levels and respective times after cessation of pumping: 3:05 Water Level 8' 3:35 water level 16.9' 4:05 water level 16.9' 4:35 water level 16.9' 5:05 water level 16.9' 5:30 water level 16.9' 6:00 water level 16.9' 6:35 water level 16.9' 7:00 water level 16.9' Finished pumped an estimated 3,120 gallons within a 4 hour period Reference point used for all measurements: Well tank Pump test performed by: David LeBel Dave's Well and Pump 51 Kenney Road Middleton, MA 01949 978-646-9902 Matt Nichols (home owner) present Please fill out form completely and return to the Salem Board of Health along with the Water Well Completion Report. Pump test report is a requirement prior to issuing a Water Well Supply Certificate CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"`FLOOR TEL.(978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGREENBAUM(&SALEM.COM DAVID GREENBAUM ACTING HEALTH AGENT Well Water Supply Certificate Application The issuance of a Water Supply Certificate by the Board of Health shall certify that the private well may be used as a drinking water supply. A Water Supply Certificate must be issued for the use of a private well prior to the issuance of an occupancy permit for an existing structure or prior to the issuance of a building permit for new construction which is to be served by the well. The following must be submitted to the Board of Health to obtain a Water Supply Certificate 'copy of the Well Construction Permit 'copy of the Water Well Completion Report as required by the DEM Office of Water Resources (313 CMR 3.00) 'copy of the Pumping Test Report 'copy of the Water Quality Report ------------------------------------------------------------------------------------------------------------ Location of well: 53 Intervale Road Salem, MA. Owner of property:_Matt Nichols —Tel. 978-335-2250 Owner's address: 53 Intervale Road Number of bedrooms:–3 Date: July 31, 2009 ------------------------------------------------------------------------------------------------------------ B.O.H. use only Permit # Nashoba Analytical, LLC Ted:978-486-3316 Fax:978-486-3319 LabNumber: 108196 29 King Street,Littleton MA 01460 `website:http://www.NwhobaAnalytical.com Use this number with all correspondence Client: ReportDate: 7/28/2009 Dave's Well&Pump 51 Kenney Rd Middleton, MA 01949 Certificate of Analysis Parameter Method Result MCL MRL Date of Analysis Analyst MCL=Maximum Contaminant Level(EPA Limit),MRL=Minimum Reporting Level Sodium Guidelines-Mass 20,EPA 250, #=Result Exceeds Limit or Guideline ND=None Detected(<MRL), '=Background Bacteria Noted Massachusetts Certified David L.Knowlton Laboratory#MA1118 Laboratory Director I Nashoba A-_al}rt1Cal, LLC Tel:978-486-3316 Fax:978-486-3319 LabNumber: 108196 29 King Street,Littleton MA 01460 Website:http://www.NmhobaAnalytical.com Use this number with all correspondence Client: ReportDate: 7/28/2009 Dave's Well&Pump 51 Kenney Rd Middleton, MA 01949 Certificate of Analysis Parameter Method Result MCL MRL Date of Analysis Analyst Matt Nichols, 53 Intervale Road, Salem MA,Wellhead Sampled: 7/16/2009 7:10:00 PM by Client Total Coliform Bacteria,/100ML MF-SM9222B Absent 0/Absent Absent 7/17/2009 10:45:00 AM M-MA1118 Aluminum,MG/L EPA 200.8 ND 0.2 0.01 7/20/2009 M-CT008 Antimony,MG/L EPA 200.8 ND 0.006 0.001 7/20/2009 M-CT008 Arsenic,MG/L EPA 200.8 ND 0.01 0.004 7/20/2009 M-CT008 Barium,MG/L EPA 200.8 ND 2 0.005 7/20/2009 M-CT008 Beryllium,MG/L. EPA 200.8 ND 0.004 0.001 7/20/2009 M-CT008 Cadmium,MG/L. EPA 200.8 ND 0.005 0.001 7/20/2009 M-CT008 Calcium,MG/L EPA 200.7 6 Not Spec 1 7/21/2009 DLK Chromium,MG/L EPA 200.8 0.002 0.1 0.001 7/20/2009 M-CT008 Copper,MG/L. EPA 200.8 0.001 1.3 0.001 7/20/2009 M-CT008 Iron,MG/L EPA 200.7 0.06 0.3 0.01 7/21/2009 DLK Lead,MG/L EPA 200.8 ND 0.015 0.001 7/20/2009 M-CT008 Magnesium,MG/L EPA 200.7 2.6 Not Spec 1 7/21/2009 DLK Manganese,MG/L EPA 200.7 0.005 0.05 0.005 7/21/2009 DLK Mercury,MG/L EPA 245.2 ND 0.002 0.0002 7/22/2009 M-CT008 Nickel,MG/L EPA 200.8 ND 0.1 0.001 7/20/2009 M-CT008 Potassium,MG/L EPA 200.7 ND Not Spec 1 7/21/2009 DLK Selenium,MG/L EPA 200.8 ND 0.05 0.005 7/20/2009 M-CT008 Silver,MG/L. EPA 200.8 ND 0.1 0.001 7/20/2009 M-CT008 Sodium,MG/L EPA 200.7 110 See Note 0.05 7/20/2009 M-CT008 Thallium,MG/L EPA 200.8 ND 0.002 0.001 7/20/2009 M-CT008 Zinc,MG/L EPA 200.8 0.012 5 0.005 7/20/2009 M-CT008 Alkalinity,MG/L SM 23208 196 Not Spec 1 7/22/2009 M-MA1118 Asbestos,MFL EPA 100.2 ND 10 7/28/2009 M-MA1042 Chloride,MG/L EPA 300.0 35.4 250 1 7/17/2009 M-MA1118 Color Apparent,CU SM 2120B # 528 15 1 7/17/2009 M-MA1118 Cyanide,MG/L SM 4500-CN-C,E ND 0.2 0.01 7/23/2009 M-CT008 Fluoride,MG/L. EPA 300.0 0.8 4 0.1 7/17/2009 M-MA1118 Hardness,Total,MG/L SM 23408 26 Not Spec 2 7/21/2009 DLK Nitrate as N,MG/L. EPA 300.0 ND 10 0.05 7/17/2009 M-MA1118 Nitrate/Nitrite Total,MG/L EPA 300.0 NO 10 0.05 7/17/2009 M-MA1118 MCL=Maximum Contaminant Level(EPA Limit),MRL=Minimum Reporting Level Sodium Guidelines-Mass 20,EPA 250, #=Result Exceeds Limit or Guideline ND=None Detected(<MRL), '=Background Bacteria Noted Massachusetts Certified David L.Knowlton Laboratory#MA1118 Laboratory Director Nashoba Analytical, LLC Tel:978,486-3316 Fax:978-486-3319 LabNumber: 108196 29 King Street,Littleton MA 01460 Website:http://www.NashobaAnalytical.com Use this number with all correspondence Client: ReportDate: 7/28/2009 Dave's Well&Pump 51 Kenney Rd Middleton, MA 01949 Certificate of Analysis Parameter Method Result MCL MRL Date of Analysis Analyst Nitnte as N,MG/L EPA 300.0 ND 1 0.01 7/17/2009 M-MA1118 Odor,TON SM 2150B 0 3 0 7/17/2009 M-MAI118 PH,PH AT 25C SM 4500-H-B 7.9 6.5-8.5 7/17/2009 M-MAI118 Sediment,pos/neg ------------- NEG ----- NEG 7/17/2009 M-MA1118 Sulfate,MG/L EPA 300.0 12.1 250 1 7/17/2009 M-MA1118 Total Dissolved Solids,MG/L SM 2540C 254 500 1 7/23/2009 M-MAI118 Turbidity,NTU EPA 180.1 0.39 Not Spec 0.1 7/17/2009 M-MAI118 MCL=Maximum Contaminant Level(EPA Limit),MRL=Minimum Reporting Level Sodium Guidelines-Mass 20,EPA 250, #=Result Exceeds Limit or Guideline ND=None Detected(<MRL), '=Background Bacteria Noted Massachusetts Certified David L.Knowlton Laboratory#MA1118 Laboratory Director Nashoba A alytical, LLC 108196 tin Tel:978-486-3316 Fax:978-486-3319 Lab/Invoice Number: 29 King Street Littleton MA 01460 Web Site:http://www.nmhobaanalytical.com Use this number with all correspondence Client: Report Date: 7/28/2009 . Dave's Well&Pump 51 Kenney Rd Middleton, MA 01949 Location: Matt Nichols,53 Intervale Road, Salem MA,Wellhead Sampled: 7/16/2009 7:10:00 PM by Client EPA 524.2 PARAMETER MCL RESULT PARAMETER MCL RESULT Benzene 5.0 NO 1,1,2,2-Tetrachloroethane __ ND Carbon Tetrachloride 5.0 NO 1,3-Dichloropropane __ NO 1,1-Dichloroethylene 7.0 ND Chloromethane __ NO 1,2-Dichloroethane 5.0 NO Bromomethane -- NO p-DichloroBenzene 5.0 ND 1,2,3-Trichloropropane NO Trichloroethene 5.0 ND 1,1,1,2-Tetrachloroethane __ NO 1,1,1-Trichloroethane 200.0 ND Chloroethane __ NO Vinyl Chloride 2.0 ND 2,2-Dichloropropane -- NO Monochlorobenzene 100.0 ND o-Chlorotoluene __ NO ortho-Dichlorobenzene 600.0 ND p-Chlorotoluene -- ND trans-1,2-Dichloroethylene 100.0 ND Bromobenzene -- ND cis-1,2-Dichloroethylene 70.0 ND 1,3-Dichloropropene __ ND 1,2-Dichloropropane 5.0 NO 1,2,3-Trimethylbenzene -- ND Ethylbenzene 700.0 NO 1,2,4-Trimethylbenzene __ NO Styrene 100.0 NO 1,3,5-Trimethylbenzene -- NO Tetrachloroethylene 5.0 NO n-Propylbenzene NO Toluene 1000.0 4.2 n-Butylbenzene __ NO Xylenes(Total) 10000.0 NO Naphthalene __ NO Dichloromethane 5.0 NO Hexachlorobutadiene -- NO 1,2,4-Trichlorobenzene 70,0 NO 1,2,3-Trichlorobenzene __ NO 1,1,2-Trichloroethane 5,0 ND p-Isopropyltoluene -- NO Chloroform __ ND Isopropylbenzene -- NO Bromodichloromethane ND t-Butylbenzene NO Chlorodibromomethane -- NO sec-Butylbenzene -- ND Bromoform -- NO FluoroTrichloromelhane __ ND m-Dichlorobenzene NO Dichlorodifluoromethane __ ND Dibromomethane NO Bromochloromethane -- ND 1,1-Dichloropropene __ NO *MethylTertiaryButylEther *70 ND 1,1-Dichloroethane __ NO ND=None Detected %Recovery of Internal Standards: MCL=Maximum Contaminant Level 4-Bromofluorobenzene 97 *MTBE(Optional)Mass Advisory Limit 1,2-Dichlorobenzene-d 94 Date of analysis: 7/20/2009 Detection Limit:0.5 ug/L This analysis was performed at DEP David L. Knowlton Certified Laboratory#M-CT008 Laboratory Director IM- A./POp R��TAMT MESSAGE -� FOR �I � u DATEQ� o �,y+TIMpE • 00 P.M. /J OF I �'S:R fJV0&L�22 ii J 9 `l'' //� PHONE -` G ❑ FAX N AREA CODE NUMBER EXTENSIO ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL K. CAME TO SEE YOU WILL GALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE v / SIGNED IDC FORM 4009 MADE IN U.S.A.09 NOTES I i IMPORTANT MESSAGE FOR J� DATE (e/Aldq TIME Z62-1- .M. OF I -b(J2 C Ul/�6 I M��Ul1 /, PHONE �+ slaby� 'y7 AREA CODE NUMBER EXTENSION D FAX D MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE— 'S d� (�_t i AL-Fe' u)J1 n C �_ , {`� p i. a bel )Ara SSIIG�N�ED f FOR 009 Y�/ MACE U.S.A. NOTES i i I IMPORTANT MESSAGE FOR—``— -4- DATE �P,�/Sf�O 9 TIME ��j��A. Y �� 7 / M f : �Laa L2h� I OF PHONE AREA CODE NUMBER ' EXTENSION D FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE l SIGNED F M 4009 M� EIN U.S.A. NOTES IMPORTANT MESSAGE FOR.... DATE 'G ) TIME , P.M. M Ou SS�' Y✓� Ci��O\...5 OF S 3 I pS�✓2\��V� PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL - CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE L<�O�C-�c-� <j FG j�, S)G SIGNED FORM 400A. MARE IN U.S.A.09 NOTES w COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS - DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5I/ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Addr Owner's Name: w .� �CT _ 2 00' Owner's Address: CITY OF SALEM BOARD OF HEALTH Date of Inspection- Name of Inspector: (please grint} ii� ,/ �f/lam Company Name: Mailing Address: 4f2 86 09 Telephone Number: sl��rg)<19P l-r iP--- CERTIFICATION STATEMENT 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.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ��Fails Inspector's Signature: % �= 't -- Dake: 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 4 S �1jl ****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. Z ' A Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: .]5 2 yi r Owner: Date of Inspection: ;:7 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys in Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 1 .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 re aired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will].pass. Ans r yes, no or not determined (Y,N,ND) in the_for the following statements. If"=determined'please expla The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is stracturally unso d, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existi g tank is replaced with a complying septic tank as approved by the Board of Health. •A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indi ating that the tank is less than 20 years old is available. explain: Observation of sewage backup or break out or high static water level in the distrihtuion box due to broken or o strutted pipe(s)or due to a broken,settled of uneven distnberion box.System wtil pass iinspec6cm if(with proval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed distribution:box is leveled or replaced explain: The system required pumping more than 4 times a year due to broken or obstructed piI*s).The system will p s inspection if(with approval of the Board of Health): broken pipe(s)ate replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Z +7et"- J� ^ /e rr� Owner:" ' i-.Gviy� Date of Inspection: !ZZA^ �i C. Further Evaluation its Required by the Board of Health: onditions exist which require further evaluation by the Board of Health in order to determine if.the system is f :Weng to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(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 syst m 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 s ce 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. e 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 pri ate water supply well'•.Method used to determine distance is system passes if the well water analysis,performed at a DEP certified laboratory, for coliform b cteria and volatile organic compounds indicates that the well is free from pollution from that facility and c presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other allure criteria are triggered.A copy of the analysis must be attached to this form. Other: 3 Page 4 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: o _ Date of Inspection: t D. System Failure Criteria applicable to all systems:. You must indicate`yes" or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 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. 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 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.! (Yes/No)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"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 smfam driaitingwater supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Ales—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 significant threat under Section E or failed under SectionD shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. a Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: J`�✓�1� �!�s k� Sor/e'ir/ Owner: vv Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following' Yes N� Putgpmg information was provided by the owner,occupant,or Board of Health _ WWeere any of the system components pumped out in the previous two weeks? 1��e system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection? ��Were as built plans of the system obtained and examined? (If they were not available note as N/A) 1 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 ? —Z/— Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition 7thbes 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: Y /o , ((!_ 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 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: .Svy�fP Owner:_A/Ia./;� ov Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): DESIGN flow based on 310 C�Fi 15.203 (for example: 110 gpd x tk of bedrooms): eT Number of current residents: Does residence have a garbage grinder(yes or no): X0 is laundry on a separate sewage system(yes or no}:/TO[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes orno):& Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): � Last date of occupancy: COMMERCIAL(INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_„_ industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspectio (yes or 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,ifmty) Innovative/Alternative technology. Attach a copy of the current operation and maditera=contract(to ix ob_tained from system owner) Tight tank _Attach a copy of the DFP approval Other(describe): — I Approximate age of all components,date installed if known}and sotate of information: Were sewage odors detected when arriving at the silt(yes or no): (f-5 6 T� f Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3�3'2`rJ ✓z rsfep Owner: Date of Inspection: BUILDING SEWER(locate onsite plan) Depth below grade: Materials of construction: (cast iron _40 PVC other(explain): Distance from private water supply well or suction line: -9z;' Comments (on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK:zocate on site plan) Depth below grade: Material of construction:—concrete ,metal—fiberglass,polyethylene _other(explain) If tank is metal list age:_, Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): GREASE TRAP: (locate on site pian) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): 7 r . , Page S of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .S�Z i,A Owner: ai _ Date of Inspection: 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: eallons Design Flow: i allons/day Alarm present(yes or no):_ Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX.kif present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP CHAMBER; locate on site plan) vu:nps at working order(yes or no):_ Alarms in working order(yes or no): Comments(note condition of pump chamber.condition ofpumps at.d app":.....anc , etc.): 8 t " Page9ofil OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYS'T'EM INSPECTION FORM PART C SYSTEM INFt;ORMATION,,(continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): pocate 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: —7 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.): CESSPOOLS:y(cesspool must be pumped/as part of inspection)(locate on site plan) Number and configuration: ZZ� y,2 j�irG 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 or no):_ Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: on site plan) Materials of construction: Dimensions: Depth of solids: Continents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): a t Page 1001 i i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESStIVIENTS SIMSURFACE SEWAG ' IDISPOSAL SYSTEM INSPECTION FORM DART 1` i a. , I SYSTEM INIi?Rf5Ifas32rtb'.(continued) Property Address: i � al�rr1? (Owner: z/iz . 6r'v�y.7_ Date of Inssuection: SKETCH OP SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system includinc ties to at least two permanent refe,once landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enter,the buiidirg. C7 lupi( �2r3 to Page 11 of�l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Date of Inspection: /Uv SITE EXAM Slope �' Surfaceater/7/we. Check cellar Shallow wells {/ 5 Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with IocaI excavators,installers-(attach documentation) `Accessed USGS database-explain: You must describe how you established the high ground water elevation: