413 LAFAYETTE ST y� Z,G ��y� � Esq
i
&dO ,f¢ECVCtEppp
UPC 10330
No. 153L p35fi-cons�`,
HASTINGS,MN '..
s
? 2 1997
YKYRYS Design Services W, Y s,
P . O . Box 23 H-ALTHDEPT.
Westwood , Massachusetts 02090
Salem Health Department
9 North Street
Salem, Massachusetts 01970
Attn : Mr . Mark Toleman
Dear Mr . Toleman :
I am submitting this letter to you regarding an inspection I had
made for :
Mr . Joseph Hartnett i �z Q
413 Lafayette Street
Salem, Massachusetts 01970
at which time I submitted a Department of Enviromental Protection
for , which was dated the 23rd . March , 1997 . This form was noted that
their system had a "Conditional Pass" which was dependant upon
installation of a inlet and outlet tee at their holding tank .
At this time , I was informed .that this has been complied with .
Therefore , I take this opportunity to "Pass" their system.
If I may be of any further assistance to you , you may contact me at
the above noted address of by telephone at (617) 329-1936.
Very truly o rs ,
uri yry
To
Date Time //% 2--t> Nf
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WHILE-YOU WEREOUT \
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of
Phone
Area/ de Number Extension
TELEPHONED PLEASE CALL
CALLED TO SEE YOU WILL CALL AGAIN
WANTS TO SEE VOU URGENT
RETURNED YOUR CALL
Message— L.-e- , J z,-3 a : -Q-
Operator
azo AMPAD REoaDER
EFFICIENCY9 x23-000
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CITY OF SALEM DISTRICT: WATER AND SEWER USAGE CHARGES"
PREY.READING CURRENT READING WATER USAGE DTR.ENOING CODE ACCOUNT BILL NO. BILL'ATE
1060 11800 120 1 /31 ACT 0 9 —9
PREVIOUS BALANCE LOCATION: A .AYE T E STREET
MONTH BILL NO. WATER INTEREST SEWER INTEREST
i
v�
BILLS PAYABLE : FES MAY AUG NOV
PAYABLE T0:THE CITY OF SALEM OFFICE HOURS
H.A R T N E T T JOSEPH MAIL TO:CITY COLLECTOR MOH-WED a
PO Box 2038 Salem MA 01970 T FRIiDAY ee u
0413 L A F A Y E T T E STREET COLLECTOR'S STUB-RETURN WITH PAYMENT
SALEM MA 01970 10%DISCOUNT ON CURRENT WATER CHARGES
ONLY IF PAYMENT RECEIVED BY 03/03/9
PREV.BALANCE DUE CURRENT CHARGES AFTER DI COUNT DISCOUNT D D SOCODUOR BEFOR
NT DATE E
WATER - no 16 - 80 69 15. 121
SEWER
TOTALS
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protecti ,onr `;
WBIWn F.Weld ;` , , �'='.., r=, ' : .e ',....Trudy Coxe
0or4mer sec"Ptery
Arp•o Paul Cellucel Dasrid B.SNuhs
LL common Com
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
1 .-- CERTIFICATION
Property Address: Address of Owner:
Date of Inspection: 14.4"'!-0,117 ml`L (If different)
Name of Inspector:V1.L1t=i tC`lT *lam
Company Name, Address and Telephone Number:
1PE%A= A %ftvh�tcE
p,0 my� (.,p.,,®xd%O
CERTIFICATION ST MENT t;4,t-1 '52.9 •19 3G.
I certify that I have personally inspect the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
P ses
_
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature. 1 Date:
The System Inspector all sub a copy o t nskreportthe Approving Authority within thirty(30)days of completing this
inspection. If the sys is ared syst or as 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 Department of E0ironmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure arteria not evaluated are indicated below.
BJ-SYSTEM CONDITIONALLY PASSES:
Y One or more system components need to he replaced or repaired. The system upon comuletion of the replacement o:rer3ir,
passes inspeztion.
Indicate yes, no,or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why noo
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 11/03/95) 1
One VAntw Street is Boston,Massachusetts 02106 . • FAX(617)556.1049 • Telephone(617)292-SM
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
F CERTIFICATION (continued)
Property Address:.
Owner:
Date of Inspection:
B]SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
118oard of Health):
a9,jJA�_JI p broken pipe(s) are replaced
7 obstruction is removed
y distribution box is levelled or replaced
1 bstr f
_ The system required pumping more than four times a year due to broken or obstructed pipes) The system will pass
inspection if(with approval of the Board of Health): -7
broken pipe(s)are replaced
n obstruction is removed
C
q 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 the
public health, safety and the environment. 4
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ;
_ Cesspool or privy is within 50 feet.of,asurface water,
Cesspool or privy is within 50 feet of a bordering vegetated wetland ora salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply. _
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis 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 then 5
ppm.
3) OTHER
I
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (contin'u'ed)
Property Address:
Owner:
Date of Inspection:'
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failurecriteria as defined in 310"CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E]LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threatto
public health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(PNPA) or a mapped 7_nne II of a
public wafer surpl/well)
The owner of operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. _
(revised 11/03/95) 3 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
, 1 � u t/�. rM . • .�� ' ��r. j, '� .Y'w. r ,. .:9xrn r,)
Property Address: 'Aia:w
Owner:
Ow : -..cliff
Date of Inspection:
Check if the following have been done:
� mping information was requested of the owner, occupant, and Board of Health.
"/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection.
94tAs built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
2!1-1,The system does not receive non-sanitary or industrial waste flow
.!!,—"The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
" The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or i
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
. I
(zevieed 11/03/95) 4 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
90
Date of Inspection - • "'r`
FLOW CONDITIONS
RESIDENTIAL
Design flow: ¢cellons
Number of bedrooms: '�7
Number of current residents: 'y _
Garbage grinder no):cr`�O'r _LN abE
Laundry connected to system (yes or no): trr
Seasonal use (yes or no): Nb .�I `•r
Water meter readings, if available:
Last date of o=pancy:
COMMERCIAUIN DUSTRIAL:
Type of establishment:
Design flow: aallon5/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no) <_ . •; J
Non•sanitary.waste discharged to the Title 5 system: (yes-or no) a `k
Water meter readings, if available:
.ast date of occupancy:
OTHER: (Describe)
Last daze of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes,volume pumped: Ilonst
Reason for pumping:
TYPE O�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)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known)and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I
PART C
SYSTEM INFORMATION (continued)
Property Add�retss, r> lv�vYa�,�C.6. 'R,"``�'d ic-Arzl70:)
Owner:
Date of Inspection:
SEPTIC TANK.
(locate on site plan)
Depth below grade:.4 1111
Material ofstruction: _concrete_metal _FRP—other(explain) ?
Dimensions: w. ti 7.
Sludge depth: — f. ' )
Distance from top of sludge to bottom of outlet tee or baffle: I-`u�
Scum thickness:
Distance from top of scum to top of outlet tee or bafflerY� V i
Distance from bottom of scum to bottom of outlet tee or baffle:_u
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, a c.)
GREASE TRAP:_
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal _FRP—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:
Comments:
(recommendation for pumping;condition of inlet and outlet tees or baffles, depth-of liquid,level in relation to outlet invert, structural
integrity" leakage, etc.)
• I
(revised 11/03/95) 6 '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,t SYSTEM INFORMATION
(continued)
Property rens: et`�jti+. }�3r�a.R*a1'o`h�+'>a►�a d ®����
Owner:
Date of Inspection: ,11
a'� OR1aY� �C1� .
TIGHT OR HOLDING TANK.—
(locate on site pian)
Depth below grade:_
Material of construction: _concrete_metal_FRP other(explain)
Dimensions:
Capacity: gallons
Design flow: itallons/day
Alarm level:
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
Ooate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order.(yes or no)_
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/9S) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,1 p SYSTTE�M, INFORMATION (continued)
Property Address:
Datef Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, 'd possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS: _
(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(cesspool must be pumped as part of inspection).
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:
Come> niv (no.wnXtion of soil; sig.-s of hyd'aLk a?lure, lave l of-i3nd'%, ,r4tion of._geta:i3i., atc.)
I
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Adorg� X77
. Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
7b
DEPTH TO GROUNDWATER
Depth to groundwater:J` feei
method of determination or approximation:
(revised 11/03/9s) 9 .
` 107 FOREST STREET FILE# 61499A
MIDDLETON,MA 01949
(978)774-2772
SEPTIC & DRAIN
CURRIE&
SERVICE
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNER'S NAME: KING
PROPERTY ADDRESS: 413 LAYFETTE ST. SALEM
ADDRESSOWNER: SALEM ® Silt
(IF DIFFERENT) 1JJJ,,11u���'
DATE OF INSPECTION: JUNE 14. 1999 J�
NAME OF INSPECTOR: THOMAS CHIGAS
* THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY
107 FOREST STREET I FILE#6_1499A
MIDDLETON,MA 01949
(978) 774-2772
SEPTIC&DRAIN
SERVICE
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PROPERTY ADDRESS:413 LAYFETTE STREET NAME OF OWNER: KING
SALEM ADDRESS OF OWNER: SAME
DATE OF INSPECTION: JUNE 14, 1999
NAME OF INSPECTOR: (PLEASE PRINT)THOMAS CHIGAS
I AM A DEP APPROVED INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5 (3 10 CMR 15.000)
COMPANY NAME: CURRIER SEPTIC &DRAIN
MAILING ADDRESS: 107 FOREST STREET: MIDDLETON. MA 01949
TELEPHONE NUMBER: (978) 774-2772
CERTIFICATION STATEMENT
1 CERTIFY THAT I HAVE INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED BELOW IS
TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PREFORMED BASED ON MY TRAINING AND
EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEM. THE SYSTEM:
YES PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTOR'S SIGNATURE: - DATE: JUNE 14. 1999
THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIS INSPECTION REPORT TO THE APPROVING AUTHORITY(BOARD OF HEALTH OR DEP)
WITHIN THIRTY(30)DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR HAS A DESIGN FLOW OF 10,000
GALLON GPD OR GREATER,THE INSPECTOR AND THE SYSTEM OWNER SHALL SUBMIT THE REPORT TO THE APPROPRIATE REGIONAL OFFICE
OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION. THE ORIGINAL SHOULD BE SENT TO THE SYSTEM OWNER AND COPIES SENT TO
THE BUYER,IF APPLICABLE,AND THE APPROVING.
NOTES AND COMMENTS:
�JUI 7
_ 1999
HEOF SALE
A H DEPT-
REVISED 9/2/98 PAGE 1 OF I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
PROPERTY ADDRESS:413 LAYFETTE ST.SALEM
OWNER: KING
DATE OF INSPECTION:JUNE 14, 199
INSPECTION SUMMARY: CHECK A, B, C, OR D:
A. SYSTEM PASSES:
YES I HAVE NOT FOUND ANY INFORMATION,WHICH INDICATES THAT ANY OF THE FAILURE CONDITIONS
DESCRIBED IN 310 CMR 15.303 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW.
COMMENTS:
B. SYSTEM CONIDTIONALLY PASSES:
NONE 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.
INDICATE YES,NO,OR NOT DETERMINED(Y,N,OR ND). DESCRIBE BASIS OF DETERMINATION IN ALL
INSTANCES. IF"NOT DETERMINED",EXPLAIN WHY NOT.
N THE SEPTIC TANK IS METAL,UNLESS THE OWNER OR OPERATOR HAS PROVIDED THE
SYSTEM INSPECTOR WITH A COPY OF A CERTIFICATE OF COMPLIANCE(ATTACHED)INDICATING
THAT THE TANK WAS INSTALLED WITHIN TWENTY(20)YEARS PRIOR TO THE DATE OF THE
INSPECTION; OR THE SEPTIC TANK,WHETHER OR NOT METAL,IS CRACKED, STRUCTURALLY
UNSOUND, SHOWS SUBSTANTIAL INFILTRATION OR EXFILTRATION,OR TANK FAILURE IS
IMMINENT. THE SYSTEM WILL PASS INSPECTION IF THE EXISTING SEPTIC TANK IS REPLACED
WITH A COMPLYING SEPTIC TANK AS APPROVED BY THE BOARD OF HEALTH.
N SEWAGE BACKUP OR BREAKOUT OR HIGH STATIC WATER LEVEL OBSERVED IN THE
DISTRIBUTION BOX IS DUE TO BROKEN OR OBSTRUCTED PIPE(S)OR DUE TO A BROKEN, SETTLED
OR UNEVEN DISTRIBUTION BOX. THE SYSTEM WILL PASS INSPECTION IF(WITH APPROVAL OF
THE BOARD OF HEALTH).
N BROKEN PIPE(S)ARE REPLACED
N OBSTRUCTION IS REMOVED
N DISTRIBUTION BOX IS LEVELLED OR REPLACED
N THE SYSTEM REQUIRED PUMPING MORE THAN FOUR TIMES A YEAR DUE TO BROKEN OR
OBSTRUCTED PIPE(S). THE SYSTEM WILL PASS INSPECTION IF(WITH APPROVAL OF THE BOARD
OF HEALTH):
N BROKEN PIPE(S)ARE REPLACED
N OBSDTRUCTION IS REMOVED
REVISED 9/2/98 PAGE 2 OF i I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
PROPERTY ADDRESS:413 LAYFETE ST.SALEM
OWNER:KING
DATE OF INSPECTION:JUNE 14, 199
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
N CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO
DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH, SAFETY AND 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 THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRNONMENT:
N CESSPOOL OR PRIVY IS WITHIN 50 FEET OF SURFACE WATER
N_ 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 AND SAFETY AND THE ENVIRONMENT:
N THE SYTEM 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.
N THE SYTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND THE SAS IS
WITHIN A ZONE I OF PUBLIC WATER SUPPLY WELL.
N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS
IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL.
N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS
IS LESS THAN 100 FEET BUT 50 FEET MORE FROM A PRIVATE WATER SUPPLY WELL,
UNLESS A WELL WATER ANALYSIS FOR COLIFORM BACTERIA AND VOLATILE ORGANIC
COMPOUNDS NDICATES 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. METHOD USED TO DETERMINED DISTANCE. _ _ _ _
(APPROXIMATION NOT VALID).
3) OTHER:
N/A
REVISED 9/2/98 PAGE 3 OF I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
PROPERTY ADDRESS:413 LAYFETTE ST,SALEM
OWNER:KING
DATE OF EVSEPCTION:JUNE 14. 1999
D. SYSTEM FAILS:
YOU MUST INDICATE EITHER"YES"OR"NO"TO EACH OF THE FOLLOWING:
N I HAVE DETERMINED THAT ONE OR MORE OF THE FOLLOWING FAILURE CONDITIONS EXIST AS
DESCRIBED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS IDENTIFIED BELOW. THE BOARD OF
HEALTH SHOULD BE CONTRACTED TO DERTERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE.
YES NO
N BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN OVERLOADED
OR CLOGGED SAS OR CESSPOOL.
N DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR SURFACE WATERS
DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL.
N STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE OUTLET INVERT DUE TO AN
OVERLOADED OR CLOGGED SAS OR CESSPOOL.
N LIQUID DEPTH IN CESSPOOL IS LESS THAN 6'BELOW INVERT OR AVAILABLE VOLUME IS LESS
THAN %DAY FLOW.
N REQUIRED PUMPING MORE THAN 4 TIMES IN THE LAST YEAR NOT DUE TO CLOGGED OR
OBSTRUCTED PIPE(S). NUMBER OF TIMES PUMPED_
N ANY PORTION OF THE SOIL ABSORPTION SYSTEM,CESSPOOL OR PRIVY IS BELOW THE HIGH
GROUNDWATER ELEVATION.
N ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR
TRIBUTARY TO A SURFACE WATER SUPPLY.
N ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL.
N ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL.
N ANY PORTION OF A CESSPOOL OR PRIVY IS LESS THAN 100 FEET BUT GREATER THAN 50 FEET
FROM A PRIVATE WATER SUPPLLY WELL WITH NO ACCEPTABLE WATER QUALITY ANALYSIS. IF THE
WELL HAS BEEN ANALYZED TO BE ACCEPTABLE,ATTACH COPY OF WELL WATER ANALYSIS FOR
COLIFORM BACTERIA,VOLATILE ORGANIC COMPOUNDS,AMMONIA NITROGEN AND NITRATE
NITROGEN.
E. LARGE SYSTEM FAILS:
U MUST INDICATES EITHER"YES"OR"NO"TO EACH OF THE FOLLOW
HE FOLLOWING CRITRTIA APPLY TO LARGE SYSTEMS INTION TO THE CRTERIA ABOVE:
N THE S M SERVES A FACILITY WITH A DESIGN W OF 10,000 GPD OR GREATER(LARGE SYSTEM)
AND THE SYSTEM I SIGNIFICANT THREAT TO PUB HEALTH AND SAFETY AND THE ENVIRONMENT
BECAUSE ONE OR MO THE FOLLOWING C ITIONS EXIST:
YES NO
THE SYSTEM IS WI FEET OF A SURFACE DRINKING WATER SUPPLY
THE SYSTE WITHIN 200 F OF A TRIBUTARY TO A SURFACE DRINKING WATER SUPPLY
THE SY IS LOCATED IN A NITR N SENSITIVE AREA(INTERIM WELLHEAD PROTECTION
AREA-IWP R A MAPPED ZONE II OF A PUBL ATER SUPPLY WELL
THE O OR OPERATOR OF ANY SUCH SYSTEM SHALL UPG THE SYSTEM IN ACCORDANCE WITH 310
C 5.304(2).PLEASE CONSULT THE LOCAL REGIONAL OFFICE OF EPARTMENT FOR FURTHER
FORMATION.
REVISED 9/2/98 PAGE 4 OF l l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM
PART B
CHECKLIST
PROPERTY ADDRESS:413 LAYFETTE ST.SALEM
OWNER: KING
DATE OF INSPECTION:JUNE 14. 1999
CHECK IF THE FOLLOWING HAVE BEEN DONE: YOU MUST INDICATE EITHER"YES"OR"NO"AS TO
EACH OF THE FOLLOWING:
YES NO
Y PUMPING INFORMATION WAS PROVIDED BY THE OWNER, OCCUPANT, OR BOARD OF
HEALTH.
Y NONE ON THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS
AND THE SYSTEM HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE
VOLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYTEM RECENTLY OR AS PART
OF THIS INSPECTION.
N/A AS BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED.NOTE IF THEY ARE NOT
AVAILABLE WITH N/A.
Y THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP.
Y THE SYSTEM DOES NOT RECEIVE NON-SANITARY OR INDUSTRIAL WASTE FLOW.
Y THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT.
Y ALL SYSTEM COMPONENTS, EXCLUDING THE SOIL ABSORPTION SYSTEM HAVE BEEN
LOCATED ON THE SITE.
Y THE SEPTIC TANK MANHOLES WERE UNCOVERED, OPENED, AND THE INTERIOR OF THE
SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES, MATERIAL OF
CONSTRUCTION, DIMENSIONS, DEPTH OF LIQUID,DEPTH OF SLUDGE,DEPTH OF SCUM.
THE SIZE AND LOCATION OF THE SOIL ABSORPTION SYSTEM ON THE SITE HAS BEEN
DETERMINED BASED ON:
Y EXISTING INFORMATION. FOR EXAMPLE,PLAN AT B.O.H.
Y DETERMINED IN THE FIELD (IF ANY OF THE FAILURE CRITERIA RELATED TO PART C IS
AT ISSUE,APPROXIMATION OF DISTANCE IS UNACCEPTABLE) [15.302(3)(b)]
Y THE FACILITY OWNER(AND OCCUPANTS, IF DIFFERENT FROM OWNER)WERE PROVIDED
WITH INFORMATION ON THE PROPER MAINTENANCE OF SUBSURFACE DISPOSAL SYSTEMS.
REVISED 9/2/98 PAGE 5 OF 11
SUBURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PROPERTY ADDRESS:413 LAYFETTE ST.SALEM
OWNER:KINK
DATE OF INSPECTION:JUNE 14. 1999
FLOW CONDITIONS
RESIDENTIAL:
DESIGN FLOW:2G.P.D.BEDROOM.
NUMBER OF BEDROOMS(DESIGN): 224 NUMBER OF BEDROOMS(ACTUAL): 2
TOTAL DESIGN FLOW: 220
NUMBER OF CURRENT RESIDENTS: 1
GARBAGE GRINDER(YES OR NO):YES
LAUNDRY(SEPARATE SYSTEM)(YES OR NO):NO;IF YES,SEPARATE INSPECTION REQUIRED
LAUNDRY SYSTEM INPECTED (YES OR NO):NO
SEASONAL USE(YES OR NO):NO
WATER METER READINGS,IF AVAILABLE(LAST TWO YEAR'S USAGE(GPD): UNAVAILABLE(D,TIME OF
INSPECTION.
SUMP PUMP(YES OR NO):NO
LAST DATE OF OCCUPANCY: CURRENT
COMMERCIAL/INDUSTRIAL:
>-
0
STABLISHMENT:
OW:_GPD(BAESED ON 15.203)
D `I N FLOW:
RAP P T(YES OR NO): _ _ _ _IL WASTE H ING T PRESENT(YES OR NO):. _. . .
TARY WASTE DIS RGED TO THE TITLE 5 SYSTEM(YES OR NO):. . . . .
ETER REDA ,IF A LE:. ,E OF O ANCY:SCRIBE):. . ___E OF OCCUPANCY:
GENERAL INFORMATION
PUMPING RECORDS AND SOURCE OF INFORMATION:
SYSTEM PUMPED AS PART OF INSPECTION(YES OR NO): YE
IF YES,VOLUME PUMPED: 250 GALLONS
REASON FOR PUMPING: INSPECTION TOO CESSPOOL
TYPE OF SYSTEM
N SEPTIC TANK/DISTRIBUTION BOX/SOIL ABSORPTION SYSTEM
YES SINGLE CESSPOOL
N OVERFLOW CESSPOOL
N PRIVY
N SHARED SYSTEM(YES OR NO)(IF YES,ATTACH PREVIOUS INSPECTION RECORDS,IF ANY)
N UA TECHNOLOGY ETC.ATTACH COPY OF UP TO DATE OPERATION AND MAINTENANVE CONTRACT
TIGHT TANK_COPY OF DEP APPROVAL
OTHER:N/A
APPROXIMATE AGE OF ALL COMPONENTS,DATE INSTALLED(IF KNOWN)AND SOURCE OF INFORMATION:
40+YRS:OWNER
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE(YES OR NO):NO
REVISED 9/2/98 PAGE 6 OF I1
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS:413 LAYFETTE ST-SALEM
OWNER:KING
DATE OF INSPECTION:JUNE 14. 1999
BUILDING SEWER:
(LOCATE ON THE SITE PLAN)
DEPTH BELOW GRADE: 30"
MATERIAL OF CONSTRUCTION: YES CAST IRON-40 PVC OTHER(EXPLAIN)-----
DISTANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE:N/A
DIAMETER:4"
COMMENTS: (CONDITION OF JOINTS,VENTING,EVIDENCE OF LEAKAGE,ETC.)
NO SIGNS OF LEAKAGE IN OR OUT.SOILS ARE CLEAN AN DRY
PTIC TANK: NO
(LO E 01 SITE PLAN)
DEPTH BELO ARDE:
MATERIAL OF CO RUCTION: CONCRETE METEL FB3ERGLASS POLY LENS OTHER
(EXPLAIN):- - - - - -
IF TANK IS METAL,LIST AG IS AGE CONFIRMED BY CERTIFICATE OF C LIANCE(YES/NO). ... .
DIMENSIONS:
SLUDGE DEPH:
DISTANCE FROM TOP OF SLUDGE TO BOTTOM 0 UTLE E OR BAFFLE:
SCUM THICKNESS:- --- -
DISTANCE FROM TOP OF SCUM TO TOP OF OU TEE OR FFLE:- - - - -
DISTANCE FROM BOTTOM OF SCUM TO ON OF OUTLET TE BAFFLE:
HOW DIMENSIONS WERE DETERM
COMMENTS:
(RECOMMENDATIO R PUMPING,CONDITION OF INLET AND OUTLET TEES OR B ES,DEPTH OF LIQUID
LEVEL IN REA N TO OUTLET INVERT, STRUCTURAL INTEGRITY,EVIDENCE OF LEA ETC.).. . . .
>NDATION
SE TRAP: NI
E ON SITE PLAN)
BE GRADE:
IAL OF TRUCTION: <STRUCTURAL
ETAL FIBERGLASS POLYETHLENE OTHER
IN). . . .. -
SIONS:
THICKNESS:
CE FROM TOP OF SCUME OR BAFFLE:
CE FROM BOTTOM SCUUTLET TEE OR BAFFLE:
F LAST PUMP
COMMENTS-
(RECONDATION FOR PUMPINGLET A OUTLETTEES OR BAFFLES,DEPTH OF LIQUID
IN REALTION TO OUTLET INAL INTEGRI VII
OF LEAKAGE,ETC.).. . ..
REVISED 9/2/98PAGE 7 OF 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS:413 LAYFETTE ST.SALEM
OWNER:KING
DATE OF INSPECTION:NNE 14, 199
GHT OR HOLDING TANK:N(TANK MUST BE PUMPED PRIOR TO,O TIME OF,INSPECTION)
(LO E ON SITE PLAN)
DEPTH BELO E:
MATERIAL OF CONS CTION:_CONCRETE TAL_FIBERGLASS_POLYETHYLENE OTHER
(EXPLAIN)_ _ _ _ _
DIMENSIONS:
CAPACITY: GALLONS
DESIGN FLOW: GALL /DAY
ALARM PRESENT:
ALARM LEVEL: ALARM IN WORKING ORDER: ES NO
DATE OF PRE S PUMPING:
COMME .
(CO ION OF INLET TEE, CONDITION OF ALRM AND FLOAT SWI ES, ETC.)
D'
BUTION BOX: NO
(LOCAT ITE PLAN)
DEPTH OF LIQUID LEV OVE OUTLET INVERT: _ _ . . _
COMMENTS:
(NOTE IF LEVEL AND DISTRIBUTION IS EQUAL,EVIDENCE O DS CARRYO VIDENCE OF LEAKAGE INTO OR OUT OF BOX,ETC.)
CHAMBER: NO
(LOCA SITE PLAN)
PUMPS IN WORKING O (YES OR NO):_ . _ _ .
ALARMS IN WORKING ORDER ORNO): . . . . .
COMMENTS:
(NOTE CONDITIONS OF PUMP CHAMBER, CO ON O S AND APPURTENANCES,ETC.)
REVISED 9/2/98 PAGE 8 OF I1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS:413 LAYFETTE ST SALEM
OWNER:KING
DATE OF INSPECTION:JUNE 14. 1999
ABSORPTION SYSYEM(SAS): NO
(LOCAT SITE PLAN,IF POSSIBLE;EXCAVATION NOT REQUIRED,LOCATION MAY BE APPROXIMATED BY NON-INTRU METHODS)
IF NOT LOCATE LAIN:
TYPE:
LEACHING PITS,NUMBER:. , __ _
LEACHING CHAMBERS,NUMBER:. _ _ _ _
LEACHING GALLERIES,NUMBER:. . . _ _
LEACHING TRENCHES,NUMBER,LENGT -- - - - -
LEACHING
_ _ . .LEACHING FIELDS,NUMBER,DIME NS:.. . .
OVERFLOW CESSPOOL,NUMB .-----
ALTERNATIVE SYSTEM:
NAME OF TE OLOGY:
COMMENTS:
(NOTE CONDITION OF S ,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,DAMP SOIL,CONDITION OF VE TION,
CESSPOOL: YES
(LOCATE ON SITE PLAN)
NUMBER AND CONFIGURATION: ONE:ROUND
DEPTH-TOP OF LIQUID TO INLET INVERT: 21"
DEPTH OF SOILD LAYER:N/A
DEPTH OF SCUM LAYER:N/A
DIMENSIONS OF CESSPOOL: 6'D X 5'6"H
MATERIALS OF CONSTRUCTION: FIELD STONE
INDICATION OF GROUNDWATER:NONE
INFLOW(CESSPOOL MUST BE PUMPED AS PART OF INSPECTION)THERE WAS NO SIGNS OF INFLOW OF
GROUND WATER.THE CESSPOOL WAS PUMPED
COMMENTS:
(NOTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGETATION,ETC.)
THE SOILS ARE CLEAN AN DRY NO SIGNS OF FAILURE THE CESSPOOL IS IN GOOD CONDITIONNO SIGNS OF
WETLAND VEGETATION IN OR NEAR SYSTEKTHERE IS AN OVER FLOW LINE W/O TLET TEE BAFFLE
ATTACHED.THERE IS AN METAL MANHOLE COVER IN CENTER 14"BELOW GRADE
PRIVY:_N
(LOCATE ON SITE PLAN)
MATE CONSTRUCTION:_ SIONS:
DEPTH SOLIDS:_
COMMENTS:
(NOTE CONDITION IL,SIGNS OF HYDFAIL LURE,LEVEL OF PONDING,CONDITION OF VEGETATION,ETC.
REVISED 9/2/98 PAGE 9�OF I1
SUBSURFACE SEWAGE DISPOSAL�SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS:443 LAYFET`Cp CT AL p.+OWNER:KING :; v
DATE OF INSPECTION:JSjNrE 14:19'99£„
- li Ail -
rz'r�.
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCE LANDMARKS OR BENCHMARKS
LOCATE.ALL WELLS WITHIN 100' (LOCATE WHERE PUBLIC WATER SUPPLY COMES INTO HOUSE)' -
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REVISED 9/2/98Y• eye-
PAGE 10 OF 11 ��""'-
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS:413 LAYFETTE ST.SALEM
OWNER:KIN
DATE OF INSPECTION:NNE 14. 1999
NRCS REPORT NAMEN[A
SOIL TYPE N/A
TYPICAL DEPTH TO GROUNDWATER N/A
USGS DATE WEBSITE VISITED
OBSERVATION WELLS CHECKED
GROUNDWATER DEPTH: SHALLOW N MODERATE DEEP
SITE EXAM SLOPE
SURFACE WATER
CHECK CELLAR
SHALLOW WELLS
ESTIMATED DEPTH TO GROUNDWATER 8'+APPROX FEET
PLEASE INDICATE ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION:
NL OBTAINED FROM DESIGN PLANS ON RECORD
Y OBSERVED SITE(ABUTTING PROPERTY, OBSERVATION HOLE,BASEMENT SUMP, ETC.)
Y DETERMINED FROM LOCAL CONDITIONS
N CHECKED WITH LOCAL BOARD OF HEALTH
N CHECKED FEMA MAPS
Y CHECKED PUMPING RECORDS
N CHECKED LOCAL EXCAVATORS, INSTALLERS
Y USED USGS DATA
DESCIBE HOW YOU ESTABLISHED THE HIGH GROUNDWATER ELEVATION. (MUST BE COMPLETED)
THE DOESN'T HAVE SUMP PUMP IN BASEMENT AN BASEMENT IS DRY WHILE DIGGING IN YARD THERE
WAS NO SIGNS OF WATER TABLE THE CESSPOOL IS 8' IN GROUND WITH NO SIGNS OF WATER
TABLE.NO ABUTTING PROPERTY'S WELLS OR WETLANDS WITHIN 100'FROM SYSTEM.
REVISED 9/2/98 PAGE I I OF 1 l
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