4 LILLIAN ROAD Comnort ealth of Massachusetts
DECEIVED , Massachusetts
per0 2000
,_,,Ft' OF SALEM
F0'°Ru OF HEALTH ,system ft ng.Record
—Systen aver bystem Location
Date of Pumping: 9 /!aCq Quantity Pumped: //06-0 gallons
Cesspool: No 91 Yes , ElSeptic Tank: No ❑ Yes
RAGGS SEPTIC SERVICE, INC.
System pumped by: d.b.a. E. A. COMEAU SEPTIC License
Contents transferred to: WATER SOLUTIONS GROUP TAUNTON
Date —/ I t � 709 Inspector RAGGS SEPTIC SERVICE. INC.
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
Systein'Dwner d Lk Yh System Location
Toridr,,aul.k Nadine ! l)c�n Primary Home -
4 Lillian Road 4 Lillian Road
S+.w1ti-e, P'lA, u197U &alein, MA, 171970 .
(97,1) 144 9:0"u + (978)-744 -939-0 x
'1'ondr.maul'r Nadiilra ! Don
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No YesEfT
Date of Pumping: c2 Quantity Pumped: 100c2 Gallons
System Pumped By: Wind River Environmental,LLC Permit#: -
Contents Transferred to:
Contents Disposed at:
Date: Pumper Signature: C
A� d
Condition of System/Other Comments
RECEIVE®
DEC - 4 2006 j
CITY OF SALEM
BOARD OF HEALTH
Dep Approved Form-12/07/95
Farm 4 System Pumping Record
CommomweaNh of Massachuseiss
Massachusetts
System Pumpina Record
System Owmer System Location
j,I i,i] Na�i P-e L n ��Iimaly
MA, C—q7)
:9VII-7114 -9390 x
+
Type: Emergency Routine ✓
Cesspool: w L6.� Yes Septic tank; w Yes:�d
Date of Pumping: Quantity Pumped; Gallons
System Pumped By: Wind Ahw awwwwal, LLC Permit M
Contents transferred to;
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
Dep Approved Form - 12/07/95
J
FORM 4 - SYS'T'EM
Commonwealth of Massachusetts
Massachusetts QCT 2 6 2000
System Pumping Record CITY OF SALEM
HEALTH DEPT.
- y-stew-mer ystem ocatlon
Type: Emergency ❑ Routine
Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes
Date of Pumping: A Quantity Pumped: gallons
System Pumped by (Company): �� �� permit #:
Contents transferred to:
Contents dispo d at:
Date yL Pumper Si
Condition of syste other comments:
DFP APPROVED FORM.13/07/95
olftf�t _N,p 761 ktitllll a � MUM P01114" Rtulth
bobv
tommom"01111 bf moll At 11111!111
Ml1A�Ab�IIfAAl1A hi.4Y 7 - 1997
I�V,�1lffl1lUlf�1>'ft�_�f��'il�
5yilem liwnr�..-� -
---— --------
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1,.„e of 1 un,p11,1 4( - NIIIHHld; 10,0 10IIu11l
elspnnl: lin L_1 Y!! U 5l�tl! twrlk fle U Y!!
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V
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commomoallh of Monsdchuse"s
EX9C(Alve Office of ErMohh)Wdi WWI;
Department of
Environmental protection
Wlllllte f•Wlld
oo.+ma
Trudy Cosi1
&c,etW.SOFA
Dlvld 0. Taub/
can�du ��,
SU6SURPAtE SEWAGE bISPDSAE SYMMM INSPEti1tlN tDXM
PARI A
__llII tERtifitAtION
Properly Address: L/�t'�qh 'Y� ' /L°' t f Addiett 61 d"ift 6 CvT
Date of 1pspecliom ^n/!IO 7 Of diffltent) pp�� s_ /, t�P�G✓C Ct J ( 1 j�
r Name of Inspector: t--rcve po(ah Airr1bf� Tx, 76, t ?;),
Cmpany Name, Address nd Teiepbotse Numbith Rook--- ^Zan
f�. 0, liox q>I �1cx�bboc/—tae ! '-6lg 3� ` t/��/�/
CERTIFICATION STATEMENT
1 certify that i have personally Inspected the sewage disposal system at this address and that the Information llpohCd Below Is true, accurate
- and complete as of the time of Inspection. the Inspection was performed based on my training and expehehte Ih the propet function and
maintenance of oh-site sewage disposal sytlems. The tyttern:
� Pastes
_ Conditionally Passes
_ Needs Further Evalualioh.by the local Approving Authority
_ Falls //
Inspector's SigG't u;
nalure: 4bales o//�//
the System Inspector shall submit a copy of this Inspedion report to the Apptovihd Authority Within thlhy,(30)days of complNing this
inspection. If the system is a Shared system or has a design flow of 10,000 gpd or Treater, the Inspedot and the Syttem owner shall submit
the report to the appropriate regional office of the Department of Envirohmental Proledloh.
The original should be sent to the 5isiem owner and copies Sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
Al SYSTEM PASSES:
M
1 I have not found any Inlormalion Which (ndicAW that the system-violates Any 61 the lallute GRetiS 1S defined ih lid CMR 15.303.
Any faliute crilerta not evaluated ate Itiditaled b616*.
BI SYSTEM CONVItIONAIEY PAS$ESt s
One or mote system components no#&to be teplaced at tepalted. The aysleflt, Moon to"16111oh bf thl leplateritehl of repair,
passes Inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis 61 dcohnihatloh in all hidJuitet. If°not delermlhed', explain Why holt
The septic lank is metal, cracked, Mlrudufally 0ht6und, thinks subMWMIIII Inhlttallo8 ht exhhtalibh, 6t tank failure it
Imminent. The system will past Inspedion 11 the exlsllhg septic link Is feplaced With 1 cdhlbnning septic lank At '
approved by the Board of Health.
(revised 9/ISMI i 1
Cn1 YAntlr 6tr11t 1 dolit6n, 111111446hu11tb 63i66 6 PAX(its)US-1616 1 t411yh6b1(lit)HI-606
. AY, mtri kkkw 6il&
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (contieued)
Properly 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
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The Sy"stem will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction Is removed
C] FURTHER EVALUATION 15 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
t public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH biTERMINES THAT THE SYSTEM 15 NOT kUNdIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT!
_
]me wstem nas a seuuc tank and suit absorption system and is within 100 feet to a surface svatc.. 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 than 5
ppm.
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined In 310 CMR 1 5303. 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 oveHoaded or clogged SAS or
cesspool.
(revieed 8/15/95) 2
11490111fAtt SEWAGE 011POIA10114M I1410tURM 1HAIIt
PAAt A
uAtIEIuto"m (taAlift"
►roptrly Addreltt � s
owner. -
balc of It"etllona
a
b)SYSTEM 1,AIE9(tottllnued):
Matit liquid level In the dltltibullon box above abdM ImAd dui 16 AH evedoMM at dbggetl4A9 of 4110bbl.
Uquld depth to telsp(5bl Is fell Ihan 6"below Inutd of lvAllabll vbIUFM It 19111hAN I/) day Aeon.
Rtquned pumping more than 4 tltnel In the lul yeat NUI due to doUM of obllfuttld 0110111.
Numbtr of Ilmel putoped—
Any portion 61 tho Soil AbSbrollon SySlem, tellpool of ptivy 11 416w the hlgh Atbundvyalet ellvaubb.
Any portion bf A tegspbol of privy is wlihle 100 feel of a SuRAte water supply at IdbulAly(a A 10aw valet lupply.
Any portion 61 a cesspool 6f ptivy Is wnhlo A tone 161 A publle well.
Any pbdlen 61 A teslpoel bt privy U Whhin lir feel 61 A pfIV90 *Mff supply 0411,
Any pbdidn of a telspbol of btivy if 1611 thio Im feel but AfemlIf thin 16 fell (raft A lflvatA valet supply well 0411h Its
Acrepfabld water Nuahly analysis. It the well has been Anatyted 16 be k4f)[Abil, !Nath tape bf will *M0t Shilyld 1t*
toldonn badetia, volAllle 6tgAalt tbhipbbndl, AMM MIA RNtoAON And ANfile NNfeAetl.
tl IARGt OWM tA6! /
i
the (ollowing crilwif apply to tatge lyllotnl In addillom Ib the tlllefla above:
The design (Inti of systtm is 10,000 god 6r grcalEr (lAtge tyllem) and the lylletn it A fJgnlhtafil 1691116 bubht health and lafefy
and Iht tnvlronmtnl becAust one of mote 61 the follbwing tbndltiont ekitl:
the tysltn it within 400 foot of A ludAte dtlnkihe *Mot supply
tht systtm it within 200 feel of A IttbulAty to A ludate drinkiol *met supply
tht systtm It located In A ntlfbgetl lentNwe ACOA 1lnletlM WtllhlAd PtblW160 AIN Oft of A FNapped folie If 61 A
publit wafer supply with
the owntt of opttatot of any such Sylletn shall Ming the Wow And litllliy Inlb full t6411ANEA 0,01114 ItdilNAmsf ifAA fm,4 061mm
ttqulrtmtnls of 114 CMR t.tRI And 6.00. pleaso tomoft the 1661 feglo6A1 afhtl of thl file AwftI fol 1uNllA1 (lfah"illa".
Ire�leed a/15/SSI
SURSUREAtt SEWAGE 1111PUSAI 0111M.INSRUION EbRM
PARI
t`_ CKIISt
Property Address:
Owner: L
Date of Inspection: //z I /� 7 6 Po u
Check if the following/have been n done:
G//Pumping information was tlqulsted of the owner, attupant, and Roatd of Health.
Y None of the system components have been pumped lot a1 Iesif 1w6 Welkit And the tysleot has been fateiving normal how rales
during that period. Large volumes of water have hot been Itltbdttted int6 the fyslem recently or fi!old of this Infpectibn.
,tM As built plans have been obtained find examined. Note If they fire hot fivfillable With WA.
v the facility or dwelling was Infpeded for slehs 61 Sewag!bfitk-up.
i
Z60 sytterri dols hot t#Mvi nen-Ifinuafy, of Indulttlal wute Raw
v�the site was inspected lot signs of breakout. /
V AAll system components, excluding the Sol) Absorptlnnfyslens,have been lotaled on the 1114.
V The septic lank manholes were uncovered, boned, and the Intlrlbr of the 11#011t lank Wls,litspeded for condition of baffles br
lees, material of construction, dimensions, depth of liquid, depth of sludge, depth bf:tum.
U he si{e and location of the Soil Absorptibh System on the sue has been determined bfised en exlstimg Inleritiauon of
approximated by non-intrusive methods.
b/ne facility ov.ner land occupants, If diffeient front owner) were provided with Inldtislatlbn oh the proper MAIntlnance of Sub-
Surface Disposal System.
s
' s i
trevseed !/15/951
$UASuAFAtE SEWAGE 1111001AL $V M IN1P1MUN 161M
PARI t
/
IMM INFDAM MN
Properly Address: ti`( i L Ile,r� tri( SSI,,et /1-1c c ,
Owner:
oof
In+plNlon: CIIC'7 •
FLOW tONUltION1
ANTIALt
Design allons' A
Number of bedrooms,
Number of current residenls:
Garbage grinder lyes or no):,LV(:> -
Laundry, connected to System (yes or ho):-yr57
Seasonal use lyes or nob i✓G'
Water meter readings, If available:_J.ee •��(w C G1 �(� /�1 FOre'"(twY'COta_. .
Last dale of occupancy:/t•)a#-e/s 2Tt .(9l4 -7 .
COAIMERCIAUI NDUSTRIALt
Type of establishment:
Design flow:__gallonsdday
Grease trap present: lyes or no)
Industrial Waste Holding Tank present: lyes or no)_
Non sanilary waste discharged to lie Title S system: (yes or ho)_
Water meter readings,if available:
last dale of occupancy:_
01I4ER: (Describe)
Last date of occupancy:
GENERAL MORMAtION
PUMPING RECORDS and source of Informat
ipn:
LU>1 L P/i" L r 6 f / n l'R �� 057 6('o/,,&A frr�V 1 Si fit
System purl of Inspection: lyes or nol_Yf.
r If yes, volume pumped A56C eallont
Reason for pumping: UE �na0/(T SrvL.P lf")7 j
TYPE 01-M fM
Septic lank/distrlbulitp bosrlsol) Absorption Syltm
Single cesspool
Overflow cesspool
Privy
_ shared sysleth lyes lit ho) IN yet, ARAth pitivlou! IhspEHleR fWA, If Any)
Other (explain) ......,.. .. . .. .. ..... .....
APPROXIMATE AGE of all toptpohetils, dale Installed (it khoWh)And 181111:1 61 IBItIM111186f /t t F
Sewage odors detected when Altiving a1 the site: lyes or no)yy,•
Irevieed !/15/951 1
SUASURFAtt MAU BISPt1SAt $VWM INSPtttl04 Mom
PARI It
SYSTEM INFdRMAtlON febnllfiuldl
Properly Address:
DalOwner:
rf Inspection:
•���� —
SEPTIC TANK: t/- 't
(locate on Site plan)
Depth below grade-VS,
onslrudion: AGF (a:at/Pr�
Material of cndcrete _metal _FRP —other(Explain)
Dimensions: •A'')/r QIA.+ .Y2
Sludge depth: U inr 11 PS r!
Distance from lop of sludge to bottom of outlet to of baRle:. /
Scum thickness: ak I n PS br / v i oni<0�
Distance from top of scum to top of outlet lee of baffle: O e 40c", ll[7 c^PPn f h .
Distance from bottom of Scum to bottom of outlet lel of aflle: 1.Z rr
Comments:
(recommendation lot pumping, condition of Inlet and )tide)tell bt b fRet,depth bl liquid IeVlI IB fe10111tj 1 bUlltdfivlFl, lIrCNUMI 41
i Integrity, evidence o leakage, bit.) {
Ao",.7 ( r
[A i /P
GREASt TRAP:_ _
(locate on site plan)
Depth below grade:_
Material of consttudion: _concrete _metal _rRP _bthef(explain)
Dimensions:
Senn thickness:_
Distance from lop of scum to top of outlet lee of baf ol:_
Distance from bottom nI irum t-bottom of outlet tee at baNle:_
Comments:
(recommendation (or pumping, condition of Thief and outlet feet of bafRet, depth of hqud loof itt lelallntt tb bullet hived, Aniclutal
Integrity, evidence of leakage, etc.)
Of
s t
Irevised 0/19/4151 6
' SUBSuAPACt "AOI 016POSAI SYSTIM INSPECTION PORN
PART c
SYSTEM INFORMATION leonlWoO
Property Addrelst </!L�(lt4�-, �eP� .S�/,�,.•� �� ,
Owner:
Date of Inspedlom
TIGHT OR HOLDING 1AN11i
Bocate on she plAn)
Depth below`rade:_ !
Material of construction: _comers _mgtal_FRP_olher(pxplaln)
Dimensions:_ _
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of Inlet rep, condition of Alarm and Boal switches, etc.)
DISTRIBUTION BOX:A/
(locate on site plan)
Depth of liquid level above outlet invert: Mo _
Comments:
(note i- (Ie:r1 and disuibwiuq is equal, e+id ice of solids carryover evidence of leakage Into or out of box, etc.►leI
+ z�
ui • .
si 4A
�i.'✓C to I`C'IG�'P': FO (D✓f � I : , fir• � -,.i .'� '. �tYjr
PUMP CHAMOM—
(locate on site plan)
Pumps In woskin` grdeclyps of no)_
Comments:
Inose condition of pump chimhlr, cotldilloh of pumps and"arleoancea, etc)
Irpvspe4 s/)(./ssl 7
j
SUlSURFAd SEWAGE dISMI#SYSTEM INSRMON FORM
PARt It
SYSTEM INFORMAMON (ten116ut!dl
Properly AddrNfr (f�,!��rlicr /`C/r
owner:
Dale 01 lospeNiont
y�Z l/4?
Soil A1119ORP11ON SYSTEM
(locate on site plan, II possible; excavation not IequIW, bud tnity 4 appsoxirtsaled by non-IMMSIyA melh6ds)
n
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambets, number:_
leaching galleriK number: !
leaching trenches, number,length:'2,<n�PS
leaching fields, number, dimensions:
overflow cesspool, number:_
Comments: (note condition 611611, signs of hydraulic fA lure/ level 61 podding, ton�d111166 of ygeetA06ti'lle.) Sr3i'l
TA
h Ltd v % oe le)
&/C'!"f 'CPI-"l . NFi Si4 e7 �/ �!L - •f-/Ji Ur�P . •� �
e.' �/O P fli�r nil
/ CESSPOOES: _
(loan on site plan) /
Number and configuration:
Deplh lop of liquid to Intel 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. Inose condition of toll, !lint of hydraulic failure, level 6f pondini, tondillan 61 VAIIIA1166, etc.)
M
PRIVY:
(loclle on site pion) f
Materials of cooitrudlon: • binknllohl:
Depth of solids:
Comments: (note condillon 61 tall, tignl bf hydtilulie 16111116, loll e111B6dlne, temm" 61 glen, Lit.)
Irevf sect !/15/951 E
SUISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.TORM
PART C
SYSTEM INF011MATION feonllh"
Property Address: <I L% lere .. ,o--d• J50.t pvt /`SIG c
Owner: 6&CV-59 No/L° I" .
!)ate of Inspesllon
��7�Z �Q 7
SKETCH OF SEWAGE DOOM SYSTEM,
Include Iles to at least two permanenl teferoncet landmarks of benchmarks
locate all wells withln 100'
I
�— Q tclk 01 Novs e
i
i
i
a
DEPTH TO GROUNPWATER / r
Depth to Sroundwater:�feel 4/0 6-re/V r a✓` �+
1hod of determination or rroximallorl:
' 12A �E
lrtviiad 6/15/951 9
• CT'I`Y IIF SALEM WATER/SEWER ACCOUNT INPUIRY
fiL'C:i:ilJfd'K 010077 DIST: F OWNER: NOLET JOSEPH ETUX
' HILI_ TO:
fAF UP OUDR: 0004 L IL.I-ION ROAD ADDRESS: 0004 LILLIAN ROAD
NPAUR !: 1 : B SEWER CODE : R CITY. ST: SALEM MA 01970
F: L l.. t READING 1: BILL. DISC. INT. AMT ARAM T p1_m-f BPI no,
NO, :'l.p;i=?C31:_ AMOUNT AMT. PAID PAID AMT PICT NUFi
floss 22500 0 l N 18. 20 1 . 82 . 00 16. 38 00
1300 .. . 00 . 00 . 00 . 00
i ' 077 24400 Art 26. 60 . 00
1900 . 00 . 00 . 00 . 012) 00
DON =112 1.L112 02 697
20515 25poo Mw 14. 00 .1. 40 . 00 12. 60 . 00 . 0Vj
800 is . 00 . 00 . 00 00 0:':
0 w . 00 . 00 . 00 . 00 . 00 OV!
e 0 00 . 00 . 00 00 0;;,
49 1?1 Em 4117 F: WATER, . 000 PER DIEM RATE SEWER: 000
14077N 01LUEID 58.R0 W'T'R .DUE_ . 00 CALL. INT. . 00 'T'OTAL, . 0i2l
-'D'IPD 00 SWR DLA= . 00 CAI_C, INT. . 00 TDTAL 00
Iii!.) l.17:1:: ii) TOT DUE . 00 CAL.C. INT. . 00 TOTAL . 00
'i
i
i
" CITY OF SALEM WATER/SEWER ACCOUNT INQUIRY
, .
011077 DIST: R OWNER: NOLET JOSEPH ETUX
'
BILL TO: '
*004 nILLlAN ROAD /lDDRESP: 0004 LILLIAN ROA[)
uw 1I0317& n D SEWER CODE : R CITY. ST: 5qi.EM MA
R | LL ��\/! READING C BILL DISC. INAAMT ABAMT ABMT %L |4� [`.�-
HO. /oEAGE AMOUNT AMT. PAID PAID AMT NO D(/E
00 01615 14200 A* 35, 00 3. 50 . 00 31 ^ 50 . 00 0D
n5@@ s , N0 ' 00 . . @@ . 00
'Y, V DgTE: @81695 ,
j ! 10915 18w0 Aw 56. 00 5. 60 . 00 50. 40 ^ N0
4000 s . / @ ^ 00 , NN . 00 . 0.t
PAY I`ATE: 11159".,
�
00 20258 20500 Aw 3@. 80 3. 08 . @m 27. 72 . 00 . 00
2200 . 00 . 00 . 00 . 00
PAY VATE: 022?96
P9648 21200 Mw 14. 00 1 . 40 . 00 12. 60 . 0@ @O
700 s , 00 . 00 , 00 . @17) N8
Nov \)AT[; 052996
:.AlFE NATERt . 000 PER DIEM RATE SEWER: . 000
W077! vl'!hu A35. 80 NTR DUE . 00 CAiC. INT. . 00 TOTAL . 01-')
sFH? y , ' ' RD to SWR DUE . 0* CALC. INT. . 00 TOTAL . 00
(!W` U717 10 [>UE 00 CALC. lNT. . @@ TOTAL . @0
�
'
/