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20 LINDEN AVE CS��) i Pet Commonwealth of Massachusetts vw 0 Title 5 Official Inspection For Not for Voluntary Assessments TIN 2 9 04 Subsurface Sewage Disposal System FormC � Inspection results must be submitted on this form or on the official Title 5 Inspi:tition Form dated 6/1512000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the computer, use Peter and Nicole Bickell only the tab key Owner's Name to move your 20 Linden Avenue cursor-do not use the return Owner's Address key. 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Date of Inspection: Date 8 Date 2. Inspector: Dustin L. Prieur Name of Inspector Preventative Septic& Drain, LLC Company Name 327 Asbury Street Company Address So. Hamilton MA 01982 City/Town State Zip Code 978-468-9001 Telephone Number Certification Statement: 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 ❑ eed Furthyer Evaatiop by the Local Approving Authority /� 5/15/08 Inspector's Signature Date 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. ****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. 20 Linden Ave laundry.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 20 Linden de Avenue a ue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection 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: This is an inspection report for the laundry system, it is working excellent. B) System Conditionally Passes: ElOne or mores components as described in the"Conditional Pass'section need to be system replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ 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. ND Explain: 20 Linden Ave laundry.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 2 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: 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 20 Linden Ave laundry.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ' Subsurface Sewage Disposal System Form A. Certification (cont.) 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 20 Linden Ave laundry.doc•11/2004 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owners Name Date of Inspection 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 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool NIA ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Yz day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: 0. ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. NIA El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. N/A ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A ❑ ® 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. 20 Linden Ave laundry.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 20 Linden Avenue Property Address Salem MA 01970 Cityrrown State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection 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, 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. 20 Linden Ave laundry.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 20 e Avenue Linden e e u Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? E] ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 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? ® E] information the facility owner(and occupants if different from owner) provided with 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 the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 20 Linden Ave laundry.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7 of 7 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 0 Number of bedrooms (actual): 0 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 0 Number of current residents: 4 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2 year usage Sump pump? ❑ Yes ® No Present Last date of occupancy: 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: Last date of occupancy/use: Date Other(describe): 20 Linden Ave laundry.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments wM Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection General Information Pumping Records: pumped never Source of information: Cesspool p p Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Cesspool not pumped there was only three inches. NO GW proved with soil testing info from 1 Peter Rd. 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) El maintenance technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Over 40 years old per homeowner Were sewage odors detected when arriving at the site? ❑ Yes ® No 20 Linden Ave laundry.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA 01970 Citylrown State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 30 +/ feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): 2" dia. Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer pipe is in satisfactory condition. 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 ❑ Yes ❑ No 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? 20 Linden Ave laundry.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection 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 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 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): 20 Linden Ave laundry.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection Tight or Holding Tank(cont.) 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.): Distribution Boxes (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No D-box 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.): No D-Box Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 20 Linden Ave laundry.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA 01970 Cityrrown State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection 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: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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.): 20 Linden Ave laundry.doc•11/2004 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA 01970 Cityrrown State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth —top of liquid to inlet invert 48 Depth of solids layer 0 11 Depth of scum layer 0 il Dimensions of cesspool 53"D effective X 40" Materials of construction Cinder blocks Indication of groundwater inflow 0 Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): The cesspool has tremendous storage area, the cesspool was inspected with a camera inspectgion snake, there was only three inches of liquid in the cesspool there was 48"of leaching area from the top of the liquid level to the inlet invert. There was not enough liquid to justify pumping. 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.): 20 Linden Ave laundry.doc•11/2004 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System Page 14 of 14 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch 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. PREVENTATIVE SEPTIC O�� Septic System Maintenance 327 Asbury St. 4Q S. Hamilton, MA 01982 qtr (978) 468-9001 l3[tc�[. a•F �'OuSL ao ° Y w� (� 1000 SPP ro)r. L / q 5„ No 71v snee le ,.S 1 _ m n e. c• d�"""�" /F�n1ce Ti le�6fficia�lnspection Porm:Subsurface Sewage Disposal System Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA 01970 Cit /Town State Zi Code Y P Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection Site Exam: Slope 1% Surface water none. Check cellar Partially finished and dry Shallow wells none Estimated depth to ground water: >121" 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 ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: checked soil testing for the septic design for 1 Peter Road ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed LISGS database-explain: You must describe how you established the high ground water elevation: Soil testing completed by Hancock Associates on 3/2/05 for 1 Peter Rd showed no groundwater @ 121" in T-1. The cesspools building sewer is 30" below grade, there is an additional 51" of depth from the building sewer to the bottom of the cesspool. It could be accurately estimated that the cesspool bottom is 81"-90" below grade. With no GW being found at 121"this system is not interfacing with groundwater. 1 Peter road is abutting 20 Linden Ave, the test hole is within 50 feet of 20 Linden Ave's SAS. 20 Linden Ave laundry.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16 Yahoo! Mail - dustinprieur@yahoo.com Page 1 of 3 -YA14 0tMAIL Print-Close Window a Ciaasic From: "Vadav Talacko"<vtalacko r hancocka sociatessmn> To: "Dustin PrieuraDus[nP.eurgyahoocom> Subject'. 11796formil doc Date: Tu,,,10]un 2008 08:39:57-0400 A. Facility Information 1. Facility Information Debre Daulkms Owner Name 1 Peter Road _ Mepi-ot 30113 Street Address Salem MA 01970 city State Zip code B. Site Information 1. (Check one) New Construction Upgrade Repair 2. Published Soil Survey available? Yes No If yes: 1981 1:15840 Year Published Publication Scale Sail Map Unit _Uroan land Soil Name Sail limitations 3. Suffcial Geological Report available? Yes No If yes'. Year Published Publication Scala Map Unit Geologic Meleriat Landform 4. Flood Rate Insurance Map: Above the 500 year Flood boundary? Yes No Within the 100 year flood boundary? Yes No Wthin the 500 year flood boundary? Yes No Within a Velocity Zone? Yes No 5. Wetland Area: National Wetland Inventory Map Map Unit Name Wetlands Conservancy Program Map Map Unit Name 6. Current Water Resource Conditions(USGS) February 2005_ Range: Above Normal Normal Below Normal Montbnear 7. Other references reviewed: C. On-Site Review (minimum of two holes inquired of every proposed disposal area) Deep Observation Hole A: 3Q05 _10 am 20 den sunny_ Date Time Weather 1. Deep Observation Hole Logs Deep Hole Number T-1 Ground Elevation at Surface of Hole Location(Identify on Plan) see sketch 2. Land Use: lawn _none 0-3 (e.g,woodland,agricultural field.vacant lot.spot Suface Stones Slops(%) grass Vegetation Landform Position an landscape(attach sheep 3. Distances from: Open Water Body_100+_ Drainage Way 10+ Possible Wet Area 100+ feet feet feel Property Line 10+ Drinking Water Well n/a_ Other feat feet 4.Parent Material: Unsuitable Matenals Present: Yes No If Yes: Disturbed Soil Fill Material Impervious Layers) Weathered/Fractured Rock Bedrock 5.Groundwater Observed: Yes No If Yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: ,,.has elBVallen http://us.f3 87.mail.yahoo.com/ym/ShowLetter?box=Inbox&Msgld=6894_6954599_25345... 6/12/2008 Yahoo! Mail - dustinprieur@yahoo.com Page 2 of 3 Deep Observation Hole A: Deep Hole Number: T-1 Soli Soil Matrix: Redoximorphic Features Soil Texture Coarse Fragments Soil Structure Soil Horizon/ color-Moist (mottles) (USDA) Consistence Other Layer (Munsell) %by Volume (Moist) Depth n.) Depth Color Percent Gravel Cobbles 8 Stones 0.34 Fill 34-44 Cl 2.5y7/4 MEDIUM SINGLE LOOSE SAND GRAIN 44-56 C2 2.5Y514 COARSE 15 SINGLE LOOSE GRAVELLY GRAIN SAND 56-121 C3 2.5Y4/4 COARSE SINGLE LOOSE SAND GRAIN Additional Notes NO E.S H.G.W. NO REFUSAL D. Determination of High Groundwater Elevation 1. Method used: Depth observed standing water in observation hole A. none B. inches Inches Depth weeping from side of observation hole A._none B. inches Inches Depth to soil redoximorphic features (mottles) A. none B. inches inches Groundwater adjustment(USES methodology) A. B. inches Inches 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes No D If yes,at what depth was it observed? Upper boundary: 34 Lower boundary: 121 Inches Inches F. Certification I certify that I have passed the all evaluator examination'approved by the Department of Environmental Protection and that the above analysis was performed by me Consistent with the required training,expertise and experience described in 310 CMR 15.017. 3/8/05 Slgneture of Soil Evaluator Dere Edward Cullen November 2002 Typed or Printed Name of Soil Evaluator 'Date of Soil Evaluator Exam http://us.f3 87.mail.yahoo.com/ym/ShowLetter?box=Inbox&Msgld=6894_6954599_25345... 6/12/2008 Yahoo! Mail - dustinprieur@yahoo.com Page 3 of 3 Martin Fair Salam Nem.W Board or Health Wines. Board of Hearin Note:This form must be submitted to the approving authority with Percolation Test Form 12 Use this sheet for field diagrams: http://us.f3 87.mail.yahoo.com/ym/ShowLetter?box=Inbox&Msgld=6894_6954599_25345... 6/12/2008 Commonwealth of Massachusetts Title 5 Official Inspection Forrp Not for Voluntary Assessments " " ^a Subsurface Sewage Disposal System Form " 1 I- ' Inspection results must be submitted on this form or on the official Title 5 Meirti5iffilm dated 6/15/2000. Inspection forms may not be altered in any way. c,, ` A. Certification Important: When fining out 1. Property Information: forms on the computer, use Peter and Nicole Bickell _only the tab key Owner's Name to move your 20 Linden Avenue — cursor-do not Owner's Address use the return key. 20 Linden Avenue ------ Property Address Salem MA 01970 City/Town State Zip Code Date of Inspection: Date/08 2. Inspector: Dustin L. Prieur Name of Inspector Preventative Septic& Drain LLC Company Name 327 Asbury Street _ Company Address So. Hamilton MA 01982 City/Town State Zip Code 978-468-9001 Telephone Number Certification Statement: 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 ❑ Need Further Evalu n by the Local Approving Authority oZ 5/15/08 — Inspe or's Signature Date 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. ****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. 20 Linden Ave.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System in good working order. The laundry discharges to a cinder block cesspool, a separate Title 5 Inspection report will be filed for that septic system. That cesspool is working excellent and will also meet the Title 5 Inspection criteria. B) System Conditionally Passes: ❑ one or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ 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. ND Explain: 20 Linden Ave.doc•1112004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 20 Linden Avenue —-- Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: 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 20 Linden Ave.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (c)nt.) 20 Linden Avenue Property Address Salem MA _ 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 20 Linden Ave.doc• 11/2004 Title 5 Official Inspection Form,Subsurface Sewage Disposal System Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 20 Linden Avenue _ Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool N/A ❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y�day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: 0. ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. N/A El [:1 tributary portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. N/A ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A ❑ ❑ 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. 20 Linden Ave.doc•11/2004 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System Page 5 of 5 l _ Commonwealth of Massachusetts Title 5 Official Inspection Form F Not for Voluntary Assessments w„ Subsurface Sewage Disposal System Form A. Certification (cont.) 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a 9P 9P design flow of 10 000 d to 15 000 d. 9 � � For large systems, you must indicate either"yes" or"no"to each of the following, 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. 20 Linden Ave.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 6 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments wM Subsurface Sewage Disposal System Form B. Checklist 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickel[ 5/15/08 Owner's Name Date of Inspection 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 ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 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 the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 20 Linden Ave.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ww Subsurface Sewage Disposal System Form C. System Information 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): N/D Number of bedrooms (actual): 3 -- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4______ Doesresidence 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 2year usage 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Present 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: Last date of occupancy/use: Date Other(describe): 20 Linden Ave.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue _ Property Address Salem MA 01970 Cityrrown State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Homeowner Pumped in 2006 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 Gal. _ gallons How was quantity pumped determined? Truck Sight glasses Reason for pumping: Check the septic tank for structural defects 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) F-1 maintenance technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Over 40 years old per homeowner Were sewage odors detected when arriving at the site? ❑ Yes ® No 20 Linden Ave.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection Building Sewer(locate on site plan): 30" Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC El other(explain): 4" dia. Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer pipe is in satisfactory condition. Septic Tank (locate on site plan): Depth below grade: 20 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain) Good Condition If tank is metal, list age: -- years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) Dimensions: x8'W x 52"D eff. Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness V Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Taped 20 Linden Ave.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 _— owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank was found in good condition all baffles in good condition. Liquid at outlet invert. 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 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): 20 Linden Ave.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 11 Commonwealth of Massachusetts 1psTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection Tight or Holding Tank(cont.) 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.): Distribution Boxes (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): The box is in fair condition ,distributing equally. There is no evidence of excessive solids carry over, the box seems to be watertight. The D-box is 30" below grade and the outlet invert of the leaching lines is 50" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 20 Linden Ave.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form shy C. System Information (cont.) 20 Linden Avenue — -- Property Address Salem MA _ 01970 City/Town State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection 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: Type: ❑ leaching pits number: ❑ leaching chambers number: --- ❑ leaching galleries number: - ® leaching trenches number, length: 3 X 30' _ ❑ 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.): Soil around the leaching area looks dry, no signs of breakout or hydraulic failure. The soil around the D-box is a very coarse and sandy gravel, The system has grass over the system. 20 Linden Ave.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments w Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA _ 01970 CityfTown State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection 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 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.): 20 Linden Ave.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA _ 01970 clty/Town State Zip Code Peter and Nicole Bickell 5/15/08 _ -- Owner's Name ' Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch 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. PREVENTATIVE SEPTIC — —' Septic System Maintenance 327 Asbury St. 0� S. Hamilton, MA 01982 4Q (978) 468-9001 13 � a u fid vy 1000 ��Prpk S � ��¢ � .etc• f !� 2'0"L"i� ve. oc•'1'Y/2QQ4`_�._._.._.�._....�.. .�.- � ...........�....._._._, p ._,.,�. �.._..._...._.,>�......_.___._�._...._�._...,.,>. Tile Offaal Inspection Form'.Subsurface Sewage Disposal System 15 of 15 — 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Linden Avenue Property Address Salem MA 01970 _ Cityrrown State Zip Code Peter and Nicole Bickell 5/15/08 Owner's Name Date of Inspection Site Exam: Slope 1% Surface water none. Check cellar Partially Finished and dry. Shallow wells none Estimated depth to ground water: > 121" 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 ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: checked soil testing for the septic design plan located at 1 Peter Road ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Soil testing completed by Hancock associates on 3/2/05 for 1 Peter Road showed no evidence of groundwater @ 121" in T-1. The bottom of the leaching area is no greater than 62". This system is not interfacing with groundwater. 20 Linden Ave.doc•1112004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16 Yahoo! Mail - dustinprieur@yahoo.com Page 1 of 3 MAIL Prim-Close Window From: "Vaclav Tolacko'•:v[a acko(PM1a ndocka5,ed0te9.Cumr To: •'Dustin Prieu, ou,ttRrPr,eu1C1dhoo.com> Subject; 11796formil.(loc Data: Tie,10 tun 2005 09:3957-C400 A. Facility Information 1. Facility Information Debre Caulki_ns _ Owner Name 1 Peter Road _ Maphot_i0113 Sheet Addl Salem MA 01970 qty-- State Zip Code B.Site Information 1, (Check one) New Construction Upgrade Repair 2. Published Soil Survey available? Yes No lived: _1981 1:15840_ Year Published Publication Scale Soil Map UnA _uman land Soil Name Soil limitations 3. Surfcial Geological Report available? Yes No If yes: Year Publlabed Publication Scale Map Unci Geologic Molehill Landform 4. Flood Rate Insurance Map: Above the 500 year flood boundary? Yes No Wthin the 100 year flood boundary? Yes No Within the 500 year flood boundary? Yes No Within a Velocity Zone? Yes No 5. Wetland Area'. National Wetland Inventory Map Map Unh Name Wetlands Conservancy Program Map Map Urt Name 6. Current Water Resource Conditions(USGS) _Februa 2005_ Range: Above Normal Normal Below Normal Monthi 7. Other references reviewed: C. On-Site Review (minimum of two ho/es required at every proposed disposal area) Deep Observation Hole A: 3mo5_-_ A In __ZD deg ad'_ Data Time Weather 1, Deep Observation Hole Logs Deep Hole Number—T-1— Ground Elevation at Surface of Hole Location(Identify on Plan)_see sketch 2. Land Use: lawn _none _0_3_ (e.g.woodland,agricultural field,vacant lot,etc.) Surface stands slope(.) �raas Vegetation Lindholm Position on landscape(attach sheet) 3. Distances from: Open Water Body 100+_ Drainage Way_10+_ Possible Wet Area 100+_ feet feet feet Property Line 10+_ Drinking Water Well n/a_ Other feet reef 4.Parent Material: Unsuitable Materials Present:r Yes No If Yes: Disturbed Soil Fill Material Impervious Layer(s) Weathered/Fractured Rock Bedrock 5.Groundwater Observed.. Yes No If Yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: inches elevation http://us.f3 87.maii.yahoo.com/ym/ShowLetter?box=Inbox&Msgld=6894_69545 99_25345... 6/12/2008 Yahoo! Mail - dustinprieur@yahoo.com Page 2 of 3 Deep _Observation Hole A: Deep Hole Number: T-1 Soil Soil Matrix: Redoximorphic Features Soli Texture Coarse FrVP ructure Sall Horizon/ Color-Moist (mottles) (USDA) Consistence Other Layer IMne.ell) h by V (Moist) Depth Depth Color Percent Gravel 0-34 Fill 34-44 C1 2.5y7/4 MEDIUM E LOOSESAND 44-56 C2 2EY5/4 COARSE 15LE LOOSEGRAVELLY NSAND 56-121 C3 2.SY4/4 COARSE LE LOOSESAND N Additional Notes_NO E.S HG.W. NO REFUSAL -- --- - _ - _— D. Determination of High Groundwater Elevation 1. Method used: Depth observed standing water in observation hole A. none S. inches Inches Depth weeping from side of observation hole A._Done Inches Inches Depth to Soil redoximorphic features (mottles) A. none B. Inches incl.. Groundwater adjustment(USGS methodology) A._ B. inches inches 2. Index Well Number Reading Dale Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes No E.If yes,at what depth was it observed? Upper boundary: 34 Lower boundary:_121 Inches Inches F. Certification I certify that I have passed the soil evaluator examination'approved by the Department of Environmental Protection and that the above analysis was performed by me Consistent with the required training,expertise and experience described in 310 CMR 15.017. 318105 Signature of Soil Evaluator Date Edward Cullen _November 2002 Typed or Punted Name of Soil Evaluator Data of Soil Evaluator Exam http://us.f387.maii.yahoo.com/ym/ShowLetter?box=Inbox&Msgld=6894_6954599_25345... 6/12/2008 Yahoo! Mail - dustinprieur@yahoo.com Page 3 of 3 Martin Fair_ salem Nem.of Bard of Health Vftnass gond or Health Note:This form must be submitted to the approving authority with Percolation Test Form 12 Use this sheet for field diagrams: http://us.f387.maii.yahoo.com/ym/ShowLetter?box=Inbox&Msgld=6894_6954599_25345... 6/12/2008 FORM 4 - SI'STE\f PUMMG RECORD Commonwealth of Massachusetts SALEM , Massachusetts System Pumping Record }stem �\ner }•stem Location BROWNING 20 LINDEN AVE Date of Pumping: 8/29/01 Estimated p g: Quantity Pumped: 1000 gallons Cesspool: No ❑ Yes ❑ Septic Tank: leo ❑ Yes El RAGGS SEPTIC SERVICE, INC. System Pumped b}•: d .b.a. E. A. COMEAU SEPTIC License r; Contents transferred to: WATER SOLUTIONS GROUP, TAUNTON Date . 11/7/01 lnspectorRA!_r_c CFPTrr• ennvrno TNC µ N pTMi FORM 4-SY S't'F.A1 FUl►MGRBCORD C onunonwealth of Afassachusetts SALEM , Massachusetts System Pumping Record ystem %%mer ystem Location ERIN BROWNING 20 LINDEN AVENUE Date of Pumping: 3!.31/06 Quantity Pumped: . 1000 gallons. Cesspool: No ® Yes . ❑ Septic Tank: No ❑ Yes 0 RAGGS SEPTIC SERVICE, INC . System Pumped by: d .b.a . E. A. COMEAU SEPTIC License n: Contents transferred t0: WAYLAND-S Date 411 S,i n r Inspector RAGGS SEPTIC SERVICE , INC. APR 2 0 2606 CITY OF SALEM BOARD OF HEALTH "r*c •><�� . x.,v � m � �... � '� ;. JUNe 8 2005. ., . fol a_,A u u o. � �,�. CITY OF SALEM �z ROARD OF,HEALTftbase call with questions/concerns (v�I�foYr�(rJ ��WVII We appreciate your business PO BOX 7 Wenham,MA 01984 Septic System Function.CFceckand humping 1�epOl t Property Owner's Name: PP Property Address: Q /i n H Sar lPl�i N Date of Pump/Function Check 5/11�aS Routine: ®%--'Emergency: ❑ Technician' �7A r�('U� SEPTIC TANK SYSTEM R<ngle Compartment ❑ Double Compartment *YES indicates there is a problem, NO indicates there is noproblem YES NO Tank structure v Breakout or pondingt/ Li "uidlevel5WoVeinlet invert Liquid level above outlet invert Tee or Baffles missing or broken inlet Tee or Baffles missing or broken, outlet 1/ FILTER PRESENT ❑ Yes �No TYPE: Condition: ___`� ❑Cleaned ❑Replaced .❑Installed = TANK LEVELS AND MEASUREMENTS Size of tank D Actual amount pumped /Dl O Scum layer (acceptable range 1-2") Sludge depth (acceptable range 5-10') & Li uid level o OVERFLOW TANK PRESENT ' he's Size of tank Actual amount pumped Liquid level Condition COMMENTS: tia./ 7 COMMONWEALTH OF MASSACHUSETTS - EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a` Metropolitan Boston —Northeast Regional Office JBV JANE SWIFT BOB DURAND Governor, Secretary LAUREN A.LISS Commissioner August 9, 2001 Frank E. Campbell Drains, Inc. P.O.O. BGA Winthrop, Massachusetts 02152 . Re:Subsurface Sewage Disposal System 5 Inspection Report AUG 6 2001 20 Linden Street,Salem (IS.-North Coastal) CITY OF SALEM Dear Mr. Campbell: HEALTH DEPT. On Angus;3, 2001,the Department received the enclosed copy of the Subsurface Sewage Disposal System Inspcci^r Report for the property located at 20 Linden Street in Salem. Please note tis,.the,. Salem Board of Health is thg applicable regulatory authority to which the inspection form should have i:orwarded._That is why the L'.urtar anent is returninrg the inspection form to you. — _ The Department has perused the inspection form and notes that a separate and distinct inspection fora,must be.completed for the laundry dry well. The dry well'sy stem would be inspected,in accordance with the procedures for inspection of a cesspool. Should you have any questions regarding this matter, please contact Claire A. Golden,of my staff, at (979)661-7743. Very truly yours, Madelyn Morris Deputy Regional Director Bureau of Resource Protection MM/CAG/cg \200 1 disk5\clarification\salem\201indenstinpection I - Enclosure cc: Joanne Scott,RS,CHO,Agent,Board of Health,9 North Street,Salem,MA 01970(w/o enclosure) . Elizabeth Bouchard,20•Linden.Street„Salem,M,A,01970?(w/o enclosure.): t Lawrence Muller,20•(jnd'en,Street, Salem,MA 01970(w/o enclosure) - Virginia Kieran,20'Cinden Street,Salem,MA 01970(w/o enclosure) This information is available in alternate format by calling our ADA Coordinator at(617)574-6872. 205A Lowell St. Wilmington,MA 01887 • Phone(978)661-7600 • Fax(978)661-7615 • TTD#(978)661-7679 Leta.Printed on Recycled Paper ASA ' COSI- 10:\W&UTH OF MAsSACHITSETTS INS15C. EXECUTIVE OFFICE OF EN_VIRON',NIE_X'F-A_L ArFAIR: DRA. . !:1: ,. w4f; SER� DEPAIUMENT OF ENVIRONMENTAL PI{011LCTION O-NE WINTER STREFT. 130ST0,X AL-� 0210S (6171 292-5.50o TRUDY CORE ARGEO PAUL CELLUCCI Secrets,,. Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM DAVID B. STRUTJSCommissioner PART A CERTIFICATION Property Address: [4L,�,K1. Name of Owner Date of inspection: Address of ow,a,:. NOTOO Of Impactor:11316",Print) Fr4vy, I am a DEP al) Oved 3Y st nspector pursuant 10 Section 15-340 Of Title 5 1310 CMR 75.0001company Noma: %-Prp Mailing Address Telephone Number: CERTIFICATION STATEMENT I certify that-Fhave personally inspected the sewage disposal system at this address and that the information reported below is True, accurate and complete as of the me inspection. The inspection was performed based an my training and experience in the Proper function and maintenance of on-site s age disposal systems. The system: time — Conditionally Passes — Needs Further Evaluation By the Local Approving Authority Fails ImPector's Signature: Vrzzv Date: 1-6k -c:iI The System inspector shall submit a copy Of this inspection report to the Aproving Auhority(Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design pflow of 10,t000 gpd or greater, the inspector and the system owner shall submit the repo"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 authority. NOTES AND COMMENTS TFIL AUG led. Lwa 62001 CITY OF SALEM HEALTH DEPT. revised 9/2/98 Rigs I of II NecydrJ Vann SUBSURFACE SEWAGE DISPPOOSSA SYSTEM INSPECTION FORM ASAP. CERTIFICATION(continued, ��AINS r 'ropxxty Address: :zC � r ' - _ INC. _.- -Jwner: 6L, rN .: SF yy-�t.'+`. t.(FEni °.:NER -C LEANIN b....4'v� G SERV Date of Irtspeotion: `« INSPECTION SUMMARY: Check A, B. C. of D: A- SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. criteria not evaluated are indicated below. COMMENTS: Any failure bi? B. SYSTEM CONDITIONALLY PASSES: One l more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon Pass- completion of the replacement or rep a as a approved by the Board Of Health, will pass. Indicate yes, no, or not determined (Y, N, or NDI. Describe basis of determination in all instances. If 'not determined', explain why not. The septic tank is metal, unless he owner Or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating at the tank was installed within tweet 20 the septic tank, whether or not me I, Y f I Years prior to the date of the inspection; or failure is imminent. The system will is cracked, structurally unsound, shows substantial infiltration or"filtration, or tank ass inspection if the existing Septic tank is replaced with a complying approved by the Board of Health. g P P septic tank as Sewage backup or breakout or high static w I level observed in the distribution box is due to broken or obstructed i y or due to a broken, settled or uneven distribut n box. The system will pass inspection if (with n Health). P pals, broken r pprovul of the Board of p'pelsl are replaced obstruction is removed distribution box is levelled or rePI ed The system required pumping more than four times a Ye due to broken Or obstructed pipes I. The system will pass inspection if(with approval of the Board of Health broken Pipe(s) are replaced - Obstruction is removed revised 9/2/98 Page 2 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ASAIP Y PART A D]EYAINS INC. CERTIFICATION fcontinued) LnPtit7 ::EH'ER f, 1 1EtiNING SERy Property Address: 2G Owner: Date of Inon specti : e .''•k V U-z f C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which re uire further evaluation by the Board of Health in order to determine if the system is failing to protect the Public health, safety and t environment. 1) SYSTEM WILL PASS UNLES BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A M NER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within feet of surface water Cesspool or privy is within 50 eet 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 THA PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic to and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water pply. The system has a septic tank nd soil THE system and the SAS is within a Zone I of a public water supply well. y _ The system has a septic tank a soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank an soil absorption system and the SAS is less than 100 feet but 50 feet or more from a privale water supply well, unlass a all water analysis for coliform bacteria and volatile organir. compounds indicates that the well is tree from pollution Irom that cibty and the presence of enenontu mtrupen end "Mate nitrogen is aqua) in or Inns than 5 ppm. Method used to determi distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ASAP z PART A DRAIN SI mc. CERTIFICATION Icorrdnuedl cerEr;f HILR CLEaNING SER Property Address: .;ju ti,:�r],r,�• Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either 'Yes' 'No" to each of the following: 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 identifi d below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sew a into facility-or system component due to an overloaded or clogged SAS or cesspool. Discharge or Pon 'ng of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level ih th distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more the 4 times in the last year NOT due 10 clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorpti n System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is ithin a Zone I of a public well, Any portion of a cesspool or privy is withi 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: You must indicate either "Yes" or "No" to e h of the following: The following criteria apply to larges tams in addition to the criteria shove: The system serves a facility with a design low of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment beta a one or more of the following conditions exist: Yes No the system is within 400 feet of a surfa\9de plythe system is within 200 feet of a tributng water supplythe system is located in a nitrogen sensilhead Protection Area -IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade thesystemin accordance wit\ 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ASAP PART B"FOI)iZAYNS�C. nertY Address: �Lr.iv j2�v , / 1 �Gi {ZL C�tHECtIKLIS T Owner: Date of Inspection: Jw: vc¢ ,f -pt -pj I i.J'L i!i '.}nLlr fLLANING SEI' 2#`I""v L-� Check if the following have been done: You must indicate either "Yes" or "No' as to each of the following: Yves No Pumping information was provided by the owner, ant or Board of Health. (� None of the system components have beenum rates during that period. Large volumeseastweeks nd inspection, of water have notl been introduced been oft a sys emystem fres been receiving normal flow cently or as part of this As built plans hav8 I been obtained and examined. Note if they are not available with N!A, , J _ The facility or dwelling was inspected for signs of sewage backup. 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 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. For example, Plan at B.O.H. _ 115.3 0Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptahlel _ The facility owner land occupants,if different from owner) were provided with information on the Subsurface Disposal Systems. proper maintenatu,-0f —6 to 5` 1�25C 4adl a.ti revised 9/2/98 Page 5 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. ASAP PART C DRAINS wc. SYSTEM INFORMATION 'roperty Address: ap 4, AV, � (- c� / -. 1EI f=-LiiER CLEntIING SER• Owner: rlf 2,h _ � " .7'�^� / VFU:'l 2p�r{ Date of Ins JL. fd- („�wf2,v C� 41.i l�t'_!' . pecdon: RESIDENTIAL: FLOW CONDITIONS Designflow: .I1Q g.p.d./bedroom. Number of bedrooms (design):a Number of bedrooms (actual):.3 Total DESIGN flow — Number of current residents: 1 Garbage grinder(yes or no):" Laundry(separate system) (yes or no):�� If yes, separate inspection required Laundry system inspected (yes or no) 'iCS Seasonal use lyes or no): .go Water meter readings, if available (last two year's usage(gpd): Sump Pump(yes or no): � Lest date of occupancy: L¢� COMMERCIAL/INDUSTRIAL, Type Of establishment: Design flow: d ( Bused on 15.203) Basis of design flow Grease trap Present: (yes o of —-- Industrial Waste Holding lank esent: (yes or no)_ -- Non-sanitary waste discharged to Title 5 system: (yes or no) Water meter readings, if available: — Last date of Occupan y: OTHER:(Describe)_ Last date of occupancy GENERAL INFORMATION PUMPING RECORDS and source of information: -- 1�"'�c1'�i5tr C �n�ra 21S��cl Qr��4C Str <<. lLn� �00 , ram pumped as part of inspection (yes or nol_ If yes. volume pumped: gallons Reason for pumping: Mvt TYP F SYSTEM t 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) VA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: lyes or no) revised 9/2/98 Page 64 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ASAPn,­ PART C DRAINS iNc. koperty,Address: SYSTEM INFORMATION (continued) 1 ,,Ptfil SCHER CLEANING SEF. k L.iN Owner: t�r•c.atu+1� ( ..,:.+,,,;}.i •Y� '^' ��';. L'1'1.7� . Date of Inspection: 11— Ci —Q .l 1e"A^' BUILDING SEWER: (Locate on site plan) Depth below grader Material of construction: 4 cast iron_ 40 PVC_ other (explain) Distance from private water supply well or suction linev v vim. Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK:_ (locate on site plan) rt Depth below grader �f/y./y Material of construction: 9Sconcrete_metal_Fiberglass _Polyethylene_other(explainl If tank is metal, list age_ Is.age confirmed 6y Certificate of Compliance_ (yes/Nol Dimensions: �C � DNciy� Sr �rStN+�S Sludge dept _ 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: 1 Distance from bottom of scum to bottom of outlet tee or baffle: )V_L ')(tOA How dimensions were determined: il/tBSSi �Q.t'� W I S r)c(, 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, deph of tliquid level in relation to outlet invert, structural integrity, ii evidence of leakage, etc.) .` j.t..,, :v. t ti y GREASE TRAP:_ (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene_ather(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: (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, etc.) revised 9/2/98 Pzgr7 f11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM / *T� PART C DRA�jr Sac. SYSTEM INFORMATION IconGmedl -..roti "cnER 11E'NING SERO 'roperty Address: Owner: CL. z-jr �� Jit 1C' Date of Ins � .:cV. � pecuon: �ti(. -"- ML- N1Ltl� 1�.ottr.i`c.a i-Gl TIGHT OR HOLDING K:_ (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _co crete_metal_Fiberglass_Polyethylane_othar(egtlein) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present_ Alarm level: Alarm in wo'r�\or : _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ w n /2 (locate on site plan) C01Kro, is J r[' ]..�'L'o-) Depth of liquid level above outlet invert:Ajp {r� c Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) CIC rI t i% PUMP CHAMBE\orderes y (locate on site Pumps in workio)_ Alarms in workio)_Comments: (note condition condition of pumps and appurtenances, etc.) revised 9/2/98 PaFca of 11 SUBSURFACE SEWAGE DISPOSAL SYS:NM INSPECTION FORM PART PR A INSIINNc., SYSTEM INFORMATION(condnuedl L'�Ylr 'roperty Address: Aco L.... = I -L-EN `_HAMN SSER' �. L �.0 M 1 Owner: �.L�T,.-h 2i-uJ CSc, Date of Inspection: 'a`/-Cr rvlui1'� �11�1rUt? K4�,,,—HN r$ —Gi - Cr SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; axcavation not required, location may be approximated by non intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: Ic {-4c � � 5 l�� ID Ll � leaching fields, number, dimensions: overflow cesspool, number:.. Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, CESSPOOLS:_ ILy o ------------- (locate —(locate on site plan) Number and configuration: Depth-top of liquid to inlet in art: Depth of solids layer: Jepth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumpecNas 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: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 1'aEr 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ASAP � PARTCI�RAdNSI C• SYSTEM INFORMATION(continued) 'ropertY Address: cZC �i.a da.v S� "I ::::h l "'i1NG SEIt Jwner: Date of Inspection?��c ';-'1�C 1.c.�F.rC(. C.v�;�•:n.c e -' I,u 1` Cr u i CS I•�a.q '\l Z,,.� ,� O ` i SKETCH OF S�pGE DISPOS�A�Cn!fSY.STEM: `t inclu ties to ate gYtpp$ permanent referent locat all we)l Qithin 100' (Locate where Public lwaterasupplY comes into rks or shouse) 1 , � I i I I CCI``' . 4• s.. _ 3 , F - - - 01 TN1 Lt- :5 Feet I revised 9/2/98 Page I II u(I I - - P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Aljrx PART C DRAINS INC. I 11 SYSTEM INFORMATION (contimedl :operty Address: achIN�.) SY• a SLI..v� ' Owner: GCt�a�1L-fin ' � Date of Inspection: G G✓-n.v��^«� {.t. (3r �f I rt,a �r�.:r9.,ll' NRCS Report name Soil Type Typical depth to groundwater ------- - - USGS Date website visited Observation Wells checked Groundwater depth: Shallow.Moderate Deep QU�'� model jC,r.r ,?w.yL/ 1 ( tell G SITE EXAM ✓Slope N a ti: ✓Surface water +�J,VC, ✓Check Cellar Quiz, Shallow wells JJ.A� Estimated Depth to Groundwater-C�Y—Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps _Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) NCO LZ Nzric ✓ !i t 12�. j .( Fv fro.. S c r.r ' fr, , revised 5/2/98 Pate 11 of 11