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169 MARLBOROUGH RD w 0 i x Y V 4 v t fk y!} } i o 4 r y.. Y• ♦ M MR rk ft 'f'#P' ��•�'.'tai . � k J!_ �}�Y , v t�� Customer Since A ill . � Customer Service Report E N V IRON ME N T A L System Owner System Location Thomas Mackey 6 Sons Inc. Job Site P.O. Box 366 169 Marlboro Road Salem, MA, 01970 Salem, MA, 01970 (978)-744-3849 x (978) -744-3849 x Thomas Mackey COLS Approx.Gal. Custom Clean Customer Home NO Number in Household 1 2 3 4 5 6 7 8 Zabel Filter System Type Stand I Tank Size 1000 22 20 18 16 14 12 12 12 T5 Frequency 1250 22 20 18 18 16 14 12 12 Previous Service 1500 24 22 20 20 18 16 14 14 Service Date 03/29/2007 09.gQilaAP 1750 26 24 22 24 20 18 16 16 Depth Below Grade Services Tech Name. IJ I yYN Score From Table Description Quantity Unit Price Ext Price Subtract 6 for Garbage Disposal Pumping 1001-1500 1 214.9700 $214.97 Subtract 5 if System is Older than 10 Years Fuel Surcharge Commercial 1 15.0000 $15.00 Add 8 for Seasonal Use Add 5 if System Additive is Used Net Score: Score Frequency Less than 5 Every 6 Months Subtotal $229.97 6 t 15 Every Year Tax $0.00 16 to 23 Every 18 Months Total $229.97 Greater than 24 Every 2 Years Tank Observations: Potential Solutions: Payment Details ❑System Operating Fine We suggest these 4 keys to keep your system healthy: Payment Type Invoice 1)Regular Servicing 2)Bacteria"Boost'at time of service Credit Card 3)Use Wind River Bacteria Additive Card#: 4 Use afilter ❑Excessive Solids Utilize Wind River Bacteria Additive Security Code ❑Heavy Sludge Introduce additional bacteria via Wind River Boost Program Ex Date Utilize Wind River Bacteria Additive p. ❑Tee Missing/Broken Repair/Replace Tee ❑High Liquid Level Could be an indication of system in hydraulic failure. Terms: Due on Receipt Suggest a system evaluation and/or a custom cleaning. Call the of f ice as soon as possible at 978-841-5017. El Distribution Box Issue We observed the following issues: :✓ �� ❑Missing Filter Use of a filter is one of the 4 keys to keeping our system healthy (�l i/ ❑Other t.. h 00 The observations and solutions identified may require additional treatment. Please call � 36 . __-- Amyy, our Customer Solutions Specialist, at 978-841-5017 with any questions, or for additionol information. Tech Notes: � { v�rEG` < < �" 6� 1�° tnov,en} Wind River Environmental LLC 163 Western Ave. , G1 /uccester,/34 1930 (978)-562-4500 r Time Arive Time Left Tech Initials CustomerSignature �_. WO-001 Customer Copy Rev 4/06 l _ , d.'„lw'y� Z .,r,o ' 'ex. °""-_.�L".' :' '""'"_.'°•?. ,:.L•°mv".."4','�"a.. . .L....._ � '.s '. ."` a":, " t.'"ilY"!'r,{ "i:Ra°' *"'gnCv.a�" �$yH"i��,. 310 CI a.. ME DEPARTNT OF ENVIRONlv1ENTAL PROTECTION ,' 15.302: continued (a) Determination of high groundwater elevation. A deep hole observation test is not required to determine high groundwater elevation during an inspection. It is intended that the high groundwater elevation be estimated by the inspector, using best professional judgment,based on the methods desribed herein. L The inspector shall review local maps and records of groundwater elevation (previous deep hole observation tests or groundwater monitoring results)on the site or nearby properties,if available. 2. If the system includes a cesspool,the cesspool shall be pumped during the inspection and then examinW to determine whether groundwater flows into the cesspool,indicating that the cesspool is below high groundwater elevation. 3. It the system includes a septic tank and distribution box, the condition of these components and the surrounding soil shall be observed for indications that groundwater has infiltrated the system. Care should be taken not to destabilize the distribution box or the piping to or from. These minimum requirements shall not prevent the use of additional methods. The elevation of nearby water bodies, or evidence of groundwater infiltration in other subsurface structures (for example, cellars), or hand augering to deternune depth may aide in determining whether the system is located in the groundwater. The methods used to determine high groundwater elevation shall be described in the inspection report. A system owner may choose to have the high groundwater elevation determined by an observation well or deep hole observation test to confirm or disprove the results obtained by the minimum requirements of310 CMR 15.302(3)(a),or in place of the minimum requirements. (b) Location of soil absorption system. The location of any cesspool must be determined. For systems with a septic tank and distribution box,excavation is not required to determine the location of the soil absorption system. Reference may be made to as-built plans of the system (if any). Where the failure criteria specified in 310 CMR 15.303(1)(c) are not in issue, the location may be approximated by considering design flow, location of the distribution box and direction of outlet pipes,and physical condition of the site. The location may also be determined by running a metal snake or similar device from the outlet of the distribution box and using a metal detector,or use of similar methods. Nothing in 310 CMR 15.302(3)(6)shall prevent an owner from choosing to establish the location of the leaching system through more intrusive methods. I S 303' SYstems Failing to Frotect Public Health and Safety and the Frivironment (1) If ore or more of the following conditions exist as documented by inspection by an approved System Inspector,or determined by the local approving authority or the Department, the system is failing to protect public health and safety and the environment and shall be upgraded in accordance with the timeframes of 310 CMR 15.305(1)and the standards of 310 CMR 15.404 and 15.405: (a) Criteria applicable to all systems: 1. there is backup of sewage into the facility served by the system or any component of the system as a result of an overloaded and/or clogged soil absorption system or cesspool; 2. there is a discharge of eluent directly or indirectly to the surface of the ground through ponding,surface breakout or damp soils above the disposal area or to a surface water of the Commonwealth; 3. the static liquid level in the distribution box is above the level of the outlet invert; 4. the liquid depth in a cesspool is less than six inches from the inlet pipe invert or the remaining available volume within a cesspool above the liquid depth is less than 44 of one day's design flow, 5. the septic tank or cesspool requires pumping more than four tunes a year; 6, the septic tank is made of metal; or the septic tank is cracked or is otherwise structurally unsound, indicating that substantial infiltration or exfiltration is occvrvig or is imminent; . 7. a cesspool,privy or any portion of the soil absorption system extends below the high. groundwater elevation; (b) Criteria applicable to cesspools and privies: 1. A cesspool or privy is located: a. within 100 feet of a surface water supply or tributary to a surface water supply; 11/3/95 310 CMR-548 t zN't"�+R,` MM:T,wf kMVpo' 310 GN DEPART�NT OF ENVIRONNMNiTAL PROTECTIONr N+f9 -°t-",r,*•�, _o?F rte_ _. r,^1� 15.304. continued 6. if size and use of the facility is relevant to the demonstration that an equal level of environmental protection has been provided,appropriate use restrictions shall be granted to ensure that such conditions are not changed. (c) An applicant for a determination pursuant to 310 OUR 15.304(3)shall file a request for such determination not less than two years prior to the date by which the owner would otherwise be required to obtain the groundwater discharge permit pursuant to 310 CMR 15.305(2). (d) In making any determination pursuant to 310 CMR 15.304(3), the Department shall impose such conditions as it determines appropriate to ensure protection of public health and safety and the environment. At a minimum, such conditions hall include upgrade of the system to the standards described in 310 CMR 15.304(:)(6)4., and a maintenance, monitoring and reporting plan as described in 310 CMR 15.304(3)(b)5. (4) Any system serving a facility with a design flow of 10,000 gpd or greater but less than 15,000 gpd shall be upgraded upon the order of the Department or the local approving authority when a specific circumstance exists by which the system threatens public health, safety or the environment or causes or threatens to cause damage to property or creates a nuisance as determined by the local approving authority or.the Department. Where necessary to protect public health and safety and the environment, the Department or the local approving authority may require the owner to install a recirculating sand filter or equivalent alternative technology in accordance with 310 CMR 15.202 or to obtain a groundwater discharge permit in accordance with 314 CMR 5.00 and 6.00. 15.305: Deadlines for ommlet"on of llperadcs (1) If a system is failing to protect public health and safety or the environment as set forth in 310 CMR 15.303(1) or 15.304(1), the owner or operator shall upgrade the system within two years of discovery unless: (a) a shorter period of time is set by the local approving authority or the Department based upon the existence of an imminent health hazard; or (b) the continued use of the system is permitted by the local approving authority in accordance with the provisions of an enforceable schedule for upgrade. Bases for continued use include,but are not limited to,proposals to connect to a sanitary sewer or shared system. A fiscal commitmc.lt to the sewering plan or shared system plan,together with an approved facility plan where appropriate, proposing connection or replacement of the failing system within five years,and an enforceable commitment by the owner to perform interim measures (for example, regular pumping) shall accompany any such local approval. Such approval shall expire in five years or upon the failure of the applicant for such approval to meet interim deadlines set forth in the enforceable schedule for upgrade and the plan. The Department may by specific written approval authorize the local approving authority to allow a longer period of time, where the municipality has provided the Department "a proposed implementation schedule for design and construction and has made a demonstrated financial commitment to the construction schedule. The Department may revoke any such approval if the approved schedule is not met. t 11/3/95 310 CMR-548.3 -.ITT � a Now Please call with questions/concerns e e We appreciate your business PO BOX 7 Wenham,MA 01984r Septic System Function CFieckand 1tmping Report Property Owner's Name: Aa 1 nt Vo;I Property Address: /&! /f 4r/ ,60e0L j4 woe- Date of Pump/Function Check: /01 14 / 0:9 Routine: ❑ Emergency: ❑ T CESSPOOL SYSTEM *YES indicates there is a problem, NO indicates there is no problem YES NO Tank structure Breakout or ponding1/ Liquid level above inlet invert l/ Liquid level above outlet invert t/ Tee or Baffles missing or broken inlet Tee or Baffles missing or broken outlet FILTER PRESENT [] Yes ,-No TYPE: Condition: ❑Cleaned ❑Replaced ❑Installed TANK LEVELS AND MEASUREMENTS Size of tank $C)6 44,e ►� 1► Actual amount pumped Go 6 NOV 1 Q ��� U Scum layer t t/ Sludge depth Z r CITY OF SALEM Liquid level G C o BOARD OF HEALTH OVERFLOW TANK PRESENT ❑ Yes U o Size of tank Actual amount pumped Liquid level Condition COMMENTS: LETTER OF TRANSMITTAL HANCOCK 25 Years of Excellence ASSOCIATES Providing Land Surveying, Civil Engineering, Landscape Architecture and 185 Centre Street, Danvers, MA 01923 Environmental Services Since 1978 Phone (978) 777-3050 Fax (978) 774-7816 www.hancockassociates.com TO: Salem Board of Health DATE: 11/8/2005 JOB #: 12408 120 Washington Street-4a'floor FROM: Jim Scanlan Salem MA 01970 RE: 169 Marlborough Road • We are sending you: ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order COPIES DATE JOB# DESCRIPTION 1 10/12/05 12408 Title V Inspection Report • These are transmitted as checked below: ® For approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For Bid due: ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS: Joanne: Please call me with any questions. Thanks Jim Scanlan COPY TO: SIGNED: If enclosures are not as noted,kindly 40us at once. x D fir+. 1��J N©V 1 q 2005 V GIT`t ��F H�p,LiH BOW) Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the computer,use Malachy Dillon only the tab key Owner's Name to move your 169 Marlborough Rd Salem MA cursor-do not owne use the return Owners Address key. 169 Marlborough Road Property Address d Salem MA 01970 City/Town State Zip Code Date of Inspection: 10/12/05 Date 2. Inspector: James Scanlan, P.E. Name of Inspector Hancock Associates Company Name 185 Centre Street Company Address Danvers MA 01923 Cityrrown State Zip Code 978-777-3050 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 ❑ Ned Further Evaluatiop by the Local Approving Authority In ors Signature Date e 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. Document2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 169 Marlborough Road Property Address Salem MA 01970 cityrrown State Zip Code Malachy Dillon 10/12/05 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: 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 itis structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: Document2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 L Commonwealth of Massachusetts Title 5 Official Inspection Form s Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 169 Marlborough Road Property Address Salem MA 01970 City/rown State Zip Code Malachy Dillon 10/12/05 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 Document2.doc•11/2004 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 169 Marlborough Road Property Address Salem MA 01970 Citylrown State Zip Code Malachy Dillon 10/12/05 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: Document2.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form s Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 169 Marlborough Road Property Address Salem MA 01970 CityITown State Zip Code Malachy Dillon 10/12/05 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 E] ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool E] ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %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:— ® ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. E] E] well.portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes If the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds Indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) Yes No ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. Document2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 169 Marlborough Road Property Address Salem MA 01970 Cityrrown State Zip Code Malachy Dillon 10/12/05 Owners 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. Document2.doc•11/2004 Me 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 169 Marlborough Road Property Address Salem MA 01970 Cityrrown State Zip Code Malachy Dillon 10/12/05 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? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) 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 ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® 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)] Document2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 169 Marlborough Road Property Address Salem MA 01970 City/rown State Zip Code Malachy Dillon 10/12/05 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 1 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)): 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): Document2.doc•11/2004 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 169 Marlborough Road Property Address Salem MA 01970 City/rown State Zip Code Malachy Dillon 10/12/05 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Unnown per owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 650+/- gallons How was quantity pumped determined? approximated from cesspool dimensions Reason for pumping: cesspool 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: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Document2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 169 Marlborough Road Property Address Salem MA 01970 Cityrrown State Zip Code Malachy Dillon 10/12/05 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ® cast iron ❑ 40 PVC4 ❑ other(explain): Distance from private water supply well or suction line: >10 feet to city service/water meter feet Comments(on condition of joints, venting, evidence of leakage, etc.): Building sewer pipe was observed in satisfactory condition. No leakage was observed. 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? Massachusetts Department of Environmental Protection.doc.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11/2004 Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 169 Marlborough Road Property Address Salem MA 01970 Cityrrown State Zip Code Malachy Dillon 10/12/05 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): Document2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 169 Marlborough Road Property Address Salem MA 01970 Cityrrown State Zip Code Malachy Dillon 10/12/05 Owner's Name Date of Inspection li 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 Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Document2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 169 Marlborough Road Property Address Salem MA 01970 Cityrrown State Zip Code Malachy Dillon 10/12/05 Owners 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.): Document2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection pect on Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 169 Marlborough Road Property Address Salem MA 01970 Cityrrown State Zip Code Malachy Dillon 10/12/05 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration One Depth—top of liquid to inlet invert 33"+/- Depth 3 +/Depth of solids layer 12 Depth of scum layer >1 Dimensions of cesspool 6 ft diameter 70"eff. depth Materials of construction Fieldstone Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): The cesspool was found in satisfactory structural condition. There was some inflow observed after pumping, however it subsided after 15 minutes. The lawn over the cesspool is typical for the property. There were no signs of hydraulic failure ponding or breakout observed. 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.): Document2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 169 Marlborough Road Property Address Salem MA 01970 Cityrrown State Zip Code Malachy Dillon 10/12/05 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. • t� �h 4 p =�. PL— 25 7-9 I i T—@ Massachusetts Department of Environmental Protecfion.doc.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System- 11/2004 Page 15 of 16 Ls Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 169 Marlborough Road Property Address Salem MA 01970 Cityrrown State Zip Code Malachy Dillon 10/12/05 Owner's Name Date of Inspection Site Exam: Slope 3-8% Surface water None Check cellar Extremely Damp, no sump pump. Shallow wells None observed Estimated depth to ground water: 6' 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: Nothing on file in area. ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A deep hole was excavated on 11/2/05 and evaluated by James Scanlan, Soil Evaluator. Mottling was observed 72 inches below grade, with observed weeping at 86 inches, placing the cesspool in the groundwater, and in failure. Document2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16