10 PETER ROAD /O /'�eTet tea/.
(syrt)
RECEIVED 05/18/2016 08:16AM 9787450343 Salem Health Dept
05/18/2016 08:14 9782814869 WINDRIVER PAGE 03/05
Al n7n7t 1101 �7 06120!2005
Commonwealth of Massachusetts Form 4--System Pumping Record I• 5
Massachusetts
System Pumping Record RECE6.1VED
MAY 1 a 2016
System Owner System Location Ci I Y 4- SALEM
Donadio Dominic Primary Borne 6OARU OF HEALTH
10 Peter Road 10 Deter Road
Salem, MA, 01970 Salem, DY.4, 01970
(978)-304-3170 x (976)-308-3170 x
Donadio Dominic
Type: Emergent Routine
Cesspool: No yes Septic Tank: No = Yes
Date of Pumping: z/01/N Quantity Pumped: /5-0U Gallons
System Pumped By: Wind River Environmental,LLC permit#:
Contents Transferred to:
Contents Disposed at:
Date: Pumper Signature: - ave Nll.�n
Condition of System/Other Comments (9� 4'0 S Porter St
8 radford, Ma 01835
Dep Approved Farm-12/07/95
Commonwealth of Massachusetts C-K- 3
City/Town of Salem Number
Application for Disposal System $ SU
Construction Permit Fee
Form 1A
DEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it.
A. Facility Information
Important:
When filling out Application is hereby made for a permit to: ❑ Const uct a new on-site sewage disposal system
forms on the ❑ air or replace an existing on-site sewage disposal system
computer, use epair or replace an existing system component
only the tab key
to move your
cursor-do not 1. Location of Facility:
use the return
key. /O
Address or L/ot-# Jd V !O
SG"
I�
City/Town State Zip Code
reNn
2. Owner
"Information
/�E-7V`O c'7-
Name TName
Address(if different if bove
City/Town State Zip Code
Telephone Number
3. Installer Information / /�
A,&J: � t fin/ (�D�N �T /r' �iV Teed'
Name Name of Company
Address
City/Town „a P" Sttaatttee-- Zip Code
9J�J�-�izj
Telephone Number
4. Designerinformati`nn
Name Name of Company
Address
City/Town State Zip Code
Telephone Number
t5forml a.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of Salem Number
Application for Disposal System $
Construction Permit Fee
Form 1A
A. Facility Information (continued)
5. Type of Building:
Dwelling ❑ Garbage Grinder(check if present)
Other: Type of Building Number of Persons Served
❑ Showers Number of showers ❑ Cafeteria ❑ Other fixtures
Specify other fixtures:
6. Design Flow: 3 3
Gallons per Day
Calculated Daily Flow: Gallons
7. Plan: J//T
Date of Original
Number of Sheets Revision Date
Title of Plan
8. Description of Soil: 4J/A
9. Nature of Repairs or Alterations (if applicable):
(70/IU)1i lTGC7
Z�� �r/�-i';� ��c /moi 3�✓G.
10. Date last inspected: Date
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
1
Commonwealth of Massachusetts
City/Town of Salem Number
Application for Disposal System $ qo
Construction Permit Fee
Form 1A
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and
not to place a system in operati n until a Certificate of Compliance has been issued by this Board
of
Signature Date
Application Approved By:
ra (.A Q
Name Date
Application Disapproved for the following reasons:
t5forrnl a.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
Form 4 -- System Pumping Record
Commwseealth of Massaclusetss
O
Massachusetts
System Pumdm Record
✓ /l 13�20
System O.nv System Location BOq 0,
rw; AD
�:�./
r rood '.7 pntaY [',at1. `�s.i
44A, x: 470 5�-.1 =ra, MA, 01970
741-05'Q x
Type: Emergency Routine
Cesspool: Na Yes Septic tank: hb OYes
Data of Pumping: E—� Quantity Pumped: Woo Salons
System pumped By: Wind PAw Enw wx¢nM/, UC Permit#:
Contents transferred to:
Contents Disposed at: C- �J
Date: pamper Signature:
Condition of System/Other comments
Dep Approved Form - 12/07/95
-TI
_�1
SEP 5 1996
GiTY Or SAUUM
HEALTH DEPT. FORM 4 - SYSTEM MWINCs RECORD
Commonwealth of Massachusetts
Salem, Massachusetts
System Pumping Record
System Owner System Location
Paul & Kathy Benoit in driveway
10 Peter Road
Salem
Date of Pumping: August 13, 1996 Quantity Pumped: 1000 gallons
Cesspool: No /X/ Yes /—/ Septic Tank: No /—/ Yes /X/
System Pumped by: Service Pumping & Drain Co. , Inc. License #
Contents transferred to: Salem Treatment Plant
Date: August 13, 1996 Pumper: B.M.
This is PROPRIETARY and CONFIDENTIAL information which may be used
only by the Board of Health for regulatory purposes.
A-
Commonwealth of Massachusetts
Title 5 Official Inspection Form 0�®�i
Subsurface Sewage Disposal System Form - Not for Voluntary Assessmelntse �' J220 �O
OqA�o�sq 11
u., 10 Peter Road OF,.
Property Address �T
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:
When filling out A. General Information
,
forms on the
computer, use 1. Inspector:
only the tab key
to move your Jonathan Granz
cursor-do not
use the return Name of Inspector
-
key. Preventative Septic and Drain LLC
Company Name
327 Asbury St.
Company Address
Hamilton MA 01982
renrn Cityrrown State Zip Code
978-468-9001 S113405
Telephone Number License Number
B. Certification
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
❑ Needs Further Evaluation by the Local Approving Authority
a;7
8/2/2011
Ins ct gnature 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.
t51ns•11110 Title 5 Oficial Inspection Form'.Subsurface Sewage Disposal System•Page 1 of 1
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 is in good condition.
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.
Check the box for"yes", "no" or"not determined" (Y, N, ND) 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.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2
L ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w„ 10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3
Commonwealth of Massachusetts
,p w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (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 fecal
coliform,bacteria indicates absent 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:
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
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
11 ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
Lt5m.-111110 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 4 of 4
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
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.
El ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
El ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
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.
t5ins•11/10 Title 5 Oficial Inspection Form'.Subsurace Sewage Disposal System•Page 5 of 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for 97Salem MA 010 8/2/2011
every page. City/Town State Zip Code Date of Inspection
C. Checklist
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?
El ® 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?
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(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): N/A Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins•11110 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 6 of 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. City(rown State Zip Code Date of Inspection
D. System Information
Description:
System is composed of a 1500 gallon septic tank distribution box serving two precast leachingip ts.
Number of current residents: 2
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 185.9 GPD
9 ( Y 9 (9P ))
Detail:
Water meter readings were provided by the Salem Water Department, GPD was averaged from
usage between 1/15/2009 through 1/11/2011(See attached copy).
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
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:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped every 2 years per homeowner.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. Citylrown - State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Accordingto the homeowner the system m was installed in 1984.
Y
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below rade: 31"
P 9 feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Building sewer is in good conditon, no signs of back up, leakage or any other problems. The line is
constructed of cast iron on the interior of the foundation wall and SCH40 PVC at the septic tank.
Septic Tank(locate on site plan):
2111
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 certificate) ❑ Yes ❑ No
Dimensions: 101 x 5W x 4'D Effective
Sludge depth: 2
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 31"
Scum thickness 1
11
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 15"
How were dimensions determined? Tape measure/sludge judge.
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 is in excellent condition, structually sound, no signs of leakage in or out, liquid at
outlet invert, inlet and outlet T's are in good condtion. Tank is located in driveway and has cast iron
manholes to grade over the inlet and outlet covers. The tank does not need to be pumped at this
time.
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
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
Y
every page.
Cit /Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integ,rity,
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):
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.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11110 Title 5 Oficial Inspection Form.Subsurface Sewage Disposal System•Page 11 of 11
Commonwealth of Massachusetts
up
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(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 distribution box is in fair conditon, structually sound, no signs of leakage in or out, no signs of
solids carryover, liquid at outlet inverts. D-box is 61" below grade, there is a riser bringing it to within
6" of grade. Speed levelers were installed at time of inspection to assure liquid is distributed equally
to the leaching pits.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances,
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
buts•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. Cityliown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ 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.):
The soils over the leaching pits are dry and grassy, consistant with the surounding yard. No signs of
breakout or hydraulic failure. The leaching pits were located and inspected using a push rod camera
and sonde locator. Both pits were found to be dry with no standing liquid in them. Bottom of leaching
pits are He below grade, top of pits are 66" below grade.
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
Sins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
k, 10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•11110 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 15
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
-
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high round water: 121" +
p g g feet
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 5
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
On 3/2/05 Soil testing was performed at 1 Peter Rd for a system design plan, the soil test was
performed by Edward Cullen and witnessed by Martin Fair, there was no ESHGW found at 121". The
deepest portion of this system is 8'6" (102") below grade putting it well above the ESHGW.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ma•11110 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 16 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Peter Road
Property Address
Paul & Kathy Benoit
Owner Owner's Name
information is
required for Salem MA 01970 8/2/2011
every page. City[Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t51ns•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17
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