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Septic Records y AeTe4 /W (Sewn�� I Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments jProperty Ad ss Owner Owners Nam � �•"�— information is p required for every &(md —Z(0— 1(!�- page. City/IowntaS to Zip Code Date'&Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 2/1 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: ° P � 4y ej K wife em Jr 1^� W—,4 s —10 — PR-1-50 --�i IVP S PrP f°�r �l 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): 'Al, M-C 4y;- t5ins•3113 Title 50ffdal In spection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r( �� Props A'Pess �./ c 1 C Owner Owner ams information is � -^ r- required for every CR/�/ page. City, n taS to 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. Immo out forms A. General Information filling out forms on the computer, use only the tab 1. . Inspector: key to move your cur do use the return �� Z use the return Na er�pectbr Ir661J��''��LLLL key. ArQ►�.. f� Com ISSS ��/� 7—,d) C Name yes & Compan Add as Q.fn 01970 C rrown Ste Zip Code S 79 39'8� Telephone Number License Number B. Certification Icertify 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 s performed based on my training and experience in the proper function and maintenance of on site �® swage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: 'ii T � asses ❑ Conditionally Passes ❑ Fails F 5tl ' voF r Needs Further Evaluation by the Local Approving Authority )V- p 3� Inspectors Sign re 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. t5ins•3113 Title 5 Official Inspection Fonn:Subwrface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 2 Property Address Owner Owners Name information is <:Z/1-CP - r�/� required for every `,TCP 4e // �t � - C,2 � 7 page. City/Town ` ta5 to Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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•3/13 Ttle 5 Official Inspection Fotm:Subsurtace Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P , /2,4 Property Addre Owner Owner's Name A/ C information is required for every --T {e gM / !�7" dl?70 p ' 2-4— Is page. cityrrovw 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 ❑ ❑ 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 ❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t51ns•3H3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface SewageDh•sposal System Form - Not for Voluntary Assessments Property Address// Owner Owner's Name ' information is sn� required for every D/970 -24— I. page. - City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ g/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: _ ❑ ►[x Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Eg-, 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. ❑ Ly, / Any portion of a cesspool or privy is within 50 feet of a private water supply well. El RX' 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- ❑ &;K10,000gpd. ❑ Lh 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 11 El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 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•3113 Title 5 0ffdal Ins peccion Forth:SubwKace Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ci Owner Owner'same information is �I�` A^A required for every lytn /rte of a-(-- page. Cityfro 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 2/ ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ L/ Were any of the system components pumped out in the previous two weeks? (jX ❑ Has the system received normal flows in the previous two week period? ❑ LIQ' 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 52/ available note as N/A) LTJ ❑ Was the facility or dwelling inspected for signs of sewage back up? tiG ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? B ❑ 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: ❑ 2 Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined 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): Number of bedrooms (actual): - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 3 ZD t5ins•3/13 Title 5 official Ins edon Fon:Subsurface Sewn a Di P B sposal Sys[em•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Addre , Owner Owner's information is r� c required for every page. City?own Sta a Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection El Yes No information in this report.) Laundry system inspected? X Yes ❑ No Seasonaluse? ❑ Yes (,9 No Water meter readings, if available (last 2 years usage(gpd)): Detail: 1 rr Sump pump? ❑ Yes No Last date of occupancy: r 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 1� No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes 0' No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Fom:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dispos I System Form - Not for Voluntary Assessments e Property Address Owner Owner's N information is required for every A _[ Ott? page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 26-Date Other(describe below): General Information Pumping Records: Source of information: of ger &e_r eo7c Was system pumped as part of the inspection? Yes F-1No gallons pR If yes, volume pumped: oZs O 1 0 1 n N s How wasuantit &7 q y pumped determined? OSS" � LO Reason for pumping: TIV Aee�i P 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•3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments k ad Property Addre Owner �L�•C,l.}-�l..r. C( S t% CLQ,(.,`, Owners Name r information is ,, C, required for every I� �v� —J_72 a •— �`� page. City)town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: OV\ feet Material of construction: ❑ cast ironO e Bur ❑ 40 PVC El other(explain): � f rlt .✓t Rl� r� r Distance from private water supply well or suction line: feetb Comments (on cond'tl ion of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): r� Depth below grade: feet Material of construction: 9soncrete ❑ 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: 0 "Z6&j �bHfJeef Sludge depth: WAs No Siu&qo t5ins•3113 Title 5 Oficial Ins pectlon Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments q Peel ILS Property Address n I 1 r/} Owner Owner's Name information is -S /•MA required for every 7�8.•l page. City?own 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 Wts J VSA /Alo s Scum thickness Al Q A,4 Distance from top of scum to top of outlet tee or baffle /Vol-� Distance from bottom of scum to bottom of outlet tee or baffle Nom How were dimensions determined? IR ASU L-A 4-"'be Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ur`A S Ca-r r -r c-4-- Grease Trap (locate on site plan): v!,V ¢/ 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•3/13 Title 50ficial Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address y pe4 2 O �1 Owner C / t�y`YJ Owner's Na information is In ' 7b �-2L_ Ir required for every +� /Y' J Page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): f e,e 1/0,4 1z. < . 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 ' . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 2 Owner Owners ryame information is required for every Lery 2S` (• V'r 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 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: p ❑ Yes ❑ No* Alarms in working order: L�f ❑ Yes ❑ No* Comments (note condition of pump cham er, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dispos System Form -Not for Voluntary Assessments r`a Property Address r'T Owner2AIN C OI S wner's Name information is ! + _ /w 'A- 0 q o ,�_ / required for every ,�1�¢u'/V/ /t'y�l' / ] � �(j page. Cityl-r State Zip Code Date of Inspection D. System Information (cont.) Type: U 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.): &�V-11e' o t/10 N i 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 t5ins•3113 Title 5 Widal Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P4er A Property Address �1r''e •( C � � �� Owner Owner's Nam J information is �t^ required for every M I✓{/{ —�� page. Cltyrrown tate Zip Code Date f Inspection k D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 4-r C- - 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•3/13 Title 5 ficial Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5ff' O ictal Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i` a Pew ' Property Address ' A /ytN C lS Owner Owner's NaLne information is required for every ,(/L '7 page. City/row State Zip Code Date of Tinspection 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 /q a at' a t I '- D �OC 10 '- 3 CSC a3' y c kr A +0C 161,q * 1 � .p% WA1 0 t5ins•3/13 Title 5 Official Inspection Few Subsurface Sewage Disposal System.Page 15 of 17 Commonwealth of Massachusetts u'p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /-/ /",e -� 2 Property Address Owner Owner's Name C` 5 � / i7 information is required for every eXyl DM A 01170 page. City/I own State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water [Check cellar ❑ Shallow wells Estimated depth to high ground water: mor P f AVV r 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 ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: r ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 16 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Owner Property Address O / C F`LX-i wner's Name information is C p required for every ly~,/L(tiN 01470 (� a—a ^ /c5- page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Tide 5 Oficial Inspection Fonn:subsurface Sewage Disposal System•Page 17 of 17 FORM 4-SYSTE&f PUi1gpWG RECORD •, Commonivealth of Afazsachusetts SALEM Massachusetts DEC 3 7 2603 CITY OF SALEM BOARD OF HEALTH SvStem Pum in Record FYstem «ner }•stem Loc ion CA MPBELLL 4 PETER ROAD Date of Pumping: 8/19/03 Estimated Quantity Pumped: 1000 gallons Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes RAGGS SEPTIC SERVICE, INC. System Pumped by: d .b.a . E . A. COMEAU SEPTIC License 1: Contents transferred to: WAYLAND SUDBURY TREATMENT PLANT Date 12/16/03 Inspector RAGGS SEPTIC SERVICE INC. 1: *u Com• COMMONWEALTH.,@C t! r '.:y, ,j.��.,•,Isi, y .,:f::aiLt2 D 1y�v"6�� p � OFrtMASSACHUSETTS EXECUTIVE'OFFICE9'bt,ENVIRONMENTAL AFFAIRS JUL 3 ' 1999 DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 CITY OF SALEM;,, HEALTH,DEPT,.— .-, r. :TRUDY COXE Secretary F. ARGEO PAUL CELLUCCI - DAVIDB. STRUHS Governor „ :, - X 'F - c,. e r , d 1-4 I - .. Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - - PART Ais ❑ tr ,r r - .. .. 'CERTIFICATION- Property CERTIFICATION _...._... . .. .. .... .. _�_. .. Property Address: y P,-4e r- R d,_ Salem Nameof Owner5.h Ot DGK ��' /�� Address of Owner: Date of Inspection: I Name of Inspector:(Please Print) r i!' r I am a DEP pro edsystem i pectm pursuant to Section 15 340 of Title 5 1310 CMR 15.000) Company Name: _. r ,.,.:.. . r . u,..,.,.,s _.<. .. .. Mailing Address: - :. r t.ud; t:,r,:rJ .9i. t ..;dir ;t !! ,11 Telephone Number: =1i CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address end that the Information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my trammg,andi ei p'erlence,in.the proper function and maintenance of on-site se age disposal systems. The system: Passes Conditionally Passes Needs Further.Evaluation By.the Local Appro !sving Authority — /. Inspector's Signature: k. Data: The System Inspector shall submit a copy of this inspection report to the Approving Authority•(Board of Health or DEP)within thirty (30) days of . completing this inspection. If.the systemis 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 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 SeP �I(, { nG� s�o�lc� ,6e � vNt �{ euZqA7 .Z years , revised 9/2/98 Page Iof11-v �� Primed on Recycled Paper SUBSURFACE SEWAGE"DISPOSAL SYSTEM INSPECTION FORM L•n. CERTIFICATION Icorrtinuecfl±,rl Property Address: .'t , ILIA, Owner: Date of Inspection: .. ... .. •. INSPECTION SUMMARY: Check A, B, C, or 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. Any failure criteria not evaluated are indicated below. "" i ' ""^"''" a' �%•- +•+ i`: : ' COMMENTS: �'•i',.:A°i to W,tali B. SYSTEM CONDITIONALLY PASSES: One or more system components as described In the "Conditional Pass sectionneed to be replacedor repaired The 'system, upon completion of the replacement or repair;as approved by'the Board•of'Health,°will pass.^' "��`:'.+, •+� � ,. - q � - k • Indicate yes, no, or not determined IY, N, or NO). Describe basis of determination In�all-instegces 'If"not determined explain why not. The septic tank is metal, unless the owner or operator has provided the.systam Inspector with'a copy of a Certificate of "> Compliance (attached)Indicating that the tank was Installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration"or exfiltration,'or tank" failure is imminent.-The system will will Inspedtion If'the existing septicrtenk'is'replaced�with a complying septid tank as approved by the Board'of Health: w, „ i Sewage backup or breakout or high static water level observed In the distribution box is due to broken'orobstructed pipets) or due to a broken, settled or uneven distribution box.!`The system will{pass inspection Wi vivith approval of the Board of Health). broken pipe(s)'are replaced �, M obstruction is'removed "''"r' distribution box is levelled or replaced i The system required pumping more then four times a year�cue to broken'oi obstructed pipe(s)."Th'e system-will pass inspection if(with approval of the Board ofHealth) IQ °�''� y -•4r - . broken pipes) are replacetl " " "-" o -• . . - obstruction is removed revised 9/2/98 Page2 or I, i3L ' ':SAI 1Fd . 3Aq i,^� sf >c..,vi;1 iJ.�'.,!(:i:c✓:'. SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM ,t . .;PART A'�'i't,�:;r d... :'.' CERTIFICATION (continued) Property Address: Owner: . Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which,require further evaluation by the.Board of Health to order'tordetermine.if the system is-failing.to protect the 4' ' _,. n tf. J 4l niJ kL f t 11 twr I 1 1 t Mt :IG f : -lic public health,*safety and the environment.,, " - - - ,n :.nr h ro o- C"3' €e i' 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a b'oideringtvegefated 'wetland or'a''salt marsh: 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH,AND SAFETYAND THE ENVIRONMENT: - _ The system has a septic tank and soil absorption'syste' (SAS�.and the'SAs.W ivithin.100 feet�of:e surface.water supply or tributary to a surface water supply. _ The system has a septic tank'end aoil'absorptionayetem�and tha SASis within a Zone I of public..water.supply well. _ The system has aseptic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and 'soil absorptlon'gystern endlthe'SAS�is Iess''.than'-100 feet but 50 feet or more from a private water supply well;unless'a well water analysis'for coliforimbacterla andr Volatile:organic compounds indicates that the well is free from pollution from that facility-and this"prssenbd of ammonia:nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER t : .. 1..:'./ yN .,,�^ � 'i �� :?:• t 'il,^ ...it I.. �' 1.,.'. - .. . revised 9/2/98 Page unf SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ CERTIFI6ATI011 Ifatlinued) - .. re;..;;;riinca; ili4R'Yfi.IFil t:??;,; Property Address: Owner: . . Date of Inspection: D. SYSTEM FAILS: - You must-indicate either "Yes" or "No" to each of the-following:;;. - .c ...... I have determined that one or more of the following failure conditions exist as described m 3.10 CMR 15..303. The basis foi this - - determination is identified below. The Board of Health should be contacted to'determine what wlll be.necessarg to correct the failure. Yes No - w Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. - Discharge or ponding of effluent to the surface of the.ground or surface waters due to an overloaded or clogged SAS or cesspool. - Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1l2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. " - � . •: . , ,' .� .:_.r r s;.). ,, ty ."r1 t[ •,.¢r [t ..•>. t t lt,%'1 '�, r Any portion of,a cesspool or privy is within 100 feet of e,,surface water supply or:tributary to a surface water supply. ` •Any portion of a cesspool.orprivy is within a,Zone I,-of a public well,_r,r .� Any portion of.a-cesspool or privy is within.50 feet;of,e private water;adpply well Any portion of a cesspool or pnvy;is less than 100 feet butgreater than150 feet from a private water supply well with no acceptable water.quality:analysis.,lf,the well hesi analyzed to be acceptable, etts k copy of well water analysis for coliform bacteria„volatile.organic compounds, ammonla.nittogen and nitrate nitrogen. . - E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systema In addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd-or greater(Large System).and the system is-a significant threat to public health and safety and the environment becausebnem mole of the following conditions exist:-'^" 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 the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area• IWPA) or a mapped Zone It of a public water supply well) The owner or operator of any such system shall upgrade the system In accordance with 310,CMR 15.30412). Please consult the local regional office of the Department for further information. revised 9/2/98 Pagel of 11 SUBSURFACESEW AGE,DISPO$Ab.SVSTER t1NSPEGTION,FOfjM:,;,y PARTIB A4 - Property Address: y Peer �� ' . Su`e 'i 7 , Owner: 5�Oti10t,(.t Date of Inspecti�ojn�;/ / o- - Check if the following have been done: You must indicate either "Yes" or "No' as.to.each,of th,a following ,. �Yes No Pumping.information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks end the-system has been receiving rrormeltlow 'rates during that period. Large volumes'of water have not been Introduced into the system recently,or as.,part of this inspection. .,. y ',� v� !..``,, , 'Cc.. :�, r,C. ,t_. ,..,'., . ;H� r: ✓"L�T As built plans have been obtained and examined. Note if they are not available with NIA VT _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. .. , _:... S _ All system components, excluding the Soil Absorption System, haye,been locatadr on the,site. ,„ _ , Ys _ The septic tank manholes were uncovered, opened and the interior of the septic tank was in for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System,on the site has been determined based on: , _C /O Existing information. For example, Plan at _ Determined in the field (if any of the failure criteria relate d'to Part C is at,issue approximation,of,distance.is unacceptable) P„ 115.302(3)(b)1 The facility owner land occupants,if different from owner) were provided with information on the proper maintenance-of Subsurface Disposal Systems. , 3 .,,'�: i .. �'.i_..,. . : i, , ..,� .u: n. '❑ a �,' .. .._, _. revised 9/2/98 Page,$ofII SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM!' SYSTEM INFORMATION Property Address: gpeeler Ret 5(Z/r,-( � Owner: Date of Inspects FLOW CONDITIONS .. . RESIDENTIAL: - "4 Design flow: g.p.d./bedro m. Number of bedrooms (design): Number of bedrooms(actual):2`'• Total DESIGN flow 33 Q - Number of current tesldents - Garbage grinder(Yes or no):-,L.10 ,IcI .,v -. 4 1.;I - Laundry (separate system) (yes or no):A!9?1 If yes, separate inspection required Laundry system Inspected (yes or no) %; . ,`.'; "r: r. ro _: c qrt . sL�i . r r,„c .•s��:. Seasonal use (yes or no):dL4 ' , ,'. , ,.,r.i a ung n�'� /rr,n ,.r•.a ,a / ,,../ fi x„ ..��/� r t Water meter readings, if available (last two years usage (gpd)af//JT Q!/GUa/{��. GCT /Mf�C►' /!'l�i�G�� Sump Pump (yes or no):. Last date of occupancy.(' sWI PGt 141046-1 COMMERCIAL/INDUSTRIAL: Type of establishment: - Design flow: ocd 1 Based on 15.2031 Basis of design flow - Grease trap present: (Yes or no)_ Industrial Waste Holding Tank present: lyes or no)_ - Non-sanitary waste discharged to the!Title 5 system: (yes or no) . -1z r,' •v:!•: .u,+ ra e r»�!.,..:, i + li Water meter readings,if available: j Last date of occupancy: co ::. a n , na:a ... .:a .ri .a:.v: er:+� c r.- `r,, c ra :, ,•s ,.`�`{ OTHER:(Describe) + r + r 1 '.est date of occupancy: GENERAL INFORMATION'S-.. PUMPING=and source of infoation F+ `+ G+,;: s r �s .rr 'u y,•z. .i or System pumped as part of inspection: lyes or no)A/Q If yes, volume pumped: . C,- gallons' Reason for pumping: .... TYPE OF SYSTEM - Septic tank/distribution box/soil absorption system , Single cesspool -All Overflow cesspool -A19 Privy ,/n Shared system lyes or no) (if yes, attach previous inspection records,if any) I/A 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: A10 iq j26QC Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page,6 of 11 . SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART ld SYSTEM INFORMATION;(continued) ., Property Address: Owner: Skanoo Date of Inspection_ BUILDING SEWER: (/ r (Locate on site plan) Depth below grader Material of constru tt.%on:_cast iron_40 PVC other (eplain) ,j _ .,n„n ,. Distance from private water supply well or suction lie Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK: ._ .. ".., (locate onsite plant Depth below grader Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Wage confirmed by Certificate of Compliance "(YeslNo) Dimensions: 77t Sludge depth:_ 3 i/ Distance from top of sludge to bottom of outlet tee or baffler- 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 baffler /, . How dimensions were determined: Tnm sf/✓l° 1 s'1,5r41° 49f N„K Comments: (recommendation for pumping, conditipn of'nlet an ou let tees or baffles, depth of liquid level in repo outlet invert, structural integrity. Aae evidence of leakage, etc.) ., "/ ,,, ser ,.,.. „ + .... ' GREASE TRAP: - (locate on site plant Depth below grade:_ 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 baffler 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 Page of 11,. SUBSURFACE SEWAGE�DISPOSACSYSTEM INSPECTION'FORM- PART C' SYSTEM INFORMATION'Icontinuedh" RcQ Salmi Property Adddl1rass: PL°7"� "✓� tip,.-.' ' . Owner: Sz0-^006( .. r Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) . (locate on site plan) - III (31 t 11❑ 't \i 41 ft Depth below grade:_ Material of construction:_concrete_metal Fiberglass—Polyethylene r..,. Dimensions: Capacity: - gallons - Design flow: gallons/day - - - - - Alarm present Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, —, PT DISTRIBUTION BOX:/0 . (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution ''" is equal, evidence of solids carryover ewdendebi leakage Into drlout'of box etc.)' '`- - - - • q PUMP CHAMBER: (locate on site plan) .. . ., Pumps in working order: (Yes or No)_ ''- Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8ofII B V..v .e SUBSURFACE SEWAGE'DISPOSAL'SYSTEM'INSPECTION'FORM`� PART e-" .. SYSTEMIN FOR MATION'(cotIW wed) Property Address: qPe fef- RcP- Su P p—L. owner: 6hamo6lk Date of Inspectio /a SOIL ABSORPTION SYSTEM(SAS):-L/11- (locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Y Type: leaching pits, number: - leaching chambers, number:_ n i leaching galleries, number;_ leaching trenches, number, length: - .- .leaching fields, number,.dimensions: - overflow cesspool, number:_ Alternative.system: . - Name of.Technology: t - Comments: (note c ndition of soil, signs of hydraulic failure, level of ponding, damp soil, condi 'on cj vegetation, etc.) i O n l! n CESSPOOLS: ,I :...__.. (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: :-;t Materials of construction: )•C \`` Indication of groundwater. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition-of vegetation, etc.)-, •-- -"- "" -" PRIVY: (locate on site plan) Materials of construction: - - Dimensions:.- - Depth of solids:_ F�< ° ,) •, - ! ' Comments: .3 t -:..-, i�•. .....� (note condition of soil, signs of hydraulic failure, level of ponding, condition,of vegetation, etc.) revised 9/2/98 Page or 11 SUBSURFACE SEWAGE DISPOSAL,SYSTEM.INSPECTION.FORM .. ' SYSTEM INFORMATION Icorronuedl. Property Address: L/ Pe le,— kd� 5a/et-t Owner: Date of Impaction; SKETCH OF SEWAGE DISPOSALS YS T EM: include ties to at least two permanent reference landmarks or benchmarks locate all.wells within 100' (Locate where public water supply comes into house) " f 3 C n l r..7 a nF Rlf4« Ir0 revised 9/2/98 Page 10otle Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirwed) Property Address: 41 Pr+er �d, Sa 4e� Owner: . 5 6 r%0 , Date of Inspection: - 641�QQ NRCS Report name Soil Type_ - .- Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM _ Slope S water heck Cellar She w wells yJ, Estimated Depth to Groundwater�eet�t�-01f1. I lxc,pcn/ 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) P `eaGhin� PI✓�" Gt/AiC, ClJGtS Oh `y c4 z°S 0� c/a w- 0GA 60f-�O r-t , Frok i +kt ho f+ *W% pF �° �`>L °s q (eek, yo So✓� r�� ov\ f ct had core �p h %;��P�- �o.^ a" 170, lre� of + t AAe 4r fo P, 0 'e "I- w e e �r Z�f �S es�� /if /zoo )Lo ls�v � � �tl0619 , A10 revised 9/2/98 Page 11 of 11 tI I � . FORM 4 - SYSTEM PUMP Commonwealth o Massachusetts f D Massachusetts MAY 2 4 1999 System Pumping RecordIITY OF DEPT. System Owner System Location I tAn AInk re TE Type: Emergency I Routine ❑ Cesspool: No _ Yes ❑( " Septic Tank: No ❑ Yes Date of Pumping. Quantity Pumped: /ten /gallon's System Pumped by (Company): O6 _ ( Permit 9: Contents transferred to: Contents disposed at: Date 5 ( ��Pumper Si;ature c Condition of sY s tem/other comments: L"jA s ur) O DEP APPROVED FORM-12/07/95 FORM 4 - SYSTEM PUKING RECORD JUN 15 1998 IMI HEA OF DEPT Commonwealth of Massachusetts Salem ,Massachusetts System Pumping Record Y A Q System Owner: System Location: Mortin Shandk back yard 9 Peter Road Salem Date of Pumping: May 13, 1998 Quantity Pumped: 1500 gallons Cesspool: No /X/ Yes /—/ Septic Tank: No /—/ Yes /X/ System Pumped by: Service Pumping 6 Drain Co., Inc. License # Contents transferred to: S.E.S.D Date: May 15, 1998 Pumper: M.F. This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes. 107 Forest St. �N FORM 4- SYSTE14f PUMPING RECORD (508) MA 01949 QAP' - (508) 774.2772 S�Qt��w�GE Commonwealth of Massachusetts Sof km Massachusetts 6 1997 ..LUL CITY CSP C ALE I 10 PT. System Pumping Record �)�� i 1 "O✓t�uv) System ocauon LI or=bcoL , �� Date of Pumping: Quantity Pumped: ---------gallons Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes S\stem Pumped by: CULPLI 0'' License 4: Contents transferred to: Date c7 — `Z7 7 _ `Z7 Inspector • THE PROFESSIONAL.EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY•