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TITLE 5 INSP FORMSImportant: When filling out farms on the computer, use only the tab key to move your cursor - do not use the return key. l t� 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. Inspection forms may not be altered in any way. A. General Information 1. Property Information: 33 Appleby Road Property Address John Collins Owners Name 33 Appleby Road Owners Address Salem City/Town Date of Inspection: 2. Inspector. Stan Bigelow Name of Inspector MA 01970 State Zip Code April 24, 2006 Date S Winthrop St. company address Beverly MA 01915 CdylToovn State Zip Code 978-777-0030 Telephone 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ZS rther Evaluation by the Local Approving Authority inspectors Sign May 23, 2006 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. title5insp.doc.doc • 0312006 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 B. Certification (cont.) 33 Applbv Road Salem city/rown Stet 01970 Collins Zip Code owners Name 4/24/06 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ `Conditional Pass" section need to One or more system components as described in the be replaced or repaired. The system, upon completion of the replacement or repair, the Board of Health, will pass. as approved by 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 exfittration ortank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and If a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: Salem 33 ApplebyRoad Title V.doc.doc • 03t2oo6 Idle 5 Official I nspectlon Form: Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts V Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 33 Appleby Road Property Address Salem MA 01864 Cayrrown State Zip Code Collins April 24, 2006 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 pipes) 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. I. 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 Salem 33 ApplebyRoad Title V.doc.doc • 03/2006 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 B. Certification (cont.) 33 Appleby Road Property Address Salem MA 01970 City/Town State Zip Code Collins 4/24/2006 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 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: Salem 33 ApplebyRoad Title V.doc.doc • 03/2006 Title 5 Ofriolal Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont) 33 Appleby Road Property Address Salem MA 01970 Cdyrrown state Z1pCode Collins 4/24/06 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 ❑ ® 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 dogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to dogged 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. ❑ ® 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. Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria ebst 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. Salem 33 ApplebyRoad Title V.doc.doc • 0312008 Title 5 Oftel 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 B. Certification (cont.) 33 Appleby Road Property Address Salem Cityrrown Collins Owner's Name MA State 4/24/06 Date of Inspection 01970 Zip Code 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 system is located in a nitrogen sensitive area (Interim Wellhead Protection Area Area — IWPA) or a mapped Zone It 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. Salem 33 ApplebyRoad Tdle V.doc.doc • 03/2008 Tdle 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. Checklist 33 ADDlebv Road Property Address Salem MA 01970 Cflyfrown State Zip Code Collins 4/24/06 Owner's Name Date of Inspection Check if the following have been done. You must indicate °yes° or'no" as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (if they were not available note as WA) ® ❑ 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 the facility owner (and occupants if different from owner) provided with information 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. ® ❑ 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)) Salem 33 ApplebyRoad Title V.doo.doc • 03/2006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information 33 ADDIebv Road Property Address Yes Salem MA 01970 City/Town State Zip Code Collins 4/24/06 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [d yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if/&7oo available Qast 2 years usage (gpd)): - 059 f oo) Sump pump? Ab°°�Y" Last date of occupancy: Commerciabindustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Other (describe): ki 3 2 ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No /9.5kj'9 2/�4d ❑ Yes ® No current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Date Salem 33 ApplebyRoad Title V.doc.doo • 03/2008 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 D. System Information (cont.) 33 Appleby Property Address Salem MA 01970 City/Town State Zip Code Collins Owner's Name Pumping Records: Source of information: 4/24/05 Date of Inspection General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Owner / Stewarts 1000 gallons ouaoe and estimation internal tank inspection ® 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/Aftemative 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 (d known) and source of information: 25-30 years, more or less (unknown) Were sewage odors detected when arriving at the site? ❑ Yes ® No Salem 33 ApplebyRoad TRIe V.doc.doc • 03/2006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Salem 33 ApplebyRoad Title V.doc.doc • 03/2006 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form MA 01970 State Zip Code 5/20/06 D. System Information (cont.) 33 Appleby Road Property Address Salem Ciy/Town Collins Owner's Name Date of Inspection 24-28" feet Building Sewer (locate onsite plan): Depth below glade: Material of Construction:® cast iron ®40 PVC ❑other (explain): Laundry PVC tie into Cl sanitary Na feet g, evidence of leakage, etc.): y problems other than age 16" feet ❑ fiberglass ❑ polyethylene C] other (explain) years Distance from private water supply well or suction line: Comments (on condition of joints, ventin Fair condition. No reason to suspect an Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete El metal If tank is metal, list age: Is age confirmed by a Certificate of Compliance? (attach a copy of ❑Yes ® No round 1000 gallon 8" Certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 33" 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bott Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 16 om of outlet tee or baffle 8"(estimate) How were dimensions determined? field measured and observed Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 33 Appleby Road Property Address Saelm Ctyfrown Collins Owner's Name MA State 4/24/06 Date of Inspection 01970 Zip Code Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump annually. Tank cover should be structurally sound to prevent accidental entry. Grease Trap (locate on site plan): Depth below grade: Material of construction: 0 concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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): Salem 33 ApplebyRoad Title V.doc.doc • 03/2006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) kw ..r M.7 Properly Address Salem MA 01970 Cityrrown slate Zip Code Collins 4/24/06 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: gallons gallons per day ❑ Yes ❑ No Alarn in working order. ❑ Yes ❑ No Dale Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? Distribution Box (if present must be opened) (locate on site plan): ❑ Yes ❑ No Depth of liquid level above outlet invert none found 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.): Small backyard area and a portion is ovedayed in concrete. safe entry not possible. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order. ❑ Yes ❑ No ❑ Yes ❑ No Salem 33 ApplebyRoad Title V.doo.doc • 0312006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 16 f;6N Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System information (cont.) 33 Appleby Road Property Address Salem MA 01970 Cityrrown State Zip Code Collins 4/24/06 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ® leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/aftemative system Type/name of technology: 1, 20'X30' Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of septic hydraulic failure. Site is level with high slope abutting. No vegetation observed that indicate hvdraulic failure. Salem 33 ApplebyRoad Title V.doc.doc • 03/2006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 33 Appleby Road Property Address Salem MA City/town State Collins 4/24/06 Owner's Name Date of Inspection 01970 Zip Code 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 n/a ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Salem 33 ApplebyRoad Title V.doc.doc • 03rM 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 D. System Information (cont.) 33 ADDlebv Road Property Address Salem MA 01970 City/town State Tip Code Collins 4/24/06 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. Salem 33 ApplebyRoad Title V.doo.doo • 03/2006 Tule 5 Official Inspection Form: Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 33 Appleby Road Property Address Salem 70 C ert State Zip Code Zp Cod Collins 4/24/06 Owner's Name Date of Inspection Site Exam: Slope yard 4eve1 l_.c asC�PQ S^13°e SIe e P Surfacewater >yop' Check cellar 516-6 toy dAd �cm Shallow wells >7$' Estimated depth to ground water. >(D'41- (as fie, ,„ ops) 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 Heafth - explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: USDA Soil Maps You must describe how you established the high ground water elevation: Soils map indicate >6.0' ESHWi Salem 33 ApplebyRoad Tdle V.doc.doc • 03/2006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16