6 Eleanor Rd Title V inspection report D.F.
CLARK D.F. CLARK INC.
TITLE V ,
SEPTIC SYSTEM PROFESSIONALS
INC.
December 27, 2019
RAG 9
Daniel & Robin
Blake
6 Eleanor Road ofUV
Salem,MA 01970 gOPA�
RE: Title 5 Inspection
6 Eleanor Road, Salem
Dear Daniel & Robin:
Please find enclosed the Subsurface Sewage Disposal System Inspection Reports for the
above-referenced property. As noted on Part A (Certification) of the reports, the system
Passes the inspection criteria. This inspection is good for the next two (2)years; you may
extend the life of the inspection to three (3)years by having the septic tank pumped
annually (before the anniversary date of inspection).
Thank you for allowing us to be of service to you on this project. Please contact us if you
have any questions regarding this matter.
Sincerely,
D.F. Clark, Inc.
0 J '
George F. Norris
Title 5 Inspector
Enclosure
cc: Salem Board of Health
D.F. Clark, Inc. file
PO Box 265 22 Mitchell Road Ipswich, MA 01938
978-356-5638 Fax 978 356 5500 Toll Free 888-DF-CLARK www.dfclark.com
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Road
Property Address
Daniel & Robin Blake
Owner Owner's Name -
information is Salem
required for every MA 01970 December 20, 2019
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 forms A. Inspector Information
on the computer,
use only the tab George F. Norris
key to move your Name of Inspector
cursor-do not D.F. Clark, Inc.
use the return Company Name
key.
22 Mitchell Road, PO Box 265
r� Company Address --
Ipswich MA 01938
City/Town State Zip Code
(978) 356-5638 S14051
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspector's SkAature Date
, - e
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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4'
6 Eleanor Road _
u Property Address
Daniel & Robin Blake _
Owner Owner's Name
information is Salem _ _
required for every MA 01970 December 20, 2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
2) 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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
v� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Eleanor Road _
Property Address - —
Daniel & Robin Blake
Owner Owner's Name --
information is Salem
required for every __ MA 01970 December 20, 2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Road
Property Address — - —
Daniel & Robin Blake _
Owner Owner's Name
information is
required
uired for every Salem _ _ MA 01970 December 20, 2019
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
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Commonwealth of Massachusetts
r= (P Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t;
6 Eleanor Road
Property Address — — - - — — — —
Daniel & Robin Blake_
Owner Owner's Name - —
information is
required for every Salem — _ MA 019_70 December 20, 2019
page. &ty/Town State Zip Code
Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 Y2 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 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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 II of a public water supply well
t5insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c Commonwealth of Massachusetts
p Title 5 official Inspection Forrn
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
� �4-
6 Eleanor Road
Property Address
Daniel & Robin Blake _
Owner Owner's Name
information is Salem
required for every MA 01970 December 20, 2019
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
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?
2 ❑ 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 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.
® ❑ 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)]
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Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Road
Property Address - - — — — —
Daniel& Robin Blake
Owner Owner's Name -
information is —
required for every Salem __ MA 01970 December 20, 2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): - Number of bedrooms (actual): 3 — —
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): — - -
Description:
There is no design flow available.
Number of current residents: .3
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit?
❑ Yes ® No
If yes, discharges to: — — —
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): 85d
Detail:
October 21, 2017 -October 20, 2019 = 62,323 gallons divided by 729 days = 85 gallons per day
Sump pump?
❑ Yes ® No
Last date of occupancy, Currently
occupied
l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Road
Property Address - —
Daniel & Robin Blake
Owner Owner's Name - -- —
information is Salem
required for every MA 01970 December 20, 2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present?
❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: - - -
Last date of occupancy/use: Date --
Other(describe below):
3. Pumping Records:
Source of information: According to owner, system was last pumped in 2017.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons — - --
How was quantity pumped determined? -
Reason for pumping: —
t5insp.doc•rev-7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 8 of 18
Commonwealth of Massachusetts
7a Title 5 Official Inspection Form
r�. o
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
cx�
6 Eleanor Road
Property Address - - - - -- - -- --
Daniel & Robin Blake
Owner Owner's Name - - -- - —
information is Salem
required for every — MA 01970 _ December 20, 2.019 _
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
4. 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):
Approximate age of all components, date installed (if known) and source of information:
According to Board of Health file, system was installed in 1963 and distribution box was replaced on
October 25, 2012.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.83
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 pipe is in good condition. There are no signs of leakage.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
commonwealth of Massachusetts
50
Title 5 Official Inspection Fora
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Road
Property Address --
Daniel & Robin Blake _
Owner Owner's Name
information is
required for every Salem MA 01970 December 20, 2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene Y El 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: 80"W x 4' D-Round
"
Sludge depth: 4
Distance from top of sludge to bottom of outlet tee or baffle 30" _
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
How were dimensions determined? Tape measure and 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.):
Inlet baffle is not in place. Outlet tee is in place. Liquid level is normal and pumping is not required at
this time. Septic tank is in good condition. -
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Eleanor Road _
v Property Address - — - - - -
Daniel & Robin Blake _
Owner Owner's Name
required for
is every
Salem —
required for eve _ MA 01970 _ December 20, 2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet - -
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene
El other(explain):
Dimensions: _
Scum thickness _
Distance from top of scum to top of outlet tee or baffle -- - - - -
Distance from bottom of scum to bottom of outlet tee or baffle - --
Date of last pumping: Date - - - - -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
El other(explain):
Dimensions:
Capacity:
gallons
Design Flow- gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of to
Commonwealth of Massachusetts
NO Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Road
Property Address
Daniel & Robin Blake
Owner Owner's Name —
information is
required for every Salem MA 01970 December 20, 2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0 - —
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.):
Distribution box("d-box") is 11" below grade. Distribution is equal. There are no signs of leakage or
solids carryover. D-box is in good condition with very little corrosion. - -
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Commonwealth of Massachusetts
p Title 5 Official Inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 Eleanor Road _
Property Address - — —
_Daniel &Robin Blake
Owner Owner's Name - -- —
information is Salem
required for every _ MA 01970 December 20, 2019 _
page. City/Town — State Zip Code Date of Inspection
D. System Information (cont.)
10. 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, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. 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: 2 -40' L
2 - 12' L
❑ leaching fields number, dimensions: -
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: — -- -- — — _ — — —
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y�
6 Eleanor Road _
Property Address - - — —
_Daniel & Robin Blake
Owner OwnePs Name
information is Salem
required for every _ _— _ MA 01970 December 20, 2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments-(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil absorption system ("SAS") is under snow at this time. There are no signs of hydraulic failure.
Leaching trenches are working properly. — — — —
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer — —
Depth of scum layer _
Dimensions of cesspool —
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 18
Commonwealth of Massachusetts
i^ pTitle 5 Official Inspection Form
fSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
� y 6 Eleanor Road
Property Address
Daniel &Robin Blake _
Owner Owner's Name
information is
required for every Salem_ _ MA 01970 December 20, 2019
page. citylrown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev-7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Eleanor Road
Property Address
Daniel& Robin Blake_
Owner Owner's Name - — — —
information is — — - -
required for every Salem MA 01970 December 20, 2019
page. City/Town State Zi Code -
P Date of Inspection
D. System Information (cont.)
14. 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
Eleanor Road
Linden Avenue
Water
Garage
Sewer
B/
A Porch
• #1 Septic tank—Center cover
#2 Distribution box
A-1 = 18'4" .lVswch, A,r.
B-1 = 16'
A-2 =23' D.F.
B-2 =24' CL�K
TITLE V
SEPTIC SYSTEM PROFESSIONALS
C.
r9�8)356.5631'
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
h � � Title 5 Official Inspection Fora
[ro Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
J�4'
6 Eleanor Road _
Property Address - — -
Daniel& Robin Blake
Owner Owner's Name - -
information is
required for every Salem_ MA 01970 December 20, 2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: > 10.08
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: pate — — -
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Neighboring property
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Bottom of SAS is 40" below grade. When Edward Cullen performed soil testing on March 2, 2005 at
an abutting property at 1 Peter Road, no ESHGW was observed at 121" in hole T-1. At time of
inspection a site exam was made, site is level, no surface water was observed, cellar was dry with no
sump pump, and no shallow wells were located.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Eleanor Road _
Property Address - — - —
Daniel & Robin_Blake
Owner Owner's Name
information is Salem
required for every __ _ MA 01970 _ December 20, 2019
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
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