4 CEDAR HILL ROAD - SEPTIC No...... ....... Fins...hal...0.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..... ....OF
Appliration for Riipo,sal Works Tonstrurtion Errant
Application is hereby made for a Permit to Construct (X) or Repair (XX) an Individual Sewage Disposal
System at:
----•--•------- r� .....G r �� 'ec--------------------- --------------------.................................
...
....................
.....................
''�� Locatio t-Address or Lot No
- T�fzfr� ... �irnlAGAI✓ -
1 ------------------------------------....----.......--------•-------.........---......---
W .150A) (,A§AIV Owner Address
---------------------------- .-..-1 -.. Tei- m4
Installer Address
Type of Building Size Lot............................Sq. feet.
U Dwelling—No. of Bedrooms............ .. ... ...................Expansion Attic ( ) Garbage Grinder ( )
--
WOther—Type of Building -------------------- ------- No. of persons_..._.,-------.__. Showers ( ) — Cafeteria ( )
dOther fixtures .--------------------------------....---------------------- -------- --------------- --------... . ��++�
W Design Flow--------------------------------------------gallons per person per day. Total daily flow-----��..J7�O............gallons.
WSeptic Tank—Liquid capacity/—gallons Length-------:........ Width-----7�----- Diameter............---- Depth.....
x Disposal Trench—No. .................._ Width...._.............. Total Length..//�..fT--- Total leaching area--------............sq. ft.
Seepage Pit No..................... Diameter---------------- --- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------............................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Lr. Test Pit No. 2................minutes per inch Depth of Test Pit........----------. Depth to ground water..................------
---.. .......�. - - - -..... - - -
.!1O Description of Soil.......... Q ..._/Y.----- .-^-----!9�.
W
..............- -/�� Ft.�3.L1Gt!1........../j-----,(YGl/1?l�.I ------ 0..f�;g/1-----P..
feG._71.17$...f...-1Qi0at7 tvtZ& o.3- ------------------ --------------- d ------ - -
/ -. ---
Nature of a airs or Alterations— nswe hen a li ble........ //..,,4. r5 k
U P PP -fes -j ........................................- 11 �CG'llG�1--...S�XI�P� - ...........................-----------•-----......---
Agreeme
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Complianc has been issue by the board of health. /
Signed .�..�xe"cF--- �"w if 070`13
Application Approved By _. ___.__...... Jeff..Vaug...... _____...._. ...._1-L/.25f2.003_-
Da'e
Application Disapproved for the following reasons. __ __.._._....._........................... _.__.......................__......................
..-.-
................................. ............_......................._.. .......... ....._.. ............
PermitNo. 1-03._____.....___.._........._............_ Issued ...... .................._.
Daae
_______________________________________________ _______ _____._.__________—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........City OF ...
Q'Iertifirate of (gomplinure
THIS IS TO CERTIFY,, That the Individual Sewage Disposal System constructed ( ) or Repaired ( XX )
by ...
at ......... ......... .........
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ......... ___..._...__.... dated ....... -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........._..___..............___........_.____...__..._..__...___...- -_._.. Inspector ..___..___...............___...._. ....... ..........
IMPORTANT MESSAGE
FOR CLAA
DATE TIME, �"��
M r[i
OFA
PHONE 2 Vy- 137eL3�51
'AREA CODE NUMBER EXTENSION
D FAX
O MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED LEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE.YOU RUSH
.RETURNED YOUR CALL 'I WILL FAX TO YOU
MESSAGE 3
SIGNED
FORM9
YYY MARE IN .A.
NOV 2 4 2003
11/20/03 CITY OF SALEM
BOARD OF HEALTH
To whom it may concern. Please see enclosed application to repair a septic system. My
company "Rooter-man to the rescue" did a title 5 inspection in June. We found the d-box
not level. The customer called several people to try and get the problem fixed. No one
responded. We are willing to do the job. I am a master plumber, title 5 inspector and a
drain layer in a couple towns. When I called and mentioned our situation the person I
spoke to sent me the enclosed permit. This is a very simple job that requires digging,
cutting the pipes and leveling the d-box. Please let us know if you require anything else
in order to do the job.
Thanks
Nelson Gagnon
Rooter-man
1-978-744-3831
i._ DM — Cmc iuc of �e��
IMPORTANT MESSAG
FOR 71,U P /17
A.M.
DATE �� 26 1 O TIME �� PA
OF
PHONE AR ODEER �� N
O FAX
O MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CALL WILL FAX TO YOU
MESSAGE
I tee
I�eLX2 _—
SIGNED
OPSFORM 4009
MARE IN U.S.A.
e s p 1 �•. I r- ry, ,� h l k a v!} v � #�"K,
.7�`��
,.Sy
y. t
ey ,� Yid
COMMONWEALTH OY1MASSACHUSETTS
°ej {a .
s• ' ` ��a^ 'rl x ' la :i' yp`"t�$^ a 'fir.w.'-'•'m'jfyspk'i}' �'BTFV 'S s "a' v y �`3
" ' � <'.EXECUTIVE OFFICE`OF'ENVIROENTAL"AFFAIRS t
a"A ",� u1Y 3h'•`.�1* nvwar + vur ^4tq'�r t, y ik -�, �.7:
DEPARTMENT:OF ENVIRONMENTAL`:PROTECTION
fih '�ri1 r
a kV �• '�i a t, - dti P '- • ° *,B3. . !•. .
y� * yi. + '- "1F q,. ,Y.�z,z>Mnydt�y�•q+ � � � � ka2f 1 .'+ ,i
p i
t TITLE 5
OFFICIAL INSPECTION FORM--.N.OT.FOR VOLUNTARYsASSESSMENTS
"i
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM"
'
PART A'+'
`� � CERTIFICATION � �4
Property Address —J Pj2¢Z /�/CL nJ. h i € "r ;,
Owner's Name: ' 1 €` € t A
Owner's Address: qC t C i� r +• . . <•, .>�� A
Date of Inspection
Name,of Inspector: (please print) t.0 Ur
Company.Name:
Mailing Address: C .
Telephone Number: 7
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this'address and that the information reported >
below is true;accurate and complete as of the time of the inspection.eTh'e�inspection was performed based on my '.
training and experience in the propenfunction and maintenance of on site'sewage`disposal systems:I'am a DEP a
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) I•Th6 system: a
t � ,
Conditionally Passes .^ +).
r Needs Further Evaluation by the Local Approving Authonty
, Fails i
Inspector's Signature:
The system inspectdr shiVsubmit a copy of this inspectionreport 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 t
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.
a ,
Notes and Comments116,tlqc, jt% , lij,! ary
g'
****This report only describes conditions at the time of inspection and under theyconditions 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. t.
Title 5 Inspection Form 6/15/2000 page 1
i'
Page 2 of]1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSALS TEM INSPECTION FORM
PARTA',
CERTIFICATION (continued)
Property Address: Y C._P44_0_ N/I C, R&),
Owner: P .� „Q.✓Q.✓
Date of Inspection
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. /System Conditionally Passes:
I! 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 fepair, as approved by the gcard of Health, will pass.
CkCr lC. T V FFt 2 /AU A0 �L(Sa w e- u°.A`f t0 67 W(fl4
Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
//OThe septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration onexfiltration 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.
ND explain:
Observation of sewage backup or bteah:ouforhigh 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
_ strrction is`removed
distribution box is leveled or replaced
ND explain:
,Vo The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Y C PLxt Pit( PC)
c�1_kz'Z4
Owner: IIP6
Date of Inspection: —O
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
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 I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
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
/clogged SAS or cesspool
�/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
/cesspool
[/ uid depth in cesspool is less than 6" below invert or available volume is less than '/, day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
f times pumped
i�yAry portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100feetof a surface water supply or tributary to a surface
water supply.
_ _� y portion of a cesspool or privy is within.azone 1 of a public well.
_ �y portion of a cesspool or privy is within 50 feet of a private water supply well.
ny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303;therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must se e a facility with a design flow of 10,000 gpd to 15,000
gpd. ,
You must indicate either"yes" or"no"to each o e following:
(The following criteria apply to large systems addition to the criteria above)
yes no
_ he system is within 400 fe of a surface drinking water supply
the system is within 2 feet of a tributary to a surface drinking water supply
— _ the system is loca d in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped
Zone II of a pu tc water supply well
If you have answere 'yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section above the large system has failed. The owner or operator of any large system considered a
significant thr t under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The ystem owner should contact the appropriate regional office of the Department.
4
Page 5 of i l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: fl (-e'z—
ZZ d let Pd
Owner: 1',1166 4T12rL46..��'
Date of Inspection: (— ;4;2_p
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes o
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?
Z— Has the system received normal flows in the previous two week period ?
c/ 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)
-L,—/—/ 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, excludingthe 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:
Yes no
_ Existing information. For example,a plan at the Board of Health.
ZDetermined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM°-NOT FORiVOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: L/ ( pc9,
Owner:_ l9P�(� /_( q/ Q/ ✓tJ
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:—_�L
Does residence have a garbage grinder(yes or no):NU
Is laundry on a separate sewage system(yes or no):4/0 [if yes separate inspection required]
Laundry system inspected (yes or no):.,06
Seasonal use: (yes or no): tD
Water meter readings, if available(last 2 years usage
Sump pump(yes or no): ,UO T
Last date of occupancy: C IL -ec�t y
COMMERCIAL/INDUSTI AL
Type of establishment:
Design flow(based on 310 15.203): d
Basis of design flow(s s/persons/sgft,etc.):
Grease trap present es or no): _
Industrial waste ding tank present(yes or no):
Non-san/itary ste discharged to the Title 5 system(yes or no):_
Water madings, if available:
Last datcupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: Gl f{/��cn4CtC�i7,
Was system pumped as part of the inspection(yes or no): 2r'
If yes, volume pumped: 106 allons--How was quantity pumped determined? 17zJ(/r Gu.tGf.
Reason for pumping e"LVT-Ac/�(.P ,
TYPE OF SYSTEM
eptic tank,:dlstributitin box, soil abswprtiomVstem
_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)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site (yes or no):
6
Page 7 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: q r-o-ilk /z/ll Pd,
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: /7 /(
Materials of construction: &,,(ast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting, evidence of leakage, etc.):
i[l/) iV 1 h ,(f,'-e nr- /ll,o.n 6/uG l me 4�cDd u�
SEPTIC TANK:l/ (locate on site plan)
N/
Depth below grade: _
Material of construction: LXconcrete metal fiberglass_polyethylene
—other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: Rd i)- ll) 7 i(J X S %;aN/'
Sludge depth: _ (:
Distance from top ofs'tu/d�e to bottom of outlet tee or baffle: r/
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: t lll�-
Distance from bottom of scum to bottom of outlet tee or baffle: e,
How were dimensions determined: r,4 j/,[ ,f/ ,45U i)-,C , 663-' -/ 2096-C 57/C�-,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
_t �( - >1f 0aw-tT C -�cr r >tilu��J , r//f_' FF/-e w4
?_� dCac 117
GREASE TRAP 60(locate'on site n)
Depth below grade:
Material of construction: c ncrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Dist
is ance from top o cum to top of outlet tee or baffle:
Distance from bo m of scum to bottom of outlet tee or baffle:
Date of last png:
Commenyt0ou't'let
umping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related invert, evidence of leakage, etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FORNOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: A / /(( Rdc
Owner.
Date of Inspection:
TIGHT or HOLDING TANK: _d(tank must 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: allons/day
Alarm present(yes or o):
Alarm level: Alarm in working order(yes or no):
Date of last p g:
Comments (c dition of alarm and float switches,etc.):
DISTRIBUTION BOX: i/ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LO
Comments(note if box is level and distribution to outlets equa(any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
1�L�rnrgu a-� �dx (r ,UuT �-etl�c �- ronRo��-e� .io c'nCrDC cA�zlzy
sv v-e r� wA� rc9rJ-ci r -
PUMP CHAMBER:A()(locate on site plan)
Pumps in working order s or no): _
Alarms in work ng or r(yes or no):
Comments (note co ition of pump chamber, condition of pumps and appurtenances,etc.):
8
Page 9 of I I
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _P 11 H11 ( pd,,
_O,it7
Owner: /).o6G1 F .4-046>4W
Date of Inspection:
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:
:: caching fields, number, dimensions: /(..Pa[ FGrYr
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.):
-�:nL /j DPV Wjr44 -,&t) �ctDiG'C �t/1QPc i. �i(�rr� ilk rJ rJc�D_u✓(
,00 �ZK,- l' e9r= RA_r.1k OQ-
CESSPOOLS-vC)d(zesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to i t invert:
Depth ofsolids layer:
Depth of scum la
Dimensions o esspool:
Materials o construction:
lndicat�rf of groundwater inflow (yes or no): _
Com ents (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY Nd(locate on site plan)
Materials of c vection:
Dimension
Depth o olids:
Cc nts (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOkVOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL<SYSTEM INSPECTION FORM
`.PART,C
SYSTEM INFORMATION(continued)
Property Address: e n /l( /V
S 17_J/
Owner:
Date of Inspection: - �7
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.
(2()r
W� 2 rr)
3
w
Cab°
noon
1211
8
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: y C_Prw)2 -NC( o'l
Owner: 9� rG FL U 1�J v
Date of Inspection: _n "
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water �- 0 feet
Please indicate(check)all methods used to determine the high ground water elevation:
btained from system design plans on record-If checked,date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
_Checked with local Board of Health-explain:
_Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must d scri e how you established the high ground water elevation:
0 —Ol Glt J.0 uJ, .-!r� ! 1041 Glttl cl .Ck21J LCA
11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS MAY 2 5 2000
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON MA 02108 (617)282.5500 CITY OF SALEM
HEALTH DEPT.
- TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI - DAVID B. STRUHS .
Governor - -- - Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - -
PART A -
n CERTIFICATION - ..
Property Address: y C eda r 01/1 I C 6( Name of OwnerFIC
Address of Owner:
Dace of Inspection: �' /7-Q9 ' . . -
Name of Inspector:(Please Print) 6O V-0 'Oal n
I am a D appro ed system pector pursuant to Section 16.340 of ride 6(310 CMO 15.000)
Company Name: r44 kN
.. .
Ma&v Address: .. G - -
Telephone Number: -
CERTlRCAT10N STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the Information reported below is true, accurate
and complete as of the time of inspection. The Inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
!/Passes
_ Conditionally Passes
Needs Further E^valuation By the Local Approving Authority qtr- /nT
Inspector's Signature; Date- -x=-00
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 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 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 -
r�h
revised 9/2/98 Page Iof 11
i~it Primed on Recycled Paper
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Yt i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
",11 PART A
CERTIFICATION (continued)
Owner: rri_d(; rr/GGn.^,'i�G( ✓�
Date of Inspection:
S- l7- 00
INSPECTION SUMMARY: Check A, B, C, o/ A
A. SYSTEM PASSES:
�CI 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.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES: ,a
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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all Instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system Inspector with a copy pf 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 passinspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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 ,
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (corrtimed)
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 in order to determine if the system is failing to protect the
public health, safety and the environment.
11 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 bordering vegetated wetland or a salt marsh. 0'
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 SAFETY AND THE 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 surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic 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 absorption system and the SAS is less then 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3 or 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessyry to correct the failure.
Yes No
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 1/2 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.
Any portion of a 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 I 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 60 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen 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 systems 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 because one or more 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 II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM
PART B
�// CHECKLIST
Property Address: K L P�CS.Ir �7 r� 2d. Su�Q r-t
owner: l=l Q Ani�a n
Date of Inspection:
5"- 1?' OO
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yew No
_✓ _ Pumping information was provided by the owner, occupant, or Board of Health.
_ _V/ None of the system components have been pumped foratleast two weeks and-the-system has been receiving mrmal flow
rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this
inspection. `
_.41 As built plans have been obtained and examined. Note if they are not available with NIA.
K 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.
(/ All system components, excluding the Soil Absorption System, have been located on the site.
y _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected 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:
Existing information. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
/ 115.30213)(b)I
The facility owner (and occupants,if different from owner) were provided with information on the proper maintananca"f
Subsurface Disposal Systems.
revised 9/2/98 Page 5 o 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: q L edor 140�t R0, S« p� r-1
owner: Flan'lr'xae%
Date of Inspection:
lB = /7- po
' FLOW CONDITIONS
RESIDENTIAL:
Design flow: 1/0 g.p.d.lbedroom.
Number of bedrooms (design): Number of bedrooms(actual):y
Total DESIGN
Number of current residents:
Garbage grinder(yes or no):-d[o '/
Laundry (separate system) (yes or no):,ez; If yes, separate inspection required -
Laundry system inspected (yes or no)
Seasonal use(yes or no):Av II
Water meter readings, if available(last two year's usage(gpd):A/#f A(/1q,r /6 6�V 61 k1141,
Sump Pump lyes or no):N�
Last date of occupancy:- Q 1( ✓fl I r
COM M ERCIA L/INDUSTRIA L
Type of establishment:
Design flow: god ( Based on 15.203)
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)_
Water meter readings, if available:
Last date of occupancy:_
OTHER: (Describe)
'.ast date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Pvet pPh A,jM A Pd h,,, f h/s agyel rg Irl,PO 4Pa tlt i s o wn e<
System pumped as part f inspec on: (yes or n )_V to;
If yes, volume pumped: �T gallons • ' /
Reason for pumping: COLO L(/C rn5.U'P D� &1#i k - sfrvr fv.�u� in fP,� ni/'7,
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
n
Shared system lyes or no) lit yes, attach previous inspection records, if any)
UA Technology etc. Attach copy of up to date operation and maintenance contract
,jZa— Tight Tank __Copy of DEP Approval
Other L
APPROXIMATE AGE of all components, date installed lif known) and source of information: _.A/i7 /- /61 OtA/*A
Sewage odors detected when arriving at the site: (yes or no)410
revised 9/2/98 Page 6o 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�// /j
SYSTEM INFORMATION(continued)
Property Address: G e C ur U!r/1 A 4t .
Owner: 16L11A/ Aan
Date of Inspection:
17
BUILDING
BUILDING SEWER:
(Locate on site plan)
Depth below grader
Material of construction: _L�Scast iron—40 PVC—other (explain) _
Distance from erivate water supply well or suction line
Diameter y t^/n L{\
Comments:+condition of joints, venting, evidence of leakage, etc.
_1 P tifY1G� To;n4.5 6Llf42r O C - .f/o Pv G/pnc P of
SEPTIC TANK:_✓
(locate on site plan)
��ff ft
Depth below grade: 6
Material of construction: (!concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: ��� Q//.t.w>° ef` IPo„vld S (&ef 4PPP ,
Sludge depth: //
_
Distance from top of sludge/to bottom of outlet tee or beffle:�
Scum thickness: / I'm /-ry /r rep la aecF !v��'� Qo L
Distance from top of scum to top of outlet tee or baffle:�r/f 1 r S�cJOW/ -410 m nq s vl1 r.`t e✓ 6
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: LCP0Se f'OP a( }>;tn kr
Comments:
(recommendation for pumpin , condition of'nlet and outl t tees or baffles, depth of liquid level In relation to outlet invert, structural integrity,
evidence of leakage, etc. 1 S , r� /�
eve r"t h n /
-4aF ( O IL"I d -
GREASE TRAP:AZJ
(locate on site plan)
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 baffle:_
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 7 or 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Rd SYSTEM INFORMATION(continued)
Property Address: y GPdQIr 14i�� Rd 5C4 /pwl
Owner: Ntun.1
Date of Inspection:
/7� 00
TIGHT OR HOLDING TANK-..A& (Tank must be pumped prior to, or 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/day
Alarm present_
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping: _
Corpments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:_ 4/17
Comments:
(note if leve and distribution is equal, evidence of solids c rryover, eviden a of leakage into or out of box, etc 1VIA r r
Vir r o
br T a —
PUMP CHAMBER:41—(/Q
(locate on site plan)
Pumps in working order: (Yes or No)-T-
Alarmsin working order(Yes or No) 1
Comments:
(note condition of pump chamber, gondition of pumps and appurtenances, etc.)
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contirwedl
Q
Property Address: N LL° �T1 I/ ',!/ 5u A9r-1
Owner: ao'l ;1-4 n
Date of Inspection:
00
SOIL ABSORPTION SYSTEM(SAS):—Z
(locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions: IF 161
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
In a condition of soil, si s of hydraulic failure, lev81 of po ding, d mP soil, con 'tion of egetation, etc.)
f- In r _
r OL
�1 der
CESSPOOLS: 0
(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 (cesspool must be pumped as pert of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_14/0
(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.)
revised 9/2/98 Page 9 o 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART C
/ / Q
SYSTEM INFORMATION(con&wed)
Property Address: G PG C!!- l7l 11 �\(� Su /to O—l
Owner: r(((yit r'X A V)
Date of Inspection:
517- 00
SKETCH OF SEWAGE DISPOSAL SYSTEM:"
include ties to at least two permanen�eference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
Cedar N" i� ' ►°� �l ' ..
tJU�tly Se F3PAV
Fron+ poor
Buck boor
I �
\
000 66t ll®n Sep
D
'b- Box IG r`n Ghes be loo/ J_IYA -e
Sedere Qrap ,' 'I Trudy 7S- 'or more
revised 9/2/98 \I/ Page toaru
C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Cedar N r 1/ Rd Sct A0#-1
Owner: Fl(innr' q.1
Date of Inspection:
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 i
Check Cella
Shallow.wells
Estimated Depth to Groundwater 71 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
_k<"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)
It) loo ;n� at 4 'e o tai •`S /orro�o
(�nG� Consi`deA t' le P v 4 Arm n CC7 -(f a.-c9, fo P�O la to U p r y fur a 6 o f. 'e a n�- � �a �"� c�/q ��✓_
r
revised 9/2/98 Page 11 of 11
FORM 4 - SYSTEM PUMPING RECORD
Commonwealth of Massachusetts
, MAY t Massachusetts 4
System Pum-ping Record
CITY OF SALEM
System weer System Location
� %�qR G '�)R
Type: Emergency Q Routine
Cesspool: No ❑ YYes ❑ Septic Tank: No ❑ Yes
Date of Pumping: 11 G Quantity Pumped: �4(yn gallons
System°Pumped by (Company): elpi i � /1/ Permit 9:
Contents transferred to:
Contents disposed at:
Date _S// `7 Pumper re
Condition of system/other comments:
PEP.V'PROVFD FORM- 12/07/95
Y�NIAY7--�-R co/Y IF-
RFD