1 Eleanor Road Title V Inspection n
FILE# R J a I
TITLE V INSPECTION
Dean G. Luscomb II & Sons
288 Maple Street
Middleton, MA 01949
978-774-4055
Title V License # S1848
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNERS NAME
PROPERTY ADDRESS -t E „I e a aCr R-D I-d
S f-M
M
DATE OF INSPECTION AuQusi laRoat
NAME OF INSPECTOR h
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form. Not for Voluntary Assessments
1 Eleanor Road
Prop Ad erty dress - - - - - - - - - - - - - - - - -
Ham_ma
o
information is _
owner wner's Name - - - - - - - - - - - - -
- -
required for every Salem — _ — MA_ 01970 _ August 1_2, 2021
page. Cityrrown - - - State - Zip Cod e 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 farms A. Inspector Information
on the computer.
use only the tab _DeanG. Luscomb 11
key to move your Name of Inspector - - - - - - -- - -
cursor-do not Dean G._Lus_co_ mb 11 & Sons_
use the return Company Name - - -- -
key. C - - -..
�'� 288 Maple Street
t�l,+a I I Company Address - - -- - - - - - -
�V Middleton — — MA 019_49
Cityrrown - - - 14 State - Zip Code
978-774-4055 _ _ 81848 _
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
4�s
�► _gAu ust 12, 2021
In ture Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
t5inap.doc-rev.7l26=6 tide 5 Official Inspecllon Form:Subsurface Sewage M%pnaal Syswm•Page 1 of 18
Commonwealth of Massachusetts
ig Title 5 official Inspection Form
iq Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1 Eleanor Road
Property Address - - - - - - - - - - - - - - - - -
Hamma _
Owner owner's Name - - - - - - - - - - -
information is -
required for every Salem MA 0197_0 _ August 12, 2021
page. City/Town - - - - _ - 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.
® l have not found any information which indicates that any of the failure criteria described
in 310 C M R 15.303 or in 310 C M R 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
j� unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent- System will pass
v 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);
Mnsp.dac•rev.MM2[]1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 W 18
Commonwealth of Massachusetts
- - Title 5 Official Inspection Form
1�v Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1 Eleanor Road
Prapeny Address - -- - - - - - - - - - - - - -
Hamma
Owner owners Name - - - - - - - - - -- - -
information is - - --
required for every Salem — MA_ _ 01970_ August 12, 2021_
page. citylTown - - Stale Zip Code Date of inspection - -
C. Inspection Summary (Cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
r1 ❑ Observation of sewage backup or break out or high static water level in the distribution box due
U to broken or obstructed pipes)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(l)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doe-rev,7l2&2018 Title 5 Cdfidal Inspection Form:Subsurface Sewage Disposal System-Page 3 of fa
Commonwealth of Massachusetts
1 10 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 Eleanor Road
Property Address — - — - - — — — — — — — — — — — —Owner —
awner's Nam
Hamma _e _
— — — — — — — — —
information is �— — — — —
required for every _Salem_ — — MA 0197_0_ Au ust 12, 2021
page. CitylTawn — — — — 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-
El 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. ❑ther-
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
t5msp.dop rev.7Q612018 Title 5 offK4ai iTispw on Form:SubsurNca Sewage DIspo391 SysWM-Page 4 of 1 S
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
411
L; 1 Eleanor Road
Property Address
Owner
Hamma
- - -
information is owner's Name —
required for every _Salem _ - - _MA_ 01970 August 12, 2021
page. City/Town - -- — _ State Zip Code — Date of Inspection — — —
C. Inspection Summary (coat.)
4] System Failure Criteria Applicable to All Systems: (cant.)
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 %day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipes). 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 'I 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 GA.
Yes No
❑ ❑ the system is within 400 fee a surface drinking water supply
❑ ❑ the system is wit ' 00 feet of a tributary to a surface drinking water supply
the sys is located in a nitrogen sensitive area(Interim Wellhead Protection
Area- IWPA)or a mapped Zone li of a public water supply well
t5rnap.doc•rev.7n6l2018 Title 5 Offidal InspaMion Form:Subsurface Sewage❑ispv at system•Page 5 of TS
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1 Eleanor Road
Property Address— — — — — — — — — — — — — — —
Ham_ma
Owner Owner's Name
information is
required for every Salem _ -- — _ _ MA 01970 ___ August 12, 2021 _
page. City/Town State Zip code tote of Inspection 4
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 C.4 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?
® ❑ 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 NIA)
® ❑ 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 C M R 15,302(5)]
l5insp-doc•rev.726M18 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 6 of 18
�L\ Commonwealth of Massachusetts
' -. 0 Title 5 Official Inspection Form
'� Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1 Eleanor Road
Property Address - - - — - _ — -- — —
Hamma_ _
owner Owner's Name
information is
required for every Salem — _ _ MA _ 01970 August 12, 2021
page. dityrrown state Zip Code date of Inspection
❑. System Information
1- Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CM 1 330 gpd
5.203 [for example: 110 gpd x#of bedrooms]:
Description:
Town and owner.
Number of current residents: 4- --
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 Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use?
❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)}:
Detail:
r� `7 y ` 0
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5kW.doc•rev 7/28/2018 Title 5 Official Irtepection Form!Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1 Eleanor Road
Property Address - — — - -Owner --
Hamma
information is
Owner's Name — —
required for every Salem — — MA 01970 August 12, 2021_
page. 6ity,town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commerciallindustrial Flow Conditions:
tl Type of Establishment: - —
Design flow{based on 310 CMR 15.203}: Gallons per day(gpd)
Basis of design flow (seatslpersonslsq.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: pumps every 18 mo. Last pumped 10 months ago.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: zero
gallons
How was quantity pumped determined?
Reason for pumping: no need at this time.cstay on schedule)
t5inap.doc-rev.712WO18 Title 5 Official Inapedion Form:Subumlace Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
�, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� ? 1 Eleanor Road
Pro perty Address — — — — — — — — — — — — —- . —
_oHwneramma`s Name_
— - ——— - --- — — — — — —— -
information is -— — —
required for every Salem _ _ — _ — MA_ _ _01979 August 12 2021
page. City/Town — —~ State Zip Cade Date of Inspection —D. System information (cont.)
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 ❑EP approval-
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Tank an d-box are from 2014. SAS is orignial to house- 1963.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5, Building Sewer(locate on site plan):
Depth below grade: 2'feet _
Material of construction:
®cast iron ❑40 PVC ❑other(explain): -
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc-):
Main line and joints are in good condition, no signs of any problems.
t5insp.doc•ray 71261201 S Intle 5 Offtcial fnapectlon Farm.Subsu7ace sewage❑i,4 a si System•Page 9 of ib
Commonwealth of Massachusetts
!�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1 Eleanor Road _
Property Address
Hamma
Owner Ownees Name - -
information is
required for every Salem MA 01970 August 12, 2021
page. Cityrtown State Zip Cede Date of Inspection
D. System Information (Cont.)
6. Septic Tank(locate on site plan):
1'
Depth below grade: feet
IMaterial of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500 gallons
If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
5' x 5'x 10'- 1500 gallons
Dimensions: - - -
Sludge depth:
1"
Distance from top of sludge to bottom of outlet tee or baffle
1rr
Scum thickness -
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 15 -
How were dimensions determined? by measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank and baffles are in good general condition. The tank is running at it's correct working height.
The d-box has a Zable filter-that was cleaned today.
t5rnsp.doe•rev-712W261 8 True 5 Official hspec[ion Form-Subsurface Sewage Dusposai System•Page 10 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
} Subsurface Sewage Disposal System Form -Not for Vofuntary Assessments
1 Eleanor Road
Property Address — — — — — — — — - - — —
Hamm
_a
Owner owner's Name — — — — — —
information is
required for every Salem — — MA 01970 Au us# 12, 2a21
page. City/Town State Zip Cede 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 ❑ 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 ❑other(explain):
Dimensions: -
�
Capacity: -
gallons
Design Flow: gallons per day
t5insp.doo•rev.712&2018 Title 5 Offtial Inspection Form•Subsurface Sewage Disposal system•Pape 11 of 18
�LN Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
—vvoiv 1 Eleanor Road
Property Address
Hamma
Owner 6wnee Name -- --
information is
required for every _Salem _ MA 01970 August 12, 2021
page. CitylTown State Zip Code Elate of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cunt.)
Alarm present: ❑ Yes ❑ No
Alarm level; Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Da
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 Zero
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box is 20" below grade, 16" x 16". The d-box is in good working condition. The d-box has
speed levels in it.
t5insp.doc•rev.7PAMI S Title 5 Off ial Inspection Farm:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
- P Title 5 Official Inspection Form
q Subsurface Sewage age Disposal System Form Not for Voluntary Assessments
1 Eleanor Road
Property Address
Hamma
❑wnei Owner's Name -
information is
required for every Salem _ MA 01970 August 12, 2021
page. City/Town State Zip Code date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
V Pumps in working order: es ❑ No*
V Alarms in working order: ❑ yes [] No"
Comments(note condition of pump cha 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:
The SAS was located by previous title v from 2014 and snake with transmitter.
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2 -40' long
❑ leaching Melds number, dimensions: -
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7I26*D18 Title 5 Official Inspection Form:Subzi eface Sewage Dpsposal System•Page 13 of 18
Commonwealth of Massachusetts
r Title a Official Inspection Form
k':
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1 Eleanor Road
Property Address — — — —
Hamma _
Owner owner's Name
information is
required for every Salem _ — MA 01970 August 12, 2021
page. CitylTown state Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) {cunt.}
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.)-
The SAS is in good general condition. This area is covered with well maintained green grass.
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.MASI=9 Tide 5 Official Inspeelion Fonn.Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
_i Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
h
L: 1 Eleanor Road
Property Address — — — — — — — —
Hamma _
Owner Owner's Name — — — —
information is
required for every Salem — — MA 01970 August 12, 2021
page. City/Town State Zip Cade Date of In&pection
D. System Information (cont,)
13. Privy (locate on site plan):
(1 Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc,):
15insp-doo•rev.7126MIS 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 - N
�p g p Y of for Voluntary Assessments
1 Eleanor Road_
Property Address — — — -- — — —
Hamma
Owner information is pwner's Name — — — — - _—
required for every Salem _ — MA 01970 _ August 12, 2021
page. GitylTown state Zip Code 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
land_marks or benchmarks. Locate all wells within 100 feet. Locate where public water pply enters
th6 building. Check one of the boxes below:—^
® hand-sketch in the area below l
El drawing attached separately C W
Font 3
3
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t5lnsp-doc•rev.712612078 Title 5 Official Inspection Form:Subsurface Sewage 0ispmal System-Page 16 f IS
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1 Eleanor Road
Property Address — -- --- --
Hamma
Owner pwrie s[Name - —
information is
required for every Salem _ MA 0.1970 August 12, 2021
page- City/Town State Zip Code Date of Inspection
D. System Information (cant.)
15. Site Exam: l
® Check Slope &V P, l
® Surface water N4tl-10—
® Check cellar 'D,�� PL) slcmp
® Shallow wells P0A-C.
Estimated depth to high ground water: +1
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: 2014
Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Previous title v done 2014 and pumRj records.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Basement is U below grade with no sump pump and dry today. Previous Title v also stated a 5' depth
to ground water table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
f5insp-doc-rev.712612018 Title 5 Of ickal Inspection Form.Subsurface Sewage Disposal System•Page 17 of 16
Commonwealth of Massachusetts
�0 Title 5 Official Inspection Form
rl Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
i.
1 Eleanor Road _
Property Address
Hamma
Owner Owner's Name
information is
required for every Salem _ MA 0197L} 9
A_u ust 12, 2021
..__ _
page. Cityfrown 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 5(Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 15 or attached
For 15: Explanation of estimated depth to high groundwater included
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