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0057 BENT TREE DRIVE - Health
57 Bent Treed Drive Centerville A= 168-045-002 o E:N A,D No.2453LOR UPC 12534 • Y.0 b.UPI► I w,wMwNaaerw SFI =Nm mm . _ TOWN OF BARNSTABLE LOCATION 6-V �1— d 1z)e_ SEWAGE#6?®1-^ ,�q6 VILLAGE ,fe,,,�—tX V�V\g_ . ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:( eQ C,�__ Cjcm ize) !a o SS X 2 C}X Q NO.OF BEDROOMS � f, OWNER �NyAo � S kVa_klb PERMIT DATE: I C��f COMPLIANCE DATE:4712 / I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility - Feet. .: .Private Water Supply Well and Leaching Facility(If any wells exist on _ site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY e Ok, ol A � �� W c3 =. SZ� C 4 = f Town of Barnstable P l 57t7D- 16 V16 ray Department of Regulatory Services n awn Public Health Division Date !'h 1+ 20 MA99. r 1-619. 200 Main Street,Hyannis MA 02601 ' En taxi PO y �-- ► �- Date Scheduled Time y Fee Pd. f ` ' 4-F Soil Suitability Assessment for SemjW Disposal Performed-By: _ILLU i G� `J L iJf�'(h Q t�yY' Witnessed By: ]LOCATION&.GENERAL INFORMATION Location Address S') 11 Owner's Name l Dr N,�i� ��►�-I`�rt�, i I� Address Qclklt-. .-Troe. Lt�� Z C����r�� I(Q Assessor's Map/Parcel: ` Engineer's Namc 17 NEW CONSTRUCTION REPAIR Telephone ff 90,-6 36ef Q Lnnd Use'- -eS I.1ile L 4i W'I Slopes(%) 2 ( fo i Surfaco Stones Distances from: Open Water Body 10 0 t ft Possible Wet•Areaf 100 T ft Drinking Water Well L O©t ft Dralhage Way 2 ft Property Line _t y ft Other ft SICETCHG(Street name,dimensions of lot,exact locations of test holes&pero tests,locate wetlands-In proximity to holes) lV r t a �0 riL1 �j Lj__L�J IJV . Cy An . 2- o 's 2.(3 ; Parent material(geologic)_p r� ��4�i ©�'� S Depth t0 Oedrook Depth to Groundwater. Standing Water In Hole: n 494 e- Wo(e�ping 1Yolrt Pit Ppeer �h Estimated Seasonal High Groundwater V10fe- +4-ill 132 <i >1. 7.rcm DETIi _ VIlNATION FOR SEASONALMIGI1 WATER TABLE Method Used: I i1 Depth Observed stand ng in obs.hole: In. Depth to soli mottlem: hope 44' Depth to weeping from side of obs.hole: Ill. Oroundwatdr Adjuettotint R. Index Well-# Roadingbato: Index Well level --, AdJr-tketor Adj.drtwndwatorlevol„,_ PERCOLATION TEST . Uatd 911Z igi8 TI'a iD K ) Observation ., Hole ff Tinto at 9" Depth of Pero 4% Thno at 6" Start Pro-soak Time @ " Tima(9"-6") 4- End Pro-soak `ti' Rate Min./Inch . 2 m 1 Site Suitability Assessment: Slto Passed Site Failed: Additional Testing Needed(•Y/N) _ Original: Public Health Division Observation Hole'Data To-Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Consepvation Division at least one (1) week prior to beginning. Q:ISEPTfCtPERCPORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soli Horizon Soil Texture Shcl Color Sall• Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. Consistency,Varavel) `' 5-Z.-i-51d C2 U vo SQhd 10 "Y3 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Sall Texture Sol]Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ConsWency. 10 -7-0 '1 Loci my Scnd l0 '{P t rt"'gb1e 4� 1 5 Z -2- �7n4 to 4 f.?- C/4 tags DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. Consistency, • i � i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soli Texture Sall Color gall Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Slopes;Boulders, Consistency, i Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No - Yes ° Within 100 year flood boundary No, Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious mlterial exist in all areas observed thrpughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? ___._. Certificatio ' I certify that on N�� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the requlred training,expertise and experienncee Jdescribed in 10 CMR 15.017. -7 0 • Signature j� Date G°I D Q:XgEPTICWERCPORM.DOC No3.:..J� .. F�$,$10.00......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town Barnstable ................. ..---...----•.-O F...........................--•---.........------------------------------•---------------•- Appliratiun for Uiupuii al Works Tonutrnrtiun ramit Application is hereby made for a Permit to Construct ( )` or Repair (X ) an Individual Sewage Disposal System at: 57 Bent Tree Dr ......... -- -:---_... ........................•--•-•--•-•--•-•---•••---•_.....Roger .......-•----...-•-•---•--•••-•---...._...-•--••------._.....---•-•-•--•-------•...............--- W. SmithLocation-Address 601 Washington SfikR,' Holliston, Ma 01746 ._.. -----••---•...........................•----••-•...._...--••-----_... ..........-•...................................................................................... W A & B Cesspool Serovice 128 Bishop's Terjjy '.ddlannis, Ma 02601 .......-- -------- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............)..............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.............._._..__.__.. Showers ( ) — Cafeteria ( ) P4 Other fixtures ------------------------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---_--------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ►-4 Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 0 Description of Soil..Sand---------------••--•-------------••-----••-------------•-------•---------------------------•------------•-•-•---•-•------------------------•---------•-•--•- x . ----•------------------------•-••---......--•--•.-•....-------•---•-•---•-•-------------•---•-•••......-•-•••-••---..---•-- V Nature of Repairs or Alterations—Answer when applicable.._Install a 1000 gallon leach pit --------------------- ---------------------------------------------------- ...... with stone Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL% 5 of the State Sanitary Code— The undersigned further agrees no to place the system in operation until a Certificate of Compliance has been issued by the and of health. Signe�� --------- ----=--!�`�- r�..�------ 5/31/83 D Application Approved By....... ,._,�....... ..�-�. . . / Date Application Disapproved for the following reasons-------------------------------------------------------------------------------•----...---••--•--•..........••-- --------------------••----------•-••---------------------------•------......-----------------------..._............--•----------------------•••-------•---------•••••--•••----•-----------•---------.._. Date PermitNo. -.8..3................................................. Issued 6� 83-------------•----.....---------- Date No83-..376_ �1a o0 F E s............................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH m own Parnstable ...........................................OF......................................................................................... Appliration for Disposal Works Tonstrnrtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: S7 Bent Tree Dr ................__......_:..................................................................... .....---......----------.._.........--------------•---•--------------......._......--------------- Roger W. SmithLoeatlon-Address 601 Washington SftJde-U; Holliston, Ma 01746 ......................--........................................................................ --..........._..•-----•......---•----------------.......------•--•-----------------.............-- W A �: B Cesspool SeRite 128 Bishop's TertAddIrWannis, Ya 02601 a ........... - ............. Installer Address QType of Building Size Lot----------------------------Sq. feet aDwelling—No. of Bedrooms...... Expansign Attic ( ) Garbage Grinder ( ) p 1 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) fl, Other fixtures ---------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... 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........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 Sand Descriptionof Soil-------------------------------------------•----------...---•--•----------•-•--------------------------------------------------------------------------.......--------- x W ---------------- - - ----------------------------------- ----------- .......---- x - -- - ---------- --------- --- - 7salT--a--ia00.-�alZori--Teach-"pig-_....._.._...__. U Nature of Repairs or Alterations—Answer when applicable..............................................•......___....._......................_.._........ packed with stone Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 5 of the State Sanitary Code.—The undersigned further agrees n to place the system in operation until a Certificate of Compliance hays b�eeen�issued by the b and off health. ` Signed._�2-" L'trc............ ✓ '`-. +,�_..... 5/31/ 3 _.d.. ................................ Application Approved B ... -....-/:�._ 6/ 1�� PP PP Y = --------------------- ----------------- Date Application Disapproved for the following reasons-------------------------------------•------------------------------------------•-------------•-•-----.......---- .......................................... ... .........-............................................................................................. ---------------------------------------••------------ 83— Permit No. ..... .......... Issued....6/---•/83----....._......------ae------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T own ...O F.Barnstable ........... ...... .................................................................................... py %'-p (rr#ifiratr of omplianrr ATjes�sQp� R �rvYCjha1Aeliv6ujeee R '�sSyse�,n( 8ucted ( ) or Repaired ( ) bY.................................................................................................................................................................................................... 57 Bent Tree Dr. Centerville, Va 02632�staller Smith at......................................................................................................._ has been installed in accordance with the provisions of TIc 5 of The State Sanitary Ve 18 jescribed in the application for Disposal Works Construction Permit No.................3.7�?.____..____ dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR D S A GUARANTEE THAT THE SYSTEM �kLLP8 NCTION SATISFACTORY. DATE.......... 3 .....--•---------------------------------- Inspector..-----,... i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable .......................O F.----.....-----...................................................................... 10.00 No. 3 ..376. FEE.............•.......... f 1 Disposal orks %onstrj1qT- tit Permission is hereby granted A & esspoolrviCe sh s . err Hyannis, Ma 02601 ' to Const tB6t) °rr&P,g�.(Ce�n$'940iig,all,�ev 3'�ispQW Soh at No. --- --- ---- • Street 83_ 66/ f 83 as shown or�t�e a,�ication for Disposal Works Construction Permit No..................... Dated.......................................... // "J � ...............................................................-----••----- ............................................................... Board of Health DATE.---.-S�/ , FORM 1255 A. M. SULKIN, INC., BOSTON as' LOCATION SEWAGE PERIPIT NO. VILLAGE C''L-"�✓f PF V1 Ile 4446 Zlgo 4��6�,� INSTALLER'S NAME i ADDRESS S�42 a o L d UILDE R OR OWNER DATE PERMIT ISSUED �1 QAT E G0MPLIANCE ISSUED 3 r' _ ��,,,,� _ ��z ' _ _ �� � � � i v , �� � e �� , �. �. � � e �1 ��( ...�� ���� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Bent Tree Drive, Centerville M - 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is required for every 50 Roosevelt Street, Marlboro MA 01752 July 26, 2012 page. City/Town 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. General Information on the computer, use only the tab 1. Inspector: ) key to move your — cursor-do not Troy Williams _ use the return Name of Inspector key. Troy Williams Septic Inspections Company Name 19 Hummel Drive Company Address South Dennis MA 02660 City/Town State Zip Code (508) 385- 1300 S1682 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4 I July 26, 2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use ' at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11110 Title 5 OfficiaU n Form:Subsurface Sewage Disposal System•Page 1 of 17 f , Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °f 57 Bent Tree Drive, Centerville M- 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is required for every 50 Roosevelt Street Marlboro MA 01752 July 26, 2012 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 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: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): N/A t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Bent Tree Drive, Centerville M- 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is required for every 50 Roosevelt Street, Marlboro MA 01752 July 26, 2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): N/A ❑ 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): N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .' 57 Bent Tree Drive, Centerville M- 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is 50 Roosevelt Street, Marlboro MA 01752 Jul 26 2012 required for every y page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A 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 ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Bent Tree Drive, Centerville M- 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is 50 Roosevelt Street, Marlboro MA 01752 Jul 26, 2012 required for every Y page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Bent Tree Drive, Centerville M- 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is 50 Roosevelt Street, Marlboro MA 01752 Jul 26, 2012 required for every Y page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ 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 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I ' Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '(a 57 Bent Tree Drive, Centerville r M- 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is 50 Roosevelt Street, Marlboro MA 01752 July 26, 2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): 11=6,000 gals. 10=6,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occasional use Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gaiions per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 57 Bent Tree Drive, Centerville M- 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is 50 Roosevelt Street, Marlboro MA 01752 Jul 26, 2012 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: ` N/A Date Other(describe below): General Information Pumping Records: Source of information: Last pumped in May of 96 per info from BOH. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ - Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Bent Tree Drive, Centerville M - 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is 50 Roosevelt Street, Marlboro MA 01752 Jul 26, 2012 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank and leach pit#1 are original to home built approx. 1973. Pit#2 was installed on 6/2/83 per as- built. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑cast iron ®40 PVC ® other(explain): Orangeburg from tank to pit#1 Distance from private water supply well or suction line: eett Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. Septic Tank(locate on site plan): 6„ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'X9'X6' 1000 gallon 411 Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Bent Tree Drive, Centerville M- 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is 50 Roosevelt Street, Marlboro MA 01752 Jul 26, 2012 required for every Y page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2'8" Scum thickness none 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 14" How were dimensions determined? probe/measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete inlet baffle and outlet tee were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: N/Afeet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): N/A Dimensions: N/A Scum thickness N/A 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 Date of last pumping: N/A Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form war-EW Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..' 57 Bent Tree Drive, Centerville M- 168 P-45002 Property Address Marie O'Neill Owner Owners Name information is required for every 50 Roosevelt Street, Marlboro MA 01752 July 26, 2012 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): N/A "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M "( 57 Bent Tree Drive, Centerville M- 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is required for every 50 Roosevelt Street, Marlboro MA 01752 July 26, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site,plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): N/A 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.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ug Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Bent Tree Drive, Centerville 'M - 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is required for every 50 Roosevelt Street Marlboro MA 01752 July 26, 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-6'X6' pit with 2 of stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pits were dry on inspection with a light visible stain line approx. 2' below inlet invert and a dark stain approx. 1'from bottom in pit#2. Pit#1 is stained up to outlet line. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "- 57 Bent Tree Drive, Centerville M- 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is required for every 50 Roosevelt Street, Marlboro MA 01752 July 26, 2012 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection' Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Bent Tree Drive, Centerville M - 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is 50 Roosevelt Street Marlboro MA 01752 Jul 26, 2012 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately n f r ' Ll 33 t5ins•11f10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..''t 57 Bent Tree Drive, Centerville M- 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is required for every 50 Roosevelt Street Marlboro MA 01752 July 26, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 13.0'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed- Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: MIW 29 Zone C 8.6' 3.9'adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 12.0'. Hand augered 5' below bottom of leaching with no water found at a depth of 13.0'. Groundwater adjustment at the time of inspection was 3.9'. Bottom of leaching at 8.0'was found not to be located in the high groundwater elevation at the time of inspection. USGS maps estimate groundwater at approx. 24.9'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Bent Tree Drive, Centerville M - 168 P-45002 Property Address Marie O'Neill Owner Owner's Name information is required for every 50 Roosevelt Street, Marlboro MA 01752 July 26, 2012 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 � � - 14 � US Commonwealth of Massachusetts m-' ` Executive Office of Environmental Affairs Department of IE 4 1997Environmental Protection TRNSTABLE William F.Weld Gorsmor seers" Argeo Paul Cellucci David B.Struhs U.Conmor commh.w w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 57 Bent Tree Dr, Centerville AddressofOwner. Roger W Smith Date of Inspection: (, —J. 6" q -7 (If different) 37 Bent Tree Dr Name of Inspector. W.E. Robinson SR Centerville Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sew disposal systems. The system: _ asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority — Fails -Inspector's Signature: 4! CQ +� Date: LS -.jo—c? �. The System Inspector shall submit a copy of this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Check A/B,�C, D: A] SYSTES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303, Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes in Indica 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, cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a gonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 • FAX(617)SWI049 a Telephone(617)292.5500 '10 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddrem 57 Bent Tree Dr, Centerville Owner. Roger W Smith Date of Inspection: 4 7 B]SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution boa 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 pipe(s)are replaced obstruction is removed C) THER 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. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is leas than 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 law than 5 ppm. OTHER (revised 11/03/95) 2 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address: 57 Bent Tree .,Dr, Centerville Owner. Roger W Smith Date of Inspection: e_�4 4 SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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 necessary to correct the failure. 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 50 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. El GE SYSTEM FAILS: 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: 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 H of a public water supply well) The owner o operator of any such system shall bring the system and facility into Rill compliance with the groundwater treatment program 00. Please consult the local regional office of the Department for further information.. requirements f 314 CMR 5.00 and 6 gl P� (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST property Address: 57 Bent Tree Dr, Centerville Owner. Roger W Smith Date of Inspection: C—,;-0—q/7 Check if the following have been done: �✓Pumping information was requested of the owner,occupant, and Board of Health. �ne of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. VAobuilt plans have been obtained and examined. Note if they are not available with N/A. V111The facility or dwelling was inspected for signs of sewage back-up. L<The system does not receive non-sanitary or industrial waste flow ,2'he site was inspected for signs of breakout. VAllsystem components, excluding the Soil Absorption System, have been located on the site. 'he 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. ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 l I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 57 Bent Tree Dr, Centerville Owner. Roger W Smith Date of Inspection: FLOW CONDITIONS RFSIDENTIAI: Design flow: '; Number of bedrooms: Number of current residents:fl Garbage grinder(yes or no): Al, Laundry connected to system(yes or no): Seasonal use(yes or no): L- water meter readings,if available: 1995 — 99, 000 gals. 1996 - 78, 000 gal ._ Last date of occupancy: COMMERCIAL/INDUSTRIAI.: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes 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) Last date of occupancy: GENERAL INFORMATION PUMPING REC R S gnd�source gf informa�e System pumped as part of inspection:iinspection: (Yelor no)_,�—p If yes,°volume pumped: gallons Reason for pumping: TYPE OF ITEM ptic taak/distr�ution box/soil absorption system Single cesspool Overflow Cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: l 9 Sewage odors detected when arriving at the site: (yes or no)Lli (revised 11/03/95) 5 r - - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Bent Tree Dr, Centerville Owner. Roger W Smith Date of Inspection: (� 0_^'✓� SEPTIC TANX (locate on site plea) Depth below grader Material of Constriction:�oo=,t,_metal_FRP_other(e:plam) Dimensions: t• k Sludge depth: -a Distance from top of sludge to bottom of outlet tee or baffle:Z/-4D 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: 13 Comments: (recommendation for pumping, condition of' et and outlet tees or baffles,depth of liq 'd level in relation to outlet invert,structural into ' Pce of evide ,etc.) �' a 44 IV leakage K&c.q -) L G E TRAP:_ (locate on site plan) Depth low grade: Mate ' of construction:_concrete_metal_FRP_other(ezplain) Dimena' no: Scum esa: from top of scum to top of outlet tee or baffle: from bottom of scum to bottom of outlet tee or baffle: Comm ts: (reco endation 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 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Bent Tree Dr, Centerville Owner. Roger W Smith Date of Inspection: (�—;L6--1j TIGE T OR HOLDING TANK_ (locate site plan) Depth be grade: Material f construction:_concrete_metal_FItP_other(e:plain) Dime ns: Cap gallons flow: gallons/day level: Comme ta: (condi ' of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BO&_Z (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP HAMBER: (locate o site plan) Pumps working order:(yes or no) to: (note co tion of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 J ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Bent Tree Dr,: Centerville Owner. Roger W Smith Date of Inspection: 4 —a.a 4-17 7 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if posidble;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,number: leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool,number: Comments: (note condition of soil, signs of hydray]�failure, le 1 of poncondition of v4, tation etcJ �t v CE9TOO LS:_ (locate on site plan) Number and configuration: Depth-to of liquid to inlet invert: Depth of lids layer- Depth of layer: of cesspool: Mate ' of construction: Indira ' n of groundwater: inflow(cesspool must be pumped as part of inspection) Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) PRIVY: (locate on 'te plan) Material of construction: Dimensions: Depth of lids: Commen : (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) g Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) property Address: 57 Bent Tree Dr, Centerville Owner. Roger W Smith Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' i PG p d, ` DEPTH TO GROUNDWATER Depth to groundwater: ) `k feet method of determination or approximation: _le-t�S 1 N 6 (revised 11/03/95) 9 • ::. .. ___ .gym— - - 2 I I { = D I V I i N L.� Ito M Alp i w I+ c.�• ff M1A � F i i , - a _ w. i v i ; + W - - I rr� eb as CD1M afin? i C aa� I I i {,> ���� ������'f1!"' ..���k�*�.'a�'i t11�i�(��;I,r{�1m2�flC�Y§(3'�.�i4 �'1' <�$��asr.�3�,>��i�+u¢?'i�t'. •. _ - � ' - 40 1`t ._ + 1 f 71 fR _ TI) as I _ f �I�r +wwa.a.:.NtSdkK::/�awW xir..r. }.� -Nbr..;iVxL :.�• i c 4. ' c I � F i } -r w . j sr,w-:' r y�4 n • l I ;Z5 f --,4-L % .......... ......_ _.__, ,