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DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED �� 25 8.7
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ADDRESS: 4 Patriot Way, Centerville, MA
ASSESSORS' REFERENCE: 'Map 192, Parcel 127
OWNER'S NAME: William L. Schulze
RIECEPM VEp
DATE OF INSPECTION: May 10, 1995
LLMAY 2 5 1995
PART A HEALTH D i,
CHECKLIST T OF o
Check if the following have been done:
X Pumping information was requested of the owner, occupant, and Board of
Health.
x
None 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.
N/A As built plans have been obtained and examined. Note if they are not
available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The site was inspected for signs of breakout.
X All system components, excluding the SAS, have been located on the site.
X 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.
X The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
X The facility owner (and occupants, if different from owner) were provided
with information on the proper maintenance of SSDS.
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If Residential
3 Number of Bedrooms
2 Number of Current Residents
No Garbage Grinder, yes or no
Yes Laundry Connected to system, yes or no
No Seasonal use, yes or no
If Nonresidential, calculated flow:
Water meter readings, if available:
May 9, 1995 Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
5/17/91; Water Polution Control
No System pumped as part of inspection, yes or no
if yes, volume pumped:
Reason for pumping:
Type of System
X 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)
Other (explain):
Approximate age of all components. Date installed, if known. Source of
information: May 25, 1985; Board of Health Records.
No Sewage odors detected when arriving at the site, yes or no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION (CONT.)
SEPTIC TANK: x ; (Locate on site plan)
Depth Below Grade: 3 Feet
Material of Construction: x Concrete; Metal; FRP; Other (explain)
Dimensions: 4 x 9 x 4; 1000 Gallon Tank
1.5" Sludge Depth
46.5" Distance form top of sludge to bottom of outlet tee or baffle
8" Scum thickness
4.5" Distance from top of scum to top of outlet tee or baffle
8" Distance from bottom of scum to bottom of outlet tee or baffle
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,
recommendations for repairs, etc.)
Recommended pumping.
Liquid Level is at bottom of outlet pipe.
Conrete baffle; Built-in tee.
DISTRIBUTION BOX: None (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, recommendation for repairs, etc.)
None.
PUMP CHAMBER: No (Locate on site plan)
Pumps in working order, yes or no
Comments: (Note condition of pump chamber, condition of pumps and appurtenances,
.recommendations for maintenance or repairs, etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION (CONT.)
SOIL ABSORPTION SYSTEM (SAS): Yes (Locate on site plan, if possible;
excavation not required, but may be approximated by non-intrusive methods.
If not determined to be present, explain:
TYPE
Leaching Pits and Number: 6 x 6 (1)
Leaching Chambers and Number:
Leaching Galleries and Number:
Leaching Trenches, No., & Length:
Leaching Fields, No., & Dimensions:
Overflow Cesspool, Number:
Comments: (Note condition of soil, signs of hydraulic failure, level of ponding, condition
of vegetation, recommendations for maintenance or repairs, etc.)
No signs of hydraulic failure, normal vegetation, recommended tank be pumped.
CESSPOOLS (Locate on site plan):
Number and Configuration: N/A
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 part of
inspection):
Comments: (Note condition of soil, signs of hydraulic failure, level of ponding, condition
of vegetation, recommendations for maintenance or repairs, etc.)
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION (CONT.)
PRIVY (Locate on site plan):
Materials of Construction:
Dimensions:
Depth of Solids:
Comments: (Note condition of soil, signs of hydraulic failure, level of ponding, condition
of vegetation, recommendations for maintenance. or repairs, etc.)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent references landmarks or benchmark. Locate all
wells within 100 feet.
47 wrru,.,iu a
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DEPTH TO GROUNDWATER
40 Feet (est.)Depth to groundwater
Method of determination or approximation:
U.S. Geological Survey Map.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all
instances. If "Not Determined", explain why not).
N Backup of sewage into facility?
Interior inspection
N Discharge or ponding of effluent to the surface of the ground or surface waters?
Observation
N/A Static liquid level in the distribution box above outlet invert?
No Distribution Box
N/A Liquid depth in cesspool <6" below invert or available volume < 1/2 day flow?
N Required pumping 4 times or more in the last year? Number of times pumped?
Last pumping 1992
N Septic tank is metal? cracked? structurally unsound? substantial infiltration?
substantial exfiltration? tank failure.imminent?
N Is any portion of the SAS, cesspool or privy: below the high ground water elevation?
N Within 50 feet of a surface water?
N Within 100' of a surface water supply or tributary to a surface water supply
N Within a Zone I of a public well?
N Within 50' of a bordering vegetated wetland or salt marsh (cesspools& privies only,
not the SAS)?
N Within 50' of a private water supply well?
N Less than 100' but greater than 50' 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:
I
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
NAME OF INSPECTOR: ROBERT W. SABEN, JR.
COMPANY NAME: BARNSTABLE COUNTY SYSTEMS INSPECTORS
COMPANY ADDRESS: 25 MID-TECH DRIVE, WEST YARMOUTH, MA 02673
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and
that the information reported is true, accurate and complete as of the time of inspection.
The inspection was preformed and any recommendations regarding upgrade,
maintenance and repair are consistent with my training and experience in the proper
function and maintenance of on-site sewage disposal systems.
Check One
X I have not found any information which indicates that the system fails to
adequately protect public health or the environment as defined in 310 CMR
15.303. Any failure criteria not evaluated are as stated in the FAILURE
CRITERIA section of this form.
In have determined that the system fails to protect public health and the
environment as defined in 310 CMR 15.303. The basis for this
determination is provided in the FAILURE CRITERIA section of this form.
INSPECTOR SIGNATURE:
DATE: May 12, 1995
Recommended concrete rises be installed to septic tank within 1 feet of
f;�gro.tindelevel.
Original to system owner
Copies to:
Buyer(it applicable)
Approving Authority