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�-\ COMMONWEALTH OF MASSACHUSETTS
ExECUTIVE OFFICE. OF ENVIRONMENTAL AFFAIRS
MEW
DEPARTMENT OF ENVIRONMENTAL,PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAI SYSTEM FORM
L
PARTA
CERTIFICATION
Property Address: 1'28 Rolling Hitch Rd Centerville STq ,Owner's Name: Bressler P.r
Owner's Address:
' -- b
Date or Inspection: :5
MAP
Name of Inspector:(please print) wi 1 1 i am E_ . R(-)hi n son Sr. PARCEL d
Company Name: . William E. Robinson Septic Service 2
Mailing Address: P O Box 1089 - LOT �d
Centerville, MA Telephone Number: ( 5m _ 775-8776
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.The inspection was performed based on my
training-and experience.in the proper function and maintenance of on site sewage disposal systems.1 am a DEP
approved system inspector,pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signiature: � ;�/C_b ` . Date- v
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heaitfi of
DEP)within 30 days of completing this inspection.If the system is a:shared system or bas 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 appro.ving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of l l
OFFICIAL INSPECTION FORM' NOT FOR VOLUNTARY ASSESS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
128 Rolling Hitch Rd
Property Address' i e
er
Owner.
Date of Inspection: -7 —
11
Inspection Summary::Check A,B,C,D or E/ALWAYS complete'sll of Section D
A. Sy em Passes:
found any information which indicates that any of the failure criteria described in 310 CMK
l have not
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
r
B. System Conditionally,Passes:
One or-more system componenu as described in the o"Conditional e a'rras .P approved by�the Board of Health on need to:be rep aced
11 pass:
repaired.The system,upon completion of the replacementp PP
Answe yes,no or not determined(Y,N,ND)in the for the following statements..If"Wort determined"pleas'
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 exfiitration 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
•A met it septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicati�g that the tank is less than 20 years old is available.
ND ex,lain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obs cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
appr val of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 tunes a year due to broken or obstrticted Pis)'The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obsuuctiun is removed
ND expl in:
Page 3 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARTAA
CERTIFICATION(continued)
Property Address
128 Rolling Hitch Rd.
Owner:
Date of Inspection: 3 — "0-5
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 defermines in accordance with3l0 CMR 15.303(1)(b).that the
s�stem.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.
i
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines.that the
system:islu"Aoning in a manner that protects the public health,safety-and environment:
The system has a_septic tank and soil absorption s and the SAS is within 100 feet of a
rP system(SAS))
surface water supply or tributary to'a surface water supply:
I 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 frotil a
prorate water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is Gee 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:
I .
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM
;•'PART A
CERTIFICATION(continued)
128 Rolling Hitch Rd
Property Address: •`•
Owner:
Date of Inspection: 3 w. `� b
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 oT`:
cesspool
_ Liquid depth intesspool is less than 6":below invert s less
or available volume i than'/:day flow
_ ear NOT due to clogged or obstructed pipe(s) Number
Required pumping more than 4 times in the last y
wof 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 l 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 feetbut greater 50 feet from a private water;
supply well with no acceptable water quality analysis.[Tbis.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.]
(YcstNo)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 I5,000
gpd- 'You must indicate either"yes"or"no"to each of the following:
(The t fo llowing criteria apply to large systems in addition to the criteria above)
1
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 swfirx 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 su
pply well
_
consid
ered significant threat,or answered -
If you have answered"yes"to any question in Section E the system is c�oms �e system considered a
"yes"in Section D above the large system has fatted.The owner ar operator of any Iarg y
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.
4
Page 5 of I I '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM
"PART B
CHECKLIST`
Property Address:
128 Rolling Hitch Rd
_„
een1 e1 v±i i n
Owner: L es s es r _..
Date of Inspection:
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, .:.
t/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_?
7-✓ 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)
i/ _ Was the facility or dwelling inspected for signs of sewage backup?
_ Was'the site inspected for signs of break out.?
V _ Were all system components,excluding the SAS,located on site?
_ _� Were the septic tank manholes uncovered,opened,and the interior 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.
Determined in the field(if any of the failure criteria related to Part Cis at issue approximation.of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6 of I l
OFFICIAL INSPECTION FORM NOT FOR::VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
SYSTEM INFORMATION
g Hitch Rd
Centerville
Rollin
Property Address: 12 en ervi e
O
Bress
wner: er
Date of Inspection:
FLOW CONDITIONS
RESIDEN...T1AI.
Number of bedrooms(design):._ �/ Number of bedrooms(actual):
DESIGN flow based on 310 CMA 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no): /y
Is laundry on a separate sewage system(yes or no):�4 [if yes separate inspection required]
Laundry system inspected(yes or no):L
Seasonal use:(yes or no):./,1C/0
Water meter readings,if available last 2 ears usage d 2 0.0:2 8 5,.0 0 O: gals
Sump pump(yes or no): A-0 2UU1 62, 0U0 gals
Last date of occupancy: S'0
COMMERCIAL/INDUSTRIAL
Type of estabt'hnment:i
Design flow edon 310 CMR 15.203): ; pdBasis of desiow(seats/persons/sgft,etc.):
Grease trap pnt(yes or no):_
Industrial wastil holding tank present(yes or no):_
Non-sanitary caste discharged to the Title 5 system(yes or no):- -
Water meter r1 dings,if available:
Last date of occupancy/user
OTHER(describe):
IGENERAL INFORMATION
Pumping Records
Source of information: i/�q Y--c5 V 3
Was system pumped as part of the inspection(yes or no): j;:
If yes,volume pumped: d allons-=How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_Septic tank,distribution box,soil absorption system
_ mgle 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:
� 5 7
Were sewage odors detected when arriving at the site(yes or no): (�
6
Page 7 of 11
OFFICIAL INSPECTION FORM=NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. `
PART C
SYSTEM INFORMATION(continued),:,.
Property Address: 128 Rolling Hitch Rd
Bressler
Owner.
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials 4construction:_cast iron 40 PVC_other(explain):
Distance dom private water supply well or suction line:
Commenis(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC1, NK:—(locate on site plan)
Depth below ade:
Material of co struction: ..concrete_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:
Sludge depth: I
Distance from op of sludge to bottom of outlet tee or baffle:
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:
How were dimensions determined:
Comments on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related It
outlet invert,evidence of leakage,etc.):
GREASE P:—(locate on site plan).
Depth below gra e:_
Material of cons ction:—concrete_metal_fiberglass_polyethylene_other =
(explain):
Dimensions:
Scum thickness:
Distance from to of scum to top of outlet tee or baffle:
Distance from bo�tom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on p mping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to out et invert,evidence of leakage,etc.):
J
7
Page 8 of I 1
OR.VOLUNTARY ASSESSMENTS
OFFICIAL IN
ON'FORM-NOT F -
SPECTI ,
CE SEWAG
E DISPOSAL SYSTEM INSPECTION.FORM
SUBSURFA
PART C
SYSTEM-INFORMATION(continued).
128 Rolling Hitch Rd
Property Address: rvi e
Owner: ress Fer
Date of Inspection:
TIGH or HOLDING TANK: (tank must be pumped at time of inspection)(►ocate on site plan)
Depth be w grade:
Material of construction: concrete- metal fiberg lass___polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Fk w: gallons/day
Alarm present(yes or no):
Alarm level:
Alarm in working order(yes or no):
Date of last pumping:
Commen s(condition of alarm and float switches,etc.):
DISTIL( TION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: f
Coments( otc if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence o
m ,..`
leakage into r out of box,etc.):
I .
PUp4P C I MBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in Zrking order(yes or no):
Commentd(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Rolling Hitch Rd
Owner: Bressler
Date of Inspection: 3 9= o 3
SOIL ABSORPTION SYSTEM(SAS): Z(&cate on site plan,ezcavation'not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
aching fields,number,dimensions:
overflow cesspool,number:46
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.):
CESSPOOLS: v(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: x X
Depth—top of liquid to inlet mv—rt
Depth of solids layer: (o
Depth of scum layer: 2 "
Dimensions of cesspool: 6
Materials of construction: A s
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRI (locate on site plan)
Mate ials of construction:
Dim signs:
Dept of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of l 1 `
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
TS
PART C
SYSTEM
INFORMATION(continued)
Property Addres • 128 Rolling Hitch Rd
P s.
en er
Owner: Bress e
Date of Inspection: — ,I'= �,3
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 ter supply enters the building.
g
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It
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10
Page l 1 of 11 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Rolling Hitch Rd
Centervtlle
Owner: Bressler
Date of Inspection: 3—
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
.x
Estimated depth to ground water"P-vF feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained 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 describe how you established the high groun water elevation:
y
it
4L
aAd
' COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
t
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 128 Rolling Hitch Rd.
Centerville, MA
Owner's Name: Jeffrey Zoufaly
Owner's Address: same
Date of Inspection: �, — C) —0
Name of Inspector: (please print) Wi l_1_i am E_ • Rob i_nson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1 089
Centerville, MA
Telephone Number: ( 5 0 8) 7 7 5—8 7 7 6
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.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:
_J/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 6o i�l .% Date: 2, -Gi —6
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of fleanh ar
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.
Notes and Comments
i
****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.
Title 5 Inspection Form . 6/15/2000 page I
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 128 Rolling Hitch Rd.
Centerville
Owner: �j-
Date of Inspection: 0
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys m 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. S stem Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaire .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answe yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsoun ,exhibits substantial infiltration or exfiitration or tank failure is imminent.System will pass inspection if the
existin tank is replaced with a complying septic tank as approved by the Board of Health. I .
*A me I septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indica ing that the tank is less than 20 years old is available.
ND plain:
Observation of sewage backup or break out or high static water level in the distribution box due to-broken or
o structed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
a proval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND xplain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass spection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 128 Rolling Hitch Rd,,
Centerville
Owner: Zouf aly
Date of Inspection: 2 —Q — 0 1
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 failin to protect public health,safety or the environment.
1. S stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
s tem 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. Sy tem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
syste 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
s rface 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
rivate water supply well**. Method used to determine distance
*This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
acteria and volatile organic compounds indicates that the well is free from pollution from that facility and
e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
ailure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of l 1
OFFICIAL INSPECTION FORM-NOT•FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 128 Rolling Hitch Rd.
Centerville
Owner: Zouf aly
Date of Inspection:
D. System.Failure Criteria applicable to all systems:
You ust 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 %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 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 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:
T be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
g d-
Y u must indicate either"yes"or"no"to each of the following:
( e following criteria apply to large systems in addition to the criteria above)
es no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary,to a smface 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 .
I you have answered"yes"to any question in Section E the system is cmisidered a significant threat,or answered
" es"in Section D above the large system has faded.The owner or operator of any large system considered a
si nificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
1 .3 4.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 128 Rolling Hitch Rd.
Centerville
Owner: Zouf aly
Date of Inspection: 2 —9 —G
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes/No
a/ 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:
Yes no
_ _ Existing information.For example,a plan at the Board of Health.
1//_ 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(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 128 Rolling Hitch Rd.
Centerville
Owner: Z ou f a l y
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3-f Number of bedrooms(actual): L�
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): G D
Number of current residents: LI
Does residence have a garbage grinder(yes or no):tL dd
Is laundry on a separate sewage system(yes or no):,,j�_o[if yes separate inspection required]
Laundry system inspected(yes or no): ti °
Seasonal use: (yes or no): h., .:
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): 11-D
Last date of occupancy: ;L.
c�
CO ME RCIAL/INDUSTRIAL
Type of establishment:
Desig flow(based on 310 CMR 15.203): zod
Basis f design flow(seats/persons/sgft,etc.):
Greasq trap present(yes or no):
Indus ial waste holding tank present(yes or no):
Non-s itary waste discharged to the Title 5 system(yes or no):
" Wate meter readings,if available:
Last ate of occupancy/use:
OT R(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): Y -z
If yes,volume pumped: zrOgallons--How was quantity pumped determined? (9.0 c
Reason for pumping: -(-
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
—S�gle 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): / U
6
Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Rolling Hitch Rd.
Centerville
Owner: Z ou f a l y
Date of Inspection: Z— --b L
B LDING SEWER(locate on site plan)
Dep below grade:
Mate ials of construction:_cast iron _40 PVC_other(explain):
Dis ce from private water supply well or suction line:
Co ents(on condition of joints,venting,evidence of leakage,etc.):
SEP C TANK:_(locate on site plan)
Depth elow grade:
Materi 1 of construction:_concrete_metal_fiberglass polyethylene
_o r(explain)
If is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certifi ate)
Dime sions:
Slud depth:
Dista ce from top of sludge to bottom of outlet tee or baffle:
Sc thickness:
Dist nice from top of scum to top of outlet tee or baffle:
Dis ce from bottom of scum to bottom of outlet tee or baffle:
Ho were dimensions determined:
Co ents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as re ted to outlet invert,evidence of.leakage,etc.):
9
GREAS TRAP:_(locate on site plan)
Depth be ow grade:
Material f construction:_concrete_metal_fiberglass polyethylene_other
(explain):
Dimensio s:
Scum thi kness:
Distance om top of scum to top of outlet tee or baffle:
Distanc from bottom of scum to bottom of outlet tee or baffle:
Date of ast pumping:
Comm is(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relate to outlet invert,evidence of leakage,etc.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Rnl1 inq Mitch Rd.
Centerville
Owner: il
Date of Inspection:
T HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Dept below grade:
Mate 'al of construction: concrete metal fiberglass polyethylene other(explain):
Dime sions:
Capa ty: gallons
Desi Flow: gallons/day
Al present(yes or no):
Al level: Alarm in working order(yes or no):
Dat of last pumping:
C ents(condition of alarm and float switches,etc.):
DISI RIBUTION BOX: (if present must be opened)(locate on site plan)
Dep of liquid level above outlet invert:
Co ents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leak ge into or out of box,etc.):
PU P CHAMBER: (locate on site plan)
Pump in working order(yes or no):
Al s in working order(yes or no):
Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
ptl-
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Rolling Hitch Rd.
Centerville
Owner: Zouf aly
Date of Inspection: 1-4 0 1
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:
eaching 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.):
y
CESSPOOLS: V (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: Lz `-( -e 9-
Depth—top of liquid to inlet covert: �e
Depth of solids layer: /-3
Depth of scum layer: /--
Dimensions of cesspool: c
Materials of construction: 12 ld c,X3
Indication of groundwater inflow(yes or no):mac)
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
o
PR (locate on site plan)
Mate ials of construction:
Dim nsions:
De h of solids:
C ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Rolling Hitch Rd.
Centerville
Owner: Zoufaly
Date of Inspection: .—
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.
� J v
2-L
3 ri 3 �'
J v .
1 2.
a
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: 128 Rolling Hitch Rd.
Centerville
Owner: Zoufaly
Date of Inspection: �L--9—O 1
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
x
Estimated depth to ground water I g feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
�bserved site(abutting property/observation hole within 150 feet of SAS)
LXChecked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
6 4D i/P7, eP 3 ) `• 07
y �
x..
11
V
Commonweatth of MossoChusetts ,John Grad
Executive Office of ErMronmental Affairs D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
' Environmental Protection Teaticket,MA 02.536
(5
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
PART A
CERTIFICATION 6'
Property Address: 128 Rolling Hitch Rd. Centerville Address of Owner: t ��
Date of Inspection:1212196 (if different) -
Name of Inspector:John Grad Mrs WilliamWllcox
i
Company Name,Address and Telephone Number: ! _ /
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 sewage disposal systems. The system:
X Passes
_ Conditionally Passes
Needs Furthe Evaluation By the Local Approving Authority
Fails
Inspector's Signature: / Date: 12117196
The System Inspector shall su mit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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, or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as 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 inspection.
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, 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 conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 128 Rolling HKch Rd.Centerville
Owner: Mrs William Wilcox
Date of Inspection:12J2198
Sewage backup or breakout or high static water level observed in the distribution box is 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 leveled 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] 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.
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 aseptic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 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 less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] 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 in 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
cesspool.
SAS is in hydraulic failure.
(revised 11115/95)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 128 Rolling HKch Rd.Centerville
Owner: Mrs William Wilcox
Date of Inspection:1212196
D] SYSTEM FAILS(continued)
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).
Numbers 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 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. 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:
The following criteria apply to large systems in addition to the criteria:
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 II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11115195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 128 Rolling Hitch Rd.Centerville
Owner: Mrs William Wilcox
Date of Inspection:1212196
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 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.
GaAs 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 system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,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 Soil Absorption System 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 Sub-
Surface Disposal System.
(revised 11115195)
4
' D
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 128 Rolling Hitch Rd.Centerville
Owner: Mrs William Wilcox
Date of Inspection:11212196
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 0 gallons
Number of bedrooms: 4
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): yes
Seasonal use(yes or no): No
Water meter readings, if available: Na
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: n<a
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings, if available: nla
Last date of occupancy: Na
OTHER: (Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last two years.
System pumped as part of inspection.(yes or no)Yes
If yes,volume pumped: 2500 gallons
Reason for pumping: Maintenance.
TYPE OF SYSTEM
Septic tank/distribution box/soil absorptions system
X Single cesspool
X Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
X_Other(explain) 3-separate systems
APPROXIMATE AGE of all components,date installed(if known)and source information:
Approximately 25-30 years.
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Rolling Httch Rd.Centerville
Owner: Mrs William Wilcox
Date of Inspection:1212196
SEPTIC TANK:
(locate on site plan)
Depth below grade: n1a
Material of con struction:_concreate_metal_FRP_other(explain)
Dimensions: n/a
Sludge depth:nla
Distance from top of sludge to bottom of outlet tee or baffle: n1a
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:►ya
Distance form bottom of scum to bottom of outlet tee or baffle: n1a
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.)
nla
GREASE TRAP:
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: nla
Scum thickness:nia
Distance from top of scum to top of outlet tee or baffle:rVa
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
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.)
n1a
(revised 11115195)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 128 Rolling Hitch Rd.Centerville
Owner: Mrs William Wilcox
Date of Inspection:1212196
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n1a
Material of con struction:_concrete_metal_FRP_other(expIain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: rda gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
nla
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.)
n1a
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
nla
(revised 11115195)
7
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Rolling Hitch Rd.,Centerville System One
Owner: Mrs William Wilcox
Date of Inspection:1212196
SOIL ABSORPTION SYSTEM (SAS):X
(locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Na
Type:
leaching pits,number: nla
leaching chambers,number:n1a
leaching galleries, number: n1a
leaching trenches,number,length: Na
leaching fields, number,dimensions:n1a
overflow cesspool, number:6'x6'block
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Overflow cesspool was empty at the time of the inspection It is structurally sound.
CESSPOOLS: X
(locate on site plan)
Number and configuration: one
Depth-top of liquid to inlet invert: 1'
Depth of solids layer: 2'
Depth of scum layer: U
Dimensions of cesspool: 6'x6'
Materials of construction: block
Indication of groundwater: none
inflow(cesspool must be pumped as part of inspection)
Na
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Main cesspool and all components are structurally.Recommend pumping system every year for maintenance.
PRIVY:_
(locate on site plan)
Materials of construction: n1a Dimensions: n1a
Depth of solids: Na
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
PrivyComments
(revised 11115195)
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Roiling Hitch Rd.,Centerville System Two
Owner: Mrs William Wilcox
Date of Inspection:1212196
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Na
Type:
leaching pits, number: n1a
leaching chambers,number:n1a
leaching galleries, number: n1a
leaching trenches,number, length: n1a
leaching fields,number, dimensions:n1a
overflow cesspool,number:6'x6'block
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Overflow cesspool had 1'of water in it at the time of the inspection.It is structurally sound.
CESSPOOL$:x
(locate on site plan)
Number and configuration: one
Depth-top of liquid to inlet invert:4"
Depth of solids layer: 4'
Depth of scum layer: 2'
Dimensions of cesspool: 6'x6'
Materials of construction: block
Indication of groundwater: none
inflow(cesspool must be pumped as part of inspection)
Na
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Main cesspool and all components are structurally.Recommend pumping system every year for maintenance.
PRIVY:_
(locate on site plan)
Materials of construction:n1a Dimensions: n1a
Depth of solids: Na
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
PrlvyComments
(revised 11115195)
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Rolling Hitch Rd.,Centerville System Three
Owner: Mrs William Wilcox
Date of Inspection:1212196
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present, explain:
nla
Type:
leaching pits, number: n1a
leaching chambers,number:n1a
leaching galleries,number: n1a
leaching trenches,number, length: n1a
leaching fields, number,dimensions:n1a
overflow cesspool, number:n1a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
n1a
CESSPOOLS:x
(locate on site plan)
Number and configuration: one
Depth-top of liquid to inlet invert: empty
Depth of solids layer: 0
Depth of scum layer: 0
Dimensions of cesspool: 5'x1o•
Materials of construction: block
Indication of groundwater: none
inflow(cesspool must be pumped as part of inspection)
n1a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Main cesspool and all components are structurally.Cesspool has never been more than 112 full.Recommend pumping system every year for maintenance.
PRIVY:
(locate on site plan)
Materials of construction: n1a Dimensions: nia
Depth of solids: n1a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PrivyComments
(revised 11115195)
8
� J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 Rolling Hitch Rd.Centerville
Owner: Mrs IMlllam Wilcox
Date of Inspection:1212196
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
Dk
C�r�SN
I�
�3
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
IISGS Maps and Charts
(revised 11115195)
9