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Home My WebLink AboutInspection Report 2015 Apr 16 - REVISED � Commonwealth of Massachusetts ' ""' ��'J Title 5 Official Inspection Form a��oa�� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SEP 14 2015 , ° 149 Lewis Rd. _. _ _ -- _ _--- _ _ — Property Address PT Dorothy Caprera - _ _ __ _ __ _ . . _- - - - Owner Owner'S Name inromiation is West Yarmouth MA 02673 4/16/2015 requindforevery -- -. __ .. _._. . . _. _ .___. . -- - ---- ._.- — �ge. Cdy/Town State Zip Cotle Date ollnapeUion Inapection results muat be submitted on this form. Inspection forms may not be alterod in aoy way. Please see completeness cheeklist at the end of the form. ImportaM:When A. General information filling out forms on the computer, useonlythetab �. Inspector: key to move your wrsor-donot PaulMartin use the retum - -- .. .._ . _. ..__ ._ ._. --- ____.. ---_ — key. Name of InspeCor � Cape Cod Septic Services - _ _ . _ _ — r CompanyName 350 Main St _ - - - Company Addreas � W.Yarmouth MA 02673 _._ _ -_ --- City/Town - � - � State Zip Code 508-775-2625 S15016 ----__ __ __ ____ ___ --- Telephone Number License Number B. Certification I certify that I have personaliy 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 purauant to Secfion 16.3/0 of Titie 5(370 CMR 15.000).The system: � Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �� -„_ __ 4/26/2015 __ _ _ __ _- - ----- — Inspector's Signature Date The system inspector shail submit a copy of this inspection report to the Approving AuthorRy(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow ot 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 condRbns of use at that time.This inspection do� not address how the system wfll psrfam In the tuturo under the same or different conditions of use. �5ins•3H a Ttle s orncial Man��m Fam�.suuwn+ca Swro•Di�paY eM�•Pow�a n � Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments 149 Lewis Rd. Property Address Dorothy Caprera Owner pwner's Name information is West Yarmouth MA 02673 4/16/2015 required for every page. CirylTown State Zip Code Date of InspeGion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E l 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 in working condition. 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): t5ins•3/13 Ti�le 5 Olfidal Impaqion Form:Subsurtaw Sewaga Dispmal System•Pege 2 of 17 �� Commonwealth of Massachusetts . Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `� 149 Lewis Rd. Property Address Dorothy Caprera Owner Owner's Name information is �yest Yarmouth MA 02673 4116/2015 required for every page. City/Town State Zip Code Date of Inspedion B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): ❑ 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): 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. 7. System will pass unless Board of Health determines in accordance with 310 CMR 75.303�7�(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•3A 3 Title S INfiaal Irepedion Form�Subsurtace Sewage Dispowl System•Pege 3 of 17 j � Commonwealth of Massachusetts ' Title 5 Official Inspection Form � Subsurtace Sewage Disposal System Form -Not for Voluntary Assessments ` 149 Lewis Rd. Property Address Dorothy Caprera Owner Owner's Name information is west Yarmouth MA 02673 4/16/2015 � required for every page. Cirylfown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Heatth (and Public Water Supplier, if any) detertnines 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 surtace 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, pertormed 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: D) System Failure Criteria Applicabte 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 t5ins•3/13 Title 5 Olfidal Inspedion Form:SuEsuNace Sewage Disposel System•Page 4 oF t7 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurtace Sewage Disposal System Form -Not for Voluntary Assessments °� 149 LeWis Rd. Praperty Address Dorothy Caprera Owner p�ers Name information is West Yarmouth MA 02673 4/16/2015 required for every � page. CitylTown 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, perfortned 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,OOOgpd. � � 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. GSins•3/13 Title 5 O(firial Inspection Form:Subwrtace Sewage Disposal System•Page 5 of 17 i � Commonwealth of Massachusetts Title 5 Official Inspection Form SubsurFace Sewage Disposal System Form - Not for Voluntary Assessments r 149 Lewis Rd. � Property Atldress Dorothy Caprera Owner Owners Name information is West Yarmouth MA 02673 4/16/2015 required for every page. Citylfown 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 Condkions: 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): �10x3 = 330gpd t5ina•3H3 Titla 5�ual Inspeqion Form:SuCsuRace Sewege Disposel Syslem•Papa fi vf 1] � Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 Lewis Rd. Property Address Dorothy Caprera Owner pwner's Name information is West Yarmouth MA 02673 4/16/2015 required for every page. CitylTown State Zip Code Date of Inspedion D. System Information Description: Number of current residents: � Does residence have a garbage grinder? ❑ Yes � No Is laundry on a separate sewage system? (Include laundry system inspection � Yes � No information in this report.) Laundry system inspected? � Yes ❑ No Seasonaluse? ❑ Yes � No Water meter readings, if available (last 2 years usage (gpd)): '14-101 GPD '13-121 GPD Detail: Previously existing garbage disposal has been removed. Sump pump? ❑ Yes � No Current Last date of occupancy: �ace Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): canons per day{ypd� Basis of design flow(seats/persons/sq.ft., etc.): 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: 15ins•3/13 Tdle 5�ual hspeUion Form:Subsurtaca Sewege Disposal System•Paga 7 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form SubsurFace Sewage Disposal System Form -Not for Voluntary Assessments ' 149 Lewis Rd. Property Address Dorothy Caprera Owner pwner's Name infortnation is yyest Yarmouth MA 02673 4/16/2015 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: oace Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes � No If yes, volume pumped: ganons 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•3/13 Tdle 5�Gal InspeGion Fortn:SubsuAace Sewage Disposel System•Pape 8 ot 1] � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 149 Lewis Rd. Properry Address Dorothy Caprera Owner pwner's Name information is yyest Yarmouth MA 02673 4/16/2015 required for every page. City/Town State Zip Code Date of Inspedion D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1996 Per Boh Records. Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: � 6 feet Material of construction: ❑ cast iron � 40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10' feet Comments (on condition ofjoints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 6 feet Material of construction: � concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, �ist age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal H-10 Sludge depth: 4� t5ire•3/13 Title 5 Ofidal Inspedion Fortn:Subsurtace Sewage Disposal Syslem•Page 9 of 11 � Commonwealth of Massachusetts . Title 5 Officiai Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "` 149 Lewis Rd. Property Address Dorothy Caprera Owner Owners Name information is yyest Yarmouth MA 02673 4/16/2015 required for every � page. City/Town State 2ip Code Date of Inspedion D. System Information (cont.) Septic Tank(contJ Distance from top 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? Estimated Comments (on pumping recommendations, inlet and outlet tee or bafFle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1,500 Gall H-10 tank in good condition. PVC tees in place and clean. Tank at normal operating level. Covers 6" below qrade. Grease Trap(locate on site plan): Depth below grade: �e� Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ pol eth lene y y ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: oate t5ins•3/13 Tttle 5 OKGaI Inspection Fam:Subwrface Sawege Disposel System•Page 10 of 17 i I � Commonwealth of Massachusetts � Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `` 149 Lewis Rd. Property Address Dorothy Caprera Owner Owner's Name infortnation is West Yarmouth MA 02673 4/16/2015 iequired for every � page. Citylfown 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No AIBrm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: oate Comments (condition of alarm and float switches, etc.): 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Titk 5 Otfidal Inspedion Form:Sibsurtace Sewage Oisposal System•Page 11 0!17 � Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` 149 Lewis Rd. Property Address Dorothy Caprera Owner pwner's Name information is �/est Yarmouth MA 02673 4/16/2015 required for every pyyy, Cirylfown State 2ip 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.): H-10 DB-3 with 1 line in and 1 line out in good condition. Minimal solids carryover. No sign of overloadinq or hydraulic failure Cover 12" below grade 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.): 'If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 TiHe 5�ual Inspection Fortn'Subwrface Sewage Dispoaal Syalem•Page 72 of 17 � Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "` 149 Lewis Rd. Property Address Dorothy Caprera Owner Owners Name infortnation is �/�/est Ya�mouth MA 02673 4/16/2015 required for every Pyye. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: � leaching chambers number: 5 ❑ Ieaching 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.): 5-Cultex units in a 40.6'x9'trench configuration. 2-3"of liquid in chambers at time of inspection. No sign of overloading or hydraulic failure. Driveway has been removed over leaching units. Stone around units was excavated at time of driveway removal and was found to be clean. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No GSins•3H 3 Ti�le 5 Otfidel Inspedion Form:Subsur/aw Sewaga Disposal System•Page 13 W 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '' 149 Lewis Rd. Property Address Dorothy Caprera Owner Owners Name information is West Yarmouth MA 02673 4/16/2015 . required for every page. Cily/Town 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.): 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, etc.): , t5ins•3H 3 Title 5 Otfidal Inspection Form:Subsurtace Sewage Disposal System•Pege 14 of 17 � Commonwealth of Massachusetts ' Title 5 Official Inspection Form SubsurFace Sewage Disposal System Form - Not for Voluntary Assessments °� 149 Lewis Rd. Property Address Dorothy Caprera Owner pwner's Name information is yyest Yarmouth MA 02673 4/16/2015 � requiredforevery j page. Citylfown 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 Nvo 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 t5ins•3A3 � Titk 5 Olficiel Inspeqion Form:SubsuNace Seaape Disposal System•Paga 15 of 17 � i , /. ; � 1 � � I ' , ! � � � I � I ; �-, j :� � ^ J �-_ ,.� � - f ��{ ' � , • _ ti._ '- , � � -� � J ;� � � '� '� .. � � � _ � � �, r!1 in � �c'd , � '�. � � . � � Commonwealth of Massachusetts Title 5 Official Inspection Form � � SubsurFace Sewage Disposal System Form - Not for Voluntary Assessments ' 149 Lewis Rd. Property Address Dorothy Caprera Owner p�ers Name information is yyest Yarmouth MA 02673 4/16/2015 required for every . page. City/Town State Zip Code Date of Inspedion D. System Information (cont.) Site Exam: � Check Slope � Surface water � Check cellar � Shallow wells Estimated depth to high ground water: +11' 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: 1996 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: You must describe how you established the high ground water elevation: Test hole data per plan on file at BOH. Test hole to 11'. Bottom of leaching at 4' Max. Minimum of 7' separation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. ��"6��13 Title 5�ual InspeUion Form:Subsurtace Sewaga Disposal System•Page 76 of 17 � Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurtace Sewage Disposal System Form -Not for Voluntary Assessments 149 Lewis Rd. Properry Add2ss Dorothy Caprera , Owner pwners Name infomiation is West Yarmouth MA 02673 4/16/2015 required for every page. CitylTown State Zip Code Date of Inspedion 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•3/13 Title 5 Offidal Inspection Form:S�bsurtace Sewage Dispmal Sys[em•Papa t7 ot 17