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HomeMy WebLinkAboutInspection Report 2014 Oct 22 - RearOwner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. fA If Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments OCT 3 0 2014 56 Route 6A L tip$ 11P 01 Property Address t; " - HUGHES JOANN %� Li��� t `- re, ' ' rUw. J �H ti .. Owner's Name Yarmouthport MA 02675 10/22/14 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. A. General Information Inspector: Trevor Kellett Name of Inspector TK Septic Inspections Company Name 38 Vacation Lane Company Address West Yarmouth City/Town 508-579-5502 Telephone Number B. Certification Lcicjtc;,�- I certify that 1 have personally inspected the sewage '�`' l -e- information reported below is true, accurate and cor was performed based on my training and experieno sewage disposal systems. I am a DEP approved syoaGrrr rnspecior 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 Inspector's Signature 10/16/14 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 • 3/13 Title 5 Offldel Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dispa�al Syste�n Form-Not for Voluntary Assessmerds 56 Route 6A Propem naaress HUGHESJOANN Omier p,yner's Name "�Of"�ti0�� Yarmouthport MA 02675 10/22114 required for every Pa9e. CitylTown S[ete ZiP Code Date oF lrepection B. Certi�cation (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: B) System Conditionally Passes: ❑ One or more system components as described in the°CondiUonal Pass°section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Boatd of Heatth,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 str�cturally unsound, exhibits substantiai infittration or exfiRration or tank failure is imminent System will pass inspection rf the existing tank is replaced with a complying septic tank as approved by the Board of Heatth. '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): t5Vn•3/13 T�Ib 5 Olfitld 9nsDecSon Form:9iLanc�e Ser.'e9�p�^fi�•PNa 2 of 1] � Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for VoluMary Assessments 56 Route 6A Property Address HUGHESJOANN ��� Ovmer's Nama infom,aton is Yarmouthpoft MA 02675 10/22l14 required for evary �te Lp�e ��o����p^ Pa9e� CilYlToxn B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Heatth approval if pumps/alarms are repaired. B) Syste�n 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,settied or uneven distribution box. System will pass i�spection if(with approval of Board of Heaith): ❑ 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 pumpirg 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 Heatth): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(F�cplain below): ❑ obstructio� is removed ❑ Y ❑ N ❑ ND(F�cplain below): C) Furtlier Evaluation is Required by the Board of Health: ❑ Conddions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public heaRh,safety or the environment. 1. Sysbem will pass unless Board of Health determines in acxordance with 310 CMR 15.303(1)�b)that the system is rat functioning i�a man�er which will protect public heatth, safety and tlie environment: ❑ Cesspool or privy is within 50 feet of a surtace water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Ttla 5 OlfitlY Iny�ac9on Fam:SW�M1ce Se'ua9a aSV��'�P�3 of 1T YHns•3/13 � Commonwealth of Massachusetts Title 5 Official inspection Form ' Subsurtace Sewage Disposal Systern Form -Not for VoluMary AssessmeMs 56 Route 6A Provanr addres: HUGHESJOANN ��� ONr�ersName iM�ommdon is ry Yarmouth uiredforeve Port MA 02675 10/22/14 pa9a. Ctly/Town Sfate Zip Code Date of Irspection � B. Certi�cation �cont.� 2. System wili fail unless the Board of Heatth(and Public Water Supplier,if any) determines that Cie system is functioning in a mannc�r that protects tl�e public health, safety and environment: ❑ The system has a se�ic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water suppiy. ❑ 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 tha� 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 certrfied laboratory, for feca� coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Iess than 5 ppm, provided that no other failure crReria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applipble to All Systems: You must indicate"Yes" or"No"to each of the following for all inspectio�: Yes Na � � Backup of sewage into facitity or system component due to overloaded or clogged SAS or cesspooi � � Discharge or ponding of effluent to the surtace of the ground or surface waters due to an overloaded or clogged SAS or c�spool � � 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 t5ms•3/13 Ttle 5 OIAtld InSpectior�Fam:SLpspTxq Scwgge pi�y y�•Paqe 0 U 1] � Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessmenis 56 Route 6A PropeAy Address HUGHESJOANN Owner Owrier's Name iMomweonis Yarmouthport MA 02675 10/22/�4 required for avery C�rto� �p� ZiP Code Date of Irspection page. B. Certification (cont.) Yes Na � � Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: _ [� � My 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 suppiy or trilwtary 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 suppiy well. ❑ � My poRion of a cesspool or privy is less than 'I�feet but greater than 50 feet from a private water supply well with no acceptabie water quality analysis. [Thia system passes ff the we��water analysis,pertormed at a DEP certiFied laboratory,for fecal col'rform bacteria indicates a�ent and the presence of ammonia�ihogen and nitrate nitrogen is equal to a Icss thari 5 ppm, provided that rro other failure criteria are triggered.A copy of the ana�ysis and chain of custody must be attached to this form.] � � The system is a cesspooi servirg a facility with a desgn flow of 2000gpd- 10,OOOgpd. � � The system fails.l have determined that one or more of the above failure criteria exist as described in 3'10 CMR 15.303,iherefore the system fails. The system owner should contact the Board of HeaRh 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 adddion to the questior� 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 2o�e II of a public water su�ly well If you have answered'yes°to any question in Section E the system is considered a signifirant threat, or answered°yes' in Sedion D above the large system has failed.The owner or operator of any large system considered a signiFlcant 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. rm s araa m�ea�Fam:smw�m�sa�.ye usv��^•Pme s a» t5ins•3,13 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurtaoe Sewage Disp�al System Form-Not for Voluntary Assessmerits 56 Route 6A Property Address HUGHESJOANN �� Ovmar's Nama �rmefion is ry Yarmouth uiretl for eve f�oR MA 02675 10/2?114 page. C@y/Tovm Sate Zip Code Date of Inspectbn C. Checklist Check rf 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, occuperrt, or Board of Heatth ❑ � Were any of the system components pumped ou[in the previous two weeks? � ❑ Has the system received normal flows in the previous two week period? � � Have large volumes of water been inhoduced to the system recently or as part of this inspection? � � Were as buitt plans of the system obtained and examined?(If they were not available note as WA) � ❑ Was the facility or dwellirg inspected for signs of sewage back up? � ❑ Was the site inspected for sigrs of break out? � ❑ Were all system components, excluding the SAS, located on sfte? � ❑ Were the septic tank manholes uncovered, opened, and the iMerior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and de�h of scum? � � Was the facility owner(and occupants if drfferent 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 Heatth. � � Determined in the field(if any of the failure crderia related to PaR C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residentlal Flow Conditions: Number of bedrooms(desgn): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): `�� tSMs•Y13 Tne 5 Olfitld InspxEm fortn:SLGarthm Spwegp puposy S�hrt�•Pege 6 M 77 � Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurtace Sewage Disposal System Form-Not for Voluntary Assessments 56 Route 6A Properly Address HUGHESJOANN �r prvnersName information is YamloutFt rt MA 02675 10/22/l4 reQuired Wr every � �9a_ C�,Ro� State Zip Cade Date of Irapectbn 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 Seasonal use? � Y� c � Water meter readings, rf available(last 2 years usaqe(gpd)): � Detail: �,i.t3 �� GO�, ? C \`'� ��5 t)U v Sump pump? ❑ Yes � No current Last date of occupancy: �,ia Comrt�cial/lndustrial Flow Conditions: Type of Establishment: Design flow(based on 3�0 CMR 15.203): c,ians per dey�pd) Basa of design flow(seats/persons/sq.ft., etc.): Grease hap present? ❑ Yes ❑ No Industrial waste holdirg tank preseM? ❑ Yes ❑ No Nonsanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, 'rf available: 251ns.3/13 rtb 5 OIPtlY Inyec9on Fmn:SLDwlxe Sn+'age U�Osel SY�^'P4ge]W 1] � Commonweaith of Massachusetts Title 5 Officiai Inspection Form Subsurtace Sewage Disposal Systern Form -Not for Voluntary AssessmeMs 56 Route 6A �ro�,em,waress HUGHESJOANN ow.re� ovmers Name ����� ', Y8fRI0UU1 u;red for eve Port MA 02675 10/22/14 pa9e. Cily/Tonn State Zip Code Date of 1'rspection D. System Information �cont.� Last date of occupancy/use: �� Other(describe below): General Information Pumpirg Records: Source of information: Was system pumped as part of the inspection? � y� � No If yes, volume pumped: �eo�: How was quantity pumped determined? Reason for pumping: Type of Systern: ❑ Septic tank, distribution box, soil absorption system � Single cesspool ❑ OveRiow 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 coMract(to be ol�ained from system owner)and a copy of latest inspection of the UA system by system operetor under corrtract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•Y13 rne 5 araa Insyecim Form:9�GsuRem Seerege plsposnl yygen•P�ge 8 af 1] � Commonwealth of Massachusetts � Title 5 Official Inspection Form ' Subsurface Sewage Disposal Systern Form-Not for Voluntary Assessments 56 Route 6A Properry Atldress HUGHESJOANN �e� Oxrtier's Name irrformaoonis yarmouthport MA 02675 �OP22/14 required for every �9e. CityRoNn Sate Zip Code Daffi o(Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 40 years+ Were sewage odors detected when arrivirg at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: fa'� Material of construction: � cast iron ❑40 PVC ❑ other(eacplain): Distance from private water supply well or suction line: feet Comments(on condition ofjoints,venting, evidence of Ieakage, etc.): Septic Tank(locate on sde plan): Depth below grade: raec Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certficate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 15kis•113 Title 5 OMdY Iny�x:9m Farm:SLDaatece u^ewage Oisposel S/aBm'Pflge 9 oi 1] � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syste�n Form-Not for VoluMary Assessmenis 56 Route 6A Property Address HUGHESJOANN �� W�ner's Name �reyuiredrorewry �'armouthport MA 02675 10/2?J14 py9e. Cily/Town State Zip Code Date of I�xpection D. System Information (cont.) Sepdc Tank(cont.) 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 ftom bottom of scum to bottom of outlet tee or baffle Howwere dimensions determined? Comments(on pumping recommerxiations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap Qocate on sRe plan): Oepth below grade: ree� Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(eacplain): 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 t5Vrs.113 Ttla 5 OIfltlN Irnpec4on Fam:SWsurtero Sesege p�osel S)s�n•Pego 10 of 77 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Volu�tary Assessments 56 Route 6A pmperty Address HUGHESJOANN Ov.ner Owner's Name infortretion is MA 02675 10/22l14 required Mr every Yarmouthport �te Zip Code Date of Irepection Pa9a. Ci�'ITovm D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle conddion, structural integrity, liquid ievels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(ta�k must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ po�yethylene ❑other(expiain): Dimensions: Capacity: 9airons Design Flow yeiwr�s car dar Alarm present: ❑ Yes ❑ No Alarm level: PJarm in working erder ❑ Yes ❑ No Oate of last pumping: oaea Comments(conddion of alartn and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No T�tle 5 Olfitlel InspecBon Fam:SuCexhce Sm'°9e�9°��n'Peye 11 ot 11 t4ns•3H3 � Commonweaith of Massachusetts Title 5 Official Inspection Form Subsurfaoe Sewage Disp�al System Form-Not for Voluntary Assessments 56 Route 6A Prope�ty Address HUGHESJOANN �� Owne�s Name iMormation is requiredrorevary Yarmouthport MA 02675 Pe9e. City/iown 1012?J�4 Sfate Zip Code Date of Irspecdon D. System Information �cont.� Distribution Boz('rf present must be opened)(Ixate on site plan): Depth of liquid level above outlet invert N�p` 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.): No D BOX Pump Chamber(locate on site p�an): Pumps in woricing order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No` Commerrts(note condition of pump chamber, condition of pumps and appurtenances, etc.): *�f pumps or alarms are not in working order, system is a conditional pass. Soil Absorptlon Systern(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: f5rn.3113 Title 5 OIFtltl Insyeclpi�:,�.ypgy�pce�9a����•Peye 17 of 1] � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurtace Sewage Disposal System Form-Not for Voluntary AssessmeMs 56 Route 6A Property Address HUGHESJOANN Or-mer pmmers Name i�ormationis Yarmouthport MA 02675 10Y221'14 required tor every State Zip Code Date of Irspection Pa98� CilyRown D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overfiow cesspool number: ❑ innovative/atternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, cond'Rion of vegetation, etc.): Cesspools(cesspooi must be pumped as part of inspection)(locate on site plan): 1 Number and configuration 30" Depth—top of liquid to inlet invert �,� Depth of solids layer ��� Depth of scum layer 5'x5' Dimensions of cesspool drywell block Materials of construction Indication of groundwater inflow ❑ Yes � No Title 5 OIfitlY Ing�xtian Fam:SUDaWe�e^xwage as�el SR�^'Page 13 0�1T t5ins.Y13 � Commonweaith of Massachusetts Title 5 Official Inspection Form Subsurtaoe Sewage Disposal Systern Form-Not for Voluntary Assessments 56 Route 6A a�o�ny naaress HUGHESJOANN O�vner p,Ma��s wame iMormetion is reyuired ror every Yarmouthport MA 02675 10/22/1q Pa9e. Gy'lTown State Zip Code Date of Ire P�� D. System Information �cont.) Commenffi(note cond'Rion of soil, signs of hydraulic failure, level of ponding, cond'Rion of vegetation, etc.): The 5x7 drywell block pd only seems to service a sink in the kitchen Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, conddion of vegetation, etc.): 1$i116•.'1/�3 Title 5 OIRtld In�ectlon Fam'SUDsurteca$eweye Oi9��Sysbm•Peye i!M 11 � Commonwealth of Massachusetts Title 5 Official Inspection Form = Subsurtace Sewage Disp�al System Form-Not for Voluntary Assessments 56 Route 6A Property Address HUGHESJOANN Ov.ner Owtier's Name iMormaoonis Yarmouthport MA 02675 �0122/14 required Wr every �9e_ C�,Ro�.,� State Zip Code Date of Irepection D. System Information (cont.) Sketch Of Sew�e Disp�al System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 1�feet. Locate where public water supply enters the twilding. Check one of the boxes below � handsketch in the area below ❑ drawing attached separately 13.5 6 MLti11J H'��,SE � ��L t51ns•3/t3 TI9e 5 OIRtiY In�acfon Fam:SiDartece Sevege OisposY SJsMn•Pege 15 ot 1] � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurfaae Sewage Disposal Systern Form-Not for VoluMary AssessmeMs 56 Route 6A Properry Adtlress HUGHESJOANN �^a� Oxner's Name �rmationa ry Yarmouth rt uired tor eve Po MA 02675 10/27/14 page. CityRown Sfate Zip Coda Date of Irepedion D. System Information (cont.a Site Exam: � Check Slope ❑ Surtace water � Checkcellar ❑ Shallowwells Estimated depth to high ground water: 20+ raec 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: ��e ❑ Observed sde(abutting propertylobservation hole within �50 feet of SAS) ❑ Checked wRh local Board of Heafth-explain: ❑ Checked with local excavators, installers-(attach documentation) � Accessed USGS database-explain: You must describe howyou established the high ground v✓ater elevation: USGS Maps show GW at over 20 feet Before filing this Inspection Report, ple�e see Report Completeness Checklist on neut page. t5ins•Y13 TiBe 5 Wfdd Insyxtian Fam:S�wrtece:swage pisposal SysYn•Pega 16 M 1"! � Commonwealth of Massachusetts Title 5 Official Inspection Form SubsurFace Sewage Disposal System Form -Not for Voluntary Assessments 56 Route 6A Property Address HUGHESJOANN a"^1ef O.�mer's Name imormaeonis YarmoUth R MA 02675 �0l22/14 requiredforavery PO a uge. CitYRoxn Stale Zip Code Date of hcpection 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 groundmrater � Sketch of Sewage Disposal System eRher drawn on page�5 or attached in separate file i�•sna Title 5 Olfidal In�9ectlm Fam-SWanc�e Se�e O4yosY Syabn•Pqle R ot t'