HomeMy WebLinkAboutInspection Report 2002 May 01r
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COMMON'��VEALTH OF MASSACHUSETTS MA'� � 6 2002
� E X E C U T I�E O F F I C E O F E N V I R O N M E N'I'A L A FFAIRS
D E P A R T M E N T O F E N V I R O N M E N T A L P R OTECTION HEALTH DEPT.
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLU10'fARY ASSESSMENTS
SUBSiJRFACE �SEWAGE DISPOSAL SYSTEM FORM
. PART A
CERTIFICATION
Property Address: 2 CHECKERBERRY LANE YARMOUTH PORT,MA fi'675 �� 3�l ���--� I 3,
Owner's Name: CATHERINE GEBO GO BILL HARRISON REALTORS
Owner's Address: 299 RT 28 W. YARMOUTH MA 02673
Date of Inspection: 5/1/02
Name of Inspector: (please print), .J�HN GRACI
Company Name: SEPT[C INSPECTIONS
Mailing Address: P.O. BOX'2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
1 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 pursuant to Section 15.340-of Title 5(310 CMR 15.000). The system:
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Conditionally P sses
Needs Furt valuation by the Local Approving Authority
Fails
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Inspector's Signature: �, Date: 5/1/02
The system inspector shall submit copy of this inspection report to the Approvirig r'�athority(Board of Health or DEP)within
30 days of completing this inspec on. If the system is a shared system or has a desi�n flow of 10,000 gpd or greater,the
inspector and the system owner sh211 s'ubmit the report to the appropriate regional cf,ice of the DEP. The original should be
sent to the system owner and copies sent t�:the'buyer, if applicable,and the approvir�g authority.
Notes and Comments '
SYSTEM PASSES TITLE V INSPECT.ION. RECOMMEND PtJMPING EVERY 7 WO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****TI►is report only describes cc�ndilions:�t fhe timc of inspeclioi� �ind o�ider:I:c coudili�►us of us��ul Ihul limt�.'I'lil�
inspection does not address how the system will perli►rm iu Ihe fnture imder Ihe yume�►r�Ifl�f�v���ul ��imililfunr�►f nr��,
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� OFFICIAL INSPECTION FORM—NOT FOR VOLUNT:�RY ASSESSMENTS
SUBSURFACE S.EWAGE DISPOSAL SYSTEM INSPECTION FORM
( PART A
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CERTIFICATION (continued)
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j Property Address: 2 CHECKERBERRY LANE YARMOUTH PORT,MA 02675
Owner: CATHERINE GEBO C/O BILL HARRISON REALTORS
Date of Inspection: 5/1/02
Inspection Summary: Check A,B,C,D or E/At.WAYS complete all of Section D
A. System Passes:
X I have not found any information which inu+icates 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 PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
One or more system components as describecl in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or r�epair,as approved by the Board of Health,will pass.
Answer yes,no or not determined'(Y,N;ND)in`the for the following statements. If"not determined"please explain.
n/a 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 exfilfration'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.
ND explain: n/a
n/a 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
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more,than 4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Boa►'d°of Health):
_bro,ken pipe(s)are replaced
_obstruction is removed
ND explain: n/a , „f
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� OFFICIAL INSPECTION FORM -NOT FOR VOLUI�'�'ARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM IN�PECTION FORM
PART A
CERTIFICATION(continued)
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Property Address: 2 CHECKERBERRY I.ANE YARMOUTH PORT,MA G�b75
Owner: CATHERINE GEBO CIO BILL HARRISON REALTORS
Date ot Inspection: 5/1/02
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further eva(uation by the Board of Health in order t�determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board;o�'Health determines in accordance,wit'r�3i0 CMR 15.303(1)(b)that the system is
not functioning in a manner whech will protect public health,safety ar:��the environment:
_ Cesspool or privy is within.50;f�et caf a surface water
_ Cesspool or privy is within SU feet of a bordering vegetated wetland or a salt marsh
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2. System will fail unless the Board of Health(and Public Water SuppliEr,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank ancfi'soil absorption system(SAS)and the S.aS is within ]00 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a�i�blic water supply.
_ The system has a septic tank and 5AS 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�0 feet or more from a private water
supply well**. Method used to deterr.�ine distance n/a
**This system passes if the wefl#water analysis,performed af a DEP certified iaboratory,for coliform bacteria and
volatile organic compounds indica:tes that the well is free from pollution frorr�that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal tp or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this'form.
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3. Other:
n/a `
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° OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM IN�PECTION FORM
' PART A
j CERTIFICATION(continued)
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' Property Address: 2 CHECKF�RBERRY LANE YARMOUTH PORT,MA 02675
i Owner: CATHERINE GEBO C/O�ILL HARRISON REALTORS
Date of Inspection: 5/1/02
D. System Failure Criteria appticable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
r clo ed
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded o gg
SAS or cesspool '
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
_ X Required pumping more than 4 times in the last year L�LQZdue to clogged cr obstructed pipe(s).Number of times
pumped nLa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspoo)or privy i�within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone 1 of a public well. '
_ X Any partion of a cesspool or privy is within 50 feet of a private water supply well.
_ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply welt with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,fo�co�iform bacteria and volatile organic compounds indicates that the well is free
from pollution from:tha;�;facilit,y,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. t have determined that one or more of the above failure criteria exist as described in 310
CMR 15303,therefore the system�ai�s.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 sy�teec� must serve a facility with a desig�� fl�w of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following: ,
(The following criteria apply to large systerns in addition to the criteria above)
yes no
_ X the system is within 400 feet of a surface drinking water supply
_ X the system is within 200 feet of a tributary to a surface drinking water supply
_ X 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"�es"to any c�uestion in Section E the system is considered a significant threat,or answered '
`.ycs" in S«�iun I�).ib�we llie I.itr�c �,��,;I�cni li;���,�i�ile�l. Thf�mvner��r����ei��lrn��F�t�y I�r�e.system c�nsirlPrPrl �si�nific�nt thr�at
under Section E or failed under Section D shall upgrade the system in accor�lancc w�ith 31U l'MIZ I 5,_411�1. 'I lic`ytileui u�viic�
should contact the appropriate rebional ol7ice of thc Ucparlmenl.
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� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM I1�SPECTION FORM
� PART B
CHECKLIST
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Property Address: 2 CNECKER�ERItY LANE YARMOUTH PORT, MA 02G75
Owner: CATHERINE GEBO C/O BILL HARRISON REALTORS
Date of Inspection: 5/1IO2
Check if the following have been done.You must indicate"yes"or"no"as to each c,f the following:
Yes No
X _ Pumping information was provided,by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
_ X Have large volumes of water been iniroduced to the system recently or as part of this inspection'?
X _ Were as built plans of the system obfained and examined?(If they were not available note as N/A)
X _ Was the facility or d�Ve��ir�g in`spected for signs of sewage back up?
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X _ Was the site inspected for signs of break out'?
X _ Were all system components,excluding the SAS, located on site"
X _ Were the septic tank manhole�{uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,gdamensions,depth of liquid,depth of sludge and depth of scum?
X _ 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
X _ Existing information. For exarr�ple,a plan at the Board of Health.
X _ 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)] ,
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' OFFICIAL INSPECTION FORM—NOT FOR VOLUNT�RY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM Il�'S�ECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2 CHECKERBERRY LANE YARMOUTH PORT,MA 0�675
Owner: CATHERINE GEBO C/O BILL HARRISON REALTORS
� Date of Inspection: 5/1/02
FLOW CONDITIONS
RESIDENTIA[. �
Number of bedrooms(design);3 Number of(iedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 3
Does residence have a garbage grind�'f yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2:vears usage(gpd)): g(� Z�j � — n�a,
Sump pump(yes or no): NO ��a� - t')Si�
Last date of occupancy: n/a .�( . (5(��Uv
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a �
Design flow(based on 310 CMR 15.24�): nlagpd
Basis of design flow(seats/persons/sqft,e`c.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank�resent(yes or no): NO
Non-sanitary waste discharged'to the Title 5 sy§tem(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a �, ,
GENERAL INFORMATION
Pumping Records
Source of information: n/a L.�,�`� pum�d b)►t��9 S—� ��Ol.l'rYl C�2-�Jt �
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons'=-,.How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption�system
Single cesspool
Overflow cesspool
_Priry
Shared system(yes or no)(if yes,attaeh previous inspection records, if any)
_Innovative/Alternative technology.�►ttach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP ap,proval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of inforrnation:
7/S/98 N�,VV�YCT�M P�,RMIT tl 9R-275
Were sewage odors detected when arriving at'the site(yes or no): Nn
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� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 CHECKERBERRY LANE YARMOUTH PORT, MA 02675
Owner: CATHERINE GEBO C/O BILL HARRISON REALTORS
Date of Inspection: 5/1/02
BUILDING SEWER(locate on site plan)
Depth below grade: 10"
Materials of construction: cast iron X40 PVC other(explain): n!a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 4"
Material of construction: Xconcrete metal fiberglass_polyethylene other(explain)n/a
lf tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1500G L 10'6"H�`b"W 5' 8""
Sludge depth: 1"
Distance from top of sludge to bottom o,f outtet tee or baffle:33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outiet invert,evidence of leakage,etc.}:
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUNG AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fib�erglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommenda`tions, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakatige,etc.): :
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n/a
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� OFFICIAL INSPECTI�N FORM—NOT FOR VOLUllTTARY ASSESSMENTS
SUBSURFACE SEVVAGE DISPOSAL SYSTEM Ti\T;�PECTION FORM
PART C
SYSTEM INFORMATION(continue�)
Property Address: 2 CHECKERBERRY LANE YARMOUTH PORT,MA 02575
Owner: CATHERINE GEBO C/O BILL NARRISON REALTORS
Date of Inspection: 5/1/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a ,
Material of construction:_concrete_metal fiberglass�olyethylene_other(explain): n/a
Dimensions: n/a
+ Capacity: n/a gallons
i Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
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DISTRIBUTION BOX:X(if pres�nt must b�,opened)(locate on site plan) �
Depth of liquid level above outiet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal,any evidence of sciids carryover,any evidence of leakage into
or out of box,etc.): ,
D-BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
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' OFFICIAL INSPECTION FORM—NOT FOR VOLU1rTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM I!�i'SPECTION FORM
PART C
SYSTEM INFORMATION(conti��e�)
Property Address: 2 CHECKERBERRY LANE YARMOUTH PORT,MA 02b75
Owner: CATHERINE GEBO C/O BILL HARRISON REALTORS
Date of Inspection: 5/1/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation nc. i��quired)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: nla
INFULTRATORS leaching chambers, number: 5
n/a leaching galleries, number: �/a
n/a leaching trenches, number, length: nla
n/a leaching fields, number: nla
n/a overflow cesspool, number. n/a
nJa innovative/alternative system
. Type/name of technology: �/a
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Comments(note condition of sotl;�signs of hydraulic failure, level ofponding,dar>>p soil,condition of vegetation,etc.):
INFULTRATORS ARE STRUCT�J�ALL`Y SOUND AND FUNCTIONING'I�ROPERLY.SYSTEM SHOWS NO
SiGNS OF FAILURE.BOTTOM IS�T 3'.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plz;�)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of h;�drautic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,con�i:;on of vegetation,etc.):
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; ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contihued)
Property Address: 2 CHECKERBERRY LANE YARMOUTH PORT,MA 02675
Owner: CATHERINE GEBO GO BILL HARRISON REALTORS
Date of Inspection: 5/1l02
SITE EXAM
Slope
Surface water
Check ceilar
Shallow wells
Estimated depth to ground water 80 feet
Please indicate(check)all methods used to determine the high ground water elevat;�n:
NO Obtained from system design plans on record- If checked,date of des�gn plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database�xplain;�n/a
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You must describe how you established�he high ground water elevation:
GROUNDWATER DETERMINED,BY A�BUILT-80". ADJUSTED GROUI�DWATER IS 2.1' FROM MIW 29
ZONE A. BOTTOM OF INFULTR�TOFtS`�S AT 3'.
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