HomeMy WebLinkAboutInspection Report 2000 Dec 01 , � .
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COMMONWEALTH OF MASSACHUSETTS � � � � � � � �
� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS pEC 1 Q 20Q0 '
DEPARTMENT OF ENVIRONMENTAL PROTECTION
NEALTH DEPT.
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TITLE 5
OFFICIAL INSPE��ION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SY5TEM FORM
° �' PART A
�' CERTIFICATION
Property Address: 85 TANGLEWOOD DR W.YARMOUTH,MA 02673
Owner's Name: BOHAC C/O CAPE REALTY
Owner's Address: 299 RT 28 W.YARMOUTH MA.ATT SHAWN
Date of Inspection: 12/1/00
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Name of Inspector:(please print) JO�N GRACI
Company Name: SEPTI� }1�iSPECTIONS
Mailing Address: P.O.BO�2119 TEATICKET,MA.02536
Telephone Number:508-564-6813 FAX 508-564-7270
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:
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Conditional�y Passes
Needs'Fu r Evaluation by the Local Approving Authority
Fails
Inspector's Signature:
�'' Date: 12/1/00
The system inspector shall sub t 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 senf tq�e buyer,if applicable,and the approving authority.
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Notes and Comments ��g ;
THE SYSTEM PASSES T1TLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE.
****'I'his r�port dnly describes cnndltinns�t the time ot'In�pectlon and uncler tiie condition�of uee al that tlme.Thie
inspection does not address how the system will perform in the future under the same or different conditions of use.
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUB5URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :
PART A
' CERTIFICATION(continued)
,Property Address: 85 TANGLEWOOD DR W.YARMOiJTH,MA 02673
Owner: BOHAC C/O CAPE REALTY
Date of Inspection: 12/1/00
Inspection Summary: Check A,B,C,D or E/A .�ti'�complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15303 or in 310
CMR 15304 exist.Any failure criteria not evaluated are indicated below.
Comments: �
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE.
B. System Conditionally Passes;
One or more system components,�s,�lescribed in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement.oc repair,as approved by the Board of Health,will pass.
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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 metai and over 2d°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 wil)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�nore than 4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the B��rd of Health):
_broken pipe(s)are replaced
_ohstruct�on is removed
ND explain: n/a '
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
� C�RTIFICATION(continued)
.Property Address: 85 TANGLEWOOD DR W.YARMOUTH,MA 02673
Owner: BOHAC C/O CAPE REALTY
Date of Inspection: 12/1/00
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 determines in accordance with 310 CMR 15.303(1)(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
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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:
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_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 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 public water supply.
_ The system has a septic fank 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 n/a
**This system passes if the well�water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compoun`�is ind7cates 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.
3. Other:
n/a
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
� CERTIFICATION(continued)
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. Property Address: 85 TANGLEWOOD DR W.YARMOUTH,MA 02673
Owner: BOHAC C/O CAPE REALTY
Date of Inspection: 12/1/00
D. System Failure Criteria applicabie 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
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
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 b.QZdue to clogged or 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 cesspool,;@r privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspoc�l or privy is within a Zone 1 of a public well.
_ X Any portion 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 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 weil is free
from pollution from that`�'�cility 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 faiLT.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 t6e systeni must serve a facility with a design flow 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 systems 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
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_ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped
Zone II of a public water supply weli
If you have answered','yes"tb any question in Section E the system is considered a significant threat,or answered
"yes" in�ection D above tho I�rge system h�s failed,Tho Awner or operstAr of any lar�e system considered a si�nificant 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.
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
- Property Address: 85 TANGLEWOOD DR,W.YARMOUTH,MA 02673
Owner: BOHAC C/O CAPE REALTY
Date of Inspection: 12/1/00
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information wa5 provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
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_ X Has the system received normal flows in the previous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection?
_ X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dweiling inspected 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 manholes un�l�vered,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?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsarface sewage disposal systems?
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The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
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Yes no
X _ Existing information.For e�t'dmple,a plan at the Board of Health.
X _ Detertnined in the field(if any�of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15302(3)(b)J
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' SYSTEM INFORMATION
Property Address: 85 TANGLEWOOD DR W.YARMOUTH,MA 02673
Owner: BOHAC C/O CAPE REALTY
Date of Inspection: 12/1/00
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):440
Nur�tber of current residents:0
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ls laun " on a separate sewage system(yes or no):NO [if yes separate inspection requiredJ
Laundry system inspected(yes or no):NO
Seasonal use:(yes or no):YES
Water meter readings,if available(last 2 years usage(gpd)):� C'�,�\��. �t-�,��; ��I� —��,C��
Sump pump(yes or no):NO �
Last date of occupancy:n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMRR 15.203): n/agpd
Basis of design flow(seats/persons/sqft,etc.): n/a
Grease trap present(yes or no):NO
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharged to the''I`itle 5 system(yes or no): NO
Water meter readings,if available: n/a'
Last date of occupancy/use:n/a
OTHER(describe): n/a
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GENERAL INFORMATION
Pumping Records
Source of information: n/a
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 tanlc,distribution box,soil absorptio'n system
Single cesspool
Overflow cesspool
_Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
lnnovative/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):n/a °
Approximate age of all components,date installed(if known)and source of information:
1977
Were sewage odors detected when arriving at the site(yes or no):NO
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
� SYSTEM INFORMATION(continued)
, Property Address: 85 TANGLEWOOD DR W.YARMOUTH,MA 02673
Owner: BOHAC C/O CAPE REALTY
Date of Inspection: 12/1/00
BUILDING SEWER(locate on site plan)
Depth below grade:22"
Materials of construction:_cast iron _40 PVC Xother(explain):ORANGEBURG
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: 14"
Material of construction:Xconcrete meeal fiberglass�olyethylene other(explain)n/a
If tank is metal list age: n/a Is ag�confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate)
Dimensions:6'X 6' BLOCK CESSPOOL"
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or ba�le:31"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baf�le: 12"
Distance from bottom of scum to bottom`of outlet tee or baffle: 11"
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related '
to outlet invert,evidence of leakage,etc.): '
MAIN CESSPOOL AND ALL COMPONENTS ARE STURCTURALLY SOUND.RECOMMEND PUMPING
EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a '
Material of construction:_concrete_metal_fiberglass�olyethylene_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 baf�le: n/a
Date of last pumping: n/a
Comments(on pumping recommendations,inlet and outlet tee or baf�le condition,structural integrity, liquid leveis as related
to outlet invert,evidence of leakage,etc.):
n/a
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART C '
' SYSTEM INFORMATION(continued)
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i • Property Address: 85 TANGLE�?1lOOD DR W.YARMOUTH,MA 02673 '
Owner: BOHAC C/O CAPE REALTY
Date of Inspection: 12/1/00
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
Design Flow: n/a gallonslday
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 '
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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-DISTRUBUTION BOX-SN�KED THRU '
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PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):NO
Alanns 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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Page 9 of 11
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OFFICIAL INSP�CTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
` SYSTEM INFORMATION(continued)
. Property Address: 85 TANGLEWOOD DR W.YARMOUTH,MA 02673
Owner: BOHAC C/O CAPE REALTY
Date of Inspection: 12/1/00 ;
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6'X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galieries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overtlow cesspool, number: n/a
n/a �� � ; innovative/alternative system
� Type/name of technology: n/a
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Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT
WAS EMPTY AT THE TIME OF THE IIVSPECTION.THE BOTTOM IS AT 8'
CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan)
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 hydraulic 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,condition of vegetation,etc.):
n/a ; r
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Page 10 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
� SYSTEM INFORMATION(continued)
Property Address: 85 TANGLEWOOD DR W.YARMOUTH,MA 02673
Owner: BOHAC C/O CAPE REALTY
Date of Inspection: 12/1/00
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.
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
I ' SYSTEM INFORMATION(continued)
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' Property Address: 85 TANGLEWOOD DR W.YARMOUTH,MA 02673
, Owner: BOHAC C/O CAPE REALTY
� Date of Inspection: 12/1/00
� SITE EXAM
� Slope
Surface water
Check cellar
Shaliow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES 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-explain: n/a
You must describe how you established t}ie high ground water elevation:
GROUNDWATER WAS DETERMINED FROM HAND AUGER-NO WATER AT 12'ADJUSTMENT TO
GROUNDWATER IS AT 2' S" FROM MIW 29 ZONE A-
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