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Home My WebLink AboutInspection Report 1995 Jun 16 t p/ 7 s �U • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 54 Chickadee Lane W. YarmouthIN/la M af5S Owner's name Joan Gonsalves Date of Inspection 6-16-95 r� �L JUL - - 1995 PART A CHECKLIST Check if the following have been done: U/7 P• umping information was requested of the owner, occupant, and Board of Health. v/ None of the system components have been pumped for at least two weeks 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. (/ As--built plans have been obtained and examined. Note if they are not available with N/A. T• he facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. • 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. _ T• he size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. c//The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. V414 ° \Cit( 1V4 YARMOUTH HEALTH DEPT. 1146 ROUTE 28 SO.YARMOUTH,MA 02664 8 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 34inumber of bedrooms number of current residents A, garbage grinder, yes or no laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records rand source of information: • 1 3 . .4-� �=✓( Y3 �: Lc 1 e ) o I r e: 7 "j ✓ 1 V Av System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Tyrg'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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: _ Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / SYSTEM INFORMATION continued SEPTIC TANK: 1/ (locate on site plan) depth below grade: I I- 1 material of construction: 1/Concrete metal FRP other(explain) dimensions: - ? 3 , sludge depth 3`ior distance from top of sludge to bottom of outlet tee or baffle 3 scum thickness 6." distance from top of scum to top of outlet tee or baffle / '` distance from bottom of scum to bottom of outlet tee or baffle 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, recommendations for repairs, etc. ) C lA et• ►< z 4: )6640- DISTRIBUTION 6A0- DISTRIBUTION BOX: ✓ (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) • PUMP CHAMBER: AZ (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) , 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INNFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : V (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type t' 1:c-e leaching pits and number L-�� S 1o'_ ''` leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (locate on site plan) : number and configuration /[ii' 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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction /V dimensions depth of solids Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, rec ndations for maintenance or repairs,etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 6 6-1f 0 j �;► 175 DEPTH TO GROUNDWATER S 4 depth to groundwater method of determination or approximation: To � A,- yAti 94 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) t/ Backup of sewage into facility? N Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? A/ Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped 4v Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? • Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? ,(/ within 50 feet of a surface water? /r/ within 100 feet of a surface water supply or tributary to a surface water supply? tV within a Zone I of a public well? /v within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? 4/ within 50 feet of a private water supply well? /t/ 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. , , i TOWN OF Yarmouth BOARD OF HEALTH d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 54 Chickadee Lane W. Yarmouth ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Joan Gonsalves PART D - CERTIFICATION NAME OF INSPECTOR W.E. Robinson Sr COMPANY NAME W.E. Robinson Septic Service COMPANY ADDRESS P.O. Box 1089 Centerville MA 02632 Street Town or City State LIP • COMPANY TELEPHONE ( 508 ) 775- 8776 FAX ( ) - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa1 system at this address and that the information reported is true , accurate, and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems. Chec one: System PASSED * The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public is health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. V --Z;--"Z Inspector Signature t,U Date 4 --/G One copy of this certification must be provided to the OWNER, the BUYER (where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc /3 .. Town of Yarmouth 1146 Route 28 South Yarmouth, MA 02664 398-2231 Fax: 398-2365 faXtransmittal to: OfNunitti M artin O^ Octitepi fax: ` 0®n- from: suarkn Ccf Yar44614:111-) 4s2a44472-€.03 date: - � -9 re: 5—q C. i pages: , including cover sheet _ NOTES: