HomeMy WebLinkAboutInspection Report 2020 Mar 02 RECEIVED
or Commonwealth of Massachusetts io AR 1 3 2020
* Title 5 Official Inspection Form DEPT,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessment* HEALTH
39 Violet Glen Road SCANNED
� F
Property Address -
O4/O7/V3 P To
Kenneth D. Keim r",1
tCx
Owner Owner's Name ►'��*DEW� .�'�' „� �:=`j`
hag Liz 6/4
Infomation is South Yarmouth Ma 02664 3/02/2020
required for every
page. 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.
important:When A. Inspector Information
fining out forms
on the computer, JeffreyM. Wall
use only the tab
key to move your Name of Inspector
cursor-do not Wall Septic Service
use the return Company Name
key.
ti C 771
Company Address
Harwichport Ma 02646
City/Town State Zip Code
508 432 4908 673
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 6
(310 CMR 15.000); I have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. 0 Conditionally Passes
3, 0 Needs Further Evaluation by the Local Approving Authority
4. 0 Fails
. . Aim(
✓// �
--
•:. . 'gaa u - �,, Date
�/
he 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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
tSinap.doe•rev,7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
I
—444 39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owners Name
information is
required for every South Yarmouth Ma 02664 3/02/2020
page. CityRown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
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:
LI One or more system components as described in the"Conditional Pass"section need to be
'laced or repaired. The system, upon completion of the replacement or repair, as approved by
the =-:rd of Health, will pass.
Check the box "yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," pleas- - 'lain.
The septic tank is metal an• ever 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial in' ation or exfiitration or tank failure is imminent. System will pass
inspection if the existing tank is rep - =d with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is s turally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 y - old is available.
❑ Y ❑ N 0 ND (Explain below):
t5lnep,doc•rev.7/28/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
_............... . .....
ei Title 5 Official Inspection Form
v+ -- ri
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,_
,r`' 39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name
information is
required for every South Yarmouth Ma 02664 3/02/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) stem Conditionally Passes (cont.):
❑ mp Chamber pumps/alarms not operational. System will pass with Board of Health approval if
u •s/alarms are repaired.
aired.p
❑ Observation sewage backup or break out or high static water level in the distribution box due
to broken or ob- ucted pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if ith approval of Board of Health):
❑ broken pipe(s) - = replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is remov:• ❑ Y 0 N 0 ND(Explain below):
❑ distribution box is leveled • replaced 0 Y 0 N 0 ND(Explain below):
❑ The system required pumping more than 4 times a year due broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of He h):
❑ broken pipe(s)are replaced ❑ V ❑ N ND(Explain below):
❑ obstruction is removed 0 Y 0 N ❑ ND xplain below):
❑ 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.
a. System will pass unless Board of Health determines in accordance with 310 CMR
18.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
tbinsp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
E
39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name
Information is
required for every age. City/Town South Yarmouth Ma 02664 3/02/2020
Page.
State Zip Code Date of Inspection
a e,
p9
C. Inspection Summary (cont.)
• Cesspool or privy is within 50 feet of a surface water
❑ esspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System II fail unless the Board of Health (and Public Water Supplier,if any)
determines th the system is functioning in a manner that protects the public health,
safety and envir• ment:
❑ The system has a eptic tank and orilabsorption
systems (SAS)and
the SAS is within
100 feet of a surface wa =r supplytributary to surface
❑ The system has a sept tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tan and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank an• AS 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, perfo 4ed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of a onia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria - e triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable 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
t5insp.doo•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 10
Commonwealth of Massachusetts
►�
*-4 �G Title 5 Official Inspection Form
AspI Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
+" 39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name
information is Ma 02664 3/02/2020
Sou
th Yarmouth
required for every
pe. CitylTown State Zip Code Date of Inspection
Page.
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ [1Static 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
thanY2 day flow
❑ ll 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.
❑ Q/ Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ 21 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ESK 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 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.]
ffii❑ The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑
Eg7 The system fps. 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.
n flow of 10,000 gpd to 15,000 gpd.
For larg: - -ms, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Sec I•
Yes No
❑ ❑ the system is within 400 feet o = 'ace drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a su - : • 'nking 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
tSinep.doc.rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
, Commonwealth of Massachusetts
►*•,
*�,,__� Title 5 Official Inspection Form
'ail , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.
,�..,;.� , 39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name
Information is
required for every South Yarmouth Ma 02664 3/02/2020
Page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes" to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section C.4 above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
YesNo
I ❑ 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?
El/ 0 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?
[E ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
Q7 0 Was the facility or dwelling inspected for signs of sewage back up?
0 Was the site inspected for signs of break out?
❑ Were all system components, a ng the SAS, located on site?
ire 0 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?
['a/ 0 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:
[2 0 Existing information. For example, a plan at the Board of Health.
12/ L7 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)]
(6.49 ca17o Ori L.y ll1
t5inep.doc•rev.7128/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 018
Commonwealth of Massachusetts
* ei Title 5 Official Inspection Form
_. !! y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name
information is South Yarmouth Ma 02664 3/02/2020
required for every State Zip Code Date of Inspection
Page. City/Town
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
rt?'
Description:
Cz ) gd/41.,1 zeipcdle.-//0,041,4er
Number of current residents:
Does residence have a garbage grinder? 0 Yes
10
Does residence have a water treatment unit? 0 Yes io
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes aa/No
information in this report.)
Laundrysysteminspected?ins ected? ❑ Yes No
Seasonal use?
❑ Yes ff24o
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump?
0 YesNo
Last date of occupancy: date
t5inep.doc•rev.7128/2018 Tile 5 0150.1 Inspection Form Subsurface Sewage Oisposai System•Page 7 0118
*
Commonwealth of Massachusetts
* Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
+' 39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name
information is
for every South Yarmouth Ma 02664 3/02/2020
required
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Ty.- of Establishment:
Design '• . (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design °•w(seats/persons/sq.ft., etc.):
Grease trap present? 0 Yes 0 No
Water treatment unit presen • 0 Yes 0 No
If yes, discharges to:
Industrial waste holding tank present? 0 Yes 0 No
Non-sanitary waste discharged to the Title 5 sy - ? 0 Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use:
Other(describe below):
3. Pumping Records: ''e/`re / eijoe-i a �ATA6
Source of information: C� / ,�C°AV;)
Was system pumped as part of the inspection? VeYes 0 No
/S'S-'0
If yes, volume pumped: gallons -/
How was quantity pumped determined? 7 fc ge-c $ e
Reason for pumping:
t5insp.doc•rev.7128/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pep 8 of 18
Commonwealth of Massachusetts
. *_, ff/ Title 5 Official Inspection Form
la'-
- y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,_i:` a
h.+ 39 Violet Glen Road
`J Property Address
Kenneth D. Keim
Owner Owner's Name
information is South Yarmouth Ma 02664 3/02/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of stem:
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):
Approximate age of all components, date installed (if known)and source of informsion:
. 'S" 31/eco 7/4Z104." (2¢Yrieqc /Tra)-�S—irrooco C.O.C. .
Were sewage odors detected when arriving at the site? ❑ Yes �o
5. Building Sewer(locate on site plan):
r
Depth below grade:
feet
Material of construction:
0 cast iron E10 PVC 0 other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
0 _ .5c.<.-e...r. v1 `..5ra•ec-77be)
16insp.doc•rev.712812019 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
1 * ,tI-G Title 5 Official Inspection Form
b' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name
information is South Yarmouth Ma 02664 3/02/2020
required for every City/Town State Zip Code Date of Inspection
page.
D. System Information (cont.)
6. Septic Tank(locate on site plan): /0$7 e'er- ,,t' \ T'>3 - 3
Depth below grade: 0 et f / t
ie
Materi of construction:
concrete 0 metal 0 fiberglass 0 polyethylene 0 other(explain)
years
. oege-set ed f-e-�etttfleat l dgry- if-certifteatet-^`-[' Yer-a No•--
'(02� ,/pry, et.
Dimensions: (z::s:2 ' ,6�ivws)
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
/
Scum thickness 5°--"
Distance from top of scum to top of outlet tee or baffle /�
/�
Distance from bottom of scum to bottom of outlet tee or baffle
77904 Creer,
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid as related to outlet invert, idence o�l��g etc.): u��
7 Z �Jl�l-fit et
„vioh 5-Atea oeopof,„.-( a' 'fill* A) ..57) 4,
acP (Geo-chi veer 17 is de a ' -..
r
64caer I.?a C. 1-7C-e'r /
ext T nitu-t ° . '00 av,d4il C-e. or ceAlrr e'
t5insp.doc•rev.712812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
39 Violet Glen Road
Property Address
Kenneth D. Kelm
Owner Owner's Name
Information is
required for every South Yarmouth Ma 02664 3/02/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
•- • h below grade: feet
Material o •nstruction:
❑ concrete ■ metal ❑fiberglass 0 polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffl-
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle con• '• , structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Depth be • • ade:
Material of construction:
❑concrete ❑ metal berg lass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5inep.doc•rw.7/28/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Pape 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
+ 39 Violet Glen Road
Property Address
Kenneth D. Kelm
Owner Owner's Name
information is
required for®very South Yarmouth Ma 02664 3/02/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Ala esent: ❑ Yes ❑ No
Alarm level: Alarm in working order: 0 Yes 0 No
Date of last pumping: Date
Comments(condition of alarm and floa ches, etc.):
`Attach copy of current pumping contract(required). Is copy attached? 0 Yes 0 No
9. 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, et9.):
s e-c v-e r70'
11 6ter 7--c)
3 rl' . ,,✓ca SvL, c7-CP , ,• ) d Ge4/ete.e• ,
t5insp.doc•rev,712612018 Title 5 Of tial Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
►� *� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,0+ 39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name
information is
required for every South Yarmouth Ma 02664 3/02/2020
page. City/Town State Zip Code Date of Inspection
D. System information (cont.)
Pumps i • king order: ❑ Yes ❑ No*
Alarms in working or.e . ❑ Yes ❑ No"
Comments(note condition of pump c •••er, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why: 07� o S '9 5 c /l0.7 3 r �
Type:
❑ leaching pits number: ,.--1
leaching chambers number(3) �� �,eYWe,eVWa
y� S7rJN't- o ��jjvQ
❑ leaching galleries number:63 5 )
/°2 '$ k 1
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: ----
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t6lnep.doc•rev.7/2612018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
A
39 Violet Glen Road
{ Property Address
Kenneth D. Keim
inis ner Owner's Name
required for every South Yarmouth Ma 02664 3/02/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Sell Absorption System(SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
I'� a o r1r
aoa1t' 4,L-. *Ts ' ►v.e. ikezteree 77osi
/?o/' '/vt "L. ,
mber and configuration
Depth— •• of liquid to inlet invert
Depth of solids - er
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow 0 Yes 0 No
Comments(note condition of soil, signs of hydrau , failure, level of ponding, condition of vegetation,
etc.):
t5insp,doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system.Page 14 of 18
Commonwealth of Massachusetts
xvTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
n+ 39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name
information is
required for every South Yarmouth Ma 02664 3/02/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
is of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs • - •raulic failure, level of ponding, condition of vegetation,
etc.):
•
t5lnep.doc•rev.7128/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 10
• Commonwealth of Massachusetts
*.' Title 5 Official Inspection Form
,� r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name
Information is
required for every South Yarmouth Ma 02664 3/02/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view 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 ilding. Check one of the boxes below:
hband-sketch in the area below
❑ drawing attached separately
144(3
iii i' -TSA
wortg
V_
)--
S
..zo
' :e.x
1 a
r v/oieT'0- A/ .
1 re 1.. (To ; /vo r-C:
/ - fig ' l 3� � /�iiyGod-2�sU&'
3 :: 34''Y 3: 9,S''
9 37 ' y V-2- C'
t5inep.doc•rev.7/28/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
• Commonwealth of Massachusetts
�. V,, _ Title 5 Official Inspection Form
ail-' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,.—f`' 39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name
Information is
required for every South Yarmouth Ma 02664 3/02/2020
page. City/Town State Zip Code Date of Inspection
• D. System Information (cont.)
15. S
_it
e Exam:
Li Check Slope
EE Surface water
i[yi eck cellar
Shallow wells L
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
61 Obtained from system design plans on record
If checked, date of design plan reviewed: /gls/ '�
Date
O 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:
r ix( esrC �L, �, r2 .70 ' 4
5-e/44(-)42.1-7 0 rl •• -. ".G0
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5inap.doc•rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
- • \ Commonwealth of Massachusetts
!/ Title 5 Official Inspection Form
6- ;; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name —
information is
required for every South Yarmouth Ma 02664 3/02/2020
required
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
[1A. Inspector Information: Complete all fields in this section.
C"B. Certification: Signed& Dated and 1, 2, 3, or 4 checked
[2(C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
(Failure Criteria)and 6(Checklist)completed
D. System Information:
{ For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5inep.doc•rev.7/2812018 Title 5 Official Inspection Fenn:Subsurface Sewage Disposal System•Page 18 of 18
• .Table 3-2 Do's and Don'ts of Private Septic System Management
DO... • DON'T...
Do have the on-site system Inspected and pumped by Do not use the toilet or sink as a trash can by
a licensed professional approximately every 3 to 5 dumping non-biodegradable material (cigarette butts,
years. Failure to pump out the septic tank can cause diapers, feminine products, etc.) or grease down the
system failure. If the tank fills up with an excess of sink or toilet. Non-biodegradable material can clog
solids, the wastewater will not have enough time to the pipes,while grease can thicken and clog the
settle in the tank.These excess solids will then pass on pipes. Store cooking oils, fats, and grease in a can
to the leach field, where they will clog the drain lines for disposal in the garbage.
and soil.
Do know the location of the on-site system and drain Do not put paint thinner, polyurethane, anti-freeze,
field, and keep a record of all inspections, pumping, pesticides, some dyes, disinfectants, water
repairs,contract or engineering work for future softeners, and other strong chemicals into the
references, Keep a sketch of It handy for service visits. system. These can cause major upsets in the septic
tank by killing the biological part of the on-site
system and polluting the groundwater. Small
•
amounts of standard household cleaners, drain
cleansers, detergents, etc. will be diluted In the tank
and should cause no damage to the.sslem.
Do grow grass or small plants (not trees or shrubs) Do not use a garbage grinder or disposal, which
above the on-site system to hold the drain field in feeds Into the on-site tank. If there is one, severely
place.Water conservation through creative limit Its use,Adding food wastes or other solids
landscaping is a great way to control excess runoff, reduces the system's capacity and Increases the
need to pump the on-site tank. If a grinder is used,
the system must be pumped more often.
Do install water-conserving devices in faucets, Do not plant trees within 30 feet of the system or
showerheads and toilets to reduce the volume of water park/drive over any part of the system. Tree roots wilt
running into the on-site system. Repair dripping faucets clog pipes, and heavy vehicles may cause the drain
and leaking toilets, run washing machines and field to collapse.
dishwashers only when full, and avoid long showers.
Do divert roof drains and surface water from driveways Do not allow anyone to repair or,pump the system
and hillsides away from the on-site system. Keep sump without first checking that they are licensed system
pumps and house footing drains away from the on-site professionals.
system as well.
Do take leftover hazardous chemicals to an approved Do not perform excessive laundry loads with a
hazardous waste collection center for disposal. Use washing machine. Doing load after load does not
bleach, disinfectants, and drain and toilet bowl cleaners allow the on-site tank time to adequately treat wastes
sparingly and in accordance with product labels. and overwhelms the entire on-site system with
excess wastewater. This could flood the drain field
without allowing sufficient recovery time. Consult with
an on-site tank professional to determine the gallon
capacity and number of loads per day that can safely
go into the system.
Do use only on-site system additives that have been Do not use chemical solvents to clean the plumbing
allowed for usage in Massachusetts by MA DEP. or on-site system. "Miracle"chemicals will kill
Additives that are allowed for use In Massachusetts microorganisms that consume harmful wastes.
have been determined not to produce a harmful effect These products can also cause groundwater
to the individual system or Its components or to the contamination
environment at large,
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