HomeMy WebLinkAbout291 S Shore Dr System 7 - Title 5 Report 2006A.Commonwealth of Massachusetts
Title 5 Official lnspection FoNot for Voluntary Assesaments
Subsurface Sewage Disposal System Form
lnspection results must be stbmitted on this fom or on the officiat Title 5 fnsp6/15/2000. tnspection forms not be altered in a ection Form dated
:IillEctr[v7 IED
tAN 3 1 2006
HEALTH DEPT.
ny way.A. Gertificatio n
1. Propertylnformation:
29'1 South Shore Drive System 1t-t
lmportant:
Yvhen filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
us€ the retum
key.
Property Addresa
Davenport Com pany
Owneds Nama
P.O. Box 276
Owne/s Address
South Yarmouth MA 02664City/Town State
1t26t2006
Zip Code
Date of lnspection:
2. lnspector:
Shane ala
Date
Name of lnspedor
PKM Contracto lnc.
Company Nam-
P.O. Box 775
CompanyAddress
South Yarmouth MA 02641City/Town
508-385-5993 State
I certify that I have personally inspected the sewage drsposal system at this address and that theinformation reported berow ii true, accurate ano c-ompreie ,i oi ir,".tir" of the inspection. The inspectionwas performed based on mv training
"no e*puri"*e in-tn-"-irlper runction and maintenance of on sitesewase disposar svstems. rr, " oEi "pp?!il;Jiil:ffil""ror pu-uant to section ,s.340 orTitle 5 (3r0 CMR 1S.OOO). The system:
S Passes n Conditionally passes n faits
Telephone Number
Certific ation Statement:
fl Needs Further Evaluation by the Local Approving Authority
lnspector's rgn ature Date
Zip Code
The system inspector shall submit a copyof Health or D-Ep) within 30 days of cominas a desjgn flow of 10,000 gpd or greate
repon to the appropriate regional office of
and copies sent to the buyer, if applicabte
*..*This report only describes conditions
at that time. This inspection does notthe same or different conditions of us
.of this.inspection report to the Approving Authority (Boardleting thrs inspection_. tf the system is a s"hared .r"G;; -
r,. the tnspector and the system owner shall subririt thethe DEP. The originat should be sent to the system owner
, and the approving authority.
atlhe time of inspection and under the conditions of useaddress how the system will perform in the futrr. ;il;;e.
Blue water Title 5 lnspection.doc.doc . .l.l/2004
Page 1 of 16
Title 5 Official lnspeclion Form: Subsurface Sewage Disposal System .
A Commonwealth of Massachusetts
Title 5 Official lnspection Form!o! for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
291 South Shore Dnve g
Property Address
South Yarmouth
City/Town MA 02664
Davenport Com pany
State
1t26t2006
Zip Cod€
Owner's Name Date of lnspeclion
E I n:y: lgllogF any informalion-which indicates that any of the fairure crireria described
;lj::,".Jg,:*:r3 or in 310 crun rs sd "i"i;;l ilril ir.rter.ia not e,ii,atJ#--
lnspection Summary: Check A,B,C,D o r E I atways complete all of Section D
A) System passes:
Comments:
ND Explain
B) System Conditionalty passes:
E o-ne-or more system components as described in the'conditionar pass,,section need to be
fi3 E::?"::fii"1;;i:,JffiS". ,pon .o.fLiion o'r ti"'i"pr,.".",,t o;,.i.;p"i, Ii "piffia ov
Answer yes, no or not determined (y, N, ND) in the ! for the following statements. lf .notdetermined, " please explain.
! The septic tank is metar and over 20 {g1r: gldr or the septic tank (whether metar or not) isstructuralry unsound. exhibits. substa;tiar infirtration oi"rfirir"tion or tank fairure is imminentsvstem wi, pass inspection r tr'," "xliirg i""rl! ,.iip]lI"l'ilrin a comprying sepric tank asapproved by the Board of Health.
' A metar septic tank wifl Dass inspection if it is structuraly sound, not reaking and if a certiflcateor comptiance indicatins ihat th;t"rri ii rJJr'inr'iiri;;:ffi. is avaitabte
Title 5 Ofiicial lnspeclion Fom: Subsurface Sewage Disposal System .
Blue water Ti e 5 lnspec{ion.doc.doc . 1112004
Page 2 of 16
a,Commonwealth of Massachusettg
Title 5 Officiat lnspection FormNot for Voluntary Assessments
Subsurface Sewage Disposal System Form
A.Certification (cont.)
291 South Shore Drive -System i -'l
Property Address
South Yamouth
City/Town MA 02664
Daven port Compa ny
State
1t26t2006
Zip Code
O^rne/s Name Date of lnspedion
n The system required pumpin-g more than 4 times a year due to broken or obstructed pipe(s). Thesystem will pass inspection iilwith approval of ir," do"ro-Jf-iu"rtnt,
tr broken pipe(s) are reptaced
tr obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
conditions exist which reouire further evaruation by the Board of Hearth in order to determine ifthe system is faiting to proiect pubtic t "rltnlr"i"Ui oi'tt JIir]rInr"r,.
1'- iI^"!:, will pass unress Board of Hearth determines in accordance with 310 cMR:Hf !lfl,[lt"t#"H:T is not tunctionins ir'. i"ii"' *r'icrr wirr proiect puuiii iear*r,
tr Cesspool or privy is within 50 feet of a surface water
n cesspool or privy is within 50 feet of a bordering vegetated wefland or a salt marsh
Title 5 Official lnspeclion Fomt Subsurface Sewage Djsposalsystem .
Blue water Titie 5 lnspection.doc.doc . 1 1/2004
Page 3 of 16
B) System Conditionally passes (cont.):
E observation of sewage backup or break out or high static water level in the distribution box dueto broken or obstructed pipe(s) ordue to a ilkd;;E;;; uneven distribution box. system wi,pass rnspection if (with approval of Board of Health):
n broken pipe(s) are replaced
n obstruction is removed
! distribution box is leveled or replaced
ND Explain:
n
A'Commonweaith of Massachusetts
fttl"_ 5 Officiat tnspection FormNot for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certifi
291 South
cation (cont.)
Shore D flve-System i*-lProperty Address
South Yarmouth
City/Town
DavenDo rt ComDan State
1t26t2006
Zip Code
MA 02664
Owner's NamE Date of lnspection
C) Further Evaluation is Required by the Board of Health (cont.):
2. System will fait unless the Board of.Health (and public Water Supplier, if any)3$:il:ffi"tffi:H:fi:em is runctionin;l;';';;;il;tHt"protects the pubric hearth,
D rhe system has a seotic.tank.and soir absorption system (sAS) and the sAS is within100 feet of a surface water supply or tributary to alirflce water srppty.
Ll;r",/."t"'has a septic tank and sAS and the sAS is within a zone 1 of a pubtic water
];*:r has a septic tank and sAS and the sAS is within 50 feet of a private water
The system has a septic tank and sAS and the sAS is ress than 100 feet but 50 feet ormore from a private water supply well...
Method used to determine distance:
tr
tr
D
-. This system passes if the we' water anarysis, performed at a DEp certified raboratory, forcotiform bacteria and votatite oroanic ."rpd;nl.:;l;;t". ,i"i,.n" *",, is free from po,ution fromffi:lT,t:J1[:flT,?T?":l;"onia'nitrose;a;i,iii".iii"g". is equarto or'ress rhan 5
to this form. re criteria are triggered. e copy otine anatiil;;t; "ii;il;
3. Other:
Subsurface Sewage Disposal System .
page 4 of 16
Blue water Tifle 5 lnspectjon.doc.doc . .11/ZOO4
Title 5 Official Inspection Form
A,'Commonwealth of Massachusetts
Title 5 Official lnspection FormNot for Voluntary Assessments
Subsurface Sewage Disposal System Form
A.Certification (cont.)
291 South Shore Drive-System i+-)PropertyAddress
South Yarmouth MA 02664City/Town
Daven port Compa
Stat6
1t2612006
ZipCode
Owne/s Name Date of lnspedion
D) System Faiture Criteria Applicable to All Systems:
You must indica or,,No,,to each of the following for all inspections:
Yes
tr
!
!
tr
tr
n
Yes No
No
E
E
m
EU
E
tr
Backup of s:wage into facillty or system component due to overloaded orclogged SAS or cesspool
Discharge or ponding of etfruent to the surface of the ground or surface watersdue to an overloaded or clogged SAS or cesspoot
static riquid rever in the distribution box above ouflet invert due to an overroadedor clogged SAS or cesspool
Liquid.depth- in cesspool is less than 6,, below invert or available volume is lessthan % day flow
Required pumping more than 4 times in the last year /VOf due to ctogged orobstructed 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 1OO feet of a surface water supply ortributary to a surface water supply.
Any portion of a cesspool orprivyiswithin aZonel of a publicwell.
Any portion of a cesspool or privy is within S0 feet of a private water supplywell.
Any portion of a cesspool or privy is less than 1OO feet but greater than 50 feetfrom a private water suppty wefi with no acceptable water q"uitity anafysis. ffnissystem passes if the wefl water anatysis, i".fo-J "i" Oip certifiedlaboratory, for cotiform bacteria and volatile "ig;ri" "t.-pir"a"indicates that the well is free from pollution froir that faciiitv ana tnepresence of ammonia nitrogen and nitrate nitrogen ii e!-uii'to or tessthan 5 ppm, provided that io otherfaiture crit"i'i" "* tritg;red. A copy ofthe analysis must be attached to this form.l
I
m
trm
Title 5 Official lnspeclion Form: Subsurface Sewage Oisposal System .
Blue water Title 5 lnspection.doc.doc . .l 1/2004
Page 5 of 16
tr
The system fails. I have determined that one or more ofthe above failurecriteria exist as described in 3.10 CMR 15.303, therefo; tfr" ry.ia, fails. Thesystem owner should contact the Board of Heatth to Oli"irn'i,iJ-*n"t *if r O"necessary to correct the failure.
A Commonwealth of Massachusetts
El"- 5 Official lnspection FormNot for Voluntary Assessmentssubsurface Sewage Disposal System Form
A. Certifi
291 South
cation (cont.)
Shore Dflve-System lr-'tPropertyAddress
South Yarmouth
City/Town MA
Davenport Com panv
02664Slate
1t26t2006
Zip Code
Owne/s Name Date of lnspedion
E) Large Systems: To be ctd€ign flow of io,ooo ,r*,.'rl"ffi a.large system the system must serve a facitity with a
illiffillt3"J,l',?;vou must indicate
"iii,ul.'v""' or'no" to each of the forowins, in addition to rhe
YES NO
tr tr the system is within 4OO feet of a surface drinking water supply! tr the system is within 200 feet of a tributary to a surface drinking water supplytr Tr the system is rocated in a nitrogen sensitive.area (rnterim werhead protectionArea _ tWpA) or a mapped Zoie tt oi, fro,," *"t"r suppty well
I_r_":_l::" answered_.yes, to any question in Section E the svst
!i:ilili:!!*::",';,rs?,ff :l5l1l":,Fls:#ru jHnl{{if":.l!ii,i:ff "',:l:ff i:tlr?a:
svstem in accoraanceimr iil'#;;l,;"j ;=^"1'::l^=-T l?l!:d under Section D shall upsrade ihe
r6gionar offic! ;iin;;;:#:.i"* 15 304 The svstem owner should contact the appropriate
Subsurface Sewage Disposal System .
page 6 of 16
Blue water Ttfle 5 lnspection.doc.doc . 1i12004 Title 5 Official lnspeclion Form
(4.Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
291 South Shore Drive System &1Property Address
South Yarmouth MA
City/Town 02664
Daven port Compa
State
1t26t2006
Zip Code
Owne/s Name Oate of lnspedion
YES
E
!
n
tr
m
E
B
E
E
NO
!
E
tr
K
!
n
!
tr
tr
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?
Has the system received normal flows in the previous two week period?
Have large volumes ofwater been introduced to the system recenfly or as part ofthis inspection?
Were as built plans of the system obtained and examined? (lf they were notavailable note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened, and the interior of the tankinspected for the condition of the bames or tees, material of construction,dimensions, depth of liquid, depth of sludge and depth of scumi
Was the facility owner (and occupants if different from owner) provided withinformation on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site hasbeen determined based on:
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to part C is at issueapproximation of distance is unacceptable) t31O CMR t S.aOZ(S)(U)I
E!
!m
E
Tiil€ 5 Official lnspection Form: Subsurface Sewage Disposal System .
Page 7 oI '16
Blue water Title 5 lnspeciion.doc.doc , 1112004
check if the following have been done. you must indicate,,yes, or,,no,,as to each of the following:
tr
a.Commonwealth of Massachusetts
Title 5 Official lnspection FormNot for Voluntary Assessments
Subsurface Sewage Disposal System Form
c.system Information
291 South Shore
Property Address
South Yarmouth
Drive tem
MACity/Town
Davenport Company
State
1t26t2006
Zip Code
02664
Owne/s Name Oate of lnspection
Residential Flow Conditions:
Number of bedrooms (design):Number of bedrooms (actual)
DESIGN flow based on 3 j 0 CMR 15.203 (for exampte: 110gpdx#of bedrooms)
Number of current residents:
Does residence have a garbage grinder?
ls laundry on a separate sewage system? lif yes separate inspection requiredl
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump?
Last date of occupancy:
Commerciaulndustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR tS.2O3):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
lndustrial waste holding tank present?
Non-sanitary waste discharged to the Tifle S system?
Water meter readings, if available:
oll l
EYesS
nYesE
EYes!
EYes!
No
No
No
No
Ives! No
Date
-Peto Ciob
Gallons (spd)
E ves I tto
! ves [J No
n ves Q tto
Date
Title 5 Officiat lnspeclion Form: Subsurface Sewage Disposal System .
o
Last date of occupancy/use
Other (describe):
Blue water Title 5 lnspeclion.doc.doc . 1112004
Page 8 of 16
A Commonwealth of Massachusetts
Title 5 Official lnspection FormNot for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System I rmation (cont.)nfo
291 South Shore Drive System
PropertyAddress
South Yarmouth MA 02664City/Town
Davenport Company
State
1t26t2006
Zip Code
Owne/s Name Date of Inspedao;
General lnformation
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
lf yes, volume pumped:
How was quantity pumped detemined?
Reason for pumping:
Type of System:
1t3t03,12t14t2005 mainte nance, Yarm. BOH
n Yes I tto
gallons
ts
n
!
n
D
!
n
!
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)
lnnovattve/Altemative technology. Aftach a copy of the current operation andmarntenance contract (to be obtaineo trom syitlm o;;;;i - '-'
Tight tank. Aftach a copy of the DEp approval.
Other (describe):
Approximate age of all components date installed (if known) and source of information:
Were sewage odors detected when arriving at the site?! Yes ffi 11e
Tltle 5 Official lnspeclion Form: Subsurface Sewage Oisposal System .
Blue water Tifle 5 lnspeclion.doc.doc , 1112004
Page g of 16
A,.Commonwealth of MassachusetG
Title 5 Official lnspection FormNot for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System I rmation (cont.)nfo
291 South Shore Drive System *-)
Property AddresJ
South Yarmouth
City/Town
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
fl cast iron m 40 pVC E other (exptain)
Distance from private water supply well or suction line:
Septic Tank (locate on site plan)
Depth below grade:
Material of construction:
fl concrete
lf tank is metal, list age
MA 02664
State
1t26t2006
Zip Code
Date of lnspeclion
r i-l '\
leet
feet
feet
o
q\,,
k1
g\'
Title 5 Official tnspection Form: Subsurface Sewage Disposal System .
Davenport Com panvOwne/s Name
n metal ! fiberglass E potyethytene ! other (explain)
yearsls age contirmed by a Certificate of Compliance? (attach a copy ofcertificate)!Yes! Nq
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of ouflet tee or baffle
Scum thickness
Distance from top of scum to top of ouflet tee or baffle
Distance from bottom of scum to bottom of ouflet tee or baffle
How were dimensions determined?
Blue water Tafle 5 lnspection.doc.doc . 11/2004
Page 10 of 16
tood gallzros
mp.'(drio!+ Jqpr-
s-\Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
c.system !nformation 1cont.)
291 South Shore Drive System .li')
Property Address
South Yarmouth MA 02664City/Town
Davenport Com pany
State
1t26t2006
Zip Code
Owne/s Name Date of lnspeclion
comments (on pumping recommendations, inlet and ouflet tee or baffle condition, structural integrity,liquid levels as related to ouflet invert, evidence of leakage, etc.j:
Grease Trap (locate on sile plan):
Depth below grade:
Material of construction:
D concrete E metat ! fibergtass ! polyethytene ! other (exptain):
feet
Dimensions:
Scum thickness
Distance from top of scum to top of ouflet tee or baffle
Distance frcm bottom of scum to bottom of ouflet tee or baffle
Date of last pumping:
Date
po11ent9 (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquld levels as related to ouflet invert, evidence of bakge, eti.):
Tight or Hording Tank (tank must be pumped at time of inspection) (rocate on site pran):
Depth below grade:
Material of construction:
! concrete ! metal ! fiberglass ! potyethytene ! other (exptain)
Title 5 Official lnspeclion Form: Subsurhce Sewage Disposal System .
Blue water Title 5 lnspection.doc.doc . 11/2004
Page 11 of 16
A..Commonwealth of Massachusetts
Title 5 Official tnspection Form
Not for Voluntary Aasessments
Subsurface Sewage Disposal System Form
C. System I nformation (cont.)
291 South Shore Drive System
Property Address
South Yarmouth MA 02664City/Town
DAvenport Companv State
1n6t2006
Zip Code
Owne/s Name Date of lnspedion
Tight or Holding Tank (cont.)
gallons per day
! Yes D tto
Alarm in working order:
gallons
fl Yesn ruo
Date
Comments (condition of alarm and float switches, etc.):
Distribution Box (if present must be opened) (locate on site plan)
Depth of liquid level above ouflet invert
Comments (note if box is level an
evidence of leakage into or out of
d distribution to ouflets equal, any evidence of solids canyover, anybox, etc.):
o
Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
n Yes
fl Yes
Eruo
Dno
Title 5 Ofilcial lnspeciion Form: Subsurface Sewage Disposal System ,
Blue water TiUe 5 lnspection.doc.doc . 1 1/2004
Page 12 of 16
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System lnformation (cont.)
291 South Shore Drive System *:1
Property Address
South Yarmouth MA 02664
City/Town
Davenport ComDanv
State
1t2612006
Zip Code
O,vne/s Name Date of lnspedion
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.)
Soil Absorption System (SAS) (locate on site plan, excavation not required)
lf SAS not located, explain why:
Type
D
E
tr
tr
tr
tr
u
leaching pits
leaching chambers
leaching galleries
leaching trenches
leaching fields
overflow cesspool
innovative/alternative system
Type/name of technology:
number:
number:
number:
number, length:
number, dimensions:
number:
1 - /looDi{f ,gor
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Blue water Title 5 lnspection.doc.doc . 1112004 Title 5 Offcial lnspeclion Form: Subsurface Sewage Disposal System .
Page 13 of 16
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessmente
Subsurface Sewage Disposal System Form
C. System lnformation (cont.)
291 South Shore Drive System .j* -)
Property Address
South Yarmouth MA 02664
City/Town
Davenport Company
State
1126t2006
Zip Code
Owne/s Name Date of lnspedion
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth - top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
lndication of groundwater inflow ! Yes nNo
Comments (note condition of soil, signs of hydraulic failure, Ievel of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Title 5 Official lnspection Form: Subsu.face Sewage Disposal System .
Page 14 of 16
Blue water T;tle 5 lnspection.doc.doc . 1 1/2004
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System lnformation (cont)
291 South Shore Drive System t+1
Property Add.ess
South Yarmouth MA 02664
City/Town State
1t26t2006
Zip Code
Davenport Com pany
OwneCs Name Oate of lnspection
(\ots\
sketch of sewage Disposal system: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feetl
Locate where public water s pply enters the building.
gio\c\
9t-56
Rl-516\'
A3-L)$'
G\-5(,'q"(}'r-sd
(\3-'t$'t"
Title 5 Official lnspeclion Form: Subsurface Sewage Djsposal System .Blue water Title 5 lnspecton.doc.doc , 1jZOO4
B ec,ch
Page 15 of '16
E
E
rl
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
291 South Shore Drive €,lstefi\ Ii?
Property Address
South Yarmouth MA 02664
City/Town
Davenport Company
State
112612006
Ztp Code
tr Obtained from system design plans on record
lf checked, date of design plan reviewed:Date
tr Observed site (abutting property/observation hole within 150 feet of SAS)
n Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:n
Blue water Title 5 lnspeclion doc.doc ' '1112004 Title 5 Official lnspedion Form: Subsurface Ser'vage Disposal Syslem '
Page '16 of 16
G. System lnformation (cont.1
Owne/s Name Date of lnspeclion
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water: <61(i
Please indicate all methods used to determine the high ground water elevation:
tr
You must describe how you established the high ground water elevation: