HomeMy WebLinkAbout291 S Shore Dr System 6 - Title 5 Report 2006A Commonwealth of Massachusetts
Title 5 Official lnspection For
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
l-E@tr[\i7 IE
tAN 3 I 2006
HEALTH DEPT
lnspection
6/15/2000. I
results must be su
nspection forms m
bmitted on this form o
ay not be altered in an
r on the official Title
y way.
5 lnspection Form dated
A. Certification
1. Property lnformation
29'1 South Shore Drive System*L
lmportant:
When tilling out
foms on the
computer, use
only the tab key
lo move your
cursor - do not
use the return
key.
Property Address
Daven port Compan vOwne/s Name
P.O. Box 276
Owner's Address
South Yarmouth MA 02664
*,4
City/Town State
1t26t2006Date of lnspection
2. lnspector:
Date
Shane Syrjala
Name of lnspector
PKM Contractors lnc
Company Name
P.O. Box 775
Company Address
South Yarmouth MA 02641City/Town
508-385-5993
State Zip Code
Telephone Number
Certification Statement:
I c€rtify that I have personally inspected the sewage disposal system at thrs address and that theinformation reported below is true, accurate ano comptete as oi the time of the inspeciion. rne inspectionwas performed based on my kaining and experience in the proper function and maintenance of on site:9wage disnosal systems. I am a DEP approved system inspector pursuant to section rs.g+o otTitle 5 (310 CMR 15.000). The system:
ffi Passes fl Conditionafly passes ! fails
! Needs Further Evaluation by the Local Approving Authority
/-)
nspectois Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Boardof Health or n-EP) within 30 days of compreting this inspection. rt tne system i. , ."n"reo .yJtJ, or.has a design flow of 10,000 gpd or greater, the inspector and the systam owner shal submit thereport to the appropriate regional office of the DEp. The original should be sent to the system ownerand copies sent to the buyer, if applicable, and the approvirig authorjty.
--'-This report only describes conditions at the time of inspection and under the conditions of useat that time. This inspection does not address how the system will perform in the future underthe same or different conditions of use.
Blue water Title 5 lnspection'doc'doc ' 11/2004 Title 5 official lnspection Form: subsurface t"**. ,ls0.;:l:ri:iT;
Zip Code
A, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
291 South Shore Drive rP-m Fi t:,
Prcperty Address
South Yarmouth MA 02664City/Town State
1t26t2006
Zip Code
Davenport Company
Date of lnspection
lnspection Summary: Check A,B,C,D ot E I always complete all of Section D
A) System Passes:
tr I ngvg not found any information which indicates that any of the failure criteria describedin 310 cMR 15.303 or in 310 cMR 15.304 exist. Any faiiure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
n one or more system components as described in the "conditional pass" section need to bereplaced or repaired. The system, upon completion of the replacement or repair, as approved bythe Board of Health, will pass.
Answer yes, no or not determined (y, N, ND) in the E for the following statements. If ,,not
determined," please explain.
E The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) isstructurally 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 asapproved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificateof Compliance indicating that the tank is less than 20 years old is avallable.
ND Explain:
Title 5 Official Inspection Form: Subsurface Sewage Disposatsystem.
Page 2 of '16
Blue water Title 5 lnspection doc doc . 1 1/2004
Owne/s Name
5$. Gommonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
291 South Shore Drive ,System F(.2
Property Address
South Yamouth MA 02664
City/Town State
1t2612006
Zip Code
Davenport Com pany
Owne/s Name
B) System Conditionally Passes (cont.):
Date of lnspection
f] 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 diskibution box. System will
pass inspection if (with approval of Board of Health):
tr
tr
tr
ND Explain:
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
E 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 Board of Health):
tr broken pipe(s) are replaced
tr obstruction is removed
ND Explain:
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 publlc health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1Xb) 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 wefland or a salt marsh
Title 5 Official lnspeclion Form: Subsurface Sewage Disposat System .
Page 3 of 16
Blue water Title 5 lnspection.doc.doc ' 11/2004
tr
tr
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
291 South Shore Drive- System B6
Property Address
South Yarmouth MA 02664
City/Town State
1t2612006
Zip Code
Davenport Com pany
Ownels Name Date of lnspection
C) Further Evaluation is Required by the Board of Health (cont.):
2. System will fail unless the Board of Health (and Public Water Supptier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
n 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 tank 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 S0 feet or
more from a prjvate water supply well.'.
Method used to determine distance:
3. Other:
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*' This system passes if the well water analysis, performed at a DEp certifled laboratory, for
coliform bacteria and volatile organic compounds indicates 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 sppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached
to this form.
Title 5 Official lnspeclion Form: Subsurface Sewage Disposat System .
Page 4 of 16
Blue water Title 5 lnspection.doc doc . 1 'l12004
'5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
291 South Shore Drive- System iF{,)
Property Address
South Yarmouth MA 02664
City/Town
Daven ort Com
Ownels Name
tr a
Date oI lnspeclion
The system [!lg. 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.
State
1t26t2006
D) System Failure Criteria Applicable to All Systems:
You @g! indicate "Yes" or "No" to each of the following for gll inspections:
Yes No
T-t r:'l Backup of sewage into facility or system component due to overloaded orLJ r4r clogged SAS or cesspool
T-t tv Discharge or ponding of emuent to the surface of the ground or surface watersL-J t4u due to an overloaded or clogged SAS or cesspool
r--.r Static liquid level in the distribution box above outlet invert due to an overloadedLJ tlll or clogged SAS or cesspool
rr rn Liquid depth in cesspool is less than 6" below invert or available volume is lesst-J LAi than % day flow
T-t ra Required pumping more than 4 times in the last year lVOf due to clogged or.5r obstructed pipe(s). Number of times pumped: _.
tl E Any portion of the SAS, cesspool or privy is below high ground water elevation.
fl fA Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
n m Any portion of a cesspool or privy is within aZone l ol a public well.
tr m f3; Portion of a cesspool or privy is within 50 feet of a private water supply
Tl m 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. flhis
system passes if the well water analysis, performed at a DEP certified
laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the
presence of ammonia nittogen 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.l
Yes No
Blue water Title 5 lnspection.doc.doc . 1112004 Iitle 5 Offlcial lnspection Fom: Subsurface Sewage DisposalSystem.
Page 5 of 16
ZipCode
A. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
291 Sout! Shore Drive- System *
Property Address
South Yarmouth IVIA 02664
City/Town State
1t26t2006
Zip Code
Daven port Com pany
Ownels Name Date of lnspectron
E) Large systems: To be considered a large system the system must serve a facility with adesign flow of 10,000 gpd to ,t5,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to thequestions in Section D.
YES NO
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ntr
trn
lf you have answered "yes" to any question in Section E the system is considered a significant threat,or answered "yes" in section D above the large system has failed. The owner or operJtor of any largesystem considered a signiflcant threat under Section E or failed under Section D shall upgradeifre
system in accordance with 310 cMR 15.304. The system owner should contact the appripriateregional offlce of the Department.
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (lnterim Wellhead protection
Area - IWPA) or a mapped Zone lt of a public water supply well
Title 5 Official lnspection Form: Subsurface Sewage Disposal System .
Page 6 ol 16
Blue water Title 5 lnspection. doc.doc . 11/2004
A, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
291 South Shore Drive System i+a>
Property Address
South Yarmouth o2664City/Town State
1t26t2006
Zip Code
Owner's Name Date of lnspeclion
check if the following have been done. you must indicate "yes, or ,,no,, as to each of the following
YES
E
tr
tr
tr
m
m
E
E
E
NO
tr
ts
E
E
!
tr
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 not
avarlable 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 tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
W-as 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 has
been 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) [310 CMR j 5.302(3)(b)]
E tr
!
n
tr
E
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Page 7 of 16
Davenport Company
5\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
G. System lnformation
291 South Shore Drive System ilia
Property Address
South Yarmouth 02664
City/Town State
1t2612006
Zip Code
Davenport Com pany
Owner's Name Date of lnspection
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15.203 (for exampte: 1 10 gpd x # of bedrooms):
Number of current residents:
Does residence have a garbage grinder?
ls laundry on a separate sewage system? lif yes separate inspection required]
Laundry system inspected?
Seasonal use?
nYesE
nves!
EYes!
EYesE
No
No
No
No
Water meter readings, if available (last 2 years usage (gpd))
Sump pump?
Last date of occupancy:
Commercial/lndustrial FIow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
lndustrial waste holding tank present?
Non-sanitary waste discharged to the Tifle 5 system?
Water meter readjngs, if available:
Last date of occupancy/use:
Other (describe):
nvesE ruo
Date
lT:,::Yr,r fnn
Gallons per d (spd)
1, - i.:r n ,'r.4
I ves Q tto
Evesffi ruo
!ves@ ruo
aq- 7 .:,toct)
Date
Blue water Title 5 lnspection.doc.doc . 11/2004 Title 5 Official lnspection Form: Subsurface Sewage Disposal System .
Page I of 16
MA
noiJ o.;
A, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessmenb
Subsurface Sewage Disposal System Form
C. System !nformation (cont.;
291 South Shore Drive System.id2
Property Address
South Yarmouth 02664
City/Town
Davenport ComoanV
State
1t26t2006
Zip Code
Date of lnspeclion
General lnformation
Was system pumped as part of the inspection?
lf yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
1 l3ll3, 121 1 412005 maintenance Yarm. BOH
n Yes X tto
gallons
m
tr
n
tr
tr
n
n
tr
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)
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):
Approximate age of all components, date installed (if known) and source of information:
(n,,l t,:{qo:9
Were sewage odors detected when arriving at the site?n Yes El tto
Title 5 Official lnspection Form: Subsurface Sewage Disposal System .
Page 9 of 16
Blue water Title 5 lnspection.doc.doc . 1112004
Owner's Name
Pumping Records:
Source of information:
A. Commonweatth of Massachusetts
Title 5 Official !nspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System lnformation (cont.)
291 South Shore Drive System
P.operty Address
South Yarmouth MA
City/Town State
1t26t2006
Zip Code
Davenport Com pany
Owneds Name
Building Sewer (locate on site plan)
Depth below grade:
Oate of lnspection
r *lt'
feet
Material of construction:
E cast iron E aO pVC D other (exptain)
Distance from private water supply welt or suction line:feet
Comments (on condition ofjoints, venting, evidence of leakage, etc.)
Septic Tank (locate on site plan)
Depth below grade:
Material of construction:
n concrete n metal
feet
! fiberglass ! potyethytene D other (exptain)
rl
ls age confirmed by a Certificate of Compliance? (attach a copy of
certificate)
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?
years
E Yes ! 116
)
.1\\
mP-mjj fuf i:-.9 r.l f
Blue water Title 5 Inspection.doc.doc . 11/2004
02664
lf tank is metal, list age:
Title 5 Official lnspeclion Form: Subsurface Sewage Disposal System .
Page 10 of 16
5\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System lnformation 1cont.)
291 South Shore Drive System *G2
MA 02664
City/Town State
1t2612006
Zip Code
Davenport Com pa ny
Owner's Name Date of lnspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan)
Depth below grade:
Malerial of construction:
E concrete E metal ! fiberglass ! polyethytene E other (exptain)
feet
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or batfle
Distance from boftom of scum to bottom of ouflet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on sjte plan)
Depth below grade:
Material of construction:
E concrete E metal ! fiberglass ! polyethylene n other (explain)
Title 5 Official lnspeclion Form: Subsurface Sewage Disposal System .
Page11of16
Blue water litle 5 lnspection.doc.doc . 11/2004
Property Address
South Yarmouth
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System lnformation lcont.y
291 South Shore Drive System.!Fc,
Property Address
South Yarmouth 02664
City/Town State
1t26t2006
Zip Code
DAvenport Company
Owne/s Name
Tight or Holding Tank (cont.)
Dimensions:
Oate of lnspeclion
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping
gallons
gallons per day
I Yes E tlo
Alarm in working order:n Yes ! 116
Date
Comments (condition of alarm and float swilches, etc.)
Distribution Box (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert o
Comments (note i
evidence of leaka
f box is level and distribution to outlets equal, any evidence of solids carryover, anyge into or out of box, etc.):
Pump Chamber (locate on site plan)
Pumps in working order:
Alarms in working order:
! yes
I Yes
E r.ro
E tto
Elue water Title 5 lnspection.doc.doc . 1'112004 Title 5 Ofilcial lnspection Form: Subsurface Sewage Oisposal System .
Page 12 ol 16
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
G. System lnformation 1cont.;
291 South Shore Drive System ,tf,6
Property Address
South Yarmouth 02664
City/Town State
1t2612006
Zip Code
Davenport Com pany
Ownels Name Date of lnspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.)
Soil Absorption System (SAS) (locate on site plan, excavation not required)
lf SAS not located, explain why:
leaching pits
leaching chambers
Ieaching galleries
leaching trenches
Ieaching fields
overflow cesspool
innovative/alternattve system
Type/name of technology:
number:
number: 3
number:
number, length:
number, dimensions:
number:
comments (note condjtion of soil, signs of hydraulic failure, level of ponding, damp soil, condition ofvegetation, etc.):
Type:
tr
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n
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tr
n
n
Ae.r!J{c*r=.
Title 5 Official lnspeclion Form: Subsurface Sewage Disposal System .
Page 13 of 16
Blue water Title 5 lnspection.doc.doc . 11/2004
5$. Commonwealth of MassachusetG
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System lnformation (cont.)
291 South Shore Drive System *f,
Property Address
South Yarmouth 02664
City/Town State
1126t2006
Zip Code
Davenport Com panv
Owner's Name Date of lnspeclion
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and conflguration
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 n yes n ruo
Comments (note condition of soil, signs of hydraulic failure, level 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.):
Blue water Title 5 lnspection.doc.doc ' 11/2004 Title 5 Official lnspection Form: Subsurface Sewage Disposat System .
Page 14 ol16
A Gommonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System lnformation (cont.1
291 South Shore Drive System trG
Property Address
South Yarmouth MA 02664
City/Town
Davenport Company
Zip Code
Owne/s Name Date of lnspection
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 ublic water supply enters the buil tng.oIC rue-
fc,cRin_i iol
State
1t26t2006
F\-\l' B\- rq'
Ax-9'c' G).-1.'t' ....
F3-3o'S-35"s''
Dq- lg' s{- }05 '
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(or:k Shr.r:.,-Or,
Title 5 Ofilcial lnspection Form; Subsurface Sewage Disposal System .
Page 15 of 16
Elue water Title 5 lnspection.doc.doc . 1112004
I
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(\Commonwealth of Massachusetts
Title 5 Officia! lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
c.system I nformation (cont.)
291 South Shore Drive -s \-51 e fi.l * l:Property Address
South Yarmouth
City/Town State
1t26t2006Davenport Compan v
Owner's Name Date of lnspeclion
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground waler: 6,(r
Please indicate all methods used to determine the high ground water elevation
! Obtained from system design plans on record
lf checked, date of design plan reviewed:Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
!
D
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevatjon
Blue water Title 5 lnspection.doc.doc ' 1112004 Title 5 Official lnspectjon Form: Subsurface Sewage Disposat System ,
Page 16 of 16
02664
Zip Code
tr
!