HomeMy WebLinkAbout291 S Shore Dr System 5 - Title 5 Report 2006a,Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form l
JAN 31 2006
HEALT HDEPT.
lnspection results must bG submitted on this form or on the official Title 5 lnspection Form dated6/15/2000. lns on forms ma not be altered in a wa
A. Certification
291 South Shore Drive System +4
lmportant:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Property Address
Davenport Compan v
Owner's Address
South Yarmouth MA
*A City/Town
Date of lnspection
2. lnspector:
Shane Syriala
State
1t26t2006
Date
Name of lnspec{or
PKM Contractors
Company Name
P.O. Box 775
Company Address
South Yarmouth 02641City/Town
508-385-5993
State Zip Code
Telephone Number
Certlfication Statement:
I certify that I have personally inspected the sewage disposal system at this address and that theinformation reported below is true, accurate and complete as oi the time of tne inspection. rne inspectionwas performed based on my training and experience in the proper function and maintenance of on sitesewage disposal systems. r am a DEp approved system inspector pursuant to section 1s.340 ofTitle 5 (310 CMR 15.000). The system:
E Passes n Conditionally Passes L l I-arls
E Needs Further Evaluation by the Local Approving Authority
ItsL'nspector's Signature Date
tl
The system inspector shall submit a copy.of this inspection report to the Approving Authority (Boardof Health or n-EP) within-30 days of completing this inspection. lf the system i" " ."rl"r"0 iyJtJ, o,has a design flow of 10,000 gpd or greater, the inspector and the system owner shall 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 authority.
.--.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 sewage Disposal system .
Page 1 of 16
trl
1. Property lnformation:
Owne/s Name
P.O. Box 276
02664
zhaaAe
lnc.
I rd
5$, Commonwealth of Massachuset6
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
291 South Shore Drive r'l$ia_m *{
Property Address
South Yarmouth 02664
Caty/Town State
1t26t2006Davenport Company
Owner's Name Date of lnspection
lnspection Summary: Check A,B,C,D ot E I always comptete all of Section D
A) System Passes:
[l I 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:
8) System Conditionally Passes:
! One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the n for the following statements. lf ,'not
determined," please explain.
E The septic tank is metal and over20 years old'orthe 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 will pass inspection if it is skucturally sound, not leaking and if a Certjficate
of Compliance indicating that the tank is less than 20 yea.s old is available.
ND Explain:
Title 5 Official lnspeclion Form: Subsurface Sewage Disposat System .
Page 2 ol 16
Blue water Title 5 lnspection.doc.doc . 1112004
Zip Code
A.'Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
291 South Shore Drive -System tr
Propefty Address
South Yamouth MA 02664City/Town State
1t26t2006
Zip Code
Davenport Com pany
Date of lnspeclion
B) System Conditionally passes (cont.):
E Observation of sewage backup or break out or high static water tevet in the distribution box dueto broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System willpass inspection if (with approval of Board of Heatth):
tr broken pipe(s) are replaced
tr obstruction is removed
tr distribution box is leveled or replaced
ND Explain:
! The system required pumping more than 4 times a year due to broken or obstructed pipe(s). Thesystem will pass inspection if (with approval of the Board of Health):
! broken pipe(s) are replaced
tr obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board o, Health:
n Conditions exist which require further evaluation by the Board of Health in order to determine ifthe system is failing to protect public health, safety or the envrronment.
1. system wirr pass unress Board of Health determines in accordance with 31o cMR15.303(1Xb) that the system is not functioning in a manner which will protect public health,safety and the environment:
n Cesspool or privy js within 50 feet of a surface water
f] cesspoor or privy is within 50 feet of a bordering vegetated wefland or a sart marsh
Title 5 Official lnspectjon Form: Subsurface Sewage Disposal System ,
Page 3 of 16
Blue water Title 5 lnspection doc.doc. 1112004
Ownels Name
A, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Gertification (cont.)
291 South Shore Drive- System .$r,
Property Address
South Yarmouth 02664
City/Town State
1126t2006
Zip Code
Davenport Com pany
Ownea's 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 Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
tr 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.
tr 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
" This 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 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.
Title 5 Official lnspection Form: Subsurface Sewage Disposal System .
Page 4 ot '16
Blue water Titie 5 lnspection.doc.doc . 11/2004
!
n The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
3. Other:
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
Property Address
South Yarmouth 02664
City/Town State
1t26t2006
ZipCode
Davenport Company
Owneis Name oate of lnspedion
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes,' or ,,No,, to each of the following for 4! inspections:
Yes No
E
ts
E
m
m
tr
N
E
tr
E
tr
Yes No
tr
n
n
D
!
n
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of etfluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above ouflet rnvert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6' below invert or available volume is less
than % day flow
Required pumping more than 4 times in the last year /VOIdue to clogged or
obstructed pipe(s). Number of times pumped: _.
Any portion ofthe 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.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
Any portjon of a cesspool or privy is less than 100 feet but greater than 50 feet
from a prjvate water supply well with no acceptable water quality analysis. ffhissystem passes if the well water analysis, performed at a OEp certifiedIaboratory, for coliform bacteria and volatile organic compoundsindicates that the well is free from pollution from that faciiity and thepreserce of ammonia nitrogen and nitrate nitrogen is equal to or lessthan 5 ppm, provided that no other failure criteria are triggered. A copy ofthe analysis must be attached to this form.]
The system fails, I have determined that one or more of the above failurecriteria exist as described in 310 CMR 1S.303, therefore the system fails. Thesystem owner should contact the Board of Health to determin; what wi benecessary to correct the failure.
n E
Blue water Title 5 lnspection.doc.doc . 1112004 Title 5 Ofticial lnspection Folm: Subsurface Sewage Disposat System .
Page 5 of 16
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 #i
02664
City/Town State
1t26t2006
Zip Code
Davenport Company
Owne/s Name Date of lnspection
E) Large systems: To be considered a large system the system must serve a facility with adesign flow of 10,000 gpd to 15,000 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
tr tr the system is within 4OO feet of a surface drinking water supply
tr n the system is within 2OO feet of a tributary to a surface drinking water suppty
the system is located in a nitrogen sensitive area (lnterim Wellhead protection
Area - IWPA) or a mapped Zone ll of a public water supply well
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 operalor of any largesystem considered a significant threat under Section E or failed under Section D siralt upgrade ihesystem in accordance with 310 cMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Blue water litle 5 lnspection.doc.doc . 11/2004
Property Address
South Yarmouth MA
Title 5 Official lnspection Form: Subsurface Sewage DisposalSystem,
Page 6 ol 16
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
291 South Shore Drive System +!t
Property Address
South Yarmouth lilA 02664
City/Town
Davenport Compan
Zip Code
Date of lnspection
check if the following have been done. You must indicate "yes" or "no" as to each of the following
State
1t26t2006
YES
E
tr
tr
tr
m
E
ts
E
E
Pumping information was provided by the owner, occupant, or Board of Health
Were any ofthe system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recenfly or as part of
this inspection?
Were as built plans of the system obtained and examined? (lf they were not
available 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 ofthe tank
inspected for the condition of the baffles or tees, material of construction,dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner (and occupants if difterent from owner) provided withinformation on the proper maintenance of subsurface sewage disposal systems?
The size and location ofthe Soil Absorption System (SAS) on the site has
been determined based on:
Exjsting 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 issue
approxjmation of distance is unacceptabte) [310 CMR 15.302(3Xb)]
E
tr
m
E
Blue water Title 5 lnspection.doc.doc . I 1/2004 Title 5 Offlcial lnspection Form: Subsurface Sewage Disposal System .
Page 7 ol 16
Owner's Name
NO
tr
B
E
E
n
tr
n
n
tr
tr
A, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
291 South Shore Drive System #E
Property Address
South Yarmouth MA 02664
City/Town State
1t26t2006
Zip Code
Davenport Company
Owner's Name
Residential Flow Conditions:
Number of bedrooms (design):
Date of lnspection
Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpdx#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?
Water meter readings, if available (last 2 years usage (gpd)):
EYes!
EyesE
EYesE
!yesE
No
No
No
No
Sump pump?
Last date of occupancy:
Commercial/lndustrial Flow 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 S system?
Water meter readings, if avatlable:
Last date of occupancy/use
Other (describe):
Date
Title 5 Officjal lnspeclion Form: Subsurface Sewage Disposal System .
Page 8 of 16
fl Yes n lto
Date
mar ra i- -Lr-ln
Gallons per day
t.-I Utur4
! ves Q tto
! ves Q tio
@ves!ruo
ar, - -l3,o,clo<,-oLl- \15,caa
(11") i ') -ct4
Blue water Title 5 lnspection.doc.doc . 11/2004
C. System lnformation
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 lr 6
Property Address
South Yarmouth MA 02664
City/Town State
1t26t2006
Zip Code
Davenport Company
Owner's Name Date of lnspection
General lnformation
Pumping Records:
Source of information
Was system pumped as part of the inspection?
lf yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
113t03 12t14/2005 maintenance, Yarm. BOH
E Yes X tto
gallons
E
tr
tr
tr
n
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/Alternatlve 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 (jf known) and source of information
t.t 'l q
Were sewage odors detected when arriving at the site?I ves fi lto
Title 5 Official lnspection Form: Subsurface Sewage Disposal System .
Page 9 of 16
Blue water Title 5 lnspection doc.doc . 11l20C4
A. Commonwealth of Massachusetts
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
291 South Shore Drive System .4-5
Property Address
South Yarmouth 02664
City/Town
Davenport Company
State
1t2612006
Zip Code
Owne/s Name Date of lnspection
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
E[ cast iron f] 40 PVC E other (explain)
Distance from private water supply well or suction line:
feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.)
Septic Tank (locate on site plan)
Depth below grade:
Material of construction:
fl concrete E metal
feet
! fiberglass ! polyethylene n other (exptain)
(r
lf tank is metal, list age years
ls age confirmed by a Certiflcate of Compliance? (attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to boftom of ouflet tee or baffle
How were dimensions determined?
I2h;0 g.,lto1\
4t\
o
i.3 r'
IDi4:rrJl$1__-[zPL
Title 5 fficial lnspection Form: Subsurface Sewage Disposal System .
Page 10 of 16
Blue water Title 5 lnspection doc.doc . 11/2004
Title 5 Official lnspection Form
n Yes E tto
5$, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
291 South Shore Drive System+-d
Property Address
South Yarmouth MA 02664
City/Town
Davenport Company
State
1t2612006
Zip Code
Date of lnspeclion
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid Ievels as related to outlet invert, evidence of leakage, etc.):
feet
! fiberglass ! polyethylene E other (exptain)
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 site plan)
Depth below grade:
Material of construction:
E concrete ! metal ! fiberglass ! polyethylene tl other (exptain)
Title 5 Official lnspection Form: Subsurface Sewage Disposal System .
Page 11 of 16
Blue water Title 5 lnspection.doc.doc . 1 1/2004
C. System lnformation (cont.)
Owne/s Name
Grease Trap (locate on site plan):
Depth below grade:
Material of constructlon:
E concrete ! metal
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
C. System lnformation icont.)
291 South Shore Drive System ;f,-(
Property Address
South Yarmouth 02464
City/Town
DAven Com an
Ownels Name
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
Design Flow:
State
1t2612006
Zip Code
Date of lnspection
Alarm present:
Alarm Ievel:
Date of last pumping
Comments (condition of alarm and float switches, etc.)
gallons per day
E Yes E tlo
Alarm in working order:! ves! tto
Date
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, etc.):
\ac.k i"cvol no c".rrr\ \\r)
Pump Chamber (locate on site plan)
Pumps in working order:
AIarms in working order:
Yes nruo
nruoTYes
Blue water Title 5 lnspection.doc.doc . 1 1/2004 Title 5 Official lnspeclion Formi Subsurface Sewage Disposal System '
Page 12 of 16
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
gallons
Distribution Box (if present must be opened) (locate on site plan):
5\ Commonweatth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
291 South Shore Drive System .tr<
Property Address
South Yarmouth t\4A 02664
City/Town State
1t26t2006
Zip Code
Davenport Com pany
Owne/s Name Date of lnspection
comments (note condition of pump chamber, condition of pumps and appurtenances, etc.)
Type:
tr
tr
n
tr
tr
tr
n
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' lqr -Illlgdll!
number:
comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soit, condition ofvegetation, etc.):
Title 5 Official lnspeclion Form: Subsurface Sewage Disposalsystem .
Page 13 of 15
Blue water Title 5 lnspection.doc.doc . 1.1/2004
Soil Absorption System (SAS) (locate on site plan, excavation not required):
lf SAS not located, explain why:
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System lnformation (cont.)
291 South Shore Drive System +i'-{
Property Address
South Yarmouth MA 02664
City/Town
Davenport Company
State
1t26t2006
Zip Code
Owne/s Name Oate of lnspedion
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration
Depth - top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of conskuction
lndication of groundwater inflow E Yes ENo
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Title 5 Official lnspeclion Form: Subsurface Sewage Disposal System ,
Page 14 of 16
Blue water Title 5 lnspecition.doc.doc ' 1112004
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
5$, Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information 1cont.;
291 South Shore Drive System *5
Property Address
South Yarmouth 02664
City/Town State
1t26t2006
Zip Code
Davenport Com pany
Owner's Name Date of lnspeclion
Title 5 Official lnspeclion Form: Subsurface Sewage Disposal System .
Page 15 of 16
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 w€ter supply enters the building.ssc fncL!-\ ec
Blue water Title 5 lnspection.doc.doc . 11/2004