HomeMy WebLinkAbout291 S Shore Dr System 4 - Title 5 Report 2006A Commonweatth of Massachusetts
Subsurface Sewage Disposal System Form
lnspection results must be submitted
Title 5 Officiat lnspection FormNot for Voluntary Assessments
ilt€(Gtr0ven
rat J 1 2006
HEALTH DEPT.
on this form or on ffre I Title 5 lnspection Form datedofficia5/15/2000. lnspection forms ma not be altered in an way.A. Certification
1. Property lnformation
lmportant:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
291 South Shore Drive J stem
Property Address
Daven ort Com
Owner's Name
P.O. Box 276
n
Owner's Address
South Yarmouth 02664City/Town
Date of lnspection
2. lnspector:
Shane Syriala
State
1126t2006
Zip Code
Date
Name of lnspeclor
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:
l-.,:1.ry_l!rt I have personally inspected the sewage disposal system at this address and that thelnrormalron reponed below is true, accurate and complete as of the time of the inspection. rtre inspectionwas perfo-rmed based on my training and experience in the proper function and m;ini;;;n;. oion .,t.sewage disposal systems. I am a DEP approved system inspector pursuant to Section is.sao otTitle 5 (310 CMR 15.000). The system:
E] Passes E Conditionally passes ! Fails
E Needs Further Evaluation by the Local Approving Authority
lnspector's Signature ate
The system inspector shall submit a copy.of this.inspection report to the Approving Authority (Board
:lI:1,1^:j_D,E_:) yilll3j arv: of comptetins this inspection. tf the system i. " .i"r"o ,y.'t*J, o,nas a. oesrgn flow of 10,000 gpd or greater, the inspector and the system owner shafl subririt thereport to the appropriate regional office of the DEp. The original shturd be sent to tnuifiemo*nerand copies sent to the buyer, if applicable, and the approvirig authorlty.
'-'.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.
Title 5 Official lnspection Form; Subsurface Sewage Disposal System .
Page 1 of 16
Blue water Title 5 lnspection.doc.doc , i 1/2004
I
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 5 t'; r,,-cF, *rlProperty Address
South Yarmouth 02664City/Town State
1126t2006
Zip CodeDavenport Com pany
Owne/s Name Date of lnspeclion
Title 5 Official lnspection Form: Subsurface Sewage Disposal System .
Page 2 ot 16
Blue water Title 5 lnspection.doc doc . 1 1/2004
lnspection Summary: Check A,B,C,D or E I always complete alt of Section D
A) System Passes:
B I hly:191-1ou!d any information which indicates that any of the fairure criteria describedin 310 cMR r 5.303 or in 310 cMR 1s.304 exist. Any faiiure criteria not evaruated ireindicated below.
Comments:
B) System Conditionally passes:
! one or more system components as described in the "conditional pass,, section need to bereplaced or repaired. The system, upon compretion of the repracement or repaii, ,iippi"*a uvthe Board of Health, will pass.
Answer yes, no or not determined (y, N, ND) in the ! for the folowing statements. rf ,,not
determined," please explain.
E The septic tank is metal and over 20 years 9fd* 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 tant< as
'.
approved 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 yeais old is available.
ND Explain:
(6.Commonwealth of MassachusetG
Title 5 Official lnspection Form
Not for Voluntary AssessmenE
Subsurface Sewage Disposal System Form
A. Certification (cont.)
291 South Shore Drive -System .rf 4Property Address
South Yamouth
City/Town 02664
Davenport Com pany
State
1t26t2006
Zip Code
Owner's Name Date of lnspeclion
B) System Conditionaly passes (cont.):
fl observation of sewage backup or break out or high static water level in the distribution box dueto broken or obstucted pipe(s) or due to a broken', seftled or uneven distribution ooi. sy"1"- rirrpass inspection if (with approval of Board of Health):
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 tioard of Heatth):
! broken pipe(s) are replaced
tr obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of 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 envjronment.
1. 9ystem will pass unress Board of Hearth determines in accordance with 310 cMR15'303(1Xb) that the system is not functioning in a manner which will protect pubtic heatttr,safety and the environment:
Title 5 Official lnspection Form: Subsurface Sewage Disposal System ,
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Blue water Title 5 lnspection.doc_doc . .11/2004
n Cesspool or privy is within 50 feet of a surface water
tr cesspoor or prrvy is within so feet of a bordering vegetated wefland or a sart marsh
6.Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Gertification (cont.)
29'1 South Shore Drive- S tem
P.operty Address
South Yarmouth NIA 02664City/Town State
1t26t2006
Zip CodeDavenport Compan vOwne/s Name Date of Inspection
C) Further Evatuation is Required by the Board of Heatth (cont.):
3. Other
tr
2. System will fail untess the Board of Heatth (and public Water Supplier, if any)determines that the system is functioning in a manner that protects ihe public'hearth,safety and environment:
tr ]lg:v"t"!, has a septic tank and soir absorption system (sAS) and the sAS is within100 feet of a surface water supply or tributary to a iurfacewater supply.
The system has a septic tank and sAS and the sAS is within a Zone I or a pubric watersupply.
The system has a septic tank and sAS and the sAs is within 50 feet of a private watersupply well.
The system has a septic tank and sAS and the sAs is less than .100 feet but so feet ormore from a private water supply well,*.
'* This system passes if the well water analysis, performed at a DEp certified laboratory, forcoliform.bacteria and volatile organic compounds indicates that the well is free from poliution fromthat facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or'less than 5ppm, provlded that no other failure criteria are triggered. A copy ofihe analysis must be attachedto this form.
Blue water Title 5 lnspection.doc doc . 1 'l12004 Title 5 Official lnspection Form: Subsurface Sewage Disposal System ,
Page 4 of 16
Method used to determine distance:
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 #t)Property Address
South Yarmouth MA 02664City/Town State
1t26t2006
ZjpCodeDavenport Compan
Ownels Name Date of lnspection
D) System Faiture Criteria Applicable to All Systems:
You must indicate,,yes,, or.,No,, to each of the following for all inspections:
Yes
tr
n
tr
!
n
n
!
tr
tr
n
No
tr
tr
E
tr
E
E
tr
E
tr
E
Backup of sewage into facility or system component due to overloaded orclogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface watersdue to an overloaded or clogged SAS or cesspool
static liquid level in the diskibution 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 lesslhan lz day flow
Required pumping more than 4 times in the last year /VOf due to clogged 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 or privy is within aZone 1of a public well.
Any portion of a cesspool or privy is within SO feet of a prjvate water supply
well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feettrom a private water supply well with no acceptable water quality analysis. fihissystem passes if the well water analysis, performed at a DEp ceriifiedlaboratory, for coliform bacteria and volatile organic compoundsindicates that the well is free from pollution from that faciiity and thepresence o, ammonia nitrogen and nitrate nitrogen is equaito or lessthan 5 ppm, provided that no other failure criteria are triggered. A copy ofthe analysis must be attached to this form.l
The system fails. I have determined that one or more of the above failurecriteria exist as described in 310 CMR 15.303, therefore the system fails. Thesystem owner should contact the Board of Health to determin; what wlll benecessary to correct the failure.
Yes No
B
Title 5 Official Inspection Formi Subsurface Sewage Disposat System .
Page 5 of 't6
Blue water Title 5 lnspection.doc.doc . 11i2004
tr
.4, 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 4
Propedy Address
South Yarmouth 02664
City/Town
Davenport Company
State
1t26t2006
Zip Code
Owner's Name Date of lnspection
E) Lalge Systems: To be considered a large system the system must serve a facility with a
design 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 the
questions in Section D.
YES NO
tr tl the system is within 4OO feet of a surface drinking water suppty
tr tr the system is within 200 feet of a tributary to a surface drinking water supply
T-.1 Tt 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 operator of any large
system considered a signiflcant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Blue water Title 5 lnspection.doc.doc . 1 1/2004 Title 5 Offlcial Inspection Form: Subsurface Sewage Disposal System '
Page 6 of 16
.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 *4Property Address
South Yarmouth MA
City/Town 02664
Davenport Company
State
1t2612006
Zip Code
Ownea's Name Date of lnspection
check if the following have been done. you must indicate.,yes,, or,,no" as to each of the following
YES
EI
tr
tr
tr
tr
tr
tr
m
E
NO
n
N
tr
E
tr
u
tr
n
n
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 conditton 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 djfFerent from owner) provided withinformation on the proper maintenance of subsurface sewage disposal systems?
The size and location ofthe Soit Absorption System (SAS) on the site hasbeen determined based on:
Existing information. For example, a plan at the Board of Health.
Determined in the fierd (if any of the fairure criteria rerated to part c is at issueapproximation of distance is unacceptabte) [310 CMR i5.302(3)(b)]
tr
E
tr
Blue water Title 5 lnspection.doc.doc , 11/2004 Title 5 Offlcial lnspection Form: Subsurface Sewage Disposal System .
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tr
tr
m
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System !nformation
291 South Shore Drive System vl
Property Address
South Yarmouth 02664
City/Town State
1t26t2006
Zip Code
Davenport Com pany
Owne/s Name
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? [if yes separate inspection required]
Laundry system inspected?
Seasonal use?
E ves E tto
nvesE No
fl ves E tto
EvesE No
E Yes E tto
Water meter readings, if available (last 2 years usage (gpd))
Sump pump?
Last date of occupancy:
Commercial/lndustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 1 5.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
lndustrial waste holding tank present?
Non-sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use
Other (describe):
Gallons per day (spd)
t(; U Irr t4
n Yes E tto
E Yes El ruo
@ ves E tlo
3 (j xjj
Date
Title 5 Official Inspeclion Fo.m: Subsurface Sewage Disposal System '
Page I of 16
Date
rna:ro",- tno
i 1t.tt qpo
04" \15
Blue water Title 5 lnspection.doc.doc ' 1 1/20M
Date of lnspection
A, Commonwealth 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 t[UProperty Address
South Yarmouth 02664City/Town State
1126t2006
Zip Code
Davenport Compan vOwne/s Name Date of Inspeclion
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:
General lnformation
113t03 1?114t20 05 maintenance, Yarm. BOH
tr Yes No
gallons
tr
!
tr
!
tr
!
n
n
Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspeclion records, if any)
lnnovative/Alternative technology. Attach a copy of the current operation andmaintenance 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 (lf known) and source of information
\. r,
Were sewage odors detected when arriving at the sjte?
BJue water Title 5 lnspection.doc doc . '1112004 Title 5 Official Inspection Form: Subsurface Sewage Djsposal System .
Page I of 16
MA
n yes El No
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System lnformation (cont.)
29'1 South Shore Drive System lf 4
Property Address
South Yarmouth 02664City/Town State
1t26t2006
Zip Code
Davenport Company
O,,vne/s Name Date of lnspeclion
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
B cast iron ! 40 pVC E other (exptain)
Distance from private water supply well or suction line:feet
Comments (on condition of joints, venting, evidence of leakage, etc.)
lt-
feet
Septic Tank (locate on site plan)
Depth below grade:
Material of conskuction:
El concrete ! metal
i F.v
feel
! fiberglass E polyethylene E other (explain)
lf tank is metal, list age years
ls age confirmed by a Certificate of Compliance? (attach a copy of
certificate)
Dimensions:'1 1.{. qirlt(1irj-
n ves E t'to
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 bottom of outlet tee or baffle
How were dimensions determined?
3'\
L4q'\
(>
L.\
m ersL;f i\9 iqPc._
Title 5 Ofiicial lnspection Form: Subsurface Sewage DisposatSystem .
Page 10 ol 16
Blue water Title 5 lnspection.doc.doc . 1 1/2004
g$, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System lnformation (cont.)
291 South Shore Drive System #
Property Address
South Yarmouth MA 02664
City/Town State
1t26t2006
Zip Code
Davenport Company
Owne/s Name Date of lnspeclion
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural tntegrity,liquid levels as related to outlet invert, evidence of leakage, etc.):
! fiberglass E polyethytene n other (exptain)
feet
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integnty,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Depth below grade:
Material of construction:
fl concrete ! metal ! fiberglass ! polyethylene n other (exptain)
Iitle 5 Official lnspeclion Form: Subsurface Sewage Disposal System .
Page 11 of 16
Blue water Title 5 lnspection.doc.doc . 'l 1/2004
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
n concrete E metal
Dimensions:
Scum thickness
Distance from top of scum to top of ouflet tee or baffle
Distance from bottom of scum to bottom of ouflet tee or baffle
Date of last pumping:
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site ptan):
5$, Commonwealth 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 ff4
Property Address
South Yarmouth MA 02664
City/Town State
1t26t2006
Zip Code
DAvenport Company
Owneis Name
Tight or Holding Tank (cont.)
Dimensions:
Date of lnspeciion
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping
gallons
gallons per day
nYes ENo
Alarm in working order:n vesE r.lo
Date
Comments (condition of alarm and float switches, etc.):
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.):
Pump Chamber (locate on site plan)
Pumps in working order:
Alarms in working order:
I yes
fl Yes
! tto
Eruo
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Page 12 ol 16
Distribution Box (if present must be opened) (locate on site plan):
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 *4
Propedy Address
South Yarmouth IVIA 02664
City/Town State
1t26t2006
Zip Code
Davenport Com pany
Owner's 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:
Type
tr
tr
tr
!
E
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: , a
number:
o
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
{,el) LLtarq'f Ory r:r.r itff\r r.i'Lrr.rP<<.rron
Blue water Title 5 lnspection.doc.doc . 11/2004 Title 5 Official lnspection Form: Subsurface Sewage Disposal System .
Page 13 of 16
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 ll4
Property Address
South Yarmouth MA 02664
City/Town
Davenport Company
State
1t26t2006
Zip Code
Ownefs Name Date of lnspection
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 E Yes E f.to
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.):
Title 5 Official lnspection Form: Subsurface Sewage Disposal System .
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Blue water Title 5 lnspection.doc.doc . 11/2004
.4. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System tnformation (cont.)
291 South Shore Drive
Property Address
South Yarmouth MA 02664
Cityfiown
Davenport Company
Zip Code
Owne,'s Name Date of lnspec{ion
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 water supply enters the building.
-qze l\crgr ea
State
1t26t2006
Title 5 Official lnspection Form: Subsurface Sewage DisposalSystem .
Page 15 of l6Blue water Title 5 lnspection.doc.doc . 1 1/2004
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 ?+4
Property Address
South Yarmouth IVIA 02664
City/Town Stete
1t26t2006
Zip Code
Davenport Com pany
Owneis Name
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water. Af r
Date of lnspection
Please indicate all methods used to determine the high ground water elevation
tr Obtained from system design plans on record
lf checked, date of design plan reviewed:Date
n Observed site (abutting property/observation hole within 1S0 feet of SAS)
tr Checked with local Board of Heatth - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
tr
You must describe how you established the high ground water elevation
Title 5 Official lnspection Form: Subsurface Sewage Disposal System ,
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Blue water Title 5 lnspection.doc.doc . 11/2004