HomeMy WebLinkAbout291 S Shore Dr System 3 - Title 5 Report 2006A, Commonwealth of Massachusetts
Title 5 Official lnspection For
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
IAN 3 I 2006
HEALTH DEPT
lnspection results must be submitted on this form or on the official Title 5 lnspection Form dated6/15/2000. lnspection forms may not be altered in any way
A. Certification
'1. Property lnformation
291 South Shore Drive System 'fr1
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 Com pany
Owne/s Name
P.O. Box 276
Owner's Address
South Yarmouth MA 02664
*,4 State
1126t2006
Zip Code
Date
Shane S
Name of lnspeclor
PKM Contractors, lnc.
Company Name
P.O. Box 775
Company Address
South Yarmouth 02641
City/Town
508-385-5993
State
Telephone Number
Certification 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 oithe time of the inspection. The inspectionwas performed based on my training and experience in the proper function and malntenance of on sitesewage disposal systems. lam a DEp approved system inspector pursuant to section ,ts.34o ofTitle 5 (310 CMR 15.000). The system:
I Passes E Conditiona y passes f] Faits
E Needs Further Evatuation by the Local Approving Authority
lnspector's Signa TC Da
The system inspector shafl submit a copy.of this.inspection report to the Approving Authority (Board
:ll:1tl^gj-Df-ll 1it]ln^3^o^ d"v: of completrns rhis inspection. tf rhe system t. " .irr"o ivr't,1, _nas a .esrgn flow of 10,000 gpd or greater, the inspector and the system owner shafl submit thereport to the appropriate regional office of the DEp. The original should oe sent to tne "[tum o-wnerand 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 trow ttre'system will perform in the future underthe same or different conditions of use.
Title 5 Official lnspection Form: Subsurface Sewage Disposal System .Blue water Title 5 lnspection.doc.doc . 11/2004
Page 1 of 16
City/Town
Date of lnspection:
2. lnspector:
Zip Code
'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 J i5 re$3
Property Address
South Yarmouth
City/Town State
1t26t2006
Zip Code
Davenport Com panv
Owner's Name Date of lnspeciion
lnspection Summary: Check A,B,C,D ot E I atways complete all of Section D
A) System Passes:
6l I have 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 areindicated 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. lf ,,not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) isskucturally 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 structurally sound, not leakjng and if a Certiflcateof Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
Blue water Title 5 Inspection.doc.doc , 11/2004 Title 5 Official lnspection Form: Subsurrace Sewage Disposat System ,
Page 2 of 15
02664
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 i1:1
Property Address
South Yamouth MA 02664
Clty/Town State
1126t2006
Zip Code
Davenport Com pany
Owner's Name
B) System Conditionally Passes (cont.):
Observation of sewage backup or break out or high static water level 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 Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND Explain:
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):
n broken pipe(s) are reptaced
obstruction as removed
ND Explain
C) Further Evaluation is Required by the Board of Heatth:
fl 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. system will pass unress Board of Health determines in accordance with 310 cMR15.303(1)(b) that the system is not functioning in a manner which witl protect pubtic health,safety and the environment:
n Cesspool or privy is within O0 feet of a surface water
cesspool or privy is within 50 feet of a bordering vegetated wefland or a sart marsh
Title 5 Official lnspeclion Form: Subsurface Sewage Disposal System .
Page 3 of 16
Blue water Title 5 lnspection.doc.doc . 1'l12004
Oate of lnspection
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 *
Properly Address
South Yarmoulh 02664City/Town State
1t26t2006
Zip Code
Davenport Com pany
Owner's Name Date of lnspection
C) Further Evaluation is Required by the Board of Health (cont.):
more from a private water supply well,'
Method used to determine distance:
3. Other
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 ihe public iiealth,safety and environment:
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
" This system passes rf the well water analysas, performed at a DEp certified raboratory, forcoliform.bacteria and volatile organic compounds indicates that the well is free from poiiution fromthat facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered, A copy ofihe analysis must be attachedto this form
Title 5 Officjal lnspeclion Form: Subsurface Sewage Disposat System .
Page 4 of 16
Blue water Title 5 lnspection doc.doc. 11/2004
tr The system has a septic tank and sAS and the sAS is within s0 feet of a private watersupply well.
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 *_j
Property Address
South Yarmouth
City/Town
Davenport Company
State
1t26t2006
ZipCode
Owne/s Name
D) System Failure Criteria Applicable to All Systems:
You must indica or "No" to each of the following for all inspections:
Yes No
T-t F7l Backup of sewage into facility or system component due to overloaded ort'J t-4' clogged SAS or cesspool
fl ffl Discharge or ponding of etfluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
T-t rfl Static liquid level in the distribution box above outlet invert due to an overloadedL.ar or clogged SAS or cesspool
T"l l-.;.t Liquid depth in cesspool is less than 6" below invert or available volume is lessr-r Lir than % day flow
T.t m Required pumping more than 4 times in the tast year irof due to clogged or
obstructed pipe(s). Number of times pumped: _.
tr tr Any portion of the SAS, cesspool or privy is below high ground water elevation.
f{ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
tr E Any portion of a cesspool or privy is within aZone 1of a public well
E i:l.Oon,o"
of a cesspool or privy is within 50 feet of a private water suppty
trE
Yes No
trtr
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 analysas. [Thissystem 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 thepresenee of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm, provided that no other failure crateria are triggered. A copy of
the analysis must be attached to this form.l
Date of lnspection
Title 5 Official lnspection Form: Subsurfac€ Sewage Disposal System .
Page 5 of 16
Elue water Title 5 lnspection.doc.doc . 1112004
02664
The system fails. 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 determjne what will be
necessary to correct the failure.
A, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
291 South Shore Drive- System ir j
Property Address
South Yarmouth MA 02664
City/Town State
1t26t2006
Zip Code
Davenport Com pany
Owner's Name Date of lnspeclion
Title 5 Official lnspection Form: Subsurface Sewage Disposal System .
Page 6 of 16
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 n 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 supply
- l-'l 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 o above the large system has failed. The owner or operalor of any large
system considered a significant threat under Section E or failed under Section D sirall upgradeihesystem in accordance wlth 310 cMR 15.304. The system owner should contact the appio=priate
regional office of the Department.
Blue water lit,e 5 Inspection.doc.doc . 11/2004
5}, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
29'l South Shore Drive System tl 5
Property Address
South Yarmouth 02664City/Town State
1t26t2006
Zip Code
Davenport Com pany
Ownels Name Date of lnspection
check if the following have been done. you must indicate ,,yes,, or ,,no, as to each of the following
YES
E
tr
tr
tr
E
m
E
m
E
NO
tr
a
E
4
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 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 baffles or tees, material of construction.dimensions, depth of liquid, depth of sludge and depth of scum?
W€s the.facility owner (and occupants if ditferent from owner) provtded withinformation on the proper maintenance of subsurface sewage disposal systems?
The size and location ofthe 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 drstance is unacceptabte) [310 CMR 15.302(3Xb)]
Title 5 Oftlciat lnspectjon Form: Subsudace Sewage Disposal System .
tr
D
m
N
Blue water Title 5 tnspection.doc.doc , 1112004
tr
Page 7 ol 16
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System lnformation
291 South Shore Drive System .fr3
Property Address
South Yarmouth MA 02664
City/Town State
1t26t2006
Zip Code
Davenport Com pany
Owner's Name
Residential Flow Conditions:
Number of bedrooms (design):
Date of lnspection
Number of bedrooms (actual)
DESIGN flow based on 3'10 CMR I 5.203 (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 requiredl
Laundry system inspected?
Seasonal use?
fl Yes n uo
n Yes I tto
E Yes E tto
nYesE No
I ves I tto
Date
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 Tifle 5 system?
Water meter readings, if available:
Last date of occupancy/use:
Other (describe):
1l (',
Date
Tille 5 Official lnspection Form; Subsurface Sewage Oisposal System .
Page 8 of 16
ffio ir',a iA
.1?{O crr)i')
Gattons per oay'1!pdj
'15 3
! ves @ tto
E ves Q tto
Qves! uo
a6- 3 .\ae4'
^15
.o<)()
J -a;
Blue water Title 5 lnspection.doc_doc . 11/2004
ara',
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 Orive System Ft.{
Prope.ty Address
South Yarmouth 02664City/Town Slate
1126t2006
Zip Code
Oavenport Com pany
Owner's Name Date of lnspeclion
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:
1 13103, 121 1 412005 maintenance, Yarm. BOH
gallons
E
tr
!
tr
tr
tr
tr
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 andmaintenance contract (to be obtained from system owner)
Tight tank. Attach a copy of the DEp approvat.
Other (describe):
!Yes@ No
Title 5 Official lnspection Formj SubsurFace Sewage Disposal System .
Approximate age of arr components, date instafled (if known) and source of rnformation
Were sewage odors detected when arriving at the site?
Blue water Title 5 lnspection.doc.doc . 1.1/2004
Page I of 16
E Yes X tto
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 * -l
Property Add.ess
South Yarmouth MA 02664City/Town State
1t26t2006
Zip Code
Davenport Com pany
Owne,'s Name Date of lnspeclion
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
Bcast iron E 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.):
l(\\
feet
Septic Tank (locate on site plan)
Depth below grade:
Material of construction:
ficoncrete ! metal ! fiberglass ! polyethylene ! other (explain)
i(+
feel
lf tank is metal, list age
Dimensions:
Sludge depth:
Distance from top of sludge to boflom of ouflet tee or baffle
Scum thickness
Distance from top of scum to top of ou et tee or baffle
Distance from bottom of scum to bottom of ouflet tee or baffle
How were dimensions determined?
o
r. ')
xg"
rncrd:rDcrlg fupe.
years
ls ag-e confirmed by a Certificate of Compliance? (attach a copy of
certificate)nYes! P6
l-1ac;Q gqllr\ _
? 1l
\\
Blue water Title 5 lnspection doc doc , I 1/2004 Title 5 Official Inspectjon Form: Subsurface Sewage Disposal System .
Page 10 of 16
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
C. System lnformation 1cont.1
291 South Shore Drive S stem
Property Address
South Yarmouth MA 02664
City/Town State
1t2612006
Zip Code
Davenport Com pany
Ownels Name Date of lnspec{ion
Comments (on pumping recommendalions, inlet and outlet tee or baffle condition, structural integrity,liquid Ievels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan)
Depth below grade:
Material of construction:
I concrete f] metal
feet
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or batfle
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 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:
I concrete E metal ! fiberglass ! polyethytene E other (exptain)
Title 5 Official tnspectjon Form: Subsurface Sewage Disposal System ,BJue water Title 5 lnspection.doc.doc , 1112004
Page 11 of 16
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
! fiberglass ! potyethytene ! other (exptain):
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 lfa
Prope.ty Address
South Yarmouth l\,4A 02664
City/Town
DAvenport Company
State
1126t2006
Zip Code
Owne/s Name
Tight or Holding Tank (cont.)
Dimensions:
Date of lnspeclion
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping
gallons
gallons per day
n Yes E r,lo
Alarm in working order:! ves! ruo
Date
Comments (condition of alarm and float switches, etc.)
Distribution Box (if present must be opened) (locate on site plan)
l - Rn:'t'<Depth of liquid level above outlet invert
ents (note if
ce of leaka
Comm
eviden
box is level and distribution to outlets equal, any evidence of solids carryover, any
e into or out of box, etc.):
1 oOP C
Pump Chamber (locate on site plan)
Pumps in working order:
Alarms in working order:
I ves
fi yes
nruo
nruo
Title 5 Officiallnspection Form: Subsurface Sewage Disposalsystem ,
Page 12 ot 16
Blue water Title 5 lnspection.doc.doc . 1'l12004
a
A, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
G. System !nformation (cont.)
291 South Shore Drive System *3
Property Address
South Yarmouth MA 02664
City/Town State
1t26t2006
Zip Code
Davenport Com pany
Owne/s Name Date of lnspeclion
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:
n
tr
u
tr
E
!
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
number:
X-il-&ili)rt\
comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition ofvegetation, etc.):
Tjtle 5 Official lnspection Form: Subsurface Sewage Disposal System ,Blue water Title 5 lnspection.doc.doc . j 1/2004
Page 13 of 16
fizrrl 0r.z,.n rt0cJ at firne r-.Q r-n_<,pectro\ _,
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 ++ ",Property Address
South Yarmouth 026A4
City/Town
Davenport Company
State
1t26t2006
Zip Code
Owner's Name Date of lnspeclion
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan)
Number and confi guration
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 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 lnspeclion Form: Subsurface Sewage Disposal System .
Page 14 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 ]* ",Property Address
South Yarmouth 02664
City/Town State
1t26t2006
Zip Code
Davenport Company
Owner's Name Date of lnspection
sketch of sewage Disposal system: Provide a sketch of the sewage disposal system including tiesto at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feetl
Locate where-public water supply enters the building.Sea t1\a,g\e_C
Title 5 Ofllcial lnspection Form: Subsurface Sewage Disposat System .
Page 15 of 16
Blue water Tille 5 lnspection.doc.doc ' 1112004
A, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System lnformation 1cont.1
291 South Shore Drive
Property Address
South Yarmouth IVIA 02664
City/Town State
1t26t2006
Zip Code
Davenport Com pa ny
Owne/s Name
Site Eram:
Slope
Surface water
Check cellar
Shallow wells
Date of lnspection
Estimated depth to ground water:6 ((
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:Oate
n Observed site (abutting property/observation hole within 150 feet of SAS)
n Checked with locat Board of Heatth - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:!
You must describe how you established the high ground water elevatjon
Title 5 Offlcial Inspection Form: Subsurface Sewage Disposatsystem ,
Page 16 of 16
Blue water Title 5 lnspection.doc.doc ' 11/2004
tr