HomeMy WebLinkAboutSubsurface Sewage Disposal System Part A Certification COMMONWEALTH OF MASSACHUSET`I'S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
'.• DEPARTMENT OF ENVIRONMENTAL PROTECTION
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VZ;t�S ONE WINTER STREET, BOSTON MA 0210 - n i..
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rev '��% �_:,
FFR 7 Z'(`1 TRUDY COXF
SYSTEM #1 I Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Comnusaioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 291 South Shore Drive S . Nar;eo8vir;e: Rlne Water Limited Partnership
Address of Owner:
Date of Inspection: 2/8/0 0
Name of Inspector:(Please Print) Dona 1 rl K l i mm
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)
Company Name: Robert E, Our Co. , Inc .
Maiing Address: p 0 Bair 1519 Harwich , MA 02645
Telephone Number: 508 432 0530
CERT1RCATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
I -e.'- Further E .luation the Local Approving Authority
Fail•
A. - OO
InspecLoi s Siyr►atu eI�iir7 Date: +c
The System Inspector shall submit a c.py of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
ti
revised 9/2/98 Page 1ofll
A
is Pnnled on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 291 South Shore Drive South Yarmouth
Owne<: Blue Water Limited Partnership
Date of Inspection: 2/8/0 0
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. 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.
Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
- The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipets) are replaced
obstruction is removed
revised 9/2/98 Page 2ofit
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either"Yes'or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facllityeor system component duel('an overloaded orclogged SAS or-cesspool. • • . •
Discharge or ponding of effluent 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 outlet Invert due to en overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipelsl.
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary toe surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
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. If the well has been analyzed to be acceptable,attach copy of well water analysis for `*"-
-coliform bacteria,volatile organic-compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Lerge,Systeml and the system is a significant threat to public
health end safety and the environment because one or more of the following conditions exist:
Yes No
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(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional
office of the Department for further information.
`,
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PTopefty Address: 291 South Shore Drive . South Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/8/0 0
Check if the following have been done: You must indicate either "Yes" or -No- as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
X None of the system components have been pucnped4for at Mast two week. and-the system has b en'recelving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components, excluding the Soil Absorption System, have been located on the site.
X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge. depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
X Existing information. For example, Plan at B.O.H.
X Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[15.302(3)(b)1
X _ The facility owner (and occupants, if different from.owner) were provAded.with information on the proper rnaintarnancA-,-0f
SubSurface Disposal Systems.
revised 9 / 2 / 98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 291 South Shore Drive S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/8/0 0
FLOW CONDmONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms(actual):
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) (yes or no): ; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):
Water meter readings,if available (last two year's usage(gpd):
Sump Pump(yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment: Motor Inn
Design flow: 1 3 2 0 qpd ( Based on 15.203)
Basis of design flow 12 units
Grease trap present: (yes or no) nO
Industrial Waste Holding Tank present: (yes or no) no
Non-sanitary waste discharged to the Title 5 system: (yes or no) yes
Water meter readings, if available:
Last date of occupancy:_aoy 99
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Naint. pumped 1 pr . year
System pumped as part of inspection: (yes or no)_130
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
O Privy
n Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
O Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed 4-if known)and source of information: RaPLACED IN_1 9 7 9
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore Drive S . Yarmouth
owner: Blue Water Limited Parrnership
Date of Inspection: 2/8/0 0
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction:_cast iron_40 PVC_other (explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_x
(locate on site plan)
Depth below grade:
1 '
Material of construction: Xconcrete metal_Fiberglass _Polyethylene_otherlexplain)
If tank is metal,list age_ ls.age.confirmed by Certificate of Compliance_(Yes/No)
Dimensions: about 12 ' x 6 'x 7 ' 6"
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle:
48"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 7" 2 4"
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: ruler & sludge judge
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural-integrity,
evidence of leakage, etc.)
Pump each year . Tee' s good no leakage tound
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal _Fiberglass _Polyethylene_otherlexplain)
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Page 7dII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore Drive S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/8/0 0
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal Fiberglass Polyethylene other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: equal
Comments:
(note if level and distribution is equal, evidenee of solids carryover, evidence of leakage into or out of box, etc.) — • - . --
No carryover and no leakage
PUMP CHAMBER:
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 Page8ofll `'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore Drive S . Yarmouth
Owfef: Blue Water Limted Partnership
Date of Inspection: 2/8/O O
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan, if possible; excavation not required, location may be approximated by non-Intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers,number:
leaching galleries,number:_
leaching trenches,number,length:
leaching fields, number, dimensions: 1 18 ' x 9 0 ' x l '
overflow cesspool,number:
Ahemative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
Steil_ c] Pan - _no signs of hydraulic failure. No veg .
CESSPOOLS:
(locate on site plan)
Number and configuration:_
Depth-top of liquid to inlet invert:
Depth of solids layet:_
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater: _�
inflow(cesspool must be pumped as part of inspection),_-.
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.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �(
PART C
SYSTEM INFORMATION (continued) / / " /
/:/
Property Address: 291 S . Shore Drive S . Yarmouth I
Owner: Blue Water Limited Partnership /
Date of Inspection: 2/8/0 0
/ \ /
SKETCH OF SEWAGE DISPOSAL SYSTEM: 1
Include ties to at least two permanent reference landmarks or benchmarks
,./ '"i.
locate all wells within 100' (Locate where ouhlic. wetwr All 9nly Pinp -
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revised 9/2/98 Page lOofII
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore Drive S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/8/0 0
NRCS Report name
Soil Type -
Typical depth to groundwater —
USGS Date website visited no
Observation Wells checked yes
Groundwater depth: Shallow X Moderate Deep
SITE EXAM Slope no
Surface water no
Check Cellar yes
Shallow wells
no
Estimated Depth to Groundwater Feet 3 . 28 below bottom of leaching
Please indicate all the methods used to determine High Groundwater Elevation:
yecPbtained from Design Plans on record
yesObserved Site(Abutting property, observation hole, basement sump etc.)
ye4etermined from local conditions
ypSChecked with local Board of health
no Checked FEMA Maps
yes Checked pumping records
ye-5-Checked local excavators, installers
yes Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Hand Auger
revised 9/2/98 Page flofli
11 k — -�: / COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL, AFFAIRS
•` � ► DEPARTMENT OF ENVIRONMENTAL PROTECTION
v
v , ,47 ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
SYSTEM # 2 TRUDY COX::
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 291 S . Shore Dr . S . Yarmotiknivof owner Blue Wainer Limited Partnership
Address of Owner: same
Date of Inspection: 2 / 2 / 0 0
Name of Inspector: (Please Print) D Qn a
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Compamf Name: Robert B . Our Co . , I ne . _
Many Address: P 0 B o x l 3 3 9 H a r w i c h MA- 0 2 645
Telephone Number: 5 0 8 - 4 3 2 0 5 a-0
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes
Conditionally P ; ses
• s Furth , • gir ratio, : y the Local Approving Authority
Fai .
er
---
Inspector's Si r . • JJ e / //,• 7'- Date:
The System Inspector shall sub 't copy of this inspection report to the Approving Authority (Board of Health or DEP)withu- thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of-Environmental Protection. The original should be sent to The
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9 / 2 / 98 Page t of ll
Ct Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 291 S . Shore dRive S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/2/0 0
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. 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.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
- The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass -
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of I �'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT_
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh,
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF ANY)DEILEMINFS THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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 Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page3ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facilityor system component due-to en overloaded or-clogged SAS or-cesspool. •- -
Discharge or ponding of effluent 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 outlet invert 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipelsl.
Number of times pumped_.
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less-than 100 feet but greater then 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
...conform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large.Systeml end the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
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(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further inforLnation.
revised 9/2/98 Page 4 aril
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address 291 S . Shore Drive S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/2/0 0
Check if the following have been done: You must indicate either "Yes' or "No" as to each of the following:
Yes No
Y Pumping information was provided by the owner, occupant, or Board of Health.
Y None of the system components havabeen pumpedlfor-atleast two weeks and-the rystem has b.en'secelvingmusts: flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
Y _ As built plans have been obtained and examined. Note if they are not available with N/A.
Y _ The facility or dwelling was inspected for signs of sewage back-up.
Y _ The system does not receive non-sanitary or industrial waste flow.
__ The site was inspected for signs of breakout.
Y All system components, excluding the Soil Absorption System, have been located on the site.
Y _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Y _ Existing information. For example, Plan at B.O.H.
Y _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
( 1 5.302(3)(b)1
Y_ _ The facility owner (and occupants, if different from owner) were provided with information on tha proper maintenance-of
SubSurface Disposal Systems.
revised 9 / 2 / 98 Page 5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 291 S . Shore Dr . S . Yarmouth
Owner: Blue Water Limted Parntersliif>
Date of Inspection:
2/2/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actuall:
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) (yes or no): ; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):
Water meter readings,if available (last two year's usage(gpd):
Sump Pump(yes or no):
Last date of occupancy:
COMMERC1AU1NDUSTRIAL:
Type of establishment: motor inn
Design flow: 1760 gpd ( Based on 15.203)
Basis of design flow 16 ilnits
Grease trap present: (yes or no)___no
Industrial Waste Holding Tank present: (yes or no)n0
Non-sanitary waste discharged to the Title 5 system: (yes or no►yeS
Water meter readings,if available:
Last date of occupancy: Nov. 99
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Maint. pumped 1 pr . year
System pumped as part of inspection: (yes or no)
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
0 Single cesspool
0 Overflow cesspool
It Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
0 Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information: RE--•DONE 1 9 7 9_
Sewage odors detected when arriving at the site: (yes or no) no
revised 9/2/98 Page 6ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore dr . S . Yarmouth
... Owner: Blue Water Limited Partnership
Date of Inspection: 2/2/0 0
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _ cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK
(locate on site plan)
r
Depth below grade:_
Material of construction: X concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ is-age confirmed by Certificate of Compliance (Yes/No)
Dimensions: about 12 ' x6"x7 ' 6" 2250 gals .
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 46"
Scum thickness: 5 u
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle:
23"
How dimensions were determined: ruler & sludge judge
Comments:
' (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural-integrity,
evidence of leakage, etc.) _
Pump 1 pr . year . Tee ' s good, liquid level o.k. no leakage
found --
GREASE TRAP:
(locate on site plan)
Depth below grade:__
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain)
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Page 7ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore Dr . S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/2/0 0
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction: concrete metal_Fiberglass Polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order: Yes No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: equal
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — - . - - —
No cdLLyovel no ledkdcje
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 Page8ofu
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Aderea: 291 S. Shore Dr. S. Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/2/0 0
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
It not located,explain:
Type:
leaching pits.number:_
leaching chambers,number:_leaching galleries,number:_
leaching trenches,number,length:
leaching fields,number,dimensions: 1 9 0'x 18'X 1'
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of pondng,damp soil,condition of vegetation,etc.)
Roil clean no signs of hyrlraril is- f_.ai1nra
CESSPOOLS:_
(locate on site plan)
Number end configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as pert of inspection)
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.l
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.l
revised 9/2/98 Page of II
/
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
� ;
PART CnS1 /
SYSTEM INFORMATION (continued) ,- / \�f1
Pr Address: 291 / // `
Property S S . Shore Dr . S . Yarmouth ,
Date of Inspection:
Blue Water Limited Partnership �
2/2/00 / ..—T
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks /
locate all wells within 100' (Locate where nuhlic w.tar A i t•my mice j.•• ti e-- . 7 7Aid
I .)ii
• 4
raw ` "
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revised 9 / 2 / 98 Page10orll `/
I U,, 1 \ 1 1 i
t
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 291 S . Shore Dr . S . Yarmouth
Owner:
Date or Inspection: Blue Water Limited Partnership
2/2/00
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow X Moderate Deep
SITE EXAM Slope no
Surface water no
Check Cellar yes
Shallow wells no
Estimated Depth to Groundwater Feet 3 . 25 ' below bottom of leach field
Please indicate all the methods used to determine High Groundwater Elevation:
Y Obtained from Design Plans on record
Y Observed Site(Abutting property, observation hole, basement sump etc.)
y Determined from local conditions
Y Checked with local Board of health
Y Checked FEMA Maps
y Checked pumping records
Y Checked local excavators, installers
Y Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Hand Auger
revised 9/2/98 Page llorll
s - -_ COMMONWEALTHOF MASSACHUSET TS
_�- EXECUTIVE OFFICE, OF ENVIRONMENTAL AFFAIRS
- DEPARTMENT OF ENVIRONMENTAL AL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 ( 6 17 ) 292-5500
� -
TRUDY COXi•
SYSTEM # 3 Secretar\
ARGEO PAUL CELLUCCI DAVID B. STRUMS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 291 S . Shore Dr . S . Yarmaitartiehof owned- Blue Water Limited Partnership
Address of Owner: S a m e
Date of inspection: 2 / 2 / 0 0 Name of inspector: (Please Print) Donald K l i mm
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
ComPanY Name: Robert B . Our Co , Inc .
MaeIing Address: P O B-ox 1539 Harwich , MA- 02645
Telephone Number: 508 - 432 -Q5 3D
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems The system:
X Passes
Conditionally Passes
Needs Furthett
luatio • By the Local Approving Authority
F ils
inspector's Sigruatau 4: ;0�/-e- / ram Date
The System Inspector shall submit a opy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
•
revised 9 / 2 / 98
t�! Printed on Re( vcled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 291 S . Shore Dr . S. Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/2/0 0
INSPECTION SUMMARY: Check A, B, C, of D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. 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.
Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial Infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
- The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipes) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b) THAT THE SYSTEM
IS NOT FUNCTIONING W A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
31 OTHER
revised 9 2/98 Page 3of1I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continuedl
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility'or system component due-to an overloaded orclogged SAS orcesspool.
Discharge or ponding of effluent 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 outlet invert due to en overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipelsl.
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
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. If the well has been analyzed to be acceptable.attach copy of well water analysis for
-coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater ILarge.Systeml and the system is a significant threat to public
health end safety end the environment because one or more of the following conditions exist:
Yes No
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(interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(21. Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropettyAddress: 291 S . Shore Dr . S . Yarmouth
Date of Inspection: Blue Water Limited Partnership
2/2/00
Check if the following have been done: You must indicate either "Yes ' or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
Y _ None of the system components ham. been pur»psdLfor-at least two weeks and-the system has bsen.recelwng!WeWw'a! flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
Y _ As built plans have been obtained and examined. Note if they are not available with N/A.
Y The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
__ The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Y _ Existing information. For example, Plan at B.O.N.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(15.302(3)(b))
Y _ The facility owner (and occupants, if different from owner) were provided with information on the prnpPr maintenar of
SubSurface Disposal Systems.
revised 9 / 2 / 98 Page sof 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 291 S . Shore dr . , S . Yarmouth
Ower:Ina Blue Water Limited Partnership
e ofpection. 2/2/0 0
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual):
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) (yes or no): : If yes, separate inspection.required
Laundry system inspected (yes or no)
Seasonal use(yes or no):
Water meter readings,if available (last two year's usage (gpd):
Sump Pump(yes or no):
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment: Motor Inn
Design flow: 2200 gpd ( Based on 15.203)p1US
Basis of design flow 20 units
Grease trap present: (yes or no)11O
Industrial Waste Holding Tank present: (yes or no) no
Non-sanitary waste discharged to the Title 5 system: (yes or no)y_c S
Water meter readings, if available:
Last date of occupancy:Nov. 99
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Mainf _ pumped 1 pr . year
System pumped as part of inspection: (yes or no)no
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
o Single cesspool
O Overflow cesspool
Q Privy
O Shared system (yes or no) (if yes, attach previous inspection records, if any)
8 I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed{if known) and source of•information: REDONE 1 9 7 6--
Sewage odors detected when arriving at the site: (yes or no) no
revised 9/2/98 Page 6of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore Dr . , S . Yarmouth
Datwe of Inspection: Blue Water Limited Parnership
2/2/00
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Materiel of construction: cast iron _40 PVC other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grade:
14"
Material of construction: Xconcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age Is_age-confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 14 ' L X 7 'W x7 'D 3 , 000 gallon
Sludge depth: 6" 3 9"
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: 4 "
Distance from top of scum to top of outlet tee or baffle: S " 2 4'IDistance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: ruler & sludge judge
Comments:
' (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural-integrity,
evidence of leakage, etc.)
Pump 1 pr. year as maint. Tee ' s good, liquid level U.K.
No signs of leakage
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: concrete_metal Fiberglass Polyethylene _other(exptain)
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Page7ofl1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
291 S . Shore Dr . S . Yarmouth
Property Address:
Owner: Blue Water Limited Partnership
Date of Inspection: 2/2/0 0
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction: concrete metal _Fiberglass_Polyethylene _otherlexplain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order: Yes No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_X
(locate on site plan)
Depth of liquid level above outlet invert: equal
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — -
No carryover - no leakage
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 Page 8of 1l
SUBSURFACE SUINAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contiiKred)
291 S . Shore Dr . S . Yarmouth
Proporty Address
0wnor Blue Water Limited Partnership
Date of Inspection 2/2/00
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, it possible excavation not royuired location may be approximated by non mtrusivo methods)
If not located, explain
Type —_. ----- -_
leaching pits, number:
leaching chambers, number: 40 30 ' x65 ' with stone, found dry on 2/2/00
leaching galleries, number:
leaching trenches, number, length: _
leaching fields, number, dimensions:
overflow cesspool, number:__
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
boil- clean. no signsof hydraulic tailure. No veg.
CESSPOOLS:
(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:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
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.)
Page a01 tl
SUBSURf ACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOEtMA1ION Icoitirnrod)
Property Address: 291 S. Shore Dr . S. Yarmouth
Own« Blue Water Limited Partnership
Date of Irutpectson 2/2/0 0 `/
SKI ICN OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or henclrnrarks
locate all wells within 100' (Locate whom ,urhtic water supply comes into house)
+ /
r\I
, � Wm
ll '
Al
t any
- - C t 10..1 a A
I i-____ _ i p .-� /O
-off.... f �.S ;
dr
, z,.., , . :-. .. , -.....-----,-;-,-:.-11-7.41' l:.:: .•- -‘..,:---1_.,1--""-1.....-: : . 1::
_5/5 (.. it ' 1 eck_ ' kr' ;11..:- 1.Ni-ii•-`;`--:: ','_ •-` _ - -'''''1.: .-_''' -
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Andre::: 291 S . Shore Drive S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/2/0 0
NRCS Report name
----- -------
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow X Moderate Deep
SITE EXAM Slope no
Surface water no
Check Cellar
Shallow wells yes
no
Estimated Depth to Groundwater Feet 3 . 25 ' from bottom leaching
Please indicate all the methods used to determine High Groundwater Elevation:
y Obtained from Design Plans on record
y Observed Site(Abutting property, observation hole, basement sump etc.)
Y Determined from local conditions
Y Checked with local Board of health
NO Checked FEMA Maps
YChecked pumping records
Y Checked local excavators, installers
yUsed USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Hand Auger
revised 9/2/98 Page llofII
u
u
Li
-7:17
!lk ' = I7 COMMONWEAI ,TI I OFMASSA( 7I I ( • s I.,-I„I.s
e -t `` EXECUTIVE ( ) FFICI OF ENVIHO \ 11 ENTAI , AI~' I�':\ I I;s
- C O
;; j DEPARTMENT ARTMENT OF ENVIRONMENTAL PROTECTION
- . : -,�� ' ( ),N E WINTER STREET, BOSTON MA ()2 I () ; . t► I ) 29 2-5;>()()
' RUI)Y ( '( )XI-
SYSTEM # 4 Sec rc�tarN
ARGEO PAW, C E: I,I,UCCI
DAVID B S T'tZ( lli:
Governor Conun::;sioneT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
291 S . Shore Dr . S . Yarmouth_
Property Address: Name of OwnerB 1 u_e Water Limited m i t ed Partnership
Address of Owner: same
Date of Inspection: 2 / 4 / 0 0
Name of Inspector: (Please Print) D ona1-. K 1 i mm
I am a DEP /approved system inspector pursuant to Section 15.340 of Tide 5 (310 CMR 15.000)
Company Name: Robert B Our _Co . , Inc .
ai Mang Address:
T N : JOQ-" 3 Q - U �i__ ar_wi chi__ MA 0 2 6 4 5
umber
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation B 'he Local Approving Authority
F . s
._ , � � —Inspector's Si9��r e: �1 - � Date:
The System Inspector shall submit a spy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection . If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised :.' / 98 1'a4;C• 1 cif II
ea p-,,i••ci un Recycled Pape
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address 291 S . Shore Dr . S . Yarmouth
ow Blue Water Limited Partnership
Date of Inspection: 2/4/00
INSPECTION SUMMARY: Check A, B, C, o/ D
A SYSTEM PASSES
X. I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass -
inspection if (with approval of the Board of Health):
broken pipets) are replaced
obstruction is removed
_ 1. I',i y;c 2 of I I ��
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection
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 the
public health, safety and the environment
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
-'�r1Sed 9 fag 3ailII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued/
Property Address:
Owner
Date of Inspection
D. SYSTEM FAILS:
You must indicate either 'Yes" or No to each of the following
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure
Yes No
Backup of sewage into facility'or system component due to an overloaded or clogged SAS or cesspool. -
Discharge or ponding of effluent 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 outlet invert 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public wet.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
-coliform bacteria, volatile organic-compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYS TE]M FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large,System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
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 (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
' E'\; i c.'i.1 ')/.: /9 8 Pagf.4 of I 1 `�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property ncktress 291 S . Shore Dr . S . Yarmouth
D,, Blue Water LImited Partnership
Date of inspection: 2/4/0 0
Check if the following have been done. You must indicate either 'Yes' or "No as to each of the following
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped,forat least two weeks and the system has been•receivv'g maraud flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
Y _ The site was inspected for signs of breakout.
Y All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on-the site has been determined based on:
Existing information. For example, Plan at B O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(1 5.302(3)(b)l
�[ The facility owner (and occupants,if differeui from owner) were provided with information on the proper maintenancesof
SubSurface Disposal Systems.
• % 8 Page 5 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 291 S. Shore Dr. S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/4/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual):
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) (yes or no): If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):_
Water meter readings,if available (last two year's usage (gpd):
Sump Pump(yes or no):
Last date of occupancy: 8 units 880
COMMERCIAL/INDUSTRIAL: 110 seats & 2 Bath 1100
Type of establishment: Motor Inn 1980 per day
Design flow: 1980 gpd ( Based on 15.203)
Basis of design flow 8 units plus 110 seat rest.
Grease trap present: (yes or no), es under sinks
Industrial Waste Holding Tank present: (yes or no) n0
Non-sanitary waste discharged to the Title 5 system: (yes or no) yes
Water meter readings, if available:
Last date of occupancy: Nov. 99
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Pumped 1 per year maint. `/
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
TYPPOF SYSTEM
Septic tank/distribution box/soil absorption system
0 Single cesspool
0 Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
U Tight Tank -Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known) and source of information: FLELD_REPLACED 1989
Sewage odors detected when arriving at the site: (yes or no) no
revised 9/2/98
Pdgr-b of l l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
291 S . Shore Dr . S . Yarmouth
Property Address: Blue Water Limited Partnership
�i Owner:
Date of Inspection: 2/4/0 0
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: cast iron 40 PVC other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage,etc.)
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 1
Material of construction: X concrete metal _Fiberglass _Polyethylene_other(explain)
If tank is metal, list age Is.age confirmed by Certificate of Compliance (Yes/No)
14 ' L x7 'W x 7 ' D 3000 gallons
Dimensions: 6"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3 6u
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle:4 n
Distance from bottom of scum to bottom of outlet tee or baffle:
24"
How dimensions were determined: ruler & sludge judge
Comments:
• (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural-integrity,
evidence of leakage, etc.)
Tee ' s good - liquid level o.k. no leakage found
GREASE TRAP: X
(locate on site plan) under sinks
Depth below grade:
Material of construction: concreteX metal _Fiberglass Polyethylene _other)exptain)
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
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
They are cleaned i per week
revise %j2 98 Pal;e7ufll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property address: 291 S. Shore Dr. S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/4/0 0
TIGHT OR HOLDING TANK: ___ (Tank must be pumped prior to, or at time of. inspection)
(locate on site plan)
Depth below grade:
Material of construction concrete_metal_Fiberglass_Polyethylene other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order: Yes No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: equal
Comments.
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — J
No leakage — no Cd1 rywez
PUMP CHAMBER:
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 Page 8of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Prey Address 291 S. Shore Dr . S. Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/4/00
SOIL ABSORPTION SYSTEM (SASE_ X
(locate on site plan, if possible. excavation riot required. location may be approximated by non intrusive methods)
If not located, explain.
Type:
leaching pits. number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions: 1 22 r X91 r X6 rr
overflow cesspool, number: Dry on 2/4/00
Alternative system:
Name of Technology: _
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
CESSPOOLS:
(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:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc I
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.)
V
revised 9/2/98 rag+ev„rII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE CIION FORM
PART C
SYSTEM INFORMATION (continued)
f'rotw(ty Address 291 S. Shore Dr. S. Yarmouth ;
/1 Owner Blue Water Limited Partnership y��
Date of Inspection 2/4/00 \ /..
SKE1CH OF SEWAGE. DISPOSAL SYSTEM j
include ties to at least two permanent reference landmarks or bonchn-u I l
locate all wells within 100 (Locate where public water supply conies ! I ���:\ /
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4.
t IN.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: 2 91 S . Shore Dr . S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/4/00
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow yeS Moderate Deep
SITE EXAM Slope no
Surface water no
Check Cellar yes
Shallow wells no
Estimated Depth to Groundwater Feet 3 . 28 ' below bottom of leaching
Please indicate all the methods used to determine High Groundwater Elevation:
y Obtained from Design Plans on record
Y _Observed Site (Abutting property, observation hole, basement sump etc.)
Y Determined from local conditions
Y Checked with local Board of health
ND Checked FEMA Maps
Y Checked pumping records
Y Checked local excavators. installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Hand Auger
revised 9/2/98 Page llofll
7.4.-v,
( - .1 _.
iT _ i 2 ( '( )MMONWE��AI ,'I'I I OFMASSA I I t ' SETTS
~ '` I XECU'FIVE OFFICE OF ENVIR( ) NMENTAL AE� FAJ Ids
} - 1 -_ DEPARTMENT OF ENVIRONMENTAL , PROTECTION
` _ ��, ( )ti v. WIN'I ER S'I'RI~: '. I'. ROSTON MA 0.21 (N ( 61 7 ) 29 2-5500
��
TRUDY COXR
Secretar\
ARGEO I'AUL, CEI.I.UCCI SYSTEM # 5 DAVID B STFZt'I-IS
Governor Comiiu_`;sioner-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 291 S . Shore Dr . S . Yarmo of Owner _ntat- er Limited Partnership
Address of Owner: s ame
Date of Inspection: 2 / 3 / 0 0 Name of Inspector: (Please Print) Donal d K 1 i m m
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Nam: Robert B . Our Co . , Inc .
Masking Address: P O Box ---1.539__ H a rw i c h , ___MA- 02645
Telephone Number: 5 0 8- 4 3 2- - 0 S 3 0
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes
Conditionally Passes
Need rther Evaluation By the /al Approving Authority
Faits 0, '/ a
Inspector's Signature: di' Date: -2
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to 'the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised ) / 2 / 9 8 P4ge < of t1
` ' Printed oo Rec\-.led 'ape'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 291 S . Shore Dr . S . Yarmouth
Owner: Blue Water Limited Partnership
Date of inspection: 2/3/0 0
INSPECTION SUMMARY: Check A, 8, C, or D.
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
- The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
'revised 9, 2/ 98 l,ege 2 of ll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CLRTIFICATION (continued)
"'sr'
Prouetty Address-
Owner.
Date of Inspection.
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 the
public health, safety and the environment
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b) THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
31 OTHER
I I a II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner
Date of Inspection-
D. SYSTEM FAILS:
You must indicate either Yes or No to each of the following:
1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility.or system component due-to en overloaded or-clogged SAS or cesspool.
Discharge or ponding of effluent 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 outlet invert 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped .
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
-coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes' or No to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large,System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
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(Interim Wellhead Protection Area - IWPAI or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional
office of the Department for further information.
I-t_' ! E_,(-1 9/2 .' y'? P.agr 4 of I I �.i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
�-' Property Address. 291 S . Shore Dr . S . Yarmouth
owner Blue Water Limited Partnership
Date of Inspection 2/3/0 0
Check if the following have been done: You must indicate either "Yes" or 'No" as to each of the following.
Yes No
Pumping information was provided by the owner, occupant. or Board of Health
None of the system components have been pumpad:for at Mast two weeks end the system has been•receivrtg nerrwrai flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection
Y _ As built plans have been obtained and examined. Note if they are not available with N/A.
Y The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
Y _ The site was inspected for signs of breakout.
Y _ All system components, excluding the Soil Absorption System, have been located on the site.
_Y The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at B.O.H.
_Y Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[1 5.30213)(bl]
The facility owner (and occupants,if different from owner) were provided with information,on tha proper maintenance—of
SubSurface Disposal Systems.
Li
I '_. -1 Page 5 of
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 291 S . Shore Dr . S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection 2/3/0 0
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom
Number of bedrooms (design): Number of bedrooms (actual).
Total DESIGN flow
Number of current residents:
Garbage grinder (yes or no):
Laundry(separate system) (yes or no): : If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):
Water meter readings, if available (last two year's usage(gpd):
Sump Pump(yes or no):
Last date of occupancy:
COMMERCIALRNDUSTRIAL:
Type of establist�r� Motor Inn
Design flow: L / 0 gpd ( Based on 15.203)
Basis of design flow 25 units
Grease trap present: (yes or no) I10 -- ---
Industrial Waste Holding Tank present: (yes or no)n0
Non-sanitary waste discharged to the Title 5 system: (yes or no) yes
Water meter readings, if available:
Last date of occupancy: Nov. 99
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information
Maint. pump 1 per year
System pumped as part of inspection: (yes or no) no
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
0 Single cesspool
QOverflow cesspool
Privy
0 Shared system (yes or no) (if yes, attach previous inspection records, if any)
8 I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed{if known) end source of-ertformation: Upgrade 1976
Sewage odors detected when arriving at the site: (yes or no) no
revi s;e;: 98
Pei g, 6of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore dr. S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection- 2/3/00
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction: concrete metal Fiberglass Polyethylene other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order: Yes No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: 2
(locate on site plan)
Depth of liquid level above outlet invert: equal
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) —
No carryover - no leakaye
PUMP CHAMBER: X
(locate on site plan)
Pumps in working order: (Yes or No) Yes
Alarms in working order(Yes or No) yes
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
clean and iii woikiiiy eit�ei
revised 9/2/98 Pageeofu
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore dr . S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/3/00
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade.
Material of construction: concrete metal Fiberglass Polyethylene other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order: Yes No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: 2
(locate on site plan)
Depth of liquid level above outlet invert: equal
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — - -
No carryover - no leakaye
PUMP CHAMBER:_ X
(locate on site plan)
Pumps in working order: (Yes or No) yes
Alarms in working order (Yes or No) yes
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
clean and- in woLkilly older
revised 9/ 2/c18 Page tofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore Dr . S . Yarmouth
°wmw: Blue Water Limited Partnership
Date of Inspection: 2/3/00
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible: excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number: #5 A 3 6 ' X 7 5 ' x 1 '
leaching chambers, number: #5 B 3 6 ' x 7 5 ' x 1 '
leaching galleries,number: Found dry on 2/3/00
leaching trenches,number,length:
- leaching fields, number, dimensions: 2
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding,,damp soil, condition of vegetation, etc.)
Soil clean - no signs of hydraulic failure
CESSPOOLS:
(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:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
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-)
\—.
revised 9/2/98 1'agc9oru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore Dr . S. Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection' 2/3/0 0 -/
o I
SKETCH OF SEWAGE DISPOSAL SYSTEM: 1,
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (locate where public water supply comes into house
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iii,revised 9/2/98 F + ./
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address- 291 S . Shore dr . S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection- 2/3/0 0
NRCS Report name
Soil Typo - --- - - - - - - _---. _ .
Typical depth to groundwater - - -_-
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow X Moderate Deep
SITE EXAM Slope n0
Surface water no
Check Cellar yes
Shallow wells O
Estimated Depth to Groundwater Feet 3 . 50 below leaching
Please indicate all the methods used to determine High Groundwater Elevation:
Y Obtained from Design Plans on record
YObserved Site (Abutting property, observation hole, basement sump etc.)
'Determined from local conditions
YChecked with local Board of health
NO Checked FEMA Maps
Y Checked pumping records
Y Checked local excavators, installers
Y Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Hand Auger
ievisej 9 / 2 /98
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