HomeMy WebLinkAboutSubsurface Sewage Sisposal System Inspection Form - Part A Certification COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
t• DEPARTMENT OF ENVIRONMENTAI. PROTECTION
• 3�j B
ONE WINTER STREET. BOSTON MA 0210r - n� .• t R is ';j i u�
•
FFR 7 1 TRUDY COXI
SYSTEM #1 T Secretary
ARGEO PAUL CELLUCCI HEALTH DPP r
DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 291 South Shore Drive S Yarmouth R1ue Water Limited Partnership
Address of Owner:
Date of Inspection: 2/8/0 0
Name of Inspector: (Please Print) J-n n a 1 cl K 1 i rnm
I am a DEP approved system inspector pursuant to Section 15.340 of Trtfe 5(310 CMR 15.000)
Company Name: _ Robert B . Our Co. , Inc .
Maing Address: _ .0 Ho x 15 3 9 H a rw i r h , M A 0 264 5
Telephone Number: -- 508 432 0530
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
•e.'. Further E .luation the Local Approving Authority
Fail-
� )0i� _ C�C�
Inspector's Signatu ,� , 1`lJ�7 Date:
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
Yi
revised 9/2/98 Page 1ofll
`�} Primed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 291 South Shore Drive South Yarmouth
Owner: 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 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 pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page2of11
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 Page3ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Icontinued)
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 facilityror system component-duel('en 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 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 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 greeter lLarge.Systeml 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 15.30412). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page aonl '�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property 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 pufnpeditor at Jeast two weeks and-the system has bsenrrecelving always! 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.N.
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 differeo.I from owner) were provided.with information on the prowl/ maintarnauc-of
SubSurface Disposal Systems.
revised 9 / 2 / 98 Page 5oftl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2 91 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: -I 33 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)jp
Non-sanitary waste discharged to the Title 5 system: (yes or no) yes
Water meter readings,if available:
Last date of occupancy:_ioV. 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 nol_O
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
0 Privy
8 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: RJPL4c D IN_19 7 9
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/98 Page6ofll `+
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:
(locate on site plan)
r
Depth below grade: 1
Material of construction: Xconcrete_metal_Fiberglass _Polyethylene other(explain)
If tank is metal,list age ls.age-confirmed by Certificate of Compliance (Yes/No)
Dimensions: about 12 'x6 'x 7 ' 6 "
Sludge depth: 4" 4 8"
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: 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 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 Drive S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspect on: 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 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 iflevel and distribution is equal, evidence 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 Page tof1I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(cantinued)
Property Address: 291 S. Shore Drive S. Yarmouth
Owner:
Date of Inspection. 2/8/ Water Limted Partnership
2/8/00
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:_
leeching galleries,number:_
leeching trenches,number,length:
leaching fields,number,dimensions: 1 18'X 9 0'X 1'
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.)
Snil_ clean — 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 layer:
Depth of scum layer:
v 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:
Mote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) •
revised 9/2/98 Page9a ll
j
I)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' /
PART C \
SYSTEM INFORMATION (continued) z /.. 1
Property Address: 291 S . Shore Drive S . Yarmouth / / /
Owner: Blue Water Limited Partnership
Date of Inspection: 2/8/0 O
/
%
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public VWTA,' Ali nl., i-n.,qC.,'... --
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revised 9 / 2 / 98 Page 10of II I I -.....--
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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
v
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
Shallow wells yes
no
Estimated Depth to Groundwater Feet 3 . 28 below bottom of leaching
Please indicate all the methods used to determine High Groundwater Elevation:
_ e btained from Design Plans on record
_ye33bserved Site(Abutting property, observation hole, basement sump etc./
yeSDetermined from local conditions
ypsChecked with local Board of health
_no_ Checked FEMA Maps
yes Checked pumping records
�.. yes 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 IIoftl
- _ _ j COMMONWEALTH OF MASSACI•IUSET"I'S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTALPROTECTION� CTIONj
Z ONE WINTER STREET, BOSTON MA 02108 ( 617) 292-5500
SYSTEM # 2 TRUDY COX}:
Secretary
ARGF,O PAUL CELLUCCI DAVID B. STRUHS
Governor
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 291 S . Shore Dr . S . Yarmot4krktof owner Blue Water Limited Partnership
Address of Owner: same
Date of Inspection: 2 / 2 / 0 0
Na me of Inspector: (Please Print) _ Dona _ d K i m m
I am a DEP approved system inspector pursuant to Section 15.340 of Tale 5 (310 CMR 15.000)
Company Name: Robert B . Our Co ,_,
Maing Address: P O Box 1 519 Harwich , MA 02645
Telephone Number: — 0 8 - 4 3 2-0 5 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 P ; ses
: . s Furth • • I _ratio; : y the Local Approving Authority
Fai . '
Inspector's Si r : - Age - Date: i%
The System Inspector shall sub 't .• copy of this inspection report to the Approving Authority (Board of Health or DEP)withir' 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 tt e
• system owner and copies sent to the buyer; if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9 / 2 / 98 Pagelofll
t) Printed on Recycled Papa
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 0:
A. SYSTEM PASSES:
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
V - 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 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 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 pprn. Method used to determine distance (approximation not valid).
31 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 whet will be necessary to correct the failure.
Yes No
Backup of sewage into fecilitwor system component duefo 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 pipalsl.
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 greeter(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 15.304121. 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
Property Address 291 S . Shore Drive S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection 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
Y Pumping information was provided by the owner, occupant, or Board of Health.
Y _ None of the system components have.been pumpeditorat.least two weeks and-the system has been'secelviny?lent& 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.
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
The facility owner (and occupants, if different from owner) were provided with information on the camper maintenance-of
SubSurface Disposal Systems.
revised / 2 / 98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 291 S . Shore Dr . S . Yarmouth
Owner: Blue Water Limted Parntership
Date of Inspection:
2/2/00
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:
COMMERCIAL INDUSTRIAL:
Type of establishment: motor inn
Design flow: 1760 gpd ( Based on 15.203)
Basis of design flow 16 units
Grease trap present: (yes or nol_110
Industrial Waste Holding Tank present: (yes or no)nO
Non-sanitary waste discharged to the Title 5 system: (yes or no) 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:
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
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-Of known)and source of information: RB DOA)-E 1 9 7 9-
Sewage odors detected when arriving at the site: (yes or no) no
revised 9/2/98 Page 6of11
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)
Depth below grade:
Material of construction: X concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ ls.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: 4 6 n -
Scum thickness: 5 n
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
Row 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
ruu.ud
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 7oltl
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 caLryover nu leakaye
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 8ofII �''
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
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 Pita,number:_
leaching chambers.number:
leaching galleries.number:_
leaching trenches,number,length:
leeching 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.)
Snit rlpan no signs of hydraulic faiLura
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 reveal!
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM /
PART C N /
1/1
SYSTEM INFORMATION (continued)
Pr Address: // / \I ,
° Y 291 S . Shore Dr . S . Yarmouth
�ate fln:peL :wner: i
Blue Water Limited Partnership ��
2/2/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks / 1\ /
locate all wells within 100' (Locate where nubile wptwr all nI.v ...fit.).,. I, .�
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revised 9 / 2 / 98 Page IOof 11 ` 1 \ ' �/
1 U 1 I
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore Dr . S . Yarmouth
Owner:
Date of 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 . 2 5 ' 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 llofit
COMMONWEALTH OF MASSACHUSETTS
•
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
9
:" DEPARTMENT OF ENVIRONMENTAI. PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617 ) 292-5500
TRUDY COX.:
SYSTEM # 3 Secretar\
ARGEO PAUL C ELLUCCI DAVID B. STRUM;;
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 291 S . Shore Dr . S . YarrnadmitkhofownerBlue Water Limited Partnership
Address of Owner: same
Date of Inspection: 2 / 2 / 0 0 - -
Narne of Inspector: (Please Print) Donald K l i mm
I am a DEP approved system inspector pursuant to Section 15.340 of Tile 5 (310 CMR 15.000)
CornPanY Name: Robert B . Our Ca._ , Inc .
Mad'i"g Address: P 0 Box 15-3 9 —fir w i t h , MA-- 02645
Telephone Number: 5 QB - 4 3 2 - 0 5 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
Needs Further' aluatio► By the Local Approving Authority
F ils
61( 4 ,
Inspector's Signatu4: :of
" � � Date: ‘2 •-• :"2
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 Page l of ll
¶,, Panted on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERT1F1CAllON (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, 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 CONDf11ONALLY 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 pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2ofll
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 facility'or system component-due-to an overloaded or clogged SAS or-cesspool. • -•
Discharge or pending 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 pipels).
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
—cofiform 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 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 feat 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 Pagr4arll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 291 S . Shore Dr . S . Yarmouth
owner:
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 have.been pumped:tor at Jeast two weeks and-the system has boen.recelving eeenaal 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.
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))
The facility owner (and occupants, if different from owner) were provided with information on the prnpir maintenarsco4f
SubSurface Disposal Systems.
revised 9 / 2 / 98 Page 5ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 291 S . Shore dr . , S . Yarmouth
Owf1ef: Blue Water Limited Partnership
Date of Inspection: 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):
Lest date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment: Motor Inn
Design flow: 2200 gpd ( Based on 15.203)plUS
Basis of design flow 20 units
Grease trap present: (yes or no1ao
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:NOV. 99 OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Ma i_nt _ pumped 1 pr . year
System pumped as part of inspection: (yes or no►ao
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
U Single cesspool
O Overflow cesspool
O 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 `�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 291 S . Shore Dr . , S . Yarmouth
Date oflnspection: Blue Water Limited Parnership
2/2/00
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)
Depth below grade: 14 "
Material of construction: )(concrete_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 n
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: 4 n
Distance from top of scum to top of outlet tee or baffle: S"
Distance from bottom of scum to bottom of outlet tee or baffle: 24"
How dimensions were determined: ruler & sludge_u] dge
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 l 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(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 Page7ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
291 S . Shore Dr . S . Yarmouth
Property Address. Blue Water Limited Partnership
Owner:
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 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 Page8ofll �'
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 2/2/00
SOIL ABSORPTION SYSIIM (SAS):
(locate on site plan. if possible excavation not royuerod. location may be approximated by non intrusive methods)
If not located, explain
Type. — -- —
leaching pits. number:
leeching 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.I
Soil clean. 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 layer: -
1 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.)
V
i
• I !::;E:C1 1 ' )r3 Page o ui I I
SUBSURFACE-SEWAGE DISPOSAL. SYSTEM INSPECTION f ORM
PART C
SYSTEM INFORMATION (coitirxiod)
Property Address: 291 S. Shore Dr . S . Yarmouth
own« Blue Water Limited Partnership \
Date of inspection: 2/2/0 0 y
SKI ICH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent roforonca landmarks or bow tunarks
locate all wells within 100. (Locate whom. public water supply conuos into house/
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: 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
YChecked local excavators, installers
_yUsed USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Hand Auger
revised 9/2/98 Page llofit
/ ti
. .:.-1 .f.T) ,:_ .,, .:2 COMMONwEAI ,TI I OF MASsAC I i ( ' ti E.;'I\/I\S
....- Jir I .XECU I IVE ( ) 1 EF ICE OIL 1�NVIIz( ) \ NI E'.N I AI , AEt' E�':� I PsO)
DEPARTMENT OF ENVIRONMENTAL PROTECTION
c,,4;,14,
:-: ���`; ( )N E•: WINTERSTREI+T, BOSTON MA 02 It), - t► 1 ; ) 2.9 2-.`): 0O
'I RUD)Y ( 'cJXi.
Secretary
SYSTEM # 4
ARGEO PAUL (• EI.I,UCCI I)AVID B STRl1HS
Governor Conun11;stoner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
291 S . Shore Dr . S . Yarmouth
Property Address: m ae o wnerBlue Water Limited Partnership
Address of Owner:
Date of Inspection: 2 / 4 / 0 0 -same
Name of Inspector: (Please Print) Donald K 1 imm
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 .
Mad"ing Address: Q _ _ H a n w�c i---8h -MA 02645
T Number: JOO —f 3L—UJ
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
,,/ . ''`*2 — e_D e
......, Inspector's Signature: .j -. y1 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 ttte
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
r e v i se '-1 9 8 Page l of II
n
r
P,,ni.•d can Recycled Pace'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 291 S . Shore Dr . S . Yarmouth
Owner. Blue Water Limited Partnership
Data of Inspection 2/4/00
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 pipes) are replaced
obstruction is removed
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address
Owrux:
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
SE'_<j 9 �� Page i t I I
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
have determined that ono 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 duet() 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 112 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 - 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.
,� _i '! , - 3 rag,.4 of I I ��
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
291 S . Shore Dr . S . Yarmouth
�i Property Address.
Owner: Blue Water LImited Partnership
Date of Inspe€tion 2/4/00
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.
None of the system components have been punnped4or at least two weeks and-the system has been'receiving enrol 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.
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.
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.
`i _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)(bll
Y - The facility owner (and occupants,if different from owner) were provided with information on the proper maintenancwf
SubSurface Disposal Systems.
9 8 Page 5 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Properly 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
COMMERCIALANDUSTRIAL: 110 seats & 2 Bath 1100
Type of establishment: Motor Inn 1980 per day
Design flow: 198 0 gpd ( Based on 15.203)
Basis of design flow 8 units plus 110 seat rest.
Grease trap present: (yes or no)-yes under sinks
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: NOV. 99
OTHER:(Describe)
Last date of occupancy'
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Pumped 1 per year aint. ....1
System pumped as part of inspection: (yes or no)
If yes, volume pumped: gallons
Reason for pumping:
TYPF OF 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
o Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed Of known) and source of information: FLELD_.REPLACED 198 9
Sewage odors detected when arriving at the site: (yes or no) n0
_revised 9/2/98 Pazc6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continuod)
291 S . Shore Dr . S . Yarmouth
Property Address: Blue Water Limited Partnership
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_otherlexplainl
If tank is metal, list age Is.age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 14 ' L x7 'W x 7 ' D 3000 gallons
Sludge depth:
6"
"Distance from top of sludge to bottom of outlet tee or baffle: 36 Scum thickness: 4"
n
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:
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(expiain)
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 1 per week
rev sei / " !`.)8 Page 7 of I 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: 2/4/0 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.) — . _
\—/
No leakage - no caLLyOver
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 8ofII
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: 2/4/00
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 22 t X91 t X6 tt
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.)
Sill 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.)
V
revised 9/2/98 rage 9r,fll
SUBSUIIFACF SEWAGE DISPOSAL SYSTEM INSPECTION FOI1M
PART C
SYSTEM INFORMATION (continued)
291 S. Shore Dr. S . Yarmouth
Property Address
Ow1e, Blue Water Limited Partnership ,_
Date of Inspection 2/4/0 0 p
1
SKETCH OF SEWAGE DISPOSAL SYSTEM. i , r
include ties to at least two permanent reference landmarks or hem- —hnu [
locate all wells within 100 (Locate where public water supply comes r 1 \ `\ / \S
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- Teo
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mow ~
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I
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pr VI II.
7,- - -iil_t I, .,till', , is
h rr-r— li'Tr r,s�L.iv s;,
-; - T.
rr I
S�s 1 I I I
i 'E- 1 _ t__
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_ 2/4/00
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 r 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
NO 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 Pagellofll
COMMONWEALTH I OF MASSAC I I [ ' S Ii;'I"I'S
- f � --- _ EXECUTIVE OFFICE OF ENVIIZ( � NMEN'I'AI , AFFAIRS
O 'fft I ) EPARTM.F.NT OF ENVIRONMEN'I'AI . PROTECTION
:; , �1��``� ( )NE WINTER sTRE ET, BOSTON MA 02 l I),`i t 6 1 ; > 29 -5500
TRUDY c'OM",
Secretary
ARGEO PAUL CEI,I,UCCI SYSTEM # 5 DAVID B ST''RUI-IS
Governor Conumi;stoner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 291 S . Shore Dr . S . Yarmo of owner__B_lue _ Water Limited Partnership
Address of Owner: same
Date of Inspection: 2 / 3/ 0 0 - - --Name of Inspector: (Please Print) !Donald K 1 i mm
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 .
Mang Address: P 0 Box _L 539 - H a r w i c 1 T—MA. 02645
Telephone Number: 508- 4 3•2- 0530
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
Fails �/' ��
•
Inspector's Signature: � Dater 49e3
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 j 2 / 9 8 Page l t►f l l
t46, Printed ors iZeo,t'ed Pape,
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, 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 pipe(s) are replaced
obstruction is removed
r�vls. d 9. 2 98 P40.. 2411
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Icootirxredl
"ft./
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
11 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
I I '1 Pagt. of I I
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 facilityror system component-due-to en overloaded orctogged 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 - 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.
-�,..� I =E': `f/2 r Page 4 of
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 291 S . Shore ,Dr . S . Yarmouth
Ow 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
V�s No
Pumping information was provided by the owner, occupant, or Board of Health
None of the system components have been pumped:tor at least two weeks and the system has b.en'receiving taarwtal 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.
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.N.
`i Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b)I
The facility owner land occupants,if different from owner) were provided with information on the proper maintenancaof
SubSurface Disposal Systems.
Pau 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: 2/3/0 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(gpo):
Sump Pump(yes or no):
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establisfualerg:0 Motor Inn
Design flow: Ll �� qpd ( Based on 15.203)
Basis of design flow 25 units
Grease trap present: (yes or no) no --
Industrial Waste Holding Tank present: (yes or no)110
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
Overflow 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) and source of in - -u�JC3rad
— 1976
Sewage odors detected when arriving at the site: (yes or no) _10
rev se;_i / 9 8 Pagt•6ofII
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
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 - nu leakage —.
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 working uidei
Li revised 9/2/98 Page gorll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continuod)
PropertyA(Wass: 291 S . Shore dr . S . Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection 2/3/0 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: 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 leakage
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 wotkiily urde'.
revised 9/2/99 Page of 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
SOIL ABSORPTION SYSTFJN (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 Page 9or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued}
PtoportyAddress: 291 S . Shore Dr . S. Yarmouth
Owner: Blue Water Limited Partnership
Date of Inspection: 2/3/0 0 \....../
0 f.
v
SKETCH OF SEWAGE DISPOSAL SYSTEM: I,
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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revised 9/2/98 F V
I
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- 2/3/00
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 210=
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
YChecked 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
Lam/ Page 11 of II
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