HomeMy WebLinkAboutSystem A Inspection Report 2004 Apr 10-20� _
� • COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVII20NMENTAL PROTECTION
Gi 1= 15 '_- _ . 's DD
o�
' f�,^;��Y � ;) 2C04
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFI ATION
�e�c� 'N To�u� �a/e !� [/
Property Address: '� ' �Z�j � s' a�m��-�j � �� O�� /
Owner's Name: S/�S f� Ti/1 G • '/,S��Om����`�� ��.5�
Owner'sAddress: �.q�e
� Py
Date of Inspection: I�/,/O�d-00 Y� '�/�O /O7'
IVame of Inspector: (please print) Joseph M.Martins
Company Name: Accu Sepcheck
Mailing Address: 17 Northside Dr., S. Dennis,MA 02660
Telephone Number. 508-385-5891
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the infortnatio�reported
below is true,acc�sate and complete as of the time of the inspection. The inspection was perfortned based on my
training and experience in the proper functian and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system:
'� Passes �
Conditional Passes
Needs FuRh�valuation by the Local Approving uth ity
Fail
Inspector's Sign Date: dd �
'fhe system inspector shal ubmit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 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 repoct to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority. /, � �L � /�Q�.S'P�
L!) - S �1 � T n� ��/jl� �o v�
Notes and Comments: � w�f��,,i Git A/C grQ �
v
��c�m.�+7�r�c�( �0 vla� /"'ar4f" Pv.a i
��'� e�e,-y y�R— fo� -�s -�.,K � �
****This report ooly describes conddions at the time of inspection and under the conditions of use at t6at
time.This inspection dces oot address how the system wili perform in the future under the same or differeut
conditioos of use.
Page 2 of 1 I
OFFICIAL INSPECTIOIY EORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1261 Route 28, S.Yarmouth, MA
BEACH `N TOWNE MOTEL � SyS T"f� ��
Owner. RSP [ncl., Sleepy Hollow Trust
Date of Inspection: 4/]0-4/20/04
Inspection Summary: Check A,B,C,D or E!ALWAYS complete all oTSection D
A. Sys m Passes:
I have not found any informarion which indicates that any of the failure criteria described in 310 CMR
I5303 or in 3l0 CMR 15304 exist My Eailure criteria not evaluated aze indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to aced or
repaired.The system,upon completion of the replacement or repair,as approved by the B f Health,will pass.
Mswer yes,no or not determined(Y,N,ND)in the_for the following stat �ts. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septi k(whether metal or not)is structucally
unsound,eachibits substantial infiltration a exfiliration or tank �ure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as a oved by the Board of Health.
*A metal septic tank will pass inspection if it is stru y sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is a �lable.
ND explain:
Observation of sewage bac r break out a high static water level in the distribution box due to broken or
obstruded pipe(s)or due to a brok ,settled or uneven distribution box. System will pass inspection if(with
approval of Boazd of Health):
_ broken pipe(s)aze replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass in ion if(with approval of the Boazd of Health):
broken pipe(s)are replaced
obstrudion is ranoved
ND explain:
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, Page 3 of 1 1
OFFICIAL INSPECTION FOR1�I _ NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SySTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address;
Owner: 1261 Route 28, S. Yarmouth,MA
Date of Iaspection: BEACH `N TOWNE MOTEL� S,IST "f}"
RSP Incl., Sleepy Hotlow Trust
C. Further Evaluation is Required 6 4/10-4/20/04
y the Board of Hea�th:
�S ����g o protect public h�ealtl�uire further e�aluation by the Board of Health in order to det
safety or the environment �n�ne if the system
1• System wi11 pass unless g�rd ofHea�th determines in acco
system is not functiouing�o a maouer which will prute Iic healthh�{e CMR 15.303 I
( xb)that the
_ Cesspool or privy is witl��50 feet of a s ' �3'aod the environment:
_ Cesspool or priry is within 50 feet w'ater
rdering vegetated wetland or a sa�t marsh
2• System wip fail un�ess the Board of Health(aud Pu61ic Water Su
system is functiuniug io a manner that prutec�y the
pplier,ifany)determines that the
public health,safety and envlronment:
T'he syst �P� r�t���d soil absorption syyKem (SAS)and the SAS is within (00 feet ofa
surface water s
�'y to a swfice water supply,
_ The system has a septic tarig a�d SAS and the SAS is w{thin a Zone t o
— The system hu a lic water supp�y.
septic tank a�d SAS and the SAS is wi '
feet ofa private water suPP�Y well.
— Tha system has a yeptic tank and SAS�d�
private water suPP�Y well'*. M���t is less th� 100 fe�et bu[50 feet or more from a
ermine distance
"This system P�ses ifthe wel
bacteria and volatile organ' ��aly�is,per�o�'med az a DEP
the prese�c�of�m . P�nds indicates that the well is Gee from�laboratory, for coliform
failure critaia nitrogen and nitrate nitrogen is Pollution from thaz facility and
�ggered.A coPY of the analysis m��ual to or less than 5
be attached to this form�,�ovided that no other
3• Other:
\
Page 4 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM [NSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1261 Route 28, S.Yarmouth, MA
BEACH `N TOWNE MOTEL, Sy}� �'/� �'
Owner: RSP IncL, Sleepy Hollow Trust
Date oF Inspection: 4/10-4/20/04
D. System Failure Criteria appiicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ �Dischazge 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 a
cesspool
� Liquid depth in cesspool is less than 6"below invert or available volume is less than Y:day flow
✓Requ'ved pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
f of times pumped_.
My portia�of the SAS,cesspool or privy is below high ground water elevation.
_ ✓ My portiai of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
� Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ My portion of a cesspool or privy is within 50 feet of a private water supply well.
— y My 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. �This system passes if the well waMr analysis,
periormed at a DEP certified labontory,for coliform bacteria and volatile organic compounds
indicates that t6e well is free from pollutiou from that facility aod the presence of ammonia
nitrogen and oitnte nitrogen is equai to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.�
�(Yes/No)The system fsils.I have determined that one or mae of the above failure caiteria exist as
described in 310 CMR 15303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system t6e system must serve a facility with a desigo flow of 10,000 gpd to 15,0110
SPd•
You must indicate eitha`5res"or"no"to each of the following:
(The following critaia apply to lazge systems in addition to the criteria a
yes no
- - the system is within 400 feet of a s drinldng water suPP�Y
_ _ the system is within 2 of a tributary to a surfice drinking water supply
_ the syst � ocated in a nitrogen sensitive area(Intaim Wellhead Protection Area—IWPA)or a mapped
Zo of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a signi6cant threat,or answered
"yes"in Section D above the large system has failed.The owna or operator of any large system considered a
significant tiveat�mder Sedion E or fiiled undex Section D shatl upg�ade the system in accordance with 3l0 CMR
15304.The system owner should contact the appropriate regional office of the Department.
�
Page 5 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1261 Route 28, S.Yarmouth, MA
BEACH `N TOWNE MOTEL � S y ST��.a '�
Owner: RSP Incl., Sleepy Hollow Trust
Date of Iospectioo: 4/10-4/20/04
Check if the following have been done You must indicate`�es"or`ho"as to each of the following:
Yes �1Vo
� Pumping information was provided by the owner,occupant,or Board of Health
_ /� Were any of the system componerts pumped out in the previaus rivo weeks?
__ ✓ Has the system received nornial flows in the previous two week period?
_ (�Have large volumes of water been irtroduced ro the system recently or as pazt af this inspection?
✓_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_L/ Was the facility or dwelling inspected for signs of sewage back up?
� Was the site inspected for sigus��r�lc out?�
^g��l/
t/� Were all sys[em components, g�SAS,located on si[e?
� Were the septic tank manlioles uncovered,opened,and the interior of the tanlc inspec[ed for the condition
of the ba8les or tees,material of consUuction,dimensions,depth of liquid,depth of sludge and depth of scum?
� Was the faciliry owner(and occupanis if different&om owner)provided with infornia[ion on the proper
maintenance of subsutface sewage disposal systems?
The sae and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
�/ Existing infortnation.For e�cample,a plan at the Board of Health.
✓ Determined in the field(if any of the failure critaia related to Part C is at issue approximatiai of distance
is imacceptable) [310 CMR 15.302(3xb)]
�
Page 6 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1261 Route 28, S.Yattnouth, MA
BEACH `N TOWNE MOTEL � S�/ST n���
Owner: RSP Incl., Sleepy Hollow Trust
Date ot Iuspection: 4/]0-4/20/04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):� Number of bedrooms(actual): _ J?3 �
DESIGN flow based on 310 CMI2 15203 (for e�mple: 110 gpd x#of bedrooms):
Number of cuirent residents: (^J --
Does residence have a garbage grinder(yes or no): ��
Is laundry on a sepazate sewage system(-ygs or no):Q�/ [if yes separate inspection required]
Laundry system inspected(yes or no):N a oZ 00 3 = S/�i 00D — 3.soo0 f.a p� L � �a OJ U
Seasonal use: (yes or no): �
Water meter readings,if a�ble(last 2 years usa8e(gpd)): �-bDe2 = ri�Y O O D ^,3 S�a�a o C = Sd9 e•�
SumP P�P(Yes or no):�� �V� �s Q� = �3��� S S�M S
Last date of occupancy: �
COMMERCIALINDUSTRIAL
Type of establishment: /Y/0 TEL
Design flow(based on 310 CMIt 15.203): gpd
Basis of design flow(seatslpersons/sqft,etc.):
Grease trap present(yes or no):_
[ndustrial waste holding tank present(yes or no):_
Non-sanitary waste dischazged to tl�e Tide 5 system(yes or no):_
Water meta readings,if available:
Last date of occupancy/use:
OTIIER(describe):
GENERAL INFORMATION
Pamping Records p� ,20D 2 ZO�d 19! �/ �/(O�O �-e�C Qj�
Source of information: ` u��� � L O 7 � ,�/
Was system pumped as part of the inspection(yes or no):�Q
If yes,volume pumped:_ga��m�s--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
fG Septic tank,disiribution bo�c,soil absorption system
_Single cesspool
Overflow cesspool
_�'rvY
Shazed system (yes or no)(if yes,attach previous inspection records,if any)
InnovativelAlteana[ive technolagy. Attach a copy of the cucrent operation and maintenance contract(to be
obtained from system owner)
_Tight tanlc _Attach a copy of the DEP approval
_Other(describe):
Ia ApQroximate��C�/�e i�,talled(if lmown)and��of infojm�t�n:
, /.[' J � Y �
/4�i�--T�—
Were sewage odors de[ected when arriving at the site(yes or no):�a
Page 7 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1261 Route 28, S.Yartnouth, MA
BEACH `N TOWNE MOTEL�s'Y.��'�'�
Owner: RSP Incl., Sleepy Hollow Trust
Date of Inspection: 4/10-4/20/04
BUILDWG SEWER(Iocate on site plan)
Depth below grade: eZ -' 3 I
Materials ofconstruction: ✓cast'von 40 PVC_other(explain):
Distance from private water supply well or suction line: �/o�
�Co ments(on condition ofjoints,venting,evider�ce of leakage,et
r,�,� o� �y � ✓����.Q. d � /QG�oQ
SEPTIC TANK:`/(locate on site plan) (( —Z O Ti`�'��/ /�
�chbe�oW�ade: .Z —3 � //Q.$ o�l I71��/ CO✓'P.✓S Tp JC'Yqp�.�
Material of construction:_concrete metal_fiberglass_�olyethylene
other(explain)
If tank is metal list age:_ Is age con5rmed by a CertiScate of Compliance(yes or no):_(attach a copy of
D m'en(stons: ��/D // nr S� 7�� X O'/(� // f 000 Ci 41��'l
\/
Sludge depth� 3 a,,
Distance from top of sludge;o bottom of outlet tee or baftle:
� Scum thiclmess: a _� , ��� �
Distance from top of scum ro top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee a bafIle:
How were dimensions determined: �'?/"Qa�l/G�Yel s�7�� S L�/�SC 6r ✓��--
Comments(on pumping recammend�a ions,inlet and oudet tee or ba e cond�don,slructural u�tegnty, liquid Ievels
as relazed to ouNet invert,evidence of 1 age,etc.): u V , /
� 7ql nI� S�KV/GPSPI�R UA113n�
� �c�n o ' T/f�
�/ QJ11J /�pr.�e R �/P��•
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Mataial of construdion:_conaete_metal_fiberglass_�olyethylene_other
(explain):
Dimensions:
Scum thiclmess:
Distance from top of scum to top of outlet ftle:
Distance from bottom of scum to of outlet tee or baftle:
Date of last pumping:
Comments(a�p�nn � ecommendations,inlet and ouHet tee or baflle condition,slructural inte@�ity,liquid levels
as related to ou mvert,evidence of leakage,etc.):
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1261 Route 28, S.Yartnouth, MA
Owner:
BEACH`N TOWNE MOTEL�SyST��i4��
Date of[nspection: RSP Incl., Sleepy Hollow Trust
4/10-4/20/04
TIGHT or HOLDING TANK:_(tank must be pumped at time of inspectionxlocate on site plan)
Depth below grade:_
Material of wnstrudion: concrete_metal_fiberglass ethylene_other(explain):
Dimensions:
Capacity: �allons
Design Flow: gall y
Alazm present(yes ar no):
Alarm level: AI ui working order(yes or no):_
Date of last pumpin •
Commenu ion of alarm and float switches,etc.):
D[STRIBUTION BOX:_" (�t present must be opened)(locate on site p(an)
Depth of liquid level above outlet invert: 1�'�/V V G/`�
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): D n O x eL�d �
� �`� �r
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or na):_
Alartns in working order(yes or no):_
Comme�ts(note condition of pump chamber,condi6on of pumps purtaiances,etcJ:
Page 9 of 1 I
OFFICIAL INSPECTION EORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
1261 Route 28, S. Yarmouth, MA
D te of[nspection• BEACH `N TOWNE MOTEL � SYSTn/}��
' RSP Incl., Sleepy Hollow Trust
SOIL ABSORPTION SYSTEM(SAS): _pocate oo site plat���Qc913�d1Anot required) �/�p < </�J-d/D y
[f SAS not located explain why:
TyPe / �I �/G G���Me— Grad� t� �I�UV N(/Nl,
�leaching pits,number: ^ � ��
leaching chambers,number:_ �
leaching galleries,number:
leaching h�ches,mm�ber,length:
_leaching Selds,number,dimensions:
overflow cesspaol,number:
innovative/alternative system Typelname of technology:
Comments(note condition of soil,signs of hydraulic faih¢e,level of ponding,damp soil,condition of vegetation,
etc.): •
O /bN O F Gr�-av !c u/Ld,[E •S T�`h�v G�n L
/!�D �� .. �� � D,o-c _ STdi.. L.ire
�,4e.�r,.��-� > ��>� ,��a,,,� „P, ,o� L2a� S'�n� i� v�s�tilp �01�
s�,,.rc„r.e ��•� T �s O/Z� a —/ G(Q��� .
CESSPOOLS:_(cesspool must be pumped as part of inspech xlocate on site p an)
Number and con5guration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dima�sions of cesspool:
Mataials of construdion:
Indication of groundwater' ow(yes or no):_
Comments(note con ' ' of soil,signs of hydraulic failiae, level of ponding,condition of vegetation,etc.):
PRIVY:_(locate on site plan)
Materials of conshuction: _
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hy c fiilure,level of ponding condition of vegetation,etc.):
Page 10 of I 1
OFFICIAL [NSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM [NFORMATION(continued)
Property Address: 1261 Route 28, S. Yazmouffi, MA
BEACH `N TOWNE MOTEL �SyST�!{ ��
Owaer: RSP Incl., Sleepy Hollow Trust
Date of InspeMion: 4/10-4/20/04
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties ro at least two permanent reference landmarks or
benchmazks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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, Page I I of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE D[SPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
� Property Address-
1261 Route 28, S. Yarmouth, MA
Owner: BEACH `N TOWNE MOTEL� S�IST^���
Date of Inspection: RSP Incl., Sleepy Hollow Trust
SITE EXAM 4/10-4/20/04
Slope
Surface water
Check cellar
Shallow wells �
Estimated depth to ground water � /�• 2"
Please indicate(check)all methods used to detertnine the high ground water elevation:
Obtained from system design plans on record-[f checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Acce�ssed USGS database-explain:
You must describe how you established the 6igh ground water elevation:
�. r.�s� � r#� -�2 ��s��-�✓ �'/3/��
_ /1/U wq'fe r A�. ._ / 3 . Z�
� . �rrdv�� w��� �C�vs�7ijP�t ��6//��
/�? !�/ � y', � . _ _ , . - a �
3 . ��'a d..� 77� �� Y�d��d�L, . . _ _ f 3
y, /�f a�� l 3. .�. a 7 t- f�. 3 - Z. Z