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Home My WebLink AboutSystem E Inspection Report 2004 Apr 10-20 ` � , � COMMONWEALTH OF MASSACHUSETTS EXECUITVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIItONMENTAL PROTECTION G �z �, �� ,� io r �� CS _ N9�,�' 2 �) 20�J4 HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATIQN � t3Q�N 'N -�uJNE �� Property Address: 12� I �� Z O �Q� a�itad�� V I�Q' D 2b 6�f 5 ST£ME ' OF�ICG' � L Y ,�— AriN.v�� Owner's Name: � Q Z'NG• � S��jp`{ �pL(�W �,��"� Owoer's Address: s Qrn�' � Date of Inspectioo: y� 'Q � /J� � I D/J. I � Name of Inspector: (please print) Josep6 Martins Company Name: Accu Sepcheck Mailing Address: 17 Northside Dr., S Dennis,MA 0266Q Tekphone Number: 50&3855891 CERTIFICATION STATEMENT ] certify that]have personally insnected the sewage disposal system at this address and that the information reported below is true,accurate and compl�e as of the time of the inspection.The inspectioo was performed based on my training and exp�ience in the proper fimction and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuaot to Section 15340 of Title 5(310 CMR 15.000} 71ie system: �asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority �Inspector's Signatu • Date: � SB ll The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of campleting this inspection. If the sys[em is a shazed system or has a design flow of]0,000 gpd or greater,the inspector and the system owner shall subroit the report to the appropriate regional office of the DEP.The�iginal should be sent to the system owner and copies sent to the buyer, if applicable,and the approving autha�ity. �/ ) / NotesandComm�ts: �7(� ��//� OU��/^n�� .,di��/\ � �.v i W N7l G�/ �? G�/�'1�(/✓ 6�� O l� ,rl/I,��- CZI Co,.�i1ue, wil2► R�IQ� /�fai�7� ��rt�pi�✓v. ****This report only describes conditions at t6e time ot inspection and uoder the conditions of use at that time.This inspecdon dces not address how the system will perform in t6e future under the same or different cooditions of use. ` Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (wntinued) Property Address• 1261 Route 28, S. Yazmouth,MAS S�il�l�� q Owner: BEACH `N TOWNE MOTEL y Date of IospeMioo: RSP Inc., Sleepy Hollow Trust 4/10-4/20/04 Inspectioo Summary: Check A,B,C,D or E/ALWAYS compiete all of Section D A. System Passes: � I have not found any information which indicates that any of the fail�e criteria described in 310 CMR 15303 or in 310 CMR 15304 exist Any failwe criteria not evaluated are indicated below. Commenls: B. System Conditionally Passes: One or more system componenu as described in the"Conditia�al Pass"section need to be replaced or repaired.The system,upai completia�of ihe replacement or repa'v,as approved by the Board of Health,will pass. Answer yes,no or not detamined(Y,N,ND)in the_for the following statements.lf"not determined"please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal W not)is structinally unso�md,e�chibits substantial infiltration w exfiltration or tank failure is immin�t. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is struchually sound,not leaking and if a CertiScate of Compliance indicating that the tank is less than 20 years old is available. ND e�cplain: Observation of sewage backup or break out or high staiic water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box System will pass inspection if(with approval of Board of Health): _ broken pipe(s)arereplaced obstruction is removed _ distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obsuucted pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced abstruction is removed ND explain: ' Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 126] Route 28, S.Yarmouth, MA �� p BEACH `N TOWNE MOTEL �Sy�i'7EW1 E Owoer: RSP Inc., Sleepy Hollow Trust � Date of Inspection: 4/]0-4/20/04 C. Furt6er Evalustion is Required by the Board of Health: Canditions exist which require further evaluation by the Board of Health in ader to determine if the system is failing to prMect public health,safety or the�v'vonment. 1. System will pass uoless Board otHealt6 determines i cordsoce with 310 CMR 15.303(lxb)that t6e system is oot functioning in a manoer which wil tect public health,safety and the envirooment: _ Cesspool or privy is within 50 fcet s�sface water _ Cesspool or privy is withm 5 of a bordering vegetated wetland�a salt mazsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determioes that the system is fuoctiooing in a manner that protects the public healt6,ssfety snd 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 watea supply. _ The system has a septic tank and SAS and the SAS is withi�a Zone 1 of a public wata supply. _ T'he system has a septic tank and SAS and the SAS is within SO fcet of a ' e water supply well. The system has a septic tank and SAS and the SAS is less than feet but 50 feet or more from a private water supply well'•.Method used to determine distan **This system passes if the well water analysis,perfo ed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicaf at the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate ogai is equal to or less than 5 ppm,provided that�o other failw e cait�ia are triggered.A copy of alysis mus[be attached to this form. 3. Other: ' Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1261 Route 28, S.Yartnouth, MA BEACH `N TOWNE MOTEL�S�TE(b1"E" Owoer. RSP Inc., Sleepy Hollow Trust Date otlnspection• 4/]0-4/20/04 D. System Failure Criteria applicable to all systems: You must indicate`�es"or"no"to each of the following fw all inspections: Yes No _ �'Backup of sewage into facility or system component dce to overloaded or clogged SAS or cesspool _ �Discharge or ponding of efFluent to the swface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ ✓ Static liquid level in the distribution box above ouUet 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 %z day flow _ �lRequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number �of times pumped_. _ My portion of the SAS,cesspool or privy is below high ground water elevation. _ ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface _ '� wate,r supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ 1 Any portian 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 fcet but great�than 50 feet&om a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, per[ormed at a DEP certified Iaboratory,for coliform bacteria and volatile orgaoic compounds indicates t6at the well is free from pollution trom that facility and the presence of aromonia oitrogen aod nitrate nitrogen is equal to or Iess than 5 ppm,provided thst no other failure criteria are triggered.A copy of the aoalysis must be attached to this form.� �(Yes/No)T6e system fails 1 have dete�mined that one or more of the above failure critaia exist as described in 3]0 CMR 15303,thaefore the syst� fails.The system owner should contact the Board of Healih to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facitity with a design tlow of]0,000 gpd to 15,000 BPd• You must indicate eith�"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 feet of a swface drinking wa upply _ _ the system is within 200 feet of a tributary s�face drinking water supply _ the system is located in a nitrog sitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water s y well If you have answered"yes" y question in Section E the system is consid�ed a significant threat,or answered "yes"in Section D abo e large system has failed.The owner or operator of any large system considered a significant threat er Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15304.The system owner should contact the appropriate regional office of the Department. � Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLLTNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1261 Route 28, S.Yarmouth,MA Owner: BEACH `N TOWNE MOTEL�S�t�wl�� Date of Inspection: RSP Inc., Sleepy Hollow Trust 4/10-4/20/04 Check if the following have been done.You must indicate`�es"or"no"as to each of the following: Yes No � Pumping information was provided by the owner,occupant,or Board of Health _ �Were any of the sys[em componenis pumped out in the previous two weeks? _ �Has the system received normal flows in ihe previous hvo week period? _ � Have large volumes of water been inuoduced to tl�system recenUy or as part of this i�ispection? ✓_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) � _ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was ihe site inspected for signs of break out? Q,�� AG/�.D/NL- 7�� _� Were all system components mg[he SAS,located on site? (/— Were the septic tank roanUoles imcovered,opened,and the imerior of tt�e tank inspected for the condition of the ba8les or tees,material of conshuctioq dimensions,deptk�of liquid,depth of sludge and depth of scum 7 v Was ihe facility owner(and occupants if different from owner)provided with information on ihe proper maintenance of subsurFace sewage disposal systems? The size sud lacatioe of the Soil Absorptioo System(SAS)on the site has been determined based on: Yes no � _ E�cisting information.For e�mple,a plan at the Board of Health. � Decermined in the 5eld(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] ' Page 6 of i l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1261 Route 28, S.Yarmouth, MA Owner: BEACH `N TOWNE MOTEL�S�sTE'!bt pE � Date of Iospedion: RSP Inc., Sleepy Hollow Trust FLOW CONDITIONS 4/]0-4/20/04 RESIDENTIAL Number of bedrooms(design):L Number of bedrooms(actual): � /`� � �^L O w DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): i.7e Number of current residems: aZ Dces residence have a garbage grinder(yes or no):� Is laundrv on a separate sewage sys[em(yes r no):�O[if yes separate�u�spection required] Laundry system inspected(ves or no):�� 0'2003 ' S�7°"0 —3S000�Pzt� _ �(�2Goo Seasonal use: (ves orno):�/QS aooa � S�yoo� -35�� Q o00 Water meter readings,il'available past 2 yeazs usage(gpd)): /�c) ^ S2`j SumP pump(Yes or no): NO /}V�c. (� P� = �3�'� Last date of occupancy: .OM.rP�jL� �S'�s��s ��`« COMMERCIAL/INDUSTRIAL / Typeofes[ablishment: mFFlCE f' Lf/llSsl� /j1Q'Gy�l�$ n Desig�flow(based on 310 CMR 15.203): ��Z gpd 2)LC'P6,S 7�C U�J° '�T� �(� Basis of design flow(seats/persons/sqft,etc.): in i.�.��'� �yQS y/ Grease trap present(yes or no): NO p� �j S Industrial waste holding tank present(yes or no):_ � v� �� Non-sanitary waste discharged to the Title 5 system (yes or no):NZ� .d._� � n/,�n Water meter readings,if available: �'`�S s � Last da[e of occupancy/use: �iYcO� ��..` OTHER(describe): - GENERAL INFORMATION Pumping Records p Sourceofinformation: � mpe� a�o�, ��i �l9� - Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped: Qallw�s--How was quantity pumped determined? Reason for pumping: TYP OF SYSTEM � _Septic tank,distribution box, soil absorptian system —� � 6� Single cesspool Overflow cesspool Privy Shared system(yes ar no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the cwrent operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Oth�(describe): App roximate e of all�onents, te 11g��(�f known)and source of info ation: ;��4�f , ds,ST91�� 7'9S D�-�� . Were sewage odors detected when amving at the site(yes or no):�Q ' Page7oflt OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1261 Route 28, S. Yarmouth, MA Owoer: BEACH `N TOWNE MOTEL�S�S'7�'IIqKE � Date of lnspection: RSP Inc., Sleepy Hollow Trust 4/10-4/20/04 BUILDINC SEWER Qocate on site plan) Depth below grade: Z � Materials of construction:_cast iron 40 PVC other(explain): Distance from private water supply well or suction line: c rossPS /�¢q✓ ?.s � /'� ZO� Con nents(on condition of joints,venting,evidence of 1�ge,etc.): I LY�a✓ O�C /�l�Q��lu�Z 6�-'f— �$�K��- s /ee/�v ✓�0.yc✓�i A� qve.— p 1a„ . SEPTIC TANK:�locate on site plan) / � p �tt�be�oW�ade: 32 �� 2� � w �lK �� by �d.S�AA� � l �Q�' 1�� Material of construction:�concrete_metal_fiberg►ass�olyethylene otha(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: �� D X.s � 7 X �� 0 A Sludge depth: ,3 3 I p Distance from top of sludge to bottom of outlet tee or baftle: Scum thiclmess:� O-lI Distance from top of scum to top of outlet tee or baftle: � �! Distance from bottan of scum to bottom of outlet tee or baftle: How were dimensions detamined: pYACI(1q,�P� ST� S��'e I V�� Comments(on pumpmg recommen on�and outlet tee or bat}le condition,struc�ual integity,liquid levels as related to ouUet invert,evidence of Ieakage,etc.): nlefi t t 2P asfi f T� iN vo� e� vi �.�nce ��pA a � �� {�" i�vP� T �1/d GREASE TRAP:_(locate on site plan) Depth below grade:_ Mat�ial of construction:_concrete_metal_fiberglass_polyethylene_oth (explain): Dime�sions: Scum thiclrness: Distance from top of scum to top of outlet tee or baf�le• Distance from bottom of scum to bottom of outl or baffle: Date of last pumping: Comments(on pumping recommend ' s,inle[and outlet tee or baflle condition,structwal integrity,liquid levels as related to outlet invert,evid of Ieakage,etc.): � . � Page 8 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1261 Route 28, S. Yarmouth,MA Owaer. BEACH `N TOWNE M07'EL�SYS7FN�1 N� n Date otlospeMioo: RSP Inc., Sleepy Hollow Trust 4/10-4l20/04 T1GHT or HOLDING TANK:_(taok must be pumped at time of inspectionXlocate on site plan) Depth below gade: Mat�ial of construction:_wncrete_metal_fiberglass ylene_other(explain): Dima�sions: Capacity: pallon Design Flow: �s/day Alarm present(yes or no):_ Alarm level: am� in working ord�(yes or no):_ Date of last mg: C conditim of alarm and float switches, etc.): DISTRIBUTION BOX: ✓ (if present must be openedxlocate on site plan) Depth of liquid level above outlet invert:� p�� /f yP,�(,' Commenu(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.): / v s A �e�`/eY Q 'P��LI .P.�ICL2� �—�qr�y6zdP�,�d �f �° P"�� P[IMP CHAMBER:_(locate on site pian) Pumps in working order(yes or no):_ Alarms in working order(yes or no):_ Comments(note condition of pump charnber,condition of pumps and appiut�ances,etc.): � Page 9 of i t OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owoer. 1261 Route 28, S. Yarmouth, MA �� ,� Date otinspectioo: BEACH `N TOWNE MOTEL�Sy$��A E RSP Inc., Sleepy Hollow Trust SOIL ABSORPTION SYSTEM(SAS): _(locate on site p1�()eXgaHpbipn not required) ]f SAS not located explain why: Ty� y ' / ',�ra ' ��►d� p� Q .q��,r _leaching pits,mm�ber:� X (�J V" � I (�B ry v/�'(� . _leaching chambers,number._ �_ `�� ;� �2 _leaching galleries,number: , _leaching trenches,number,length: " �� "" !Q 3 _leaching Selds,number,dima�sia�s � overflow cesspool,number: innovative/altanative system Type/name of technology: Comments(note condition of soil,signs of hydraulic fail�ue,level of ponding,damp soil,condition of vegetation, etc.): _ ` SOIC.. C�eah �QVP. A�TCo✓[.��/a" �OYti � a�P 1 . C/�#.S l.��Y, �-P /�3�° o F ci 4 O��S k rr�a • � <e � � ,�.paJ Co" oF sr�9c.. 4'r� earrav�— �,�vs��• CESSPOOLS:_(cesspool must be pumped as part of inspec[ionxlocate on site plan) Number and con5guration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Mazeaials of cansWaion: Indication ofgroundwater' (yes or no):_ Comments(note con ' 'on of soil, signs of hydraulic failwe,level of ponding,condition of vegetation,etc.): P1tIVY:_(locate on site plan) Materials of conshvdion: Dima�sions: Depth of solids: Comments(note condition � ,signs of hydraulic failwe,level of ponding,condition of vegetation,etc.): r , tX �i= !o t,x 4 _` ` �6� � �_ __ — �t �' ., � p : ., „ � , . +�3 �; ; - � ? a� .- . , !Zl�.7� . a� ''� � � � r �� - � �'� � '� � ii.*.�w.- ��, 1�` � r 30, � � � �'� ' � �'__ �e } q ,- - ,�;— . -� - _ _; ��;' � - - _,,�, - . . ,� .. - -___ ! � � �.1� , n,� � ' _ % � '�.-. t � ��ur��Tia lopXl ]� �.fw�.R 5 r ., ' � � '• / sYs`� �Y , ., f' i� ! � �q�. /zp�= - , _ _�o ; � l , ,. �� . � '� i -•Y� ( .' � .-. ��`�r � '�_. ., s��i4 �.: . � �; \ i• t'� i ..\ � /o.! .. , , ,� �, � 7 �� "-- �i• + � / � 5Y$7� ,. . . � i .� � ;. - � +_ �'A �` ".� Y ' � C ___,_. : -J c. � i�- . ��t� Lo%: � � r,. � r � !p� '� � ' - :� Q . � i � s t�' ,/� ' � � - Z --. � � � ," `' � ,2e' "' :r. �- �� - .. � '� u,�► 3��7 s�,�e,,, �� ' _� � ,� t � ; � �S: . :;7�� Y:7�� W a ��y' � h L • J O _ ' •'% `6D� aa� . ' w � �� , _ r :�K�`sfi � f �v r i, p `�. �+ p v. �.� j 5y57� i,� `'f}`) � � �� , .�. ' .� �_ '�r� ` . � �� fl � � —�� _ � ,. �� s � . - - � _ _ \,R _� �er�mc ,:'- ';' eo• ' � � '•• . ' --_ : �:,_ � . � ,; ,: lnaY6 � ' ` k�� -�,` / • .' ' Page 10 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DI5POSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1261 Route 28, S. Yarmouth, MA n� N Owner: BEACH `N TOWNE MOTEL��SySUSlbi Date of Inspection: RSP Inc., Sleepy Hollow Trust 4/10-4/20/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal sys[em including ties to at least two permanent reference landmazks or b�.mchmarks.Locate al]wells within 100 feet.I,ocate where public water supply entas the building. M�1'N�rG�Y1.�S L�T- 0 �G�cC- [.AuWDR� Sys�n� �� Rv►�� A' B p[STA�NG�S ' vo/ ► A1-al•s;81=135� 2 o A��_�S.�- �9.5� , _ 3 /�-3=,�q � B3 =�3 �" `�=37 ; �`f =3 ( o ° � �"�3�s l�'y� � �� z� . . '_ Page 11 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) � Property Address: Owoer: 1261 Route 28, S. Yarmouth, MA Date of Inspection: BEACH `N TOWNE MOTEL �Sys7F'K1°E�+ SITE EXAM RSP Inc., Sleepy Hollow Trust S�o� 4/10-4/20/04 Surface water Check cellar Shallow wells � Estimated depth to growd water � � � • ?+ Please indicate(check)all methods used to determine the high ground water elevation: �Obtained from system design plans on record-]f checked,date of design plan reviewed: q *Z Observed site(abutting property/observation hole within I50 feet of SAS) Checked with]ocal Board of Health-explain: Checked with Iocal exravators,installas-(attach documentation) ,i Accessed USGS database-eacplain: C�@ JM�TE/C I��/� You must describe how you established the high ground water elevation: (. � �s ��-r� �5-�— �l�; 1s�" o� �3.� �- �` 3 �R Z- . . �l� IVa�1Cv- e�Ca�Pr � � �ac�e 7v P�T (�o ttr�rv��max� = I D,Z 3- ��S17Hh �iU� M��n1 �--� � ��z, = � � ' �(� �a-Kn 13. Z - l4 � Zf2 -7 � �, 2.� �, ��puc�juv� ��57MPti� �'ween �f�-o% �I allo( TPs�-/�-o�e �3 = O, ,S�i rS��i � sLow��c� ( • t�t a � Q...s� t�. Z �D. 7 �