HomeMy WebLinkAboutSystem G Inspection Report 2004 Apr 10-20 , ,
� COMMONWEALTH OF MASSACHUSE'I"fS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
, DEPARTMENT OF ENVIRONMENTAL PROTECTION
Y
G3 � C� � � M � D
,,;+a� ?, � 20'J4
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
BeQ� �� �w�� �of�/ � �.�f /y� a (�
PropertyAddress: lOZ�OI l�fe �-�' nS'/9/'-Y4vV/�'� / ��//r!/7i�7
S ��� �� (Y" � /CW'�'iS ��j ��/ /Sf�
Owner's Address: �`�a� �• , s��P�y �/ldw ��us�
Date of[nspection: �!/���OD t� � L�/��p/LC�d y
Name of Inspector: (please print) Joseph M. Martins
Company Name: Accu Sepc6eck
Mailing Address: 17 Northside Dr., S DCOOIS�MA 02660
Telephone Number: 50&385-5891
CERTIFICATION STATEMENT
I certify that 1 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 the inspection.The inspection was performed based on my
traming and experi�ce in the proper fundion and maintenance of on site sewage disposal systems. I am a DEP
approved system iospector pursuaot to Section 15340 of Title 5(310 CMR 15.000). The system:
�Passes
Conditionally Passes
Needs Further Evaluatian by the Local Approving Authaity
Fails
Inspector's Signatu Date: �a� �y
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healtti or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of]0,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP."[he original should be sent to the system owner and copies sent to the buyer, if applicable,and the aporoving
authority. C� ) S�/L�/��� C�J�i-�i v� 4 j�f�,{ft—�✓Q/e
NotesandComments: /'-tiT/S�(�_�� ��/�'�- ����
*•t•This report ooly describes conditions at the time of inspectioo and under the conditions of use at t6at
time.This iospection dces not address how the system will perform in the future under the same or difierent
conditions of use.
Page 2 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.Yarmouth,MA �
BEACH `N TOWNE MOTEL� .SrST��G �
Owoer: RSP Inc., Sleepy Hollow Trust
Date of lnspection: 4/]0-4/20/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete ali of Section D
A. Sys m Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15303 or in 310 CMR 15304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditiooally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repa'ved.The system,upon completian of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y>N,ND)in the_for the following statemenu.If"no ermined"please
explain.
The septic tank is metal and over 20 yeazs old"or the septic tank(wh er metal ar not)is structurally
unsouod,exhibits substantial infiltration a exfiltration or tank fail�e is� inent.System will pass inspection if the
existing tank is replaced with a comp1ying septic tank as approved e Board of Health.
'A me[al septic tank will pass inspection if it is slructurally so not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is availabl .
ND explain:
Observation of sewage backup or out a high static water level in the distribution box due to broken or
obslructed pipe(s)or due to a broken, led or�meven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstrudion is removed
distribution box is leveled or replaced
ND explain:
e system requ'ved pumping more than 4 times a yeaz due to broken or obstructed pipe(s).T'he system will
pass ' spectimi if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
� Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARy ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
1261 Route 28, S. Yarmouth,MA
Owner: BEACH `N TOWNE MOTEL�S�fST�����
Date of InspeMiun; RSP Inc., Sleepy Hollow Trust
C. Further Evsluation is Required by tbe Board of Health:4/10-4/20/04
Conditions exist which�eyuire furtha evaluation by ue goard of Health in order to determine if the system
is failing to protect public health,s��y,m�e�v'vonment.
1. System will pass unless g��of Health determines i cordance with 310 CMR 15.303(]xb)that the
system is not fuoctioning in a manner whic6 wil tect public healt6,safety and the environment:
_ CeseSsp�ool or privy is within 50 f� s�face water
of a bordering vegetated w���d�e sa�t marsh
Z- Systero wi11 fail unless the Board of Health(and Public Water Suppliey if any)determines that the
system is functioning ie a manner that protects the public health,satety and environment:
�e��n has a septic tank and soil absorpti�system SAS
sw'�ce water supP�Y o+ b'ibutary to a sur�ce w�ter supply. ( e SAS is within 100 feet of a
— �e��n hat a septic tanlc and SAS and the is withi�a Zone 1 of a public water supp]y.
— �e��+n hes a septic qnk and S d the SAS is wittiin 50 feet of a private water supply well.
'Ihe sys[em has a�ptic d SAS and the SAS is less than ]pp
private wat�y�pp�y���«s feet bu[50 feet or mwe from a
ethod used to determine distance
*•1'his system p� �f�e well water analysis>Pet'fornied at a DEP
bacteria and vo �e aganic compou���di���at the well is fr frm polluqon from that'fa��j�,and
�e Pr�n of arnmonia nitrogen and nitrate nitrogen is equal ro or less ihan 5 PPm>provided that no other
fail�e crita�ia aze trigg��.A�py of the analysis must be attached to this form.
3. Other:
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
1261 Route 28, S.Yartnouth, MA
Property Address: BEACH `N TOWNE MOTEL� $yST "G'��
Owner• RSP Inc., Sleepy Hollow Trust
Date of Inspection: 4/10-4/20/04
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into faciliry or system component due to overloaded or clogged SAS or cesspool
_ fDischarge or ponding of effluent to the surface of[he gound 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 cesspoo] is less than 6"below invert or available volume is less than %a day flow
_ �/Requ'ved pumping more than 4 times in the last year NOT due to clogged or obstructed pipels).Number
of times pumped_.
�Any portiai of the SAS,cesspool or privy is below high gound water elevation.
_ �My portia�of cesspool or privy is within 100 feet of a s�face water supply or tributary to a swface
water supply.
_ 1 Any portioa�of a cesspool or privy is within a Zone 1 of a public well.
_ �✓ y portim�of a cesspool or privy is within 50 feet of a private water supply well.
y portion of a cesspool or privy is less than ]00 feet but great�than 50 feet from a private water
supply well with no acceptable water qualiry analysis. (This system passes if the well water analysis,
pertormed at a DEP cerlified labontory,for coliform bacteria and volatile organic compounds
indicates t6at the well is tree from pollntion trom that facility and t6e presence of ammonia
nitrogen aod nitrate oitrogeo is equal to or less thsn 5 ppm, provided that no ot6er failure criteria
NDare triggered.A copy of t6e analysis must be attached to this form.�
(Yes/No)The system fsils.I have determined that one or more of the above failure critaia exist as
described in 310 CMR 15303,therefore the system fails.The system owner should contact the Board of
Health to detertnine what will be necessary to corred tlie failure.
E. Large Systems:
To be considered a Isrge system t6e system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd•
You must indicate eitha"yes"or`S�o"to each of the following:
('Ihe following critaia apply to large sys[ems in addition to the criteria abo
yes no
_ _ the system is within 400 fcet of a surfa mking�vat�supply
_ _ the system is within 200 f of a tributary to a swface drinking water supply
_ the sys[em is 1 ed in a nitrogen sa�sitive area(Interim Wellhead Protection Area—[WPA)or a mapped
Zone II public water supply well
If you have answered"yes"to any question in Section E the sys[em is consid�ed a significant threat,or answered
"yes"in Section D above the lazge system haz failed.The own�or operator of any large system considered a
si�ificant tFveat unda Section E or failed�mder Saction D shall upgrade the system in accordance with 310 CMR
15304.'Ihe system owner should contact the appropriate regional office of the Departrnent.
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�/ST G ��
Owoer: RSP Inc., Sleepy Hollow Trust
Date of lospection: 4/]0-4/20/04
Check if the following have bcen done You must indicate`�es"or"no"as to each of the following:
Yes No
J�_ Pumping information was provided by the owner,occupant,or Board of Health
_ = Were any of the system components pumped om in the previous two weeks?
� Has the system received normal flows in ihe previous two week period?
�Have large volumes of water beea introduced to the system recendy or as part of this intipection T
� Were as built plans of the system obtained and e�camined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
� Was tLe site inspected for signs of bx�a�out?
inc u/ D.✓+��`�
� Were all system components,e g the SAS,located on site?
!� Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the ba8les or tces,material of constiuctioq dimensions,depth of liquid,depth of sludge and depth of scum?
� Was the facility owner(and occupants if different from owner)provided witl�infonnation on the proper
mauitenance of subsurface sewage disposal systems?
'Ihe size and locadon of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
✓_ E�cisting mformatim�.For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximatia�of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 1 I
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
BEACH `N TOWNE MOTEL� S yST^���
Owner: RSP Inc., Sleepy Hollow Trust
Date ot Inspection: 4/10-4/20/04
FLOW CONDITIONS
RESIDENTIAL (,f
Number of bedrooms(design):! Number of bedrooms(actual):_
DESIGN}low based on 310 CMIt 15.203 (for e�mple: 110 gpd x N of bedrooms): ��
Number of c�urent residents: � � '{
Dces residence have a garbage ginder(yes or no):��
Is laundry on a separate sewage system(ye or no):/�� [if yes sepazate inspection required]
Laundry system inspected(ves or no): �/}� �q� 3 ; S/7�Doo —3S��oo L = y�2��
Seasonal use: (yes or no):�S .�d Z : ,S(,yi oad —3Soov �pe� = s29�
Water meter readings,if av�ilable past 2 years usage(gpd)): e
SumP P�P CYes or no):LJ� s/'(�� �. P. ,f� � �3�.�/�i
Last date of occupancy: O� 6 S��$�.N'LS
COMMERCUIL/INDUSTRIAL
Type of establishment: O7�L
Design flow(based on 310 CMIt]5.203): �pd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):_
Induslrial waste holding tank present(yes or no):_
Nm�-sanitary waste discharged to the Title 5 system (yes or no):_
Water meter readings,if available:
Iast date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Puroping Records OV� �n� 2vd t� ZB�J� I 4�� �9�. �Y-"'�
Source of information: 1 (���
Was system pumped as part of the inspection(yes or no): A! ?�
If yes,volume pumped: Qallais—How was quantity pumped detamined?
Reason for pumping:
TYP$OF SYSTEM
✓Septic tanlc,distribution bon,soil absorption system
Single cesspool
Overflow cesspool
Priry
Shazed system (yes or no)(if yes,attach previous inspection records,if any)
InnovativeJAltemative technology. Attach a copy of the cwrent operation and maint�ance contract(to be
obtained from system own�)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
�Ap roximate age of all componen•�ts date installed(if Imown)and source of information:
� 1�Qai . �TG !� L �'!�'7 � y�2�[�
Were sewage odors detected wh�arriving at the site(yes or no):��
Page 7 of 1 I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contiwed)
Property Address: 1261 Route 28, S. Yartnouth, MA
BEACH `N TOWNE MOTEL � SYST•��G'��
Owner:
Date of lnspection: RSP Inc., Sleepy Hollow Tntst
4/]0-4/20/04
BUILDING SEWER(locate on site plan)
Depth below grade: 2 '3 �
Materials of construction: ✓cast iron 40 PVC other(explain):
Distance from private water supply well or suction line: �/O�
Comments(on wndition of joints,venting,evidence of leakage,etcJ:
.i Ne
SEPTIC TANK:_(locate on site pla�)
Depth below grade: � �,� � CO��'S W ��� � n �./ �a `.�.
Material of construction:_concrete_metal_fiberglass_�olyethylene
Mher(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) ,/ y � y �� e7 /
Dimensions: 7 �/D ry � 6 �� /1 S / � l�C�l��
Sludge depth: /'/ 3 ��
Distance from top of s�'dge to bottom of outlet tee or baftle:_�
Scum thicFa�ess:�_ / ��
Distance from top of scum to top of outlet tee or baftle: (O �r
Distance from bottom of scum to bottom of ou let t�e or_�f�l�e�. `__��t�—s� �� � .
How were dim�sions determined• 4J� �.� c Gd� v
Comments(on pumping recomm t�ons,mlet and outlet tee or ba condit�on, uctural integr Iiquid levels
as related to utl invert,evid ce of lea age,etc.):
O /! O A?� rl.Ss
hvssiSl�tJ
ha s �✓c o ✓r"l�r ��� /7 a .S'is r� o�-,�� .
GREASE TRAP:_(laxte on site plan)
Depth below gade:_
Matexial of construction:_concrete metal_fiberglass�olyethylene_other
_ (explain):
Dimensions:
Scum thiclmess:
Distance from top of scum to top of outlet tee or bafEle:
Distance from bottom of scum to bottom of outlet tee e:
Date of last pumping:
Comments(on pumping recommendations ' et and outlet tee or bafile condition,structural integriry, liquid Ievels
as related to outlet invert,evidence of 1 age,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.Yarmouth, MA
Owner: BEACH `N TOWNE MOTEL�,S�T ��G��
Date of Inspection: RSP Inc., Sleepy Hollow Trust
4/10-4/20/04
TIGHT or HOLDING TANK:_(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:_
Mata�ial of construdion:_concrete_metal_fibergl _�olyethylene_other(explain):
Dim�sions:
Capacity: Ralbns
Design Flow: Qall y
Alarm present(yes or no):
Alartn level: A1 working order(yes or no):_
Date of last pmnpin '
Comments(condi ian of alarm and float switches,etc.):
DISTR[BUTION BOX:�(if present must be openedxlocate on site plan)
Depth of liquid level above outlet invert:��/f(�Qi�_
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, c.): / D { �
s � / �
� �21��
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):_
Alarms in working orda(yes or�o):_
Comments(note conditiai of pump cl�aznber,co�dition of pumps and appwten >
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Page 9 of I 1
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
Owner: BEACH `N TOWNE MOTEL � �
Date of Inspection: RSP Inc., Sleepy Hollow Trust,S�� �
SO1L ABSORPTION SYSTEM(SAS):_(locate on site p1a���Qc���not required)
If SAS not located explain why:
T�eaching pits,number:� � /1 (9 l�� � ( � / �'`^— p`P�- �Q/�R �'l
=leaching chambers,number:_ �� _/� � n /� p �,w
leaching galleries,number: GC6l �/ O�I00�•' �
_leaching trenches,number, length: /
_leaching fields,number,dimensions: .-- �, ,G
overflow cesspool,number:
innovative/aitemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condi[ion of vegetation,
etc.)��Q��. //� ��T �S C�Q� • � J � !—'/.�- 1
�-�� I S �t ��---�B��—f'��?' �� � �n1���N
QY d�J,�lLA'ilG(C �A-�Lu ,2-Q ,
CESSPOOLS:_(cesspool must be pumped as part of inspectionxlocate on site plan)
Number and con5guration:
Depth-top of liquid to inlet invert:
Depth of solids tayer:
Depth of scum layer:
Dimaisions of cesspool:
Mat�ials of construction:
Indication of groundwater inflow(yes or no):
Comments(note conditia�of soil,signs of ulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: te on site plan)
Materials of construction:
Dimensions
Depth of solids:
Comments(note conditia� of soil,signs of hydraulic Tail e of ponding,condition of vegetation,etc.):
Page 10 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. Yarmouth, MA �)
Owner: BEACH `N TOWNE MO'TEL �S�vTG ��
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 system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building.
(Zuo MS �1(a �''ts� ��f �3 I - -
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/9f3 = ZI � &3 = Zg .
�f =35s1 �c� = Zos
. � � '
' Page I I 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 !l ��
Date of Inspection: BEACH `N TOWNE MOTEL� S�/,$�G
RSP Inc., Sleepy Hollow Trust
SITE EXAM 4/10-4/20/04
Slope
Surface water
Check cellaz
Shallow wells /
Estimated depth to gramd water � �3, �
Please mdicate(check)all methods used to determine the high ground water elevation:
, �' Obtained from system design plans on record-If checked,date of design plan reviewed: % �
Observed site(abutting properfy/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local eaccavators,installas-(attach documentation)
s�Accessed USGS database-explain: F.e�w+�07�dT�9�
You must describe how you established the high grouod water elevation:
� . 17�5/(r /!/ Tes�— �,1�� l 9�3�y2-
—�� 9��,���kr a�'` �� ,�
.
Z . �i-a�2 � �l7- �v'�1`Jhi1 /S 7- �
3• ���s�rrrP✓1� /�'I l� ��1 � �/9,Z = �. 7 �
1
y �19 � �3. � - �. � � � �� > � . 9