HomeMy WebLinkAboutSystem F Inspection Report 2004 Apr 10-20 4 �
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
, DEPARTMENT OF ENVIRONMENTAL PROTECTION
G± C� � � � M [� DD
P,1,'�Y � i� 20U4
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
�a�ti 'N Tou��-e. /Vl o�e/
PropertyAddress: �� � 2-!� ag.� s y,�n,ro�f� , M�- Qa 6��
Sys�m" F " Rao�u i�, �/g�,,i9, ad,a �
owoer�s Name: 2 S P Z"NG.� SI�P/aj' /'rv IIOGt/ T i(ST
Owoer's Address: 5 a m�
Date of Inspection: if!//a —�/�p/�}pOy
Name of Inspector: (please print) Joseph M.Martins
Company Name: Accu Sepcheck
Mailing Address: 17 Northside Dr., S.Deonis,MA 02660
Telep600e Number: 508-385-5891�-
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported
below is true,accw�ate and complete as of the time of the inspection.77ie inspection was performed based on my
training and exp�ia�ce m the proper fimdion and maintwance of on site sewage disposal systems.I am a DEP
approved sys[em inspector pursuaot to tion 15340 of TiUe 5(310 CMR 15.000). The system:
// Passes
Conditionally Passes
Needs Furtha Evaluation by the Local Approving Authority
Fail
Inspector's Signatu : Date: a O �O d l,�
/
7he system inspector shall submit a copy of this inspection report to the Approving Authoriry(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shazed system or has a design flow of 10,000
gpd or geater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The aiginal should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
e„�n��Ty. �� ��� q� /� 0vt/�t Co vP� �QlS�c�
Notes and Commarts: �—�, �� ,/�/�n 6�� d I� 52 Q�-�
/N
�2) �ec�om.�.�n� Ca� �nve v✓ �Pyv���—
M ain �ehah�e O�mP,�r
*"**T6is report ooly describes cooditions at the time of inspection and unde�e conditions of use at that
time.This iospection dces not address how the system will perform in the future under t6e same or different
conditions of use.
��
Page 2 of I 1
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 'I'OWNE MOTEL �S�rs�g1�F'
Owner: RSP Inc., Slerpy Hollow Trust
Date of lnspeMion: 4/]0-4/20/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syste asses:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15304 exist My failure cxiteria not evaluated are indicated below.
Comments:
B. System Cooditiooslly Passes:
One or more system componenu as described in the"Conditional Pass"sectio eed to be replaced or
repa'ved.The system,upcxi completian of the replacement or repair,as approved b e Board of Health,will pass.
Answer yes,no or not det�mined(Y,N,ND)in the_for the followin tem�ts.If"not determined"please
explain.
'Ihe septic tank is metal and over 20 years old•or the sep' tank(whether metal or not)is structurally
unsoimd,exhibiu substantial infiltration ar ex511ration or tan ilure is immina�t. System will pass inspection if the
existing tank is replaced with a complying septic tank as ap oved by the Board of Health.
'A m�al septic tank will pass inspedion if it is stru sound,not leakmg and if a Certificate of Compliance
indicating that the tank is less than 20 years old is ava' ble.
ND explain:
Observation of sewage backup or b out a high static water level in the dislribution box due to broken or
obstrvcted pipe(s)or due to a broken, ed or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
oken pipe(s)are replaced
obstrudion is ranoved
dislribution box is leveled or replaced
ND explain:
7Ue syst equired pumping more than 4 times a year due to broken or obstructed pipe(s).77ie system will
pass inspection ' (with approval of the Board of Health):
Ixoken pipe(s)are replaced
obstrudion 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;
1261 Route 28, S. Yarmouth, MA
D te of Ins BEACH `N TOWNE MOTEL � S�1tx/��Fy
pection: RSP Inc., Sleepy Hollow Trust
C. Further Evaluation is Required by t6e Board ofHealth:4��0-4/20/04
Conditions exist which�eyu've further evaluation
is failing to protect public health,safety or ue environme�,the of Health ir� order to determine if the sys[em
1. System wi11 peys ualess Board of H
determines in accordacee with 310 CMR 15.303(lxb)that the
system is not functionipg ip e ner whicb µ•i��protect public health,safety and t6e environment:
_ CessPool or pri ' within 50 feet of a surface water
_ Casspool o rvy iS with� 50 feet of a bordering vegetated weHand or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if a determines�bat the
system is function➢og in a maooer that protects t6e public health,safety an nvironment:
The system has a septic tan►c and soil absorptia�systert�(g �d�e SAS is within lpp feet of a
surface water supply or tributary to a surface wate.r supply,
— �e sys[et°has a�Pt���ank and SAS and the is within a 7Ane 1 of a public water supply,
— The systero has a septic tanlc and SAS the SAS is within 50 feet of a private water suPP�Y well.
�e��h�a�Pn°�nk en AS and the SAS is less than 1 pp feet but 50 feet or more¢om a
private water supply K.e��s. M
osed to determine distance
*`7'his system passes if ell water anal is,
bacteria and volatile � �Om'�a�a DEP�ertified laboratory, for coliform
ic compo���di���at the well is free from pollution from that facility�d
ue���of� ia nitrogen and nitrate nitro en is
fail�e critaia triggered.A coPY ofthe analysi mus[be atta hed to th s formpm�provided that no oth¢r
3. Otber.
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 126] Route 28, S. Yarmouth, MAS �M "1���
BEACH `N TOWNE MOTEL i Y
Owner: RSP Inc., Sleepy Hollow Trust
Date of Inspection: 4/10-4/20/04
D. System Failure Criteria applicabie to all systems:
You must indicate`�es"or"no"to each of the following for sll inspections:
Yes No
_ �Backup of sewage into faciliry or system component due to 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
spool
_ Liquid depth in cesspool is less than 6"below invert or available voiume is less than '/s day flow
_ _�IZequired p�unping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).N�nnber
of times pumped_
_ �Any portion of the SAS,cesspool or privy is below high gro�d water elevation.
_ �Any portia�of cesspool or privy is within ]00 feet of a s�face water supply or tributary to a surface
water supply.
✓My portion of a cesspool or privy is within a Zone 1 of a public well.
_ ✓fYny portia�n 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 ]00 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if t6e well water analysis,
performed at s DEP certified Iaboratory,for coliforro bacteria and volatile organic compounds
indicates t6at the well is free from pollutioo from that fscility and the preseoce ot ammonis
nitrogen aod nitrate nitrogen is equal to or less than 5 ppm,provided t6at o0 other failure criteria
are triggered.A copy of the analysis mast be attached to this form.�
�(Yes/No)The system faila I have determined that one or more of the above failure caitaia exist as
described in 310 CMR 15303,therefore the system fails.The sys[em owner shou�d cantad tlie Board of
Health to determine what will be necessary to corred the failure.
E. Large Systems:
To be considered s large system the system must serve a facility th a design flow of 10,IX10 gpd to I5,000
SPd•
You must icidicate eith�"yes"or`ho"to eac�of U�e follo '
(77ie following criteria apply to large systems in additi the crita�ia above)
yes no
_ _ the system is within 400 feet of a s ce drinking water supply
_ _ the system is within 200 f f a tributary to a surface drinking watcx supply
the system is located' a nitrogen sa�sitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a publi t�supply well
If you have answered' es"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section ve the lazge system has faileA.'[t�e owner or operator of any large system considered a
sig�ificant thr under Section E or failed und�Section D shall upgrade the system in accordance with 310 CMR
15304.The em 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
Properry Address: 1261 Route 28, S. Yazmouth, MA
BEACH `N TOWNE MOTEL�Sy.r/F�nF'�
Owner: RSP Inc., Sleepy Hollow Trust
Date of Inspectioo: 4/]0-4/20/04
Check if tfie following have been done You must indicate`�es"or"no"as to each of the following:
Ye� No
�/ Pumping information was provided by the owner,occupant,or Board of Health
_ ►�Were any of the system components pumped out in the previous tsvo weeks ?
_ � Has the system received normal flows in the previous two week period?
_ � Have large volumes of water been iNroduced to the sys[em recently or as part of this inspection?
t� Were as built plans of the system obtained and examined?(lf they were not available note as N/A)
!� Was Ihe facility or dwelling iaspected for signs of sewage back up?
� Was the site inspected for sig�s of break,out?A�
�n c/vd�ty l�—
a� Were all system components,exc ' t�ie SAS,located on site?
�_ Were the septic tank manholes uncovered,opened,and ihe interior of the tank inspected for the condition
of the ba8les or tces,material of cons[cuctioq dimensions,deptL of liquid,depth of sludge and depth of scum?
� Was the facility owner(and occupants if different from owner)provided with informalion on the proper
maintenance of subsuface sewage disposal systems?
The s'vx and locstion of the Soil Absorptian System(SAS)on the site has been detamined based on:
Yes no
�/ _ E�cisting information.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 approximation of distance
is uciacceptable)[310 CMR 15302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Addrcss• 1261 Route 28, S. Yarmouth, MA
BEACH `N TOWNE MOTEL
Owner: RSP Inc., Sleepy Hollow Trust
Datc of Inspcction: 4/10-4/20/04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): � Number of bedrooms(actual):_ _ S5-� �? f}V
DESIGN flow based on 310 CM'R 15.243(for eacample: I 10 gpd x#of bedrooms): �l 1}��—
Number of currant residents: O �S 2�ES/(�-N
Dces residence have a garbage grinder(yes or noj: /vv
Is laundry on a separate sewage system(yes or no)�[if yes sepaz'dte inspection requiredl
Laundry system inspected(yes or no):N1f! �ao,3 -- S�70oo —3S��G...� ��2GY�0
Seasonal use: (yes or no):�l'E S o'100.2 �— S�a�f�OG — 2,500� POOL �OOB
Water meter readings,if available(last 2 years usage(gpd)): / / i
Sump pump(yes or no):�/!J ,g�E 6 PD /,38$�j8 S-�s
Last date of occupancy: V Y2a o�
�
COMMERCIAL/INDUSTRIAL
Type of establishment: MO��
Design flow(based on 310 CMR 15.203): RyS�j1F QDd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):_
Induslrial waste holding tank present(yes or no):_
Non-sanitary waste dischazged to the Title 5 system (yes or no):_
Water metu readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORM.4TION
PumpingRecords ���pP� ad� �4� � �,�� ��/_
Source of information: / 1 9 , ��
Wu system pumped as part of the inspection(yes or no): NQ
If yes,volume pumped: Rallons--How was quantity pumped detamined?
Reason for p�unping:
TYPE OF SYSTEM
✓Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
_PnvY
Shazed system (yes or no)(if yes,attach previous inspection records,if any)
InnovativeJAltemative technology. Attach a copy of the curr�t operatia�and mainta�ance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Ap roximate age of all com onaits, te talled(if Imown)and source of information:
� L/�aiS ��/�P� �9�i� D 2 �Y�4 0�
Were sewage odors detected wh�amving at the site(yes or no):��
Pagc 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.Yarmouth, MA
BEACH `N TOWNE MOTEL
Owner. RSP Inc., Sleepy Hollow Trust
Date of Inspection: 4/]0-4/20/04
BUILDING SEWER Qocate on site plan)
Depth below grade: ��3 '
Materials of conswction: ✓cast iron _40 PVC other(explain):
Distance from private water supply well or suction line: 7/D �
�Com enu(on condition ofjoints,v,e�n1ting,evidence of leak/a2�e,etc.
���F��� C,l C n (J�Y� � ��9�
SEPTIC TANK:_(locate on site plan)
veepth be�ow grade: oI�`S �/ L� OdP2S W/�li n ��/
Material of construction:_concrete_metal_fiberglass_polyethylene
other(explain)
If tank is meta] list age:_ Is age wnfirmed by a Certificate of Compliance(yes or no):_(attach a copy of
D'ime.�cstons: 7/����X✓'r��/( /1 Tl/(� '� Q' (/. ����9 q��QY)
Sludge depth:_�3 �� 3 ��
Distance from top of sludge to bottom of outlet tee or baffle:_�_
Scum thiclmess:_/'j // O/�
Distance from top ot scum to top of outlet tee or bafile:�_ ��
Distance from bottom of scum to bottom of ou et t or f�le: �
How were dimensions detamined: v ��� �
Comments(on pumping recommen �ons,inlet and ouUet tee or ba e condition, ctural int ity, liquid levels
as related to outlet invert,evidence of leaka e etc): L �Q��
T
O�lB i�vP�e. .
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construdion:_concrete_metal_fiberglass�olyethylene_other
(explain):
Dimensions:
Scum thiclmess:
Distance from top of scum to top of outlet tee or bafD •
Distsnce from bottom of scum to bottom of ou ee or bafFle:
Date of last pumping:
Commenu(on pumping recom tions,inlet and ouUet tee or bafFle condition, structural integrity, liquid levels
as related to oudet inv ence of leakage, etcJ:
Page 8 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
4/}0-4/20/04
TIGHT or HOLDING TANK:_(tank must be pumped at time of inspectionxlocate on site plan)
Depth below gade:_
Material af construction:_wnaete_metal fi s_�olyethylene_oth�(explain):
Dimensions:
CapaciTy: 2a�
Design Flow: allons/day
Alarm present(yes or no •
Alarm level: larm in working order(yes or no):_
Date of Iast p g:
Comments dition of alarm and fl�t switches,etc.):
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
�_
Depth of liquid level above ouUet invert:_�—�/f�iC�
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
�leaka e to or out o box,etc. : '
v� ' D•�� �vf�-rf o�� (J•�-� � .� e �� � .
PUMP CHAMBER:_(locate on site plac�)
Pumps in working order(yes or no):_
A►arms in working orda(yes or no):_
Comments(note conditiai of pump chamber,co ' of pumps and appurtenances,etc.):
Page 9 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 i� „
Owner. BEACH `N TOWNE MOTEL�SrS7� �
Date ot Inspection: RSP Inc., Sleepy Hollow Trust/ //
SOIL ABSORPTION SYSTEM(SAS): _(locate on site pla�}��QC9�iQd�not required) ��p�y�p �1,�
�
If SAS not Iocated explain why:
Type / / /
leaching pits,number: / l0 X� �✓ 3 /
leaching chambers,number:_ -S�7�'l2_�� p�s�GN
_leaching gallaies,mnnber: �+rd d� �j �/T �0�-�
leaching tr�ches,number,I�gth: (�� �
_leaching fields,number,dimensions: _ �O� .3
overt]ow cesspool,number:
innovative/altanative system Type/name of technology:
Commenu(note condition of soil,signs of hydraulic fiilwe,level of ponding,damp soil,condition of vegetation,
etc.): S7�/�l L /A�
7Vv S'/�N O� /5���v��/i� ��/�,e�
�S 30�� PiT Bo �fi�
CESSPOOLS:_(cesspool must be pumped as part of inspectionxlocate on site plan)
Number and conSguration: /
Depth—top of liquid to iniet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Mataials of construction:
Indication of groundwater' ow(yes or no):_ e
Comments(note con ' 'on of soil,signs of hydraulic failwe,level of ponding,condition of vegetation,etcJ:
PRIVY:_(locate on site plan)
Materials of construdion: /
Dimensions:
Depth of solids:
Commenu(note condition of soil,sign ydraulic failure,level of ponding,condition of vegetation,etc.):
' -� ,
• �X �i;.. _!Dt^x4 _ �6� _
_ _ ,� ; - _ �
�'; -,
p �
� �3 ,'; .i
- E� .. � '� /7y' J,�
t� _� • a , �
. . .�' �r; �.. , �
r � � �
�1 � � ,.. . . . ,
1 �� i�.�;��+::-
� y` � � -
r
- , ,
G �,� e 3O ��e �
�Y � - ` ''--_ .
q '��
; : _� �J,
- - � , .. . . ' .. ----_-- �
,-
� 1 ; �
, .: i
.`�e� ! ., ,�
�� —�Ur���T��s /Op�,�
i.fw,�.�
R
I ' '
� . _� SyS�� �Y `
i�- _�: �' �
� � �,A�� �20�; � - _ip' . � � .
, � : �
� J
i__.Y . � �� ,,
� �� ' �. ���� �( '
�r ; � . . �}�
. �� ���� %� { � Y �
l� :"`l, ! �
i
/ �j 5Ys7� ,. r
,' / 'IM G�' �. .' � /
- / `.�._• �t .. � . � - �
i j c __,,�. : '/
' , \ �r_- t �1
c. �1 e �` zn, ' c
.S ,� ' •/t� , J, •,I r y
��� ' O� � ; x��'_• ` ' -r� � .
� �Z�,'_. � J� 2 .
� s��M ��. _ f "J ,�
, (`�
- +o' '
. ; � �� �ys-r�„�
'�:: .':�Yd`_ „ �i " o
/ y i ' ' .L�_, I r :6+c�st, ` ) �y
� � y „�,
�
�� � � •.� � �
' sw7�� - �j ~��!J '7/ � � , �
� � ; � f t
r� r' F _ _,`. �
{r `._ ~ s
� .��� ._ - �
� -N.
:. __;,
_ \�R �
�— �e�m� - �
�:'_ '�' Lo
, �•� • _ - :.
/�: ` � . �
�=� . !�ar(� .
� � —�. y�� ` � �-, /
, , ' r
Page 10 of I I
OFFlCIAL 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
4/10-4/20/04
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at Ieast two permanent reference landmarks or
benchmarRs.Locate all welis within 100 feet. Locate where public watex supply enters the building.
�I_I ��� ��7
�Zo
� �� • -B
�"
21
3
I 20
W oy
r
D �s�c�-�
�4 � �s.s ; �6/=/6 s '
R�� = J� ; r�Z = Is�
A�3 = ao.s� ds - /6
A'Y = 3�"� .gy = 3a.�
� l�/I,�yvl�Sff/NG�i� NEXT Tb DDD,C��/D�> � �6Y�J�D?���
, ;.
Page I I of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSDRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
1261 Route 28, S. Yarmouth,MA
' D te of Inspectioo• BEACH `N TOWNE MOTEL
RSP Inc., Sleepy Hollow Trust
SITE EXAM 4/10-4/20/04
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground wat� l � 3 • I �
Please indicate(check)all methods used to determine the high ground wat�elevation:
�Obtained from system design plans on record-If checked,date of design plan reviewed: 9 Q L
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,install�s-(attach documentation)
✓Accessed USGS database-explain:f�l/w 2�► �L�le y
You must describe how you established the high ground water elevation:
1 • � �S/6� T�S'T� fFd Lt�� �
/U� �ld✓nd�v�,�e� a� /3. z �
� 9/3 ��Z
/
z - �r�A�.� � ��7' .�o� �- l� . 3
3. /�l/cv z q �3 >I'�J vs7�i�rP���9z = Z- 7
Y. �����,�,.. �j �.(-��� -�-i �s 7—�z
f�aT�-��fi � f-�ea�,�. � �T— - p � ►
C��I-'K I t�w�- �� e(p�c►�i�n �
� . M ��-I'� � 3. z �— �. 7 _ ��. 3 t 2.�� -
�
D - 9 �