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Home My WebLink AboutSystem D Inspection Report 2004 Apr 10-20 . . � � � COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIItONMENTAL PROTECTION G3 � C5I� i7 �" �� n ti1r�Y 2 � Zr04 HEALTH DEPT. � TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �2aoh 'ill �wn� /�l o{�L _.(.J /� �f- �// PropertyAddress: /oZ�O� /�,� �.� S• y(.j/2/YfOI�Ivl � /'�// Q �(O�y Sy5?�M ,D�� Cvv/hS # /� Z. Owner'sName: �SP �C • 7 SL�y � /'� L�w / ��7,� Owner's Address: Date of Inspection: ��a� �� /0 t/ 7 Name of Inspector:(please print) Joseph M.Martins Company Name: Accu Sepcheck Mailiog Address: 17 Northside Da, S DCOOIS�MA 02660 Telephone Number: 50&3855891 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 inspedion.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of TiUe 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Autharity Fails Inspector's Signatu : .� Date: 7 0�o O 'Ihe system inspecror shall su mit a copy of this inspection report to the Approving Authoriry(Boazd of Health or DEP)within 30 days of completing this inspection.If the system is a shazed system or has a desigp flow of 10,000 gpd or geater,the inspector and the system owner shall submit the report to the appropriate regional oflice of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authaity. ��) Se�� n�c 0��/�!/'�f �✓�� I�Q�� Notes and Comm�ts: GU I/�'/I�l �� G!'C� W �il�✓ Ca�- ��-) �77nue._ vt/ �'v`av /�!A'/n� �"�n'1��`l� ****This report ooly describes conditions at the time of inspection and under t6e conditions of use at that time.This inspection dces not address how the system will perform in the future under the same or different conditions ot use. � , ` _ . . � Page 2 of I I '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, MA BEACH `N TOWNE MOTEL Sr,s'7�M��D�� Owner: RSP Inc., Sleepy Hollow Trust - Date of lnspection: 4/10-4/20/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst�m Passes: / � 1 have not fowd any information which indiqtes 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 Cooditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repa'ved.The system,upcm completi�of the replacement or repa"v,as approved by the Board of Health,will pass. Mswer yes,no or not determined(Y,N,ND)in ihe_for the following statements.If` detamined"please explain. The septic tank is metal and over 20 years old*or the s ' (whether metal or not)is s[ruct�sally unsound,exhibits substantial infiltration or exSltration or ilure is imminent.System will pass inspection if the existing tank is replaced with a complying septic approved by the Board of Health. "A metal septic tank will pass inspection if it' cMally sound,not leaking and if a Ca-tificate of Compliance indicating that the tank is less than 20 y old is available. ND explain: Observation wage backup or break out or high static water level in the distribution box due to broken or obstructed pip r due to a broken,settled or�meven distribution box. System will pass inspection if(with apExoval of d of Health): _ broken pipe(s)are replaced obstruction is r�noved distribution box is leveled or replaced ND explain: 'Ihe systecn requ'ved pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspedion if(with approval of the Board of Health): _broken pipe(s)are replaced obstrudion is removed ND explain: , Page 3 of 1 I \ t = i` 1. t 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�S7�M�'D�� Date of InspecNon: RSP Inc., Sleepy Hollow Trust C. Further Evaluation is Required by the Board of Health:4/10-4/20/04 Conditions exist which require further e�,a�uation by the Board of Health in order�o dete�Ne�f the system is failing to protect public healih,safety m�e�v'vonment. 1. System wi11 pays�o�¢�g��otHealth dete nes in accordance witb 310 CMR 15.303 1 6 t6at the system is not functiooing io a manner will proteM public health,safety and tbe en ironmeot: _ Casspool or privy is wi " 0 feet of a surface water _ Cesspool or privy ' �� 50�of a bordering vegetated weUand or a salt marsh 2. System will fail un�ess the Board of Hea�th (and Public Water Supplier,if aoy)determines that the system is funMioning in a maooer that protects t6e public health,safety and environment: The systetn has a�ph��d��a�a�t�a�system(SAS)and the SAS is within ]00 feet of a swface weter supply or tributary,to a surface water supply, — The��m has a septic tank and SAS and the SAS is within e I of a public water supply. — The sYstem has a septic tank and SAS and the S � within 50 feet of a private water supply well. — �e��has a septic pnk and SA d the SAS is less thari 100 feet but 50 fe�or more from a private water suPP�Y�'ell•*.M� to determine disiance "lhis system pa�i f� ell water anal is, bacteria and volatile � �fO��at a DEP certi5ed laboratory,for coliform the prese�ce of ic COmpO��dicates tl�at the well is frce from pollution from that facility�d onia nitrog��d nitrate nitrogen is equal to or less than 5 PPin,Provided that no oth� failiue crit�ia are triggered.A copy of the analysis must 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.Yarmouth,MA �� BEACH `N TOWNE MOTEL SyS�'cNt ,� . 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 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 overioaded or clogged SAS or cesspool �Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool ✓�-iquid depth in cesspool is less than 6"below invert or available volume is less than %s 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 SAS,cesspool or privy is below high ground water elevation. _ � My portion 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 priry is within a Z.one 1 of a public well. ,��y portion of a cesspool or privy is within 50 feet of a private water supply well. �/My portion of a cesspool or privy is less than 100 feet but greata'ihan 50 feet from a private water supply well with no acceptable water quality analysis. �This system passes if the well water soalysis, perforroed at a DEP certified Iabontory,tor coliform bacteria and volatile organic compounds indicates that t6e well is free from pollutioo from that facility and the presence of ammonia oitrogen and oitrate nitrogen is equsl to or less than 5 ppm,provided that no other fsilure criteris � are tri�ered.A copy of the analysis must be attached to this form.� /� (Yes/No)The system fails.I have deteimined that one or more of the above failure critaia exis[as described in 310 CMR 15303,therefore the system fails.7t�e system owner should contad the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a faciGty with a design flow of 10,000 gpd to 15,000 SPd You must indicate eitha`�es"or`t�o"to each of the following: (The following critaia apply to large systems in addition to the aitaia above) yes no _ _ the system is within 400 feet of a surface � ng water supply _ _ the system is within 200 f a tributary to a s�face drinking water supply the system is 1 in a nitrogen sa�sitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of ublic wata supply well If you hav swered"yes"to any question in Section E the system is considaed a significant tiveat,or answered `�es" ' Section D above the large system has failed.The owner or operator of any Iarge system considered a significant threat�mda Sedion E or failed unda Sedion D shall upgade the system in accordance with 310 CMR 15304.'Ihe system ownea should contact the appropriate regional office of the Depardnent. ' � 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 y SyST• ��D�� Owner: RSP Inc., Sleepy Hollow Trust ' Dateotlnspection: 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 system components pumped out in the previous two weeks? � Has the system received nomal flows in the previous two week period? _ v Have lazge wlumes of water been uuroduced to the sys[em recently or as part of this inspu-tion 7 �_ 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 7 ✓ Was the site inspec[ed for signs of b out? � —/— /�c( qy.� ,/ _ Were all system componems,e the SAS,located on site? � Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of wnstmctioq dimensions,depth of liquid,depth of sludge and depth of scum? �/ Was the faciiity owner(and occupanis if different from owner)provided with infomiation on the pmper maintenance of subsurface sewage disposal systems 7 The siu and location ot the Soil Absorption System(SAS)on the site has been determined based on: Yes no � _ Existing information.For euample,a plan at the Board of Health. `� Determined in the field(if any of the failure crit�ia related to Part C is at issue approximatim�of distance is unacceptable)[310 CMR 15302(3)(b)� ' Page 6 of 11 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 �SySr ,DI� OR•ner. RSP Inc., Sleepy Hollow Trust Date of Inspection: 4/10-4/20/04 FLOW CONDITIONS RESIDENTIAL Number of bedraoms(design): Z' Number of bedrooms(aaual):�� Z� . 3 93 �IV DESIGN flow based on 310 C�5_2� (for example: 110 gpd x#of bedrooms): � J''l C_. Number of current residents: Dces residence have a gacbage grinder(yes or no): N� Is laundry on a separate sewage system(yes or no):/✓� [�Y��P��e inspectio required] �,aundty syscem inspeccea�yes or no�� 2 003 :S/� no 0 3�ovo� Po o L �l�Z boo Seasonal use: (yes or no):��S �.�a; �y OOJ 7s000 Oo L S�Q�� Water meter readings,if avdilable(lasl 2 years usage(gpd)): ,P Sump pump(Ves or no):�VU ,�-v � G P� = 13 8/ p .n� Last date of occupancy: �y sr'��p U COMMERCIAL/INDUSTRIAL y Type of establishment: /�lb,/�I Design flow(based on 310 CMIt 15.203): i}'t�✓ QPd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary weste dischazged to the Title 5 system(yes or no):_ Water met�readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pum in Records (/� �^ ! p q \/ �- Source of infortnation: r i/MQ� � D d � 90 � /� P'� J�� Was sys[em pumped as part of the ins�ection(yes or no):�p If yes,volume pumped: Rallons--How was quantity pumped determined? Reason for p�unping: TYPE OF SYSTEM y�Septic tank,distribution bmy soil absorption system Single cesspool Overflow cesspool —�'� Shared system(yes or no)(if yes,attach previous inspection records,if any) InnovativeJAltanative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all com ts,date installed(if lmown)and source of information: �v,�S �-raJ�� y-yf ✓1 �.✓,/3 o tf' Were sewage odors detected when arriving at the site(yes or no):�[� � Page 7 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ' Properry Address: 1261 Route 28, S. Yarmouth, MA BEACH `N TOWNE MOTEL S ".D�� - Date ot Inspection: RSP Inc., Sleepy Hollow Trust� � 4/10-4/20/04 BUILDING SEWER(locate on site plan) 1 Depth below grade: ^' Z Materials of construction: ✓cast iron 40 PVC other(ex�lain): Distance from private water supply well or suction line: > /0 Comments(on condition of joints,venting,evidence of leakage,etc.): L SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 3/ Material of construction: ✓concrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a CeRificate of Compliance(yes or no):_(attach a copy of certificate) �/ //v i ii I Dim�sions: � '� /� � 6 /�s � � �. ��Qd �j Sludge depth: �� Distance from top sludge to bottom of outlet tee or baffle:�� Scum thiclaiess:�^02 �/ // Distance from top of scum to top of outlet tee or baftle:�_ �� Distance from bottom of scum to bottom of ou et t or affle: �.O How were dimensions determined: -�1 T a U � /✓� �V S'n .� f Comments(on pumping recommen ions,inlet and ouUet tee or baffl condition, structural in grity, liquid levels as related to ouUet�ert,eviden of 1 age,et .): / �/��Q ✓C an.ar o /C�l b /..�� . GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_�olyethylen _ (explain): Dim�sions: Scum thiclaess: Distance from top of scum to top of ou ee or battle: Distance from bottom of scum om of outlet tee or baffle: Date of last pumping: Comments(on mg recommendations,inlet and oudet tee or baffle condition,structwal integrity,liquid levels as related Net invert,evidence of leakage,etc.): Page S 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�SyS?''�p" - Date of Inspectioo: 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) pepth below grade:_ Material of wnstruction:_concrete_metal_fiberglass lyethylene_other(explain): Dim�sions: Capacity: �allons Design Flow: s/day Alarm present(yes or no): Alartn level: in working order(yes or no):_ Date of last pum � Comments ditioc� of alarm ac�d float switches,etc.): DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of l�a e into r ou��bojc,et� ' O� ,� �� /� On� o�� N a /1� .o�..�cg � �SLty�'1q-C�-��6'A� C'b / PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no):_ Alazms in working ord�(yes or no):_ Comments(note conditimi of pump chamber,conditio pumps and appurtenances,etcJ: Vage 9 of 1 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 Owoer. BEACH `N TOWNEMOTEL �SyST"�� Date of Inspection: RSP Inc., Sleepy Hollow Trust SOIL ABSORPTION SYSTEM(SAS): _(locate on site pla��Qc��aQ��oot required) If SAS not located explain why: TyPe � � (O Gt� r�,. . �s'�C�-�✓ �l I'� _leaching pits,number:� _leaching chambers,num _ ��--�� /� ��-T}� leaching galleries,number: l�v•�•+ leaching trenches,number, length: r _leaching fields,number,dim�sions: '-- S,9 ' overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, ��,: ��_ is n2y. `��n� Uk..� i �-`` �;2� �8a� CESSPOOLS:_(cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dim�sions of cesspooL• Mataials of construction: Indication of groundwate.r inflow(yes no):_ Comments(note condition of soi gns of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIV]':_(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,sig�s of h �c failure,level of ponding,condition of vegetation,etcJ: , �X ��= -_1p►_xa _` � /26�, . - _ _ - � ��' ., ' � " � : .� � �3 1' •�! ' � a� � . ,' �Zl�.7� « a N ,.. ` r ' , ` �f � 4 . � , =i;.�.1�-_ I �, ,�= � - � _ , . l � �,� � - 3° �o� � � l q , �-,_, � -�,._ � i� - ; _� �J . . � . ,_1 � �' �. �_' ' -- !' ,� :'��EM , •; '`� N ��uT�..,r i� ��X� �.�w�., S R i , ' �,• .r SYST� �. � f� � '� l �,A�'� �zo', ` �r _�O• I I f� �r4 .� j . 1� ' � '_Y (� �_ ••`� . � .. 6',. .��'� �� -.. � � ` /' `� � � . ` � �;��__ „ �,. �,, -�� . . � '�[' / - � � SYST� i., ..f ;' . � 1 '1� G' -. �. :- \ �-- , i ' `.� ' �� `i fr ;- _ _' . � C 1��. � ��_t � . ( � . O r C 1 F /p� ; _ '-_'' cS � � f s t�' .(t _ .-J � '• ' � �- �9 - `� ' r ' 1 �2e' , � f2,2 �R fb� j__ ; -j 7 / � _� � �� . � � �i iYt7�� -�;2` �+.\�` �a � � �� ' t"_ � r :E+c�sri ' , �� N � � f:-, y � y�! r - r , a t. '� v j 5y5�, iu� �f� C� 2 � , .s ,� ' �.f. �' ._ .�__�'� � � � � �` _ s � �1 L ' `!� � ' -; '�{" ' : ;_i - � �iR �- �rm� _ � �;'_ ' •i' Zo' � �. . � _ -_ ;. ��'' '� • ,: !naY6 �'—:• �� . ` `� '�, / Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE D15POSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1261 Route 28, S. Yarmouth, MA �� BEACH `N TOWNE MOTEL �G�y�-�� Owner: RSP Inc., Sleepy Hollow Trust ' Date of Inspection: 4/]0-4/20/04 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 fcet. te where public wata supply enters the building. �DOM �L � � � �I I �, Q C.o p,r.�� I z ° � 4 3 � � (s-r-f�1C�s : A--r = is; ai = �as� tr2_z�.s; 62 = Zo � �3=�zs � t33 � � ,s � �-y,3G j a y ^ 3D � � � F� Cc�s�rS�rNG��NE,rT� ��z ,�i�d8, Car� anPn�— � � � � Page I 1 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. 1261 Route 28, S. Ysrmouth, MA �� Date ot lnspection• BEACH `N TOWNE MOTEL �SySl n � , RSP lnc., Sleepy Hollow Trust SITE EXAM 4/10-4/20/04 Slope Surface water Check cellar Shallow wells � Estimated depth to ground water � ��' Z Please indicate(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: q 7 t' 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) _;�Accessed USGS database-explain:�/.uLVT�.QT�/�''AE7�8�gy You must describe how you established the high grouod water elevatioo: �• � �Sl� � T�S,% �L��Z Tv /3. 21 pYt 9/3�f Z /`I/�/ Ql?/6(1�2 �/1Cdi/✓GY�'��G� � z �Sraa�2 � �l� �o �rt/L = � � l .3. �vs�'i�27— /�1/�/Z�, �/3 &/y'z = ,z. 7� �, �� ,3. 2 _ ��. � f2. �� , � �