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Home My WebLink AboutSystem C Inspection Report 2004 Apr 10-20 r � COMMONWEALTH OF MASSACHUSETTS E?CECU'I'IVE OFFICE OF EI`NIRONMENTAL AFFAIRS , , DEPARTMENT OF ENVIRONMENTAL PROTECTION G;i !� C� �� C�? i� DD �9AY � +3 2009- TITLE 5 HEALTH DEPT. � OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A � CERTIFICATTON � ry1�� (��,,(/.� �N TO�V✓l� MO I{.' � '/� �/,,/ �'.y/ PropertyAddress: I,Z�p 1 /C./�• Z�j S ' a,/�i��O�J /'!� 4`�'1/� / T ti K./R sYs�f.r�. ��.c.N . Ro �s # 3. y Owner'sName: � � �/�JG.) S� �`Ldy�J ��.�,(,S7` Owner's Address: ��C DateotlnspeMion: ��o — y/3.p/Oy Name of Inspector: (please print) Joseph M.Martins Company Name: Accu Sepcheck Mailing Address: 17 Northside Dr., S Dennis,MA 02660 Telephone Number: 50&3855891 i CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accwate and complete as of the time of the inspection.The inspection was performed based on my training and e�cpericx�ce in the proper function 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: A/ Passes Conditionally Passes Nceds Further Evaluation by the Local Approving Authority ils Inspector's Signature: !� Date: �d � The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.lf the system is a shared 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.'It�e aigi��al should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authaity. [�� L �� Q�/ �✓�.. �Cl(.�� Notes and Commen[s: �y�� '/� �� o L. Lz� Co��i��.� w �PS��4r /L1��d�i��e ��MP,� ***"This report only describes conditions at the time of inspection and under the conditions of use at t6at time.This inspection dces not address how the system will perform in the future under the same or differeot conditions of use. Page 2 of I 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 p u BEACH `N TOWNE MOTEL � SrSTL� C Owner: RSP Inc., Sleepy Hollow Trust - Date of lospection: 4/]0-4/20/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst Passes: 1 have not fowd any information which indicates that any of the failure criteria described in 310 CMR I 5.303 or in 3]0 CMR 15304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system componenu as described in the"Conditi�al Pass"section nced to placed or repaired.The systan,upon completion of the replacement or repair,as approved by the of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the_for the follo ' g statements.If"not det�mined"please explain. The septic tank is metal and over 20 years old* the septic tank(whetha�metal or not)is structurally unso�md,exhibits substantial infiltration or exfil on or tank failure is immin�t. System will pass inspection if the existing ta�k is replaced with a complying c tank as approved by the Board of Health. 'A metal septic tanlc will pass inspecti ' it is slruchmally sound,not leaking and if a Certifiqte of Compliance indicating that the tank is less thari ears old is available. ND explain: Observation sewage backup or break out or high static water level in the distribution box due to broken or obstructed pip or due to a broken,settled or imeven distribution box.System will pass inspection if(with approval of ard of Health): _ broken pipe(s)are replaced obstrvction is removed distribution box is leveled or replaced ND explain: The system requ'ved pumping more than 4 times a year due to broken or obstructed pipe(s).'Ihe system wi II pass inspection if(with approval of the Board of Health): _broken pipe(s)aze replaced obstruc[ion is ranoved ND explain: r , Page 3 of I I OFFIClAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1261 Route 28, S.Yazmouth, MA o ,� Owaer: BEACH `N TOWNE MOTEL�$�(Sf,� Date of Inspectioo; RSP Inc., Sleepy Hollow Trust C. Further Evaluation is Required by the Board of Heagb.4/10-4/20/04 is failing o protect public health,sa,{etY�the envi otnment the Bo ealth i� order to determine ifthe system 1. System wi11 pass unless Board of Hea1t termines in accordance with 310 CMR 15.303(1)(b)t6at the system is not functiooing in a ma which will proteM public health,safety and t6e environment: _ Cesspool or priry is in 50 feet of a s�face water _ Cesspool or pr' �s within 50 feet of a bordering vegetated wetland or a salt marsh Z• System wi11 fail unless the Board of Health(and Public Water Supplieq if any)determines that the system is functioning in a manner t6at protectc the poblic 6ealth,safety and environmenh The system has a septic pnlc and soil absorption yyyK�(SAS)and the SAS is within ]00 feet ofa surface water suPP�Y m tributary to a siuface water supply, _ The system has a sept]c tank and SAS and the SAS is within a 7Ane a public water supply. _ The system has a septic tank and SAS and the SAS is ' � 50 feet of a private water supply wel]. 7he system has a septic��d SAS and the is less than 100 feet but 50 feet ar more from a private water supply wep**,Me��o d ine distance `*This system passes i£the well xater lysis,Performed at a DEP certiSed laboratory, for coliform ba�teria and volatile organic com ds indicates that the well is free&om pollution from d�at facility and the presence of ammonia nitr and nitrate nitro en is ual to or less t}ian 5 fail�e crit�ia are trigg� .,9�Py of�e�alysi must b�e 8tqched to this formpm��ovided that no otha 3. Other: Page 4 of I 1 OFFICIAL WSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ]261 Route 28, S.Yarmouth, MA Property Address: BEACH `N TOWNE MOTEL SyS�C �� . 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`�es"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 _ _,�Discharge or ponding of effluent to the surface of the gound or surface waters due to an overloaded or clogged SAS or cesspool �Static liquid level in the distrib�tion box above outlet imert 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 '/,day flow _ �Requ'ved pumping more ihan 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped_ ✓Any portion of ihe SAS,cesspool or privy is below}iigh ground water elevation. _ � Any portion of cesspool or privy is within ]00 feet of a surface water supply or tributary to a surface water supply. _ � Any portion of a cesspool w privy is within a Zone I of a public well. _ �y portion 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 geater than 50 feet from a private water supply well with no acceptable water quality analysis. �T6is system passes if the well water analysis, performed at s DEP cerlifred laboretory,for coliforro bacteris and volatile organic compounds indicates t6at the well is free from pollutioo trom t6st facility aod t6e presence of ammonia oitrogen aod nitrote nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis mast be attached to this form.] �(YesJNo)The system fails.I have determined that one or more of the above failure aiteria exist as described in 310 CMR 15303,therefore the system fails.The system owner should contact the Board of Heslth to determine what will be necessary to correct N�e failure. E. Large Systems: To be considered a large system the system must serve a facility ' a design flow of 10,000 gpd to 15,000 Y�ou must indicate eitha"yes"or`Sio"to each of the folb � g: (77ie following criteria apply to large systems in addi ' to the critaia above) yes no _ _ the sys[em is within 400 feet surface drinking water supply _ _ the system is within feex of a tributary to a swtace drinking wat�supply _ the system,' ocated in a nitrogen sensitive area(lnterim Wellhead Protection Area—1 WPA)or a mapped Zone II of a public wat�supply well lf you have answered"yes"to any question in Section E the system is consid�ed a si�mificant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat unda Section E or failed�mder Section D sha11 upgrade the system in accordance with 310 CMR 15304.The systero owner should contact the appropriate regia�al office of the Departrnent. Page 5 of 1 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� Owner: RSP Inc., Sleepy Hollow Trust ' Date oflnspection: 4/10-4/20/04 Check if the following have been done You must indicate"yes"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 componeMs pumped out in the previous two weeks? _ �Has the sys[em received nom�al flows in the previous two week period? _ �Have lazge volumes of water been introduced to the system recently or as part of this inspection? y _ 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 the site inspected for signs of break out? /no/ ie� � Were all system components g the SAS,located on site? � Were the septic tank manholes uncovered,opened,and the interior of�he tanlc inspected for the condition of the ba8les or tces,mazerial of constmctioq dimensions,depth of liquid,depth of sludge and depth of scum? (/— Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Ye�. no � E�cisting information.For e�mple,a plan at the Board of Health. � Determined in the field(if any of the failwe criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15302(3)(b)] Page b of I 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�Sj�ST�N Owoer: RSP Inc., Sleepy Hollow Trust ' Datc ot lnspcction: 4/]0-4/20/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 7i Number of bedrooms(ac[ual):Z DESIGN flow based on 310 CMR 15.203 (for eaample: 110 gpd x#of bedrooms): �� / 3 Q Z �Tl�� Number of curreni residents:_Q�—� Dces residence ttave a garbage ginder(yes or no): N� Is laundry on a separate sewage system(yes or no): V/� [if yes separate inspection required] Laundry system inspected(yes or no): 1,C�- a003 : S!7�o -3S000 �ooL, = �/SZboo Seasonaluse: (yesorno):�/ S � �.00a : 5-dy�a _ 35"voo�foo�> = ,S2�j000 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):dQ_ / V(��y�Q - �3�S/B,S�S��5 Last date of occupancy:_�� COMMERCIAL/INDUST Typeofestablishment: /N� L Design flow(based on 310 CMR 15.203): �l30V� p,pd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste dischazged to the Title 5 system (yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL WFORMATION Pamping Records a�a'� ,(�d Sourceofinformarion: �!//YI�� -Zo�o� 199� /9I�O �� Was system pumped as part of the inspection(yes or no):_ O If yes,volume pumped:�gallons--How was quantity pumped det�mined? Reason for pumping: TYP�OF SYSTEM i/Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool —�,� Shared system (yes or no)(if yes,attach previous inspection records,if any) Innovative/Altanative technology. Attach a copy of the ciurent operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of aIl compon�t�sydate installed,(�f JImown)andsp urce of info.ni�t�a,tiopn: , /e_ � �O R �1,S liy�f>'-Tw�lP___=� /Q.S� FN�/� Y �i f� Were sewage odors detected when 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(continued) Property Address: 1261 Route 28, S.Yarmouth,MA BEACH `N TOWNE MOTEL SyST WC� Owner: - Date of Inspection: RSP Inc., Sleepy Hollow Trust 4/10-4/20/04 BUILDING SEWER(locate on site plan) Depth below grade: Z� t Materials of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line: �/o/ Co�m�enu(on condition of joints,venting,evidenj�e_of leakage,etc.): fTG!)Oa/ OL� /�o ��Q.cr �R SEPTIC TANK:_Qocate on site plan) Depth below grade: 3oZ�� L��/ '� �✓e� �u�LTVP Mateaial of construction: ✓concrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confianed by a CeRificate of Compliance(yes or no):_(attach a copy of certificate) L�//O /��(,�� /! S'�� 0.� l O Ov C{Q.�'0�'l Dimensions: �J Sludge depth:_� /� �� Distance&om top of sludge to bottom of outlet tee or baftle:�_ Scum thiclmess: (7/� Distance from top of scum to top of outlet tee or baffle:�i �� ( Distance from bottom of scum to bottom of ou et te or baffle: How were dimensions det�mined: /' U � V �v�9� Commenu(on pumping recommen ia�s,inlet and outlet tee or bafflc �n�iti�n,str ctura mteg iry li�uid levels as related to outlet inv ,evidence of leakage etc. ' ` � ��► C�� idn ,�� .� GREASE TRAP:_(locate on site plan) Depth below grade:_ Mataial of construdion:_concrete_metal_fiberglass yethylene_other (explain): Dimensions: Scum thiclmess: Distance from top of scum to top o tlet tee or baffle: Distance from bottom of sc ttom of outlet tee or baf�le: Date of last pumping: Comments(on p ' g recommendations, inlet and outlet tee or baftle condition,structural integrity, liquid levels as related to o invert,evidence of leakage,etc.): Page 8 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.Yatmouth, MA Owner. BEACH `N TOWNE MOTEL�S�ISr�C�' Date oT Inspection: RSP Inc., Sleepy Hollow Trust 4/10-4/20/04 TIGHT or HOLD[NG TANK:_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_�olyethylene_other(explain): Dimensions: Capaciry: �allons Design Flow: gallans! Alarm present(yes or�o): Alarm level: A working orda (yes or no):_ Date of last pum ' Comments �tion of alarm and float switches,etc.): DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:�� Jn vc�T Comments(note if box is level and distribution to outl�ts equal,any evidence of solids cazryover,any evidence of leakage into or out of box,etc.): --.�� nj9�� L7 �ef� l�-!7`' Na .2v1 .f�(lc� rv-r- _�� - PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no):_ Alarms in working ord�(yes or no):_ Comments(note condition of pump chamb ition of pumps and appurt�ances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE 5EWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ]261 Route 28,S.Yarmouth, MA Date otlnspection: BEACH `N TOWNE MOTEIySYST��.�l RSP Inc., Sleepy Hollow Trus� SOIL ABSORPTION SYSTEM(SAS):_(locate on site p1a��3�Anot required) y � — �f )J 0� If SAS not located explain why: Ty� / �� ! �/ �� 0 Yl vir� _leaching pits,number: leaching chambers,number._ /' � /� � � leaching galleries,number: � X (Q (,,�/�,� � _leaching tr�ches,number,I�gth: Z/ _leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Typelnazne oftechnology: Comments(note conditi of soil,signs of hydraulic failwe,level of ponding,damp soil,condition of vegetation, etcJ: � . �� '� IL N� J N �� i 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. Dima�sions of cesspooL• Mat�ials of construction: Indication of groundwater inflow(yes or�o): Comments(note conditia� of soil, signs of aulic failure,level of ponding,condition of vegetation,etcJ: PRIV1':_(locate on site plan) Materials of conshvction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of po ' g,condition of vegetation,etc.): � � , �/-- _io r^x 4 _ _ . �6� . . _ — — � � � - � ,� i. .� � ~ p i �i• �1 �3 I , • ,� � • ak` .. � ;� �z�.7� .��; ,.. . a , � 7 ' ' `f � , - � `� , "��,: , ` - G � ,� , _ 30 � —,p, j lq , �- -_` ��" �1 �!� , . _ '� �J" 1 _ i;:� , _-- , _. -___; � � � � �� M .. � !' r� , � , � � , � "�Ur�"Ttt 1o�X� � fw�RS ' _ �- ., / � ' .I S•�Si� � Y . �_ �, C � f � �� ' _ 'o• � ' �,qL'� �zo' `- - ' � �- Q�� .� 1 . '� � � � Y ' ( • , . . � • ' ` ��;, '� b�� - - � _ � /' �a � ! '�� 7, /O,~�. �� •� �� . [ � ` ''l� � - � � /Y�T� i. ..f , . . . � . . � "� G+, �. .' \ .1 '" �� • �r _. � . � ' - . . � C �� _ ' : �1 _ C. . �t'l�.-. ' �\�)" zD�; l � � !�. �•- /D� - .� _ --'� 'Q � _� t � .S �_ ��t�I�� d /�/" � . . 0 r� r � ' �� y�%A �_ . � �ZO� �7 ". � , . �,�0,1, ��?j . � � s�� ,__ ' ; '; .� , _� � �• •� - % � � '>s-rc �_, ...�L` y • "i � ' w �1� - ' ix•�_,7 r :�.c,�� , � l" .. . r - r p 'w° � � r• '� ,p v � l�VSZ� iR� ��, (� � i� , .s � r �• j ��.� �(•I� � �' �. t,i" t '�--• ' S 1 .�'J` _ _ . � , ,_`1 -y. _ �7� �- �Cimc - � ,::- •�' Zo , �•� • - -_ :. �'' ` • �: !na y 6 � `` ` �`• 'I!Y\ ` `` `�� •. , 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 BEACH `N TOWNE MOTEL�SyST��C�� Owoer: RSP Inc.,Sleepy Hollow Trust Date of Inspection: 4/10-4/20104 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 wata supply enters the building. 1ZooN�� 'S '{ 3 fF• -f3 c.o O � 3 �p. 0 2., YO � �S-�. � , � . A� � - �ss� �� A-Z = .zi S; az � Z2-� 1�3 = zz 33 _ z� �� = z� ,�y � 33� � F��S�FINGLC CLosesT TD .1�ao2�tNa►3� �v �o,mPo��eni � . . � Page I 1 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address: 126] Route 28, S.Yarmouth, MA Owner: BEACH`N TOWNE MOTEL TYS7 Date of Inspectioo: RSP Incl., 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 wat�elevation: �y �btained from system design plans on record-If checked,date of design plan reviewed: % %7i Observed site(abutting property/observation hole within 150 feet of SAS) ✓Checked with local Boazd of Health-explain: Checked with local excavators,insbllers-,Sa,ttach documentation) _�AccessedUSGSdatabase-explain: Yi2a�� A-�OTLsT.�r�'T�/9i You must describe how you established the 6igh�ound water elevatioo: � /� l��S /�N 1-��- � l� tS� '` o� /3. z� an, ��3 �9� � . . . No�wa�� ehc��,.�/��r� �. �� rv ` �, T �o� � �, � i 3. ��vs �'i��vf— /�1 i v� z q a ��9a = �. 7 l L/ /�a �. l 3 . 2 -- �- G =�2 7 = �. 9/