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Home My WebLink About0082 WARREN STREET - Health 12O Washington Avenue L=A rville 162 - 001 y - COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Tennis House Property Address: 120 Washington Avenue Osterv'ille MA 02655 Owner's Name: Wianno Club Owner's Address: 3�! Date of Inspection: April 25, 2006 Name of Inspector: (Please Print) Jaynes M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 ' Telephone Number: - (508)862-9400 t CERTIFICATION STATEMENT ` foation reported I certify that I have personally inspected the sewage disposal system at this address and that the in below is true,accurate and complete as of the time of the inspection. The inspection was performed,7lased on my i training and experience in the proper function and maintenance of on site sewage disposal systems. I=am a DES approved system inspector pursuant to Section 15.340 of Title 5(310 CAM 15.000). The system: ✓ Passes Conditionally Passes ;Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: Mav 7, 2006 The system inspector shall subCWC a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 1.0,000 gpd or greater,the inspector and the.system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if,applicable,and the approving authority. Notes and Comments . ****This report t only describes conditio ns s at the ti me of inspection and under the conditio ns of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 120 Washington Avenue Osterville MA Owner: Wianno Club Date of Inspection: April 25 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: . B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion 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 statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. 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 structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static 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)are replaced 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 obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 120 Washington Avenue Osterville MA Owner: Wianno Club Date of Inspection: April 25, 2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment.. 1. System will pass unless Board of Health determines in accordance with 310 CAM 15.303 1 b that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of asurface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2 . System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and 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 toga surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. l The system has a septic tank and SAS andthe SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 10.0 feet but 50 feet or more from a private water supply well**. Method used to determine distance -------------------- **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and.volatile organic compounds indicates that the well is free from pollution from that facility and. the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 ,.;j OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 120 Washington Avenue Osterville MA Owner:. Wianno Club Date of Inspection: Anr^it 25. 2006 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z 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. ✓ Any 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 privy is within a Zone 1 of a public well. ✓ An onion y p of a cesspool or privy is wit hin 50 feet of a private wate r supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater re than n 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to"or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of - Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flo w of 10,000 gpd to 15,000 gpd. " You must indicate either"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 surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim.Wellhead Protection Area e IWPA)or a mapped Zone I1 of a public.water supply well r If you have answered"yes"to any question in Section.E the system is considered a significant 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 under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 • Page 5 of 11 ' OFFICIAL INSPECTIOON FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 120 Washington Avenue Osterville MA Owner: Wianno Club Date of Inspection: April 25, 2006 Check if the following have been done: You must indicate"Yes"or"no"as to each of the followin : 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 normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ 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 the site inspected for signs of break out? ✓ — Were all system components,excluding 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 construction,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: Yes No ✓ — Existing 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 unacceptable) [310 CMR 15.302(3)(b)]. . .. 5 i Page 6 of 11 ` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 120 Washington Avenue Osterville MA Owner: Wianno Club' Date of Inspection: 4pril25. 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example- 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use(yes or no): Water meter readings,.if available(last 2 years usage(gpd)): Sump Pump(yes or no): 4 Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Tennis club , Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.):, -- Grease trap present(yes or no): No Industrial waste holding tank present(yes or no) No Non-sanitary waste discharged to the Title 5 system(yes or no): No Water meter readings,if available: Unavailable Last date of occupancy/use: Sumner use, OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumredv ear ly for maintenance-per management Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil.absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) _ Innovative/Alternative 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): A � pproximate age of all components,date installed if known d Installed on 315104- er as built card ( )an source of information: Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 120 Washington Avenue Osterville MA Owner: Wianno Club Date of Inspection: April 25. 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints;venting,evidence of leakage;etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 101, Material of construction: ✓ concrete _metal _fiberglass _polyethylene —other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): certificate) (attach a copy of Dimensions: _ 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or.baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Commments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): ' Tees were resent. The li uid level was even with the outlet invert. There did not a ear to be anv signs of leakage, The steel cover was to grade. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert;evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSA L SYSTEM INSP ECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 120 Washington Avenue Osterville MA Owner: Wianno Club Date of Inspection: April 25, 2006 TIGHT or HOLDING TA NK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal -_fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarn and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Conunents(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.): The D-Box was level. No solids were resent. PUMP CHAMBER:_ ✓ (locate on site plan) Pumps in working order(yes or no): Yes Alarms in working order(yes or no) Yes Comments(note condition of pump chamber,condition of pumps and appurtenances, etc,): The li uid level was normal. Steel cover was to zrade. 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 120 Washington Avenue Osterville MA Owner: Wianno Club Date of Inspection: Anri125, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type _ leaching pits,number: leaching chambers,number: 6 dwwells leaching galleries,number: leaching trenches,number,length:, leaching fields,number,dimensions: 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, etc.): The drywells were di . There did not @2pear to be an si ns nf fnilyro CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Commnents(note condition of soil,signs of hydraulic failure le vel evel of pondmg,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 120 Washington Avenue Osterville MA Owner: Wianno Club" Date of Inspection: April 25. 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties tout least two permanent reference landmarks or benchmarks. Locate all wells within 10.0 feet. Locate where public water supply enters the building. l a y 30 96 q a a - C - p vc,.4 i 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 120 Washington Avenue Osterville MA Owner: W k tanno Club Date of Inspection: April 25, 2006 SITE EXAM Slope Surface water ; Check cellar Shallow wells Estimated depth to ground water 12 +/- feet 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: Observed site(abutting property/observation hole within 150 feet of SAS Checked with local Board of Health-explain: tos nta oo rahic and water contour� o ns Check ed with local excavators,installers-(attach documentation) Accessed USGS database-explain:' You must describe how you established the`high ground water elevation: Usinz Barnstable to o ra hic and water contours maps, the ma s were showing a roximatel 12'+/-to round water at this site. This report has been prepared only for the septic system and components described herein. This septic systent has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 t PLA N LccAT ( C CON C , APpj r I t �o t `,� EN �OpGaL • / �`� � i S . 1 JCS QAL • % , 7-5 v,4 OF t t • i AY N hJ yeti N Sn EIN ^t RICHANO L s 1 ND cs,U