HomeMy WebLinkAbout0019 ERIN LANE - Health 19 ERIN LANE, HYANNIS
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COMMONWEALTH OF MASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM-
PART A
CERTIFICATION
Property Address: anto,I
Owners Name I YIQv i. i'tc P S
Owners Address: r. •
Date of Inspection: IZ-bl _00 • "� '4`C� f
Name of Inspector: (please print)
Company Name:
Mailing Address:
Telephone Number:
CERTIFICATION STATEMENT
I certify that I 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
'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 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: /�2
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. If the system is a shared system or has a design now of 10,000
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 only describes conditions at the time of inspection and under the conditions 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 I
Page 2 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Y n
Owner:
Date of Inspecti n:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
have not found any information which indicates that any of the failure criteria described in 310 CMR
1 .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:
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Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
s CERTIFICATION(continued)
Property Address: L
Owner ,5a ALP
Date of Inspecti n:
C(.� Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation b
q the Board of Health in ord
er to determine if
Y 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 CMR 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 a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
AM1
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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 to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply:
_ The system has a septic tank and SAS and the 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 100 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:
a
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: C./Z!/Zf
Owner:
Date of Inspectio
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ b 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
OCclogged SAS or cesspool
1) 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 '/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
C 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.
_ Any portion 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 100 feet but greater than 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.]
(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 Systems:
To be considered a large system the system must serve a facility with a design flow 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—IWPA)or a mapped
Zone II of a public water supply well
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
A Page 5 of 11
,1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Iq
f _
Owner:
Date of Inspection: jz-ol-a
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 system components pumped out in the previous two weeks?
C _ Has the system received normal flows in the previous two week period?
O 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
ed,and the
ior of
septic bf the baffles or tees,ateriaal of construct on,dimens dimensions,depth of liquid,r t depth of sludge and depth he tank inspected oof scum r the condition
t _ 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.0 is at issue approximation of distance
Ts—unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: I
Owner:
Date of Inspecti
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design) Number of bedrooms(actual):3�DESIGN flow based on 310 CM�R 15.203 (for example: 110 gpd x#of bedrooms)?- 3 O t
Number of current residents:
Does residence have a garbage grinder(yes or no): D
Is laundry on a separate sewage system(yes or no): b [if yes separate inspection required]
Laundry system inspected(yes or no): f�
Seasonal use: (yes or no): D
Water meter readings, if avatlable(last 2 years usage(gpd)):
Sump pump(yes or no):�- `
Last date of occupancy: '��1
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records _
Source of information:
Was system pumped as pli of the inspection(yes o.no):—
If yes, volume pumped:Jul gallons--How was quantity pumped determined?,. IZ
Reason for pumping: e�3 Cr,-
TYPE OF SYSTEM
V 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):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or 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:
Owner:
Date of Inspecti n: 0 2-6 I -L)C)
BUILDING SEWER(locate on site plan)
Depth below grade: Cl
Materials of construcriion:_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:Zlocate on site plan)
Depth below grade:�6
Material of construction: '1Pconcrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) 177-
Dimensions: ig 2C6
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: t_\
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: 5 1 c,C=- kyoe.> P tr_-SAS ,
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc. ;
ry�- �
t:��a��r- c c:Jovz✓- �1 � ,�tz.- p . �(ti't���__
GREASE TRAP:'.;(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 baffle:
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
A-
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: l�
Owner: 17k.t7j
Date of Inspecti n: f 2-.:
TIGHT or HOLDING TANK: (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: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and 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
leakage into or out of box,etc.):
PUMP CHAMBER:(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
wh
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: %Y J
Owner:
Date of Inspection: !Z--C)I—j!�:r)
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
T pe
leaching pits,number: 111 J"(42 pit
leaching chambers,number:
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.):
►v%v �i DO l) 4 1.
CESSPOOLS: (cesspool must be pumped as part of inspect ion)(]ocate 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: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,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:
Owner:
Date of Inspect' n:�/z- U% OD
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.
i
"�-- 01
U
A 3,
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Page 11 of l l
A�
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: I
w c ��
Owner 1 J
Date of Inspecti n: /Z D/ 60
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20feet
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:
Checked with local excavators, installers-(attach documentation)
__]_/Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
11
Conunonwealth of Massachusetts
Executive Office of Enviroiunental Affairs
Dept. of Environmental Protection
,Tole
One winter Street'Boston,Ma. 02108 Septic pt D.E.P. Title V Septic Inspector
P.O. Box2119
Teaticket, MA 02536
wll uAM F.wELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI `�
Lt Governor1�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ` ✓ �(�1 L
CERTIFICATION
Property Address: 19 Erin Lane Hyannis Lot 10 Address of Owner: �
Date of Inspection: 7/22/98 (If different) I�q'9� /
Name of Inspector: John Graci Richard Nocella
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) f
Company Name,Address and Telephone Number: j
f
CERTIFICATION STATEMENT
I certify that I 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
x Passes This Inspection Is based on criteria denned In Title V
Conditional Passes code 310 CMR 16.303.My findings are of how the system Is
performing atthe time of the Inspection.My inspection does
_ Needs Fur er aluation By the Local Approving Authority not Impyany warranty or guarantee ofthslongevltyofthe
Fel is septic system and any of Its components useful life.
Inspector's Signature: �( Date: 7122198
The System Inspector shall s/bmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A. B,C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
CoThpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfillration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04f27197)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
1
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 19 Erin Lane Hyannis Lot 10
Owner: Richard Nocella
Date of Inspection:7122198
_ Sewaae backup or.breakout or high.static water level observed.in-the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four 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
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 the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface 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 APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
_ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
' Yes No
Backup of sewage in facility or system component due to an 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`
cesspool.
SAS is in hydraulic failure.
(revised 0 412 719 7 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 19 Erin Lane Hyannis Lot 10
Owner: Richard Nocella
Date of Inspection:7122198
D] SYSTEM FAILS(continued)
Yes No
_ 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
_ — Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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.
Any portion 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 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking wafer 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(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
i
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 19 Erin Lane Hyannis Lot to
Owner: Richard Nocella
Date of Inspectlon:7+22f98
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
,c_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this
inspection.
x — As built plans have been obtained and examined. Note if they are not available with N/A.
x The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_c_ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)]15.302(3)(b)]
(refted 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 19 Erin Lane Hyannis Lot 19
Owner: Richard Nocella
Date of Inspection:7/22198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: aao g•p.d./bedroom for S.A.S.
Number of bedrooms: a
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla Y'
Design flow.0 gallons/day
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: nra
Last date of occupancy: nia
OTHER:(Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nla
System pumped as part of inspection: (yes or no)Yes
If yes,volume pumped:2000 gallons
Reason for pumping: Maintenance
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date installed(if known)and source information:
System was Installed In 1983
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04127)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Erin Lane Hyannis Lot 10
Owner: Richard Nocella
Date of Inspection:7122198
SEPTIC TANK:x
(locate on site plan)
Depth below grade: 16"
Material of construction:x concreate_metal_FRP_Polyethylene other(explain)
If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L8'6"h5•7'w4'iO"
Sludge depth:6"
Distance from top of sludge to bottom of outlet tee or baffle: 29"
Scum thickness:4"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 14"
How dimensions were determined: Measured
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:_
(locate on site plan)
Depth below grade: rda Pol eth lene_other(explain}
Material of construction: _concrete_metal_FRP_ y y
Dimensions: nla
Scum thickness:nla
Distance from top of scum to top of outlet tee or baffle:nia
Distance from bottom of scum to bottom of outlet tee or baffle:nla
Date of last pumpingni
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
nra
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 4„
Material of construction: cast iron x 40 PVC_other(explain}
Distance from private water supply well or suction line?own
Diameter. nia_
Q,'Im'Tents: (conditions.of joints, venting,evidence of leakage, etc,.)
(revised 0427)971
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Erin Lane Hyannis Lot 10
Owner: Richard Nocella
Date of Inspection:7122198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below,grade: Na
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: Na
Capacity: Na gallons
Design flow: rva gallons/day
Alarm level:_nla Alarm In working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Na
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: Na
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_va:
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
Na
(revised 04127197)
G i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Erin Lane Hyannis Lot 10
Owner: Richard Nocella
Date of Inspection:7122199
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Na
Type:
leaching pits, number: 1o00gallon leach pit
leaching chambers, number:Ne
leaching galleries, number: Na
leaching trenches, number,length: Na
leaching fields,number, dimensions:nra
overflow cesspool, number:nra
Alternate system: nra Name of Technology._nra
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pit was structurally sound and functioning properly.The leach pit had 1'of leaching left at the time of the inspection.
CESSPOOLS:_
(locate on site plan)
Number and configuration: Na
Depth-top of liquid to inlet invert: nra
Depth of solids layer: Na
Depth of scum layer: Na
Dimensions of cesspool: nra
Materials of construction: We.
Indication of groundwater: nra
inflow(cesspool must be pumped as part of inspection)
Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Na
PRIVY:_
(locate on site plan)
Materials of construction: Na Dimensions: No
Depth of solids: nra
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
We
(revised(M7l97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
19 Erin Lane Hyannis Lot 10
Richard Nocella
7/22I98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
I
�r
(revivedo4127197) Pay 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contlnued)
19 Erin Lane Hyannis Lot 10
Richard Nocella
7122198
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and charts
(revised04117197) f9gi IO oit 10
,OCrITION NO
TILLAGE DATE
�' FEE as
APPLICANT �K '�' h�a (Non-refundable,
T kDDRESS °��„ �a�. Z L1 i-� TELEPHONE NO.
_
:NGINEERia m L lP ,r17Lar, TELEPH NO.
)ATE SCHEDULED Gu ,
_ (APPl • is--signature)
O Q d 0 O 0 : �. . .0 0 O . : . . . . .O . O • O . . . 0 . 0 . . 0 0 . 0 . . ... . . . . . O
SOIL LOG
3UB-DIVISION NAME GyaSie}-e etq�Th DATE_ T, TIME b
?XP NSION AREA: YES NO �� rj?A.
�Qr• a ENGINEER N,
_ m� _
roWN WATER�PRIVATE WELL BOARD OF HEALTI.
EXCAVATOR
SKETCH: . (Street name,etc. 'dimensions of , lot, exact cation of test holes and
-
percolation tests -locate wetlands in proximi to test holes)
NOTES :
32
NOT TC,
0
PERCOLATION RATE 4 2 hn in I hC,t4
TEST HOLE NO: ELEVAT.ION: _ -TEST HOLE NO: ELEVATION:
1 LOAM. 1 WILLIAM LIEBERMAN
235 TIMBERLANE
3 SAND' Sug. SOIL 3 W. BARNSTABLE, MA 02668
5 5.
r...6 .' 6
7 MEDIUM SAND 7
6 8
9 4 .. 9
10 -
10 , •
1l •�/• �I 11
12 CAVING, 12
13 �• No WATER 13
14 .. 14
15 15 r,..
16 16
SUB-SURFACE SEWAGE: - LEACHING FIELD LEACHING TS
SUITABL
E FOR ----
• LEACHING TRENCHES__
UNSUITABLE FOR SUBSURFACE SEWAGE. REASONS:'
NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION
ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH
COPY: RETAINED. BY APPLICANT
4
LOCATI0N .h0l-5C# SEWAGE PERMIT NO..
VILLAGE
Ilk
INSTALLER'S NAME i ADDRESS
R UILDER OR OWNER
��►�uc�G.vs:-- P.�
DATE PERMIT ISSUED 11,117
DAT E COMPLIANCE ISSUED z�`��
'+
t'
?-'
� ay
+a`� 0
a�r
1` .
'\
V �
V
I;t ,
y�
No.. 3..:/.�.... Fizs..................
THE COMMONWEALTH OF MASSACH,USETTS
BOARD OF HEALTH
.................OF......Aq.p" mo..6IE'_..........---------------•--._....--.-..-.-.-----. -.
I
Appliratiou for Diopoottl Work,5 Tomitrurtion ramit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
Location-Addr s
................0.14... �e..2:f......................................... ............. !? .._.��G�uHt.� -•--...
caner Address
. ........ --
a •..• .. ............... Sq. feet
Installer Address
d Type of Building Size Lot../1�.y y_5..:.....
U Dwelling—No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
C4Other fixtures .....................................................................................................................................................
W Design Flow...........!l .......................gallons per person per day. Total daily flow.....k?.P............................gallons.
WSeptic Tank—Liquid capacity ..gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area........_.........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----------------------
-•----------..................
-.......
.--..................................--•---....................---•--•-----...-•--.--
Descriptionof Soil.......................................................................................................................................................................
x
W •-•..................................................
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
------------------------------------------------•-------•--------------------....----....................---------------------------------------------------------------------------......----......•---
Agreement:
The undersigned agrees to' install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITi M 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has een issued b e beard of h lth.
7/Sgd � •-------
..........•..---
Application Approved BY ........-•---•-•---••-•----•--•--•-•.......................• f�// .
Date
Application Disapproved or a following reasons-------------•--•----•-•----.......--------------....................._..._....-•-------.._.................------
..•-•-•-•••-••.........••-•-•---••••••--••--••-•-•-•--••..............••--•......................--••••---•................-••-•---•-•--•-•-•-•-...•----•---•-----•----•--•-----•-------••-••••--•-••---
Date
PermitNo......................................................... Issued.......................................................
Date
7
No.gz...... ......... t FR$...
J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. vl.................0F.... .rY.tX-(6 ' . --•-------...... ..............................
Appliration for Dhipoii al Work,5 Tonotrnr#inn ramit
Application is hereby made for a Permit to Construct ( (raf or Repair ( ) an Individual Sewage Disposal
System at
......
-Addres or �°t f
............... lfit ...: 3.�ry. ?.. .�....--••--••---...................-----•. ............... .5.. ®�.t t.'"C..-..4T -- !�i.�.'am tf's.........--
! canerAddrres�s. t
a ._..eSv�..�k .....-•.............................. ...........•GtJI & e.f:`...... .G....... �r444.dJ..........._.
Installer Address
Type of Building Size Lot.._�j�.S!`�. ........Sq. feet
U Dwelling—No. of Bedrooms................----------_-----__-_--Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ..................................
W Design Flow...........1.!c7.......................gallons per person per day. Total daily flow.-_._.��.Q............................gallons.
WSeptic Tank—Liquid capacity�0.0G0..gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W -------------•-------••--------------•------•••----------------...........................--•---......-----------....................----•---•---...---..----
0 Description of Soil.....................................................................................................................................-..................................
x
V -----...----•---••--------------------------•--•-----••------------................----------•------.....------------------•-----------•------•--------...............................................
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
---------------------------------------------------------------------------------------•-----.......----•---...-----------•-------•-----------------•--•••-------....-•---......................--•-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has Ieen issued by a beard of l
r
Signed .a.- ... .-- -fh..t. ......-•-- ....--•---------•.
- _ .£_ ate ......._....
Application Approved ._ r+ ..............."....--•--- /�
Application Disapprov f the following reasons---------------------------------------------•---------••------------------------........._....................
...............................................................-.........................................................................................................................................
,;;,;_ �aes.y{ Date
Permit No.AW4.._.:_
•-------------------------------------- Issued_.......................................................
• Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Tntif irFatr of Tomb haurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (&.j or Repaired ( )
by------------------------------------------------------1ANnke� Lis c 't' ? �� i----------•-••,---•----------------------.------------.-------.---•---•--•----•---•---
.0 Installer
at.....................................................ICY-------' --- f-)---J. . -.A!.!.......--------•-•.............................................--....
has been installed in accordance with the provisions of TITLE �rf The State Sanitary Coe as escribed in the
application for Disposal Works Construction Permit 1 ._ if ................ dat
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST AS A GUA ANTEE THAT THE
SYSTEM WIL FU CTION SATISFACTORY.
DATE.....I.�.Z .t� .................................................... Inspec -- . -----...----------------•---------------••---...-----------•........-•---
THE COMMONWEALTH O M SACHUSETTS
BOARD OF H ALTH
/jar . ................low .+............OF....... r.^:k»,SJr0..6.Ae............................................
°`nfo..--••................... FW.0...................
Uinpnnttl ork/n� Tonotrnrtion rrmit
Permission is hereby granted............ c. 9 .... r4.61 ..
to Construct ( c,,)-br Repair ( ) an Individual ewa a Disposal System
atNo....................... ....... ...... r ° --•--------•-•--------•--------------..---_................................
1 Street
as shown on the appncatio for Disposal `hocks Construction Permit ................ Dated..........................................
. ..------. _
Board of Health
DATE_. ../ _ .:. _
M 55 A. M. SULKIN, INC., BOSTON
Will All ld I
r » 3:a;3,0, 'x, .J3^ E` n _$.'•"a '...': w ^9 ,.•e. �h,., 's T'.':r"'N'a`:F'^mfi. $4 A*
. : . a e.5ya. . •.Mt gy y 5
INr.
w- w
IN
r.
SOIL LOG
EL
SITE PLAN
`1� �_-_�,_ 0 N -2-
,SJ� n ! 2 }
r 3
.ee oe TOP OF FOUNDATION EL.: MiN � Ac
t? r— ----
--
o --------------
a T=r, t
10
IN El �!� o J • )�y I«�sxi ,�+r� .,t - i _ . 1 1 --
., �I_N E l
--
_ - Ira 2' COVER 1/8 3/8 WASHED STONE
f
r�
4 LIQUID LEVEL
D/B W/ 6 SUMP n ow'� - + - 3/4 1 1/2 WASHED STONE 13
° o a1' 14
0
• _
o• p� J o1a•�
6� E FF. DEPTH! _ r 15
h � PERC TEST RESULTS
PRECAST SEPTIC TANK WITH 60 oc' PRECAST LEACHING PITS PERC RATE :
IT E �D BY : Q -Pc Imo___
CAST IN PLACE INLET AND EL '�' o } _ ___.- _ NO.. SIZE : t. g� r WH N SSE ��
' OUTLET T "S PER TITLE Y -_�;�t ._. "' LaL- BOARD OF HEALTH
SIZE : J r w �- D I A . - DATE :
PROFILE OF ' PROPOSED SEWAGE SYSTEM SYSTEM DESIGNED BY THE TOWN OF REGULATIONS AND
SCALE � 1/4"= 1 ' 0 "" �-0T`�
STATE TITLE V FOR SUBSURFACE DISPOSA I. OF SEWAGE .
3o '
N . B .
1. ALL PIPES SHALL BE SCHEDULE 40 P.V.C. SEWER PIPE 3°
2. ALL PIPES SHALL BE SLOPED 1/4 PER FOOT EXCEPT FOR z '
THE FIRST 2 fEET OUT OF THE O / B WHICH SHALL BE LEVEL N
3. DESIGN FLOW BEDROOMS AT 110 GALDAY PER BR . ,- GAL/ DAY TRH"
SEPTIC TANK SIZE X GAL . 9i� u� E;5r
USE 7:^ GAL. Wl GARBAGE DISPOSAL
LEACHING SYSTEM: USE E (s' li iA A t, &,grF P, P,: -- - - - �
or
EFFECTIVE AREA : SIDE '• _r7 t � ,
BOTTOM -
TOTAL FLOW—.---.-. Ile
TOTAL REQ'O FLOW —. - X W/-___- GARBAGE DISPOSAL f
RESERVE FLOW--_____.___ __ ---_-_ ---.__._ GAL/ DAY
REFERENCE PLANS
APPROVED BY
BOARD OF HEALTH
DATE : --- ---- SITE ANDPROPERTY OWNER : R/ AN
w
Room Sl N GlE FARM�L.`f C�rwf-Ll t w G
LOT- i o r: Lit
W 1 L_L ��VIA1 EC�L M F�til
2 3 5 T 1 m wE Tit.
rs
41,
Ze
.�. per,.:..
w
Y.5 x
# ..,.r�' '•: `aky'� .,,e°�.4 ::.:sr.+: „?�� .r��`:.._5.... .,,:._..,;.,.:.�,..xc,:.. . ..x.:.... ....:_ .: .. ..a.. -.R..4'c.:-wL.,.s,•a#*-.w,.,f� �-* wi'i• . ..,�".?"'`�'�.�a4:.. �x '. �vr'