HomeMy WebLinkAbout0036 MAINSAIL LANE - Health 36 Mainsle Dane
Hyannis
A= 288 184
i COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
60
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Prop Address:Address• 36 Mainsle-Lane
Hyaniiisport_,-
Owner's Name: Eric Maple
Owner's Address: 52 S t a r-p �a a
�=Circle .
Date of Inspection:
Name of inspector:(please print)
Company Name: William E:�'Robinson` Septc--Service
Mailing Address: P O Box 1089
Centerville MA
Telephone Number: - t 5081 775-8776.
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.1 am a DEP
approved system inspector pursuant to ection 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fai
Inspector's Sigliature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth or
DEP)within 30 days of completing this inspection.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
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approxing
authority.
Notes and Commentss5 Sep.... vSe. o Uer f 1-s Ctre-4,—c
,Se P�c I c ilk t.,�s e I we c��`` -� c o� r nsde�fi;� : biw',6u+ca�
8,tK /",sk,ll�.�
'This report only describes conditions at the time of inspection and under the conditions of use at that
lime.This inspection does not address how(tie system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
7
Page 2 of 1 I '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:-- 36_ Ma-it,s.le Lane
Hyannispor
Owner: Eric Maple
Date of inspection: J. o 6
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. S tern Passes:
I have not found any information which indicates that any of the failure eriteria-describi:d in 310 CIAR
15.303 or in 310 CUR 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 explain. for the following statements.If"not determined"please
The septic tank is metal and over 20 ears old or the septic Y p tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfrltration 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 pipes)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 obstswed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipes)are replaced
obstruction is rue W VW
ND explain:
i
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:36 Mainsle Lane
Hvannisportrx.�,l
Owner: Eric maole-
Date of Inspection: . t /3 ar=
C. Further Evaluation is Required by the Board of Health:,N/
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 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
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 I 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 front 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 Gee 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 I I '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION.(continued)
Property Address: ; 36 Mains_1eLa_ne
Hyannisport
Owner: Eric Maple
Date of Inspection: �+
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N9 -Backup 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
J Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
/ cesspool
s/ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/,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.
7 Any portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface
water supply.
_ Any portion of a cesspool or privy is within a Zone I of a public well.
-7 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
— -41 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private rater
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(hat(lie H•cll 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.]
P " (Yes/No)The system fails.I have determined(hat 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: AJ(A
To be considered a large system the system must serve a facility with a design flog 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(lu:system is comideted a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of arry 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 Deparunent.
4
Page S of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:36 Mainsle Lade
Hyannisport
Owner: Eric Ma 1 •,.,3,,: t.: '}F f r ;at {
Date of Inspection: t, oho
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?
2,/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 backup?
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,
— P red,opened,and the interior of the tank inspected for the
P g condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ J 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 CUR 15.302 3
s
5
Page 6 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION-4 . ;.j.jji ,, �e
Property Address +36 Mainsle Lane
_ __
Hyannisport'
Owner: Eric Maple
Date of Inspection: a1
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): 3P0 6TV
Number of current residents:
Does residence have a garbage grinder(yes or no): Ar0
Is laundry on a separate sewage system(yes or no):pN [if yes separate inspection required]
Laundry system inspected(yes or no):4,4
Seasonal use:(yes or no):_!�!S
Water meter readings,if available(last 2 years usage(gpd)): 2005 15, 750
Sump pump(yes or no):Nt3 2UU4 — 14, 250
Last date of occupancy: goas
COMMERCIAL(INDUSTRIAL / III
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 part of the inspection(yes or no):
If yes,volume JaDo gallons--How was quantity pumped determined?S#Ze a/"To+K
Reason for pumping: k ek vy 6,1t rcA✓k°a F S iudg e a- s co.—
TYPE OF SYSTEM
TIE
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:
6 T t . e� Sys kvV•
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of I I
OFFICIAL INSPECTION FOR AI —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOItM
PAItT C
SYSTEM INFORMATION(continued)
Property Add ress: : 36 Mainsle Lane:'
_yannisport •
Owner: Eric Ma le
Date or Inspection: 3 of® ,Fti 1 tr•.�Fn.l . r.
BUILDING SEIVER(locate on site plait)
Depth below grade: 1 S /
Materials of construction:_cast iron /40 PVC_outer(explain):
Distance front private water supply well or suction lute:
Conuncnts(on condition of joints,venting,evidence of leakage,cic.):
SEPTIC TANK;—(locate on site plait)
Depth below grade: /D
Material of construction: _<uncrcte metal fiberglass—polyed►ylene
_othcr(cxplain) _ —
If tank is metal list age:— Is age confirnled•by a Certificate of Corn►liance certificate) ! (yes or no):—(attach a copy of
Dimensions: 100 e 6G l(a,Ls
Sludge depth: to
Distance from lop of sludge I
Scutt thickness: u bottom of outlet lee or baffle: 0"
Distance from top of scum to lop of outlet Ice or baffle: 0w
Distance Gom bonom of scum to bonom of uutlet ice or bafllc: dry
]low%core dimensions dcicrmincd: 'TA�r K 1. � C(e«rG( �A`or_
pL l,&SPl6 7.&,
Comments(on pumping r cvidcnendaiions,inlet and outlet ice or baffle condition,structwal integrity,liquid levels
as rclatcJ to outlet invcn/ cviJcnceooff-leakage,eic.):
S�roc✓rnll J. wc, ( JIJ:� _
GREASE TRAP: P"I n tc on site plan)
Dcptli below grade:_
Matetial of construction:___coucrele Inetal fiberglass—pol)•elli)•Iene _olher
(explain): — —
Dimensions:
Scum thickness:_
Distance from top of scum Io tvp of outlet tee or baffle:
Distance front bottom of scum to bulium of outlet Ice or baffle:
Daic of Iasi pumping:
Conuncnts(on pumping reconutendaliuns, inlet and outlet Ice or baffle conditiu:n, structural integrity,liquid Ic�cls
as IC13ICd 10 oullcl invert,0-idcncc of leakage,c1c.):
7
'age 8 of
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: , 36 Main,sle Lane
Hyannisport
Owner: Eric Maple
Date of lospectloo: /1?1&a329;?6—
TIGIIT or HOLDING TANK: IV 1 (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal fiberglass_pulyethylelte odic*xplaut):
Dimensions:
Capacity: _ �alluns
Design flow: gallonstday
Alann present(yes or no):
Alarm level: Alarm in working utdcr(ycs or no):—
Date of last pumping:
Comments(condition of alartt and float swilcltcs,ctc.): .
DISTIUBUTION BOX:v(if present must be opcned)(locate on site plan)
)
Depth of liquid level above outlet invcn: E)
Conunents(note if box is level and distribution to outlets equal,any evidence of solids cart-)-over,any evidence of
leakage into or out of box,ctc.):
is slnked f-e-Ace � .6',J --�.f L4,45
f era.,{- ofco6- ff,O3
PUMP CHAMBER:_(locate on site plan)
Pumps in working ordcr(yes or no):—
Alarms
in working order(yes or no): _
Conmtenis(note condition of pump chamber,cundition of pumps and appurtenances,etc.):
Page 9 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Properly Address: ._36 Mainsle_Lane
Hyannispor
Owner: Eric Maple
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): V (locate on site plan,excavation not required)
If SAS not located explain why:
Type
t leaching pits,number: 1
leaching chambers,number:.
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
, G✓4 s r"
ctd- 1��c aE' �spee �a- Qif Gk.� Ale> ' ��:� s'
CESSPOOLS: (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):
Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: NI'(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 I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)"_s b a i !Z
Property Address,! 36 Mains-le Lane ;i
Hyannisport -"
Owner: Eric Ma ale
Date or Inspection: V / 3 6
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
bencluharks.Locate all wells within 100 feet.Locate where public water supply enters the building.
cc-1 o �4Dv5A-It Lis
(-e4ct. Pt f
A-3= (oS'(P"
3- 3-
10
Page I I of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 36 Mainsle Lane
Hyannisport
Owner. Eric Maple
Date of Inspection: /3 (o
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground waters 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 ISO 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:
6
-ov ate---VCf was es-6_bl, Ge"t -"Y o ccers!n
n�cP.
11
LOCATION PAA-(USAIL- SEWAGE PERMIT NO -
VI LIAG E
vow/-,3 4�
I-NST LLER'S NA E i ADDRESS
d U1LDE RR R OWNER
c5
J
DATE PERMIT ISSUED .F
D° E COMPLIANCE ISSUED" "
i
'V
V +
f
� a
�,►-
y
Fss....... ..�..._..............
THE COMMONWEALTH OF MASSACHUSETTS
1
BOARD OF HEALTH
.... .`...rycv r....................0 F....... � ..--------.........................................
Appliration for Digposal Works (foustrnr#inn Vamit
Application is hereby made for a Permit to Construct (1f) or Repair ( ) an Individual Sewage Disposal
System at: q
.n.r............................. -rt h1����cr� -. !.Yr..-----..........------.......................-•-------
Location-Address or t No.
Via . ��py-w ----------------------------------•----........_... _:_ aa�.3fr9.... .��ilr. z ..� ?.,.��!!�---01(bl........
ner� ddr.
aRl.®�...`.'®....�._.. ... ................................... 2Y•-l5a1.. ........ -!�5. ..............................
Installer Address
UType of Building Size Lot---1__0-61i-_......Sq. feet
Dwelling—No. of Bedrooms...............ti3.....:....................Expansion Attic ( ) Garbage Grinder (Nb)
Other—T e of Building No. of ersons-------------•-----•---.---- Showers
a YP g ---•---••--------•--•------- P ( ) — Cafeteria ( )
Other fixtures .----••--------------------------- ..........
w Design Flow..............11.0.....................gallons per per day. Total daily flow..........33jo......................gallons.
WSeptic Tank—Liquid capacit/&kV...gallons Length-O.•-•--..-... Width--Y../U...-. Diameter---------------- DepthS!.S w.....
x Disposal Trench—No..................... Width.•................ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.--.-.-- ..----- Diameter-----14-0.�. Depth below inlet...... ..�_*... Total leaching area.S�1.9. 2.sq. ft.
Z Other Distribution box ('O Dosing tank ),
'-' Percolation Test Results Performed by.....KU..............=Rr?........................................... Date A
Ylk�-
Test Pit No. 1..4.- r.-....minutes per inch Depth of Test Pit....zJ........... Depth to ground water........................
LT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......--...............
04
O Description of Soil..!? -'.•-•L
.............................
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 � 5 of the State Sanitary Code—.The undersigned further agree not o place the system in
oper io unt ertificate of�=g
s enIssued by the board of health. (, $ rtswe
- 1, •. s .................•••••..... /�,�F� _....
ate
Application Approved BY .....
......-.----•-----•••••. ..••... .......:5/ �gnf:;...........
Date
Application Disapproved for the following reasons:---------•-----------------•--------------------------••------•--------.......................................
-------------------------------------------•----.....------....-•---------•-•----......---•----•--•-----•-.........-•••-•-•••••............---•...-••••-..............................................
Date
PermitNo......................................................... Issued--------------•----•-•••-•.....-•----•....•-•------....
Date
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