HomeMy WebLinkAbout0033 RABBIT LANE - Health 33 RABBIT LANE, HYANNIS
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TOWN OF BARNSTABLE
y 1ON SEWAGE #
VILLAGE ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILrrY: (type) �� � �1� (size) 000,b�
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 fe t of leaching facility) Feet
Edge of Wetland an Le ng Facility( any wetlands exist
within 300 fee of 1 ility Feet
Furnished b
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '
33 Rabbit Lane
Property Address s,
Jane Lawless,
Owner Owner's Name ?::
information is .
required for every west Hyannisport >/ MA 02672 10-16-18
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the and of the form. III I
HOF rMlp�����%
Important:When
filling out forms A. Inspector Information S* 33-��fcyG,
on the computer, = JAMES R,
use only the tab James D.Sears ^z:key to move your Name of Inspector = '� r,S
cursor-do not Capewide Enterprisesuse
key.�e return Company Name5 IN SP�G
153 Commercial Street '''»Irrrnurntut1O\
�y Company Address
Mashpee MA 02649
City/Town State Zip Code
> 508-477-8877 S 1623
Telephone Number License Number
B. Certification
I certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true,accurate and complete as of the time of my
inspection; and the inspection was performed based on'mytraining and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10-17-18
spector's Signature Date
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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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 some or different conditions of use.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
,I Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owner's Name
information is required for every West Hyannisport MA 02672 10-16-18
page City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
The system is a 1000 Gal.Tank D Box and pit.
2) 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.
Check the box for"Yes", "no"or"not determined" (Y, N, ND)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.
❑ Y ❑ N ❑ NO (Explain below):
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Title 5 Olfidal Irisped on Form:Subsurface Sewage Disposal System•Page 2 of 18
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5
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owner's Name
information is required for every West Hyannisport MA 02672 10-16-18
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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 ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) 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.
a. 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:
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c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owner's Name
information Is required for every West Hyannisport MA 02672 10-16-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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 fecal
coliform bacteria indicates absent 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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
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dC.,, Commonwealth of Massachusetts
Title 5 Official Inspection Form
} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owner's Name
information is required for every West Hyannisport MA 02672 10-16-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in 40MENO is less than 6"below invert or available volume is less
than 1/2 day flow P l'r—
❑ ® 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 water supply
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 fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
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
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Ili
,, Commonwealth of Massachusetts
Title 5 Official Inspection Form
-Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
' 33 Rabbit Lane
Property Address
Jane Lawless
Owner Owners Name
information is required for every West Hyannisport MA 02672 10-16-18
'
per. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat,or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for an inspections:
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 NIA)
® ❑ 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:
® ❑ 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(5)]
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owner's Name
information is West Hyannisport MA 02672 _ 10-16-18
required for every
page Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual):
3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
330
Description:
1000 Gal Tank D Box and pit
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
2016-33,6OOGals
Water meter readings, if available(last 2 years usage(gpd)): 2017-28,000Gal's
Detail:
Sump pump? �
Yes ® No
Present
Last date of occupancy: Date
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I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1�
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owner's Name
information is required for every West Hyannispert MA 02672 10-16-18
page. City/Town State Zip Cade Date of Inspection
D. System Information (cont.)
2. Commercialllndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
_ Title 5 system? ❑ -Yes ❑
No
Non sanitary waste discharged to the Tlt e
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
na
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
15insp.doc•rev.W2612018 Title 5 Official In spection Form:subsurtace Sewage Disposal System-Page a of 16
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owner's Name
information is required for every West Hyannisport MA 02672 10-16-18
page. CayiTown state Zip Code Dale of Inspection
D. System Information (cont.)
4. 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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe).-
Approximate age of all components,date installed (if known)and source of information:
1985 permit #85-49.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
3'
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owner's Name
information is required for every west Hyannisport MA 02672 10-16-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
6. Septic Tank(locate on site plan):
26"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions 1000 Gal. Precast - H-10
:
2"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
12"
"
Distance from bottom of scum to bottom of outlet tee or baffle 17.
How were dimensions determined? Asbuilt-PlanJape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tank at working level. Tank and outlet cover at 26".below grade w/inlet cover at B". Inlet tee,outlet
baffle No sign of leakage or over loading.
t5insp.doc•rev.7/26)2016 Title 5 Official Inspection Form:SuDsdrtace Sewage Disposal System•Page toot 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owners Name
Information is West Hyannisport MA 02672 10-16-18
required for every
page City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
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: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
8. 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 per day
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
(( Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
�ctl' 33 Rabbit Lane
Property Address
Jane Lawless
Owner Owners Name
information is West Hyannisport MA 02672 10-16-18
required for every State Zip Code Date of Inspection
page. City/Town
D. System Information (cunt,)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
0
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.):
D Box is clean and solid wfone line out.
i
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owner's Name
Information is W MA 02672 10-16-18
required for every -West Hyannisport State Zip Code Date of Inspection
page. City/Town
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No'
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
' If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
1
leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ inn ovativelalternative system
Type/name of technology:
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c\ Commonwealth of Massachusetts
pTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1 33 Rabbit Lane
Properly Address
Jane Lawless
Owner Owner's Name
information is West Hyannisport MA 02672 10-16-18
required for every State Zip Code Date of Inspection
page City/Town
D. System Information (cost.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. Precast pit w/2' stone, Pit and cover at 3'below grade. 2'water in p,it w/no
sign of over load or solid carry over No high stain line.
12. 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 ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
0-1 0
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owner's Name
iquiredlon is West Hyannisport MA 02672 10-16-1 B
required for every, State Zip Code Date cf Inspection
page. City/Town
D. System Information (cost.)
13. 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.):
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Commonwealth of Massachusetts
i Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 33 Rabbit Lane
Property Address
Jane Lawless
Owner Owner's Name
information Is West Hyannisport MA 02672 10-16-18
required for every
paw, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view 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.Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached 'separately
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owners Name
information is West Hyannisport MA 02672 10-16-18
required for every cityrrom State Zip Code Date of Inspection
page.
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
Cl Surface water
❑ Check cellar
❑ Shallow wells fjo
12'
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
10-3-84
If checked, date of design plan reviewed; Date
❑ Observed site (abutting propertylobservation 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:
T.H. on design plan 10-3-84 12`no G.W.. Bottom of pit at 9' below grade. Bottom of pit at 3'above
I.H. Depth
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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<t\, Commonwealth of Massachusetts
Title 5 Official Inspection Form
7 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
33 Rabbit Lane
Property Address
Jane Lawless
Owner Owners Name
information is
required for every West Hyannisport MA 02672 10-16-18
Page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector information: Complete all fields in this section.
® B.Certification: Signed & Dated and 1, 2,3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
I
t5insp.doc-rev.71260018 Title 5 Official Inspection Form:Subsurface sewage Olsposal System-Page 16 of 18
6tr a5ed xeJ dH OO:ZZ 260Z I.Z 1)0
0ATE; .$/20/01 --- _
PROPERTY ADDRESS;,• 11._111,bb tt_Laae_ '
Mass
----------------------�,
On-the above da►�, I Inspeoted the septlo ays o&t at the above address.
ThOl system consists of the Iollowingc
1 . 1 -1000 gallon septic tank.2 . 1 -Distribution box. RECEIVED
3. 1 -1000 gallon precast leaching pit. 6 'X10 '
eased on my Inspection, I certify the following oondlt ori�UG 15 Z001
4 . This is a title five septic system. ( 78 Code ) TOWN OFBARNSTABLE
5 . The septic system is in proper working order HEALTHDEPT.
at the present:. time.
6. The JiouSE! is used seacnally.
7. Normal amc-:urit o:C peopz* 1.5► tV0._
$IQNATVRE:
9
Company: Jos. ph_P _ N•combor-6 Son , Inc , f � �
Address :_ Box 66 '
-
------------------
__CencerrilleL He ,_02632-0066
Phone .,___ 508_775: 3338-____-_
TniS CeRTIFICATION 00ts NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P, MACOMBER & SON, INC,
T+n,, Cr+tDooli•l a+chllelde
Pumpod 4 In+t0lod
Town 3#wtr COMIQIIOnf
P.0, 8ox 66 C+n►erYllle, Mil 026320066
775•JJJB 775.64.1Z
�Y
\ COMMONWEALTH OF MASSACHUSETTS
r 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
Property Address: 33 Rabbit Lane
West Hyannispart-
Owner's Name: Kenneth Hc> idp
Owner's Address:same
Date of Inspection 770 01
Name of inspector: (please print) J.P. Macomber a
Company Name:Joseph P. macomber & Son Inc
Mailing Address: Box 66
_Centerville Ma 02632
Telephone Number: 508-775-1-4-48-----
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
rraining 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:
Z/Passes
` Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
Fails
�W /
Inspector's Signature: Date: ` —&'
r
The system inspector shall mit 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 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 1
II
Page 2 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 Rabbit Lane
_West Hyannisport
Owner:Kenneth Houde
Date of laspection:T/20/01
Inspection Summary: Cbeck A,B,C,D or E/ALWAY complete all of Section D
A fSys:jem::P:a:SS:es>
1 have not f�ound, y information which indicates that any ofthe failure criteria described in 310 CMR
15.30 or in 304 exist. Any failure criteria not evaluated are indicated below,
Comments:
The septic system is in proper working order
at the present ime.
B. System Conditionally Passes:
VQ One or more system componenu as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon complexion 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 tarxJc(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 sepric 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:
106 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, senled 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:
/2 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:
I
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Properry Address: 33 Rabbit Lane
West Hvannisport
Owoer:
Date of Inspection:
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.
I. 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 wbich will protect public health, safety and the environment:
4M Cesspool or privy is within 50 feet of a surface water
' Cesspool or privy is witbin 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:
/,._t 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.
Ab 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 colifom
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nirrogen 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:
�GLI/Y-
3
f
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 Rabbit Lane
West Hyannisprt
Owner:Kenneth
Date of Inspection: 20 01
D. System Failure Criteria applicable to all systems:
You must indicate yes"or"no"to each of the following for all inspections:
Yes No
ckup 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
1 clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
esspool /_J, —/pw "I,
Liquid depth in cecsPSO is less than 6"below invert or available volume is less than 'h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped 0
�ky portion of the SAS, cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
ater supply.
— Any portion of a cesspool or privy is within a Zone 1 of a public well.
� onion of a cesspool or privy is within 50 feet of a private water supply well.
YP P P "Y. P PPY
y 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 now of 10,o00 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
� system is within 200 feet of a tributary to a surface drinking water supply
_ ��th e system is located in a nitrogen sensitive area(interim Wellhead Protection Area— IWPA)or a mapped
Y g PP
Zone 11 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
eves" 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
f
Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 33 Rabbit Lane
West Hyannisnnrt
Owner: Kenneth Houde
Date of Inspection: $/20/01,
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes ?v'o l
Pum pine 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,.*cluding the SAS, located on site?
ZWere 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:
Yno
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
• � 9 S
Page 6 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 33 Rabbit Lane
West Hyannisport
Owner:Kenneth Houde
Date of Inspection: 7/2 o/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):- Number of bedrooms(actual):3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): Xlid
Number of current residents: 2
Does residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system (yes orno):,R (if yes separate inspection required)
Laundry system inspected� c�(yes or no):
L
Seasonal use: (yes or no): � y I k1000 (A -I)5 P.D71 L
Water meter readings, if available (last 2 years usage(gpd)): _ M_!>G.Pp (01• S
Sump pump(yes or no):�
Last date of occupancy:
COMM E R C IA L/IND U STRIA L
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.): d14
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):4/il
Non-sanitary waste discharged to the Title 5 s stem(yes or no):Zdd
Water meter readings, if available:
Last date of occupancy/use: A,
OTHER (describe):
GENERAL INFORMATION
Pumping Records f
Source of information: A
Was system pumped as pan of the inspection (yes or no):4,P
If yes, volume pumped: d gallons •• How was quantity pumped determined?
Reason for pumping: —i1JQr yyl�
TYPk OF SYSTEM
Septic tank,distribution box, soil absorption system
PSingle cesspool '
Overflow cesspool
Q Privy
�f 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)
&26Tight tank /02'Attach a copy of the DEP approval
�!)Other(describe):
"A xir�at oe of �cg�onents, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no).-1
4
I
Page 7 of 1 1
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:33 Rabbit Lane
West Hyannisnort
Owner: Kennth Houde
Date of Inspection:. 7/2 0/01
BUILDING SEWER(locate on site plan)
Depth below grade: 15FAl
Materials of construction:,4?d cast iron Z0 PVC mother(explain):
Distance from private water supply well or suction line: /DS0-
Comments(on condition of joints, venting, evidence of leakage,etc.):
Joints appear tight.No evidence of leakage The system is
100?A440y vented through the house vent.
SEPTIC TANK: Zlocate on site plan)
it
Depth below grade:
Material of construction: concrete�metal.lb fiberglass,t�6 polyethylene
Material of construc 1!�ther(explain) ,U'
If tank is metal list age:Vd is age confirmed by a Certificate of Compliance(yes or no):Zg� (attach a copy of
certificate)
Dimensions: r 'gr-'7*
Sludge depth: �
Distance from top o ludge to bottom of outlet tee or baffle:/�,�
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:,�A�
How were dimensions determined: z46o L/
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of.leakage, etc.):
Pump the septic tank every 2-3 . years.Inlet & outlet tees
are in place.The tank is structurally sound and shows no
evidence of leakage.Liquid level at the outlet invert is
fifty one nches.
GREASE TRAP locate on site plan)
Depth below grade:d,&
Material of construction4.)Aconcrete4,Atmetal fiberglass,(44polyethyleneA4other
(explain): 42i
Dimensions: 4)A
Scum thickness:V
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 4)d ^
Date of last pumping:_ eV
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not—present
7
Page 8 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 Rabbit Lane
West Hyanni sprt
Owner:Kennth Houde
Date of Inspection: 1Z 2 0/01
TIGHT or HOLDING TAN je— (tank must be pumped at time of inspect ion)(locate on site plan)
Depth below grade: VA
Material of construction: V/4 concrete X4 metal A A fiberglass L- P
N� olyethylene�/A other(explain):
Dimensions: AIX
Capacity: AM gallons
Design Flow: 40 gallons/day
Alarm present(yes or no): &J_
Alarm level:�)/f Alarm in working order(yes or no): AI6
Date of last pumping: wh
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.):
Distribution box has one lateral No evidence of solids
carry over.No evidence of leakage into or out of the box
PUMP CHAMBER(locate on site plan)
Pumps in working order(yes or no): !Cy
Alarms in working order(yes or no):Vj
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber not present
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 . Rabbit Lane
West Hyannisport
Owner: Kennth Houde
Date of Inspection: _712 n.1 o 1
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Located
Type
je,5 leaching pith,number: �
leaching chambers, number: O
,y-6 leaching galleries,number: Q_
)( leaching trenches,number, length: Q
4),b leaching fields,number,dimensions: B
a�overflow cesspool,number: O r
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.):
Loamy boney sand to fine sand No signs of hydraj ; f;;j1iirLz
or ponding.Soils are dry.Vegetation is normal
CESSPOOLWri¢,(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: Q
Depth—top of liquid to inlet invert:
Depth of solids layer: 4JA
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.):
r•P-,Spnn1 s ara nnf prespnf
PRIVYdJave- (locate on site plan)
Materials of construction:
Dimensions: Ao
Depth of solids:
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Privy not present
9
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: 33 Rabbit Lane
West Hyannisport
Ownerj<ennth Houde
Date of Inspection;7 20 7 01
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.
GGi a' {' �jo�
se
3R
3�/ r
I
G
i
10
Page 1 1 of 1 1
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 Rabbit Lane
West Hyannisport
Owner: Kennth Houde
Date of Inspection:fI 20 _01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
Mthh= om em desi Tans on record-If checked,date of design plan reviewed:
site(abuttingroe / servation hole with' 15 feet of�AS�
ecked wi
local Board of Health-explain:D S
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used.
Gahrety & Model
12/16/94
11
rrn r�rnrrr�.'TT�Zrnr mr•ntnrllTnTnrrr..lrr.T+1+�rrtwRfnlr'IfserR-Y/7s7r►at s•R •rn-rrr-s—r--:,.t-.r•.•`
k' TOWN OF BARNSTABLE BOARD OF HEALTH 1
SUDSURFACF SEWA(IF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
•••T••f�T•••::(�T.III�.�TTI TtTTI T.'1f/t TTlrlRi'Tf1TI'71T'Tt'I r11'[T.'�71'R1T7••l1R�rAt�IR►�Ttf1�7 AT .•TI'•T'T-1• •�..�
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRES$ 33 Rabbit Lane '
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Kenneth• Houde cr
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.,
COMPANY NAME Joseph P. Macomber Vion Inc
COMPANY ADDRESS Box 66 Centerville Ma 02632
Street Town or City state LIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX (1 /pf)
A
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposaj system at
this nddress and that the information reported is true , accurate , and
omplete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Ch /Kne .
stelri
PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
hea1Lh or, Lhe environment as defined in 310 CMR 161303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have con tcted has found that the system fails to
protect the ptiblic health and the environment in accordance with Title
5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C ,- FAILURE
CRITERIA of this inspection for .
r -
Inspector Signature Date ^�
a� ne
copy of this c ification must be prov ed to the OWNER, the BUYER
here applicable ) and the BOARD OF HEAL11II.
* If the inspection FAILED, the owner or•01.op operator shall u P pgrade ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 ChJR 16 , 306 .
I`
partd .doc
Commorlwea th of Massachusetts John Grad
Executive Office of ErMromientai Affairs D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
Environmental Protection Teaticket,MA 02536
(508) 564-6813
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4)
/ PART A
CERTIFICATION Q�fl
!�
�'� APR
Property Address: 33 Rabbit Lane W. Hyannis Port Address of Owner: i 2 1997 laq
Date of Inspection:3129197 (If different) T01*0Fft
ar
Name of Inspector:John Gracl
Levine \� hfgfTMlAgtE
Company Name,Address and 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 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 defined in Title y
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Fu her E luation By the Local Approving Authority penmmina at the time of theInspection. e I Inspection does
P 9 tY not Imply any warranty or guarantee of the longevity of the
Fails septic system and any of its components useful life.
Inspector's Signature: Date: 3130197
The System Inspector shall submit 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.
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,cracked,structurally unsound,shows substantial infiltration or exfiltration,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 11115195)
One Winter Street • Boston,Massachusetts 02108 . FAX(617)556-1049 • Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 Rabbit Lane W.Hyannis Port
Owner: Levine
Date of Inspection:3128197
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
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 water
supply 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 is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
_ 1 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.
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 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 Rabbit Lane W.Hyannis Port
Owner: Levine
Date of Inspection:3128197
D) SYSTEM FAILS(continued)
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:
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:
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)
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.
(revised 11115195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 33 Rabbit Lane W.Hyannis Port
Owner: Levine
Date of Inspection:3129/97
Check if the following have been done:
X 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.
c1aAs 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.
X 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 existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Rabbi(Lane W.Hyannis Port
Property Address: 33R
Owner: Levine
Date of Inspection:3128197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number of current residents: U
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): Yes
Water meter readings, if available: n1a
Last date of occupancy: summer use
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:U 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: n1a
Last date of occupancy: nla
OTHER: (Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped In the last two years.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: n1a
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)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
11 years.
Sewage odors detected when arriving at the site:(yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 Rabbit Lane W.Hyannis Port
Owner: Levine
Date of Inspection:3128197
SEPTIC TANK:X
(locate on site plan)
Depth below grade: 2'
Material of construction:x concreate_metal_FRP_other(explain)
Dimensions: L 8'6'H 5'7"W 4'19'
Sludge depth:4"
Distance from top of sludge to bottom of outlet tee or baffle: 23"
Scum thickness:9
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: 0
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: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: n/a
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:ma
Distance from bottom of scum to bottom of outlet tee or baffle:nla
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.)
n/a
(revised 11115195)
Q
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 Rabbit Lane W.Hyannis Port
Owner: Levine
Date of Inspection:3129197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Wa
Material of con struction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
n1a
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
nla
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
nla
(revised 11115195)
7
I
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 Rabbit Lane W.Hyannis Port
Owner: Levine
Date of Inspection:3128197
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:
nla
Type:
leaching pits,number: 1,000 gallon leach pit
leaching chambers,number:n1a
teaching galleries,number: n1a
leaching trenches,number,length: n1a
leaching fields,number,dimensions:n1a
overflow cesspool,number:n1a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
The overflow was empty at the time of the Inspection.it is structurally sound.
CESSPOOLS:
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: n1a
Depth of scum layer: n1a
Dimensions of cesspool: n1a
Materials of construction: n1a
Indication of groundwater: n1a
inflow(cesspool must be pumped as part of inspection)
n1a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
nla
PRIVY:
(locate on site plan)
Materials of construction: n1a Dimensions: n1a
Depth of solids: n1a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
n/a
revised 11115195
( )
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 Rabbit Lane W.Hyannis Port
Owner: Levine
Date of Inspection:3129197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
AA ��
BA
DEPTH TO GROUNDWATER
Depth to groundwater: 12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
a >/
lztl C A"T ION SEWAGE P-E R M 1 T N'O.
70 94 I*t Le -Y91
VILLAGE
INSTA LLER'S A M E j ADDRESS
e U I L D E R OR OWN ER
DATE: PERMIT ISSUED
® DATE COMPLIANCE ISSUED
'-
i
No.. . llG
3 Fes$_..
� -
THE COMMONWEALTH OF MASSACHUSETTS
a' BOARD OF HEALTH
f 'l' ................
oF.....
------------.......--•---.....----
Appliration for Disposal Works Tonotrurtion Permit
j Application is hereby made for a Permit to Construct CX) or Repair ( ) an Individual Sewage Disposal
J System at:
......1' /_.T...... :�t.----------f -••--......rr� .. ,c �------..........................................
- c� l� f Lo.............. s .......or Lot No.
LelS . Own Address
a
.....................•--....------. ......... � ._......... ------••--•- .....................
Installer Address
Type of Building Size Lot....M. ......Sq. feet
Dwelling—No. of Bedrooms.._...... _----------------Expansion Attic WO) Garbage Grinder (k/Q)
04 Other—Type of Building _I�/8®.:. �..... No. of persons_.._............... Showers (�) — Cafeteria (41d)
Otherfixtures . -•flz��-� ---------------------- -------------------•--------------------------------------------------...... ------
W Design Flow...... 5.........................gallons per person per day. Total daily flow-------?5 d...__._..................gallons.
WSeptic Tank—Liquid"ca acity.,�Q.gallons Length....... A.... 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 to ( ) r�
aPercolation Test Results; Performed by. f -------- Date....1�1_;3-1%Test Pit No. 1._ _._.ininutes per inch Depth of rest Pit___-_1�:......... iepth to ground water._ .V�._...-
fL4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a.11
.......................................................................................................-..............
0 Description of Soil..... ?-_-9-......J-44M.....�_..._ � 1 ....................................•..................................................
Vi_.__ .... ......••••----
VW -•-------------- ------------ ----- a---------- �m b ram_ .---------•---------------•---------------------------------•--•-•---------.•----•--•---•--•--------
Nature of Repairs or Alterations—Answer when applicable...............................................................................................
------------------------------------•-----------•----------•------------------------...........----------------•-----------------•--•--------•-----------------------------•••-••-•---.............-•-•-
Agreement:
The undersigned agrees to ins the aforedescribed Individual Sewage Disposal System irk accordance with
the provisions of iITLF, 5 of the S e Sanitary Code— The undersigned further agrees not to place the system in
qp�eration un Certificate o liance has been issued by the b rd of health.
---- .. ?��,• . .l�/e�
D /
f—
PApproved By........ 'f= I`-----------------•-----------... ............. . l 5
Date
Application Disapproved for the following reasons:....................................................................................................
........................................................................................................................................................ .............................................
-
Date
Permit No...... 0............__,1_ .. _________________ Issued........... A..
D .................'
xy i•-r. c. i,. t.. ` �Y 'r` -;'• <''-';If: fy,._. t,0"
+ F�
r
� j}• -,� a_ ,$ ;•.�- T HE COMMONWEALTH'�OF M'ASSAACLHTUSI-E�TI TS_'r ;t _'-r
BOARD OF. HE L v
., ..... o F f�l
}e' ' , ,���Iu���arc;Ffur� � s����a� :arks C�����r�r#wn �r��ti# ,�" •_
Application is,rhereliy made for a Permit'to Construct (4) .or'Repair,.(, ) an Individual Sewage Disposal, k
T System'at .
I� .
„C -�.
: . ' .. ,� �� •� fir .�`;.. .
Locat>on Address or Lot No lIl
/Y'�I F, �P q I• T,, r
z �- Owner/y / Address
....... .------• ---.- -----
�04 f .�
Installer Address - -
/(� �0 j,
r�, Type of'Building. '. q.,feet . . ' .s U ,, F I. I ...... P " ,( L1) Size:Lot.---..__ g..� ._..S
Dwelling No. off,]Wrooms - Ex arision Attic J Garba e Gander: (ICJ)
Other Type of•Bualdang It�P�+� No of persons 5lowers (�) Cafeteria
....
Desi Flow � �kr , »1���^ s; r 'rso y.................................af t� ..+ a ? 4 gallons.
Other fixtures �.
y
�" /_ Depth:c _
�dY Se tics Tank=.•L�•1 parity•// �_gallo L� {.. .. idth._.... _.. Diameter p>� ca ns
W
sposal'Trench—No 1. kA4
x ;'Di' Width TotaleLength Total leaching area: � � le sg. ft. '
Seepage Pit No:;. .......; Diameter.. _.. Depth below inlet ................. Total,leaching area..................sq. ft.. r
o-4 Z , Other Dzstnburion boxy(+r, ) '. Dosing tank ( )
Pera at iI est�Res rf Performed b �+- „lJa.:,��9 � .. �AJ60��� ........... �. � d
y_ Date 9
�I _ ,
.. �- . v ,
}y�� < o:' .I minutes°per inch. Depth of Test Pi ....i ..bepth toffground water_.
Iw I Test 'Pit.No. 2 �_,._ _..minutes"per `inch l Depth of Test Pit...... _:: Depth to ground water_.:
pGk .................................
Descri tlOn Of S '„ �... .l . ' . ... �.. r
P Oil .. 7....\.
R1.At ! t 1�1-- it �tRY-----
-r-- e r A �.� �la-7.;A1 : _.
y - I L -� I!�1�w.11 ..
• __ } _-..
i
.. y ..... ...
`. ...�....... ......................................................- `-•-
Nat}re�o a rs or Iterations n Vt
_tiThe unders> ed;{ rees to nstal the aforede cnb p �S
' m f in 11Aup&Sewa a\D
Agreement
gn `ag g > osal System n accordance with
i po- m 5 anitar a I y}'f U•
the:, ro�> >ons f IITL ;. of;the S e S„ y e Z e nd'erslgned further•agrees not,to place'thesystem m
fi perarion:un 1� Certificate o -.h lance has.been issue ly t'e board of health.';
a
a 1 �f�tit. rt sa.P.A.. f,ae n. ,. _ (f .
Date t
• lJ
f pplication r kov`ed'.By E' �. � �c''� 6 li' '
e d 1 � ra A r :' Date
PP P = - ---
y y tlon Dlsa`p f' f 9 reasons: ... I ...__
A lira roved or the ollounn re
6 + F3
�s1' ....... ..... L _ .._.. _ _ - --.--_ ........................................
Date.
Permit;No ': ..._..... __.. Issued..... .._...... ,
AM r
nf�{ .4 �, THECOMNIONWEALTH OF MASSACHUSETTS -
a y BOARD'rOF. .HEAL'TW
,OF fJJr:.rC.:# G�✓F•JA!''P - ...
2 1. G .,e,
t v hee.Indlv>dual'Sewage THIS IrS�TO CERTIFY, That,4 Disposal System constructed or Repaired
11 t t zi., _ .. - •r . P 4 Il ).
Installer.' )5 f7
x F 1 Y11 M..: '
ordanc ,
has',been lrlst�tlled m arc e`with`the provisions 'of TITLE of f he State,Sanitary Cod(le
s des ed.in the
u „
'Ts
application for Mi p' osal;Works ConstrucUon'Permit No f // dated. � �'�
y, f a - y I I+ ti "_•" , - - r �.> :TIME ISSUANC OF THIS CERTIFICATEi SHALL7PlOT BE`CONSTRUED AS A;GU' NTEE TI�IAT THE
l• ` \IJ T1 NY S° ISFACTORY. ' ? `MI)i Inspector: . Y
-I
R ,9 TH'E:C0.71MONW,EALTFi,iOF MA55'ACHUSETT$ n
I, € T �:I
�fr; I j w � 'BOARD. OF HEALTH r, •r :r
1. _ _ ....._.
y
No: . � �:l¢cll Fay:-• .......
asat Works ikts "fUan part ' i ,�e1
I : -
` Permission is-hereby granted` : ............................................... ,1� 1
to,Construct orl Re air '
(�,n) p ( ) an Indroldual Sev�age Disposal System �.
n at`,:'No ��. A l t �' 1 �9 i
_ .. . ----- . . --- ..
n:on the application for Disposal Works Construction ,ram
r Street
f P /
as show' ermit No .` f... Dated _ .l,l--�1,,�F
t �. . _ P` u
I • r - y .
I LEI t t I Health. Board of A �.
DATE .... n ... ..
n3 FORMS 1288 A M SULKIN,I INC BOSTON � \ ` a �,
J .:•N -'° -�.t'sS 1i�i'YLq L•�.4 �CZ -�y.-�n.,.� .. � ...1�.f.. {��• -- 1 ,„ il. �..�. �:, r,...sln. ?r \,
�j
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aj
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t
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o
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d C7 ( Grp+
A.
4 / Ip ORSEI v,
n J
'" z No:109511 O
} W= i�t3` t ` rFfi LoT 2 FFSSIONAI-�a�
LEGEND
w;l vL , °TIN® SPOT ELEVATION OAO
e - CERTIFIED PLOT PLAN
ft1; 'TB4® CONTOUR --_. ® ...,_—
; NE®' 9Bs®T ELEVATION
` ' tl�In CONTOUR O / L✓esr
° � .t€ { T 2A /�n (i /T LFJh;'a NyRt,rNLS ADLC
y"' t ;The location of. any existing underground sewerage,
w11s ox; other utilities shown on this plan is approx- IN
x �imate-:only .as determined :from records .and/or ver-balISAJl a` I
VV
piformation.' The contractor is responsible for the
i� x averi€Ication. of the existing locations in, the field., SCALE, / " _.30 DATE 1JPxi 2' 'F,5
# >�RED E ENGINEERINO Ca IN CLIENT. I. CERTIFY THAT THE PROPOSED
4I 4I'S'TERE RMIS`tER!~D JOB NO, R'tog� BUILDING SHOWIN . ON' THIS 'PLAN
s CIVIL' LAN CONFORMS TO THE ZONING LAWS
E 0 EER RV ®IR:SY� -' T� OF S�►I�PISTADL7 MASS t: 7I2 MAIN STREET C.N. BY
HYANN I S, MAM
=4 = SHEET.L OF DATE REG. LAND SURVEYOR
aD FT. MIN.'. NOTE /F E/THE'R 7''NE SEPTIC 'TAN/< OR
. L�ACN/�tG P/T .4RE /►9oRE TfIAN /2'��L�LO.� ,��L�T'.E& C'0/yCR-oF7'4t COPWAP r
7-0
C®NCet�� 4 PvC pipCq 1iE.4VY CA5T be C0VEsR L.L• BE USEta."
CODERS •O�i�FT /F/IV DR/VFWAY 4
i �e9ie�I. CONC�L�TE
.4n4 CC)►IZ CLEAN SAN10
BAC,e,4=/LL
1 ULS0/PE !i a LAYER i
1C G - o n o
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BOX v • � � • • o • e ° a®a •
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