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HomeMy WebLinkAbout0035 RUSTIC LANE - Health 35 RUSTIC LANE Hyannis A= 288 -090 I 0 TOWN OF BARNSTABLE LOCATION 35-`K,3s�:1C 1,8,) SEWAGE# VILLAGE y a ASSESSOR'S MAP&PARCEL 9,0 INSTALLER'S NAME&PHONE NO. Bf®a,3M T X Sty-qX-1/S3e/ SEPTIC TANK CAPACITY /6®O '#-(O A)e(.J LEACHING FACILITY:(type) 9Wq&// Y-/0C ohrj3 (size) /�Z $ X 0-9- X Z NO.OF BEDROOMS ?2 OWNER ;!St7 PERMIT DATE: 02- //- aU;,d COMPLIANCE DATE:9 )-0 a-U Separation Distance Between the: None (_-VC6uN k ird 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 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY r M ? y 1 1 I J S M 1. d 1 J � N � No. o ,� Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippliLation for Bisposal *pstem Construction Vermit Application for a Permit to Construct( ) Repair(11�Upgrade( ) Abandon( ) QI:!omplete System ❑Individual Components Location Address or Lot No. 35" 7g;,;_-1 c L Owner's Name,Address,and Tel.No. ily�KtS Fitz ob✓�c�t Assessor's Map/Parcel a8tj y P Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. k7.A 'i3to,�A a aL S 3-YoO 7f SS a✓`J � v i 4�c Type of Building: (�l: r)t Zyrz�Q'6✓�i Y 7 ,� To w� 1,•l 3 �/P�lv`1 G '°�`' I 7 WN Dwelling No.of Bedrooms 2 Lot Size 76 p sq.ft. Garbage Grinder Other Type of Building -e5!Merv, r, No.of Persons Showers( ) Cafeteria( ) h Other Fixtures Design Flow(min.required) 2= y gpd Design flow provided -1 gpd Plan Date j.-!g 2 o.2-0 Number of sheets / Revision Date / Title Size of Septic Tank L 4GO Type of S.A.S. Z 5-00 15 G/1u,J 41em b°f S 4✓ti� �%`rj)vve Description of Soil Nature of Repairs or Alterations(Answer when applicable) 6V6,-4// y Neui 6800 ai%din. �7rJ//! 1. j�J- 16� A l-0 0 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sigrid Date p Application Approved by U Date Application Disapproved by 011 Date for the following reasons Permit No. 20 2 0 Q � Date Issued ',�i`:`'�""`+tti}..+,,,.»Irv...r.+4r"i3�„",�i.-...+^,-.w,§.rR:t+....-..%.:i+!,r,..,re",�j�jp#^^'" �.arr�'t .,.✓•.ti^."3k�•.'+�'rb,A+1•�r+. .ns.,T.+.Y"*^n.R^..y:�We,s`--r.�„i,d+7i`F2sstry`..:s•t,,r!�•-p^...^w.•.+�+..r,.,•- -=w.-` `+tN w. �.4.,'.r.". �... - - ' • Fee + /i1 './ U / ' THE COMMONWEALTH OF MASSACHUSETTS Entered in compete Yes PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Misposal *pstem Construction Permit f Application for a P..ermit to Construct( ) Repair(B°"Upgrade O Abandon( ) �omplete System ❑Individual Components Location Address or Lot No. K 6- X-54-1 c L N Owner's Name,Address,and Tel.No. r Assessor's MaplParcel a8 9 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. a•A i3tov�a �aC i5%-H00- 7i sS /" J V4 r,. , 1 Type of Building: N S G��J Jc Z-^Eyp- -117 1," Tow^ W�; .3 /0 aN`/ (A racy h e' Dwelling No.of Bedrooms 2. Lot Size 7610 sq.ft. Garbage Grinder( ) J -n , Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures n �� Design Flow(min.required) ,L y gpd Design flow provided 54/1 gpd Plan Date a•- ,?02 0 Number of sheets / Revision Date Title Size of Septic Tank �`� Type of S.A.S. 2: Soo Description of Soil Nature of Repairs or Alterations(Answer when applicable) A,,tw /SGO ui/�oa ,'r?iii r'.'.ti./ : J-ke"r Daie last inspected: Agreement: "A The undersigned agrees to ensure the construction and maintenance of the afore.described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sig _ Date --,,- 4J--',Q0JL0 Application Approved by rA4-04 Date a ' // .2u Application Disapproved by Date for the following reasons v Permit No. "fl 14 Date Issued 2 o THE COMMONWEALTH OF MASSACHUSETTS J. BARNSTABLE,MASSACHUSETTS Certificate of CompHance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓f Upgraded( ) Abandoned( )by Al C t at '� iZu s t c ..1 v�,.. . s has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 0 dated Installer 11, A S3(r w i :1'AC Designer �Gv,� /�I� &5 GC^a #bedrooms 2- 1, Approved design flow 13 U gpd The issuance of this permit shall not be construed as a guarantee that the system will f`un t o as designed. (� Date - a�,2 Inspector No. Z y 2 O V 7.0` Fee Orf THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposar *Pstem Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date.of this permit, Date Approved by .. �A a h ,714 Legend. . , ,r� ❑Zoning Districts 0 GP-Groundwater Protection i 2881,88 0 W - ell Protection 288 50 i�_ _ #59 _ Parcels 88:Q 1 " Town Boundary h 4 #49 3& r Q - w °� y aw r P� ,3 � i� — Railroad Tracks I 2$82t17 i� Buildings 1 - - �t2 EYJ Building rj Buildings nt Painted Lines 1 � Parking Lots r Paved 288,187 a — i Unpaved i i o mw,mu,a hit" i uu 4ilfi tl' ➢ '^�. imii�u in i90 ma i�ilNu yiq#ilu9�+ �... Paved Unpaved Roads J3 Paved Road + 1 2885� Ij Unpaved Road '' ti ! '� 8M + � Bridge ' - 13 Paved Median Streams ,t 288,d�Q 35r .rw Marsh 13 Water Bodies ,88 288186 S�1 2$ 1p e a.9 �! #39 """ e Zu�e -rwi" G �,N 2 P C) r # „ w� 3 �r V- 24 J k, 5 # 2 m #2 7 :c ��5,, a�����F d� _ _ _ -- �_� �P J� " �,' � ,i�"� ���, .�,i.` �ii P�n'�s ti a r� dc�,� ❑� .❑� j�iro M1 fa-8 08, { #14FIN ..sa Map Printed On: 2/11/2020 This map is for illustration purposes only.It is not Parcel lines shown on this map are only graphic Town of Barnstable GIS Unit adequate for legal boundary determination or representations of Assessor's tax parcels.They are Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street,Hyannis,MA 026oi 0 42 83 an on-the-ground survey.It may be generalized,may not accurate relationships to physical objects on the map 5o8-862-4624 reflect current conditions,and may contain such as building locations. Approx.Scale: 1 inch= 42 feet cartographic errors or omissions. gis@town.barnstable.ma.us Town of Barnstable ,.�"'E .o Regulatory Services Richard V.Scali,Interim Director 9$ M 0� Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 - Fax: 508-790-6304 Installer&Designer Certification Form .Date: y2-i 6-J0001 Sewage Permit# Z,�n _Oi i j Assessor's Map\Parcel� C, Designer: Installer. iU Address: Address: Tj�� On L�� was issued a permit to install a (date) (' taller) �' septic system at 3g 'rC lA- `—t� based on a design drawn by (address) E. •A Q,;�> dated ZID zc (designer) �Ice fy that the septic system referenced above was insialied substantiallY accordin :to g the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. -Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than-10' lateral relocation of the SAS or any vertical relocation of any component of the�septic-system).but in accordance with State& Local Regulations:.;Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I-certify that the system referenced above was construe,+ �*►liance with the terms of the I\A approval lettez (if applicable) ` ,tt1 pFADAVID 4gs\, y f �Ti NiAS�PI m staller's Signature) v � Nt1.1066 V 4i, /Ste (Design s Signature (Affix Designer s Stamp Here) r PLEASE !RETURN TO BARNSTABLE-PUBLIC HEALTH DIVISION. `CER'IMCATE OF COMPLIANCE WILL NOT BE ISSUED.-UNTIL BOTH THIS. FORM:`. AS= BUILT-CARD ARE RECEIVED BY.THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK'YOU. . Q:1SepticlDesigner C nification Foam Rev 8-14 l3.doc Commonwealth of Massachusetts °�8�"�09a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' - r� 35 Rustic Lane r r1 Property Address NI Susan & Paul Leander Owner Owner's Name " information is required for every Hyannis Ma 02601 7-16-18 � page. Cityfrown State Zip Code Date of Inspection rwt Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information 51 (:�3 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. Excavation Company r� Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-16-18 Inspector'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 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. ""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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 _ page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The two cesspools in series were in working order at the time of inspection and were pumped after the inspection as per requirements. 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. 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 ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR t 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis annis Ma 02601 7-16-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 3. Other: D) 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 35 Rustic Lane M Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1.of a public well. ❑ ® 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 2000gpd- 10,000gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 page. Cityrrown State Zip Code Date of Inspection C. Checklist 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? ❑ ® 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? ®NA ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® El 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)] D. System Information Residential Flow Conditions: A Number of bedrooms(design): No design Number of bedrooms(Actual) _2 plans DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gp ))� Detail: 2016- 1,900gallons 2017- 1,500gallons Sump pump? ❑ Yes ® No Last date of occupancy: July 1 SI—July 13t" Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 lr f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumper driver- Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 800 gallons How was quantity pumped determined? Off load ticket Reason for pumping: As needed to complete inspection 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).- 2 cesspools in series t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma' 02601 7-16-18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Original to dwelling 1961 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 8 feet Material of construction: ® cast iron ❑40 PVC orangeburg ® other(explain): Distance from private water supply well or suction line. Town feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If.tank is metal, list age: years -F Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑' No" Dimensions: Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge 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 How were dimensions determined? 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(locate on site plan): Depth below grade: NA 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 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 0 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont:) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS consists of a 6'x8' overflow cesspool that was dry when viewed. Cesspool did not show signs of past failure and is in series (2 total) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 in series (second cesspool was dry) Depth —top of liquid to inlet invert 8 Depth of solids layer 101, Depth of scum layer 3 Dimensions of cesspool 6'x5' Materials of construction blocks Indication of groundwater inflow ❑ Yes ® No a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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 Driveway I Rear A B Al-18' B1-26' A2-36' 82.17' 1 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is Hyannis Ma 02601 7-16-18 required for every y page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW @ 144" feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within.150 feet of SAS) ® Checked with local Board of Health -explain: Information provided by Board of Health ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: A plan provided by the Board of Health for a neighboring lot(#42 Rustic Lane dated 10-13-03) at the same elevation showed no groundwater at 144". A hand hole was also augured 3' below the bottom of the dry (second)cesspool and no groundwater was encountered. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 35 Rustic Lane Property Address Susan & Paul Leander Owner Owner's Name information is required for every Hyannis Ma 02601 7-16-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ASSESSORS MAP : c. r- , i,----- � I M{��.. !� O V S 1) The installation shall comply with the State Environmental Code Title V and Town of ,? . PARCEL : .____ ..._ _._._.._____----�---- ---_�•___ JA Board of Health Regulations. ; ': �" Sty S L EVALUATOR: I U i 1�f V�j./ 2) The septic system as proposed on this plan shall not be installed until a licensed town installer WJ Mn✓ � . WI TINE..S 1 receives approval and an installation permit from the applicable town. REFERENCE : '%:""' fD I �� ')ATE .._. �" ©�. I J 1 ` fy f . .. _., :.,,.�._. 3) Prior to installation,the installer shall veri the location of utilities, sewer inverts, sewer lines gpp - Z9 PERCOLATION RATE : y�_ rY w l and existing septic components prior to installation. -a' 4) All gravity sewer piping is to be 4 inch schedule 40 PVC at 1/8 / - g Y p p g p ' per foot. The first 2 feet out of TH- I TH-2 N the distribution box shall be level. All piping connections to be glued. 1`7 5) This septic design plan is not to be utilized for property line determination or for any other r purpose other then the proposed septic system installation. oru�s ,rC, x' 'f'� 1/� /� \� ?� . '-, FI All Title V components are to meet Title V specifications. Parking shall be prohibited over Title V components unless components are H2O loaded. LOCAT ION MAP i`� � � '?� 8) The existing leaching or cesspools shall be pumped and filled with material per Title V v` ) abandonment procedures, leaching and cesspool(s)and contaminated soils within the proposed SAS shall be removed and replaced with clean sand per Title V specifications. 4✓ (( 9) Septic components are to be 10'from a water service line. Sewer lines crossing a water line shal! be sleeved with an appropriately sized schedule 40 PVC with ends grouted. The water service line or the septic line can be sleeved with the sleeve being a distance of 10' on both sides of 2 crossing the line. y`' - �' 10) If a garbage grinder exists in the structure, it is to be removed if the septic system is not / �6� Lj -- �` designed to accommodate a garbage grinder. SEP i i SYSTEM DES 11 ��N 11) The installer is responsible for care of excavation around all utilities on the property and � �.._........_..__._.w.._.�.�,.._._......._____.._..___-._�.._..w.,_ __ ..._.. protecting the structural integrity of all structures during the installation process of the septic system. f"L. �' ESTIMATE MATE 12) This plan only represents that a septic system can be installed on the property meeting Title V -:.�. requirements, \b "� ^� �0X F� ` BE1,•-ROOMS AT ! GAL/DAY/BEDROOM - .�w..f.� GAL/DAY �`� \0 �� - �--• 13) The property owner shall review design criteria to approve the total number of bedrooms and design flow. Installation of the septic system as proposed and receipt of payment for the design h o SEPTIC TANK o shall be deemed approval of the design criteria by the property owner or agent of, GAi_IJA`' x ? DAYS a !� :SAL 14) The validity of this plan shall expire with the expiration of the town installation permit issued foi -� this plan or the validity of this plan shall expire on the expiration of the Certificate of Compliance W �►' �� .-'"` .� USE i GALLON .,EP .T IC TANK issued for the installation of the proposed system on this plan. ABSOR PT i CAN SYSTE .tN 4. DAVID y`�� r•, MASON ,{ Ci �i l `c r� o.1Ufi6 u j -"7 C, 901 TWA AREA `' 2'—� `t `'-: --•f `,�, f. ,"'"1 � 57 �� "L', a, `�•�'�`--"',' :3. toCIO-- S � � . T , ON ��� ��il • It JID r Tr 0 co �';t�� GAt" ��� ..� �° .+�i�.1z.-M}f�` C----�- � ' SEPTIC TANKp�\ �/ G l V 't ` rL l`�{ C�/ L(� `r (� +`�'C_ r'Sri rt _1.r{ `J� G' - SITE AND SEWAGE PLAN ell LOCATION - PREPARED ° FCR • _ SCALE DAV I D B . MASON DATE : Zlr DBC ENVIRONMENTAL DESIGNS DATE HEALTH AGENT Z