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HomeMy WebLinkAbout0034 SUDBURY LANE - Health 34 SUDBURY LANE, HYANNIS A=271-212 t„ r Y+ i V I I 1 } { No.....� .so�_ � . Yuic...3...................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH v A, Town_ .............. ....OF........--Barnstable .......... Applira#ion for Dhipvii al Workii T. nstrnrtion ramit Application is hereby made'for a Permit to.Construct (X ) or Repair ( ) an Individual Sewage Disposal qys tem-at: �� //.. .l�r� -.... :.................._- ......... �y ............... -- .._.... xra�,i� :, ,-------- ..... Ca ricorn F�eain Add s�u8t 6 . Falmouth �oa, � H rinia --------•- ....7.....�--------------------------------- �.._...�. ......._.....P.._._.........-• - - s (� Steve Lebel Owner Address ----.....---•--•-•-----....................................••--•------...._........-----•-----... ....._..-----•.._.....-----...........- Installer Address y Type of Building Size Lot-----------------------------Sq. feet Dwelling—No. of Bedrooms.........3...............................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building ranch-........... No. of persons____________________________ Showers 2 — Cafeteria Other fixtures ____________________________ W Design Flow.............53______._____ .............gallons per perso � >,�day. Total daily flow.............33Q----------------------- lons- .W Septic Tank—Liqu d capacit;000 gallons Length.. __.___. Width' .... Diameter________________ Depth_ 8...... x Disposal Trench—No..................... Width; ..__..._.__._...: Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No.._.1______________ Diameter___6._.._...__._._ Depth below inlet_._6_.___..._.___. Total leaching area____2�Z5_..._sq. ft. r Z Other Distribution box ( ) Dosin tank ( ) gildredgO.. Ukelering--- - Date-- - _._2 $1-------------- Percolation Test Results Performed by.__.___..._ _ __ __ ��— �:- . as Test Pit No. 1.( 2'0 minutes per inch Depth of Test Pit.... Depth to ground water21Yon�e_._en.counte�r Test Pit Ni . 2...N.A__._minutes per inch Depth of Test Pit NIA..____.... Depth to ground water----- ................. e ------------------------------------------------------ .............................. .......... _........ •-------- ........--------- •----------..._._...._- O :.Description of Soil.........------ �.:. .--------.I-OEM...$&...to- �Q-�1.---------- x ----------------------------------- ?- ---------10-�----medium_._.ellpw sand ________-__...--------------- v W --------------- ---------------------=---=----10------r---12------=-med.---white sand,traced-..of � v..Q1/no_._W ter... 12' VNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: . The undersigned agrees to install the aforedescribed Indivi 1 S ge Disposal System in accordance with the provisions of II I'Lh 5 of the State Sanitary &Se ersi d further agrees not to place the system in operation until a Certificate of Compliance has b i a d of healthjSigned--- --=�1­ -%" - f .7- i Date Application Approved By....... - = ------------ ................................. ----------------- Date Application Disapproved for the following reasons-----------------------------•................................................................................... ................•---...------•----•--•---....-_.....----..-.-----------•---------•----...-•-•----•-------.--....--•--•---•-------------------------------------=----------•-----•-------------------••-•- Date PermitNo......................................................... Issued....................................................... Date No................�....... r Fizz.................. { ..... ' THE COMMONWEALTH OF MASSACHUSETTS `. BOARD OF HEALTH a� Town .0 F............. rn Bastable ..............................-------..... ............---...._......--------------.....-----•----.._.................... Appliraation for Dispos al ' orks Tontrnrtion rrntit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at Lot # c7 I- .,r: �� Hyannis, MA ...... ...._. ... :.::..........y r-,,. .......... .................. ... Capricorn 'Rebel- r,Trust 765 Fa1mouthorl6&.ds Hyannis ......................-.......................................................................... ••••.......-----•••••••••-••••-•-•-..............••-•-•-•-••--•-••...........................••••. .. Steve Lebel Owner Address w Installer Address dType of Building P Size Lot............................Sq. feet Dwelling—No. of Bedrooms-__ __--..3 ..................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building rneh Other—Type g ___________________•--__--•• No. of persons............................ Showers Cafeteria ( ) OtherWures •- ............................................. •••..._....---•...... 0................................. w Design Flow t�D�-gallons per person &day. Total V'itw3 C4 Septic Tank—Liquid capacity............gallons . Length...............: Width................. Diameter________-__---_. Depth..._.•.......... Disposal Trench— To. .................... Widtg*_......___..._.. Total Length_._._.'6a._ _-• Total leaching area._._____266 sq. ft. 3 Seepage Pit No..................... Diameter..................... Depth below inlet.................... Total leaching area............ ft. Other Distribution box, ) Dosing kfi� '� . e e:.En sneer 1i-2 -81 Percolation Test Res Performed by..............................:............. Date... 3...................... a 2•0 i none encounteedr- ,.a Test Pit No. 1:__..N/A._.minutes per Inch Depth of Test Pit ....... Depth to ground water_.__.0a___....__. Test Pit No. 2................minutes per inch Depth of Test Pit.._........_........ Depth to ground water........................ Ri ........ ♦-r------ 9--------- ........... O Description of Soil------------------ — 2 loam b'c--'�0�80��.---.....---- --- ------ •-•--•-•-•--••-•---._......--•--•-------------......_...... Pz. 1�,..._.me3ium ye Iow--saria---------------------------------------------------•----_---_------- w .. ; 1�f 1�. meet: white sarii�J'traced.:.of_:graveY�no..water..,at 12' ----------------------------------------------------• ••••. VNature of Repairs or Alterations—Answer when applicable............................................................................................... •-------------------------------------------------------•--•------------------------•--••------•--------•---------------------------------------------......---------------------------•--...-•-....._.. Agreement: The undersigned agrees to install the aforedescribed Individu Sew e Disposal System in accordance with the provisions of i i L 5 of the State Sanitary C e—. un sign further agrees not to place the system in operation until a Certificate of Compliance has beens of health. Signed ..��- i - ter -t�/�� A' _.... ' Date Application Approved By............................... / . .....................•-.....................•-•_... -------------------- Date Application Disapproved for the following reasons:.....................................................................................................,........... ..............................................----•------------------------•--------•---.............--••-••••-•-•••••-••••---••-•----•••-•••••••-•••••------•-•-••.....__......--••••......•-••...._. Date - PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town...........OF.............Barnstable...$........ i %rrtif irFatr of Tontpliattre THIJ IS TeO fFIRYFY, That the Individual Sewage Disposal System constructed ( X) or Repaired ( ) by..............•tev•••••------e-------------•-•--------------------------------------------------------------••--------------------.........-•-•--•----._._.................----..........._................._ Lot �( " •- _ I Installer has been installed in accordance with the provisions of TITI' j. T e State Sanitary Code as described in the application foi(Disposal Works Construction Permit No.___.- �.. ��_.......... dated................................................ THE ISSUAN E THIS CERTIFICATE SHALL NOT BE CONST AS A-GUARANTEE THAT THE SYSTEM WILL N ION SATISFACTORY. ! DATE............. .. ...................................................... Inspector.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town ......OF.....:......Barnstable 2. ............................ NO.............•••:..-•---. FEE,}5•-•---........... Disposal Iforks CLonntr ion erntii Steve e Permission Is hereby granted --------- ---------Leb--�,. to Constrict (X ) r Repair ( ).an.Individual Sewage Disposal System at No. ..... ' -ry - - HYa31Il�Ss Ma{ ~r` Street as shown on the application for Disposal Works Construction Permit No............4___.__I Dated.......................................... �, Board of Health DATE............... --- ,fl -:?,'.-4�aM, ....•--•-••-----._.... 1 FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 92 - S-0) •� LOCATION SEWAGE PERMIT 110•. VILLAGE • INSTA L L E 'S NAM-E i /A DR ESS To h i i �sP / , BUILDER 'OR.' OWNER, QATE PERM-IT IDSSUED DAT-E C-OMPLIAN-C-E IS-SVE9 ic.A1- 4 L� y b2 n { WIc rH 1c3c, ' 2o F.5. B 2-7.. sae` 134."7o 80 `. 7 0 5� y VOo`7c EXPAwslc5 l 0 0 8 0 m � � p�sTa��.,,�o..i aor � �l 0v ' 0 0 cc W (oJ O PPo Der sR...r 24't < LXDTIL 2� �- -- - ---I j2 (o$CoSF � pQa�D DQa.iBwnY I � ILq t 0 o rA Z / y/ 1' LoT 3 �'T M0r s ^ �i X\yfNo. 169514� e ``N OF M,'s� 4hbrrtv �ryb LEGEND �``� sqy CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION Oz0 0� JOHN EXISTING 'CONTOUR --- 0 -- - ERt LoT L7 _ suDBve�( LAf..1E=- FINISHED SPOT ELEVATION ,� .1 H�A►a�i S 'I FINISHED CONTOUR 0 /^ �� IN APPROVED t BOARD OF HEALTH~ No SUM _ DATE AGENT SCALE= I DATES 12.2I •`ii LDf�EDGE ENGINEERING CO IN CLIENT FP�+�co I CERTIFY THAT THE PROPOSED £GISTERE REGISTERED JOB NO. g�2o5 BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS ENGINEER .SURVEY.OR DR.BY OF BARNSTAB E, M SS. 712 - MAIN STREET CH. BYE AaM/RBE HYANN i S, MASS. 12'21•Q, � � ' SHEET OF 2' DATE R LAND SURVEYOR .3w � � �J W Q � 0 a p wN V Q °0 Vi Z Ili Q 14 Qtio° c o 40. -4 tea . • °44" H .� Po 0 � ap � W� z � 44 . �,. rk o . . . . . . . . 1L. ti@v► � WQ 4 0 hUv � w � t�w � � o ° ` ° 4 h �� yJ ` , O 4 0 ♦ b Q O • rA O to ° n e • eaa `J \ ' W v V41 � �; k o � q n 40 � Wl• '' a c: LO 4tjJ � � t4 lu : 'K Ji DO 00 i oil O 0 Q. 0 D, rr ut y o a � 6c- m , � YYro • F � � QaocW � 2 � � 2ot� i 14 aa � � 4' � 0 f) ��C �, J �► ti � � ? V W Q � 11Q�,, 2 i Z V ���sEzrs "� zx W � hh0o � , f �. No. � � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rppfttatton for I"s?/1s f _ stern �CQn t juctto� Prmtt /A%514 ,�- aox ©W/ Application for a Permit to Construct Re ai r 7 pp ( ) p ( ) Upgrade( ) Abandon( ) ❑Complete System rvidual Components Location Address or Lot No.3�/�'�/ /�y�,a�lil/= Owner,'s Name,Address,and Tel.No. Assessor's Map/Parcel H 64f9%'Il f' i'j'I/,5?S / 210 Ins ller's N e,Address,and Tel.NoSOFS'—el Designer's Name,Address,and Tel.No. o -ea, ct 305-;!So� r �s� G 14,-.3foylS' d�ii//jY Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) iU fir}' gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ) 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. Signe Date ® V ,f!/o Application Approved by Dater Application Disapproved by Date for the following reasons Permit No. 00GO -- 3-0—5 Date Issued L01917.91s Ol .".. t�. 1 No. �' "'30 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Nplitation for hisvosal stem CDlIBtrurtion i3ermit V- T Xors/� �� s� �p Zo W "O� Application for a Permit to Construct( ) Repair?( ) Upgrade( ) Abandon( ) ❑Complete System 04-ndividual Components t. Location Address or Lot No.3'v /t7i4/� Owner.'s Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. O6-4✓. a_ Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms l� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ^)`Cafeteria( ) Other Fixtures Design Flow(min.required) j gpd {Design flow provided gpd Plan Date; '; -^ Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs orAlterations(Answer when applicable) //1/�1'/�/� l� yX al-714," Z4 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. Signed .2. __ Date Application Approved by - Date( r' v Application Disapproved by Date for the following reasons O Permit No. calf «» Q y' Date Issued } THE COMMONWEALTHAF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS I / Certifitate of C OMPlian' re THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( a) Upgraded( ) ' Abandoned( )by 125e,'%G, . /_:e at y L d{/ / has been constructed in accordance- with the provisions of itle 5 and the r for Disposal System Construction Permit No.70I 8 70 dated Installer(JO.5 rW/1 � i�/'/^C�f Designer #bedrooms Approved design flow ^^' A" gpd The issuance of this permit shah.not beercconststrued as a guarantee that the system iffuncta'b. ' desi ed. � Date1�," // C1 Inspector .---- - - - -- _ - - -- ---- ------ - - ---- ---- - = - --- No. 7018 _10-5, Fee a THE COMMONWEALTH OF�MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS d4//y,_ Disposal 6pstrm Cone-6Uttion Permit (''Permission is hereby granted to Construct( ) Repair(`-/)b Upgrade( ) Abandon( ) System located at a"4 a/?V Ll�I�J 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 ��`7 �/ Approved by c4 rKE ram, Town of Barnstable Barnstable Regulatory Services Department ASAmedcaC 1 aa"STASM 9q, 6 9 ,�� Public Health Division '�Fa"tp�p 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 9248 October 17, 2018 BAROKAS, TERESA 34 SUDBURY LANE HYANNIS, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 34 Sudbury Lane, Hyannis, MA was inspected on 09/17/2018 by Chad Hathaway, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Distribution box needs to be replaced. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S.; CHO Agent of the Board of Health I . Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\34 Sudbury Lane Hyannis.doc I Town of Barnstable ILUMSrnsi.e, Mass 1639, prFB��a Regulatory ulatorY Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool V,4ny"conditionally passed systems" (broken cover, relocation of a pipe, relocation / of_a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER ❑ VQ Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts 19Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 4 t�3 34 Sudbury Lane f A. Property Address h. Barokas ' Owner W1 Owner's Name tv information is r. required for every Hyannis Ma 02601 9/17/18 'c page. City/Town State Zip Code Date of Inspection Fes, .t h 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 A. Inspector Information filling out forms on the computer, use only the tab Chad hathaway key to move your Name of Inspector cursor-do not H PS use the return Company Name key. P.O.Box 151 Company Address Forestdale Ma 02644 City/Town State Zip Code 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); I 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 my training 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 9/17/18 Inspector's ature Date The system inspector it 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 same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 1 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. Cityrrown 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: 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 ❑ ND (Explain below): Lt5inspxoc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts �s Title 5 Official Inspection Form I ,. p Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. Cityrrown 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): Dbox is rotted out at water level and dirt is starting to infill box. ❑ 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts !n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. Cityfrown 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 t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 P Y rY 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. Cityrrown 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 cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /� 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. Cityrrown 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 all 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 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. 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): min. 220 Description: Number of current residents: 1 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 Z No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial 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 Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: owner pumps every 3 years Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. City/Town State Zip Code Date 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: 1982 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 1.75' Depth below grade: feet Material of construction: ❑ cast iron E 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): no evidence of poor venting or leaks t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.25feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) 1000 gal H10 tank 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 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and 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.): baffles in place tank at working level no evidence of cracks or leaks no major deco t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts r ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . Y 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. Citylrown 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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): Depth of liquid level above outlet invert 0 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.): Dbox is rotted out at water level dirt is starting to in fill box t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. City/Town State Zip Code Date of Inspection 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: ® leaching pits number: 1 6'x6' precast pit ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v v 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit uncovered and inspected. current water level is 5 feet below invert with a stain line 3'10" below invert. House is occupied by 1 person and has had light usage 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.): Lu5mspAoc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts t� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �o 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is.required for every Hyannis Ma 02601 9/17/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts �n p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Sudbury Lane. Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. CitylTown 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 33 3s 3� �f31 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1" a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Sudbury Lane Property Address Barokas Owner. Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater then 20' 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: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: town of barnstable GIS mapping You must describe how you established the high ground water elevation: lot el. in area of septic is el. 54' low in area 30' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Sudbury Lane Property Address Barokas Owner Owner's Name information is required for every Hyannis Ma 02601 9/17/18 page. Citylrown 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report Prepared For: Report Dated: 11/7/2007 Teresa Barokas Order No.: G0744052 34 Sudbury Lane Hyannis,, 1M,1A 02601 Laboratory ID#: 0 t 44052-01 Description: Water-Drinking Water Sample#: Sampling Location: 34 Sudbury Lane Hyannis,MA Collected: 11/5/2007 Collected by: T.Barokas Received: 11/5/2007 Routine ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Nitrate as Nitrogen 0.48 mg/L 0.10 10 EPA 300.0 LAP 11/5/2007 Copper ND mg/L 0.10 1.3 SM 311113 LAP 11/6/2007 Iron 0•63 mg/L 0.10 0.3 SM3111B LAP 11/6/2007 Sodium 27 mg/L 1.0 20 SM 311113 LAP 11/6/2007 Total Coliform Absent P/A 0 0 SM9223 AF 11/5/2007 Conductance 140 umohs/cm 2.0 EPA 120.1 DCB 11/5/2007 pH 6.7 pH-units 0 SM 4500 H-B DCB 11/5/2007 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a physician. The water may present aesthetic problems(taste,odor,staining)due to Iron. - -- -. . ..... ... .__.. _ ._._.--------------- Approved By (L irector) I CZ) y. .� ;c- III SF ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 �E'CEIVEJ 14AY 3 pppp r0WN0F �sy COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS ��' 'b DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 34 SUDBURY LANE HYANNIS, MA 02601 M271 P212 L28 Name of Owner GURWITZ C/O WIANNO REAL ESTATE CYNTHIA SHIELD Address of Owner: BOX 496 OSTERVILLE MA.02656 Date of Inspection: 6/1/00 Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Tifle 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 608-664-7270 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 _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date:6/1100 The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 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. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life" THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. �U revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 34 SUDBURY LANE HYANNIS, MA 02601 M271 P212 L28 Name of Owner GURWITZ C/O WIANNO REAL ESTATE CYNTHIA SHIELD Date of Inspection: 6/1/00 INSPECTION SUMMARY: Check A, B, C, o!D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. n/a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass Inspection If the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n/a Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed pipe(s)or 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 levelled or replaced n/a 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 revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 34 SUDBURY LANE HYANNIS, MA 02601 M271 P212 L28 Name of Owner GURWITZ C/O WIANNO REAL ESTATE CYNTHIA SHIELD Date of Inspection: 6/1/00 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 IN ACCORDANCE WITH 310 CMR 16.303(1)(b)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 surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla(approximation not valid). 3) OTHER n/a revised 9/2/98 Page 3 of 11 x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 34 SUDBURY LANE HYANNIS, MA 02601 M271 P212 L28 Name of Owner GURWITZ C/O WIANNO REAL ESTATE CYNTHIA SHIELD Date of Inspection: 6/1/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: a I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No - X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. - X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below Invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Q. - X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. - X Any portion of a cesspool or privy is within a Zone I of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy Is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply - X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 34 SUDBURY LANE HYANNIS, MA 02601 M271 P212 L28 Name of Owner: GURWITZ C/O WIANNO REAL ESTATE CYNTHIA SHIELD Date of Inspection: 5/1100 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X - As built plans have been obtained and examined.Note if they are not available with N/A. X - The facility or dwelling was inspected for signs of sewage back-up. X - The system does not receive non-sanitary or industrial waste flow. 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.The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information,For example,Plan at B4O,H, X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 34 SUDBURY LANE HYANNIS, MA 02601 M271 P212 L28 Name of Owner GURWITZ C/O WIANNO REAL ESTATE CYNTHIA SHIELD Date of Inspection: 6/1/00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual): Total DESIGN flow: 220 gpd Number of current residents:0 Garbage grinder(yes or no):YES Laundry(separate system)(yes or no): NO If yes,separate Inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a 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: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1982 PERMIT 82-601 Sewage odofs detected when artiVing at the site:(yes or no): NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 SUDBURY LANE HYANNIS, MA 02601 M271 P212 L28 Name of Owner GURWITZ C/O WIANNO REAL ESTATE CYNTHIA SHIELD Date of Inspection: 611/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 18" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) THE SYSTEM HAS TOWN WATER. SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: nla Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a 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 9/2/98 Page 7 of 11 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 SUDBURY LANE HYANNIS, MA 02601 M271 P212 L28 Name of Owner GURWITZ C/O WIANNO REAL ESTATE CYNTHIA SHIELD Date of Inspection: 6/1/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 SUDBURY LANE HYANNIS, MA 02601 M271 P212 L28 Name of Owner GURWITZ C/O WIANNO REAL ESTATE CYNTHIA SHIELD Date of Inspection: 6/1/00 SOIL,ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN 1'OF WATER IN IT. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 SUDBURY LANE HYANNIS, MA 02601 M271 P212 L28 Name of Owner GURWITZ C/O WIANNO REAL ESTATE CYNTHIA SHIELD Date of Inspection: 6/1100 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) �c� g O ec� � e1R 0e O � AP at I& r . BC �3 revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 SUDBURY LANE HYANNIS, MA 02601 M271 P212 L28 Name of Owner GURWITZ C/O WIANNO REAL ESTATE CYNTHIA SHIELD Date of Inspection: 5/1/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet n/a Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET revised 9/2/98 Page 11 of 11