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HomeMy WebLinkAbout0045 MARYALICE LANE - Health x, -lRZ 45 Mary I ane Hyannis �Y•KA' a3`291�,�07gx`�x�"i'��„:: rr`'� '3 ri-n ,,,� r a 2 � a ° 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M '< 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is Hyannis MA 02601 September 25, 2010 required for Y P every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form: Important: A. General Information //V l �s When filling out r forms on the / computer,use 1. Inspector: only the tab key J to move our David D. Flaherty Jr., R.S. EY R FCp cursor-do not Name of Inspector use the return �\ J� key. Flaherty Environmental Services \ J Company Name a �J ffi P.O. Box 81 Company Address Yarmouth Port MA 02675 Cityrrown State Zip Code 508-362-1657 S14713 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address antat tl�e information reported below is true, accurate and complete as of the time of the inspectAPl-heihspection was performed based on my training and experience in the proper function and mainten�e n site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15 40 of Title 5(310 CMR 15.000).The system: -n cti w ® Passes ❑ Conditionally Passes ❑ Fails � z ❑ Needs Further Evaluation by the Local Approving Authority C=) ca n r O rn September 28, 2010 Ins ectorsSignature 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. l � t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dispose ystem•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information isequired for Hyannis MA 02601 September 25, 2010 every 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: B) System Conditionally Passes: ❑ One or more system components as describ in the"Conditional Pass" section need to be replaced or repaired. The system, upon co pletion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not det mined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 0 years old*or the septic tank(whether metal or not) is structurally unsound/,indicatithat exhibits sit stantial infiltration or exfiltration or tank failure is imminent. System will pass insing tank is replaced with a complying septic tank as approved by the Board of He *A metal se inspection if it is structurally sound, not leaking and if a Certificate of Compliance tank is less than 20 years old is available. ❑ Y ND (Explain below): t5ins-09108 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owners Name information is P required for y H annis MA 02601 September 25, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high s/lee the di ribution box due to broken or obstructed pipe(s)or due to a broken, stri ion box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ (Explain below): ❑ obstruction is removed ❑ (Explain below): ❑ distribution box is leveled or replaced ❑ (Explain below): ❑ The system required pum/(with 4 times a year due to broken or obstructed pipe(s). The system will pass inspectioval of the Board of Health): ❑ broken pipe(s) ar ❑ Y ❑ N ❑ ND (Explain below): obstruction is rem ❑ Y ❑ N ❑ ND (Explain below): C/Further luation is Required by the Board of Health: ❑ xist which require further evaluation by the Board of Health in order to determine if is failing to protect public health, safety or the environment. will pass unless Board of Health determines in accordance with 310 CMR )that the system is not functioning in a manner which will protect public health, 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is required for Hyannis MA 02601 September 25 2010 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public W r Supplier, if any) determines that the system is functioning in a manner tha rotects the public health, safety and environment: ❑ The system has a septic tank and soil absorpti system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a s ace water supply. ❑ The system has a septic tank and SAS a the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and S S and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS nd the SAS is less than 100 feet but 50 feet or • more from a private water supply we *. Method used to determine distanc . **This system passes if the w water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent an he presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided at 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 El ® 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 Y2 day flow t5ins•09/08 Title 5 Official Inspection Forth: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 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is Hyannis MA 02601 September 25, 2010 required for Y P every page. Cityrrown 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. ❑ ® 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 st serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"n " o each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is withi 400 feet of a surface drinking water supply ❑ ❑ the system is ithin 200 feet of a tributary to a surface drinking water supply ❑ ❑ the syste is located in a nitrogen sensitive area (Interim Wellhead Protection Area— PA)or a mapped Zone II of a public water supply well If you have answered"y 'to any question in Section E the system is considered a significant threat, or answered"yes" in S ction D above the large system has failed. The owner or operator of any large system considered significant threat under Section E or failed under Section D shall upgrade the system in accord ce with 310 CMR 15.304. The system owner should contact the appropriate regional office the Department. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is Hyannis MA 02601 September 25, 2010 required for Y p every 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? ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is p required for y H annis MA 02601 September 25, 2010 every page. Citylrown 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2010 Date 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. , etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank p sent? ❑ Yes ❑ No Non-sanitary waste disch ged to the Title 5 system? ❑ Yes ❑ No Water meter reading , if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is Hyannis MA 02601 September 25, 2010 required for y P every page. Citylrown 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: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments M 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is Hyannis MA 02601 September 25, 2010 required for y P every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate.age of all components, date installed (if known)and source of information: 4/8/2002, BBOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >30feet Comments(on condition of joints, venting, evidence of leakage, etc.): joints good, venting through dwelling adequate, no evidence of leakage Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 4" t5ins•09/08 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 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is Hyannis MA 02601 September 25 2010 required for y P , every 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 30" Scum thickness • 1" 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 13" How were dimensions determined? stick, tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pumping not necessary at this time, inlet&outlet tees good, tank seems structurally sound, liquid level appropriate, no evidence of leakage N Grease Trap(locate on/meER3 Depth below grade: feet Material of construction: ❑ concrete ❑ ❑ polyethylene ❑ other(explain): /.e p of scum to top of outlet tee or baffle ottom of scum to bottom of outlet tee or baffle ping: Date t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,..�' 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is Hyannis MA 02601 September 25 2010 required for y P , every page. Citylrown 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 a/inspecli ate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fibhylene ❑ 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 pump/of Date Comments(condim and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form OW Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is Hyannis MA 02601 September 25 required for Y p , 2010 every 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 n/a 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 seems level, no evidence of leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pu chamber, condition of pumps and appurtenances, etc.): Soil Abs/cated, ystem (SAS) (locate on site plan, excavation not required): If SAS nexplain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is Hyannis MA 02601 September 25 2010 required for Y P , every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2)w/stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no signs of hydraulic failure or breakout, vegetation typical (lawn) Cesspools (cesspool must be pumped as rt of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet inve Depth of solids layer Depth of scum layer Dimensions of ce pool Materials of struction Indicatio of groundwater inflow ❑ Yes ❑ No t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is Hyannis MA 02601 September 25 2010 required for y P , every 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/signs Materials of construction: Dimensions Depth of solids Comments(note conditioulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is Hyannis MA' 02601 September 25 2010 required for y p every page. City/Town 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 Uja 31 76 _ 2..o( " n - 3 31 l0 `' J 6Z - Z1ft t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is Hyannis MA 02601 September 25, 2010 required for Y P every page. Cityrrown 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: >25 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: Town of Barnstable Groundwater Contour Maps ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: TOB Groundwater Contour Maps show groundwater approximately at el. 25, dwelling is at grade el. 50+/- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I � . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Maryalice Lane Property Address Aleksandr Bizunok Owner Owner's Name information is required for Hyannis MA 02601 September 25, 2010 every page. Cityrrown 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•09/08 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS u DEPARTMENT OF ENVIRONMENTAL PROTECTION h W� e !n SJey TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 45 Mary Alice Lane Hyannis MA 02601 Owner's Name: Aleksandr Bizunok Owner's Address: 767 Central Ave Needham MA 02492 Date of Inspection: July 28,2005 Job#05-225 Name of Inspector: PATRICK M. O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 °'- �5. CERTIFICATION STATEMENT _R I certify that I have personally inspected the sewage disposal system at this address and that the information reported -`,i below is true,accurate and complete as of the time of the inspection. The inspection was performed�ba`sed 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 systemH-)i _XX_ Passes '.•� Conditionally Passes �' P RICK Needs Further Evaluation by the Local Approving Authority Fails y 'C NELL :CO Z Si nature• Date: 7/28/OS ,�ij Rj�F� '< Inspectors g 5INSPEG•\ �. • F The system inspector shall submit a copy of this inspection report to the Approving Authority(Board DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching chambers empty with no sidewall stains.Tank is not in need of pumping at this time. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I . Page 2 of 11 T FOR VOLUNTARY ASSESSMENTS —N OFFICIAL INSPECTION FORM O SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 45 Mary Alice Lane,Hyannis Owner: Aleksandr Bizunok Date of Inspection: July 28,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: T41. 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 45 Mary Alice Lane,Hyannis Owner: Aleksandr Bizunok Date of Inspection:July 28,2005 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 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a su_rface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Titla G incnartinn Fnrm A/1 4;i11)nn 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 45 Mary Alice Lane,Hyannis Owner: Aleksandr Bizunok Date of Inspection: July 28,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X Backup of sewage into facility or system component due to 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 '/z 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 _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X_ Any portion of 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 1 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. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Titles 1; inenortinn Fnrm 6/1 Vnnnn 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 45 Mary Alice Lane,Hyannis Owner: Aleksandr Bizunok Date of Inspection: July 28,2005 Check if the following have been done. You must indicate"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_ Were any of the system components pumped out in the previous two weeks? _X_ Has the system received normal flows in-the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(if they were not available note as N/A) _ _X_ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Titla i Tnonantinn 17nrm 411 5 r Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 45 Mary Alice Lane,Hyannis Owner: Aleksandr Bizunok Date of Inspection: July 28,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Max. bedrooms allowed by BOH may differ. Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Yes Water meter readings,if available(last 2 years usage(gpd)): Two years total consumption: 48,000 gal.=65 gpd. Sump pump(yes or no): No Last date of occupancy: Occasional weekend use. COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ I Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: - Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: 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) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 4/8/02 Were sewage odors detected when arriving at the site(yes or no): No Titla 1; Tnen—tine Rn—fil si)nnn 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Mary Alice Lane,Hyannis Owner: Aleksandr Bizunok Date of Inspection: July 28,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 6" Materials of construction:—X_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: - Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 3" Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5' long x 5.2' long—1000 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: - Scum thickness: 0" 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: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank has liquid only,tees are intact and clear. Liquid level at bottom of outlet invert. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): T41.G 1.e Pt;n Pnr r.ii,;mnnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Mary Alice Lane,Hyannis Owner: Aleksandr Bizunok Date of Inspection:July 28,2005 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): No solids or hil?h stains. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Titla C Tnen-6nn P—fil annnn 8 • Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Mary Alice Lane,Hyannis Owner: Aleksandr Bizunok Date of Inspection: July 28,2005 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers,number: Two 500 gal drywells. leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Chambers empty with no sidewall stains. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Title S incnertinn Fnrm�ii si�nnn 9 Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Mary Alice Lane,Hyannis Owner: Aleksandr Bizunok Date of Inspection:July 28,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Mary Alice Lane Driveway #45 Garage 41 24 34 19 44 48 Titlo G Tncnortinn T+'nrm�ii�nnnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Mary Alice Lane,Hyannis Owner: Aleksandr Bizunok Date of Inspection: July 28,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 25 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.25 and topo map shows property above el.50. Titles G Tnenartinn Rnrm All si*)nnn 1 l TOWN OF B STABLE . r LO'ATION �7 I TYA SEWAGE # VP,.LAGE ASSESSOR'$ MAP & LOT AME&PHONE NO. Q.TI" G (J one L SEPTIC TANK CAPACITY "0 U A- . LEACHING FACILITY: (type) � i (size) 0 0 All NO. OF BEDROOMS IL Bb1ffiH€R-k3R OWNER JL A PERMITDATE: COMPLIANCE DATE: 602 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet. Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by n r k3, TOWN OF BARNSTABLE c/ 1i'OCATION ` J l c f L SEWAGE #�00� c y VILLAGE ASSESSOR'S MAP & LOTS?/— INSTALLER'S NAME&PHONE NO. yr 09. L-L 5-0a "q7,7-q SEPTIC TANK CAPACITY ® D 4 LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNERT PERMITDATE` 13 ol y -Z_ COMPLIANCE DATE: L v,2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) N Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 3 / 00 feet of leaching acility) `�I Feet Furnished by e p � o � w � 411 No. �n�'4 FEE _ 4 COMMONWEALTH Of MASSAF-KHUSETTS Board of Health, 1,RF?2 rl STAaLE MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair ' Upgrade( ) Abandon( ) - ❑Complete System Individual Components Location A a� Owner's Name '�_ ti ti ,� :. P - cLm Map/Parcel# P ,� 8 Address �o� Lot# 2*- R Telephone# O _ 3 (024,44 Installer's Name Designer's Name �' Address LR S0(y%Q,C5Vk P Address34 -T Telephone# snq4 - S005 Telephone# _ -C) as& Type of Building Lot Size 1-�+000 sq.ft. Dwelling-No.of Bedrooms Garbage grinder (A41q Other-Type of Building one- No.of persons �J Showers (►'j,Cafeteria (vY Other Fixtures -a yC3.�hC�) �C�'�C�1� c�ink, Lo oc--C y Design Flow (min.required) �i?,D gpd Calculated design flow 0 Design flow provided gpd Plan: Date 12, 1 Number of sheets 1 Revision Date Title S C� Description of Soil(s) Soil Evaluator Form No._� 1 Name of Soil Evaluator Date of Evaluation cc�la�1 O 1 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above d scribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place em' peration until a Certificate of Compliance has been issued by the Board of Health. Signed Date �G H Ok� zeU Inspections - �f _ �.-•w_..,. _' - AS�� FEENo. . ,C® 1QNWLAILTH ®f SETTS r Board of Health AR rJ STA c'3LE '1VIA. , hPPLIC'ATI®N FOR-DISPOSAL SYSTEM[ `�ONSTR CTION PERMIT Application for a Permit to Construct( ) RepairrX Upgrade( Abandon( - +❑Complete SystemIvIndividual Components Location g.`7 r GC"u c&k%'(-Q Loop nl`f Owner's Name Map/Parcel# P a -?C Address Lot# Telephone# r Installer's Name ! Designer's Name SA �J- s1Cs. Address erne-�e� d A`++P F_ Address 3 T-H _P- le,clp al J` i. Telephone# _ sus Telephone# a Type of Building �O \C�C.(1��0.�\ Lot Size hi• ©�sq.ft. Dwelling-No.of Bedrooms Garbage grinder 04A Other-Type of Building N ode No.of persons 3 Showers (✓I,Cafeteria (v) Other Fixtures -C�yC��rt71e\I Design Flow (min. 'required) h b gpd Calculated design flow Design flow provided •�J gpd t..,- Plan: Date Number of sheets ` Revision Date Title Description of Soil(s) G C` (--\ C , )( `X v Soil Evaluator Form No. '� Name of Soil Evaluator 1=� it-k AY Date of Evaluation DESCRIPTION OF REPAIRS ORALTERATIOI3S, The undersigned agrees to install the above . scribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place Osy em' operation until a Certificate of Compliance has been issued by the Board of Health. Signed f Date r Inspections ~�1J �. No. U ° .2 COMMONWEALTH OF MASSAC14US ETTS Board of Health, ��rn I �� MA. CERTIFICATE OF COMPLIANCE Description of Work: l Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ,Upgraded ( ),Abandoned ( by: at MGt M U LP 1 u K has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. Zoo-o`u dated Approved Design Flow (gpd) Installer P ft i Designer: Inspector: Date: (I 6 v - t The issuance of this permit shall not be construed as a guarantee that the system �unction as designed. No.ZGG _ G U FEE�7(J COMMONWEALTH Of MASSAC14USETTS Board of Health, 6 1,rA r A b � , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair96 Upgrade( ) Abandon( ) an individual sewage disposal system at MU r✓/ q �.t� 1'a.�. '" as described in the application for Disposal System Construction Permit No. a 00)-'0 Y 0 , dated Provided: Construction shall be completed within three years of the date of this permit. All locaj conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date (( 1) U12 Board of Health 01: �. r e TOWN OF BARNSTABLE p- C LOCATION yJ c L SEWAGE #�W� ``� l O VILLAGE ASSESSOR'S MAPS& INSTALLER'S NAME&PHONE NO. 3�,2 q SEPTIC TANK CAPACITY f, © D O / LEACHING FACILITY: (type) A2 (size) NO. OF BEDROOMS / BUILDER OR OWNER /W.1-. �PP/ / /(�6e r tf PERMTTDATE: l 0�_2__ COMPLIANCE DATE: c � d.2 I j Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist xOithin 300 feet of leaching acility) Feet Furnished by LF 1 _ 3 3 '—lo„ � Z Z6 �, - - 0 tsSep-20-01 13: 52 BARNSTABLE HEALTH DEPT 5087906304 P . 02 r Sr2VOt 'NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. — i PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM [, �ARt�>✓� N�l'� hereby certify that the engineered pian signed by me dazed 12_12-8 I o f concerning the property located at 45 MARY F�\1 Cp— -Zk--\\Y\-- meets all of the tol':owing criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is ciassi;:ed as.CLASS I and the percolation raze is less than or equal to rrunutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the sire without a health agent present. • There is no increase in Flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility wilt not be located less than Fourteen .;14) feet above the maximum adjusted groundwater table elevation. (Adjust the nundwwer table using the Frimptor method when applicable)' Please complete the following: ra.) Top of Ground Surface Elevation (using GIS infor-matron) A 4 r B) G.W. Elevation, F adjustment for high G.W. _. _ ..___ a�• q t t: LT-FER—ENCE BETWEEN .A and B J SiGN-ED _ DATE: i a 1 �o NOTICE i Based upon the above information, a repair pet-t-rit wi11 be issued for 5edroems ' i maximum. No addiu:anal bedrooms are authorized in the future without engineerec sept!c �yste^ plans. c:hc_llh!CIdu percczmP i Permit Number: Date: Completed by: (2 pAZy\E.r-,\ HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 45 M 4ZYq t-\CE LANE Lot No. Owner: tERe\ 4vGVX S Address: 2 C�12 Contractor: Cf- eta\EvS 5*1gy Address: c )9 TAR Cl1ER LANE �G Imcr�i� Mfl Notes: U253� STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... MIW19 OB Water-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ..................... month year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 26) determine water-level adjustment .......................................................................................... 4•a STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ............. 2-tl Figure 13.--Reproducible computation form. 15 Cape Cod Commission: USGS Well Data - December 2001 Page 1 of United States Geological 'Survey Observation Wells As a service to Cape officials, engineers and other interested parties, the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from United States Geological Survey (USGS) observation wells and compiled during the last week of each month. They are published as soon as possible thereafter. Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001 to predict high groundwater levels. For your convenience, we've also provided links to USGS national and state data. See the I,uf ctilun►n in the table and the footnotes below. For further information, please contact Hydrologist Gabrielle Belfit at the Commission offices (508-362-3828). December 2001 Water Record Record Departure from l (;:` tii�c 'vtiuil,cr' Location Well No. Level* High* Low* Average** (I i n ks to Monthly Overall ,iter-leNcl �lat,ii�,.t�ci Barnstable 230 26.3*** 20.5 26.6 -2.1 -2.6 413956070164301 Barnstable 24W 27.0 20.5 28.6 -1.8 -2.5 41411 54070165001 Brewster BMW 21 12.8 6.9 13.3 JI -2.3 -2.7 414518070020301 Chatham CGW138 25.7 20.9 26.61 -1.3 -1.7 414100070011101_ Mashpee MIW 29 9.9*** 5.6 10.0 -1.0 -1.4 413525070291904 Sandwich SD 2 47.8 45.9 48.2 -0.3 -0.5 41441_8070241601 Sandwich SDW 53.1 45.8 55.1 -2.6 -3.1 414124070265901 Truro TSW 89 12.8*** 10.2 13.0 46 -0.7 420206070045901 Wellfleet WNW 17 12.3 7.3 12.8 -1.3 -1.9 415353069585401 * Measurements are in feet below land surface. * Measurements are in feet above mean sea level. *** New monthly low. USGS national water-level database provides historic data, hydrographs, and site maps. The USGS compiles the above data and other water levels into a monthly, online Water Resources Current Conditions Report that covers all of Massachusetts. http://www.capecodcommission.org/wells.htm 1/3/200 f FORM 11 — SOIL EVALUATOR FOR Page 1 of No.: Date: 12/21/01 COMMONWEALTH OF MASSACHUSETTS Barnstable , Massachusetts Performed By: Carmen E. Shay Date: 12/21/01 Witnessed By: Waiver— Per Barnstable BOH Location Address or #45 Maryalice Lane, Owners Name: Terri Hughes Hyannis,MA Address: P.O. Box 1042,Forestdale,MA Lot# Map 291 Lot 78 02644 New Construction : Repair : X Telephone Number: 508-477-4913 OFFICE REVIEW: Published Soil Survey Available: No ❑ Yes ❑ Year Published: Publication Scale: Soil Map Unit: Drainage Class: Soil Limitations: Surficial Geologic Report Available: No❑ Yes❑ Year Published: Publication Scale: Geologic Material: (Map Unit): Landform: Glacial Outwash Flood Insurance Rate Map: Above 500 Year Flood Boundary: No ❑ Yes a Within 500 Year Flood Boundary: No X❑ Yes ❑ Within 100 Year Flood Boundary: No a Yes ❑ Wetland Area: None Observed National Wetland Inventory Map (map Unit): Wetlands Consercancy Program Map (map unit): Current Water Resource Conditions (USGS): Month Range: Above Normal ❑ Normal Below Normal ❑ Other References Reviewed: USGS Topographic Map DEP APPROVED FORM 12/7/95 FOAM 11 — SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No.: 445 Maryalice Lane, Hyannis, MA On -Site Review Deep Hole Number: #1 Date: 12/21/01 Time: 9:00 PM Weather: Sunny, Warm, 65OF Location (identify on site plan): Refer to Sketch Landform: Outwash Plane Position on Landscape (sketch on back): Refer to Sketch Distances From: Open Water Body N/A feet Drainage Way N/A feet Possible Wet Area N/A feet Property Line 25' feet Drinking Water Well N/A feet Other N/A feet DEEP OBSERVATION HOLE LOG Depth From Soil Soil Soil Soil Other Surface Horizon Texture Color Mottling Structure, Stones, (inches) (USDA) (Munsel) Boulders, Consistency, % Gravel 0" — 5" A Sandy 10 YR 3/2 None Friable Loam Friable 5" — 48" BW None <5% Gravel Sandy 10 YR 5/6 Loam 48" — 168" C1 None Med-Coarse Sand, Sand 2.5 Y 6/3 5% gravel/cobbles, Loose Parent Material (Geologic): Glacial Outwash Depth to Bedrock: N/A Depth to Groundwater: Standing Water in the Hole: None Weeping From Face: N/A Estimated Seasonal High Water Table 168"Assumed DEP APPROVED FORM 12/7/95 FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No.: #45 Marvalice Lane, Hyannis, MA Determination of Seasonal High Water Table Method Used: ❑ Depth observed standing in Observation Hole: inches ❑ Depth weeping from side of Observation Hole: 168" inches (assumed) ❑ Depth to Soil Mottles: inches ❑ Groundwater Adjustment: None feet Index Well Number: Reading Date: Index Well Level: Adjustment Factor: Adjusted Groundwater Level: N/A DEPTH OF NATURALLY OCCURING PERVIOUS MATERIAL: Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system: Yes CERTIFICATION: I Certify That on September 17, 2000, (date), I have passed the soil evaluators examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature: Date: FORM 12 - PERCOLATION TEST Location Address or Lot No.: #45 Maryalice Lane COMMONWEALTH OF MASSACHUSETTS Hyannis , Massachusetts Percolation Test Date: 12/21/01 Time: 9:45 AM Observation Hole #: #1 #1 Depth of Perc 48"-66" Start Pre-soak 9:45 End Pre-soak 9:51 Time at 12" Will Not Hold 24 Gallon Presoak Same Time at 9 Time at 6" Time (9-6") Rate Min./inch < 2MP1 Assumed @ 48 " Same * Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Performed By: Carmen E. Shay Witnessed By: Waiver per BOH Comments: Would Not Hold 24 Gallon Presoak - <2 MPI Assumed (cD 48" Site Passed X Site Failed DEP APPROVED FORM 12/7/95 SKETCH OF PERC TEST & DEEP HOLE LOCATION Property Address: #45 Marvalice Lane Barnstable,MA Owner: Terri Hughes Date of Pere Test: 12/21/01 Test Hole #1 Existing House 3 Bedrooms Maryalice Lane I I SECTION A -A 1' 2000'min. from from Au OuW�FININ "� 10� m PROFILE VIEW OF LEACHING SYSTEM �,,1111u7 ,em 11041 ME house to septic tank *NOTE: ALL PIPES ARE TO BE 4' SCHEDULE 40 P.V.C. SET LIM FOR AT LLAXT 2 FT. ODwvaEIX aDVMM Existing Foundation S�ptfo ter* aware nwwt be Zr3• of 1/a' - 1/2' Washod Peostan FS MIhIn a in. of f"wd grade w w s�- as°o 3/4' to 1 1/2 ' Washed Crushed - s•auTl Er Grade ovw leptk Tank - 98.30 iivde over D-sn- sE 00 / pp � 4P f/ As• ,Y N.ET s - a02 s-a 3 HOLE eoz20 T �� cqr.. Tap of SAS- � -e7.25 An i - o, SEPTIC TANK 20'GAL ,s �°°� r,,r...e,e, o 0 0 0 0 0 1°� 4• - sclt. 40 r - ,.� SI E Gedr C„ BfgR ATE � o H-10 `� g o o s tad y Stoney" 19' PLAN SECTION CROSS-SECTION e a 03 SYSTEM PROFILE E " 3/4'-"/r r ' e 3 5' 3.5$ 26' 3 HOLE H-10 DISTRIBUTION BOX `y Not to Soule eta �30 Effective Width Effective Length NOT To SCALESµ� L.❑CUS MAP IPOUT ALL AROUN.5 ELEV.POUT ALL SOIL ABSORPTION SYSTEM (SAS) i e rra ted at 1/2• 500 - C LEACHING UNITS / WIGGINS PRECAST oorripacted stuns aatt m of Tent hake Not to Scale GENERAL NOTES 1. Contractor is responsible for Digeofs notification Note: Remove Boll down to el. 94.50 A: replace with Note: Certification of Fill Motaial Required. and protection of all underground utilities and pipes. dean coarse sand w/pere. rate less than or Before and After Placement by Solve Analyses 2. The septic tank a d distn tdion box shall be set or equal to 2 min./in. before do after placement Per 310 CMR 15.255(3) level on 6� of 3/4 -1 1/2 stone. 3. Backfill should be clean sand or gravel with no NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE stones over 3e in size. 4. This aystem is subject to inspection during installation FROM THE EXISTING CESSPOOL TO BE DISPOSED by Carmen E. Shay - Environmental Services, Inc. 2-ir °". AaaEss MANHOLES 5. The contractor shall install this system in accordance OF AS PER BOARD OF HEALTH SPECIFICATIONS. e with Title V of the Massachusetts state code, the approved plan ACCESS COVERS OF SEPTIC TANK TO BE and Local Regulations. + '" `-�ti-=- ' °' '� RAISED WITH THE APPROPRIATE RISER TO WTHIN 6. If, during installation the contractor encounters any ? >, e• OF THE ExISTING GRADE AS PER TITLE V. EXISTING LEACH PIT TO BE PUMPED DRY & soil conditions or site conditions that are different from those shown on the soil log or in our design y THE ACCESS COVERS FOR THE SEPTIC TANK. _ DISTRIBUTION Box AND LEACHING COMPONENT FILLED IN PLACE. installation must halt dt immediate notification be ou SET DEEPER THAN 1 FOOT BELOW FMgSliED made to Carmen E. Shay - Environmental Services, Inc. GRADE SHALL BE RAISED TO WITHIN 12 OF FISHED GRADE. 7. No vehicle or heavy mochinery shall drive over the septic system unless noted as H-20 septic components. .7-2.t;.,ih-7,- {•- -. .' INSTALL TUF-TITE GAS BAFFLES OR EQUALS Note: Remove soil down to el. 94.50 do replace with 8. Install Tuf-rite gas baffles or equals on ail outlet tee ends. STEEL REINFORCED PRECAST CONCRETE clean coarse sand w/perc. rate less than or 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. PLAN VIEW or equal to 2 min./in. before & after placement 10. All solid piping, tees do fittings shall be 4' diameter .1-2e 11010VAM COMM (5 FOOT STRIPOUT ALL AROUND AS SHOWN) Schedule 40 NSF PVC pipes with water tight joints. Cc & 11. Municipal Water is Connected to The Residence and Abutting 4' r' r Properties Within 1jc F et. j eiLFT J1.5' nr�. ..r,�rda to ou Wt r:-• ..� >r •' ' N 81 d;48' 45" Ill ' e�T tJv�r..r N ouTtET "Ta• _r 1 95X 0 /�/ /� 98X08 100.00' 97)46 TH PROPERTY LINES ARE APPROXIMATE AND 4'-4T min. COMPILED FROM THE SURVEY PLAN GENERATED BY LOT #8 i �_-- �� 2 WHITNEY ENTITLED & PLANS OF LAND SURVEYORS. OF AB RN TA LE, MA 1963) 96--- 13,000 Square Feet +/- ,> MA . .r •i .c., ; ) %> ,> �.\ LC 14034-H SHEET #1 - e•-r s• _ia• , > t6 �____ AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN • % �� ^"?.?- >>'__- B.6 i�-98 R SHOULD 3E USED FOR NO PURPOSE OTHER THAN CROSS SECTION END-SECTION / 1.;:' a• i TEST HOLE 1 f.: • I i THE SEPTIC SYSTEM INSTALLATION. j !� 0 ; ELEV.= 98.50 I1 AREA i • U I I ,� USE EXISTING 1000 GALLON H- 10 SEPTIC TANK X , 98.50, i'=' I XI '►L- -� eq LEGEND NOT TO SCALE _ 97 --- , / / Failed DENOTES PROPOSED PERCOLATION TEST , Leach Pit 3 , F1 04X 11 SPOT GRADE 0 98.85 ; Data of Percolation Test: SEPTEMBER 28, 2001 X ; X 104.46 DENOTES EXISTING Test Performed By. CARMEN E. SHAY, R.S., C.S.E. EXIST. 1000 go� 0 SPOT GRADE Results Witnessed By. Robert Scgorzi ( for Plymouth B.O.H.) Septic Tank , 97.34 Excavator. Shay Environmental Services, Inc. I 98 37 i X PL PROPERTY LINE Percolation Rate: Less Than 2 min./inch i X w 96P PROPOSED CONTOUR ----- ---- W i EXIST. c I EXISTING GARAGE h 97- - - - - -97 EXISTING CONTOUR Test Hole > II 3 BEDROOM No. 1 c LEV.SO DEPTH ILS - E i BOUSSS C _ , DEEP TEST HOLE & 0 9e.50' 00 ll 1�10 PERCOLATION TEST LOCATION LSa dy 98.101, w ,a YR 3/2N X 0•-5' A 98.00 //i 98.80 �, 6 FOOT STOCKADE FENCE � ,J Sandy __ X Loam 98 ,o ni 5/6 v 5'- 4W Be 94.50 Meld Sand 99 --- ------------. -------------- P LAN 4a'-1es' G e4.5o , P LOT S 81d 34' 20" E 100.0o OF PROPOSED SEPTIC SYSTEM UPGRADE Perc #1 PREPARED FOR Depth to Perc: 48" to 66' 99.84 Perc Rate=<2 min./inch X Ms. T E R R I H U G H E S Groundwater Not Observed PROJECT BENCH MARK No Observed ESHWT TOP OF FOUNDATION AT ADJUSTED H2O Bev. = None ELEV. = 100 (assumed) #45 M A RYA L I C E LANE MAR YALICE LANE HYANNIS , MA (40 FOOT RIGHT OF WAY) Design Calculations lay > "a� OF,,, =;��', PREPARED BY: Number of Bedrooms: 2 Equivalent to 220 Gol./Doy (330 Gol./Doy Min. per Title V) Garbage Grinder. Na .rii•.'a ARMEN E. ,SHA Y Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) E. i.,; Septic Tank - 2 x 220 Gal./bay - 440 USE 1,500 GAL. Septic Tank. i{" ENVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rote of <2 min./Inch Bottom Area: 0.74 gal/sq. ft. x 300sq. ft. - 222.00 gallons o 1 c 34 THATCHERS LANE Sidewall Area: 0.74 gal./sq. ft. x 148 sq. ft. - 109.50 gallons 0 20 40 50 cc/;, /14tEAST FALMOUTH, MA 02536 Providing: - 331.50 gallons I I I �a ,,fit Use: (2) PRECAST 500-C UNITS, HAVING A 2' EFFECTIVE DEPTH, a ��I ` TEL FAX 508-548-0796 �i To BE USED WITH 3.5' OF WASHED STONE ON THE SIDES AND SCALE: 1"=20' DRAWN BY: CES DATE: DEC. 28, 2001 3' OF WASHED STONE ON THE ENDS AND 2 FEET IN BETWEEN 2 UNITS. SCALE: 1'=20' PROJECT#SD282 FILENAME: SD282PP.DWG SHEET 1 OF 1