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Home My WebLink About0191 BRISTOL AVENUE - Health 191 .BRISTOL AVE., HYANNIS r I I Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , u 191 Bristol Ave Property Address a Victor Rodriguez Owner Owner's Nam information is H annis ✓ Ma 02601 9/3/19 required for every y 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:When A. Inspector Information S/ filling out forms *3 S on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane Co Company Address t�l Cotuit Ma 02635 Cityrrown State Zip Code 508-364-9587 S 113522 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); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on 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 913/19 Ins ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 3Q 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 Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 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: ® 1 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: System contains a 1500 Gallon septic tank as well as a concrete distribution box and 5 Infultrators. 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 FIND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �;1 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is Hyannis Ma 02601 9/3/19 required for every y page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form Pt Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Bristol Ave u Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 page. Citylrown 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: i 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 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 i Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 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? j ® ❑ 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 4' 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 page. Citylrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 276 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 page. City/Town 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: Not Provided 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Bristol Ave �1J Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 page. CitylTown 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: Installed 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof line 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? 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 is recommended I t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 page. Cityrrown 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 F Title 5 Official Inspection Form �OSubsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 page. Cityfrown 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 Level and at normaol level 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 page. Cityrrown 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.): Sewage pump in basement functional * 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: Working as designed with no sign of failure. Camera inspection from vent pipe Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 5 Infultrators ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 page. Cityrrown 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.): No sign of failure 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is H required for every annis Ma 02601 9/3/19 � page. Cityrrown 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 Commonwealth of Massachusetts s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4' 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 page. Citylrown 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 I i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 9/3/2019 Assessing As-Built Cards '1UWN Ur 1$AKNSTA1SLC LOCATION 19 l _8_R a f71 e�1,7/ _ SEWAGE N VILLAGE ��yif�//r ASSESSOR'S MAP dr LOTQ1— INSTALLER'S NAME&PHONE NO. 1e,C,4Af,0 fjt t�Lc s S-O,? SEPTIC TANK CAPACITY LEACHING FACILITY:(type) S ♦,t/�'r l,f AA fa,?F.(size) /7x 3,f NO.OF BEDROOMS 3 BUILDER OR OWNER ' ve PERMITDATE: 91r0 COMPLIANCE DATE: Wain Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 7. 7S- 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 Furnishedby d6 a,K 3'y 3a' https://townofbamstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar=291232&seq=1 1/2 Commonwealth of Massachusetts p Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '•u 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 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: 10+ 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: 9/1/99 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: You must describe how you established the high ground water elevation: Test hole data on file BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.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 u 191 Bristol Ave Property Address Victor Rodriguez Owner Owner's Name information is required for every Hyannis Ma 02601 9/3/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included I l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page'16 of 18 •y i t¢ I I i 1 . I 1 T n �d� 3 I j : f 1 �3 1 f N i I Vol i p� i I I I � I , 4 Ul y TOWN OF ;3ru-u'VS YABLE J v 1 LOCATION SEWAGE 4 � 0 VILLAGE ��y�,c/il ASSESSOR'S MAP & LOT.2Q1 INSTALLER'S NAME&PHONE NO. le(Q� lr -0 ��A�D��S S�� 6�!�•acs i SEPTIC TANK CAPACITY /S �Q LEACHING FACILIT`Y: (type) L�� Ks��a R d' (size) NO.OF BEDROOMS BUILDER OR OWNER ` Zl e PERMIT DATE: 9�i�o �Q COMPLIANCE DATE:_ d Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ?� 7�' 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 /;:,ZAe12 XZA1742-S O � X , ' e /per' � l n I I No. FEE /60! �r COMMONWEALTH OF M/ SSACH SETTS PT\ �d Board of Health, ��a.r r►��'4'�O �� ,MA. ��.��ATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Applicatio for a Permit to Construct(l<fepair( ) )Upgrade( ) Abandon( ) - &Complete System ❑Individual Components Location 191 Rfij�L Ve— vy" Owner's Name Map/Parcel# — oZ 3 Address Lot# Telephone# �t Installer's Name Designer's Name Apktw I'V el Address Address 90 a Z V iV l—X P,44 1�MAIQ S'h>A-)M►l�s Telephone# Telephone# L/d$—Qp ss' Type of Building Lot Size 31 00 3 sq.ft. Dwelling-No.of Bedrooms 3 Garbage grin Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) Do gpd Calculated design flow 336 Design flow provided 3 8 ( gpd E Plan: Date /— / S 1 C?cy Number of sheets Revision Date Title Stye i- 51!/a'><-1 C 42 10W Description of Soil(s) S e{ /4 N ' Soil Evaluator Form No. Name of Soil Eva1uato;DCO29 4W1UP- ate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr =,otto, c the SYStP111 in operation until a Certificate of Complia ce has been issued by the Board of Health. Signed&eL Date / -60 Now 1 +sa x ara FEE 6 / Board of Health 1ar✓t PLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Applicatio for a Permit to Construct(LYRepair( ) Upgrade( ) Abandon( ) - QoComplete System El Individual Components r Location 191 Rfi,,'-p 1, V v k-4 Owner's Name ��('�L 6:'p C b19 U S Map/Parcel# — a 3 ' Address Lot# Telephone# C Installer's Name Designer's Name APk"te ,Xt"rV-e �UHS�7-14N Address Address L�6 ZfV bV C!R Z Ro,q`1;�MAPWS U u Mill V701 Telephone# Telephone# Type of Building Lot Size 31 DO 3 —sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinc�'�,/r (e ' Other-Type of Building No.of persons Showers( ),Cafeteria ( ) r aOther Fixtures Deign Flow (mein. required) 3 3 o gpd Calculated design flow 3 36 Design flow provided 3 gpd Plan: D'�te /— S 9 Number of sheets '" Revision Date 0. Title SIC al C Description of Soil(s) Soil,!Evaluator Form No. Name of Soil Evaluator/[CvU9 �l�w� Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further ag rees to of to do the em in operation until a Certificate of Compliance has been issued by the Board of Health. Signed` G / Date e�n� •Yam�'. .��'�.� _ � �-�. 9 /� .g � t iT 4 No. / FEE CV/ COMMONWEALTH OF MASSACH SETTS , Board of Health, &A N ST�.�/f •MA. CERTIFICATE OF COMPLIANCE � Description of Work: O Individual Component(s) '$'Complete System The undersigned hereby ce th t th e a e Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) by: P- at ` ! L �/4 V CT a",-, ' has been installed in acc rdance with the r•visio of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. �a dated Approved Design Flow(�g (gpd) Installer Designer-�JbQ N ICPY Sy✓Vq vt'uhS CtwN75 Inspector: �!�6`-G V, ,r'.'i• The issuance of this permit shall not be construed as a guarantee that the syste function as designed. No. / lY Q FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, IJ2/K4�/p NrA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( L-Y Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system } at V 7 I A Q 1006 /9 V Gy as described in the application for r Disposal System Construction Permit No./ 9'v , dated / `a-11 17 Provided: Construction shall be completed within three years of the date of permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health Y t./ /fYMiK tl700D)Ji]D .. 7. 4 10 K �• �;~ - tk �� )i. �� ,� •�`. ISM ?. � ... .k •�'� tea. 'c�i:;� �r• , R?' �� w .. r,•..�^:.:.: '.`. •'• ti' aid! 1 mg, .'� V ,. 1•! '.` y i �, f •:LL. .... r , ie 7 !; �I ' I CAS i. NO P�,�, •r. + +` 1, �' Yi•: Ile- -li �t II `�3i :i 6Cr4E ELAN NO; OMMf� ,q pD Du ��&ASSpC'�19iS•BUILDEf{$, ��N� '.�.CNrr;�r' . ., •h�� ! i ro�n�rrn.wrmw►rw.. 't= b�o G:p• � 1 1 •' 2 1 ,t w 0 s•e 9�4� 3:1G �a r -- Fu V ,t fa • c: ilk .y 77 ,——, �• or--- -- - - -- :� 'f.i.�•.•: .> N ••��-:Wit.'_ �'— - -p..._i°w--•-� -� '_ , W i 2 a s .� TOWN OF ARNSTABLE LOCATION ! 91 1-7-RI r7tG� SEWAGE # D VILLAGE / y/�,!//j ASSESSOR'S MAP & LOT 12 :33-� INSTALLER'S NAME&PHOINE N0. SEPTIC TANK CAPACITY LEACHING FACIL=: (type) S_ l.�/G%14 AA fa? (size) /7'` 3J, NO. OF BEDROOMS 3 BUILDER OR OWNER DAR1�`��` v,-S PERMITDATE: 21' 14 COMPLIANCE DATE: Separation Distance Between the: r Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 7. 7S' 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 Ar.l11�''S � Of � � 1 aE ,11 x 101' _ VENT 719P OF FOUNDATION 20' MIN. IF S.A.S. IS MORE THAN 3,0' BELO W SURFACE 10' MIN. CONCRETE COVERS �, 4" SCHEDULE 40 P. VC. MIN. PITCH 1/8 PER FT. 27LA YER OF 1/8"-1/2" EL=100 EL=100' WASHED STONE CO VER / ♦ / / / ♦ / / / / —T / / . . ♦ ♦ / / ♦ EL=101.0 6" MAX / ♦ i i / / / / / / ♦ / / / ♦ / / / / / / / / / / i 4" CAST IRON PIPE / ' (OR EQUAL MINIMUM PITCH I/4 PER FT CLEAN SAND 9 FLOW LINE EL=97.25 \MIN, INVERT 1 N 14" Lr —2.0'— EL.= 98_5 CAS INVERT 6 SUM LEVEL o c o000000 INVERT BAFFLE EL.= 98.0 /NVERT INVERT� 0 0 0 0°0 ° EL.= 9_8.25' EL.= 97. 75 EL.= 97.50 00° ° EL.=95. 75 (710 BE PLACED ON FIRM BASE) DISTRIBUTION MECHANICALLY COMPACTED OR 6" OF S70NE 1 BOX EL.=RB 75 GALLONS TO BE WATER TESTED 11' X 38' TRENCH FORMATION SEPTIC TANK IF MORE THAN ONE OUTLET PLACE ON 6" STONE 3/4" 7b ,_1/2. SOIL ABSORPTION PROFILE OF DOUBLE WASHED STONE S ySTEM (SAS SEWAGE DISPOSAL SYSTEM BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE ELEV. =_88 __. NOT TO SCALE NO OBSERVED WATER TABLE (8126199) ELEV. =_ 88__ t OBSERVATION HOLE �1 ELEV. L� PERCOLATION RATE <2__ MIN./ INCH AT _4&'_ INCHES OBSERVATION HOLE 2 ELEV.__ 9_5.5' DEPTH RORIZ TEXTURE COLOR M07T OTHER DEPTH HORIZ TEXTURE COLOR MOTT. OTHER 0-3" 0 WOOD LOAM IOYR 2-1 NONE FRIABLE 0-3" 0 WOOD LOAM 10YR 2-1 NONE FRIABLE 3-8" A LOAMY SAND 10YR 4-2 NONE FRIABLE 4-8" A LOAMY SAND 10YR 4-2 NONE FRIABLE 8"-36" B LOAMY SAND 10YR 4-6 NONE LOOSE 8"-40" B LOAMY SAND 10YR 5-6 NONE LOOSE GENERAL NOTES I 36"-120' C MEDIUM SAND l0Y 5-4 NONE LOOSE, 40"-120 ' C MEDIUM SAND IOY 6-4 NONE LOOSE, X S7VNES 5X 57VNLS 1) ALL WORKMANSHIP AND MA TERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TO WN OF BARLVSTABLE-___ RULES AND NO WATER ENCOUNTERED NO WATER ENCOUNTERED REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. I SOIL TEST 2) ONE COVER ON SEPTIC TANK SHALL BE BRO LIGHT TO WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12" DATE OF SOIL TEST 8/26/99 WITNESSED BY: EDWARD BARRY B.O.H. 3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN SOIL TEST DONE BY ECO-TECH ENVIRONMENTAL-DAVID D COUCHANOWR, R.S. 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE DESIGN CA L C ULA TIONS.' USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. ' NUMBER OF BEDROOMS . 3 4) ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL S BE MORTERED IN PLACE. TOP LOAD GARBAGE DISPOSAL NO 5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH 5 INFILTRATORS WITH TOTAL 110 ESTIMATED GAL FLOW x 3___ BR. 330 GAL/DA Y DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO 4 STONE SOES AND ENDS ( ----- OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 11' X 38' REQUIRED SEPTIC TANK CAPACITY 1500 GAL 6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCA VA TION CONTRACTOR SOIL CLASSIFICA TION . . . . . . . . 1 IS TO CALL "DIG- SAFE" AT 1-800-322-4844 AT LEAST 72 HOURS INSTALL IN MEDIUM SAND DESIGN PERCOLATION RATE . . . . . < 2 MIN./IN. PRIOR TO COMMENCING WORK ON SITE. 74 GAL/DAY/S.F. 7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS EFFLUENT LOADING RATE . . . . . SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. LEACHING CAPACITY (AREA X RATE) 381 GAL/DAY 8) PARCEL IS IN FLOOD ZONE___"C" RESERVE LEACHING CAPACITY . . . 381 GAL/DAY 9) LOT IS SHOWN ON ASSESSORS MAP 291 AS PARCEL _232 , (38XIIX 74)+(38+38+I1+IIX 74) 2 0 2 JOB NUMBER _ 52093 4 HYANNIS '0 vo 28 BENCHMARK TOP OF CA TCH BASIN ELEV. = 100, O'(ASSUMED) $ x U E�T �'��" of AUL LOCUS � d A A. TR 10 .$� _ ' ME"EW K S TOL Na T N _ YD. � E o M _ _ g 0F z_ _p — fo o;v `ems � E D - - �� _10 38 \PIPE - - 102. - - - - 01.9 4 LOCUS MAP R-1 103.5 %�� ASSESSORS MAP. 291, LOT 232 cB I i o . 38 t '�sRtl CE 'G j I 10 g ! G r, PLAN REF 14034 E I �� 'U o �.i _ _ _ A�URPiiY ZONING.• RB (� ?V T tVa.749 ,� FLOOD ZONE- WATER ti b o ° _ 100 �� - �I i��s fC WATER PROTECTION "AP" I 4 ly/T A� o , 3610 - - TIC PLAIN Q I 4.0' T.0.F EL=101 _ _ ,SITE AND SEPTIC I I 2 le,103 29 g, i PRO p OM _ - ss PROJECT L OCA TION o ° 3 10 SE ARA � � 191 BRISTOL AVENUE G o I HYANNIS, MA. I �0 .9 AS/LOT 107 q 60.0'� rn APPLICANT.- - J �� W �� , _ DARLENE DA VIS Ooj HO �10.7 co — 9 38. 0 I YANKEE SUR VEY CONSUL TAN TS AS/LOT 232 RESERV _ �M \ \ P. O. BOX 265 AS/LOT 108 AREA= 13,003fSQ,FT. UNIT 5, 40B INDUSTRY ROAD MARSTONS MILLS, MA. 02648 PH.(508)428-0055 - FA X(50V420-5553 24 SCALE. 1 2 DA TE.•9 15 0'45"E 159 FREV.• REV.• ASILOT IRON — SILO T 16 0 _ JOB NO. 52093 DCB SHEE T 1 OF 2 PIPE ALIT