HomeMy WebLinkAbout1051 PITCHER'S WAY - Health 1051 Pitcher's Way
Hyannis `p
A = 272 - 150
TOWN OF BARNSTABLE
LOCATION 10S 1 -P;46,C r 5 tdoq SEWAGE# Z O 16 -263
�FILLAGE Jquan n,S ASSESSOR'S MAP&PARCEL 2 7.2-/5V
INSTALLER'S NAME&PHONE NO. R4 .3 6Xe:LVa4 i o A Ll`)01- 0653
SEPTIC TANK CAPACITY OR `2e ylaccrc�cni �1(�1. • I�
LEACHING FACILITY:(typ'e)/ (size)
NO.OF BEDROOMS' ►V i
OWNER (J�1�•►arv� eii�Vrc��
PERMIT DATE: $• y -)L COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on,
site or within 200 feet of leaching facility) Feet
Edge of Wetland and'Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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L4C AT ION S E W A G E PERMIT NO.-
VILLAGE
AL
INSTA LER'S NAME & ADDRESS4 _
B U I'L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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No. / - Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYicatiou for Disposal 6pstrm Construction gcrmit
Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1051 M r- cr le!A Y Owner's Name,Address,and Tel.No.(��I j a rA C j w1 S re-1
Map/Parcel �?cp —)50 �0$) Q� ckc-P S ✓A Y
Installer's Name,Address,and Tel.No. J3-4'{3 - .m%o p.;O^ Designer's Name,Address,and Tel.No.
ILI-Tc ►ycrry 1.j FPcsialalc L 7. O G53
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Aatel
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) -Z 130X ProlaCG mZn A t w l y N 20
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
gne Date • Z' 1.
Application Approved by Date Him
Application Disapproved by Date
for the following reasons
Permit No. �a � 19 Date Issued Z4
5'
No.
THE COMMONWEALTH OF MASSACHUSETTS Entered incomputer: —
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pprication for -Misposal *pstrm Construction 3permlt
Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. OS 1 �i�e t r W A Owners Name,Address,and Tel.No.
/ V 011IiaM � i►nSrcl
Assessor's Map/Parcel A Y
r,
Installer's Name,Address,and Tel.No.,Q<r G CaJcrlrO n Designer's Name,Address,and Tel.No.
ILITzaScrrH LO Fores-Idlo is y '?• O 6S3 '
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures i
Design Flow(min.required) �� gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank r Type of S.A.S.
Description of Soil t
Nature of Repairs or Alterations(Answer when applicable) .S .QUx Rc.pla z C rn r,
Y
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
f Compliance has been issued by this Board of Health.
1gne Date ZJ 1 Z,
Application Approved by Date �!
Application Disapproved by ? Date
for the following reasonsr
Permit No. C�_69 Date Issued
--------------------------------------------------------------------'-------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate Of Compliantr
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓S Upgraded( )
Abandoned( )by g� _R E X CCX U0.A 1 0^
at JO-S) -N-4-c h c r S G!A Y has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Nc'W 6 -t),i lated y Iva
Installer S,_(� CxCGj<XA 10N Designer
#bedrooms /.Y Approved design flow A gpd
The issuance of th s perm trshall not be construed as a guarantee that the system will fit albr( design/
Date I Inspector
~_________________ -__—.------_----
---
_----_ _J__ ____-- _ __ ___—
1. i.. yew ........... .. a.. —.. .... ... ... - r'
No. / 616 l5� Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal bpstrm Construction 3permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at 1 O S 1 -P;c-11,t.r S W ga A
'i
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must a completed within three years of the date of this pe
Date ��� I ,q Approved by
No....... Fss...... .................
THE OARDALTH OFUA�SSA;HU u TS / _�� y,
7...........oF ....... ..:..... ... ........ �0 I��
I Apphration -fur M-4postt1 Marko Tomitrurtiott Vrrtttit
O� Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
0 Q2 2 1f're�era
Locution-Address or Lot No.
Owner Address
------. .. •-
Installer Address
d Type of Building Size,Lot.11.4_4.6--------Sq. f t
U Dwelling—No. of Bedrooms------------ .............................Expansion Attic ( ) Garbage Grinder ,
Other—Type of Building ____________________________ No. of persons.--------------------------- Showers Cafeteria ( )
a' Other fixtures ------------ -----------------------------------------
w Design Flow............... ... ......•.--.•-.-__gallons per person per day. Total dail flow
i_-_V--_:-___.._..__.gallons.
WSeptic Tunk—Liquid capacity/Wd.gallons Length---------------- Width_..___..-__ li-- Diameter___._..--_..____ Dept .__._.___._.._.
x Disposal Trench—No. .................... Width.................... Total Length------------_----- Total leaching area--------------------sq. ft.
Seepage Pit No.J40-6 Diameter.................... Depth below inlet...... .... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by-------------------- ----------------------------------------------------- Date._..-----------------------------------
a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water..._._..__._.__.__.__._-
' f14 Test Pit No. 2----------------minutes per inch Depth of Test Pit_................. Depth to round water------------------------
0 �=of it �, �d L-;- -- -..It .'. - -- ------------------------------
Description
x d
....---
w
1W------------------------------------
UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- .
.-......--••---------------••------------------------------•-------------------•-----------------------------._...------•-------------------•----------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of --
Signed------------- --- --- ---------------------------•---------------------•---•-•--- • /.. Y_ ----
i Date
Application Approved By-------- / T7
at
Application Disapproved for the following reasons:....................... .:.--••----••..._._....---____-._____._.-..._._____._____ __.-___-.--.
..•-•----•-•...------••-•-•••-----•••-------•.............••--------•-....•-•••••-•••-....--•----•-••----...-•-...•-•------------•-••-----------...•----- •--------------•------------------------.------
Date y
PermitNo......................................................... Issued........................................................
Date
n.:
j
. J.... . .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HE L
�x .........OF.......
Appi ifflo't -for 4:31ti o-4 r� Cn tt� rttr t�ti rr ti
:.
Ap hcation is hereby made for`a;,Permit to`Construct ( ) or'Repair ( } an Individual Sewage Disposal
System at
Ldoc io Address - - or Lot No
Owner Address
`Installer Address
d Type of Building ? Size Lot_1. . :..__..._..Sq./�f at
V Dwelling—No. of Bedrooms---------- -----------------------------Expansion Attic ( ) Garbage Grinder ( t
� p.
p, Other—Type of Building ----------_----------------- No. of persons. -------------------------- Showers ( — Cafeteria ( )
a' Otller3 fixtures
,�,..## ------------------------- --- ------- ------------------------------
W Design`Flow_:_ __... '�#✓ _. -______-gallons per person per day. Total daily flow_______ _ " gallons.
Septic i'..nk=Liquid capacity/3-1Q---gallons Len-th---------------- Width-------------- Diameter-_-_.------------ Depth----------
Disposal Trench—No. .................... Width-_-_._.--___-___ __ Total Length...._--------------- Total leaching area----------- sq. ft.
Seepage Pit-No A4_1 %41. Diameter.......... ...... Depth below inlet-'__:___ Total leaching area-------____ --___sq. ft.
z Other Distribution box ( ) Dosing tank ( ) '`` -W
la Percolation Test Results Performed$by ---- - ------------- ............................................ Date--------------------=
Test Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water. -_ -----.
1= Test Pit No. 2_____ ________minutes per.:inch Depth of Test Pit-------------------- Depthto round water
F}
---
to
- .
D Description of o11.,P - � '- - ~-
0--- =
yy /r
.._...... j\�- P'° '. ,i .. _�!.. }._ .... ' .__. Yf'MEa.'�1 *-__ _ _________ ____ ____
U. Nature of Repairs`or Alterations Answer when applicable___:'___- ---------------- " _ -__ _.. ._.I ._-_.--____.
Agreement L
The undersigned agrees to install the aforede'scribed Individual Sewage.Disposal System'an accordance with
the provisions of Article XI of the State Sanitary:Code The undersigned further"agrees riotto place the system in
operation until a Certificate of Compliancehas been isstied.by the board of health
..' S ibI>.-d -----_------------------
Application .
Approved By s _� _�% Date
r
------
Application Disapproved for the following reasons'.. ...:.... .......-- --. .------ - _--- .------ ---- -_------..______
Date
PermitNo----------------- ----------------•-- ..: Issued.............................................. Date - -
THE COMMONWEALTH OF MASSAtHUSETTS
BOARD-: OF, HEALTH
OF
&r#t m li�tttrr ti
THIS IS TO ER" IFY, That the I divi .Rt
age_Disposal System constructed (' , or Repaired ( )
by....................... = --•------------------•- ------ ...........................
a er
at..... .... ....V-:� e°'. ,r _ �° P .t ' ._:_-:-----••-•---••---------------------- ....................................
been installed in accordance with th�ovisions' Ar XI of The State Sanitary C derma de illgd in the
application for Disposal Works,Construction Permit No.-
-- __________ -------- dated-..-_ -----------------____..............
THE ISSUANCE ;OF THIS ICERTIRCATE'SHALL NOT BE C RUED AS A UARA.I& THAT THE
SYSTEM WILL FUN TION TISFACTORY
DATE Inspector !o'er-
------ ----- ---- . --•--•• -•------•-••----
'THE COMMONWEALTH OF MASSACHUSETTS . .
BOARD OF H LTH
�e .. .. OF......................... ` .` ............._.... �,
N....... a_ FEE..... .......
Din:r teal in ,q �a tr tt;. rr tf
Y g . A ,
Permission is he eb 'ranted -=---- "--•- --- Q?:..---•---._...
to Constr or Repair ividual Sewage Disposal tem
+^
at No. e/�' r i +Et ........41
r
�- .• Str et
_ - as shown on the application for Disposal Works Constry ion Pe t No ated_._-_ *!!_"_
..........................
Board'of Health"
x: DATE.-...... f -`--77------
FORM 1255 HOBBS & WARREN. INC.;. PUBLISHERS
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AsBuilt Page 1 of 2
LOCATION SEW G E PERMIT N0.
VILLAGE
• INSTA LERIS� NAME & ADDRESS � ^
8UI-LD.ER OR OWNER
1--T 4 ST ce, cl
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED3d
Ci Nt[.IQy
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=272150&seq=1 5/24/2016
I. S. /S_0
N Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
C
M 1051 Pitchers Way
Property Address
William Cimbrelo r
Owner Owner's Name
information is H annis ✓ Ma 02601 8-10-16
required for every y
page. City/Town State Zip Code Date of Inspection
W
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Matthew Gilfoy
use the return Name of Inspector
key.
B&B Excavation
Company Name
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113640
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8-10-16
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�o� V�
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°wM 1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is required for every Hyannis Ma 02601 8-10-16
page. City/Town 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:
System was in working order at time of inspection. D-box was replaced prior to inspection. Tank is not
in need of pumping at this time but tank should be pumped every 2 years for maintenance.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old`` or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is required for every Hyannis Ma 02601 8-10-16
_
page. CityFrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is required for every Hyannis Ma 02601 8-10-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17"
J
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is required for every Hyannis Ma 02601 8-10-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion.of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is H
required for every y annis Ma 02601 8-10-16
page. City/Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is
required for every Hyannis Ma 02601 8-10-16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Off and on
Does residence have a garbage grinder?. ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes Z. No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d See below
9 ( Y 9 (gP ))�
Detail:
2015- 55,352gallons 2014-40,392gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: WeekendsDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
NA
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 1051 Pitchers Way
'M
Property Address
William Cimbrelo
Owner Owner's Name
information is required for every Hyannis Ma 02601 8-10-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Owner-last pump unknown
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M0 1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is required for every Hyannis Ma 02601 8-10-16
page. City/Town State. Zip Code Date of.Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Tank and pit 1977, D-box 2016
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1'6"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
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: 1000gallons
Sludge depth: 4
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is
required for every Hyannis Ma 02601 8-10-16
page. City/Town 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 32
Scum thickness 0
11
Distance from top of scum to top of outlet tee or baffle NS
Distance from bottom of scum to bottom of outlet tee or baffle NS
How were dimensions determined? Measured
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 was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in
need of pumping at this time but should be pumped every two years for maintenance.
Grease Trap (locate on site plan):
Depth below grade: NA
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is required for every Hyannis Ma 02601 8-10-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is required for every Hyannis Ma 02601 8-10-16
page. City/Town 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 0
11
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box is in working order at time of inspection. D-box was just replaced with H-20 DB3
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 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
1051 Pitchers Way
M
Property Address
William Cimbrelo
Owner Owner's Name
information is required for every Hyannis Ma 02601 8-10-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1- 6'x6'
❑ leaching chambers number:
❑ 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.):
Leaching was in working order at time of inspection with no sign of hydraulic failure. Pit was dry.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is required for every Hyannis Ma 02601 8-10-16
page. Ciityrrown 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.):
e
Privy (locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is required for every Hyannis Ma 02601 8-10-16
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
REAR
SI s 22g.
A2. 5. 2.
83-33W:
U2- 8T-.501
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is
required for every Hyannis Ma 02601 8-10-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: NO GW 12'
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: 5-4-77
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:
Plan on file with BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 1051 Pitchers Way
Property Address
William Cimbrelo
Owner Owner's Name
information is
required for every Hyannis Ma 02601 8-10-16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17