HomeMy WebLinkAbout0063 WOODBURY AVENUE - Health (2) 63 Woodbury,Avenue
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Commonwealth of Massachusetts
Title 5 Official Inspection Form r
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63-65 Woodbury Ave ;.•;
Property Address
Joseph Cipolla rr,
Owner Owners Name
information is
required for every Hyannis ✓ MA 02601 5-20-19
page. City/Town 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.
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153 Commercial Street �,,,�s INSPE���r°•
Company Address
Mash pee _ MA _ 02649
City/Town State Zip Code
508-477-B877 S1623
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
- 5-24-19
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 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7126MI8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page t of fe
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Commonwealth of Massachusetts
p Title 5 Official inspection Form
11. Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
vo 63-65 Woodbury Ave
Property Address
Joseph Cipolla
Owner Owner's Name
information is required for every Hyannis MA 02601 5-20-19
page. Clty/Tcwn State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary:Complete 1, 2, 3,or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1500 Gal. Tank D Box and three chambers,
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
fig Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
VyJ 63-65 Woodbury Ave
Property Address
Joseph Cipolla
Owner Owner's Name
information is required for every Hyannis MA 02601 5-20-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
s
❑ 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 ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (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 ❑ NO (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:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L 63-65 Woodbury Ave
Property Address
Joseph Ci olla
Owner Owner's Name
information is
required for every Hyannis MA 02601
5-20-19
page. CftyfTown State Zip Code Date of Inspectlon
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 asses if the well water
P e analysis, performed t
Y , p a s DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of se
ammo
nia onla nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
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Commonwealth of Massachusetts
Title 5 official Inspection Form
'• Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
63-65 Woodbury Ave
Property Address
Joseph Cipolla
Owner Owner's Name
information is required for every Hyannis MA 02601 5-20-19
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, sespookis less than 6" below invert or available volume is less
than '/zdayfIow /X,4c1,11,&/
❑ ® 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.
E] ® 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 C.4.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7126l2018 Tithe 5 Of dal Inspection Form:SubStrface Sewage Disposal System•Page 5 of 18
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 63-65 Woodbury Ave _
Property Address
Joseph Cipolla
Owner Owner's Name
information is required for every Hyannis MA 02601 5-20-19
page, City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304, The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no" for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner,occupant,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as NIA)
® ❑ 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)]
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1.
63-65 Woodbury Ave
Property Address
Joseph Cipolla
Owner Owner's Name
information is required for every Hyannis MA C2601 5-20-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Description:
1500 Gal.Tank D Box and three chambers.
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 2017-23B4O00Gal
g ( y g (gpd)}: 2017-226,000Gals
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
15insp.doc•rev.712612018 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
9 a5ed xe� dH L£ZZ 660E K AeW
Commonwealth of Massachusetts
1P Title 5 Official Inspection Form
. Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
y 63-65 Woodbury Ave
Property Address
Joseph Cipolla
Owner Owner's Name
information is required for every Hyannis MA 02601 5-20-19
-
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Comm arcialllndustrial 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 occupancyluse: Date
Other(describe below):
3, Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 63-65 Woodbury Ave
Property Address
Joseph Cipolla
Owner Owner's Name
information is MA 02601 5-20-19 Hyannis
required for every
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ cesspool
Single of
9 Po
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a co of the current gy copy 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:
2004 Permit # 2004-520.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
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.):
Pipeing is 4"PVC SCH -40.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
63-65 Woodbury Ave
Property Address
Joseph Cipolla
Owner Owners Name
information is
required for every Hyannis MA 02601 5-20-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate:on site plan):
Depth below grade: 2,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: 1500 Gal. Precast H-10
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle -
17"
How were dimensions determined? Asbuilt-Plan-Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tank at working level. Tank at 2' below grade wlboth covers at 1". Inlet baffle w/outlet tee. No
sign of leakage or over loading.
K
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
V� 63-65 Woodbury Ave
Property Address
Joseph Cipolla
Owner Owner's Name
information is required For every Hyannis MA 02601 5-20-19
page. CltylTown 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):
' I
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
C�
63-65 Woodbury Ave
Property Address
Joseph Ci olla
Owner Owner's Name
information is required for every Hyannis MA 02601 5-20-19
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cunt.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order, ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level .above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover,any
evidence of leakage into or out of box, etc.):
D Box is 16"xl&'=39"below grade w/three lines out. Box is clean and solid w/no sign of over
loading or solid carry over,
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Commonwealth of:Massachusetts
,p Title 5 Offilcial Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63-65 Woodbury Ave
Property Address
Joseph Cipolla
Owner Owners Name
required information ie Hyannis MA 02601 5-20-19
required for every
page. City/Town State Zip Cade Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No'
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located,explain why:
Type:
❑ Teaching pits number:
® leaching chambers number: 3
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doe-rev.7/26I2018 Title 5 Official Inspeefion Form:Subsurface Sewage Dispose.System-Page 13 of 18
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Commonwealth of Massachusetts
,P Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63-65 Woodbury Ave
Property Address
Joseph Cipolla
Owner Owner's Name
information is
required for every Hyannis MA 02601 5-20-19
page. Cityfrown 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.):
Leaching is three 500 Gal. drywell chambers (41.5'x13'x2'). Chambers at 43" below grade 7"water
w/no high stain line. No sign of over loading.
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-oc•rev.712612M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 14 01118
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f
Commonwealth of Massachusetts
�p Title 5 Official Inspection Form
_ r i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 63-65 Woodbury Ave
Property Address
Joseph Cipolla
Owner Owner's Name
information is required for every Hyannis MA 02601 5-20-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
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Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-� 63-65 Woodbury Ave
L
Property Address
Joseph Cipolla
Owner Owner's Name
information is required for every Hyannis MA 02601 5-20-19
page. City/Town 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
t5insp.doc-rev.7126/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16
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Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63-65 Woodbury Ave
Property Adcress
Joseph Cipolla
Owner Owners Name
information is Hyannis required for every Y MA 02601 5-20-19
page. City/Town 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: 15+
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: 2004
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board cf Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Bottom of chamber's at 5' above ADJ High G w per plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5losp.doc•rev.7f2672018 Tille 5 Official Inspection Form:SUbwface Sewage Disposal System•Page 17 of 18
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Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V63-65 Woodbury Ave
Property Address
Joseph Cipolla
Owner Owners Name
information is Hyannis
required for every MA 02601 5-20-19
page, City/Town 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
15
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g i P4 G w
t5insp.doc-rev.7,2612018 Title 5 Oticial Inspection Form:Subsurface Sewage Disposal system-page 18 of 18
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No. 4100.00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpprication for Zigozar *pztem Conotruction Permit
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. 7 81 —3 41 —5 9 7 0
A,&Q/pag,qodbury Ave Hyannis Bob Kaseta 307 225 86 Buckskin Path, Centerville
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4
Wm E Robinson Sr Septic Eco—Tech
PO Box 1089 Centerville 43 Triangle Cir, Sandwich
Type of Building:
Dwelling No.of Bedrooms 5 Lot Size sq.ft. Garbage Grinder Po)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of R pairs or Alterations(Answer when ap h able) Install Title 5 leach system
wiM gas baffle, for 5 bedrooms, to plans of Eco—TechETE-1803 .
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 En ironmenta Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this d Health.
Signed �� A Date
Application Approved by Date
Application Disapproved for We following reasons
Permit No. Date Issued tu U
,.,.a:.....,.,t,,..n-- r'W' .... ,�ry.r:. ..-:��*.... �-.... .- -Nw' ., �.,..y.ti ti�r•„r Y' h...,,..w..- -„...yrh -!` .4 ,,,..� ,, ,�.:�, ., �...�.
No�_ _ _ _ 4
`i., • < THE COMMONWEALTH OF MASSACHUSETTS Entered in computer
Yes j
�` ` PUBLtG HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
�-Zlpplicatton for loig ogar 6potent Con!6truction Permit
Application for a Permit to Construct( . )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. 7 81-3 4 1-5 9 7 0
H bbb Kaseta
As es oY' M'a i>?a i33odbur Y Ave► Hyannis 86 BlOkskin Path, Centerville
307/225
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4
Wm E Robinson Sr Septic Eco—Tech
PO Box 1089 Centerville 43 Triangle Cir, Sandwich
Type of Building:
Dwelling No.of Bedrooms 5- Lot Size sq.ft. Garbage Grinder(no) " -
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow _'gallons.
Plan Date Number of sheets Revision Date
Title
Size.of Septic Tank Type of S.A.S.
Description of Soil
Nature ofgRg airs orAlte ons(A saver when ap licable) Install Title 5 leach system
wit '. gas bale, for 5 bedrooms, o p ans o co-Tech E- 3.
Date last inspected:
Agreement:H
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 En ironmenta Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this afd Health. �j
Signed A r Date_`J
Application Approved by 2 L Date --36 rU L
Application Disapproved for e following reasons
Permit No. {( UU U Date Issued u U
— -
Kaseta THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS r
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired ( X ) Upgraded( )
Abandoned( )by Wm E Robinson Sr Septic Service
at 63/6: Woodbury Ave. , Hyannis has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ;�UO -.S U dated 04
Installer Designer
The issuance of this p t shall not be construed as a guarantee that the s"temill f otion as de i ne .
Date V )�' Inspector IY
r
Kaseta THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
l gpogal *pgtem Congtruction Vermit
Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( )
System located at 6 3/6 5 Woodbury Ave. , Hyannis
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction
be completethin three years of the date of this pe it. !
Date:_ 1 d Approved by "W_ j
TOWN OF BARNSTABLE
LOCATION rnZ (ps 1 jooD9 ury A-Y(- SEWAGE #
VILLAGE aAn i ASSESSOR'S'MAP & LOT 3 O
INSTALLER'S NAME&PHONE NO. WM G bo ia-, 9,04c .S'?sc ,, e SM 775 b 74
SEPTIC TANK CAPACITY /mil.; 6A-L
LEACHING FACILITY: (type),3-k5Z)d 6& bryr..elli ' (size) y1,5X I A I'
NO.OF BEDROOMS
BUILDER OR OWNER GC�SG
PERMIT DATE: 91 S�'f COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
I
i
.
l
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
BMWSPABLE,
9�A '6 9 Public Health Division
TEDntAyA Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: I
Designer: Eco-Tech Installer• Wm E Robinson Sr Septic
Address: 43 Triangle Circle Address: PO Box 1089
Sandwich Centerville
On Wm E Robinson Sr Sept ikqs issued a permit to install a
(date) (installer)
septic system at 63/65 Woodbury Ave, Hyannis based on a design drawn by
(address)
Ec -Tech dated 09-27-04
(designer)
t,/I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
jiA OF
G G p DAM
i-z(Installer's Si a c mG o 3OWR y
9� i T 6P�o
�A A%gNI7. Vk%
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC-HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
HYANN6S. MA f
J I CONTOUR 4R,
PLAN REFERENCE EISTIN�- ' ��� ___3O Lu
PLAN .BOOK 209 PAGE 23 BENCH MARK FINAL 30
ASSESSOR'S MAP:' 307 ` FINAL COVER SHALL SLOPE TOP OF CONC BOUND WLOT: 225 ELEVATION - 25.18 4�5 ft x 13 ft x 2 {t � TO PREVENT RAIN WATER NLEACHING GALLERYFROM POOLING OVER SAS. FocuUSGS`DATUM ASSUMED25 2627
\ LOCUS MAP
PAVED DRIVEWAY ul NOT TO SCALE
o; 1
w 24 �\ VENT 1
LLJ WATER LINE PIPE
l
O W
N
or W
o0 1— c,C o oN o o LEGEND
M � EXIS�)
ING
�► —� 1 1500T GALLON
W o00
Q ' ap i 1 SEPTIC TANK
O OAS D-BOX
GA TES, GAS LnE LOT 8
(c,
TEST PIT
� AREA - 13550 s{ +-
PAVED DRIVEWAY � v EXISTING �
~ —
LEACH PIT l�
175.51 ft 25 26 27 UTILITY POLE
24
FLOW PROFILEPLAN
TOP OF FOUNDATION RAISE COVERS TO WITHIN VENT SCALE: 1 in = 20 ft
6 in OF FINAL GRADE PIPE
EL - 25.66 ;
24.75
2" LAYER OF 1/8"
3 DROP 3 I, I/2 STONE SEWAGE DISPOSAL SYSTEMµ,PLAN
FLOW LINE -TO SERVE EXISTINCr-DWELLING y,'>
I �o-
T 3 1A,
x ,,,�,'�` f - RICIA KASE-STY
48 --"GAs� :rt.trt'. YWELL* v /STONE4 �ytNOF NIS r1
PR A T
�EXISTING BAFFLE o .spa: �. 63 65 WOODBURY<AVE
6'in. r DR V BOTTOM of �d� HYAN A t.
!4F
60. �1' _" SOIL ABSORPTION . �A7�
EXISTINGSYSTEM
TA
STONE
�20BASE COUG,wLEA�CHINC�. SYS � CO� TECH ENUIRON21,33 C� r_ _. GALLERY 9R MA 0256
EXISTING> _ 2►.os 43 TRIANGLE CIRCLE . ,
.
=•a(END VIEW
s..�.: s:r E
: t p
t. . ,3.6:4089.4
., ; .. CC77 0� ALLON ��. .. • ..IJO V
EXISTING .:• ?O h
v
--SEPT
� �,�
d s rt v „_
-. A BAN ULESS IT r
. ETE 1803:A
ADJUSTED BE CONSIDERED A'DRAFTPL ,
' ... �. .
- .. . .. w..»rw ... -... .-sue ?'...... . .,» ,.. ;W - - a a+,i.• �'
� •� D TF9S PLAN IS•=J0
„ -�: - , -<r,;�, ��,.,:: •._. ,: _, , • .• --.SEASONAL HIGH S►GN ER
y.. ...;. : .,.. ;� • -�,.4 . . .: . ,_. ..:. t, ..., ,_- r - -." : ;�. S L BEARS THE STAMP AND` �OF,�THE DE .ENGNE
. . .. - . gib. SIGNATURE Y r�
I
GROUNDWATER
- . . �,., :.-_ •.. ,. K ,,,. :. . � NA PAN PTO FE�B x:
. .,,•� _ , : ... ,� . _ �_. �,.. . . �'•, .., , ,. . ,, . :. .. ._ ,� ;�-. ORIGINAL PLANS NTE ffTAl
NDED`FOR`SUBM �T D�.
.. .a � nn ,OAR .
'€ >" _ /�/ 0�1 OF HEALTH WLL BE SIGNED N BLUE'AND'STAhPEDN.RED
/ �3
g -
... ., r •x- : _•- 4::'..^ - . ..s::'. ,....-L. s;.., .. - `.:q * ' .^".,:� s .. _. _ • _ a - t ... � ^.S�LY '.x'Ka{+^f.`%y3
-.. .. t
_w.
r
SOILTE`ST LOG _ ALCULAIOSTN. .GN C
DATE OF TEST: SEPTEMBER .24. 2004
SOIL EVALUATOR: DAVID. D, .COUGHANOWR, RS DESIGN FLOW: 5 BEDROOMS X 110 GPD - 550 GPD '•
WITNESS-;REOUIREMENT -WAIVED - NO;.VARIANCES-SOUGHT
NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 550 GPD X 2 DAYS 1100 GALLONS
TEST PIT I PARENT MATERI SH - - -- - USE EXISTING 1500 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL CONDITION. -
ELEVATION - 25.4 .;- PERC AT 54 in : 2 MIN/INCH IN C SOILS
IF NOT INSTALL A NEW 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) Y
DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: USE 3 OUTLET D=BOX.
(INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING
SOIL ABSORBTION SYSTEM: A 41.5 ft x 13 ft x 2 ft LEACHING GALLERY CAN LEACH
0-10 A LOAMY SAND 10 YR 3/4 NONE FRIABLE A b o t - ( 41.5 x 13 ) - S39.5 a f
10-34 B LOAMY SAND 10 YR 4/4 NONE FRIABLE A s d w - ( 41.5 - 41.5 - 13 - 13 ) x 2 - 218 s f
Atot - 757.5 sf
34-134 C MEDIUM SAND 10 YR 6/6 NONE LOOSE V t 0.74 x 7 5 7.5 - 560.55 G P D
At
USE A 41.5 ft x 13 ft x 2 ft GALLERY. Vt - 560.55 GPD > 550 GPD REQUIRED
WAT R ADJUSTMENT
GROur� E LEACHING GALLERY
EXISTING GROUNDWATER LEVEL
BASED ON TOWN OF BARBSTABLE CONSTRUCTION DETAIL
GIS DEPARTMENT RECORDS.
INDICATED GW 8.00 �'DRYWELL UNIT STONE
INDEX .WELL MIW-29 a'-5'x 5' x DE
2 ft EFF, DEPTH
ZONE B '41.5 f t
READING 9.2
ADJUSTMENT 3.5
ADJUSTED GW 11.5
v
NOTES IT
M � "'
I) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN q ;� 8.5' 4 ft 8.5' 4 fr 8.5' 4 fr
2) ALL LINES TO BE SCH 40`..PVC' .AND-'PITCH AT 1/8 INCH PER FOOT MINIMUM.
41.S f 1 NOT TO
3) ALL COMPONENTSv.INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS SCALE
OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15)
4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES
BEFORE EXCAVATING FOR SYSTEM.
5) EXISTING LEACH PITS TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED
6) ALL STONE ^TO-BE- DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE F~' "' :u
a+
7) LINES._EXITING D-BOX TO RUN LEVEL FOR 2 O BEFORE PITCHING DOWN .
SEWAGE DISPOSAL SY.STEMPLAN 2� �
8) ECO-TECH ENVIRONMENTAL RECOMMENDS,THE:"`;INSTALLATION OF LOW FLOW FIXTURES
_ AND APPLIANCES: AND BIANNUAL PUMPING OF,TH6 SEP IC TANK a
_ _ .. ,. _ _
. .__ . ... �.,#w .e..a-'-�•- -� - .-._. _ ,.��_ M., NG DWELLI � �
T TO SERVE EXISTING G
9) SYSTEM IS ;NOT..DESIGNED TO WITHSTAND:,fVEHICULAR LOADING. DO NOT -
PARK OR DRIVE VEHICLES ,OVER SEPTIC:!SYSTEM.
-, .._ PATRICIA AwS T A
PAT IA E� ,�� ��
I ) INSTALLER' :TO OBTAIN DISPOSAL WORKS'.i.PERMIT BEFORE STARTING WORK. 63/65 WOODBURY AVE HYANNIS AMA
s q
ry.::.
,_ .,«,. .,,k,,....-. ..._,: .., �..••--- „.
�,. ...,:.,:. - , .ri .,: - - '. <t3"• s w;.;:n„•w.a�.r.2--;1... : ':..�^z;-K r -wM'- �: zT,*=k+arG
a .TRUE-TO ,GRADE>=ONpA „L`EYEL .n., _.
:a:� HA f.. -,INSTALLED LEVEL 'ANb,a, r, x
q SEPTIC T ANKS:S . ..LL ..BE_ �. ,
.,,. #. . '' i _
«h. �` 7
x _W IC
. r .. . ... ,. ,,, :�,. � ,A: N.!.MECHANIC, LL � .. _ ��,, a. .,��
TABLE .BASE, THAT:,HAS.,BEE .. �. .� �, N O:NMENT;aL ,
r ::: T N `HAS''=BEEN PLACED 170 -. INIMIZE' UNEVEN SETTLING _'• E.V E .�Y I1\. r. t =t <
SIX NNCHES . OF, CRUSHED S O E _ ,
0 'L
..'»: `,. 5 ��-^", ,i^•f.�,:..y.'w.-..ry.:..�..:. '.. _ ,...,3.�. .. :��H'.,,�, _ ...� �
PTIC' TANK TO BEPUMPED DRY'AT TIME OF.;.SYSTEM `REPA'IR'"AND ;CHECKED;: : ` ;
1.2) sE fi E'CIRCLE. SANDWICH
43-TRIANGL
�¢. P =" UTLET TEE' FITTEDti•WITH .,.GAS .BAFFLE
_. A ,INT RIT.Y. aNSTALL V.C. O
TRUCTUR L EG u-f -
FOR S. _ ' , M .
"M>.. yy.�. .."n .... vf.n1 s�T r.:..,. .. n dz- ..:. ... �, ,,. .. �.. r..j�r.. ..3� M,.«... P. .. e'p...r.ry t. N.... .Mh'I' _.f.,. l.i. •f s� hs.,,' .. ..:.. .. „ 4 xf. .f..
.. .. ..>........,.:x'e... _. ...,n.. M. .,, :.t:. u ., 4.9...... a..cz .... • ._ _..�.�1/.. n..
,.,, _:� ETE=1803 SEPT,,27
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