HomeMy WebLinkAbout0045 BRIARWOOD AVENUE - Healthr45 Briarwood Ave.Hyannis
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TOWN OF BARNSTABLF
LOCATION SEWAGE #
;VML_AGE l -��u' ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well arid,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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TOWN OF BARNSTABLE
,,LOCATION '4150' �g rw ub 1 ✓�V�• SEWAGE#
,,)fVILLAGE ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY I COD R LEACHING FACILITY: (type) t CX (size)
NO.OF BEDROOMS 3
OWNER ��A^Sf n
PERMIT DATE: 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 7'/1STT 0,1
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Commonwealth of Massachusetts
-= - Title 5 Official Inspection Form
o Subsurface sewage((Disposal System Form Not for Voluntary Assessments
Property Address / o • e r'i V'7
ON ner Ov ner's Name AA �� G,� /,L /SG
information is ___._L/ �'�0 f s Zip Cod required for every — Slate e Date of Inspe tion
page GtylTown
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.
M portant:Men A. General Information
filling out forms
on the computer,
use only thetab 1. Inspector:
key to move your ✓�/ O /St�i l��
cursor-do not
use the return Name of Inspector
key. r--
VQ Company Name •�W V �(� U p +
Company Address
warn Zip Code
City frown State
ego--� �d �o(�
Telephone Nu
License Number
mkYer—
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 C 15.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4specto 11 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 god 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 aescribes 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. q
I I*ntla SCrnc1a4 iris. ti F ' ssubsurtaca SIL�J'System•Page 1 of t7
15in5•y13
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address Z;
Ow ner Cw ner's Narne / I
information is /
required for every _Z____
page. City/Town State Zip Code Bate of irispecf1on
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E I always complete all of Section D
A) System 'sses:
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;
fit V"V 10
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
Healt h.
* 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):
l5i ns•3J13 Tiuo 50ffirial Ins per.am f arm Subsurface Sewage Disposal System•pegs 20l 17
' Commonwealth of Massachusetts
ra
Title 5 official Inspection Form
- 6 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
/I
4
Roperly Address
ON ner Cw ner's Name �y` �� �d
information is
required for every State Zip Code Date of I�peciio
CRy/
page. Town
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:
Q 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
N e 5 01 fICI N lne pec ti m F orm Su bsu l we sewed a 01600sal s Ate m•Paa e 3 0117
l5ns 3113
1.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
ON ner ON ner's Name 1j![ Q) 6 (7 y
information is G V1 A
required for every State Zip Code Date of inspection
page. GtylTow n
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
❑ lk__� Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ l5' 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 5" below invert or available volume is less
than 1/2 day flow
Tine 5 CNhci J liis pectica Form'.suosul ace sewage oisposal system•Pepe 4 of 17
Wins•303
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
N r
Property Address
ON ner Ow ner's Name o �,� von ��/ 9 ,
information is _ / ' 'J --
required for every �s State Zip Code Date of Insp ction
page. CitylTown
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-
10'000g pd.
❑ �'/ The system fai . 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
der Section E or failed under Section D shall upgrade the
system considered a significant threat un
system in accordance with 310 CMR 15,304, The system owner should contact the appropriate
e of the Department.
artment.P
regional o
7 ie 50trjcjal tru pec 6m Form Subsutace Sewago Disposal System•Page 5 ot»
Iat�•y13
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
ue
115i✓L1.1100C
Property Address
Cw ner ON ner's Name l
information is A4 o, � 6 0l
required for every ---
page. CitylTown Slate Zip Code Date of Insg6ction
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?
L`7 ❑ 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)
IJ �❑ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
L1�
Were all system components, excluding the SAS, located on site?
l�' ❑ 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?
/r Was the facility owner (and occupants if different from owner) provided with
El information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
een determined based on:
❑ Existing information. For example, a plan at the Board of Health,
r Determined in the field (if any of the failure cnteda related to Part C is at issue
❑ approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions: -3
Number of bedrooms (design): Number of bedrooms (actual):
�O
DESIGN flow based on 310 CMR 15.203 (for example. 110 gpd x # of bedrooms):
I
fyrts.yt 3 Title 5 Official Inspection Form Suburf ace Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessmefnts
Property Address
Cw ner ON ner's Name infor zf �4 b G
mation is �f f
required for every State Zip Code Date of I spect'ron
page. CityRo n
D. System Information
Description: / ` G
Number of current residents:
Does residence have a garbage grinder? ❑ Yes L�1/N�o
IS laundry on a separate sewage system? (Include laundry system inspection ❑ Yes l� Nc .
information in this report.)
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ YesNo
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ es No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CM R 15.203): Gallons per day(gpd)
Basis of design flow (seatslpersons/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:
Title 501664 Ins fwtion Form Subsurface Sewage Disposal System•Page 7 of 17
5re•3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
ON ner ON ner's Name - // ✓/ U� 0 / I l a' /
information is G,�✓J/S
required f or every State Zip Code Date of I spectio
page. City/Town
D. System Information (cont.)
Last date of occupancy/use: Date
Other (describe below):
General information
Pumping Records:
Source of information; /
Yes No
Was system pumped as part of the inspection?
❑
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of Sys�a
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
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):
Title 5 01ficial ins pec tion F or SUIDSLe ace Sewage Disposal System•Page 8 of 17
15rta•W 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r �� �l l G✓L1/c�t�C
Property Address
ON ner ow ner's Name information is � �
required for every
page. CftRy own State Zip Code Date of I spectio
D. System Information (cost.)
Approximate age of all compone is date installed f known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer (locate on site plan):
Depth below grade: feet / (O
Materi of constructi�40
cast iron PVC ❑ other (explain):
Distance from private water supply well or suction line: feet l
Comments (on condition of joints, venting, eudence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: feet
Materi f construction:
concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
i
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
-5 X 8
Dimensions:
Sludge depth:
t5tis•3113 True 501ficia'inspecuw Form Suosu'face Sewage Disposal System•Page 9of 17
Commonwealth of Massachusetts
• Title 5 Official Inspection Form
' - a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
ON ner ON ner's Name
information is � U 0 I T[4
required for every
page. C yrrown State Zip Code Dale of nspection
D. System Information (cont.)
Septic Tank (cont.) 3O </
Distance from top of sludge to bottom of outlet tee or baffle /
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 — J
v
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
01 w hi G V1 C
go
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
Distan
ce from bottom of scum to bottom of outlet tee or
baffle
Date of last pumping: Date
TiUe50fficial inspection Fome subsurface sewage Disposal system•Page 10ot 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
— Subsurface Sew/ague Disposal System orm - Not for Voluntary Assessments
Property Address
Ow net Cw ner's Name / yd-6:0/
v /
information is N�S
required for every Slate Zip Code gate of In pection
page. Citylfown
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:
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
5ris 3r13 1',Ue5ofgciai inspocuon For m:Subsurface Sewage Disposal System-Page 11 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal system Form - Not for Voluntary Assessments
j �iG✓ c,�>9� N ��
Property Address
Ow ner ON ner's Name - A /)")(O �
information is ����f ,!� v
required for every State Zip Code Bate of In pectlon
page. WTow n
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan).
,�--v'e
Depth of liquid level above outlet invert
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.):
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 alarfnS 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 3113 Tite501Aciallnspect,orForm:subsLeacesewageDlsposel system•Page 12of17
'\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Ow ner ON ner's Name 60 9 a i
information is �`? f
required for every �--- State Zip Code Date of Insp tion
page. City/Town
D. System Information (cont.)
Type:
leaching pits / number:
❑ 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.):
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liqula to inlet invert �-
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Tibe 50f6cial inspection Form,subsurface Sewage Disposal System-Page 13of 17
l5ins•3i13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form Not for Voluntary Assessmentrs--
r�
Property Address
infner Ory ner's Name
inf
orm o)lation is � �N fs � cJ b C/ _
required for every
page. CityTrown State Zip Code Date of I pection
D. System Information (cont)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan).
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
5ns-3113 iiue5Official Iris perGonForm subsutace Sewage oisposal System Page 14 of 17
Commonwealth of Massachusetts
ra Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
A /
Property Address
ON ner ON ner's Name
information is �N f
required for every State Zip Code Date of I pectin
page, ChfTown
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 pu 'water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
Dot C�
i
a
,4 6 6 .
TM05MICIai InspecbonForm.SubsurfaceSewegeDlsposei system-Page 15o117
15ins•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l
Property Address
Ow ner Owner's tJame
information is
required for every P e;j 0
page. City rrown Slate Zip Code Bate of In pection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with loca Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must d ribe how yor established the high ground water elevation: /
U VlGh C)G414 gyp' �,j �" ` v
��
4
z S rAya k �__7
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5lns 3113 Title 5of6ciailr)sWUcnForMsubsuixeSewegeDisposelsystem•page 16of17
v
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.� —l- �� /l Ge✓ D v�_ �y
Property Address
2,2 c. ✓t
Cw ner O v nWs Name
information is / 14 V1 r 1 ��
required for every
page. City rrown State Zip Code Date of Ins action
E. Report Completeness Checklist
Inspection Summary: A, 6, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
9T System Information — Estimated depth to high groundwater
L7 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
MIS•3113 Title501fiGa IrupecucnFrrm.SuDsirlace Se wag 8DisposA System-Page 17 d 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 45 Briarwood Avenue
Hyannis, MA 02601
Owner's Name: Alun Hansen
Owner's Address: ! yf
Date of Inspection: September 8. 2006
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
e
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the i} rmation1-2portep
below is true,accurate and complete as of the time of the inspection. The inspection was perfo based oit-tny
training and experience in the proper function and maintenance of on site sewage disposal system6' I am a'SEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sy"';
✓ Passes ca
Conditionally Passes crt *
Needs Further Evaluation by the Local Approving Aut ority Cn
Fa' s
Inspector's Signature: Date: September 12, M06
The system inspector shally* aof 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
• Page 2 of 11
• OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 45 Briarwood Avenue
Hyannis. MA
Owner: Alun Hansen
Date of Inspection: September 8 2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
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Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 45 Briarwood Avenue
Hyannis. MA
Owner: Alun Hansen
Date of Inspection: September 8, 2006
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.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
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 1.00 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
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Page 4.of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 45 Briarwood Avenue
Hyannis, M4
Owner: Alun Hansen
Date of Inspection: September 8 2006
D. System Failure Criteria applicable to all systems:
You must indicate either"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
✓ 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
✓ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 45 Briarwood Avenue
Hyannis, MA
Owner: Alun Hansen
Date of Inspection: September 8, 2006
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 detennined based on:
Yes No
✓ _ 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(3)(b)].
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Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 45 Briarwood Avenue
Hyannis, MA
Owner: Alun Hansen
Date of Inspection: September 8. 2006
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
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): n1a
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): _—____gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a co of the curre
nt ent operation
copy nand main
tenance ntenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
.Installed on 413195-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 45 Briarwood Avenue
Hvannis. MA
Owner: Alun Hansen
Date of Inspection: September 8. 2006
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 10"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.).
Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
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Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION continued
Property Address: 43 Briarwood Avenue
Hvannis. MA
Owner: Alun Hansen
Date of Inspection: September 8 2006
TIGHT or HOLDING TANK: None (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: allons
Design Flow: allons/day.
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ .(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. No solids were resent.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
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Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Briarwood Avenue
Hyannis, MA
Owner: Alun Hansen
Date of Inspection: September 8. 2006
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: _ I -6'x 6'(1000 aQ l.)
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.):
The nit had P ofliauid on the bottom The scum line was 2'un from the bottom There did not appear to be any signs of failure The bottom
to grade was 8.5'. The cover was T below Trade
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Briarwood Avenue
Hvannis, MA
Owner: Alun Hansen
Date of Inspection: Sep ember 8 2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Briarwood Avenue
Hyannis, MA
Owner: Alun Hansen
Date of Inspection: September 8 2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 15 +/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps the mans were showing approximately
site. I5'+/ to ground water at this
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,
relating to the septic system, the inspection, this report and/or any components of the septic system which have not
been located and inspected.
11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 45 BRIARWOOD AVENUE HYANNIS,MA 02601
Owner's Name: JEFFERY MORIN
Owner's Address: 45 BRIARWOOD AVENUE HYANNIS,MA 02601
Date of Inspection: 8/13/01
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: 114.0.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of 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:
X Passes
_ Conditionally Pofises
_ Needs Furth r _valuation by the Local Approving Authority
Fails
Inspector's Signature: a Date: 8/13/01
The system inspector shall submit �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.
Notes and Comments y,
SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM.
****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.
Tiflr, C T,ivirr-firm Form 6%1 S;�nnn 1
Page 2 of I 1
OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 45 BRIARWOOD AVENUE HYANNIS,MA 02601
Owner: JEFFERY MORIN
Date of Inspection: 8/13/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
u
X 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.
Y
Comments:
SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM.
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.
4
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a 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 uneveri'distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND uplain Wil
Page 3 of I 1
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 45 BRIARWOOD AVENUE HYANNIS, MA 02601
Owner: JEFFERY MORIN
Date of Inspection: 8/13/01
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:
_ �'Y P or Cesspool privy is within 50 feet of a surface water
P
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a 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 n/a
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3. Other:
n/a
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 45 BRIARWOOD AVENUE HYANNIS,MA 02601
Owner: JEFFERY MORIN
Date of Inspection: 8/13/01
D. System Failure Criteria applicable to'all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool fl
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/Z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped Wa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this forma
(Yes/No)The system fails. I have,determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems: ,.
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems,in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 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
°ye9" in Section D above the large system lies failed, The owner or operator of any large system considered a significant threat
under Section E or failed under Section D ishall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
A
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 45 BRIARWOOD,.AVENUE HYANNIS,MA 02601
Owner: JEFFERY MORIN
Date of Inspection: 8/13/01
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection '?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum '?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
1.
of subsurface sewage disposal systems?:'
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X Existing information. For example;a plan at the Board of Health.
X _ Determined in the field(if any ofthe failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
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Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 45 BRIARWOOD AVENUE HYANNIS,MA 02601
Owner: JEFFERY MORIN
Date of Inspection: 8/13/01
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 4
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO .
Seasonal use:(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a i I '<
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sqft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged'to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe):n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons,-How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner) `
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1942,UPGRADED IN 1991 & 1993,PER OWNWER
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 BRIARWOOD AVENUE HYANNIS, MA 02601
Owner: JEFFERY MORIN
Date of Inspection: 8/13/01
BUILDING SEWER(locate on site'plan),
Depth below grade: 14"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 8"
Material of construction: Xconcrete_metal fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7" W 4' 1011"
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
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.):
THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND
FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S
USEFUL LIFE SYSTEM.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7
}
Page 8 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 BRIARWOOD AVENUE HYANNIS,MA 02601
Owner: JEFFERY MORIN
Date of Inspection: 8/13/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working,order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
DISTRIBUTION BOX APPEARS TO BE STRUCTURALLY SOUND AND ALSO APPEARS TO BE
FUNCTIONING PROPERLY.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO ,
Comments(note condition of pump chamber;condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 BRIARWOOD AVENUE HYANNIS,MA 02601
Owner: JEFFERY MORIN
Date of Inspection: 8/13/01
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
-Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PIT APPEAR TO BE FUNCTIONING PROPERLY,NEVER MORE THAN 1 FOOT IN PIT..
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a Y
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
n/a
i .
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
n/a
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 BRIARWOOD AVENUE HYANNIS,MA 02601
Owner: JEFFERY MORIN
Date of Inspection: 8/13/01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
O I
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Page I 1 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 BRIARWOOD AVENUE HYANNIS,MA 02601
Owner: JEFFERY MORIN
Date of Inspection: 8/13/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+,feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators,4nstallers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS-10+FEET
r
>' TOWN OF BARNSTABLE
LOCATION ,S /fie/tcfDO% ter . SEWAGE #94 ^- ;
VILLAGE /� � /. ASSESSOR'S MAP & LOTO d'A97
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
r
LEACHING FACILITY:(type) (size) /, 4ZV
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERd �
i
BUILDER OR OWNER
DATE PERMIT ISSUED: o// //�
DATE COMPLIANCE ISSUED: ''
VARIANCE GRANTED: Yes No
r �(
i✓ _�/SIB
ASSESSORS MAP N0: ;F AT
PARCEL NO _
Fps......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
AVV iration for BioVa!3al Work,i Tomitrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: /
Location-Address ✓ or Lot No.
'---.. QkjN................................................ -------------------•------------------.........--••-
.Owner ddres
Installer Address
d Type of Building Size Lot_.........................Sq. feet
V Dwelling—No. of Bedrooms.._.��----------------------------------
Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ---------------------
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity/AQX)_gallons Length---------------- Width---------------- Diameter_............. Depth................
x Disposal Trench—No. -- .----_•------_-- Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------f--------- Diameter-------4--------- Depth below inlet-__._j:;;�.......... Total leaching area..................sq. ft.
Z Other Distribution box (Jj Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date--------------.........................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water.....................--.
(% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ----------------------------------------------------------•-- ••---•-•-••----•••......------.=•-•--.......--••---•••--•---••......-•••-............_.......
0 Description of Soil.............................................................................................................................. ..........................................
W
V
............. -------•----------•----------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.----� �._ .__..�... D .....® �.
l(J
1 .rJl s."------�`--------loa0... ...... --�----- i,— ------ - - ---
Agreement:V
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complian has een issued by e bo of health.
Signed ------------------------ - - - ----- ------------------ ......
Date
Application Approved By ............" ........................ .�...........:........... '_.....
Dace
Application Disapproved for the following reasons- -- --------------------------------------------- ------------------- - - - ................................
........... -------------------------------------------------------------------------------------------------------------------- ---------- --------------------------------- ........................................
Date
Permit No. ..... L Issued ��` �
---------------- ------------ --
Date
1�
A
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH `
TOWN OF BARNSTABLE
TertiftratE of Complia ue
THIS IS CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by �z er e/ In sall rr --------------------- -----------------t i------------------------------
•
has been installed in accordance with the provisions of TITLE 5 of The St to Environmental Code as described in
the application for Disposal Works Construction Permit No w......f 41:55j.----- dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NO CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL UNCTION SATISFACTORY. _
DATE �/ ...._ ....._�G�-� ._. _... Inspector ...... .. -s" ...:.-------.,-._.... -- .................
r /
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No ....�%...!�....S.i 1 7 FEE..�,G�s
Rapla ial Workii Tomitrudion "rrntit
Permission is hereby granted.........T-P------
to Construct ( ) or Re air an Individual Sewage Disposal System *�
at No.--------.4�'C-------fK05.A'`I-A.....A--1�Re ----- -- ------ - -=-�' l ?t �------------------------•--•-••-•---•-•-.
Streety
as shown on the application for Disposal Works Construction PermitiN�`'___ ��`---- Dated_._. ..': :
- 4 -/ ...................... Board of Health
DATE-------=---- -----�--•-••--�-- ---•-
FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
_ Appliratilan for Di-tipnittl Wnrlw Tomitrur#inn Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.....LI.S ------.f ry . ..s ,Q V r �.wv v(� .
Loc4tiou-Address or Lot No.
owner Address
•-- .......--- -• .....................
Installer Address
UType of Building Size Lot............................Sq. feet
►� Dwelling—No. of Bedrooms--_.3__________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers O — Cafeteria ( )
04
W Design Flow.Other fixtures ..------------._gallons per person per day. Total daily flow............................................gallons.
d
WSeptic Tank—Liquid capacity/e9W.-gallons Length--.--_._-_-__-_ Width................ Diameter._.-.-.--_-_-_- Depth................
x Disposal Trench—No. .................... Width--_---------------- Total Length-------------------- Total leaching area....................sq. ft.
3 Seepage Pit No----------/--------- Diameter-------e-._._.__- Depth below inlet.___./ .......... Total leaching area..................sq. ft.
Z Other Distribution box (,0 Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date--------- •-•----------•-•-----
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.--_-.__-___-_-.. --.
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
94 ----•------------------------•---••-•••--•-••----••-•-••--•---------•--••--•-•-•••-••--------------------------------•--------------------.-.--. -------
0 Description of Soil........................................................................................................................................................................
x
U
w .......................... -- - _ l
U Nature of Repairs or Alterations—Answer when applicable.--_.__._�D --�'-:_------_y.----- -..'a_�_b �..__ --- . -
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Complian e` has been issued byte o rd of health.
fSigned - ----- ......................' ...................... ...
Date
Application Approved By ............... �. ... --------------------- �-
Date
Application Disapproved for the following reasons: .... -....- ... . ....................--------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------..................................-------------------------------------------------..........._.._...._.----..._.................._-------------------------------------------------------------- ........................................
�� � , Date
Permit No. ..... ..................... Issued ... :�...'G'�........�....1T�.....,1>..`..........
Date