HomeMy WebLinkAbout0147 BRAGG'S LANE - Health 147 Bragg§ Lane
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Commonwealth of Massachusetts 7.
a= Title 5 Official Inspection .FOr�t
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
147 Bragg's Ln
Property Address W
Sylvia Doiran s, m
Owner Owner's Name '
information is ✓ '�1.•
required for every Barnstable MA 02630 1-26-17
page. City/Town r ; State Zip Code Date of Inspection :I
Inspection results must be submitted on this form. Inspection forms may not be altere$1n dAy
way. Please see completeness checklist at the end of the form.
A. General Information
. 1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services ^. .
Company Name
P.O. Box 73 r •r . . : r
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
"Title 5 (310 CMR 15.000).The system: '
® Passes,.,. i , U, Conditionally Passes ,. . " , ❑ Failsi.
"Needs Further Evaluatio a Local Approving'Authority t.- Y-:y
c. 1-26-17 �
spector's Signature Date
The system inspector shall submit`a�copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
i +
Commonwealth of Massachusetts
Title 5 Official Inspection Form
, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�_ !✓ 147 Bragg's Ln
Property Address
=� Sylvia Doiran
Owner Owner's Name
information is`required for every Barnstable MA 02630 1-26-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts .
I+ , Title 5 Official Inspection -F.orm
Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments
147 Bragg's Ln
Property Address
Sylvia Doiran
Owner Owner's Name s'
information is
required for every Barnstable' MA 02630 1-26'17 - +:
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) �.•
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
l f: 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 ❑ Y4`❑'N ❑� ND (Explain below):
t' -
A
❑' ' obstruction is removed ,` , , k ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑'Y.. ❑ N ❑ ND (Explain below):
f
❑ 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)-'A`Further Evaluation is Required by the Board of Health:-,• r ."
❑ 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
L15.303(1)(b)that the system is not functioning in a`manner which will protect public health,
I
"safetyand the environmentCesspool or privy is within 50 feetof a surface water
❑ Cesspool or privy is within 50 feet of a'bordering vegetated wetland or a salt marsh
113' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
• Commonwealth of Massachusetts
fry Title 5 Official Inspection Form
R' 1 Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments
147 Bra99's Ln
Property Address
Sylvia Doiran
Owner Owner's Name
information is Barnstable MA 02630 1-26-17
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® 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"h day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposnl System•Page 4 of 17
Commonwealth of Massachusetts .i.
a=l Title 5 Official Inspection Fora
' .,r-1 Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments { r
147 Bragg's Ln
Property Address i•
Sylvia Doiran t '
Owner Owner's Name
information is
required for every Barnstable MA 02630 1-26-17,
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
i Yes,,.' No.r,
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
t t ❑ :� ®. <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. °
♦ ..,+:,- • ❑ :c�i:®- • ; -Any portion of a cesspool or privy is within a Zone 1 of a public well.
ET ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
r ❑ ® 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
- ._ �. 4• -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-
i 10,000gpd.` r.-
r: . ❑. ; rr®Y- The system fails. I have determined that one or more of the above failure
The
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
_..,; Jv I« t s necessary to correct the failure. cc
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. • ; t
Yes No
❑ ❑ the system is within 400 feet of a surface d"rink,ng water supply
El ❑ the system is within 200 feet of a tributary to a surface drinking water
Y fy 9 supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public watersupply well
If-you have answered "yes"to any question in Section E the system*is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13* Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
�a=1 Title 5 official Inspection Form
IfE, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
147 Bragg's Ln
Property Address
Sylvia Doiran
Owner Owner's Name
information is required for every Barnstable MA 02630 1-26-17.
page. City/Town State Zip Code Date of Inspection
C. Checklist • I -
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?
® ElWere as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example;,a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based-on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3113 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System^Page 6 of 17
Commonwealth of Massachusetts s;•- :
�a=1 Title 5 Official Inspection, Fdr rn,
y1�;l Subsurface Sewage Disposal System Form =Not for-Voluntary Assessments
t ,} d 147 Bragg's Ln � •
it
Property Address
Sylvia Doiran -1
Owner Owner's Name
information is required for every Barnstable. MA 02630 1-26-17
page. City/Town f,: State Zip Code Date of Inspection
D. System Information -
Description: t .,
Number of current residents: 1
Does residence have a garbage grinder?.`•. ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ,.., , .: . ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):. .. ,
Detail:
1
c d
Sump pump? 1_ ,,,..,r .'. Y t. ❑ Yes ® No
Last date of occupancy: r 1-2017
Date
Commercial/Industrial Flow Conditions: s '
Type of Establishment:
Design flow(based on.310 CMR 15.203): + .,< ' Gallons per day(gpd)
..Basis of design flow(seats/persons/sq.ft., etc.):.,..
i... A ,, I. . 0 ' I , .1, . J
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
• i
Non-sanitary waste discharged to the Title 5 system? : ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Rl f Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
147 Bragg's Ln
Property Address
Sylvia Doiran
Cwner Owner's Name
information is required for every Barnstable MA 02630 1-26-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Owner--pumped within last 2 yrs
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: -gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy '
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
I
Commonwealth of Massachusetts w
a Title 5 Official Ins ection. Form' .
�t ri Subsurface Sewage Disposal.System Form:-Not%for Voluntary Assessments ••.'
147 Bragg's Ln t
Property Address
Sylvia Doiran (1. a„ . L
Owner Owner's Name
information is a.. .
required for every Barnstable a' vi MA 02630 1-26-17 r
page. City/Town ,4 _ State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2006
Were sewage`odors detected when arriving at the site? . .. ❑ Yes ® No
Building Sewer(locate on site plan): .sJ -
1211
Depth below'grade: ... a _ .. feet
Material of construction:
` ®'casf iron ® 40 PVC #' ❑ other.(explain)` '
- P' 1.-. .1 t .n- •• ..1 1•. iy .'. ,r .off
Distance from private water supply well or suction line' : feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: _.
3"
' 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: �: r •.. , .; 1000 gal
Sludge depth: 12", :' - -
t5ins-3/13 ° Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
a= Title 5 Official Inspection Form
N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�'t
p. ! 147 Bragg's Ln
Property Address
Sylvia Doiran
Owner Owner's Name
information is required for every Barnstable MA 02630 1-26-17
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign of leakage.
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection For'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
a
147 Bragg's Ln : ..
Property Address -
Sylvia Doiran - a
Owner Owner's Name
information is . Barnstable MA 02630 1-26-17!
required for every A.
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee.orfbaffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of Ieakage, 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:
r .._. Capacity: gallons -
Design Flow:. .
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
1a=1 Title 5 Official Inspection Form
f
' '�-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�_f2 147 Bragg's Ln
Property Address
Sylvia Doiran
Owner Owner's Name
information is required for every Barnstable MA 02630 1-26-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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.):
Good condition with water at working level and no sign of back-up from field.
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts F= t
,a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments- a. .
147 Bragg's Ln
Property Address
Sylvia Doiran w
Owner Owner's Name
information is
required for every Barnstable MA 02630 1-26-17--is
page. City/Town _ State Zip Code Date of Inspection
D. System Information (cont.) t., .
- ,
❑ leaching pits number:
® leaching chambers number:
3-3050 Infiltrators
4 4t
❑ 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.):
Leach field in good working order and empty at inspection with no sign of back-up into d-box or
surrounding stone.
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
I Materials of constr
uction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
, Commonwealth of Massachusetts
Vill Title 5 Official Inspection Fora
I^i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
}!' 147 Bragg's Ln
Property Address
Sylvia Doiran
Owner Owner's Name
requiratifo is Barnstable MA 02630 1-26-17
required for every.
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids -
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
1a=1 # Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments
•�.,!, 147 Bragg's Ln
Property Address ,
Sylvia Doiran
Owner Owner's Name
information is Barnstable,• : MA 02630 1-26-17 r
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below: _
® hand-sketch in the area below
❑ drawing attached separately
k
C l
P44
r
r, ry
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
147 Bragg's Ln
Property Address
Sylvia Doiran
Owner Owner's Name
information is required for every Barnstable MA 02630 1-26=17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:'
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed LISGS database- explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
-Till Title 5 Official Inspection Form
�'fl-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
147 Bragg's Ln
Property Address
Sylvia Doiran
Owner Owner's Name
information is required for every Barnstable MA 02630 1-26-17
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17
TC}�i -O B TST; BI.F
LQCATiQId / TrQ S S _L.� SEWAGE#
ASSESSt}R'S hiAP
WSTAi,LER'�s'1A11£&FliOATE iv[3
L 11MG'�FACIg;I'l'1t ttypr) n 1� (sue) C
NO:CF73Fd3�OQNS 3:
0, -,;m777
BR{?R O fi`tER
PBITD�1�: C{3MMPTfAPTC DATE:
Sapazanon Distance BeLv�esn the
Maxi numAdfusteclor'oundwatcxTat let6/iWB'6fiftofLeachmgFacef�ty ,Fee4
PnYate dater SuppSy Edell and I.escbing Fctiity (€stray ureils exist
on site arrw�ttun Za0 feet of teslnng fatty) poet.
Edge o£ l and and Leaching FaAty(if any wetlands exist
withlst 3(i.0 fee a leaciuig facdtty} � Feet;'
Y
a Q
� W
Q
TOWN OF BARNSTABLE
'LOCATION I�I� des �� SEWAGE## �ZCs'S®I
`'I?�LAGE_ ,�n ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO. ke�i C ON56,d6r, 409-7]f AXII
SEPTIC TANK CAPACITY
LEACHING FACILITY.(type) kg &4t3 CZ) (size)
NO.OF BEDROOMS
OWNER Pei r ,� i ;a
PERMIT DATE: COMPLIANCE DATE: g a
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 360 feet of leaching facility) Feet
FURNISHED BY
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No. - Fee All
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THE COMMONWEALTH OF MASSA(:HUSE�TS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZippYicatiou for wig aY �pgtcm Construction Ver 't
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System
/ Individual Components
Location Address or Lot No.Iy7 g�555 a� Owner's Name,Address,and Tel.No.P,/,4 59 4. Z"~-''
��ar+vS�afi rn� lv4 /3.c,,.,w 4-1
Assessor's Map/Parcel �4j.4r 44..7
Installer's Name,Address,and Tel.No. J&41,,0,,gj ✓ Designer's Name,Address and Tel.No.��S Aw"-- eov"'` ,-,
Type of Building: t��y
Dwelling No.of Bedrooms Lot Size f/�7-� 3 sq. ft. Garbage Grinder (X'
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 336 gpd Design flow provided �39 gpd
Plan Date Number of sheets j Revision Date
Title 57i -e WG n �' /V S �✓
Size of Septic Tank a4yo 6_4 Type of S.A.S. -2
Description of Soil -1
Nature of Repairs or Alterations(Answer when applicable) geglor Ls li
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this d f th.
Signed Date _
Application Approved by Date / U(a
:ApplicationDisapproved by: Date
for the following reasons
Permit No. �o�� Date Issued t>
�^T�— --"v--n.-i.-y.`.;.s...:;:.M .,•=;t ,�(�1�1r+Y'�y---::"' ..,«.,_r,,;.lC,�. :r- ..;`
No. 2_06 lY Fee 141590
THE COMMONWEALTH OF MASSNbCiUSI=TTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplication for Mir ar �p�tem Construction "Indivi'dual
tApplication for a Permit to ConstructO Repair O Upgade O Abandon O ❑ Complete System Components
Location Address or Lot No./V 7 J;,�155f 44 H-e Owner's Name,Address,and,Tel.,No.
`7
Assessor's Map/Parcel a C'f 77- s--� ! / '�"'n�R3ti' 4�Y,-- 7612 $S,77
Installer's Name,Address,and Tel.No./-30.-•VIIeWl' �`' Designer's Name,Address and Tel.No.d, A", C'�S�`"N'riJ
, Al 0 x•/,718
Type of Building: y
Dwelling No.of Bedrooms Lot Size 411 93 sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) -gpd Design flow provided 732 gpd
Plan Date Number of sheets Revision Date
Title $i fJfG o `t 7 3 5: L�✓
Size of Septic Tank /1100 6A Type of S.A.S. 3' -Lo 305v ,�q. y Y/v
Description of Soil S,rr 61 vl
Nature of Repairs or Alterations(Answer when applicable) 1 111f0GiY' GrriG/i trr
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board f,H-21th. o4
f
Signe / Date
Application Approved by )A-. t'_P ...4.-. Date
Application Disapproved by: � -�'� Date
for the following reasons
PermrfNo. 2 0o(7 Date Issued- / � l� (i - - - �- - - --
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
. certificate of Compliance
THIS IS TO CERTIF//•Y,,j tliat the OnPsite Sjjewag�e Di"sposal System Constructed ( ) Repaired (`, )\+°Upgraded ( )
Abandoned( )by &r
at Zy7 /3rei S L uJ i��irwS),_� has been constructed in accordance
r�
with the provisions of Title 5 and the for Disposal System Construction Permit No. t dated
Installer n,y /G�r�; �oz� �L, Designer Zs)
#bedrooms J v Approved design w gpd
The issuance of this permit/shall ript be construed as a guarantee that the syste K ll functio a eJ�_
ed.
Date /� f� f' Inspecto��
No. oob I Fee /OV
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
Bigoal i§p5tem Con5tructton Permit
Permission is hereby granted to Construct ( ) Repair (J' ) jUpgrade ( ) Abandon ( )
System located at ly'7 / aoey Z.)
and as described in the above Application for Disposal System Construction Permit.The a plicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditior}s.
c
Provided: Constructio must be completed within three years of the date of this perm .
Date 1121r7�. Approved by `n^` 2c
I
_�v
0CATION SEWAGE PERMIT NO.
N VILLAGE ASSESSORS MAP NO' J q B
Le
3s �L PARCEL NO: o S
INSTA LLER'S . NAME 6 ADDRESS
® UILDER OR OWNE
A Y xlwae
DATE PEIt III IT ISSUED
f983
DATE COMPLIANCE ISSUEDy��
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C-01- 7-0
to
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FROM FAX NO. Dec. 15 2006 11:03AM P2
n Town of,Barnstable
Regulatory Services
Thomas F..Ceder,Director -
.
Public Health Division
' Thomas McKna,Director
200 Main Street,Hyannis,MA 02601
Ofte: $08-9624644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: Sewage Permit# '-06. 5'0 1 Assessor's Map\Parcet
Designer: $ASS )ZId+f+i' rcNQ#XER•IN& Installer: BOIZULoY7'l Co.J f K
'f
Address: P.O. B6,x 110 Address: P.O. Sax T04
EA SY OJENIA 5 InA 67-611 l nw4(tS�orvS Mt t,t_$ InA oUg6
On �01- 1(' T -was issued a permit to install a
(date) (installer
septic system at I q 7 $IZA-&65 LAB 'based on a design drawn by
(add)
EON s.S-F4 L EIv6)N6VLW& dated '
10- 5-O L
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank-
1 certify that the septic system:referenced above was installed with major chance (i.e.
greater than l r lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State&Local Regulations. Plan revision or
certified as-built by desig=to follow.
N�
WWI
(IrpuYd�l11W •
lIee$Signature) Q
(Designer' S gnawre) (Affix Designei's Stamp Here)
PLEASE RETURN t[) t3A 11PfiT& E PUBLIC DEALW DIVISION ERTMCATE OF
COWLiANkEL LA NOT BE 1SSUSD L3NM MnH IMS MW AM AS-BLW BAR[) ARE
RECEIVED BY THE 13A NSY LE PUBLIC HEALTH blvpN THANK YOU.
Q=ffCWdV PddD0igW ce<t�Farm 3-26.04.doc
1
N KEY:
ROUTE 6A EXISTING CONTOUR: - - SEPTIC SYSTEM DESIGN SEPTIC SYSTEM SECTION
PROPOSED CONTOUR: ..................
EXISTING SPOT ELEVATION: 25.5 2" PEASTONE
FLOW ESTIMATE: COVERS WITHIN 12" OF
PROPOSED SPO ELEVATION: 25.5
TEST HOLE: 3 BEDROOMS AT 110 GAL/DAY = 330 GAL/DAY 129,64 FINISED GRADE VER 3!4" - 1 1!2"
UTILITY POLE: --0- _ _ TO BE WITHIN 6 OONE INSPECTION F GRADE)
TOP OF FOUNDATION " WASHED STONE
FENCE LINE: SEPTIC TANK: 3' MAX.
HYDRANT: -6- COVER INSPECTION PORT
330 GAL J DAY x 2 DAYS = 660 GAL (1' MIN) ELEV.= 119.0
RETAINING WALL:
USE 1000 GALLON SEPTIC TANK (EXISTING) 120.32 Lei
LOCUS (EXISTING) ELEV.
MARASPIN RD LEACHING AREA: (EXISTING)
120.83 119.08
USE 3 INFILTRATOR CHAMBERS(MODEL 3050)WITH 3'OF 1000 GAL 119.25 ELEV. - 116.5
(EXISTING) SEPTIC TANK ELEV- D-BOX 3 3 4 ELEV.
F77 STONE AROUND SIDES AND 4'AT ENDS (29.4' x 10.2' x 2' DEEP) (6"OF STONE UNDER) 118.5 29.4'
UNDER SLAB ELEV.
LOCATION MAP SIDE AREA: (29.4' + 10.2')x 2 x 2 = 158 SF (0,74) = 117 GAL/DAY TEE SIZES: (TO BE CONFIRMED) 3 INFILTRATOR CHAMBERS(MODEL 3050)
LOT 6A (19,993 SF) INLET: 6" UP, 13" DOWN GAS BAFFLE WITH Y OF STONE AROUND SIDES AND
BOTTOM AREA: 29.4'x 10.2' = 300 SF (0.74) = 222 GAL/DAY OUTLET: 6" UP, 14" DOWN AT OUTLET TEE 4'AT ENDS (29.4' x 10.2' x 2' DEEP)
ASSESSORS MAP: 298 PARCEL: 56
PLAN BOOK: 260, PAGE: 42 SHEET 2 CAPACITY = 339 GAL/DAY
FLOOD ZONE: C
r
TH-1 120.0 TH-2 115.0 TH-3 117.0 TH- 120.0
N TEST HOLE LOGS 30" FILL ELEV. O/A HORIZON ELEV. O/A HORIZON ELEV, 30, FILL ELEV.
SANDY LOAM SANDY LOAM
O/A HORIZON 9' IOYR 4/2 114.2 9' 10YR 4/2 116.2 O/A HORIZON
ENGINEER: THOMAS-R McLELLAN, P.E. SANDY LOAM B HORIZON B HORIZON 46„ SAANDY LOAM 116.2
'��-�"! ►�J�pj p 46 IOYR 4/2 116.2
AD WITNESS: DON DESMRIAS,R.S. B HORIZON 36" SOYNR 7/6 OAM 112.0 „ IOYRSAN
7 LOAM B HORIZON
DATE: 8-16 06&9-29-06 SANDY LOAM Cl HORIZON 36 114.0 " SANDY LOAM
R-5 9 5 7. 65
60 IOYR 7l6 115.0 SANDY LOAM Cl HORIZON 60 10YR 7/6 115.0
PERCOLATION RATE: < 2 MINAN Cl HORIZON LAYERS OF SAND SANDY LOAM Cl HORIZON
A=2 9 . 3 5 ' "`�- SANDY LOAM
144" 2.5Y 6/6 103.0 2.5Y 6/6 SANDY LOAM
_~'"'"\ 138" 2.5Y 6/6 108.5 156" 2.5Y 6/6 107.0
USGS GROUND WATER ADJUSTMENT: C2 HORIZON C2 HORIZON C2 HORIZON
118 1-1 � WELL: A1W-247, ZONE: B, ADJUSTMENT: 1.9' MED SAND WITH SILT LOAM WITH MED SAND
ADJUSTED GROUND WATER ELEV.= 100.9 LAYERS OF LAYER OF 216" OBSERVED 99.0
1 SANDY LOAM 106.0 BLUE CLAY
�\'IN \�� �'�) C3 HORIZON " GROUND WATER
10120r�/-
i$0" MEDIUM SAMD 105.0 204 98.0 300 92.0 204" 103.0
124
`\ \\ \\ NOTES
126� \ \
\ \ \ \ SUN
\ \ \ \ X\ ROOM DECK 1. VERTICAL DATUM: ASSUMED
\ \ \ \ \ J \ 2. MUNICAPAL WATER IS AVAILABLE.
11$ BEDBATH ��
\ \\ \ \ ROOM BATH DINING KITCHEN 3. SCHEDULE 40-4 PVC PIPE TO BE USED THROUGHOUT SEPTIC SYSTEM.
ROOM
4. ALL PRECAST UNITS SUBJECT TO TRAFFIC LOADS TO CONFORM WITH AASHTO H-20 LOADING SPECIFICATIONS.
128\ I \ \\ \ \\ 5. PIPE PITCH = 1/4" PER FOOT(UNLESS NOTED OTHERWISE).
126 \\ VAv \ \ \ \ BED BED 6. FIRST 2' OF PIPE OUT OF D-BOX TO BE SET LEVEL.
W Room ROOM ROOM ` )200M
7. THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE USE OF A GARBAGE DISPOSAL.
\ \\ \ 120 PORCH 8. ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE STATE OF MASS. ENVIRONMENTAL
o~ 124 �\ \ \ \ \ GARAGE CODE(TITLE FIVE)AND LOCAL HEALTH REGULATIONS.
00
`"v' EXISTING FLOOR PLAN 9, CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION.
10. GROUND COVER OVER ALL SEPTIC SYSTEM COMPONENTS NOT TO EXCEED 31.
122 �� / \ \ \ 11. ALL UNSUITABLE SOIL(SANDY LOAM,APPROX. 13'-14' DEEP)WITHIN 5' OF PROPOSED LEACH AREA IS TO BE
REMOVED AND REPLACED WITH CLEAN MEDIUM SAND.
126 \\ ,t lj
12. FIELD SURVEY PROVIDED BY MICHAEL LADUE,P.L.S.,BREWSTER, MA.
120 122 13. EXISTING LEACH PIT IS TO BE PUMPED AND FILLED WITH SAND OR REMOVED.
11$
116
\ \ \\ ST G 124 - -- -- BENCHMARK AT
ELEMAG NAIL
VATION EVA ION = 123.01
G� w
\ \
\ TH- --
� DOGWOOD � °o
(SAVE)
i ol LP i
SITE PLAN
EXISTING 1000 GALLON �S77
SEPTIC TANK 14 3' '•�•... LOCATION:
1. "'
�HOF
147 BRAGGS LANE, BARNSTABLE, MA
EXISTING LEACH PIT 116 118 \ \ Ml V j ? NI N PREPARED FOR:
(SEE NOTE 13) 120 C No� 71 C6 PETER & SYLVIA DOIRON
a
122 " 9�
5' SOIL REMOVAL ¢
(SEE NOTE 11) SCALE: 1" = 20' DATE: 10-5-06
40 MIL POLY LINER
(45' x 3' DEEP)
TOP OF LINER ELEVATION = 119.0 BASS RIVER ENGINEERING
BOTTOM ELEVATION = 116.0
THOMAS MCUELLAN, P.E, P.O.BOX 1163, EAST DENNIS,MA 02641
JOB#M6-40
508-385-3426
i
- - - ---- -