HomeMy WebLinkAbout0186 BRAGG'S LANE - Health r •
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Bamst. • - .
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. , TOWN OF BARNSTABLE
LOCATION � � 6 ��� � L� l d�`' '��'`41' SEWAGE # ��'Ll S ja-
N-°�,j,AGE 1 "-�wr a ASSESSOR'S MAP & LOT 229 y D
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 400 a
LEACHING FACILITY: (type) �S:S'�Xi kO;� l (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: J"NA
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 f le Ching facility) Feet
Furnished b � �t ram. y U94
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TOWN OF BARNSTABLE °
LOCATION G ��w4 L SEWAGE#
ASSESSOR'S MAP&LOT IPJ No'?
4P.
INSTA-UR'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) P�•�" (size) c s X 6.
NO.OF BEDROOMS
BUILDER OR OWNER
PERMi a4,TE: COMPLIANCE DATE: `.. /��
� .
Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by /—r("J
s
4 v ry
a a..
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Commonwealth of Massachusetts
u
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L
186 Braggs Lane, Barnstable
Property Address
Richard Saunders
Owner Owner's Name
information is P.O. Box 1206, Barnstable MA 02630 August i�, 2009
required for every - -
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms ma not be altered in any
way.
Important:When A. General Information a
filling out forms
on the computer,
use only the tab 1. Inspector: COPY
key to move your
cursor-do not Troy Williams _
use the return Name of Inspector
key.
_Troy Williams Septic Inspections
raS Company Name -------------- — — -
19 Hummel Drive
Company Address
Bm� South Dennis MA 02660
City/Town State Zip Code
(508)_385-1300 S1682
Telephone Number License Number
B. Certification - —
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
August 5, 2009
Inspector's signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the'conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use:
186 Braggs Lane,Barnstable•03/08 Title 5 Official Inspection Fogn:Subsurface wage Disposal stem r Page 1 of 15
Commonwealth of Massachusetts',"
Title 5 Official .1rispectiort, Fora
Subsurface_Sewage Disposal System Form -Not for Voluntary Assessments
186 Braggs Lane, Barnstable,
Property Address - -— —— --- — -- ---° --- -- —
Richard Saunders
Owner Owner's Name
information is P.O. Box 1206, Barnstable MA 02630 Au ust 2009
required for every _ -- --- . - — — —g -- — --
page. Cityrrown State Zip'Code Date of Inspection.
B. Certification (cost.) — -
Inspection Summary. Check A,B,C,D or /always complete all 'f 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 meets minimum standards set by Mass DEP at the time of inspection only. This inspection is
not a uaranteeor warrant r�on_the future working conditions of leaching, pipes or components.
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. r ;t
❑ 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
❑ a Observation of sewage backup,or 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)
Q broken pipe(s) are replaced; a < r
obstruction'.is removed
186 Braggs Lane,Barnstable•03/08 ,Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
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k f s
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 186 Braggs Lane, Barnstable _
Property Address
_ Saunders Richard Sau c
Owner Owner's Name
information is bl n P.O. Box 1206, Barnstable MA 02630 Au ust , 2009
required for every _- -- _ -- -- --- - ------- -
page. City/Town State Zip Code Date of.Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):-
El distribution box is.leveled or.replaced
ND Explain:
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 Explain:
N/A
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in-a manner which.will protect public health,
safety and the environment;
❑' Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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.
186 Braggs Lane.Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 or 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
186 Bra gs Lane, Barnstable
Property Address
Richard Saunders
Owner Owner's Name
information is P.O. Box 1206, Barnstable MA 02630 August 2009
required for every —� ' —
page. Citylrown State Zip Code Date of inspection
B. Certification (cont.) - ---
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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:
N/A
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
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El
® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow,
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 0 Any portion of the SAS, cesspool or privy is below high groundwater elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
186 Braggs Lane,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
186 Braggs Lane, Barnstable
Property Address
Richard Saunders
Owner Owner's Name
information is P.O. Box 1206, Barnstable MA 02630 August , 2009 .
required for eve .
9 every
State Zip Code Date of Inspection
to e
page. City/Town P p
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
El M 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 rivate water supply well with no acceptable water quality analysis. [This
P
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.]
❑ 101 ,
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ w ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be .
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to.each of the following, in addition to the
questions in Section D.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑ ® 'the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area-IWPA)or a mapped Zone-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 "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.
186 Braggs Lane;Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachuset9
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 186 Braggs Lane, Barnstable
Property Address
Richard Saunders _
Owner Owner's Name
information is required for every P.O. Box 1206, Barnstable MA 02630 August 2009
page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes' or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,_
dimensions,;depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
® 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 .
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)]
186 Braggs Lane.Barnslable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 15
Commonwealth of Massachusetts
to Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G M '' 186 Braggs Lane, Barnstable -
Property Address
Richard Saunders
Owner Owner's Name y
information is P.O. Box 1206 Barnstable MA 02630 August!, 2009
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information -
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpdx#of bedrooms): 220 gpd
Number of current residents: 0 2prior) ,
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 08=80,000gals
9 ( Y g (gpd)): 07=80,000gais
Sump pump? ❑ Yes ® No
.Last date of occupancy: Vacant 3 days
Date
Commercial/industrial Flow Conditions:
Type of Establishment N/A
N/A
Design flow(based on 310 CMR 15.203). Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
Grease trap present? ❑ Yes ® No
Industrial waste holding tank present? ❑ Yes 0 No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available: N/A
Last date of occupancy/use: N/A
Date
Other(describe): N/A
186 Braggs Lane,Bamstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System;page 7 of 15
t ,
_ s .y 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
yyY 186 Braggs Lane, Barnstable
Property.Address
Richard Saunders
Owner Owner's Name
information is P.O. Box 1206, Barnstable _MA 02630 August 4, 2009
required for everyState Zip Code Date of Inspection
page. Cityfrown
D. System Information (cont:)
General Information
Pumping Records:
No pumping info available.
Source of information:
Was system pumped as part of the inspection? El Yes. ® No
N/A
If yes, volume pumped: gallons
N/A
How was quantity pumped determined?
N/A
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy,
❑ Shared system (yes or n6) (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):
No d-box _
Approximate age of all components, date installed (if known)and source of information:
Tank&leaching are original to home built approx. 1977 to 79:
Were sewage odors detected when arriving at the site? El Yes No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
186 Braggs Lane,Barnstable•03108
K
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 186 Braggs Lane, Barnstable
Property Address
Richard Saunders
Owner Owner's Name
information is P.O. Box 1206, Barnstable MA 02630 August 2009
required for every —�__
page. City/Town State Zip Code. Date of Inspection
D. System Information (cont_) "
Building Sewer(locate on site plan):
Depth below grade: 18"+
feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain): NIA
--
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage,.etc.)-.
Flushed lines and found clear at the time of inspection. _
Septic Tank (locate on site plan):
Depth below grade: 18" _
feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: _N/A
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5'X 9'X 6' 1000 gallon
Sludge depth 4„
Distance from top of sludge to bottom of outlet tee or baffle 2,
Scum thickness Thin Layer
Distance from top of_scum to top of outlet tee or baffle 6,._ ---- -----
14"
Distance from bottom of scum to bottom of outlet tee or baffle -- —
How were dimensions determined? Probe Measured
186 Braggs Lane,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
r Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y 186 Braggs Lane, Barnstable
Property Address -- --
Richard Saunders
Owner Owner's Name--- —
information is P.O. Box 1206, Barnstable MA 02630 Au ust�, 2009
required for every —. -- - — �
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Concrete inlet baffle and outlet tee were resent. No evidence of leakage or damage was found.
Grease Trap(locate.on site plan):
Depth below grade: N/A _
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass. ❑ polyethylene ❑ other(explain):
N/A r
Dimensions: N/A
Scum thickness N/A
N/A
Distance from top of scum to top of outlet tee'or baffle - -
Distance from bottom of-scum to bottom of outlet tee or baffle N/A _
Date of last pumping: N/A
Date
bate
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 -
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
186 Brag0 s Lane Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
186 Braggs Lane, Barnstable
Property Address
Richard Saunders
Owner Owner's Name
information is P.O. Box 1206, Barnstable MA 02630 Au ust , 2009
required for every —g
page. Cityfrown State Zip Code Date of Inspection
D. System Information .(cont.)
Tight or Holding Tank(cont.)
Dimensions: N/A .
Capacity: N/A
gallons
Design Flow_ WA
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A. — Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/A _
Date
Comments(condition of alarm and float switches, etc.):
N/A
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
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.):
Snaked line through to leaching with no d-box found present. No original as-built was available. Past
inspection also showed no d-box present.
PumpChamber locate on site plan):
( P )
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
186 Braggs Lane,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -`Not for Voluntary Assessments
186 Braggs Lane, Barnstable
Property Address
Richard Saunders
Owner Owner's Name
information is P.O. Box 1206 Barnstable MA 02630 August , 2009
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
N/A
Type:
1-5.5'x6'pit
® leaching pits number: w/1'stone
❑ 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.):
Soil was 'sandy. Leach pit was found with 3' of water present with a visible stain line approx. 18"
below inlet invert. No evidence of hydraulic failure or problems in the past was found at the time of
inspection.
186 Braggs Lane,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System!Page 12 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
186 Braggs Lane, Barnstable _
Property Address
Richard Saunders
Owner Owner's Name
information is P.O. Box 1206, Barnstable MA 02630 August' 2009
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration N/A
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 ® No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy(locate on site plan):
Materials of construction: N/A
Dimensions N/A ---
Depth of solids NIA --- -
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
186 Braggs Lane,Barnstable•03l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
186 Brag sg Lane, Barnstable
Property Address
Richard Saunders
Owner Owner's Name ----- — - yy
information is P.O. Box 1206 Barnstable MA 02630 Au us f, 2009
required for every ,-- - ---- -. —�---- — —
page. Citylrown State Zip Code Date of Inspection
D. System Information (coat.)
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.
It
I
I I I
r , � �,
186 Braggs Lane,Barnstable•03108, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts .
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-'Not for Voluntary.Assessments
M 186 Braggs Lane, Barnstable
Property Address - - -- - -
Richard Saunders
Owner Owner's Name - -- — -- q
information is P.O. Box 1206, Barnstable MA _02630 Au.ust p, 2009.
required for every . --- --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)'
Site Exam:
® Check Slope
❑. Surface water
® Check cellar
❑ Shallow wells
18'+
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: pate
® Observed,site (abutting property/observation hole within 150 feet'of SAS)
Checked with local Board of Health°explain}
❑ 'Checkedswith local excavators;installers- (attach documentation)
;® Accessed USGS database-explain:
AIW 247 Zone B 23.1' 2°4' adjustment
You must describe how you established the high,ground Water elevation:
Soil was sandy. Hand augered 3.2' belowbottom.of leaching with no water found at 12.0'.
Groundwater adjustment in area at the time of inspection was 2.4'.. Bottom of leaching at 8.8'was
found not.to be located in the high groundwater elevation at the time of inspection.
186 Braggs Lane,Barnstable-03108 a Title 5 Official Inspection Form:Subsurface Sewage Disposal Systems•Page 15 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
M 186 Braggs Lane, Barnstable _
Property Address
Richard Saunders _
Owner Owners Name
information is p O. Box 1206, Barnstable MA 02630 August , 2009
required for every
page. City[Town State Zip Code Date of Inspection
D. System Information (coat)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
18'+
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: pate
® Observed site (abutting property/observation;hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation) .
® Accessed USGS database -explain:
AIW 247 Zone B 23.1' _2.4'adjustment
You must describe how you established the high ground water elevation:
Soil was sandy. USGS groudwater map for Barnstable shows groundwater to be approx. 55.6'.
Groundwater adjustment in area at the.time of inspection was 2.4'. Bottom of leaching at 8.8' was
found not to be located in the high groundwater elevation at the time of inspection.
186 Braggs Lane.Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
e
TROY WILLIAMS �, `
SEPTIC INSPECTIONS .r7n
i
i Nw.
Certified by MA Department of Environmental Protection ` _¢rC v , �p"� (508) 760-1819
40 Old Bass River Road
South Dennis,MA 02660 '
C II
Conynonwem of Massachusetts OD
Execow Office of Ertivkorxrientol Affairs
Department of
• 1 Environmental Protection
WUUam F.Weld
tao•wwrwr
�avld Crum
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Date �Prop Inspection:Address: /LS fo ra'fi S 1,v,. (jw-5 Al fi l< Address of Owner. /fir,S %�, ;5 r
(If different)
Name of In
spector: /ry y f/iJ i /��wvr S �c•N+ c
Company Namel,Address ar(d Telephone Number:
JGL G,O0Va r
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 inspection.-The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
asses
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 subunit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, 8, C,or D:
A) SYST PASSES:
7have not found any information which indicates that the system violates an of the failure criteria as defined in 310 CMR 1 Y 5.303.
Any failure criteria not evaluated are indicated below.
III SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon conmpletion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all Instances. If'rat determined', explain why not)
_ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revl•ed 9/1S/9S) 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: I ` �,�,j� s
Owner:
Date of Inspection:
61 SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
Pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed ,
distribution box is levelled or replaced
The system required pumping more than four 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
C1 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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The Svctem hall, a septic tank ano sou absorption system anti is within 100 feet to a surface water supply or tributary tG a
surface water supply.
The s\•stem has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The systen, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis 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.
')I SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an 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
:evised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
�??�__ CERTIFICATION (continued)
Property Address: ) �6 1��7 IS
Owner:
Date of Inspection:
D) SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen..
EI LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(reviaed 8/15/95) 3
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check'if the following have been done:
_V/Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection,
/'//4As built plans have been obtained and examined. Note if they are not available with WA.
ZThe facility or dwelling was inspected for signs of sewage back-up.
ZThe system does not receive non-sanitary or industrial waste flow
✓The site was inspected for signs of breakout.
ZAII system components,-excluding the Soil Absorption System, have been located on the site.
ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
/tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility ow np (aid occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: ji�1 r 5 t7 vi 1
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: as o gallons
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):_.t/o
Laundry connected to system (yes or no):�GS
Seasonal use (yes or no): Jio
Water meter readings, if available:_ 9`/ —S's = yaio.:;'o
i
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: / }
/y
System pump4as part of i spection: yes or no) 1Va _
If yes, volume pumped. gallons
Reason for pumping:
TYrSeptic
SYSTEM
tank/44tfib►kmLbox/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no)- (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: ID 1 o k%-e.
4 a.2� ✓s c.yo , �
Sewage odors detected when arriving at the site: (yes or no) IV J
irevised 8/15/95) 5
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: / >
Owner: kj
Date of Inspection:
SEPTIC TANK:_f
(locate on site plan)
Depth below grade:
Material of construction: Zoncrete _metal _FRP—other(explain)
Dimensions:_ o yw/rD N .
Sludge depth: '� T
Distance from top of sludge to bottom of outlet tee or baffle: v?
Scum thickness: NOH
Distance from top of scum to top of outlet tee or baffle: /1/0 S c-
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) L-o., y 41 t s - I� i U N rA �D" f/-e 4- -a ;,
s f t c. )c ci D r � rx A, rc c 7-7
J 1
l�Q- S GI i. T" / (n ►1! G- U` d T— iO r%-
GREASE TRAP:/y11i9
(locate on site plan)
Depth below- grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
>cum thickness:
Distance from top of scum to top of outlet tee or baffle:
`11stance from bottom ro crlim I- t)Otl()m OI OWIP! tee Or banlP'
Comments:
recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
,ntegrity, evidence of leakage, etc.)
:revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: l 6 "Yj S
Owner. W 15
Date of Inspection:
TIGHT OR HOLDING TANK:2//
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal _FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.) »
i
DISTRIBUTION BOX:_N/47
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution i5 equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:��
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised B/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4 0'1�A S Z-&i
Owner: I/U; o
Date of Inspection: ,a/i3/9s
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number: Oh c. a Jcv ..� ct s S a
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegeltationn,tc.)
C. lV Sa ��
J A t1 !�O L / 0 .S a T
CESSPOOLS:�/7f
.locate on site plan)
Dumber and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
%4aterials of construction:
ndication of groundwater:
inflow (cesspool must be pumped as part of inspection)
omments: (note condition of soil signs of hydraulic failure, v g yd u e, level of pondmg, condition of vegetation, etc.)
PRIVY: / 1119.
locate on site plan)
"aterials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinuecl)
Property Address: / 6 y j 1 L
Owner.
Date of Inspection: _
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
as '
va '
DEPTH TO GROUNDWATER
Depth to groundwater-. feet adjusted high groundwater level
method of determination or approximation:
h c L� 7`� In o u� J-t n _(�
revised 8/15/95) 9