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Commonwealth of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
284 Braggs Lane
Property Address
Partin
P John a
Owner Owner's Name ,
information is Barnstable {" Ma 02630 8/29/2014
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer, • I
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
S M Jones Title V Septic Inspection
r;®meany Name
74 Beldan Ln.
Centerville Ma 02632
City town State Zip Code
774-248=4850 smjonestitle5@gmail.com SI4522
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. 1 am a DEP approved system inspector pursuant to Section 15.340 of '
Title 5(310 CMR 15.000).The system:
® Passes 0 Conditionally Passes [1 Fails r
❑ Needs Further Evaluation by the Local Approving Authority
k
Inspector's Signature `Date [
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner'
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at'the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Inspection Po :Subsurface Sewage Disposal System Page 1 of 17
f
•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
284 Braggs Lane
Property Address
John Partin
Owner Owner's Name
information is Barnstable Ma 02630 8/29/2014
required for every - —
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E I 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.
E
Comments:
The dwelling located at 284 Braggs Lane Barnstable is served by a Title V septic system consisting of
a 1000 gallon septic tank and 2 precast leach pits. The system was found to be in proper working
condition at the time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.,System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if.a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17,
Commonwealth of Massachusetts
r Title 5 Official Inspectidn Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
284 Braggs Lane r
Property Address
John Partin
Owner Owner's Name
information is Ma 02630 8/29/2014
required for every Barnstable
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
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval,of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
distribution box is leveled or replaced ❑ Y ❑ N ❑ "ND(Explain below):-
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation.is Required by the Board of Health:
❑ -Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment. ;
1. System will pass unless,Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public-health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
f
t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
AR Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 284 Bragas Lane
Property Address r
John Partin
Owner Owner's Name
information is required for every Barnstable Ma . 02630 8/29/2014
page. Cityrrown 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.
C] 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: j
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
11, ® 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 Y day flow
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
f ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.yr< 284 Braggs Lane
Property Address .
John Partin
Owner Owner's Name
information is required for every Barnstable Ma 02630 8/29/2014
page. City/Town State Zip Code. Date of Inspection
B. Certification (cont) -
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:.
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® , Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is Tess than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a -
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes or"no"to each of the following, in addition to the
questions in Section D.
Yes -No ,
A ❑. ❑ the system is within 400 feet of a surface drinking water supply
El ❑ the system is within 200 feet of a tributary to a surface drinking water supply
r ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone Il 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 i
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 284 Braggs Lane
Property Address
John Partin
Owner Owner's Name
information is required for every Barnstable Ma 02630 8/29/2014
page. Cityrrown 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 u ?
9 9 p
® ❑ 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:
Z ❑ 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 gpd
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
284 Braggs Lane
Property Address
John Partin
Owner Owner's Name
information is required for every Barnstable Ma 02630 8/29/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) El Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: vacant
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 284 Braggs Lane
Property Address
John Partin
Owner Owner's Name
information is required for every Barnstable Ma 02630 8/29/2014
page. Cityrrown 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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason.for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° 284 Braggs Lane
M
Property Address
John Partin
Owner Owner's Name
information is required for every Barnstable Ma 02630 8/29/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
tank and pit original 1976, leach pit added 1989
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
Depth below grade: .5
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: 1000 gallons
6.,
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
284 Braggs Lane
Property Address
John Partin
Owner Owners Name
information is required for every Barnstable Ma 02630 8/29/2014
page. Cityrrown 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
3"
Scum thickness 3
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined?
opened covers, took
measurements
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 does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
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
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 284 Braggs Lane
Property Address
John Partin
Owner Owner's Name
information is required for every Barnstable Ma 02630 8/29/2014
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 284 Braggs Lane
Property Address
John Partin
Owner Owner's Name
information is required for every Barnstable Ma 02630 8/29/2014
page. Cityrrown 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 N/A
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 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
IJ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 284 Braggs Lane
Property Address
John Partin
Owner s Name'wn r O e a e
information is required for every Barnstable Ma 02630 8/29/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ 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.):
Leach pits were dry with no sign of past hydraulic overloading.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 284 Braggs Lane
Property Address
John Partin
Owner Owner's Name
information is required for every Barnstable Ma 02630 8/29/2014
page. Cityrrown 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 284 Braggs Lane
Property Address
John Partin
Owner Owner's Name
information is required for every Barnstable Ma 02630 8/29/2014
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
tjo
/43
III
c
735„
6 3 yS
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 284 Braggs Lane
Property Address
John Partin
Owner Owner's Name
information is required for every Barnstable Ma 02630 8/29/2014
page. Cityrrown 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: 124
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 USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
45ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
JIiA
j Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
284 Braggs Lane
Property Address
John Partin
Owner Owner's Name
information is required for every Barnstable Ma 02630 8/29/2014
page. Cityrrown 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
\e
1. 2010 9: 25AM NO. 544 P, 1
` Town of Barnstable =Health Inspector
� Office Hours
Regulatory Services. 8:30—9:30
�+ Q, Thomas F.Geiler,Director 3:30—4:30
BAPJWARMMrw Public Health Division.
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM, APPLICANT—'SEPTIC QUESTIONNAIRE '-
Date:JLWO
1. General Information: Size of Property: .83 Acres
2.Address:284 BRAGG'S LANE BARNSTABLE,MA.02630 M 2 Parcel 679
Name:JOHN G III&DAWN C PARTIN Phone#:
2a. How many bedrooms exist at your property now?3
2b. Are you planning to add any bedrooms? NO No If yes,how many?
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?3 Mr.Partin has agreed to rehabilitate the
main house and have only two bedrooms in the main house and one bedroom in the accessory apartment.,Mr.Partin will
accommodate this by opening the door way to an upstairs room to a five foot opening.
2d, Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the
home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room
clearly.
3. Is the dwelling connected to public sewer? NO
If the dwelling is,connected to public sewer,skip questions#4 through#9 below.
4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone?
5. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply yells?
6. Is the dwelling connected to an PUBLIC WATER
7. Is a disposal works construction permit on file? NO 7 a
8. If yes,how many bedrooms were approved according to this peinut? Bedrooms. w
9. Were any building permits obtained for construction of additional bedrooms? YES or NO
N.
10.. Is there an engineered septic system plan on file at the Health Division? YES or NO to, M
11_ Has fhe septic system been inspected by a DEP certified ins ector within the last two ears. YES or NO r,
_— ------- ��--_�e_o._--- -------- - —p------------------—y--� --- ------- -- dw�dam/
w FOR OFFICE USE ONLY —' - /'^'
The Public Health Division' has-no objection to bedrooms at this property.
Special Conditions:
Signed: _... Date: /�
Front
Entrance
Front
Entrance
Front Porch
Family Room Closet Closet
Day Cate Room 21' 6"x 13'6"
15' 6"x 15' 6"
'Bed Room
15,x,9,.
Food Pantry Closet
41'6" Living Area 24' Long
Living Room Area µ Bathfoorrt
13' 6"wide Kitchen Area . 8''x 8.' Kitchen`Area . .
1/2 Bath S,X 8,
5'x5'7"
Rear Door Bear Door'
Back Door
Apartment Area
24'x 21'
Back Qeck
12'x26'
28'�t p1 r� S: Lv� t31
o �
CAL
M
w.: Closet
�, Closet Closet
.Stairs_ 7
6 Ft.Door '
Bed Room Unfinished Room
Maier Bedroom 21'x 1tY 5" 21'x 10'6'
18'W x 1&9" Closet
J. Study
Bathroom 12'x 11'2" }
9'x6'6" 1'
" Closet
3
Lim
c
SA OLQ
I, CV
O a
Un-Funished Basement
Basement 26' 6"x 29' 4
26'6"x 16' 9"
Office.
Fumace 19' x 1o'
Room
4'7" x9'2°
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Closet Closet - Closet
Stairs.
5 Ft. Door Bed Room Unfinished Room
.21'x10'5" 21'x10'5"
Mater Bedroom
18'10"x 13'4„
Closet Study
Bathroom 12'x 11'2"
9'x6'6"
Closet
• � tN
5 I�a9 9S viol
Front
Entrance ry
Front - .
Entrance
Front Porch
Famil Room Closet Closet
y
Day Care Room 21'6"x 13'6"
Bed Room .
15'x9'r
Food Pantry Closet
41'6" Living Area 24' Long
Living Room Area Bathroom
ITT wide Kitchen Area 8'x 8' Kitchen Area
1/2 Bath 6 x.8
5'x5'7
Rear Door Rear Door
Back Door
Apartment Area
24',x 24'
Back Deck
12'x 26'
�L
o Un-Funished Basement
Basement o 26'T x 29'
26' 6"x16' 9"
0
Furnace. Office
Room 11,x 10'
4'7"x9'2
i
r
1 �
Town of Barnstable Health Inspector
�1HE rop, Regulatory Services Office Hours
.p 8:30-9:30
Thomas F.Geiler,Director 3:30—4:30
STABLE, * Public Health Division
v 039.� 10� Thomas McKean,Director '
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT - SEPTIC QUESTIONNAIRE'
Date:June 2,2010
1. General Information: Size of Property: .93 Acres
2.Addressa28�4 BRAGG'S LANE BARNSTABLE,MA.02.630 Map 289 Parcel 079
Name:JOHN G III&DAWN C PARTIN Phone#:
2a. How many bedrooms exist at your property now?4
2b. Are you planning to add any bedrooms? NO No If yes,how many?
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?3 Mr.Partin has agreed to rehabilitate the
main house and have only two bedrooms in the main house and one bedroom in the accessory apartment. Mr.Partin will
accommodate this by opening the door way to the upstairs bedroom to a five foot opening.
d 2d.Please include a copy of"the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the
home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room
clearly.
3. Is the dwelling connected to public sewer? NO
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone?
5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? El
6. Is the dwelling connected to an PUBLIC WATER ,
7. Is a disposal works construction permit on file? NO i
8. If yes,how many bedrooms were approved according to this permit? Bedrooms. "
t
9. Were any building permits obtained for construction of additional bedrooms? YES or d NO
10. Is there an engineered septic system plan on file at the Health Division? YES or NO
11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
t v
FOR OFFICE USE ONLY -�
ol
The Public Health Division has no objection to bedrooms at this property. �d -
Special Conditions:
,.a
Signed: • Date:
Front
Entrance
Front
Entrance
Front Porch
Family Room Closet Closet
Day Care Room 21'6"x 13'6"
15' 6"x 15' 6"
Bed Room
15'x 9'
Food Pantry Closet
41' 6" Living Area 24' Long
Living Room Area Bathroom
13'6"wide Kitchen Area 8'x 8' Kitchen Area
1/2 Bath 6'x 8'
5'x5' 7"
Rear Door Rear Door
Back Door
Apartment Area
24'x21'
Back Deck
12'x 26'
Closet Closet Closet
Stairs
tj
Bed Room Unfinished Room
21'x10'5 21'x10'5"
Mater Bedroom �\
18' 10"x13'4
Bathroom 12'x 11'2"
9'x6'6"
y
�� G �1w
Basement Un-Funished Basement
26' 6"x16' 9" 26' 6"x29'
Office
Furnace 111,x 10'
Room
4'7"x9'2"
SEP.25.2009 1:35PM BARNSTABLE BOARD OF HEALTH NO.690' P.1i1
Town of Barnstable Health Inspector
Office Hours
Regulatory Services 8:30-9:30
Thomas P.Giesler,Director -3:30—4:30
E • � Public Health Division
MAC:
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
.AMNESTY PROGRAM APPLICANT—SEPTIC 0IM5110NNAIRE
I Dato:July 31,2009
1. General Information: Size of Property: .83 Acres
2.Address:284 BRAGG'S LANE BARNSTABLE,MA,02630 Map 289 Parcel 079
Name:JOHN 0 III&DAWN C PARTIN Phone#:
2a. How many bedrooms exist at your property now?3
2b. Are you planning to add any bedrooms? No If yes,how many?
2e. How many bedrooms total are proposed at this properly(including the amnesty uni ?3 e-A C90
2d.Please include a copy of the floor plans for the M&S property. Neatly use a straight-edge, Show all existing rooms in the
home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room
clearly.
3. Is the dwelling connected to public sewer? ` NO
If the dwelling is connected to public sewer,Aip questions#4 through#9 below,
r� s:r
4. Location of dwelling is INSIDE or� �' a Saltwater Estuary Protection Zone?
i
5 . Location of dwelling is INSIDE or OUTSI a Zone of Contribution to public supply wells?
6. Is the dwelling connected to an PUBLIC WATER
7. Is a disposal works construction permit on file?. NO ;d; .�n
8. If yes,how many bedrooms were approved according to this permit?; ems.
9, Were any building permits obtained for construction of additional bedrooms? YES or
10. Is there an engineered septic stem plan on file at the Health Division? ;YES or
. � y GN
QJ v
11. Has the septic system been inspoeted by a DEP cortifiod inspector within the last two yoars? YES o
----------------------------------- --------------- _--------- .----.--- - -------------- e���
- FOR OFFICE USE ONLY �y
*h
The Public Health Divis' as no objection to bedrooms at this property.
Special Conditions: 1seo C Qi►�, r L
e i
6 rovMS lops
e � tr�.
Signed: Date:
\Gt.2b r;ousinAweeessory Aftydable Apartment Pro==1AD?4 VIFORM9&LETTER91 =4,Forms amriesry3pp1.DOC '
., J "
I
Crocker, Sharon
From: Crocker, Sharon
Sent: - Tuesday, September 21, 2010 4:13 PM
To: McKean, Thomas
Subject: FW: 284 Bragg's 'Lane; Barnstable
F _ '
Revision: •
Referencing the revised floor plan with the 7/1/2010..application, they show three bedrooms (office in
basement-no windows), day-care room on first floor with two interior entrances.
As you mentioned, if they have one of the day-care doors opened to the 5 feet opening-no door, they are
ok'd for the amnesty apartment. (The septic inspection shows 3 bedroom system at 360 daily flow and assuming
one of the two leaching pits is in failure as there is no d-box connecting them.
Art and Cindy will be meeting Thur afternoon, 9/23, here, if.you want to go over anything with them. .
Thanks,
Sharon
-----Original Message----
From: Crocker,Sharon
Sent: Tuesday,September 21,2010'3:25 PM
To: McKean,Thomas
Subject: 284 Bragg's Lane,Barnstable
Update
I spoke with Cindy Dabkowski, Amnesty Program, x4743. The application hearing is tomorrow night. I
conveyed to her that the applicant needs to hire a certified engineer to determine whether the septic is built to
handle the flow rate of.3 bedrooms and a,daycare. I reiterated that the three bedroom approval is contingent.on it
being used solely as a three bedroom. With the use as a daycare as well, the certified engineer must determine
whether the system is designed to handle it.
-Sharon
y t
a
' t 1
Crocker, Sharon
��ryC
From: Crocker,.Sharon
Sent: Tuesday,September 21, 2010 3:25 PM
To: McKean, Thomas
Subject: 284 Bragg's Lane, Barnstable
Update
I spoke with Cindy Dabkowski, Amnesty Program, x4743. The application hearing is tomorrow night. I
conveyed to her that the applicant needs to hire a certified engineer to determine whether the septic is built to
handle the flow rate of 3 bedrooms.and a daycare. I reiterated that the three bedroom approval is contingent on it
being used solely as a three bedroom. With the use as a daycare as well, the certified engineer must determine
whether the system is designed to handle it.
- Sharon
�� 2 ` l (r'
a
Tn
AIA
S -u
XIA
/.,I? �� s
Om
r
McKean, Thomas
From: McKean, Thomas
Sent: Friday, October 08, 2010 5:02 PM
To: Dabkowski, Cindy
Subject: RE: 284 Bragg's Lane BA
Please ask the following questions:
1) How many children maximum will be in the."day care room"which is shown on the submitted plan?
2) Will there be a five feet wide opening in the doorway to the "day care room."
3)Will there be a door at the entrance to the "day care room."
-----Original Message-----
From: Dabkowski,Cindy
Sent: Friday,October 08;2010 3:32 PM
To: McKean,Thomas
Subject: 284 Bragg's Lane BA L
Hello Mr. McKean
I am scheduled to go before-the Zoning Board of appeals'Hearing.Officer on October 20, 2010 for property 284
Bragg's Lane BA. I want to be sure that the property-owners Mr. and Mrs. Partin are clear on the things they
need to do to conform to Health Department conditions. Can you please give me a list of items? Thank you
Cindy Dabkowski
a
• i
{'t '
Town of Barnstable Health Inspector
'THE Regulatory Services Office Hours
8:30—9:30
Thomas F.Geiler,Director 3:30—4:30
BMWgrABLE, * Public Health Division
v�pTFD 9.�s � Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT - SEPTIC QUESTIONNAIRE
Date:July 31,2009
1. General Information: Size of Property: .83 Acres
2.Address: 284 BRAGG'S LANE BARNSTABLE,MA.02630 Map 289 Parcel 079
Name:JOHN G III&DAWN C PARTIN Phone#:
2a. How many bedrooms exist at your property now?3
a
2b. Are you planning to add any bedrooms? No If yes,how many?
2c. How many bedrooms total are proposed at this property(including the amnesty uni ? 3
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the
home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room
clearly.
3. Is the dwelling connected to public sewer? NO
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
4. Location of dwelling is INSIDE or OUT a Saltwater Estuary Protection Zone?
5 .. Location of dwelling is INSIDE or �OUTSIa- Zone of Contribution to public supply wells?
6. Is the dwelling connected to an PUBLIC WATER r3 B Q
7. Is a disposal works construction permit on file? NO {o
8. If yes,how many bedrooms were approved according to this permit? Bed.ooms.
9. Were any building permits obtained for construction of additional bedrooms? YES or
10. Is there an engineered septic system plan on file at the Health Division? -YES or
11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or(__�.
---------------------------------------------------------------------------------------------------------- ---
FOR OFFICE USE ONLY
The Public Health Divisi as no objection to bedrooms at this property. 0-ea�
Special Conditions: 1 �S �,o-n� �►3,?I0e
'n 0' Prf� � Cam.
Signed: Date: Q 5' 0� 2 J'A 4
:\GMD-Housing\Accessory Affordable Apartment Program\ADMIN
Nam. \FORMS&LETTERS\Blank Forms amnestyapp].DOC 1�
Car '( ro-OA,- � �. ���u�e� rip p er„�•3 6e j,e
�T 113�l
COMMONWEALTH OF MASSACHUSETTS
ExE.cuwvE,OFFICE OF,ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
CE 7VE
APR
TITLES TOWN OF BARNS7ABLE;
..
HE.ALTP.D',
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address- 284 .Braggs .Ln MAP
aniir9i
Owner's Name: Ed � PARCEL. O7_q
Owner's Address: LCT
Date of Inspection: . ; ,' 3 ---
Name of Inspector:(please print) W j 1 jam _ - Robin son Sr.
CompanyName: . William E. Robinson Septic Service
Mailing Address: P 'O'-Box" 1089 -
_Centerville, MA
Telephone Number: (508). 775-8776
}
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 Sec 'on 15.340 of Title 5(310 CMR 15.000). The system:
VPasses ,
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
i
Inspector's Signature:. ?�/, ;, Date: J 9.7-0-�?
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthvr'
DEP)within 30 days of completing this inspection.If the system is a shared system or bas 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 DISPO SA RT AXSTEM INSPECTION FORM
CERTIFICATION (continued)
284 Braggs Ln
Property Address:
Owner.
Date of inspeetion: >�
Inspection Summary:.:Check A,B,C,D or E/ALWAYS complete all of Section D
A.75ys,"ll,
Passes:
ave not found any information which indicates that any of the failure
criteria
ated odescribed in 310 CMR
15.303 or in 310 CMR,15.304 exist.Any failure criteria not evaluated are
Comments ..._ ... _ =.
B. Sy tem Conditionally Passes:
e or more system components as described in the"Conditional Pass"section need to be replaced or
repa'ved. a 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 se tic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exit its substantial.infiltration or cAltration or tank failure is imminent.System will pass inspection if the
existing tank i replaced with a complying septic tank as approved by the Board of Health: `
•A metal septi tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that a tank is less than 20 years old is available.
ND explain:
Observa ion of sewage backup or break out or high static water level in the distribution box due to'broken or
obstructed pipe )or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Boa d of Health):_
broken pipe(s)are replaced-
obstruction is removed
distribution box is leveled or replaced
ND explain:
The sy tem required pumping more than 4 tines a year due to broken or obstructed pipe(s).The system will
pass inspecti if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION_ FORM
PART"A
CERTIFICATION(continued)
Property Address: 284 Braggs Ln
. ..... .......
Owner:
Date of Inspection: — S
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 fa ing to protect public,health.safety or the environment.
1. System will pass unless Board of Health determines m accordance with 310 CMR 15.303(I)(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. ystem will fail unless.the Board of Health(and Public Water Supplier,if any).determines that the
s st m is funetionin in a manner that rotects the public health safe and environment:
Y ,.. h. P,, . P h'
The system has aseptic 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 frorl a
rivate water supply well".Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
b�acteria and volatile organic compounds indicates that the well is free from pollution from that facility and:,,
tltie 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. her:
3
Page 4 of 11 `
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM
-PART A
CERTIFICATION(continued)
284 Braggs •Ln
Property Address:
Owner: -
Date of Inspection:
D. System Failure Criteria applicable to all systems:.
Yo must indicate"yes's 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 duet an overloaded or clogged SAS or'
cesspool
_ Liquid depth in cesspool is less than 6"below invert.or available volume is less than'/: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.
An portion of a cesspool or privy 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:]
(Yes/No)The system fails.I have determined that one or more of the above fa•►lure 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. L rge Systems: �' with a desi n flow of 10000 god to 15,000
To be onsidered a large system the system must serve.a facility g
gpd•
You in st indicate either"yes"or"no"to each of the following:
(The fo lowing criteria apply to large systems in addition to the criteria above)
yes n
_ 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 y u have answered"yes"to any question in Section E the system is considered a significant threat,a�tiered
"ye "in Section D above the large system has foiled.The owner or operas any
largi sign ficant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.3 .The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAI SYSTEM INSPECTION FORM
PART B • .:.,
284 Braggs Ln CHECKLIST
Barnstable
Property Address:
Owner. T
Date of Inspection: .3 —�-5'00
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? ,
t/_ Has the system received normal flows in*the previous two week period? - r.
V 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 mspected for the condition
oft/he battles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
1� 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:
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)]
I •
5
Page 6 of I 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY%ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C,
SYSTEM INFORMATION
Property-Address:
284 Braggs Ln
Bar Lit,tab±e
Max ptly
Owner:
Date of Inspection: S—o'L•S-03 3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):.3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 C
Number of current residents: a_
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):X 0 [if yes separate inspection required]
Laundry Ys stem inspected(Yes or no):.�v
-
Seasonal use:(yes or no): /L-O 2 0 02 3.1 3,0 0 0 gal s
Water meter readings,if available(last 2 years usage
Sump pump(yes or no): NU
Last date of occupancy* -�
. — ..
COM RCIAL/INDUSTRIAL
Type of tablishment:
Design fl w(based on 310 CMR 15.203):_ mod'
Basis of d sign fl,0.*(seats/persons/sgft,etc.):
Grease tr present(yes or no):—
Industrial aste holding tank present(yes or no):—
Non-sani waste discharged to the Title 5 system(yes or no):
Water m ter readings,if available:
Last datt of occupancyluse:
OTNE (describe):
GENERAL INFORMATION
Pumping Records
Source of information:_ -�a (' _ 0 3
Was system pumped as part of the inspection(yes or no): A.d
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPJ/OF SYSTEM
i/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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tigbt tank Attach a copy of the DEP approval
—Other(describe):
Approximate age of all com onents,date installed(if known)and source of information:
79 __65
Were sewage odors detected when arriving at the site(yes or no): A, c)
6
Page 7 of 1 I
OFFICIAL INSPECTI,ON FORM-NOTFOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ._.
PART C
SYSTEM INFORMATION(continued)
284 Braggs Ln
Property Address: Barnstable
Mtirph3Z
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction _casciron _40 PV.0_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: v locate on siteplan)
-
Depth below grade:
Material of construction:�ncrete metal_fiberglass—polyethylene
—other(explain)..
If tank is metal list age: Is age confirme&b a Certificate of Compliance
g — g ` � y p (yes or no):_(attach a copy of
certificate) � � � --
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: P�q —
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:.
How were dimensions determined: d -
Comments(on pumping recommendations,inlet and outlet tee or baffle condition;structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc):
.� Czw
GR SE TRAP:_(Ideate on site plan)
Depth b ow grade:—
Material construction:_concrete_metal—fiberglass_polyethylene other =
(explain):
Dimensions
Scum thic ss:
Distance fro top of scum to top of outlet tee or baffle:
Distance fro bottom of scum to bottom of outlet tee or baffle:
Date of last umping:
Comments n pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related t outlet invert,evidence of leakage,etc.):
00
Page 8 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'
PART C
SYSTEM-INFORMATION(continued) .:
284 Braggs Ln
Property Address:
Owner: P Y
Date of Inspection:
TIGH or HOLDING TANK: (tank must be pumped at tune of inspection)(locate on.site plan)
Depth be ow grade:
Material f construction: concrete. metal fiberglass_polyethylene other explain):
Dimensi ns:
Capacity gallons
Design F ow: gallons/day
Alarm p esent(yes or no):
Alarm I vel: Alarm in working order(yes or no): :. . ..
Date of ast pumping:
Co nts(condition of alarm and float switches,etc.):
BOX: �Cfresent must be opened)(locate on site plan)
DISTRIBUTION .
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 CHALM
ate on site plan)
Pumps in wor no):Alarms in wr no):
Comments( ump chamber,condition of pumps and appurtenances,etc.):
8
y Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
284 Braggs Ln
Property Address: Barnstable
Murphy
Owner:
Date of Inspection: 3 -�-5`( -2
SOIL-ABSORPTION SYSTEM(SAS): (locate on site plan,excavation*not required)
If SAS not located explain why:
Type
✓ leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
� lC-
CESSPOO S: (cesspool must be pumped as art of inspect 1 P P P p p )(ocate on site plan)
Number and c nfiguration:
Depth-top of iquid to inlet invert:
Depth of solids ayer.
Depth of scum I yer:
Dimensions of c sspool:
Materials of cons ction:
Indication of gro dwater inflow(yes or no):
Comments(note ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (lo(ate on site plan)
Materials of cons ction:
Dimensions:
Depth of solids:
Comments(note c ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
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:_ 84 Braggs Ln
Owner. 11..1`.11
Date of Inspection: 3
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.
g
rt, Sy
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1
10
Page I I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
284 Braggs Ln
Property Address: Barnstable
Murphy
Owner.
Date of Inspection: 3 �-
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
w _
Estimated depth to ground water JP�S' 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: /w, P-3
Checked with local excavators,installers-(attach documen Lion)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
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TOWN OF BARNSTABLE
0
LOCATION: ' 13ZPt SEWAGE #
VILLAGE 0
�`�� _�— ASSESSOR'S MAP 6z qLOT��
INSTALLER'S NAME PHONE NO, t"fIcx5'tr (20*z ST
SEPTIC TANK CAPACITY t 1 000 'T►NW—
LEACHING FACILITY:(Cype)_. �(000 (size)
NO. OF BEDROOMS PRIVATE WELL PUBLIC WATER
BUILDE 0 OWNER
DATE PERMIT ISSUED: 46'v tdi
DATE COMPLIANCE ISSUED: ��
VARIANCE GRANTED: Yes No ,
a�
� s
3
HS ' b
rr
3r5
No.. ...VA.5. Fi i......9.0.:. ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,f a
\ ............
...........oF...............
R
Appliration for Dispu,ial Works Tonfitrurtion Famit
"-Application is hereby made for a Permit to Construct ( ) or Repair (-pan Individual Sewage Disposal
System at• /,
............ ......... ..... • ........... ....--- - ..............
Location Address r I.ot No.
-------------•-- t - •----. ......----.........--.............. ----•-. ............. � —.................................................
e, Owner Address
K .......... .....
Installer Address
Type of Building Size Lot.............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building .. No. of persons.......................: Showers — Cafeteria
Otherfixtures -----------------------------------------------------------------•---•----------------
WDesign Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench— ..N . Widt _.. .._._.. Total Length............. Total leaching area....................sq. ft.
Seepage Pit No...T ..... Diameter..... .------- Depth below inlet........ -........ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed b Date........................................
,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 -----------•----------------------•....-••---••--------•......._............----•-............_....•......•.--
O Description of Soil..... ........�1 `1= 1
x ------------------- ......t_r••-•••--------•- •-•---------------••------------------••--•-•-•••-----------•.............---•-••-----------•----•--•----------------•---•-----•----------••---•------...........-----...---••---
W --------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—An wer.when applicable---------�----------- ------- _"--% ....................
---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT:LI 5 of the State Sanitary Code-The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha een issued e board of health. (.v
Signed-------- -
Date
Application Approved By---•-•------ -t :. -------- - +-Sl
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------•-----
-------------------•----------------------------•--•--- ------•------------•-•-----------....------........
`` Date
Permit No...... .:.7 �- Issued.......................................................
Date
Fzcs.....& . '.... .�,
THE COMMONWEALTH OF MASSACHUSETTS
. BOARD OF HEALTH
.....u�...........---...OF.......................................f�R
Appliration for Di-spusal Workg Tonstrurtion ami#
Application is hereby made fora Permit to Construct ( ) or Repair (>-f an Individual Sewage Disposal
System at
................................................... - ...................... ..._...----•-------•...-•-••••----•--......---.....----...._...._...........................---••-
Location-Address _ r Lot No.
(� lC J�°�a 13 7-- �Ad r ss L{l�- y j t , 4�1��V,
a •..................................•--••---.._._...-----•--.........-••--...•-----•-•---•--....... ..................... °..._....••---....-••-••---•....------......_..........................
Installer Address
Q Type of Building Size Lot............................Sq. feet
U 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............gallons Length................ Width................ Diameter_________-__.._- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.........._.........sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water-----------------_--___.
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
D Description of Soil......0........................ ........................................................... v�
==----------•-----•---------. ...........................
x
W -----------•------------------------------------------------------------•----••------------•--••---•----••-------------------------------------•---••-•--•--•-------•------------- --•-
U Nature of Repairs or Alterations—An wer when; applicable.--_____ j ---
---___._.1... � ....................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has--�.een issued. �theard of health.
Signed----�: ------.
� � Date
Application Approved B . ` __.__ .._.....?:...� _ ......
R..' Date
Application Disapproved for the following reasons------------------------------------ •----------------------------------------------------------•----------•-_...
•-------------------•-----...----•----------------------------....--•---....----•---•------••-------......---•-•--•------------------------------•------------------------------•-----•-•----------------
Date
PermitNo.--- ..r--------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�� p t�J� ��LC-
i�.....i✓� .......................OF........:.......:...................................................................
err ifirtt#r of Tompli aatrr
THIS S TO CE4RTIFY,� That,the Individual Sewage Disposal System constructed ( ) or Repaired
-.r- "'A
by...•. .•. =......----•....... ---•--•-•-•......-•••-•••--•••----------------•-------------------•--••---•---•-••-----•---...........-•-•---•---..........----...---.............
------------
� L Pi Installer
at. --_---. . • ----....-•---•---•----•----------------•-------------------•------------- . .....................................................
has been installed in accordance with the provisions of TITZ 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No-------- __ -___I`�-_� dated........................__..._.._....._...._...
3- -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................... ........................................ Inspector................ ....................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............
�` f. . ......................
No.... +. ..:.... rr..� FEE...
� urk� Vo�a� a „�aa�- rrmi�
Permission is hereby granted.... . ..-------•--------•------••----•-----------------•---------------•---------------•-------.......................-•---
to Construct,( � or Repai (( �Ir Indivi.u 1 Sewage Disposal System .
at No.................a-` j<LF�G.0 S _ (7s � is tL
------------ --- --•••-•.....-•••-•••-------•-----•-......------•-•...------------. --------•-•-----------•---•---•.....----------•-•.....--------•--............._
Street C.(`
as shown on the application for Disposal Works Construction Permit No- �� Dated..........................................
............................. -- ....-----------------•--•--------••••--•---------...-----•._........
r C Board of Health
DATE................. = --;�-------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
TOWN OF BARNSTABLE
I
LOCATION: `3 ,
�� SEWAGE #
VILLAGE .
ASSESSOR'S MAP& LOT �-0 9
INSTALLER'S NAME & PHONE NO,
SEPTIC TANK CAPACITY pp p I
LEACHING FACILITY: t Y
( YPe)_,_�� �1S OOC� (size) ..
NO. OF BEDROOMS
PRIVATE WELL PUBLIC WATER
BUILDE.OWNER
DATE PERMIT ISSUED:.._._-2,�-�\(.�,,` R—
DATE COLIPLIANCE ISSUED:
VARIANCE GRANTED: Yes. , Nb
THE COMMONWEALTH OF MASSACHUSETTS
e JOIq
..........7........ ..... .................
.. .... . . ...... ........_......
Application is herejy mate for a Permit to Cpnstruct F) or Repair an Individual Sewage Disposal
-----------------------------------------
Address
Address
Type of Building Size .......Sq. feet
P4 Septic Tank—Liquid capacitv_/A��----gallons
nn LI I
> ��6�4iflb�JPowffain ..4etal`l.`ea�ching areaf.!PP_��....sq. ft.
Other Distribution box Dosing tapk
�4 Test Pit No. 2...... .........niinutes;.)ernch Depth of Test Pit..................... Depth to ground ater_------------------
---------------------------------------
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code--The undersigned further agrees not to place the system in.
'^ operation until a Certificate of Compliance has been issued by ard of health.
Si
Date
�
Application�* '`py^",=" "y.. ��mm��� w ��������—°°.°'-^`'.°
'- __ ' Date
D� for the �Dmn�o reasons: �� =
� Application~ ^~rr^```^ following ~ �----�, ---'------------'-----------------'--
� —.—.—_----'-_-----_-----.'----_-------------_---_----_------_—.-_—.__—.-----
Date
Permit
-------_''—'~�-------------------------------__—' — `
fu_l
No..O.:2...... Ficz .............
T HE COMMONWEALTH OF MASSACHUSETTS
�_�OARD 0 HE H
F
. .... .....
..... ---------0 ........ .... ......... ...............
Apphration -for R-opog.,q, I Workii Towitrurtion Vrrtnit
Application is' hereby made for a Permit'to..Construct (7or Repair an Indlividual Sewage Disposal
S stem at:
y
4-3
........................... ... 5TZ6,�e..................................................
f J�ocation,-Addrete�_7'-�i,,, r17
--- ............
---------------------------------------------
_Owfier Address
.. ......................................................... ... ...../J;a!�;;i........
ln�taller Address
T y ul i Yng ----Sq. feet
pe of Buil ing Size Lot.-
Dwelling—No. of.l3e&o'oms,---9--------------------------------------Expansion Attic b�,
ge.,Grinder
OtherT�pe of Building ----------------------- No. of persons...... ................Sh6' e' Cafeteria
w rs
Other fixturesw%------------------------ ',!r*:
..... . ........................................................................ ------------ .................
De�ign--Tlow............................................gallons p ier day—Tot9l '61 ow... .............. ...gallons.
tr person F
Se ic Tank—Liquid capa�c�itv)410__gallons Lengtht__�I 7. ---- Diameter------_------- Depth------------
pt ..... Width.
D ---- ---- rot I
ispo,sal Trench—No------ .............. Width th- L
_iln�area--------------------sq. f t.
Seepa�
0e. hill
Pit No......I------2:.'�'.. Diamete -.'�;O?al laeac g area.,A0. -------sq. t.
eac iiii
�2; Other Distribution box ��Dosmg tank ( )
Percolation Test Results Performed ....................................................... Date......... ..........
y---------------- -----------------
Test Pit No. I................minutes per...iiich Depth of Test Pit.................... Depth to ground water.-_----------------------
Test Pit No. 2----------------minute p�,p i ch Depth of Test Pit-------------------- De th to �6und ter----------------------
40V p
......................... ... ----- ...... .. .. ............................
...........
- -- - ----------------------------------
0 Description o, V
U --------- .......... ---- ----------------------------------------
------------------------- ---------- -------------------- ---------------------------...... .................... -------------------------- --------------
- --- ----------------------------
U Nature of Repairs or Alteratio Answer *hen applicable-------------------------------------------------------------------------------------------------
- ---------------------------------------------- - --------- --------------------I----------------------------------------------------------------- ............................... ------------------
Agreement:,�
Tlie,'Stidersigned.,-agree b install the aforedescribed 'Indiv*idual Sewage Disposal System in accordance with
the,provisions of Article XT.,,6f t e State Sanitary Code— The undersigned further agrees not to place the system in
,operation until a Certifica:e�'of Compliance has been iss ed by th oa f health.
Si - ----- - ---- ........ ... ..... .. .....
/Date
Application A
pp�ON,Td By_' -------------------------------
Date
Applic ion Disapprov for the following reasons:.............. ..................................-----------------------I............ ..........................
............�.i--------------------- ............................................................................ ----------------------------------I------------------------------------------------
Date
PermitNo........................................................ Issued.........................................................
Date
F41
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF. HEALTH
..... .....
OF....... ... ..................................
"VOIrdifiratr of 01.11,11mv.4ana
�V i�/�)�otRep.air led
Till/S ISJO CE I`IF4Y, at the Larlividual Se age Disposal System constfiic'i�_
bi....
..........
LIC. ....... ....... .............................. ............ .
-------------------
------ -------
4 a
. . .... ............... . .... .... - ---- --
-W_ -_---_- t . -----------------
wjt� ;e State Sanitary Code as'Hescribed in the
�Of
,;11 has been installed in accordance with the�pvisions of .- i; I of
application for Disposal Works Constructi Permit ....
- -----------m------- dated-------- ................
THE ISSUAN, OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL, FUNCTION SATISFACTORY.
DATE.................................................................................
THE COMMO NWEALTH OF MASSACHU.SETTS
4
aoAK'n OF, HEALTH
OF ...... . A. . .....�-.
No........................ FEE...
R-spog ark rurt oti
Permissioa,ij granted-......4��_ .... ...........................
.........................M�-- ----------------------------
to Construc ir Y"'an Individu I a e i s stem
�O& ...4�Ze 4
at NO.. .............
......... .. ........
...... Street
as shon
the application for Di posal Works Construction&rmi --- - ---"D_,ted
of �.Jt
. ..,.I, I -*. -- , .. ...........................
e0__ 0� .1. ..........................
ard of H�ealth
DATE.... Aa-07------ ..................
FORM 1 55 Hoeas & WARREN. INC..'PUBLISHERS
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