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HomeMy WebLinkAbout0429 BRAGG'S LANE - Health 4Z9 Bra ggs Lane "` Y Barnstable �� ..1 A= 298-028 o _ n p Commonwealth of Massachusetts Title 5 Official Inspection Form' I1; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 429 Braggs Ln Property Address Ginny& Brian Otoole Owner Owner's Name / information is Barnstable V Ma. 02630 8-5-20 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. . fmngoutf Important: A. Inspector Information filling out forms on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Jim The Inspector Man ' use the return Company Name key. P.O.Box 784 r� Company Address West Yarmouth Ma. 02673 City/Town State Zip Code 508-364-4398 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes jN OF 2. ❑ Conditionally Passes ��``� MICHAEL '.N 3. ❑ Needs Further Evaluation by the Local Approving Authority = z; SEARS '* No.SI14430 4. ❑ Fails •., �� RTIF�. I 8-5-20 Inspector's Knature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 AN, Commonwealth of Massachusetts �n Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l; 429 Braggs Ln V� Property Address Ginny & Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 429 Braggs Ln v— Property Address Ginny& Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 429 Braggs Ln Property Address Ginny & Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: ** This system 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts �A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 429 Braggs Ln Property Address Ginny & Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 429 Braggs Ln Property Address Ginny & Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any,of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 429 Braggs Ln Property Address Ginny& Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2018- 34000 gal g ( y g (gp )) 2019- 58000 gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ��- Title 5 Official Inspection Form }I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 429 Braggs Ln V� Property Address Ginny & Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 7-25-2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 429 Braggs Ln u� Property Address Ginny & Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. Cityffown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 25"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G � 429 Braggs Ln u Property Address Ginny & Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 15" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 1" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 8" ; Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge Judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with in and out tees,inlet cover at grade outlet cover 15" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts �v Title 5 Official Inspection Form �lbl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 429 Bra99 s Ln V Property Address Ginny& Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts w ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 429 Braggs Ln Property Address Ginny& Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D box is 16x16 with 1 outlet pipe, box is at 21"with cover at 8" below grade 1 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 cAN, Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 429 Braggs Ln Property Address Ginny& Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i . 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No*_ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I I i I� I * If pumps or alarms are not in working order,,system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: f i t i Type: 3 1 I ® leaching pits number: ❑ leaching chambers number: I ❑ leaching galleries number: i ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 429 Braggs Ln Property Address Ginny& Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is a 6' pit with 14" of water, pitis 4'with cover at grade 12. ,Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc,-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form �1; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 429 Braggs Ln Property Address Ginny& Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts le Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form Not for Voluntary Assessments v— 429 Braggs Ln Property Address Ginny& Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately rf4 R g I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Ii; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 429 Braggs Ln Property Address Ginny & Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 40+ 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: 404 per Board Of Health Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c u � 429 Braggs Ln Property Address Ginny & Brian Otoole Owner Owner's Name information is required for every Barnstable Ma. 02630 8-5-20 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included GrgCie o-C SAS 0 /Ve grd,�n wq�ar� l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Jul 25 2017 22:26 HP Fax page 1 Commonwealth of Massachusetts Title 5 Official Inspection FormFLI Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 429 Braggs Lane Property Address a:• Claude Levesque Owner Owner's Name information Is required for every Barnstable MA 02630 7-25-17 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submltted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:out f When A. General Information \n �/� filling out Forms v I I 4 `�' 01 -,,r%`OF I �f/I on the computer, use only the tab 1. Inspector. key to move your '� � JAM ES N cursor-do not James D.Sears r"= use the return x ke Name of Inspector Y. Capewide Enterprises _�••o� ��o Company Name �� . !?�iF,,.G� 153 Commercial Streer �'�ignrr5�"Ns4�\`,���� Company Address » Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S 1623 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 I 7-25-17 spectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. i5ins.doc•rev.5116 Title 50Kcial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Loytd Jul 25 2017 2226 HP Fax page 2 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 429 Bragas Lane Property Address Claude Levesque Owner Owner's Name information is required for every Barnstable MA 02630 7-25-17 page. City(Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal.Tank D Box and pit. 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 ❑ NO (Explain below): t5ins.doc•rev.6116 7ille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Jul 25 2017 2226 HP Fax page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 429 Braggs Lane _ Property Address Claude Levesque Owner Owner's Name information is required for every Barnstable MA 02630 7-25-17 page. CityrTown State Zip Code Date of Inspection B. Certification (cunt.) ❑ 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 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage D Wassi System-Page 3 of 17 Jul 25 2017 22:26 HP Fax page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 429 Braggs Lane Property Address Claude Levesque Owner Owner's Name information is required for every Barnstable MA 02630 7-25-17 page. CityfTown State Zip Code Date of Inspection B. Certification (cons.) 2. System will fail unless the Board of Health (and Public Water Supplier, If any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well''. Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than %day flow PIT' I50s.00c-rev.6/16 Tile 5 offdai Inspection Form;Suosorface Sewage Disposal System•Pege 4 of 17 Jul 25 2017 2226 HP Fax page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 429 Braggs Lane Property Address Claude Levesque Owner Owner's Name information is required for every Barnstable MA 02630 7-25-17 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 less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes If the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® The system falls. 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 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section 0 shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.$116 Title 5 Official Inspection Form:SLb"ace Sewage Disposal System•Pape 5 of 17 Jul 25 2017 2226 HP Fax page 6 Commonwealth of Massachusetts _ Title 5 official Inspection Form " Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 429 Braggs Lane Property Address Claude Levesque Owner Owner's Name information is required for every Barnstable MA 02630 7-25-17 page. City/Town 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 ❑ ® 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)1 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 t57ns.doc•rev.6116 Title 5 Ofliciai Inspection Form:Subsurface Sewage Disposal system-Page 6 of 17 Jul 25 2017 2227 HP Fax page 7 t\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 429 Braggs Lane Property Address Claude Levesque Owner Owner's Name information is Barnstable MA 02630 7-25-17 required for every page. City(Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): 2015-79,000GaIs2016-72,000Ga1's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatsipersons/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; 15hs.doc•rev.6116 Tllle 5 011iclai klsaectlon Form:Subst0ace Sewage Disposal System•Page 7 al 17 r Jul 25 2017 2227 HP Fax page 8 I. Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments F I 429 Braggs Lane I Property Address I Claude Levesque Owner Owner's Name information is required for every Barnstable MA 02630 7-25-17 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) , Last date of occupancy/use: Date Other(describe below): I N I I i I i I i General'Information Pumping Records: I'I Source of information: I NA j Was system pumped as part of the inspection?' ❑ Yes ® No f i If yes,volume pumped: lgauons How was quantity pumped determined? i Reason for pumping: Type of System: ® Septic tank, distribution box, so,il absorption system ❑ Single cesspool .I I ❑ Overflow cesspool ❑ Privy ' ❑ Shared system (yes or no) (if yeIs, 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 I ❑ Tight tank.Attach a copy of the,DEP approval. ❑ Other(describe): I t5ins.doc•rev.6116 Title 5 Offldel Inspection Form:subsurface sewaee Disposal System•Page 8 of 17 Jul 25 2017 2228 HP Fax page 9 Commonwealth of Massachusetts Title 5 Official Inspection Foram Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 429 Braggs Lane Property Address Claude Levesque Owner Owner's Name information is required for every Barnstable MA 02630 7-25-17 page. CitylTown Sate Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: NA 7-2017 New D Box and outlet tee. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 22" Depth below grade: feet Material of construction: ❑ cast iron ®40 ?VC ® other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC - SCH 40 & SCH -20. Septic Tank(locate on site plan): Depth below grade: 1 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 Gal. Precast H-10 Sludge depth: 1" 15ifts.aoc•rev.6i16 Title 5 official Inspection Form.Subauface Sewage Oispasal System•Page 9 of 17 Jul 25 2017 2228 HP Fax page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 429 Braggs Lane Property Address _Claude Levesque Owner Owner's Name information is Barnstable MA 02630 7-25-17 required for every State Zip Code Date of Inspection page. cityrrown D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 29" 0" Scum thickness ll Distance from top of scum to top of outlet tee or baffle a Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge u udg g -Tape Sle Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc,): Tank at working level. Tank and covers at 1'. In and outlet tees. No sign of leakage or over loading 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 t5ina.doc•rev.6116 Tine 5 Offclal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Jul z5 2017 2228 HP Fax page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 429 Braws Lane Property Address Claude Levesque Owner owner's Name information is Barnstable MA 02630 7-25-17 required for every Zip Code Date of Inspection page. City(Town Stwe 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.doc rev.6/16 Title 5 Official Inspection Form.Subsurlace Sewage Disposal System•Page 11 of 17 Jul 25 2017 22:29 HP Fax page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 429 Braggs Lane Property Address Claude Levesque Owner Owner's Name information is required for every Barnstable MA 02630 7-25-17 page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D Box is 16" x 16"-22" Below grade wlone line out. Box is new 7-2017 wlcover at 6" 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.doc•rev.6AS Tine 5 Offidal rnspedion Form:Subsurface Sewage Dlsposal System•Page 12 of 17 Jul 25 2017 2229 HP Fax page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 429 Braggs Lane Property Address Claude Levesque Owner Owner's Name information is Barnstable MA 02630 7-26-17 required for every Y pace. Cit !Town State Zip Code Date of Inspection D. System Information (cont.) Type: 1 ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leabhing is a 1000 Gal. precast pit. Pit at 42" below grade w1coverat 1'. Pit is dry wino sign of over loading or solid carry over, i 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.doc-rev.6116 Title 6 Dfridel Inspectron Form:Subsurface Sewage Disposal System-Page 13 of 17 Jul Z5 2017 22:29 HP Fax page 14 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 429 Braggs Lane Property Address Claude Levesque Owner Owner's Name information is Barnstable MA 02630 7-25-17 required for every per, Citylrown State Zip Code Data of Inspedion 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Jul Z5 2017 2229 HP Fax page 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 429 Braggs Lane Property Address Claude Levesque Owner owner's Name information is Barnstable MA 02630 7-25-17 required for every Page. Cityaown 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 1 OD feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately L7 F,4 �9 ,,A `�' ��- i o 15 ns.doc-rev.8MB Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Jul 25 2017 22:30 HP Fax page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 429 Braggs Lane Property Address Claude Levesque Owner Owner's Name information is required for every Barnstable MA 02630 7-25-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 4 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: G.W. on file at BOH 404 no G.W.. Bottom of pit at 9'-6" below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6116 Title 5 Official InspecNon Form:Subsurface Sewage Dlaposal Systam•Page 16 of 17 Jul 2.5 2017 2230 HP Fax page 17 Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 429 Braggs Lane Property Address Claude Levesque Owner Owner's Name information is required for every Barnstable MA 02630 7-25-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t51ns.doe•rev 6116 Title 6 Olricial Inspection Form:Subswface Sewage Disposal System-Page 17 of 17 Fee No. I Cj� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplicatiou for 13i.5po!5a1 Abp.5tem Con0truction Permit Application for a Permit to Construct( ) Repair(A Upgrade( Abandon( ) ❑.Complete System ®Individual Components Location Address or Lot No. qX9 bA 's _td BAfJV Owne-'s Name,Address,and Tel.No. C LA�•�' eztoF�Gat�r`. Assessor'sMap/Parcel air Q s q 91 AP.1104Z PZ 6i0GVAA Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. CAPE;uJcbi5 eVtQQkL5ES 153 Type of Building: ee� Dwelling No.of Bedrooms If Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building A�01'06_XPTt A4— No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 17-tO o!w wrl" vi-se $O.6mE -k- sowl-Tb&PL f� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and nct to place the system in operation until a Certificate of Compliance has been issued by this Board f Health. �r Signed Date [ Q- 24 C1 Application Approved by - Date /012.01-7 Application Disapproved by Date for the following reasons Permit No. ?,01? — ZZQ Date Issued :? (i 701_7 �:----------------------- --------- ..r No. I C%� Fee I ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Digo!gal i§p6tem Congtruction Permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. q;.9 6"(j4 S C A Ook Owner's Name,Address,and Tel.No. G'C.A UDF c,.�v�SGJv a .,r Assessor'sM.ap/Parcel ;t js � g, q Cri hu0-r-b An d✓wr&�_ cuatb �X Installer's Name,Address,and Tel.No. I Designer's Name,Address and Tel.No. 4�_A PEP ' 'Al r+ QtSU$ t 1/A 153 Type of Building: Dwelling No.of Bedrooms KA Lot Size sq.ft. Giarbage Grinder ( ) - Other Type of Building No.of Persons Showers( ).;Cafeteria"( ) Other Fixtures Design Flow(min,required)' gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S Nature of Repairs or Alterations(Answer when applicable) �Xwswl(j_ A,6-V.) 1 "1U D7W ujrl k �5f� Date last inspected: Agreement: " The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date i Application Disapproved by Date for the following reasons + .Permit No. Date Issued 4t o Z01-7✓ fir - i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed (' ) Repaired ( q ) Upgraded ( ) Abandoned( )by `//., e-W(6 6 EoTeatpkjslE�: at OR BpAq--. _-) LAIiX MANSTI(S E _has been constructed in accordance with the provisions of Title 5 and the rforr Disposal System Construction Permit No. � _ 2 dated Installer `A9&W(D6 rifv/�c Gl�y�f� Designer N A #bedrooms IJ4 Approved design flow } gpd The issuance of this pe' it shall of be construed as a guarantee that the systel will fu do aned. Date / .> Inspector _.w,, __ _ M.,.. � �jc, J ———No. �� ZOD Fee ' % J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS f ti �kgponl *p!5tem C.Ion.5truction Permit Permission is hereby granted to Construct ( ) Repair ( A ) Upgrade ( ) Abandon ( ) System located at 4-151 UA(4�5 Cf � S AID" and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. 1- 2 Provided: onstruction must be completed within three years of the date of th�penyr . z0/ � Date F (3 Approved by i Town of,Barnstable �F'THE r Regulatory Services Thomas F. Geiler,Director Public Health Division * BARNSTABLE, * Thomas McKean,Director 9 MASS. 0Q OO 1639. `� 200 Main Street, Hyannis, MA 02601 ArFD MA't A , r 1 Phone: 508-862-4644 Email: healthQtown.barnstable.ma.us Fax: 508-790-6304 Office Hours: M-F 8:00-4:30 , t May 12,2009 j Mrs.Delores Mello RE: Underground Storage Tank Removal 429 Braggs Lane Order,429 Braggs Lane,Barnstable,MA Barnstable,MA 02630 Map Parcel 298028 Tank# 1,Tag#00018 Dear Mrs.Mello: The Barnstable Public Health Division is in receipt of a copy of the tank removal Application and Permit issued by the Barnstable Fire Department demonstrating that the above referenced underground storage tank was removed on,or about May 6,2009. j The Public Health Division appreciates your attention to this matter and has updated its database to reflect this fuel tank status change. Should you have any further questions please contact Cynthia Martin of this office at 508-826-4645. i Tho s `c ean,RS,CHO Director of Public Health 1 r Make application to local Fire Department. .iill���l!i°010 Fire Department retains original a lication and ' 0 II PP issues duplicate as Permit. uim!uul�lm ' O Z 12 �Iplll!IIII;I I _ �� it iilllliiuild Ili � ��(/J�e '�J �UI�P ✓�?�2k�r2�Go�I2 �! ' . V APPLICATION and PERMIT EFe:e:= "" storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148; Section 38A, 527 CMR 9;00, application is hereby made by: 7Address e lease print) /':'.�, '` r .� _- a t cpuyuig rorpeanKJ '{ !ZT,-_, a. �, 4.�\�� j�'L Street �- ( .6 /. 1I 'lit r.1 iC �,!� City Sate Zip Company Name . '�'��J; - _ ✓ Print o.or Individual Print Addresst'.�) ` `'�.�/(���� � �'`Jv Address Pant Si nag ure-(4-applying for permit) '�' �1`�I t+ •J� ..; Print Signature(if applying for.permit) '\J❑ IFCI C�ert�'f�'ed Other ❑ IFCI Certified Other ❑ LSP n . Tank Locations I.Tank Capacity(gallons) Sleet dr=ss `'' city , { _`._�( � ,� Substance Last Stored ' Tank Dimensions (diameter x length) Remarks: Firm transporting waste ;� 5' � ��1 a,�, ,( i✓s 1'� L� State Lic.T ?, cc Hazardous waste manifest? EPA. r Approved tank disposal yard - Tank yard 9 Type of inert gas Tank yard address City or Town FDID �( �` r E� Permit" Date of issue =� tr ` Date of expiration / Dig safe approval number: Dig Safe Toll Free Tel. Number-800-322-4844 Signature!Title of Officer granting permit After rem send Form FP-29OR signed by Local Fire Dept.to US Regulatory Compliance Unit, One Ashburton Place; Room 1310, Boston. MA 02108-1618. FP-292(revised 9/96) s ♦ Bamstable AS& Town of Barnstable 1a14. , 111I. Regulatory Services Department 2007 P Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F..Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO Date: April 1, 2009 TO: Robert R. &Dolores J. Mello O D 429 Braggs Lane Barnstable, MA 02630 RE: Underground Storage Tank at: 429 Braggs Lane Barnstable,MA Map Parcel: 298028 Tank NO: 1 Tag NO: 00018 Our records indicate that your underground fuel (or chemical) storage tank is over 20 years old, and has not been removed as required by section 326-3: subsection 2 of the Town of Barnstable Code regarding fuel and chemical storage systems. You are directed to remove this tank within sixty(60) days from the date of this notice. After your tank is removed, please furnish this office evidence in the form of a permit from your local Fire Department within ninety(90) days of the receipt of this notice. You may request a hearing provided a written petition requesting same is received by the Board of Health within ten (10) days after this order is served. t Per Order of the Board of Health Thomas A. McKean, RS, CHO Health Agent Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 429 Bragg's Lane Property Address Doleres Mello Owner Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 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: A. General Information When filling out forms on the 45I 5232, computer,use ✓ ^? •IS, only the tab key 1. Inspector: c s 1 to move your Robert Paolini cursor do not Name of Inspector G'` -• use the return Ti key. Capewide Enterprises,LLC. 1%0 Company Name © � rab P.O.Box 763 Company Address ` Centerville Ma. 02632 emm City/Town State Zip CodC (508)428-4028 S14454 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 E aluation by the Local Approving Authority 10/22/2008 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. f l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 429 Bragg's Lane Property Address Doleres Mello Owner Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2 Commonwealth of Massachusetts IL W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 429 Bragg's Lane Property Address Doleres Mello Owner Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 429 Bragg's Lane Property Address Doleres Mello Owner Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 '/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � M 429 Bragg's Lane Property Address Doleres Mello Owner Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis, and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. ❑ ® 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 ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 429 Bra 's Lane M gg Property Address Doleres Mello - Owner Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 every page. City/Town 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? E ❑ Has the system received normal flows in the previous two week period? ❑ E 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? ® El information the facility owner(and occupants if different from owner) provided with . information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. •. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design)' 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 429 Bragg's Lane Property Address Doleres Mello Owner Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon septic tank,Distribution box and a 1000 gallon Leaching Pit. Number of current residents: 2 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 Seasonal use? ❑ Yes N No Water meter readings, if available last 2 ears usage 2008:41,000 9 ( �Y 9 (gpd)). 2008:41,000 Detail: 2007:162 gpd. 2008:112 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: 10/22/2008 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o^M 429 Bragg's Lane Property Address - Doleres Mello Owner Owner's Name' information is required for Barnstable Ma. 02630 10/22/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date i Other(describe below): General'Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No ` If yes, volume pumped: j gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution-box, soil absorption system i ❑ Single cesspool i i ❑ 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): • ,I j i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 429 Bragg's Lane Property.Address Doleres Mello Owner Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 'Depth below grade: 18"feet Material of construction: ❑ cast iron. ❑ 40 PVC lightweight pvc ❑ other,(explain): Distance from private water supply well or suction line 20'+: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic"Tank (locate on site plan): Depth below grade: 16"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 gallon 411 Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 429 Bragg's Lane Property Address Doleres Mello Owner Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" _ 1 Scum thickness 7" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet-and outlet tees are in place.No evidence of Ieakage.Tank appears to be 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 429 Bragg's Lane Property Address Doleres Mello Owner Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 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.): 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments �M 429 Bragg's Lane Property Address Doleres Mello Owner Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution io outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 429 Bragg's Lane Property Address Doleres Mello Owner Owner's Name information is Barnstable Ma. 02630 10/22/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. ® leaching pits number: 1 ❑ 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.): Sandy sry soil.No signs of'hydraulic failure.Leaching Pit water level was 3'to invert at time of inspection.Stain line observed 21" below invert. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 f Commonwealth of Massachusetts W Title 5 Official Inspection , Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 429 Bragg's Lane Property Address Doleres Mello Owner . Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Map Page 1 of 2 Town of Barnstable Geographic Information System Map Size Zoom Out Parcel Viewer Custom Map Abutters In a IC r L t 71 0 i. 1. •:. y' ..':lip ......,, ..,.. .. ..-.- , ... ..... a .. "• Set Scale 1" _ 20 I Aerial PhotosJW I MAP DISCLAIMER Coovriaht 2005-2008 Town of Barnstable.MA All rights reserved. http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=298028&ma... 10/22/2008 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 429 Bragg's Lane Property Address Doleres Mello Owner Owner's Name information is required for Barnstable Ma 02630 10/22/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 50' 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: USED:USGS Observation Well Data. USED:Technical Bulletin 92-000-01 Plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Forts Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 429 Bragg's Lane Property Address Doleres Mello Owner Owner's Name information is required for Barnstable Ma. 02630 10/22/2008 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in.separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 LOCATION SEWAGE PERMIT N.O. V It L A G E ASSESSORS MAP NO: 29 F3 PARCEL NO: C)9, INSTA LLER'S NAME i ADDRESS i $-O LU OR OWNER /J DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ds'_ 131 i i � sr w ---- Fnic 16................ THE COMMONWEALTH OF MASSACHUSETTS BOARDHEALTH..............._.OF...........- ...........................--.................................... Appliration -fur 43iiiVosal Works (fuuuitrurtiuu Vrrulit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at q- .. ............ L,oc�f --`Address or Lot No. /Y ------------•---------•-•------------------- --------------•--•---•-- � •�^,[/� pv Owner a -------------------------------------- ------------------------------------------------------ ------Address------•-•----_____-•---•- --•--•------•-•--•--••------•---•------ Installer Address Type of Building Size Lot_ Q!/__&_6@ e3------Sq. feet U Dwelling—No. of Bedrooms _______________________Expansion Attic 0) Garbage Grinder (A"8) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------- ---------------- 40 W Design Flow..........5� Mons per person per day. Total daily flow ................. ........gallons. �aw- g P P P Y Y g� WSeptic Tank iquid capacity-_.....____gallons Length---------------- Width................ Diameter.....---_------- Depth-----_---_--_. x Disposal Trench!No.�...___..._._•-__. Width____________________ 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 ( ) d- -91,1 44a — 4/— f1=7S— Percolation Test Results Performed bY.......................................................................... Date......... ...........------------------ ,� Test Pit No. 1----------------minutes per inch Depth of "lest Pit-------------------- Depth to ground water-.-___--___-_-___-_---. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-__-_____-_-e___-.--- �+ -------------------- ----- ---------------- ---- -- +..... -------------- ----- O Description of Soil---- --- ` � x U ----------••-- W ----------- ----------_----------------------------------------------------------------------------------------------------------------------....................................................... V Nature of Repairs or Alterations—Answer when applicable.-____________________________________________-------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has)&ytheebboard of h al . ned._ = .. �--------=-------- Date Application Approved BY-------- - 1- ��/ �.-'-_7_ Date Application Disapproved for the following reasons_________________________________________________________________________________________________________________ ..........................-........................................................................................................................... ......................................---......... c Date PermitNo......................................................... Issued........ . ✓.................................. Date �� J No.. --•----J�`�I Fly$.... .-....... THE COMMONWEALTH OF MASSACHUSETTS BOARD O/f 2 HEALTH _.....4. ... ... ........ ....OF............I-D............................................................ ... Applirtation -fear ]i.ipniittl Works Tomitrurtion Vaniit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: Loc tin Address or Lot No. �} Owner Address .................................................. .................................................................................................. Installer Address UType of Building Size Lot18/_. _ !-------Sq. feet Dwelling—No. of Bedrooms tt -----------------------Expansion Attic Garbage Grinder (96) aOther—Type of Building ............................ No. of persons..--____---_____________-._- Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ __ Design Flow__ _-___.__S®___ _____________________ Mons per person per day. Total daily flow_...._.__7�3.�__...._... W i -- g P P P Y. y gallons. WSeptic Tuck i Liquid capacity------------gallons Length---------------- Width........----.... Diameter--.-....-------- DeptlI--------------- x Disposal Trench—No.,___________________ Width--___-----_---_-__ Total Length_--.-_-__--__.--_--- Total leaching area--------------------sq. ft. Seepage Pit No..l.'.10 -_�P_. Diameter.................... Depth below inlet-------------------- Total leaching area------- ----------sq. ft. z Other Distribution box ( ) Dosing tank ( ) 04 Q<--�. - 1 /-. 4 -75— aPercolation Test Results Performed bY------------ -----•-----•------------------•-•-----------------------•---- Date----------------------------•----•----- ,� Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...-_-.---.---.--.--_-- fiq Test Pit No. 2.___--_--_•___-_minutes per inch Depth of Test Pit----------------•__- Depth to ground water----. ---_.-------_----. = ----- ------- ____ ______ J .. ............................... Descri ----------- Description of Soil---- ~ -� �71v�� -------.. ......(_pcZv_.s � � G p � �� 2 .� - - -------------- v --- ------------------------------------------------------------------------------------- - W x ------------------------ ----------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ V Nature of Repairs or Alterations—Answer when applicable-----------------------------__--.--_--_-----___--.-____--.--.--._-.------------_-..-----.-.---- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I 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,the board of health. gned... '�r� .jJ.l`� ...----•-•-•---••---•--.._- , .:,tZ .'. ... Jf� Date _ Application Approved BY-----------/ ��iL-1A...... -�-"f----kedA--------- -- ----------------- ----�----!"-� 1-`-7 Date -- Application Disapproved for the following reasons____________________________'____ ----------•--•-•-•-•-••-•-•-•--•-•------------------------- __------------ -----•-------------•--------•---•-------•.---------------------------__....-----------•---•------------- Date PermitNo......................................................... Issued...................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF �EALTH / ........OF................./.S/ILL� -Pad.......................... 01rrtifirate of mWOmphaurr THIS IS T0,fEPTIFY, That tJa�e Individual Sewage Disposal System constructed (><� or Repaired ( ) Y..............................r/ f / --- at..._._ /-- / ! G�l r/-+� 1� /LY!/3 Insta =lle ((J/jt-✓ / J� has been installed in accordZIZ with the provisions of Xrt ele XI of The State_Sanitary Code as,described in the application for Disposal Works Construction Permit N�r_-_a_ ____._____.. dated_____________l .y 7 -__.:.__.._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS '1 BOARD OF HEALTH ...................Jd2rn-a..... OF........ Gr?� _ . .- �..�- � ,................... N ........ FEE---�5.............. Permission is hereby granted........... ___....... to Construct ( ) or Repair ( ) an Individual Sewage'Disposal-System at No.--.----- 1- .................. ...� ..C" = `���- ............................ ..-- . S�/treet ^ as shown on the application for Disposal Works Construction fnit No _ ._.~....__ . Dated--------- f .7........ z/ : _�, ------------------------ 'ho _ ard oY Health DATE.......� I................................................. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS Y` J /VIF lv/GTo.v P, /'7425N�gLL. -rAlt r o z8 )',Q r R 2 EXisTiNG. 10 EvuNDA?foN' Q i / �8 86o sue..Fr ,c �g � / Q i SAGE / a 3a' DATE TAla-.2.Z 1977 Lo 7- . aw 1/C-'7-om/Mtn �4r/a 2ECG eDt"D /A/K(;i o� EDWARD . G� E. - I �-��y �r ter- Xrsr�tiG No 26100 ,*CAI PA77l o v -5 6 WA/ GA/ /S PG4-Al srE¢4,a� is LorAr.&a 0" 7f/E- G,eavva A3 .5A6wA.1 hD s V6 h/FPEo l q"P 771,97- /T Oavfa&AfS T 7W of 8gieivsTABGE ,Z.2 /977 2E(,'. lAivD.S[1/2VE,/b TOWN Or BARNSTABLE UALW�/ *#IF '! UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS- u - ASSESSORS MAP NO. 999 PARCEL N0. O ADDRESS; 7 I-A VILLAGE: A ?, /J i j CONTACT PERSON PHONE NUMBER Zo LOCATION OF TANKS;. .' CAPor .LY: ..TYPE- OF-FUEL. AGE: TYPE: LEAK OR CHEMICAL: DETECTION cl-- A�D2 A- No TNT or HouSE r DATE OF PURCHASE OF EACH: 1. 2. 3. 4. 5. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS Aw PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. k �✓ Nal m�,,� zi TOWN OF BAR.NSTABLE Permit No. 19348 O t � Building Iuspector Cash one. N/A OCCUPANCY PERMIT Bond "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." =. T • Issued to Robert R. Mello . Address , 429 Braggs Lane Barnstable wiring Inspector Inspection date Plumbing Inspec U ction date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. 19 uilding Insp et