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Home My WebLink About0039 HIGHLAND AVENUE - Health 39 Highland Avenue �_ ^ A= 020=047 -- — Cotuit a i i I I II 1 ENVIROTECHLABORATORIES,INC. MA CERT. NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sand►vich,MA 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name: Desmond Well Drilling Location Address: PO Box 2783 39 Highland Ave Orleans, MA Cotuit,MA 02653 Lab Number: DW-210402 Collected By: Desmond Well Drilling Date Received: 02/03/21 Sample Type: Well Specs: Irrigation 55/37 3 Locn/ton Source Dale Collected Time Collected Comments Y A 02/0{2121 14 - � 93 Analysis Requested Units Recommended Limits AnalysisResuftl Method jDateAnalyzedl Analyzed By Total Coliform CFU/100mL 0 0 SM9222B 02/03/2021 KF @ 17:00 pH pH units 6.5-8.5 6.18 SM 4500-H-B 02/03/2021 SD Specific Conductancer, umhos/cm 500 76 EPA 120.1 02/03/2021 SD Nitrite-N mg/L 1.00 <0.006 EPA 300.0 02/04/2021 SD Nitrate-N mg/L 10.0 1.50 EPA 300.0 02/04/2021 SD Sodium mg/L 20.0 13 EPA 200.7 02/05/2021 KB Total Iron mg/L 0.3 0.03 EPA 200.7 02/05/2021 KB Manganese mg/L 0.05 0.007 EPA 200.7 02/05/2021. ..... KB.. Comments: pH is below recommended limit and may have corrosive characteristics. All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. Water meets EPA standards and is suitable for drinking for parameters tested. Date 2/5/2021 Ronald J.Saari Laboratory Director BRL=Beloiv Reportable Limits *See Attached Page 1 of 1 oCertifrcation is not available for this analyle for potable water samples.. Massachusetts Department of Environmental Protection Bureau of Resource Protection Well Completion Reports Well Driller Please specify work performed: Address at well location: f' New Well Street Number: Street Name: t 39 HIGHLAND AVE Please specify well type: Building Lot#: Assessor's Map#: it gation 020 Assessor's Lot#: ZIP Code: Number Of Wells: 047 02635 City/Town: Well Location BARNSTABLE In public right-of-way: GPS G Yes C,No , North: West: —I 41.61862 70.01407 S ubd ivision/Property/Descri ption: Mailing Address: click here if same as well location addres Property Owner: Street Number: Street Name: CURTIS NEWCOMER 39 HIGHLAND AVE City/Town: State: Engineering Finn: BARNSTABLE MASSACHUSETTS ZIP Code: 02635 Board of health permit obtained: (-Yes ( ,Not Required Permit Number: Date Issued: W202039 11/03/2020 Massachusetts Department of Environmental Protection Bureau of Resource Protection-Well Driller Program '. .y^ Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock uger Choose Bedrock- WELL LOG OVERBURDEN LITHOLOGY From(ft) TOM Code Color Comment Drop in drill Extra fast or slow Loss or addition stem drill rate of fluid 0 F20---7 I Fine To Coarse S„ Brown YE7N00 Loss Addition 20 40 Medium Sand Brown 7 - - -� Fast: Slow f NO � Loss Addition 40 50 Medium Sand Ei� Brown r' (7. (((i f_� FastFast('Slow t YES NO Loss Addition .....:. 50 55 Fine To Coarse S ) Brown f r Fast C"Slow --- YES NO = Loss Addition WELL LOG BEDROCK LITHOLOGY --_................................ .-................................................---...-.-...._._.......-.......................- ------........._..........................._........................................_................._.__........_..........................._.................._.................................-- ..._..........................................................----............... ......_............_.......... Drop In Extra fast or Loss or Visible Rust Extra From(ft) To(ft) Code Comment drill stem slow drill rate addition of Staining Large fluid Chips :` ..........I...................................-.......... .............. ............. Choose Code C', r� r� Yes Yes ............................................... YES NO Fast Slow Loss Addition .................................................... ...........................I.."... .....-.....- .... ...................................................................................... ADDITIONAL WELL INFORMATION Developed I t Yes (7 No Disinfected C Yes f�No Total Well Depth 55 Depth to Bedrock Surface Seal Type None racture Enhancement f'`Yes No CASING r Is Casing above ground? From To Type Thickness Diameter Driveshoe 52 Polyvinyl Chloride _JI Schedule 40 I+ I� Yesl SCREEN r No Screen From To Type Slot Size Diameter 97771 55 Stainless Steel Well Point ,, 0.012 4 WATER-BEARING ZONES LEE] WELL From To Yield(gpm) 37 55....................... 12 PERMANENT PUMP(IF AVAILABLE) Pump Description Wire Constant Speed Horsepower Submersible I 3/ L71Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) ,Pump Intake Depth(ft) 51 Nominal Pump Capacity(gpm) 15 ANNULAR SEAL/FILTER PACK From To Material 1 Weight Material 2 Weight Water Batches Method Of (gal) (count) Placement t__ C� Choose Material + �� Choose Material . WELL TEST DATA Date Method Yleld(gpm) Time Pumped Pumping Level(ft Time To Recover Recovery(ft (HH:MM) BGS) (HH:MM) BGS) 02/02/2021 Constant Rate Pump 12 01:30 41 00:01 37 WATER LEVEL Date Static Depth BGS(ft) Flowing Rate(gpm) Measured 02/02/2021 37 12 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. WILLIAM Supervising Driller DESMOND, DrillerUROUHART Registration# 877 Monitoring[M]Signature PATRICK, DESMOND WELL Firm DRILLING INC. Rig Permit# 0551 Date Job Complete 03/16/2021 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. I U No. Fee . BOARD OF HEALTH TOWN OF BARNSTABLE 01ppricatiou Jf or Yell Cou5tructiou Permit Application is hereby made for a permit to Construct( Alter( ), or Repair( ) an individual well at: Location-Address Assessors Map and Parcel Owner Address Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well Capacity Purpose of Well 1 Y Y(0. Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificat of Compl' nce has been issued he Board of Health. Signed n Date Application Approved B(::jz Date Application Disapproved for the following reasons: / Date Permit No. Issued Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed"'�, Altered( ), or Repaired( ) Installer at � �-r1 f� �G�i'1G� U j7Wt t has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Wel Projection Regulation as described in the application for Well Construction Permit Nok -c>3n Dated 11 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector ilaw No. IV „ ''� 3 Fee } � - , BOARD OF HEALTH TOWN OF BARNSTABLE —- t� µ ZIppYication for Veff Con5tructiori Permit Al licatiori is hereb made for.a ermit to` Construct +: pp y: p (,� Alter( ), or Repair O an individual well at Location-Address Assessors Map and Pazcel Owner v Address 1 .e5"-NmA U xiVt'0Ytllthr% . 60-c Or �vunS Nth'" o2(n5 Installer-Driller Address Type of Building` Dwelling Type of Well , Y t'1 A 1Ne.4 Capacity .,r Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the r 'Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed _ . A. AA_ii l - � Date_ PP PP C Application Approved B Date Application Disapproved for the following reasons: ' Date v - Date' BOARD OF HEALTH TOWN OF . BAR. NSTABLE Certificate of Compliance THIS IS TO CERTIFY;that the individual well" Constructed , Altered( ), or Repaired( ) .;z , Installer � at � has been installed in accordance-with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.tr -c'.;5-1 Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Yell Cou5tructiou Permit No. Fee Permission is hereby granted to �0 Sm o Y'l,Ct Ux-K D l I�l 1'l A Jn C< Installer to Construct( Alter( ), or Repair( an individual well at: . vt Street / $ as shown on the application for a Well Construction Permit No. 1n - Qj- Dated / 1'. C Date t 1 Approved By,,, �,e . COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 39 Highland Avenue Cotuit, MA 02635 s l- 3 Owner's Name: Abigail Burlingame Owner's Address: : _C Date of Inspection: July 10, 2005 `r L Name of Inspector: (Please Print) James M. Ford *` Company Name: James M. Ford l Mailing Address: P.O.Box 49 Z l ' Osterville.MA 02655-0049 Telephone Number: (508) 862-9400 ou C3'e CERTIFICATION STATEMENT rn 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 CAM 15.000). The system: ✓ Passes Condiho lly Passes Needs F her Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: July 18, 2005 The system inspector shall sub 't copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completi this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments - ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 ' Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Highland Avenue Cotuit, MA Owner: Abigail Burlingame Date of Inspection: July 10, 2005. Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Highland Avenue Cotuit, MA Owner: Abigail Burlingame Date of Inspection: July 10, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Highland Avenue Cotuit, MA Owner: Abigail Burlingame Date of Inspection: July 10, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. barge System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 39 HiQhland Avenue Cotuit, MA Owner: Abigail Burlingame Date of Inspection: July 10, 2005 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 39 Hifzhland Avenue Cotuit. AM Owner: Abigail Burlingame Date of Inspection: July 10, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Current.1y occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of infonnation: Pumped in 2003-per owner . Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool. Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 12115195-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Highland Avenue Cotuit, MA Owner: Abigail Burlingame Date of Inspection: July 10, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 6" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of.outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not annear to be any signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Highland Avenue Cotuit, MA Owner: Abigail Burlingame Date of Inspection: July 10, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was clean. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Highland Avenue Cotuit, MA Owner: Abigail Burlingame Date of Inspection: July 10, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 5-Cultec 330s w/1.5'stone(per as built card) leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The chambers were dry. There did not appear to be any signs of failure. The bottom to grade was 3'. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Highland Avenue Cotuit,MA Owner: Abigail Burlingame Date of Inspection: July 10, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. a 6 . y a 3� ys 3 yy sa y yq 5� 10 Page 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 39 Highland Avenue Cotuit, MA Owner: Abijzail Burlingame Date of Inspection: July 10, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours neaps, the maps were showing approximately 20'+1-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection andlor this report. 11 O OF BARNSTABL,E H'39 i SEWAGE # �?y 'VILLAGE C UTU,I ASSESSOR'S MAP & LOT NO- Oy INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S'Q 0 LEACHING FACU,=: (type) S' CUI hL 3 3 0 S (size) NO.OF BEDROOMS WELDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility) J Feet Furnished by 4:0 i a 6 3 �► 38 y a 3� ys 3 yy sa y y9 �� TOWN OF BARNSTABLE _ 1,0C';':"lON SEWAGE# ASSESSOR'S M 020'D � jAP&LOT INSTALLER'S NAME&PHONE NO. �'+� �, I 3�r` (. — '4 SEPTIC TANK CAPACITY _ % 3 c, LEACHING FACILITY: (type) C / ,lJ (size) NO.OF BEDROOMS BUILDER OR OWNER J��j w,/-4/is 41 j.4wi C PERMTTDATE: A/O✓•�;,X 1 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by s Aae MCC No. /CHUSETTs FeeTHE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MA 01pplication for �Dizpooal *raem Com5truction Permit Application is hereby made for a Permit to Construct( )or Repair(1-<an On-site Sewage Disposal System at: Locations (Address or Lot No. Owner's Name,Address and Tel.No. 3q NiGtl,RtvrAvY— CO�zIT 1'itOi�Ail vt2�(i�s4mC - 9a8-s303 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. C� L,�.�� - tiaa�s6�o Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of�e✓or Alterations(Answer when applicable) Fi�c 0 Sva/(*m f /n,i la// /s-O .o6,o %A,J c�/iu.j -go X— S C 3 -Cv17-e30 iPeCA�r2 /' ''W /� 5Am e a✓l barh J)b - 3/r5�r S7'atc a: ,P_ 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 Certifi- cate of Compliance has been isss ed by this Board of It. Signed Date Vow l q/Cs- Application Approved by Application Disapproved for the following reasons Permit No. `L Date Issued A, No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MA VSCHUSETTS, 2pplication for Mi2;po.5a1 *p5tem Con!5truction Vermit Application is hereby made for a Permit to Construct or Repair(k-jan On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. �V-e- Co Vi a,8-:53 03 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Gort'DOA__Bvtv\ Us H _8 Type of Building: 3 .Dwelling No.of Bedrooms - Garbage Grinder Other Type of Building No. of Persons Showers Cafeteria( Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan-Date Number of sheets Revision Date Title Description of Soil Nature of epairs or Alterations(Answer when applicable) :X osy rm: Mu7q 1,5-006417441 c 330 &rAAjeW Zh;�W /Y ST&1 e, 710 a Y- S204 e a bdri/,f ;),-j - -31,3 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 Certifi- cate of Compliance has been is d by this Board of e th. Signed_46� 11 Date A/,P(/.dot, 199s" Application Approved by Application Disapproved for the following reasons Permit No. L Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificated Compliance THIS IS TO CUTIFY,that the On-site Sewage Disposal System installed or repaired/replaced on 42 f-4/,-9rby 1" 4`'C4 for as IAo 14 h A C4.P has been constructed in accordance V3 V dated/ with the provisions of Title 5 and the for Disposal System Construction Pen-nit No. 9-15,1, /-7 z-iw.� Use of this system is conditioned on compliance with the provisions set forth below: No. L4 Fee I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSAC HUSETTS Mi5poe;al *p5tem Con!6trurtion Permit -by eC2& Permission is hereby to to construct repkr O an On-site Sewage System located t a;F 5VL_j X VC t"t,G� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: /Z- Approved by LI) CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, coe-DON'UMouS , hereby certify that the application for disposal works construction permit signed by me dated A16&,.Ou %9FS- , concerning the property located at 39 meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED A DATE: LICENSE SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. I . --� 30�02 olo2C } Ir aa O p�✓/Clod C o l N I I I 1 �I r a r _ _ __ _ _ 1 - �' - - -- -��i - - -I i ii i _ li i __ _ _ � __ i� _ _ u _ - __ _ _ �i - _ _ �- TTW ALI 040 Pd CQ PLAN BOM 91 PACE 7 0 �iw PW N 449.96' CB to road sideline S 86'56'07" E 449.93' Ce to CB 463' f edge pond (GIS) to road sideline .. �jt9ila ZONE LINE a _. LLI 15-FOOT OFFSET 04 0.87 ACRES !UST �.� 0 0 _.. 2- w Ead - - 3 6" W Zo .O ¢�® N pMATE ROP °' rn I h n .� o P ERTY_ 00 01 `JNE Cv \' ZONE ONE I 34.2' z � � o ' tS-FOOT OFFSET " � ®mom S 87'50'49" W 88.76 N 84'29'45 `4 p N W. 14 8-82' -----oo_ _____ ______ _ e � � 148.59' CB to ®AM FWD 0proad sideline to CB ill. � °fPISY�i ... 237.09' �. m®0000 � � - ' ni' 8 -21'29" W 236..85 CB of "CB PROPERTY I ear WELD LOT BOLWDAM3 AS SK43M AT 1 in .ei o �} L e� eat+ �- � .. !n c - eti`L lS ql(-L4�a j ® o 6 EtAVeL ®.n1Y[91ay j o Aga 020 Pd Oro U) LrARI --L ET UX I j Itt r3 t5—PAGE 67 , INCUSE me. 25 as 0 I i i m , 39 HIGHLAND AW'EIVIlE � 01 G®tuit, Massachiusetts, 02635 I ' co j AM 020 Pd 071 c cj NjT ROBERT H. McWURRAY, ET UX P'REPAR® FOR j Z ' LOT 7 ® PLAN BOOK�26 PAGE 79 Nj1= REBECCA S. PATTERSON � r,.! ® R. Duke Rates, Jr. j NOMINEE TRUST � o I } o tn ; ( i ° N I nT1P PROPOSED SITE PLAN 1 7 j o N I ----------------------- .� BAXTER NYE ENGINEERING & SURVEYING