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Home My WebLink About0050 JACKSON DRIVE - Health ,.50 JACKSON DRIVE, COTUIT A- 01 mot'.- �I P: C I I I I f. 7 1 D a Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments 50 Jackson Drive Property Address J. R.Macon Owner Owner's Name information is required for every Cotuit MA 02635 12/11/13 page. Cityrrown State Zip Code Date.of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form.. Important:When A. General Information. ` filling out forms 4 on the computer, use only the tab 1. Inspector: j 1�7 _. key to move your cursor-do not Kevin Cochran 33 use the return Name of Inspector y Co key. Aardvark Environmental Inspections' Company NameVQ PO Box 896 Company Address . East Dennis MA 0 641 Cityrrown State ' Code =,2 c i 508-385-7608 S113356 00 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 E Fails, F] Needs Further Evaluation by the Local Approving Authority , • 12/12/13 k Insp c ignature Date r The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner. and copies sent to the buyer,if applicable,and,the approving authority. ****This report only describes"conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in'the_ future under the same or different conditions of use. t5ins•11/1p 4 - Tide 5 Offcial Inspection I bsur ace Sewage Disposal.System•Page 1 of W , 4 • t. Commonwealth of Massachusetts ° Title 5 Official Inspection Form 141 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Jackson Drive Property Address J. R.Macon Owner Owner's Name information is required for every Cotuit MA 02635 12/11/13 ' page. Cityrrown State Zip Code Date of Inspection B. Certification (cant.) 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. 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"orthe septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration ortank 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•.11/10 - Tfile 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form-Notfor'Voluntary Assessments 50 Jackson Drive Property Address J. R.Macon Owner Owner's Name information is required for every Cotuit MA 02635 12/11/13 ' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) , B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or breakout 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).- ' * `y C) Further Evaluation is Required by the Board of,Heatth: ❑ 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 mannerwhich 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 i5irs•15i i u F Tire 5 Gilival Inspector,Fomnu $ubsufiace Sewage Usposai Sy�.Lem e?age 3 of 17 , r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 50 Jackson Drive Property Address J. R.Macon Owner Owner's Name information is required for every Cotuit MA 02635 12/11/13 page. City/Town state Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ' ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ .The system has a septic tank and SAS and the SAS is less than.100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. z r 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 El ® 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 ' El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5ins•11/10 Tine 5Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . = Subsurface Sewage Disposal.System Form-.Not for Voluntary Assessments 50 Jackson Drive Property Address J. R.Macon " Owner Owner's Name s . information is ' required for every Cotuit MA 02635 .12/11/13 page. Citylrown ;State Zip Code Date of Inspection- B. Certification (cost.) r Yes No , ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0` Any portion of the SAS,cesspool or privy is below high groundwater elevation. El ®' i Any portion of cesspool or privy is within 100 feet of a surface Water supply or tributary to a surface water supply.' ❑ 0 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. ❑ z 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 searing 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 s ❑. ❑ the system.is within 400 feet of a surface drinking water supply ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered `fifes"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•11/10 - '-Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official InspectionForm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Jackson Drive Property Address J. R.Macon Owner Owner's Name ` information is required for every Cotuit MA 02635 12/11/13 page. Citylrown State Zip Code ;Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: . Yes No ; ® ❑ Pumping information was(provided by the owner, occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or.as part of this inspection? ® El 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'corriponents,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 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 atissue . approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Numberof bedrooms(design): y 2 Number of bedrooms(actual): 2 226 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f ' Commonwealth of Massachusetts ' Title 5 Official Inspection Fora _ s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Jackson Drive Property Address J. R.Macon Owner Owner's Name information is required for every Cotuit I\M 02635 12/11/13 page. City/town state Zip Code Date of Inspection D. System Information ' _ Description: ` Number of current residents: '0 Does residence have a garbage grinder? ❑ -Yes ® .No Is laundry on a separate sewage system?[if yes separate inspection required]' , ❑ 'Yes ® No Laundry system inspected? ❑ Yes ®• No Seasonaluse? • ® Yes ❑ No Water meter readings,if available (last 2 years usage(gpd)): Detail: 'Sump pump?. . ❑ Yes ® No Last date of occupancy: 09/13 Date CommercialMdustrial 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.): _ a Grease trap present? ❑ Yes ElNo Industrial waste holding tank present? ❑ _Yes.❑ No ; Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑. No Water meter readings, if available: t5ins•11/10 Title 5.Official Inspection Form:Subsurface Sewage Disposal System'•Page 7 of 17 , f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Jackson Drive Property Address J. R.Macon Owner Owner's Name information is required for every Cotuit MA 02635 12/11/13 ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): ' General Information Pumping Records: . Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons _ How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑. Single cesspool, ❑ Overflow cesspool o ❑ Privy ❑ Shared system (yes or no) (f yes,attach previous inspection records; if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and M +maintenance contract(to be obtained from system owner)and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval _❑ Other(describe): t5ins•11/10 - Title 5Official Inspection Form:Subsurface Sewage Disposal System a Page 8 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Jackson Drive = Property Address ` J. R.Macon Owner Owner's Name information is required for every Cotuit MA 02635 12/11/13 " - 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: 08/08/83 per BOH ' Were sewage odors detected when arriving at the site? ❑ Yes E No Building Sewer(locate on site plan): Depth below grade: 4.4 • feet • " Material of construction: t ; cast iron ®40 PVC` ❑ other(explain): j Distance from private water supply well or suction line: feet. t Comments(on condition of joints,venting,evidence of leakage,etc.): ' Septic Tank(locate on site plan): Depth below grade: 3.8 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: 1,000 gal ' Sludge depth: • t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 50 Jackson Drive Property Address J. R.Macon Owner Owner's Name information is required for every Cotuit MA 02635 12/11/13 - page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt,) ' - 28„ Distance from top of sludge to bottom of outlet tee or baffle . 3" Scum thickness 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 16" How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structu el integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. 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•11/10 - . -• .., .t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t I - , f Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Jackson Drive 4 Property Address J. R.Macon Owner Owner's Name e information is required for every Cotuit -MA 02635 12/11/13 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): i . Depth below grade: Material of construction: ❑ concrete - ❑ metal 0-fiberglass ❑ polyethylene' ❑ other(explain): Dimensions: - Capacity: gallons Design Flow: gallons per day Alarm present: ❑ YesM ❑ No` Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): b v Attach copy of current pumping contract(required). Is copy attached? ❑.Yes ❑ No , t5ins•11/10 Title 5 Official Inspection Foan.Subsurface Sewage Disposal System•Page 11 of 17 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,- ^M 50 Jackson Drive Property Address ` J. R.Macon Owner Owner's Name , information is required for every Cotuit MA 02635 12/11/13 page. Cityrrown State Zip Code - Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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 box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): , Pumps in working order: a El Yes ❑ No Alarms in working order: El 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•11/11 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 50 Jackson Drive Property Address J. R.Macon Owner Owner's Name information is required for every Cotuit MA 02635 12/11/13 ,. page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type. .. .' . . ® leaching pits r. number: 1 ❑ leaching chambers _ number: W: ❑ leaching galleries number: 1 ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system ' Type/name of technology: Comments(note condition of soil,signs_ of hydraulic failure,level of ponding,damp soil, condition of vegetation,etc.): This system has a 6'W precast pit surrounded t y two feet of stone.There was no liquid in the pit and a stainline halfway up the pit.° 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts ' P. Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments, 50 Jackson Drive Property Address J. R.Macon k Owner Owner's Name information is required for every Cotuit MA 02635 12/11/13 page. Citylrown 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•11/10 Title 5 Offkial Inspection Form:Subsurface Sewage Disposal System-'Page 14 of 17 ' r Commonwealth of Massachusetts Title 5 Official Inspection Form w s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'a , 50 Jackson Drive Property Address J. R.Macon Owner Owner's Name information is required for every Cotuit MA 02635 12/11/13 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a.view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t _ 42 25 14. , 15 22 r 54 t5ins-11/10 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Jackson Drive Property Address J. R.Macon Owner Owner's Name , information is required for every Cotuit MA 02635 12/11/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar " a ❑ Shallow wells Estimated depth to high ground water: 20.0. + fleet 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: USGS maps show an elevation of over 20.0 feet: 3 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 - , - TRfe 5 Official Inspection Form:Subsurface Sewage Disposal System•Rage.16 of 17 - f - Commonwealth of Massachusetts. ' Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form-Not forVoluntary Assessments. 50 Jackson Drive Property Address J. R.Macon Owner Owner's Name information is required for every Cotuit MA 02635 12/11/13 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist' ® Inspection Summary:A, B, C,D, or E checked ,` y ® 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 A y • t5ins-11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION S �rLdd* SEWAGE # 96—l7I VILLAGE ASSESSOR'S MAP & LOT® C5d INSTALLERS' NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITYAtype) ,4 (size) Z999.12�. NO. OF BEDROOMS RIVATE WELL, R PUBLIC WATER BUILDER OR OWNER r� fQS DATE PERMIT ISSUED: � �96 DATE COZIPLIANCE ISSUED: VARIANCE GRANTED Yes -No ��zv�ni�� a� �-f-v-c-tS�.; \_ � � � .,a i� ,,. I _ } No... ( .-=� --- Fps.. . ....... . THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ow"......................................OF........... rhfT�..O. ... Appliration for B44paii al Workii Tnntrnrthin ramit Application is hereby made for a Permit to Construct (>C) or Repair ( ) an Individual Sewage Disposal System at: ................................................+ I' .........................• ................................................... ... , . L. // Location-Address SX or Lot No. / ................ +f�er �v��C.r;�l..!19^K-..._... .Z a Z 6 G .. Owner Address �..............��.._ ......!�. �.. ......... Installer Address ? U Type of Buildifig Size Lot__2S--- 2 0.....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ----------- No. of persons............................ Showers — a g ---------•------- P (----)-------Cafeteria ( ) dOther fixtures ------------------------------------------------------------------ W Design Flow......................-�5............gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity!2000._gallons Length_!�_'G".. Width4''/q_" Diameter________________ Depth_s'7g. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......L----------- Diameter. Z Depth below inlet... Total leaching area...z:!K�..sq. ft. Z Other Distribution box (x) Dosin tank ) p- -s92�3 '-' Percolation Test. Results Performed b _�-ls� *-,1.... .............. Date.!! _ Test Pit No. 1------zZ__---minutes per inch Depth of Test Pit---!i X"... Depth to ground water...r-✓____.--__-_. �, 44 Test Pit No. 2--------- per inch Depth of Test Pit....ZyK...... Depth to ground water... -.-_-. -- -------------- -••-•---------------•------.-----.-........ O Description of Soil------'-�-�)e• yK l s"6so��. V -- -....PVSe .. W ----•------------•---•-•------...•-------------•--••----------•----•-.......................4-"....... rJP v k. t!!..�.......... U 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 I IIU,, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee s ed by t board of health. Signed., ...... g Application Approved BY Date -•--- -------------------------•------• ......G�' ! �f.e----- Date Application Disapproved for the following reasons-----------------------------•-----------------------------------------------------......._..................... ...--------•-••-------------------------------•----------------•--••--------••-------------------•-----•----•--•-•--------•---•----------- c� Date Permit No.._._1.��..-.�__ --...................... Issued............................................ ate....... Date No...7 _ -. FEB.... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Disposal Works Tontrnrtion frrmit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal t System at• / Location-Address �, or Lot No. / ......................_.._..::P.:......... ......._..._..._.............._._.._......_..._ ......................................... Owners•-„ _ _ Address_ /J a / /i✓ Q .........0 � _.._ _........._ . [ `/�`�...... ........ Installer Address PQ d Type of Building Size Lot__ 5.___!_ _o_._._Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—TYP e of Building ............................ No. of Persons____________________________ Showers Cafeteria a ( ) — ( ) QOther fixtures -----------------------•------------------•--------•---•--••-••••--•---•---------•----- ............................................................. Design Flow.................... _...`._._______...._gallons per person per day. Total daily flow...._.._____.____....__'_Q_._____._.___gallons. WSeptic Tank—Liquid capacityl.c'.°O__gallons Length_P__�.L Widthy_'��e`: Diameter________________ Depths_'7_"' x Disposal Trench—No_ ____________________ Width.................... Total Length............._...... Total leaching area--------------------sq. ft. Seepage Pit No......./........... Diameter__�_..__ .._.. Depth below inlet__. Total leaching area...:L'�4_.sq. ft. z Other Distribution box (x ) Dosing tank `-' Percolation Test Results Performed by.c _____________ Date___�'!� Test Pit No. I...... ......minutes per inch Depth of Test Pit... Z%''___ Depth to ground water____ fLq Test Pit No. 2........Z`-_____minutes per inch Depth of.Test Pit---- ...... Depth to ground water____: ------ - ------------------- •......... ......_.. --•---•----•--•--•----------_____________-�------------------------- •--------------• --•--- D Description of Sol l•--� .... �.` _...... �s a `�'�s a / W ----•--------------------------------....................................................... F --••- �---------- U 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'ssled by the board of health. Signed__f� � °_P �!_.._:r _:l!!_f, �, ?�� =G r/ - Date Application Approved BY -,.�,.�,�;= ----•••-� 1 . = y 4/ •-•--•-•-•-----•--••••--•------•••-•-••-•............................. Date---....._..... Application Disapproved for the following reasons____________________ -------------------------------------•----------•--•--------•------•------....--------•---•-•--------•-•---•--•-•-•--•----•••••-•--•----•---------•--------••--••-••------------•-••-••-----•-•---••---- Date PermitNo...... :j-.7.. ---------------------- Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS _/ BOARD OF HEALTH ... /.. (.:rr?� ;. ......OF.., .... ?. e?�'�� !��..................................... I. Tertifiratr of Tontplittnrr THIS IS TO CERTIFY, That•the Individual Sewage Disposal System constructed (1>11) or Repaired ( ) by �•-� Installer has been installed in-a ordance with the provisions of 1',-1 mIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._•.�V__=__yl__7_,�,,........ dated_..........._................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................................•-•--•----------•--•-•-----••----.....,.. Inspector.......................................... .......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j 7 ........ LI-4!q,...............OF....._.....fL�� 7<r..�]M.04 ......_.._...._.... F F CC t J 1... ........... FEE/0- Disposal arks Sono r ion r-ermit Permission is hereby granted.............x .�to Construct ( ) or2epa ) n Individual Sewage Disposal Syst at No....... �•--•l__....._. et'h.:� r1� j Street �� as shown on the application for Disposal Works Construction Permit o. . _:___.. ._ Dated.......................................... --------------------•-•••. . •-a ............................................................ DATE.................. .................................... Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - i !ij '� TOWN OF BARNSTABLE �Di 7H E T0� i6�P w ` ♦o, OFFICE OF i DABDITDBL i BOARD OF HEALTH y ■yea A t639' `em 367 MAIN STREET RFD MAY A. HYANNIS, MASS.02601 March 16, 1990 Jamie Regan 27 Cape Drive , Mashpee, MA 02649 RE: Variance Requests/Lot 1 off Jackson Drive, Cotuit Dear Ms. Regan: You are granted variances to install a well 100 feet from the proposed onsite leaching pit and 120 feet from an abuttor's leaching pit, in lieu of the required 150 feet, on your property located off Jackson Drive, Cotuit, listed as parcel 150 on Assessor's Map 19, with the following conditions: (1) A Massachusetts licensed well driller shall complete and submit an application for a Well Construction Permit (attached). (2) The well must be installed and the water tested bacteriologically, chemically, and for volatile organic compounds as required by the Board of Health Private Well Regulation, effective June 1, 1989. (copy enclosed). (3) The water must meet all the standards established by the Safe Drinking Act of 1974, amended 1986. (4) The applicant shall submit a written letter to the Board which states the Town will not be held responsible when or if the well water does not meet all the standards established by the Safe Drinking Act of 1974, amended 1986. The letter shall further state if or when the well water fails to meet the established standards of the amended Safe Drinking Act, the owner shall connect the dwelling to Town water. (5) The well water shall be tested at least once every two (2) years for the following parameters: total coliform, pH, conductivity, sodium, copper, and iron. (6) The well water shall be tested at least once every five (5) years for EPA methods 502.1/503 or 502.2 or 524.1, or 524.2. The variances are granted because the designing engineer, David Sanicki, stated the groundwater flow direction is such that sewage effluent would not flow toward the well. Very truly yours, � I . U� G� Ann Jane Eshbaugh Acting Chairperson Board of Health Town of Barnstable AJE/bs Enclosures i i 1 i Bob Powers Staples Road Cumberland, RI 02864 Town of Barnstable Board of Health 367 Main Street Hyannis, Mass 02801 March 23, 1990 RE: Variance Requests/Lot 1 off Jackson Drive, Cotuit Dear Chairperson: As an applicant for a well to be located off Jackson Drive, Cotuit listed as parcel 150 on Assessor's Map 19. I understand that the Town of Barnstable will not be held responsible when or if the well water does not meet all the standards established by the Safe Drinking Act of 1974, amended 1986. I also understand that if or when the 'well water fails to meet the established standards of the amended Safe Dr' t, the owner shall connect the dwelling to Town water. Si er 1 rt Powers '.� Itilltiitiiittiiti11t1ititiiiiSiitttittltiitiiiltitt1111tiiti111t tttttt"tiltitltitilti"tttittiittitSiiiti11t1ii11iitiit tt1111titi11tt1iiiiiittiiilttiltitit(Stflttititttiiitiitititt11tt1ititttSittitititiiitiiltiitliiliitittiiitititiitl�iJ ENVIROTECH LABORATORIES 449 Route.130 Sandwich, MA 02563 • (508) 888-6460 = CLIENT: Robert Powers LOCATION: Lot 6A Off Jackson Dr. ADDRESS: Pole 46 Staples Rd. Cotuit, I+1A Cumherlsnd,RT _ COLLECTED BY: Quality wells SAMPLE DATE: 4/3/90 TIME: DATE RECEIVED: 4/3/90 SAMPLE ID:ET494 JOB : WELL DEPTH: 331 RESULTS OF ANALYSIS: - Parameter Units Recommended limit Result - Coliform bacteria/100 ml (MF Method) 0 0 PH pH units 6.0-8.5 5.23 - Conductance umhos/cm 500 - 301 Sodium mg/L 20.0 57.5 Nitrate-N mg/L 10.0 0.70 - Iron mg/L 0.3 _ _- <0.05 - �= Manganese mg/L 0.05 = == Hardness mg/L as CaCO 3 500 - B Sulfate mg/L 250 Potassium mg/L 20.0 = Alkalinity mg/L 200 - Chloride mg/L 250 Turbidity NTU 5.0 — -�= Color APC units 15.0 - ;r Background bacteria COMMENT: Results indicate high corrosive characteristics. If on low sodium diet consult a physician before drinking. Consult local Board of Health - regulations concerning the sodium level. YES No WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. XOX DATE /tllli!!!l i11111t11!!lilui!lllilll!!!!lull!l11tillilll!l1i11lualulliulll!llillll11111i11litlli!l111t11111llillilllll111lfill!!llltiili;il!!11!l111111illiiul`1111llUlill11U111f11U111!llilillll1111111111111111111111lllUlilllili�� i d-P V Z06- _ ).. r'fb. 1 �^ � ;2i�i. f 1�:k :.� �rY,'..;w y •,l }3 R t17cf�R • .. � �. ,011�N 0 BORTOLOTTI CONSTRUCTION*,. INC: 0 45 INDUSTRY ROAD, MARSTONS MILLS, MA 02648 508-771-9399 508-428-8926 'FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION j Property Address: Date Of Inspection ` $ J00 Inspector's Name: ner's Name and Address: CERTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewage Disposal System at this.address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of.On-Site Sewage Dis- posal Systems.Tbof systems i} [ i/ Passest r {• ,+_ _ , . ` Conditiona sses F Needs F th Ev ti By the Local Approving Authority'' Fail e _.. Inspector's Signature Date: The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty , (30)Days,.of completing this Inspection. If the System is a Shared System or has.a Design Flow of 10,000 gpd or greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Office of the Department of Environmental Protection. The Original should be sent to theSystem Owner and copies sent to,the Buyer,if applicable and the Approving Authority. INSPECTION SUMMARY: „ A) SYST�k PASSES - , I have not.found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure.Criteria not evaluated are indi- cated below. } B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. . Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The Septic Tank is Metal Cracked,Stru Y ctural) Unsound,shows,Substantial Infiltration or exfil- , ' tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic;yank as Approved by the.Board Of Health. Sewage Backup or Breakout or High Stec Water Level observed in the Distribution Box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health):. . -1 - c .. SUBSURFACE''SEWAGE =DISPOSAL SYSTEM`INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). „ The System will pass inspection if(with approval of The Board Of Health): __.Broken pipe(s)_are.replaced Obstruction is removed. 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 the Public Health,Safety and the Environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE- a SYSTEM IS NOT FUNCTIONING IN A MANNER.WHICH WILL PROTECT THE PUBLIC,HEALTH,AND SAFETY AND THE ENVIRONMENT: Cesspool.or Privy is;within 50 Feet of a Surface Water. Cesspool or Privy is within 50 Feet of a bordering Vegetated Wetland or a Salt Marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER , SUPPLIER,IF APPROPRIATE)DETERMINES THATTHE,-SYSTEM IS,FUNCTION= ING IN_A'.MANNER fTHAT:PRO:TECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ,. .., ,. The system has a Septic Tank and Soil Absorption System and.iswithin 1001eet to a Surface Water Supply or Tributary to a Surface Water Supply. The System has a Septic Tank and Soil Absorption System and is with a Zone 1 of a Public Water Supply Well. The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and Soil Absorption System and is less than 100 Feet but 50 Feet or more from a Private Water Supply Well,unless it Well Water Analysis for coliform bacteria and volatile organic compounds indicates that the Well is from pollution from the facility and-the presence of-ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the System violates one or more of the following Failure Criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overload 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 outletmvert,due to-;an overloaded or clog- i ,ti zx :,;ged SAS or:cesspool. y;r g,,�;• .. Y; t, ,, .,r '. ,,, ,G, .., - �� Liquid depth in cesspool is I s;;than 6"below invert or available volume-is less than 1/2 day flow. Required pumping more than 4 times.i,i 1the last year NOT due to clogged or obstructed pipe(s). Number of times pumped. - 2 - SUBSURFACE SEWAGE'DISPOSAL'SYSTEM:INSPECTION FORM PART A , , CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below'the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or,tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed .to be acceptable,attach copy-of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. Ir E) LARGE SYSTEM FAILS: i L . The following criteria apply to a large system in addition to.the criteria above: ,. . The design flow of a system is 10,000 ggd or greater(Large System)and the system is a significant 'threat to public health and safety and the environment because one or more of the following conditions exist: The system is withm"400•Feet of a`surface drinking water'supply {' ` The system�swvithin 200 Feetof'a tributary'to a surface'drinking:water supplyThe system is located in a nitrogen sensitive area Interim Wellhead Protection Area, (IWPA)or'a mapped'Zone 11 of a public water supplymell. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 315 CNJR 5.00 and 6.00,. Please consult the local regional office of the Department for further information. - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the f lowing have been done: g the information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast two weeks and thesystem has; been receiving normal flow rates during-that period. Large'volumes:of water;,have not been introduced into the system recently or as part of this inspection. Ts-built plans have been obtained and examined. Note if they are not available with N/A.' he facility or dwelling was inspected for signs of sewage back-up. ,. he`system'does not�receive,non-sanitary'oi-industrial waste flow. ., The site was inspected for signs of breakout:° « f . r 71'system"components,ei cluding the Soil AbsorptionSyste'm,have beemlocated on site. The septic tank manholes were uncovered,opened,and the-interior.,of the septic;tank was in- '�£ = « spected'for-con'dition-of bafflesror tees,material'of construction,dimensions,depth of liquid,, depth of sludge,depth of scum. L. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods.' ` _ 3 - . i. t�, tt' c #._tea 8v '.'., 5�.�#� • _ �. :.SUBSURFACE SEWAGE,DISPOSAL.SYSTEM INSPECTION-- FORM PART B CHECKLIST(continued) // The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface.Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION . . . / FLOW CONDITIONS RESIDENTIAL; vT Design Flow: 6D gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: Laundry Connected To System:(� Seasonal Use:„/�'/)-- Water Meter Readings,i vailable: Last Date of Occupanc CO MF.RCI LANDUSTRIAi 4 -" . TYPe'of Esta,boghil ent Design Flow:- allons/daY,- reasa°TraP�Prese t. (Yes o ) , a k Present:W n _aste'Holdin �T Industrial Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL FORMATION PUMPING RECORDS any source of information:- 4 System Pumped as part of inspection: I�es, me pumped: V �g,�Mn Reasodfor`Pumping;' TYPE S1F SYSTEM: _Zseptic.Tank/Distribution'Box/Soil Absorption System Single Cesspool Overflow'Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): AP ROXI 'A 'c'AGE(/y�I■+all components;date.installed(if known)-and v source of information v Sewage odors detected when arriving at the site: /9---� - -- - - �sd - -4- eX SUBSURFACE SEWAGE--DISPOSAL I SYSTEM INSPECTION.:FORM PART .0. / GENERAL INFORMATION. (continued) _ SEPTIC TANK: Depth below grade: VA Material of Construction: k! concrete 'a: metal FRI, Other (explain) Dimensions: Sludge Depth: =�Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 7 / Comments: (recommendation for pumping,.conditioin of.inlet•and outlet tees or baffles,depth of liqui level In relati01 to outle 'nvert,structural integrity,evidenc of leakage, GREASE TRAP: _ Depth.Below Grade: Material of Construction: concrete metal . FRP Other r (explain): Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: _ Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of ligiud level In relation to outlet invert,'structural integrity,;evidence of.leakage tefc) - TIGHT OR HOLDING TANK: ZIAeo— Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): , . Dimensions: Capacity: W gallons Design Flow: gallons/day, Alarm Level- Comments:(condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments:(not level and distribution is equ ,evidenc o solids carryover,evide#ce o eakage'nto or o9t of bpx,etc.) .PUMPCIiAMBER'T Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc) y - 5 - , P 1 • i :.. SUBSURFACE SEWAGE DISPOSAL SYSTEM=.INSPECTION,F. ORM . PART C SYSTEM IIN`FORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): t/ (Locate on site plan,if possible;excavation not required,but may be approximately by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: J Leaching chambers,number.: Leaching,galleries,number: Leacahing trenches,number,length: Leaching fields,number;dimensions: Overflow cesspool,number: omments:o,(note con idtion o oil,signs of hydraulic failure level of pon ' g,condition of vegetation,eh.)_ . CESSPOOLS: ` 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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY:'_ Materials of construction: Dimensions: Depth of Solids: Comments:(note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) ._ +'`-4�J _..ry�._.......� .__ ........ �..♦.;`S'', ,;6...::''� _.... i t.•v8's+L �C'C.. i.. `s{`. .daa.xM�',�.- It•is "� •}.e:t •2 - 6 - f ?' SUBSURFACE'SEWAGE'DISFOSAL-SYSTEM',INSPECTION`,FORM PART .0 SYSTEM INFORMATION(continued) '. SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. 15 V �/ / .. �l.-nt?. � iYi°s}.� a.. `*1-.' R+G Ll5..1}y,j ! �..I aia;�I}iR F 3 S�' ..`fiRxS • R f (%ak +�«?� , `--s t 5t• `J�, DEPTH .TO GROUNDWATER: / Depth to groundwater: .7 Feet yJ Method of Determination or Ap roxi ation: �? r��-1,rrro /q �°0 Q i R�i�O u�Y _ .; No.-------------------- Fee--- - ----------- BOARD OF HEALTH TOWN OF BARNSTABLE Applicat ion-*rVeir Con.9tructionpermit A plicat'on,is her HyyTm4de for a emit to Construct (� ), Alter ( ), or Repair ( )an individual Well at: -- _v Q --------- '��,- ---------------------------------------------- - ----------------- - ------------------------- Location — Address Assessors Ma and Parcel P �_� ---p DS--------------------------------------- ---------------------------------------------------------------------------------------------- p p Owner Address --------- -- - - - Installer — Driller Address Type of Building -2 /� DwellingV o -40 Use— Other - Type yf Building ------ No. of Persons---------------------------------------------------- Type of Well --- Capacity ------------------------------------ Purpose of Well - � 11_ ------------------------ Agreement: The undersigned agrees to install the aforedescribed 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 Certificate of Compliance has een issued by the Board of Health. Signed- - - - —- --- -- - date Application Approved By ------------------ -- ------ - date Application Disapproved for the following reasons:----------------------------------------------------------------- ------ ------------- -- ------- - --- -- - ---- -- ------------ —_—__— ,� y date Permit No. -- 'V - - - --- - - Issued ----—---- - ----- date BOARD OF HEALTH TOWN OF . BARNSTAB LE Certificate ®f Compliance THIS I TO CERTIFY, Tha the Individual Well Constructed ( Altered ( ), or Repaired ( ) by- - � ---------- -----_------------------------- ---_------------------------ -4--------------- _--------- --------------------------- ------------------ at--- —1----- � � L�_ o nsta. Sl-___� ---------------------------------------------------------------- has been installed in accordance with the provisions of"the Town of Barnstable Board of Health Private We ro ctiio�n Regulation as described in the application for Well Construction Permit No L_-U f� Dated------_OZ =�1 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------------------------------------------------------- Inspector------------------------------------------------------------------------------------ 5 No.-------------------- Fee-------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Application -*OPefi Con5tructfonVermit A plication is her`eb -!d"e for a penpit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: _Location — A ss Assessors Map and Parcel -- (/J�t �_— ---— — —---- — ------- ----- O 1 O Owner f Address � 61VAI N -- - a- -- - -- ---------- - ___---- --------------- ---------------- szy Installer — Driller Address Type of Building 3 �� eom 40 0� Dwelling ----�--` --- --—--- -- Other - Type/yf Building No. of Persons----------------_______—------__-_---------- Type of Well-- "- = —' - Capacity -Purpose of Well---� '1 �S1NC- _—____ Agreement: The undersigned agrees to install the aforedescribed 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 Certificate of Compliance has been issued by the Board of Health. Signed-�------�-----/' .-7-- -- - - date — Application Approved By - date Application Disapproved for the following reasons:-------------------------------________�____________�—___--____ date __ _--_-- --- ---- Permlt No. -- +!'�- !------- _ Issued-!- date r ` BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, Tha the Individual Well Constructed ( Altered ( ), or Repaired ( ) �- � -------------------- -=---------------------------------------- (�'� I Install�r/�'}��r J 1 at- /�" ' --l----- - °` - J✓✓ -�-t! ! ----------------------------------------------------- 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 Noi�-�--, -�� !Dated—j-,!--F7- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- -- -- -- - --- - — ---- ---- - Inspector---- - — - ---------- -- - ---- BOARD OF HEALTH TOWN OF BARNSTABLE Yell ConMructionVermit No. "0--6 p � Fee -----__— W Permission is ereby granted---perG�+!�m --/------- to Construct ; Alter or Repair ( ) an I dividuaal,fWe11 at:)Street as shown on the application fora, Well Construction Permit No. '-------——- -- -- Da )/,v4 DATE Board of Health ----;- �- --------------- I � mmes!|! l !!| t!lml,ttnfllE7! . . k .�� 49 Route 13 Sandwich, ma05a • (50) 8*66 . g r CLIENT Robert P T Powers LOCATION: tot 6A 0 Jac kson ckson D. & ADDRESS: Pole 46 Staples R. Cot=it, MA g Crmberland,kT COLLECTED BY: Quality wells SAMPLE DATE: 4/3/90 TIME: d DATE RECEIVED: 4/3/90 SAMPLE ID:� q E F K JOB f WELL DEPTH: 33, EF — RESULTS OF ANALYSIS: . F Parameter Units Recommended limit Result � G Co 6r b c! r/10 m| (MF Method) O O k _ 2 pH pH units 6.0-*5 5,23 kConductance umh7/cm 500 301 % Sodium mg/L 20.0 % % 57.5 2 k NUgeN mg/L 10.0 _ 0.70 2 Iron mg E 0.3 ' K <0.05 Manganese mg/L 0.0 K k U Hardness mg L « CaCO 3 500 . \ . . � . a kR Sulfate mg E 250 2 Potassium mg L20.0 2 F E 2 F Alkalinity mg L 200 � F E % Chloride mg L 25 2 . q 2 Turbidity NTU &O E Color APC units 15.0 g q � kBackground bacteria . . F , K k COMMENT Results indicate high corrosive characteristics. If on low sodium diet k consult a physician before drinking. Consult local Board of Health k regulations concerning the sodium level. � 2 % YES NO WATER ISSU TABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. E � 2 XWX F — 414 DATE .� S YS TEM PROFILE NOT TO SCALE TOP FDN. FINISH GRADE ... FINISH GRADE OVER EL . =� FINISH GRADE OVER SEPTIC TANK L 'v . DIST. BOX ZO• c FINISH GRADE OVER • LEACHING PIT _... -':o: VARIES / 3„ OF 1/B" - 1/2 u " o-.• ' :o.•o• .q.•.q• •'q,a:e::•e•.:o.e:a?e�;•e:e;o::.:o:.a:�;;b•.o.::.. •o•..•e..•!: •.e•o. 12 MAX PRECAST CON.'. OR ASHED PEA STONE :°tea.:° ' 3„ e° °. BRICK 6 MORTAR OUTLET PIPE LEVEL TO 12" BELOW GRADE FOR 2 FT. MIN. •'Q.oO. 0: '�O.•• :�C� �'j'�:G.40: Ef:e,b:e D:,00.;•,:•e � :.p,.o A.: .a � `'ate `- 1 , � � •°•e::: . "'•% � .. •o.•.:°•.' :o y: `•C'.�'e•.oQ, o O C. I. OR PVC TEES-1 esMr. FLR. e GALLON DISTRIBUTION BOX o I o - 4 PRECAST CONCRETE INSTALL ON LEVEL BASE 3/4" TO 1-1/2" a; PRECAST P WASHED o H— 1/0 REINFORCED CRUSHED 0. CONCRETE f °.°:o' •, oq:e: e:a:::o-•o o 0 0. Q.: 'Q.' ::.;' . ' e:o.. STONE ` b::°: o.o..o.°?.0:0 a•.d,o o:,;o;R:o.o;•°,o o:o o;.• ;o. . o:. o c.:o:: Q .' o..l :o H— ' 0 REINF. b_ SEPTIC TANK INSTALL ON LEVEL BASE °' e NOTE.• EXCAVATE TO ELEV. ?0.5Y OR , •°.°. .'°: :o. ' . 40 LOWER TO REMOVE ALL IMPERVIOUS MA TERIAL BENEA TH THE LEACHING AREA REPLACE EXCA VA TED MA TERIAL WI TH eA <o O CL EAN, CLA Y FREE SAND _ EFFECTIVE DIAMETER . v LEACHING PIT GENERAL NOTES 4 `e 1. AL L EL EVA TIONS SHOWN ARE BASED ON INSTALL ON LEVEL BASE f 2. AL L PIPES IN THE S YS TEM MUS T BE CAS T IRON - OR SCHEDULE 40 PVC. OBSER VA TION PIT O _ 3. THE BOARD OF HEALTH MUST BE NOTIFIED F A SINGLE O*'-•,OF HA LES 7�0 BE PLAClf CD l I X;S T:' G ;-'STAKED, 6 AI TA O INv C VSTgtdc*� WHEN CONSTRUCTION IS COMPLETE PRIOR - - C=' S hUO L _L _ �.. TO BA CKFIL L ING PERCOL A TION RATE: 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED L MIN./IN. J �, x �• �\ \ BY THE BOARD OF HEALTH AND CAPE 6 ISLANDS WITNESSED BY.' SURVEYING CO., INC. � 5. MATERIALS AND INSTALLATION SHALL BE IN T (` O ' `, - COMPL IANCE WI TH THE S TA TE SA NI TARP BRD. OF HEALTH DESIGN DA TA ' BUFF STRI TO r•,L'JNA .^I O DATE:• 4,,;`� s N / . TS TU.*RAL STATE CODE - TITLE V - AND LOCAL APPL ICABL E RULES AND REGULATIONS "( ��. Z4.a Tt5T" 2 12.5 � �• � / --- ., � �f�a►.' � 7 L NUMBER OF BEDROOMS 6 6. NORTH ARROW IS FROM RECORD PLANS AND o T � ~ IS NOT TO BE USED FOR SOLAR PURPOSES Op5 Oi GARBAGE DISPOSAL !U 7. FLOOD HAZARD ZONE G :4' `` L4' SU�50�L DAILY FLOW GAL . \ B. WA TER SUPPLY W E 1000 GAL 8 p t,tATFQ � o�ED iw€c j SEPTIC TANK REO D. s s - - 8 SEPTIC TANK PROVIDED 0 GAL . to `' �. LEACHING REQUIRED 0 GPD. l � ; SIDEWAL L AREA = S. F. iv ry . + S. F. X G/S. F. = 5,�_GPD Q �,�� 8 j BOTTOM AREA S. F. ti `\ LEGEND S. F. X ) GIS. F. _ 1 , � GPD EST*Z l4 �- za Lp '�'� ��T`' G �1 " iO kIQT 1 LEACHING PROVIDED 4 GPO _ I 14 4 L- ; L . Z S.5' Z2 . r �/ JrC' • 1.�/!•1t (� r(iti ' r) PROPOSED ELEVA TION z 4 J EXISTING CONTOUR SINGLE FA MIL Y RESIDENCE G 40 . ` // 6� ` OBSERVA TION PIT l . 24.60 DIS TRIBUTION BOX L_o-r � A i w Z� PROPOSED SEW GE DISPOSAL S YS TEM r�( O LEACHING PIT PREPARED FOR 24 SEP TIC TANK LJA MI E PEGA N PRECA+3T CONCRETE L 's f IR?l RESERVE �� r,� 1:4 LOT 1 :JA CKSON DPI VE L_ o T � '• f BA RNS TA B'E - CO TUI T - MASS . 1C`" I J.00 PIPE INVERT EL EVA TION DA TE.' Y. a CAPE 6 ISLANDS SURVEYING, INC. PLOT/ PLAN v SCALE AS NOTED P. 0. BOX 334 SCALE.' I .. �`C.:) U��:� ��.lT t �� t �„-> �� ,, PLAN NO. ? TEA TICKET, MASS. 7 MAP SEC PCL LOT HSE - r