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HomeMy WebLinkAbout0845 MAIN STREET (COTUIT) - Health 845 :Main Street;(Cotuit) i a I Cotuit _fi� A = 035. 059001 1 d i I� - I 1 Ii �� ----�- `� h .-� ,� � � , ��� ��� � '� ao �- � � '' � � II .�\ I -. �.. :` f Massachusetts Department of Environmental Protection Lo Bureau of Resource Protection «: Well Completion Reports `1 3 1 Well Driller ' t.,., Please specify work performed: Address at well location: New Well Street Number: Street Name: -' 845> MAIN ST Please specify well type: - Building Lot#: Assessor's Map#: . ;4 Imgation- 035-D t Assessor's Lot#: ZIP Code: Number Of Wells: G59-002 02635 G 0-r L&C3` CitylTown: Well Location BARNSTABLE In public right-of-way: GPS 0 Yes r No North: West: 41.61869 70.43601 Subdivision/Property/Description: Mailing Address: click here if same as well location addres Property Owner: Street Number: Street Name: DANIEL LEVERONI 845 MAIN ST City/Town: State: Engineering Firm: BARNSTABLE MASSACHUSETTS ZIP Code: 02635 Board of health permit obtained: Cs Yes r" Not Required Permit Number: Date Issued: W2021003 09%14/2021 i 1 Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program A 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 Fast Slow YBrown �E�20 Loss Ad 1.dition 20 40 Fine To Coarse S j► Brown ,�! E =YESN0 Fast{� Slow --- . I_ dition — . ._ ...... ............................ 40 FlBrown ': (°Fast Slow [ 7, " YES NO Loss Addition WELL LOG BEDROCK LITHOLOGY Drop in Extra fast or Loss or Visible Rust Extra From(ft) To(it) Code Comment drill stem slow drill rate addition of Staining Large fluid Chips �� „� Choose Code Yes Yes ------ --- YES NO Fast Slow Loss Addition ADDITIONAL WELL INFORMATION Developed Yes( No Disinfected ( Yes f?No Total Well Depth 50 Depth to Bedrock Surface Seal Type None -- _�racture Enhancement '`Yes t No CASING r Is Casing above ground? .......... __ ___ __ . ................................................................._-........................-._._..............._.................. ......._.._....-._—__... —— — — From To Type Thickness Diameter Driveshoe ... __ ._..... ..... ......................................................._....._ ........._._......-...--..................... .. ----- --._._.....------ —, -- 46 P. l nyl Chloride Schedule 40 _...................................... SCREEN f-No Screen From To Type Slot Size Diameter +" 0.010 -- 4 46 50 — Stainless Steel Well Point. WATER-BEARING ZONES 11 DRY WELL From To Yield(gpm) 28 50 12 PERMANENT PUMP(IF AVAILABLE) Pump Description Wire Constant Speed Horsepower 0 Submersible 1 Pump Intake Depth(ft) 45 Nominal Pump Capacity(gpm) 25 Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) ANNULAR SEAL/FILTER PACK From To Material 1 Weight Material 2 Weight Water Batches Method Of (gal) (count) Placement Choose Material J Choose Material .'; � �� _Choose One— :,7r WELL TEST DATA Date Method Yield(gpm) Time Pumped Pumping Level(ft Time To Recover Recovery(ft (HH:MM) BGS) (HH:MM) BGS) 02/03/2021 I Constant Rate Pump ) WATER LEVEL Date Static Depth BGS(ft) Flowing Rate(gpm) Measured 02/03/2021 128 —7 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, DrillerURQUHART Registration# 877 Monitoring[M] Signature PATRICK, DESMOND WELL Job Complete Firm DRILLING INC. Rig Permit# 0551 .Date NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. f ENVIROTECHLABORATORIES,INC. MA CERT. NO.:M--MA 063 e 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name: Desmond Well Drilling Location: Address: PO Box 2783 845 Main St. Orleans, MA Cotuit,MA 02653 Lab Number: DW-210414 Collected By: Desmond Well Drilling,Inc. Date Received 02_/04/21 Sample Type: Well Specs: Irrigation 50/28 Locahan Source -� � .Date Collected `Time Collected ,� ��`� C'omtttents � > �.. Analysis Requested Units Recommended Limits Analysis Result Method Date Analyzed Analyzed By pH pH units 6.5-8.5 6.32 SM 4500-H-13 02/04/2021 SD Specific Conductance=_ umhos/cm 500 309 EPA 120.1 02/04/2021 SD Nitrite-N mg/L 1.00 <0.006 EPA 300.0 02/04/2021 SD Nitrate-N mg/L 10.0 5.30 EPA 300.0 02/04/2021 SD Sodium mg/L 20.0 68 EPA 200.7 02/10/2021 KB Total Iron mg/L 0.3 0.05 EPA 200.7 02/10/2021 KB Manganese mg/L 0.05 0.010 EPA 200.7 02/10/2021 KB Total Coliform(Presence/Absence) Present/Absent Absent .. A.... SM9223B 02/04/2021 KF @ 16:30... Comments: Nitrate level should be monitored periodically. pH is below recommended limit and may have corrosive characteristics. Sodium level is not a health hazard,but if on a low Sodium diet,consult a physician before drinking 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 2/12/2021 Ronald J.Saari Laboratory Director BRL=Below Reportable Limits 'See Attached Page 1 of 1 oCertifrcation is not available for this analyte for potable water samples.. r CommohWealth of Massachusetts a W Title 5 0-fficial. Inspection Form .� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 845 Main St F M . sV Property Address Y Leveroni ., E Owner's Name Bamstable t�lTi U + MA -02635 �11/9/12 City/Town ' State Zip Code ' Date of Inspection Inspection results must be submitted on this form.,Inspection forms may not be altered in any way. ti A. General Information ; 1. Inspector: ' Frank Nunes III . ` , Name of Inspector saa , Company Name ` Box 841 Company Address East Falmouth - MA 02536 Cityfrown State Zip Code 508.272.6433 ,. , Telephone 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 16.340 of *, Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ' ❑ Needs Further Evaluation by the Local Approving Authority 11/9/12 InspecWs Ugnattire ...Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner .and copies sent to the buyer, if applicable, and the approving authority. } ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. LIc 845 Main St•03/08 Title 5 0 'al spection Fonn:Subsurface Sewage Disposal System•Page I of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 845 Main St a Property Address Leveroni Owner's Name t Barnstable MA 02635 11/9/12 Cityrrown State Zip Code` Date of Inspection r B. Certification-(cont.) ' Inspection Summary: Check A,B,C,D o_r 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: t Comments: _ Pumping suggested every.3 yrs to prolong the life of the system. Septic Tank pumped post inspection B) System Conditionally Passes: ` ❑ One or more system components as described in the4`1 Conditional Pass"section'need to tie 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 i`not determined," please explain. y ❑ The septic tank is metal ana over 20 years,old*or.the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.- System will pass inspection if the existing tank is replaced with a,complying septic tank as ' approved by the Board of Health. - *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than'20 years old is available. . ND Explain: ° n/a 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 ❑ obstruction is removed a 845 Main St-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts r Title 5 Official ' Inspection Form Subsurface Sewage Disposal System Form -Not foryoluntary Assessments Cs 845 Main St ; Property Address ; Leveroni Owner's Name ' Barnstable MA 02635 11/9/12 Cityrrown '. State Zip Code Date of Inspection B. Certification (cont.) B) ,System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced -ND Explain: n/a ❑ The system required pumping more than-4 times a year due to broken or obstructed pipe(s). The { system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ` ❑ obstruction is removed` • } `. s� f ND Explain: . t n/a ' , C) Further Evaluation is Required by the Board of Health: . - _ ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if,the system is failing to protect public health, safety or the environment.} , 1. System will pass unless Board of Health determines in accordance with 310 CMR ' 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water „ ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) 4 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. y t, ❑ ' 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: 845 Main St•03/08 S Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page_3 of 15, - a F r t Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 845 Main St Property Address Leveroni Owner's Name Barnstable MA 02635 11/9/12' Citylrown + (' State r Zip Code Date of inspection`,• B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.); ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.. , Method used to determine distance: , **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that.no other failure criteria are triggered. A copy of.the analysis must be attached to this form. } 3. Other: ` n/a ' D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool , ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool , Static liquid level in the distribution box above outlet invert due to an overloaded ❑ ® - or clogged SAS or cesspool, a ® Liquid depth in cesspool is less than 6" below invert or-available volume is less r than Y2 day flow ', - ❑ ® • Required pumping more than 4 times in the last year.NOTdue to clogged or obstructed pipe(s)' Number of times pumped: P ' ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. E * Any portion of cesspool or privy is within 100 feet of a surface water supply or® tributary to a surface water supply. r 845 Main St-03/08 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments q,M 845 Main St Property Address Leveroni Owner's Name Barnstable MA 02635- 11/9/12 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): ` Yes No s ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than.100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis- and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. l have determined that one or more of the above failure ®' criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system_ the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. ' For large systems, you must indicate either"yes"'or"no"to each of the following, in addition to the questions in Section D. g 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 El 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. 845 Main St•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 e Commonwealth of Massachusetts Title 5 Official Inspection Form.. Subsurface Sewage Disposal System Form Not for Voluntary Assessments 845 Main St Property Address Leveroni Owner's Name Barnstable MA 02635 11/9/12 ". City/Town , State Zip Code Date of Inspection C. Checklist , Check if the following have been done. You must indicate"yes" or"no"as to each of the following: ' F Yes No . . ^ F , Z _ ❑ , Pumping information was provided by the owner, occupant, or Board of Health ❑ ® F 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 ' rt'of this inspection? ® ❑ ' Were as built plans of the system obtained and examined?(If they were not available note as N/A) r ' ® ❑ 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 occupantsif different from owner) provided with. - information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue ® approximation of distance is unacceptable) [310.CMR'15.302(5)] 845 Main St•03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 845 Main St Property Address s Leveroni Owner's Name . r Barnstable r MA 02635 11/9/12 Citylrown State Zip Code Date of Inspection D. System Information' Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: �:� 9-2 Does residence have a garbage grinder? ' ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection.required] ❑ Yes ® No Laundry system inspected? ; ❑ -Yes ® No' Seasonal use? t ® Yes ❑ No. Water meter readings, if available(last 2 years usage (gpd)): Sump pump? ❑ Yes ® No. ' , - Last date of occupancy: seasonalDate ' Commercial/Industrial Flow Conditions: ti •.' ` ' i Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Ganons per day gpd) „ Basis of design flow(seats/persons/sq.ft., etc.): , Grease trap present? , ' 4A ❑ Yes ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system?' ❑, Yes ❑ ',No y a + Water meter readings, if�available: Last date of occupancy/use: . , Date other(describe): n/a 845 Main St•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 1 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 845 Main St Property Address Leveroni Owner's Name Barnstable r MA 02635 ' 11/9/12 Cityrrown State Zip Code- Date of Inspection D. System Information (cont.) General Information Pumping Records: , " Pumped 2'yrs ago per owner Source of information: , . Was system pumped as part of the inspection? . 0 Yes ❑ No. If yes, volume pumped: i gallons How was quantity pumped determined? " maintenance Reason for pumping:., ' Type of System: , h7. ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool � ❑ Privy. ❑ - Shared,system (yes or no) (if yes;attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and , maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑, Tight tank. Attach a copy of the DEP approval. v El Other(describe): .* ' Approximate age of all components,-date•installed (if-known)and source of information: 1984 per BOH reccord Were sewage odors detected when arriving at the site? ❑ Yes ® No 845 Main St•03/08 i Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System°Page 8 ofe15 ` f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 845 Main St Property Address Leveroni • ` Owners Name F Barnstable MA 02635 11/9i12 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): j a Depth below grade: feet• 4 Material of construction: ❑'cast iron 0 40 PVC ❑ other(explain): Distance from o private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.)- Septic Tank(locate on site plan): F Depth below grade:" - 18 feet Material of construction: ® concrete = 0 metal ❑ fiberglass El polyethylene , „; El other(explain) Riser to unlet cover to 6"of grade If tank is metal, list'age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: T '15006 n Sludge depth: -undetermined-- Distance from top of sludge to bottom of outlet tee or baffle .- 611 f Scum thickness", , >21, Distance from top of scum to top of outlet tee or baffle , - >21, Distance from bottom of scum to bottom of outlet tee or baffle " How were dimensions determined? measured 845 Main St-03108 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts . f Title 5 Official Inspection Form p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , R ' ' M 845 Main St Property Address Leveroni + Y Owner's Name Barnstable MA 62635 11/9/12 3 Citylrown State -Zip Code. Date of Inspection D. System Information (cont.) Comments(on pumping recommendations; inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Excessive scum/grease at inlet T:Septic Tank pumped post inspection Grease Trap(locate on site plan): yy Depth below grade: ` • ., feet Material of construction: y ❑ concrete ❑ metal.' ❑fiberglass ❑polyethylene ❑ other"(explain);_, n/a t . . Dimensions: ti • t N Scum thickness , Distance from top of scum to top of outlet tee or baffle' Distance from bottom of scum to bottom of outlet tee or baffle Date of last-pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): n/a 1 Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grader Material'of construction: t ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): nia 845 Main St•03/08, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 845 Main St "M _ _ Property Address Leveroni Owner's Name- Barnstable MA . 02635. 11/9/12 ' Cityrrown State Zip Code - Date of Inspection D. System Information (cont.) ; Tight or Holding Tank(cont.)- Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: - ❑ Yes ❑ No Alarm level: Alarm in working order- ❑ ,Yes ❑ No. Date of last pumping: Date , Comments(condition of alarm and,float switches, etc.): n/a r *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan):` Depth of liquid level above outlet invert Level w/the bottom of the pipe Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): - D-box is 3' below grade and in average condition for its age _ Pump Chamber(locate on site plan): ` Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 845 Main St•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ' M 845 Main St Property Address _ Leveroni Owner's Name_ Barnstable MA 02635 , 11/9/12 CityrFown i State `' Zip Code Date of Inspection' D. System Information (cont.) Comments(note condition of pump chamber,'condition,of pumps and appurtenances, etc.): n/a ' Soil.Absorption System (SAS) (locate on'site plan,excavation not required): If SAS not Iodated, explain why: ,,; ' • , Type: ® leaching pits : number. , ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches ;,number, length: ❑ leaching fields j. 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.): : 4 { Both Leach Pits are 3'-below grade, have risers to 18"of grade, are dry at this time, clean sidewalls, and no obvious stain line with either pit 845 Main St•03l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page'12 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form >= - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 845 Main St ,- Property Address t Leveroni , Owner's Name Barnstable MA 02635 , , 11/9/12 ' Cityrrown State Zip Code _ . -Date of Inspection r D. System'Information (cost) Cesspools (cesspool must be pumped as part of inspection) (locate on site,plan): + Number and configuration ' Depth—top of liquid to inlet invert E Depth of solids layer Depth of scum'layer Dimensions of cesspool Materials of construction ` Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,'signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f e A - Privy (locate on site plan): Materials of construction: r Dimensions ' Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,,condition of vegetation, etc.):. . } n/a 845 Main St•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 jr . Commonwealth of Massachusetts , W Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 845 Main St .^{ Property Address w ' Leveroni Owner's Name W Barnstable MA 02635 11/9/12 ` Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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. _ f s . .UOA � � , ✓ l/ l a'kn/ � .. •ha. . .�. ' .. /dal a a S 1 845 Main St•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 f f a Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments M 845 Main St a Property Address . V Leveroni Owner's Name Barnstable _ MA- i' 02635 11/9/12 City/Town State ` Zip Code- Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope • " = f ❑ Surface water #' r ❑ Check cellar A ❑ Shallow wells r Estimated depth to high ground water: -12'. ►, feet - Please indicate all methods used to determine the high ground water elevation:' ❑ Obtained from system design plans on record If checked, date of design plan reviewed: ',pate ❑ Observed site(abutting property/observation hole within 150,feet of SAS) . ❑ Checked with local Board of Health-explain: Checked with local excavators, installers-(atta6 documentation) ® Accessed"USGS database-explain. per elevation to nearby surface water 1 You must describe how you established the high,ground water elevation: _ see above a f s . e r t , 845 Main St•03/08 ", Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 16, No. V" Fee 41,;_ BOARD OF HEALTH TOWN OF BARNSTABLE 01ppYicatiou if or lVerr Cott.5truction Permit Application is hereby made for a permit to Construct Y), Alter( ), or Repair( ) an individual well at _ ` Location-.Address Assessors Map and Parcel Owner Address Da—c-rrl ain d V�yel k p r°��\�r1 C,s Q 6 So k 279 3 0 r 1tavv, + 11►^1 b� fv�� Installer-Driller j Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well Capacity Purpose of Well [>yrl 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 Certific to of Compliance has been issued by the Board of Health. y Signed 1 II 7tpz1 _Date Application Approved By Date Application Disapproved for the following reasons: Date Permit No. 0 9- t D o 3 Issued Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed 4), Altered( ), or Repaired( ) by '(�?5 Inn Q- Vy-e Y Q Y`A U(Y)k V%Q_, 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.W 7o 31- d 03 Dated —)14 9 4 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector � 01)_ DOS No. � Fee BOARD OF HEALTH TOWN OF BARNSTABLE 2pplication _for Yell Construction Permit Application is hereby made for a permit to Construct( ), Alter( ), or Repair( ), an individual:well at-2 x r' Location-.Addre is Assessors Map and Parcel a > �cAn�e_t L�Yerc i 245 M 01 11 5+.'a' 0+ Af 1 . a Mk' OZ z .r Owner Address t`� ��nGt Wet Q 6 60� Z7g31 Or Ltt�.115 , MA7 bZCp S3 Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well Ca aci w . P . h'"_ Purpose of Well ,rV(CJG1 h Orl 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 Certificate of Compliance has been issued by the Board of Health Signed-, Date Application Approved By f i ` Date Application Disapproved for the following reasons: { Date Permit No. `b Q 3 Issued Lf'�� l Date ... ��— BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed�), Altered( ), or Repaired( ) by S f(1'1 h V1J Q Y.1 1( E i'2G1 inc . Installer at 4 s.. b�et 1 n 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.W)o 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 Construction 'Permit No. e) 01 1— Do r.,77Fee Permission is'. preb ranted to L SYY1f'y)G' l r ( � h y g Installer _ s V. to Construct`O Alter(;� O ' or Repair an individual well at: fA' Y Street as shown on the application for a Well Construction Permit No. Dated I 1 n Date I Approved By N/F 8225116 , Madeline M Do nniels TR 353:20_ _ 2585.11254 " E — --- --- - --- := — Proposed Driv� __ --------- —�--------- -- ----��, ----- -------- .— —Shed to i I be elocote Lawn R own O µ� It I 1 I Parcell �M ti 1. Acre I7, I i VA 1' Lawn . �"," .:. ¢ .._. ,, ...; •:1:... �.:. ... _. ... . .,.. 'ks.i.�:i :�m,e� ���,;..s�t � -`.r*S'; .:`w�.•:��''. � '4, �.:n;:; =-s - a��µ � fi � �* z , t Lawn s `P A,r 11 V j �— _---- --- --- u $ i L POGO! Plan#ings 2 sty w/f ( 1• Dwelling f CI i N7 ;t• `/ zW 9 r 8� Wood ;20: 6 Deck \ I w 1 -—�" l 1—_ ____— Brick' 1 - � Pnfib .—brick:J �. Parcel"2, J4. -= n 4 l J _ s ' 5 A crps , Rooia porch �/ 1 Stone i #853 r _- Approximates location �,, 1 Drive 2 V? sty p % of Existing Septic_ 1 w/f Dwellin —'�,i to be, obondbned g Woad I �� or Remover! Deck O ra-2 D 1 .4` O _ � 1 d t Le Rem°"e �• — i hj i 10.1.a, ' Stone Drive g 0-0 22 :NIF, r �n1 ,42„ peter D Field . NSF 215 5 $' ' a D Field /F e a sa Suaon 31240 a5. I g-1 1 k I N SEWAGE W A E PERMIT NO. LOt; AT G i V1LlAGE a 7a.4011tJ No * . . INSTALLER'S NA E i ADDRESS . .0,U I L D E It OR OWNER DA T E PERMIT ISSUED G DATE COMPLIANCE ISSUED, G Aq _ V.8 �f coo j THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........................................OF.....-.......I................ -........ Appliration for Bispnsa1 Works Tonstrnrtiun Prrutit Application is hereby made for a Permit to Construct V or Repair ( ) an Individual Sewage Disposal Systemt .. :!".. ........................ ------------. No ------------.....------................-- 4 Vfy it Lo tion-Add r C�.......�- �P. Elf............... �r�'®----..�-�-='-'A—!-- ?ti. .11 ••= caner '�,�- W -•-• bo ram'•••d�� � ©- #W' re s e Installe Address Type of Building Size Lot....... `. °Sq. feet Dwelling—No. of Bedrooms____.__.._'..............................Expansion Attic ( ) Garbage Grinder ( Cj `4 Other—Type T e of Building p,, yp g .....I,V PtP4...___._.. No. of persons........ _________________ Showers Cafeteria (/ ) 114 Other fixtures . '-��-••••--•••••-••-•-•-•---•••-•••--•-•-----•••--••••-••-•--•-••----••-•-••••--••---•••••-•-•-•---•••-•--•-•............ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacityk.T gallons Length................ Width................ Diameter--.__-___-____._ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.••.---•---.--__-__•- Diameter.................... Depth below inlet.......---.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date......................................... Test Pit No. 1...........:....minutes per inch Depth of Test Pit.................... Depth to ground water........................ G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W .....---•-•----------------------------------------•---...-•----•--••---•-------...---• . 0 Description of Soil.............31 --------------•--.......--------------•-----------------•-------------•------------•------------------------------------.............-- x U W U Nature of Repairs or Alterations—Answerlep applicabl ___ _________ _______________ __ .....1.S(a_L1--•---.........••----.S .t�. :.------•---."..--------- _... 0.?�-ff----------I--e44N...•------4-- ........................... Agreement: The undersigned agrees to install the aforedescribed Indiv' ual Sewage Disposal System in accordance with the provisions of TIT1Z 5 of the State Sanitary Code and i u s not o place th— system in operation until a Certificate of Compliance has ued y e b = Sig . . c ................................ Date Application Approved By........................... •••-_... ............•- -------------------------- Date Application Disapproved for the following reasons:................................................................................................................ ........•••••-•-•-•-•-•---••-•••------•••-••-•••-.....---•••--••-•----••-•------•---•------•-•--•-•-•-•--••----•--........--•-••............•.......................................................... Date PermitNo......................................................... Issued....................................................... Date No J_... y--• 7C � ` Fx$.....1 .:_ ....... r� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF....................................... ...... Applirtation for Disposal Works Tonstraartton Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: St b ....._..... _T....._...................................................................... ....................••_.... ---......- -- ••-------- ........ .- -ocation-Address r Lot t o. •--••--•-- >4N� k �51.-� ONA...................••••...... _ l(9•� a IJ �� . & &bLCQ&-- ftAAdr w er i � K In alley Address ' a UType of Building l l.d•Q _ Size Lot...a.A.A-f_._._..Sq. fee Dwel ng—No. df Bedrooms_.__.::.. ..............................Expansion Attic ( ) Garbage Grinder jjo) p I Other--Type of Building`-_Oj'Ot .......... No. of persons...........(a.............. Showers ( — Cafeteria (r ) Otherfixtures - -•-................................................................................................................. W Design Flow''' i� .t__ `;� _..... allons per person per day. Total daily flow--------------------------------_.. ......gallons. WSeptic Tank Liquid-cap4cityh�AQ..gallons Length.............•. Width................ Diameter................ Depth.............._ x Disposal Trench—N0. .._..ry:.............. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No. ..__ Diameter _. Depth below inlet.................... Total leaching area..................sq. ft. {, Z Other Distribution box ( ) � Dosing t nk ( ) Z �....... - .. a Percolation Test Results 1. Performed by.. -------------------------••••--------•---••••-••••-•••••--••-= ate........................................ Test Pit No. I................. ..............minutes per inch Depth of Test Pit..................... Depth to ground water_____----.-----_-____--. f q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ RI' ..................................................... .............................................................................................� D Dekfiption of Soil-------- 4!�-Ao ••-•-••--•--••---•-•--•••.... __-._--•-------------•--•----------=:... --- ......................................................................................................... W .............._.................__.......------....__s._._..__...........-----........._.........._.__.._......-'--._....... ......................................................... U Nature of Repairs or Alterations—Answer when applicable-___; 5 OCR -C -¢ -t---•-_•__-•-•---...*°.;;-...... •-_••- •-- •- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the#,State Sanitary Cod T undersi ed furth , ees no he system in operation until a Certificate of Compliance has- sue a rd § ea b :. Si ed. ......... . ; Date Application Approved By......... ` t Date Application Disapproved for the following reasons:----------•-••...........•••;-------------------------------------------------------------------------------- Date Permit No.................................. ...................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - z +- %unrtgfirate of TonapliFanrr THIS IS 0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by••-• w ul:1 -:C...:�//F��a4.�tc s. `----•--- tall - ----•-•-•.......................•----.....--•----•------- t o y '- S Ins _ Installer 5 ----------------------------- ----------------------------------- •-•................................ "Tins been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal 1Vorks Construction Permit No......................................... dated....._..._....._....__._.._......_..._.......... THE ISSUANCE '91k THIS.CE.RTIFICXTE}'SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFA TOR7Y CC QQ DATE................................ ..•.....__ ........_. { �._1._.L1. z. Inspector k . ..... ..... ..............................................•.•_.... THE COMMONWEAL TH OF MASSACHUSETTS BOARD OF-,,'HEALTH ............................................OF................- .. ...._•--•-•....................... d .................•-••... �..............._... FEE/j................ �t��o� ork� � on��a �rn �ernai� y Permission is hereby granted.. .j.•-.....r %mo w. tall. ......................... 1 to Construct ( ) or�Repair ( ) an Individual Sewage Disposal System �/ atNo-------------------- ----•-------•-------------------..._..._----------------------•------.-------------------------------------------•----------------------------------•talltall••---... Street as shown on the;`application for Disposal Works Construction Permit No..................... Dated �=._-,._....__.__....._.............. A 4 Board of Health DATE-------------------- �� � / FORM 1255 A. M. SULKIN, INC., BOSTON Mn'W L T I O N °_ �- �N � SEWAGE PERMIT Q. i V I L AGE S�' 6l—� -.- x1 Se- ` , INST/A�LLER'S NAME i ADDRESS BUILDER " OR OWNER lloDA. T. E PERMIT ISSUED G C. ODATE COMPLIANCE ISSUED \VA � i s 9 ��� ®V \ 1. .�.. t s. ,,