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HomeMy WebLinkAbout0027 PINE ROAD - Health (27 Pine. Road Cotuit .P { A 018_ 125002 Commonwealth of Massachusetts d�8 I p2 DDa- �� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Pine Road Property Address Grice . Owner Owner's Name information is Cotuit ✓ Ma 4/1/19 ' required for every 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 filling out forms A. Inspector Information cSl �3 33 on the computer, Chad hathaway use only the tab key to move your Name of Inspector cursor-do not HPS use the return Company Name key. P.O.Box 151 I�SI Company Address E Forestdale Ma 02644 Citylrown State Zip Code ram, 774 274 2581 12866 Telephone Number p e Nu be License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5' (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes .3. ❑ Needs Further Evaluation by the Local Approving Authority. 4. ❑ Fails 4/1/19 ector's Signat Date The system inspector shall sub P-and of this inspection report to the Approving Authority(Board of Health'or DEP)within 30 d sleting this inspection. If the system has a design flow of 10;000 gpd or greater, the ins he system owner,shall submit the report to the appropriate. regional office of the DEP. The original form should be sent to the system owner and copies sent to 'the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5,Of cial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are. indicated below. Comments: Septic in working condition. No Failure critera was encountered during inspection 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form'' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will' ` pass inspection if(with approval of Board of Health):, ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ® Y N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The . system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑)Y ❑ N ❑ ND(Explain below): i 3) Further Evaluation is Required by the Board of Health: El Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts - w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due.to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.)_ Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool - El ❑ Liquid depth in cesspool is less than 6",.below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply ❑ Z. well. t ® 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 1.00 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.] 0 ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ❑• The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board_of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 460 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 1:1 El the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up. ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered; opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 118 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma f 4/1/19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 min. Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No. information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ° . ❑ Yes ® No- Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts - w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes,.discharges to: Industrial waste holding tank present? ❑ Yes. ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 4 3. Pumping Records: Source of information: owner pumped march 2019 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: L gallons How was quantity pumped determined? Reason for pumping: maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool. ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1993 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line 24+feet Comments(on condition of joints, venting, evidence of leakage, etc.): no evidence of leakage or poor venting t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.75 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑.other(explain) 1500 gal H10 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'6"x5'6" . Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle' 34" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle 0 How were dimensions determined? 0 4 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank was pumped 6 weeks prior to inspection no solids in tank. pump every 2 years under normal usage. tees in place. no visable leaks or decay t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: - Capacity: gallons Design Flow: gallons per day 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts - (P Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Dbox is solid no major decay or leaks present a • I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit ' Ma 4/1/19 required for every page. CitylTown State .Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms.in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): i *If pumps or alarms are not in working order, system is a.conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1)6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑. overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �n io Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 27 Pine Road Property Address Grice Owner Owner's Name information is COtult Ma ' 4/1/19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System,(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding; damp soil, condition of vegetation, etc.): pit was uncovered 2 feet of water in bottom of tank. no staining over current level. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition.of soil, signs of hydraulic failure, level of ponding, condition_of vegetation,. etc.): z t5insp.doc•rev.M6/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 18 Commonwealth of Massachusetts Title, 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14.,Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 2- - Do 2 [' OP() e�J t5irisp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 27 Pine Road Property Address Grice Owner Owner's Name information is Cotuit Ma 4/1/19 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope , ® Surface water ® Check cellar ® Shallow wells 11' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: hand augered hole in back rear corner and encountered ground water 18" below bottom of pit el. Confirmed with barnstable health that actaul witnessed ground water was a sufficent el. to use for report Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments 27 Pine Road Property Address Grice Owner Owner's Name information is COtuit Ma 4/1/19 required for every page. CityrFown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist) completed ® D. System Information: For 8: Tight/Holding.Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 f� pF,NAgN�• �' Page: 1 CERTIFICATE OF ANALYSIS �. Barnstable County Health Laboratory Report Dated: 8/10/2006 Report Prepared For: Order No.: G0637456 Linda Grice PO Box 74 Cotuit, MA 02635 Laboratory ID#: 0637456-01 Description: Water-Drinking Water Sample#: Sampling Location F27 Pine Rd.Cotuit,MA ? Collected: 8/8/2006 Collected by: L.Grice Received: 8/8/2006 Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen BRL mg/L 0.10 10 EPA 300.0 8/8/2006 LAB: Metals Copper 0.12 mg/L 0,10 1.3 SM 3111B 8/10/2006 Iron BRL mg/L 0.10 0.3 SM 311113 8/10/2006 Sodium 9.5 mg/L 1.0 20 SM 311113 8/10/2006 LAB: Microbiology Total Coliform Absent P/A 0 0 309 8/8/2006 LAB: Physical Chemistry Conductance 81 umohs/cm 2.0 EPA 120.1 8/8/2006 pH 5,8 pl-l-units 0 EPA 150.1 8/8/2006 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved By: (Lab irector) i ra z' t Mt� r' tV.i f� A RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I. CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report Prepared For Report Dated: 10/01/2002 P O Box 2117 Order Number: G0217499 John O'Donnell Cotuit, MA 02635 Laboratory ID#: 0217499-01 Description: Water-Drinldng Water Sample#: 17499 Sampling Location: 27 Pine Road,Cotuit Collected: 09/24/2002 Collected by: John O'Conne 018-11125-002 , Received: 09/24/2002 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates 0.7 mg/L 10 EPA 300.0 09/24/2002 LAB:Metals Copper 0.2 mg/L 1.3 SM 3111B 09/27/2002 Iron <0.1 mg/L 0.3 SM 3111B 09/27/2002 Sodium 11 mg/L 20 SM 3111B 09/27/2002 LAB. Microbiology Total Coliform Absent P/A Absent 307 09/24/2002 LAB: Physical Chemistry Conductance 107 umohs/cm EPA 120.1 09/25/2002 pH 5.8 pH-units EPA 150.1 09/25/2002 Note: Water sample meets the recommended limits for drinking water of all above tested parameters. Approved By: - - — (Lab Director) -. L.4, Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECE S IVE® Y EP 3 0 2002 „ TOWN OF BARNSTABLE TITLE 5 HEALTH UEPT, OFFICIAL INSPECTION;FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A I�$ CERTIFICATION Property Address: 27 PINE RD COTUIT,MA 02635 pt 1 ZS 002. Owner's Name: JOHN O'CONNELL Owner's Address: PO BOX 2117 COTUIT MA 02635 Date of Inspection: 9/18/02 't Name of Inspector: (please print) .JOHN GRACI Company Name: SEPticC INSPECTIONS Mailing Address: I'.'?P:O.BOX 2119 TEATICKET,MA.02536 cob Telephone Number: 508-564-6813;FAX 508-564-7270 CERTIFICATION STATEMENT'" I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenanceof on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section :5 340 of Title 5(310 CMR 15.000). The system: X Passes` _ Co1copy s _ Neuation by the Local Approving Authority _ FaDate: 9/18/02 Inspector's Signature:The system inspector shall suis inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. the 'system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner,shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to.the buyer, if applicable,and the approving authority. Notes and Comments i �F SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE:: This report only describ"e§„co�diti©ees at the time of inspection and under the conditions of use at that lime.This inspection does not address how-;the.system will perform in the future under the same or different conditions of use. s (1` Title 5 IncnPrtion Perm A/I snnnn""'I . Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE;SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 27 PINE RD COTOIT,MA 02635 Owner: JOHN O'CONNELL, Date of Inspection: 9/18/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Sectiau D A. System Passes: 3: X 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 criteriaynot evaluated are indicated below. .,, Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. '_,,, 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 rep lacement-'or,repAir,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N',NG)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it.is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20`'years old is,available. ND explain: n/a psi, n/a Observation of sewage backup#•or:brewK`out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled#or do vAen distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced 'o,bst0 tior'is removed +'distribution Gox is leveled or replaced ND explain: n/a n/a The system required pumping more than4 times a year due to broken or obst ucted pipe(s). The system will pass inspection if(with approval of the Board'of Health): v#'t. 1 . _broken,pip, Is)are replaced _obstruction is removed ND explain: n/a i, Page 3 of 1 •r, OFFICIAL INSPECTIONYORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A :CERTIFICATION(continued) Property Address: 27 PINE R'U'COTUIT, MA 02635 Owner: JOHN O'CONNELL, Date of Inspection: 9/18/02 C. Further Evaluation is Re'quired,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. i 1. System will pass unless Board''of Health determines in accordance with 310 CMR 15.303(l)(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 i; 9�s; 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 SA.S and the SAS is within a Zone I of a public water supply. a t k i.j The system has a septic;ia'hV"and SAS!and the SAS is within 50 feet of a private water supply well. _ The system has a septic tanWand 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 n/a "This system passes if the well watai analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indickes that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attachetd'to this form. P 3. Other: ♦ f5 �i h n/a �3 S. Page 4 of I I , [3i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM << PART A CERTIFICATION(continued) Property Address: 27 PINE RD`COTUIT,MA 02635 Owner: JOHN O'CONNELL Date of inspection: 9/18/02 a. D. System Failure Criteria applicable to all systems: You trust indicate"yes"or"no"to teach of tle following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t, X Static liquid level in ttie distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NO PUMPING ANFORMATION. X Any portion of the SAS,cesspool_or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspoo,`I,or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 laboratorys for,coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that"facility'and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.f',,4', : 4 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system"fails,The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or."no to each of the following: (The following criteria apply to lar,'ge sy'stems'in addition to the criteria above) yes no 1 i } _ X the system is within 460 feet of a s,urface drinking water supply X the system is within 200'feet of a tributary to a surface drinking water supply X the system•is located it a nitrogen'sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered;4y"' o ariy question in Section E the system is considered a significant threat,or answered "yes" in Section 1)above the alive Sy410 has foiled. 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. 5.. rk 3 Page 5 of 1 1 a.•;.. r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 27 PINE RD`COTOT, MA 02635 Owner: JOHN O'CONNELL Date of Inspection: 9/18/02 Check if the following have been done`: You must indicate"yes" or"no" as to each of the following: Yes No X _ Pumping information was;pro'vided'by the owner,occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system rece►ved.normal flows in the previous two week period? X Have large volumes of"wate'r b�?eh introduced to the system recently or as part of this inspection ? X _ Were as built plans of the sy"ster:obtained and examined?(If they were riot available note as N/A) X _ Was the facility or dwelling fn*spected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,exuding the SAS, located on site'? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal`sys items"? M t' The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no `r X _ Existing in format iotf:Pdr example,a plan at the Board of Health. X _ Determined in the field(if'an'y of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] ¢.t 0 �., S•,� ` s, �I t 1 4 .' Page 6 of I 1 jiF • ! OFFICIAL INSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 27 PINE RD COTUIT,MA 02635 Owner: JOHN O'CONNELL Date of Inspection: 9/1-8/02. ;FLOWACONDITIONS RESIDENTIAL Number of bedrooms(design): 3 'Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: I Does residence have a garbage grinder(yes cr no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no).:'NO. Seasonal use: (yes or no): NO Water meter readings, if available,(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a ; Design flow(based on 310 CMR 15.203) n/agpd w seats/ ersons/s ft etc. : n/a Basis of design flow q ) S ( P Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available:n/a, Last date of occupancy/use: n/a- 1 OTHER(describe): n/a t V GENERAL INFORMATION Pumping Records Source of information: NO PUMPING INFORMATION Was system pumped as part of th'e inspection(yes or no): NO If yes,volume pumped: n/agallons; How was quantity pumped determined? n/a Reason for pumping: n/a i TYPE OF SYSTEM ' X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no),(,if�yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components.,date installed(if known)and source of information: 1988,SYSTEM 1993 BY OWNER. Were sewage odors detected when arriving a'khe site(yes or no): NO k , i' / Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART C SYSTEM INFORMATION(continued) Property Address: 27 PINE RD COTUIT, MA 02635 Owner: JOHN O'CONNELL Date of Inspection: 9/18/02 BUILDING SEWER(locate on site plan) ' Depth below grade: 22" ' Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints;venting,evidence of leakage,etc.): WELL WATER , SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age:confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 150OG L 10' 6" H 5' 7;" W 5' 8"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" Distance from top of scum to top of outletttee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage;etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) L Depth below grade: n/a '. Material of construction: concrete_metal fiberglass_polyethylene_other(explain): n/a -. Dimensions: n/a Scum thickness: n/a Distance from top of scum to top ofoutlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a ,t , Comments(on pumping recon"nendations inlet and outlet tee or baffle condition,structural integrity, liquid levels as related i;1 -1. to outlet invert,evidence of leakage,,.etc), V. n/a . . i it I * 1, 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 27 PINE RD;COTUIT,MA 02635 Owner: JOHN O'CONNELL Date of Inspection: 9/18/02 TIGHT or HOLDING TANK: ti(tank musl;be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A + '' Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a ' r i DISTRIBUTION BOX: Xt( f present must be�opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF 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 STRUCTURALLY'SOUND. • 3i i PUMP CHAMBER: _(locate on.site plan) Pumps in working order(yes or no NQ Alarms in working order(yes or no):NO Comments(note condition of pump chamber;condition of pumps and appurtenances,etc.): n/a Y � s i t A 1 # Sii', - R 'Page 9 of 1 1 OFFICIAL INSPECTION•FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 27 PINE RD COTUIT, MA 02635 Owner: JOHN O'CONNELL Date of Inspection: 9/18/02 SOIL ABSORPTION SYSTEM 4(SAS):"X (locate on site plan,excavation not required) If SAS not located explain why: n/a e Type 1000 GAL 6' X 6' °fx leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a .. leaching fields, number: n/a n/a ': :; .,z overflow cesspool, number: n/a n/a ii't,;..t;;; :innovative/alternative system f, ;; .Type/name of technology: n/a Comments(note condition of soil,signs'of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. PIT WAS EMPTY AT TIME OF INSPECTION.THERE ARE NO STAIN LINES,INDICATING PIT HAS NEVER HAD ANY LIQUID IN IT. BOTTOM IS AT 8 FT. CESSPOOLS: (cesspool must e`pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a It Materials of construction: n/a Indication of groundwater inflow(yes or no)"NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a s PRIVY: (locate on site plan)`''r Sri Materials of construction: n/a Dimensions: n/a Depth of solids: n/a nbs of hydraulic failure, level of ponding,condition of vegetation,etc.): Comments(note condition of soil, sig n/a ; d, •1 1 n II -Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 27 PINE RD COTUIT,MA 02635 Owner: JOHN O'CONNELL Date of Inspection: 9/18/02 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. rr , r\� �rut, v i .f Page 1 1 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C R ,SYSTEM INFORMATION(continued) Property Address: 27 PINE RD COTUIT,MA 02635 Owner: JOHN O'CONNELL Date of Inspection: 9/18/02 �4 SITE EXAM _Slope _Surface water _Check cellar ,��e•, _Shallow wells Y Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local`exca`vators, installers-(attach documentation) NO Accessed USGS database-,explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 10+FT. t 4 7 r•Y, 4 e 11 TOWN OF B/AARNSTABLE LOCATION u f � �,,r �d "�` /� SEWAGE:# 93 - 27,3 I VILLAGE C��tu — ASSESSOR S MAP TT j INSTALLER'S NAME PHONE NO.a VO4.1 [ K SEPTIC TANK CAPACITY /,5-00 LEACHING FACILITY:(type) /wp �P (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER v =" BUILDER OR OWNER , To C,,vqo DATE PERMIT ISSUED:. DATE COMPLIANCE ISSUED (�19 73 , VARIANCE GRANTED: Yes No � o per, f�� � 5h'-:�pA :� � ��N; o ;� ! �' �� � �,�._- 'f �! • f ' . .� S II I - y1 r i t � r Y FEx 7...._............ THE COMMONWEALTH OF MASSACHUSETTS i BOAR® OF HEALTH V1 ..----.....l..D..c,il.�1................OF........ bl< __ a pplirFation for Di-qVnoal Workii Tutw4.rurtion Prrulit Application is hereby made for a Permit to Construct )c or Repair an Individual Sewage Dis osal- PP Y ( ) P ( ) g p ' C� at: t Systemi � Location_Address �' or Lot N7- ^... +� t er yt Address e404- 1 ................•.... ..... .......................................... .......--•----••---•...-•-...... ..--•-••--•................•--•--......----........_..._----_. Installer Address d Type of Building Size Lot_._A/2 S-T-fee v Dwelling—No. of Bedrooms.._.... .......................Expansion Attic (11S/e) Garbage Grinder (N10) '4 Other—Type of Building No. of persons............................ Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) Q' Other fixtures ________________•_______•-_-----_. Design Flow.....................................S._gallons per person per day. Total daily flow.............................. .e_gallons. 1:4 Septic Tank—Liquid capacity/9 oQ..gallons Length WidthAl-10"._ Diameter________________ Depth...tZ_�n!_c`.... Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....mg -------- Diameter.....19_.......... Depth below inlet-..:........... Total leaching area..o2.6.6_....sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.. 3�vc.._ic2i.l��......_�at�2sl�s�.�__N_�Jiw........ Date___F.:i_1n-... .......... ,4 Test Pit No. 1-----.2.......minutes per inch Depth of Test Pit.....1AA...... Depth to ground water•-------- ------------- aTest Pit No. 2...: _minutes per inch Depth of Test Pit------1-.-3-z` I. Depth to ground water---_-_ OF 0 Description of Soil...:1P!i .0 ( "_,- n�, l�san2 $��a4s 3� l99 eu✓h �� u u to y STEPHEN U ......................... .......... 2_�-.Q._�t�.. . .............- . •----•-- --•--...t•'a_Q-•--.L_7...-•----................................. ��' •Att'fW_ W -- -----------------•- --------------- ------------------•---- ....---•••--_...._-------•----••-----•--•-----•-------_._.....--•----•••••......------••-•-•---• ------- H - ...._�c1LSON.. UNature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------- No.30216�® , .. �� Agreement: N The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in a or eeaiGoo the provisions of'T`: . . 9•/j p 5 of the State Sanit de T ndersigned furti e, agrees not to place the system in operation until a Certificate of Compliance ha ,b s th bard o lth Sign =-------------- --- .. ..........._.. ............................... Application Approved By...... .................................................... Date Application Disapproved for the following reasons:--------•-------------•-------------------------------------•-----------------............................... Date Permit No------ - .`------------ ---------- ---- Issued-------------------------------------------------------- D�tz � S y• s 1465 /� f ...4b.& - Fes$. ,—_')_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............OF..... �- ApplirFatiun for Disposal Works Tonstrurtiun rrmit Application is hereby made for a Permit to Construct (ye) or Repair ( ) an Individual Sewage Disposal ' System at: „-•.................................. .._ ..._.. ............_....__.....------..----•- ................... ............................................................. Location-Address or Lot No. O'wner Address a111r..<� r r> ................................................. ....................te f��z�............... Installer Address Type of Building Size Lot__/a _z&___._-_-_ fPet ., Dwelling—No. of Bedrooms___... ........................Expansion Attic Garbage Grinder V,) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures -•---'•----•-••'-•'--•--•-•-'----•-••--•-•--•-------........••-•-•'------'-•--••••-----------•----•-'••-••-----•'................."'--.........••_... W Design Flow.....................................ems__gallons per person per day. Total daily flow............................. ,;.m;_s2...gallons. WSeptic Tank—Liquid capacity/r4 o..gallons Length.'-'.:`...... Width./4'._eq�'__- Diameter--. Depths j 'c... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...... -------- Diameter.....t-0.......... Depth below inlet....4,'.......... Total leaching area._,,76.&.....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by._ „_« _r� ,_q_;;::.____:1t�p, _t..t ........ Date..��,•41._-�_c_k fg ----------- Test Pit No. 1.....�---____minutes per inch Depth of Test Pit.....l..4t*........ Depth to ground water------------------------ f=, Test Pit No. 2.._�......minutes per inch Depth of Test Pit----- ter. "_._ Depth to ground water. . •-•-----'-------------------••'••-•-•-•---'--•-•--'••-••---••-••-•---••-••••••--'---..................---"-"-----•......•-- D Description of Soil---- 3^rI •_.Q-7�, c. �.� cs� _,..<<� — " ntl` °`L '7'_ _�...ti. -a1�E-r� -L_"'_�• 't'-d' i�c;,'ce-':a ti _ •'_"__'_ (� N +� " ST_PHE W ALLYN UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------ .NU:3SUN..... Agreement: t The undersigned agrees to install the aforedescribed Individual Sewage Disposal System I �a�4 the provisions of T I T Li: 5 of the State Sanitary Code—The undersigned furthef agrees not to place the system in operation until a Certificate of Compliance has been issuA by the board o ` ealt:W1 hl Signed'----- �^� {{r' �� p�r3 --•-- r ... ................ `�/� Date Application Approved By__.-_x'._ G' = -::. l--�_ 35 . •••-•---•-•-'"........................"- .................... Date Application Disapproved for the following reasons:__...•••••-•'----•-•----•'-•-"-•-•••--•••--•'•-•--•'•.............."----••---................................. .................'-•--.............._........._...-'---•""--........._..-----•----.....-'-'-----'-•-•---••-----".............._..•••----•••---"-'-.....-•'---._....-•'-'-..._......-'..--•....'-_..... DatePermit No....- . .. Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... P-%t'.L..............OF...... .�.'.` �`� : ...................... Culvdif irFatr of ToutpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by--'--r ...........................................---•-•-"-----•-•-...•._.......--------•------------•---•---•---...-•-------.....•........._..-••-•---.... ' Installer at......q ......... ........-2 ......_<..?_... 1► r has been installed in accordance with the rovisions4of`TITIE 5 of The to Saxri �C 'de as des ribed in the - f application for Disposal Works Construction Permit 'N " :���dat dy-.----I /_-S�-- --••----•-•••• THE ISSUANCE OF T IS C RTIFICATE SHALL NOT BE CONSTRUE® A , UNTEE THAT THE SYSTEM WILL FUNCTI SA F FA ORY. DATE................................ �.1.. -- --••--;-----... Inspector..........------'--- •-....-•-'---- ........ ................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................l..i u7/.N......OF [. ........................................ FEE.. .. Disposal Works Tunstrudiun Vvrrmit 1 Permission is`hereby granted........Z(t A_jam...;....�.:.................'-••-•--••.....-'-•...-•-•-••••---........•••-•-.......•..................-. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System r� at No......�•, >........... ........... r-n 'C� �3....._..r. ,�1.1 - .• Street L/1 . as shown on the application f6r Disposal Works ConstructionPer mit IaTo����G,Dated ��/�`� n DATE. ........ �f- Board'of Health _. --- -------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS GHR ANALYTICAL A DIVISION OF GHR ENGINEERING ASSOCIATES, INC. o2 "7 ►�� R� k MAIN STREET ` \\ LAKEVILLE, MA 02347 (508) 947-5077 REPORT OF ANALYSIS TRACE METALS Client: Paul DeMattos Job No: 40-958 Project: Water Analysis Date Collected: September 15, 1989 Collected by: Client ----------------------------------------------------------------------- Sample ID: Well - Lot #2 Acceptable Range GHR Lab ID: 102913 Parameter Test Results in ma/1 Iron 0.28 0 - 0.3 Approved by: Analytical Method Reference: U.S. EPA, 1983. "Methods for Chemical Analysis of Water and Wastes". EPA 600/4-79-020, EPA/EMSL, Cincinnati, OH. Iron: Method 236.1, Atomic Absorption, Flame i " 7675 Bottle # BC Date: March 10, 1589 Log Number:________ - oF BARti BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT s SUPERIOR COURT HOUSE C � BARNSTABLE. MASSACHUSETTS 02630 t� R! PHONE: �iA St" WATER LABORATORY ANALYSIS Eut: 337 Paul DeMattos Collector: T Paul D tQs.�. _--__ eMat __ --- Client: ;.`, Affiliation: real or -- Mailing Address• Pine Road Time & Date of Cotuit, MA 02635 „Collection: . �14�89 _J?•00 Noon _.__ 428-1077 Type of Supply: _W 1L-- ----- Telephone: Well Depth: _ 8'- ------- -- - Sample Location: Pine Road. Lot Date of Analysis: Cotuit MA _— �SAMPLE RESULT RECOMMENDEU LIMITS PARAMETER _ Y 0 Total Coliform,Bacteria/100 mlPH - �� 0c a �• 5-4 .� .oA 41 500.0 Conductivit (micromhos/cm40) am —13.5 — Iron m) -� °c 1.2 Jc. •. \�� tig 10.0 S Nitrate-Nitro en (p m y �co 1.2l �� y°0 2 0- m _0 ---- -- Sodium ) • �y Water sample meets the recommended limits for d inking of all above tested paramete ted for this sale,I • p . II • XX Based only on results of the parameters teSroblems checkedmbelow: water is suitable for drinking but mayr .pres p ure A. Water sample has higher than `.average levels of Nitrate.rd trends monitoring is recommended (2-3 times per year) to establisha y p The low pH of the water may shorten the useful life of the house's plumbing.. B. C. X Water may present aesthetic ,problems, (taste.,• odor, staining) due to iron . high levels oftsodium. Persons on low sodium diets should D. Water sample has g consult their doctor. I II. Due to one or more of the reasons checked below, this water trasample is unfit for human consumption: A. High B Bacteria High tes REMARKS: Iron removal systems are available to reduce the iron level in this sample. of Health • stable Board CC. Barn _ CC: Laboratory Director 117185 > 7'. "dJ # ;3 Pt Explanation of Test Results Total Coliform Bacteria Coliform bacteria are. an indicator of the sanitary quality of a water supply. Water, supplies may become contaminated from malfunctioning septic systems, cesspools and surface runoff. A total coliform count of zero indicates that your water supply is safe and approved for human consumption. A total coliform count of greater than zero is most often the result of accidental contamination of the sample bottle through improper sampling methods. For this reason, it would be advisable to retest any well water that is not approved. pH pH is the measure of acidity oralkalinityof the water:•un the pH scale,the number 7 is neutral, less than 7 is acidic and more than 7 is alkaline. The pH of water on Cape Cod tends to be acidic in the range of 5.0 to 6.5.. .r .9 Conductivity Conductivity is a measure of the dissolved salts in solution. Amounts in excess of 500 micromhos/cm are generally considered unacceptable 'and may have a laxative effect upon users. Iron i,j The presence of iron in water of m or greater may: give the water a bittersweet astringent p �,. Pp g Y� g g taste, cause an unpleasant odor, often gives the water a brownish color and cause staining of laundry and porcelain. The average concentration of iron in Capt,Cbd's water is .2 - .6 ppm. Although the presence of iron in water may cause the problems listed above, it is h considered deleterious to health. Iron may be removed by use of an iron ,a i removal system. Nitrate-nitrogen , The Massachusetts Drinking Water Regulations have set a maximum contaminant level for nitrates at 10 ppm. Excessive concentrations may cause methemoglobinemia (an in disease) and have been suggested to form potentially carcinogenic nitrosamines. Contamination sources include fertilizers, cesspools and industrial wastes. Copper Due to the acidic nature of the water on Cape Cod, copper tends to leach from pipes. This normally does not present a health hazard; however, concentrations in excess of 1.0 ppm may cause a metallic taste and/or a bluish-green stain,on porcelain fixtures. r• 7 ,, s Sodium A concentration of sodium over 20 ppm is only of concern to people who are on a low sodium diet. If the water supply has more than 20 ppm sodium, it is up to the people who are on such a diet to find another source of drinking water or contact their doctor to determine if consuming the water is advisable. Concentrations exceeding 50 ppm indicate that there may be ocean water or road salt,runoffwater getting into the well. , ` e �a GROUNDWATER Groundwater Analytical, Inc. ANALYTICAL Buzzards Main Street Buzzards Bay, MA 02532 Telephone (508) 759-4441 FAX(508) 759-4475 September 15, 1989 Mr. Paul DeMattos ?'J.2< Pine Road I Cotuit, MA 02635 Dear Mr. DeMattos: Attached is the Volatile Organic Analysis for Lot # 2 Well. Groundwater Analytical is currently certified by the Massachusetts Department of Environmental Quality Engineering for the analysis of Volatile Halocarbons, Volatile Aromatics and Oil and Grease in Secondary Parameters. Groundwater Analytical is also certified for the analysis of Trihalomethanes and Volatile Organics in Primary Parameters. Quality control procedures are performed in accordance with EPA protocol. The information contained in this report is certified to be accurate and complete. Thank you for your business. Sincerely, %:s�' David L. Sanford Vice President Laboratory Operations GROUNDWATER ANALYTICAL EPA METHOD 502.2 Volatile Organics (GC/PID/ELCD) Sample Designation: Lot # 2 Well Project Name/Number: DeMattos Laboratory Number: 925808 Date Analyzed: 09-15-89 Sample Matrix: Water PARAMETER CONCENTRATION DETECTION LIMIT (ug/L) (ug/L) Dichlorodifluoromethane BDL 2 . 0 Chloromethane BDL 0.5 Vinyl Chloride BDL 0.5 Bromomethane BDL 2. 0 Chloroethane BDL 0. 5 Trichlorofluoromethane BDL 0.5 1, 1-Dichloroethene BDL 0. 5 Methylene Chloride BDL 0.5 trans-1,2-Dichloroethene BDL 0.5 1, 1-Dichloroethane BDL 0.5 2 ,2-Dichloropropane BDL 0. 5 cis-1, 2-Dichloroethene BDL 0.5 Chloroform BDL 0. 5 Bromochloromethane BDL 0.5 1, 1, 1-Trichloroethane BDL 0.5 1, 1-Dichloropropene BDL 0. 5 Carbon Tetrachloride BDL 0.5 Benzene BDL 0. 5 1, 2-Dichloroethane BDL 0.5 Trichloroethene BDL 0.5 1,2-Dichloropropane BDL 0. 5 Bromodichloromethane BDL 0.5 Dibromomethane BDL 2 .0 Toluene BDL 0.5 1, 1, 2-Trichloroethane BDL 0.5 Tetrachloroethene BDL 0. 5 1, 3-Dichloropropane BDL 0.5 Dibromochloromethane BDL 0.5 1, 2-Dibromoethane BDL 0. 5 Chlorobenzene BDL 0.5 Ethylbenzene BDL 0.5 1, 1, 1,2-Tetrachloroethane BDL 0.5 m+p Xylene BDL 0. 5 o-Xylene BDL 0.5 Styrene BDL 0.5 Isopropyl benzene BDL 0. 5 Bromoform BDL 2 . 0 1, 1, 2,2-Tetrachloroethane BDL 0.5 1,2, 3-Trichloropropane BDL 0.5 Page 1 of 2 GROUNDWATER ' ANALYTICAL sample Designation: Lot # 2 Well , 925808 PARAMETER CONCENTRATION DETECTION LIMIT (ug/L) (ug/L) n-Propylbenzene BDL 0.5 1, 3 ,5-Trimethylbenzene BDL 0.5 2-Chlorotoluene BDL 0.5 4-Chlorotoluene BDL 0.5 tert-Butylbenzene BDL 0.5 1,2 , 4-Trimethylbenzene BDL 0.5 sec-Butylbenzene BDL 0. 5 p-Isopropyltoluene BDL 0.5 1, 3-Dichlorobenzene BDL 0. 5 1,4-Dichlorobenzene BDL 0. 5 n-Butylbenzene BDL 0. 5 1,2-Dichlorobenzene BDL 0. 5 1, 2-Dibromo-3-Chloropropane BDL 3 . 0 1, 2,4-Trichlorobenzene BDL 0.5 Hexachlorobutadiene BDL 0.5 Naphthalene BDL 0.5 1, 2, 3-Trichlorobenzene BDL 0.5 BDL = Below Detection Limit. "Trace" indicates probable presence below listed detection limit. Method Reference: Method 502.2 - volatile Organic Compounds in Water by Purge and Trap Capillary Column Gas Chromatography with Photoionization and Electrolytic Conductivity Detectors in Series, U.S. Environmental Protection Agency, Environmental Monitoring and Support Laboratory - Cincinnati OH, September 1986. Page 2 of 2 AA CHAIN OF CUSTODY RECORD GROUNDWATERPROJECT CONTACT _ ANALYTiCAL COMPANY ADDRESS PROJECT NAME bE M4--) 7-D 7 PROJECT NUMBER FAX NUMBER SAMPLED BY P.O. NUMBER Please Print CONTAINERS a: J x DATE SAMPLE IDENTIFICATION g a cc PRESRV ANALYSIS REQUESTED/COMMENTS LAB NUMBER TIME NO. SEE G/P O / �y 9258 0.8 O-rTI 2. jit�f=�L L �-z Sam d/Rel `q he by: Date/Time Received by: Relinquished by: Date/Time Received by: �� 1'9 1-5- fl9 (Signature) /ys +7 nnat re) (Signature) (Signature) Relinquished by: Date/Time Received by: Relinquished by: Date/Time Received by: (Signature) (Signature) (Signature) (Signature) Method of Shipment Remarks: US Express Map � Label No. r ( ' Other /4ANG C�i21*j�z 11 (508) 759 4441 GROUNDWATER ANALYTICAL, INC. 228 MAIN STREET BUZZARDS BAY, MA 02532 - l�L'n eso d+J `C04v it 11�,. L sys,-Ell/\ L 00 q 47 P Ae • ' i#r� r j`r I 1 i � _ ( - -- ' I - _ 4,.� � I _1, , �r•�- `' '�/ 1 ' � 2.u•.1 I I I ( t �. r i sh t ' 110 r + t � t 0t0 Ao 1 W r I : ► ..fir_ . !I _ 3 ,� �aL> N,,S —. FY...�Ar Tge FovN.DATlbb1 IoWN U vN '�a��••'`�ri. !1�v tt�4:, -t d(E�:. S Ip ice!-+tJ Fs�- 4 fJD 5�i"i3AGIL �.���v�,�� j` ; ,;: t 42VAENTS. OJT. 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