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0315 VINEYARD ROAD - Health
315 VINEYARD ROAD, COTUIT A^ i i I i r _ -aYr r Commonwealth of Massachusetts A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 315 Vineyard Rd. Property Address Prudence Rosenthal owner _ Owner's Name infotmationis Cotuit MA 02635 12-11=12 requited for every page. Cityrrown State Zip Code Date of Inspection . inspection results must be submitted on this form. inspection forms'rhtay not be altered in ally way.Please see completeness checklist at the end of the form. filling out forms A.A General Info.rrn.atio:n filling outforms OFrM�sii�;��� on the oomputer, use only the tab 1- Inspector o`' tiC_ key to move your JAM ES •u' cursor-do not James D. Sears o. use the return _ IRS, . ke Name of Inspector :*` Capewide Enterprises,LLC o Company Name S�''�i 55•I N SPA 0 153 Commercial St. 'fill n111;i0o Company Address Mashpee MA 02649, Cityrrown State Zip Code 508-477-8877 81623 Telephone Number License Number B.. Certification certify that I have personally inspected the sewage disposal system at this address'and 'Mat the information reported below is true, accurate and complete as of thee time of the inspection:The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails . ❑ Needs Further Evaluation by the Local Approving Authority �9 r t S_3 4 1-4 12-11-12 ey 4fispector's Signature Date --.4 ,. The system inspector shall submit a co of this inspection report to the A avin Author roard y P PY P P PP 9 ,� tty of Health or DEP)within 30 days.of completing this inspection. If the system 'is a shar6dsystem. or has a design flow of 10,000 gpd or greater,the inspector and the system owr"er shall submit the report to the appropriate regional office of the DEP.The original should be sent to the!W,�terrfftner 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. Sins•1 tlto Tine 5 otfidal Inspeclan Fotrm Subsurface Savage Disposal System•Page 1 of 57 i ?� Ali Dec 1212 11:54a p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal Owner Owners Name information is required for every Cotu it MA 02635 12-11-12 page. Cityrrown state Zip Code Date of Inspection B. Certification (font.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 3.10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'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): Wins-11/10 This 5 official Inspection form:Subunface Sewage Disposal System•Page 2 of 17 Dec 121211:55a p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal Owner Owner's Name information required for every Cotuit MA 02635 12-11-12 page_ City/Town State Zip Code Date of Inspection B. Certification .(cunt.) B) System Conditionally Passes (cunt): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are.replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Ofrrdal Inspection romt Subsurface Sewage Disposal System•Page 3 Y 17 Dec 12 12 11:55a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal owner Owner's Name information is required for every Cotuit MA 02635 12-11-12 page, City/Town State Zip Code Date of Inspection B. Certification (cant.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in eesspeot is less than 6' below invert or available volume is less than Y2 day flow J-CA C'A(i V G 151ns•11110 Mtle'5 Offical hspecfion Form:SubsuKace Sewage Disposal System-Page 4 of 17 Dec 12 12 11:55a p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal Owner Owners Name information is required for Cotuit MA 02635 12-11-12 . page. Cityfrown State Zip Code Dale of Inspection B. Certification (cunt.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number.of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ED 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. ❑ 0 The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.. For large systems, you must Indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface.drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department t5ins-I M0 Title 5 Offdal Inspection Form:Subudece Sewage Disposal System•Page 6 of 17 Dec 12 12 11:56a p.6 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 315 UneYard Rd. Property Address Prudence Rosenthal Owner Owner's Name information is required for every Catuit MA 02635 12-11-12 page. City/Town Stale Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes'or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 t5ins•11110 Tills 5 Official Inspection Farm:SubsuAace Sewage Disposal System-Page 6 cf 17 Dec 12 12 11:56a p.7 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal Owner . Owner's Name information is required for every Cotuit MA 02635 12-11-12 page. cftyrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 precast tank, D Box and four 500 gal dry well chambers Note: outlet tee has a filter Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ER No Is laundry on a separate sewage system?[if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? 0 Yes ❑ No Water meter readings, if available last 2 ears usage d 2011-29,000Gals g ( y g (9P )) 2012-21,000Gals Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercialtindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personstsq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-1 1110 Title 5 Official lnspecton Form:Subsurface Sewage Disposal System-Pege 7 of 17 Dec 12 12 11:56a p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal Owner Owner's Name information is required for every Cotuit MA 02635 12-11-12 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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): t5ins-11110 Title 5 Official lrspectlon Forth:Subsurface Sewage Disposal System-Page 8 of 17 Dec 121211:57a p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 316 VineYard Rd. Property Address Prudence Rosenthal Owner Owners Name informations required for every Cotuit MA 02635 12-11-12 page. Cityirown State Zip Code Date of Impedion D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2009 Permit# 2009- 174 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 14"feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal Precast Sludge depth: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Dec 121211:57a p.10 Commonwealth of Massachusetts Title 5 official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal Owner Owner's Name information is required for every Cotuit MA 02635 12-11-12 City/Town page. Slate Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont) Distance from top of sludge to bottom of outlet tee or baffle 28" 1 Scum thickness Distance from top of scum to top of outlet tee or baffle 8a Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape-Plan Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank and covers at 6" below grade,outlet tee wKlter. Tank at workinking level no sign of leakage or over loading Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins-1 V10 Title 5 Of iclal hlspectlon Form:Subsurlaee Sewage plsposal System-Page 10of 17 Dec 12 12 11:57a p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal Owner owner's Name information is required for every Gotuit MA 02635 12-11-12 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal C]fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 111 of'7 Dec 12 12 11:58a p.12 Commonwealth of Massachusetts -- I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal Owner Owner's Name information.s required for every Cotuit MA 02635. 12-11-12 page. Cityrrown State Zip Code Date of Inspection D. System information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-35" below grade w/cover at 18". Box is clean and solid w/two lines out. No sign of over loading or solid carry over. _ Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins-11110 Tole 5 Official Inspection For:Subsurface Sewage Dispo",System•Page 12 of 17 r Dec 12 12 11:58a p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal Owner Owners Name information is Cotuit MA 02635 12-11-12 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number. 4 ❑ leaching galleries number- El leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is four 500 Gal dry well chambers w/4' stone. Chamber's are 42"below grade w/two covers at 1�0"chamber's are clean and dry,like new. No sign of over loading or solid carry over 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 t5ina•11110 Title 5 Official Inspection Forth.Subsurface Sewage Disposa!System•Page 13 or 1T Dec 12 12 11:58a p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal Owner Owner's Name information is required for every Cotuit MA 02635 12-11-12 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspecllon Farm:Subsurface Sewage Disposal system-Page 14 of 17 Dec 12 12 11:59a p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 315 yneYard Rd. Property Address Prudence Rosenthal Owner Owner's Name information is required for every Cotuit MA 02635 12-11-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (coat.) 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 Q drawing attached separately i s { I i j /ti a f Dec 12 12 11;59a p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal Owner owner's Name information is required for every Cotuit MA 02635 12-11-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water 1 I V+ et 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: 10-11-08 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: T.H. on design plan 10-11-08 No G.W. at 11+' Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins-11/1 D Tide 5 OKieiial hTspection Forth:Subsurtace Sewage Disposal System•Pepe 16 of 17 Dec 121211:59a p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 315 VineYard Rd. Property Address Prudence Rosenthal Owner Owner's Name information is required for every Cotuit MA 02635 12-11-12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•1 I/1D Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 U.S. Postal ServiceTM CERTIFIED MAIM. RECEIPT (Domestic Mail,Onlj No Insurance Coverage Provided) � �F,o�,delivery;info`rmation;visit ouiwebsite'at www.usps.com® _ I hi � 1I � L► Ulm1 PS Form 3800,August 2006 See Reverse for Instructions Certified Mail Proviges: a A mailing receipt a A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mails. a Certified Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSs postmark on your Certified Mail receipt is required. in For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". a If a postmark on the Certified Mail receipt is desired,Please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 SECTIONSENDER: COMPLETE THIS •MPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,:and.3.Also complete b. A. Signature item 4 if Restricted Delivery is desired. 9��35 a n_{, 1 ❑Agent o Print your name and address on the reverse '\ l 1/� 1 'Cl Addressee so that we can return the card to you. Rece' by( C. Date of Delivery ® Attach this card to the back of the mail iece or on the front if space permits: p L— P' ted Nam ��� D. Is delivery address differen4mrn item 1? ❑Yes 1.Article Addressed to: If YES,enter delivery address below: P No 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number �- (Transfer from service label) C 7 0 0 6 2150 0002 1042 0040 PS Form 3811;February 2004;?i 11 ( Domestic Return Receipt, 102595-02-M-1540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid { USPS PjermiL.No.G-10 I o � • Sender: Please print your name, address, and ZIP 4i box 0 �;fiC1J� L�VVIiC °�b Anil Pv I � I � I I I lll>>11 dill I I �;I t Barnstable , , Town of Barnstable bvftyl Regulatory Services Department srABLE DAM � m 9� MASS. �,g Public Health Division Zoos prfb MA't A 200 Main Street, Hyannis MA 02601 Thomas F.Geiler,Director Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 July 2, 2008 Prudence Rosenthal 2105 Devonshire Road Ann Arbor, MI 48014 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 315 Vineyard Road, Cotuit,MA was last inspected on June 13, 2008,by Brad J.White, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: The primary cesspool is not structurally sound. The sidewalls are severely corroded with heavy root infiltration. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean,R.S., CH Agent of the Board of Health T CERTIFIED MAIL#7006 2150 0002 1042 0040 Q:\SEPTIC\Letters Septic Inspection Failures\315 Vineyard Road.doc Ys� of THE rpm � _ P�Posz,q - Town of Barnstable r• o Public Health Division i +� 200 Main Street 2 PITNEY 6OWES Hyannis, MA 0601 j ! 02 1 A 05.320 0004606238 JUN 25 2008 cV 7006 2150 0002 1041 9891 MAILED FROM ZIP CODE 02601 i C\j -. - -- - - - Prudence Rosenthal N: J� MP, 315 Vineyard Road Cotuit, MA,02635 W N 3i I>i IE 029 4C I RETURN TC SENDER NO MAIL RECEPTACLE UNADLE TO PO;:?W!dPD 1 0260141.4 lil��>») 1>11t>11�7>>z>k111�,111�,�i1>>>>}l,ill>rtl1�»tltl�l rw . r�, �::�; 3 f . �� ( � �r a.� � � �, ,� J �, 1 i �— ._ � - ,. . '_ .�+! i+l � � . .. �r SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery Is desired. X ❑Agent ■ Print your name and address on the reverse_ ❑Addressee so that we can return the card to you.. B. Received by(Printed Name) C. Date of Delivery ® Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No n G 3. Service Type� ❑Certified Mail ❑Express Mail � w ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7006 2150 0002 1041 9891 (Transfer from service label) ` PS Form 3811.,February 2004 Domestic Return Receipt 102595-02-M-1540 I UNITED STATES POSTAL SERVICE First-Class Mail I Postage&Fees Paid USPS Permit No.G-10 M • Sender: Please print your name, address, and ZIP+4 in this box • v tS\CsvL- Cl,-(-N- fN S ; Y---)- GaCQ j mC Town of Barnstable Barnstable Y ! Regulatory Services Department e`Ce�j > BARNSTABLE. MASS. 059. Public Health Division �� ArfDN4°�A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Th omas A.McKean CHO June 25, 2008 Prudence Rosenthal 315 Vineyard Road Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 315 Vineyard Road, Cotuit, MA was last inspected on June 13, 2008,by Brad J.White, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: The primary cesspool is not structurally sound. The sidewalls are severely corroded with heavy root infiltration. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE B ARD OF HEALTH I Thomas McKean, R.S.,-CHO Agent of the Board of Health CERTIFIED MAIL #7006 2150 0002 1041 9891 ..r c.. 1 9. 'w�#3 ..�.r„+ '��.I..,�f ...'1.•t`Ja ._ � • .... 7.\/Cr rill �.Yt. jl�l^ tas T� l�l.�� .. 1. .. S.IV .•rf Y .. ,, ' —. .- 1 Q:\SEPTIC\Letters Septic Inspection Failures\315 Vineyard Road.doc fflaff• @Mdlam Y r-R i. • Er CEI Q' OFFICIAL USE p Postage $ � �o2sor rl �\ Certified Feea . V ru v tma p Return Receipt Fee p (Endorsement Required) tiHere V p Restricted Delivery Fee p (Endorsement Required) rr-1 Total Postage&Fees $5 3 a J ru V - p Street,Apt.Ao: M or.PO Box No. fty, to +4,. ................ ....................... IS 1 Certified Mail Provides: a A Whiling receipt o A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders. o Certified Mail may ONLY be combined with First-Class Mail®or Priority Malls. e Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. to For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". • If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 Town of Barnstable Barnstable t�r ti Oft Regulatory Services Department a`68C j RN MA 9� MAC.1639. Public Health Division �� m ArFD"`A�A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO June 25, 2008 Prudence Rosenthal 315 Vineyard Road j Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 315 Vineyard Road, Cotuit, MA was last inspected on June 13, 2008,by Brad J.White,,a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: The primary cesspool is not structurally sound. The sidewalls are severely corroded with heavy root infiltration. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE B ARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 9891 Q:\SEPTIC\Letters Septic Inspection Failures\315 Vineyard Road.doc COTUIT WATER DEPARTMENT WATER SERVICE APPLICATION DIG SAFE TICKET NO. SERVICE NO. DATE 5 a3 hereby make application for wa er se ice at Lot No. nin treet i e in the Village of 1 and agree to abide by the rules and regulations of the Water Department. No connections will be made to water service lines located within 20 feet of any cesspool, cesspool drain lines or lines entering cesspools. No connections will be made to water service lines located within 10 feet of electric, telephone or gas lines, or to water service lines which pass under electric or telephone lines.Capital Improvement Fee of$600.00 must accompany this application unless dwellinq built prior to Ma r�, 29,1973). _ Service Bills are charged at Labor, Materials, Sales Tax, and Connection Charge. Service Bill must be paid before water is turned on. Water Department is not responsible for excavation,backfilling,or the repair or patching of foundation prior to any such backfilling. Name of Owner per Deed Present Address I (/ M & Future Billing Address CZ 1 D J U4WO 11 K VU � !k bi)ri �g 6 Signature of Owner or Agent Name and Phone#of Contact Person a S81&�I 6139 (0� 0'5 4 1 :1Iq-` -b Za3 lease sketch on reverse any utilities including cesspool and location of where water is to be installed. Service Box will be staked upon request. - hAl 1/1 7-3, RIOENCE� R05ENTH�►I:N 1kRBOR MI 48104MTV— .`.U; � i S 4 ra r g ` OLLARS t AnnAcboc1v11CkugarC48104 ! t m o 0 b0 b 08 78ho� 5u■ �0 399 z Town of Barnstable. P4t-z °F Departinent of Regulatory Services ti Public.Health Division, Date MOM � � Miss. s� 200 Main Street;H annis MA 02601 ' . ,bsy, ♦ j''. ' - + . . Date Scheduled / 'Time Fee Pd • E I oil ,Sr�itahility Assessment for Sewage Dis osal' 10 � Performed By: ! Witnessed i O LOCATION & GENERAL INFORMATION Location Address 3 Y Q 0��It,r► p�,� i Owner's Name F"VIE N(F 60 7v 1T fit" t`-✓`1 i Z1 05 pevoel SN-r2a R� Address 0.A— M( 00 Assessor's Map/pocel. O l /�� ' I Engineer's Name Q x NEW CONSIRU#ION REPAIR j Telephone# :s rs z" QA Z Slopes Surface stones Land Use (g'o) Distances from: C1pen Water Body ��� €t ,Possible Wee Areaft .Drinking Water Well /:� ft Drainage Way > OZ� ft Property Line=ft` Other - ft SKETCH:($treet name,dimensioris`of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) CD i ; I i i ; Parent material(geologic a S"I Depth to Bedrock Depth to Groundwa(;er. Standing Water in Hole Weeping from Pit Face , Estimated Seasonal thigh Groundwater N/ DtTERMINATION FOR SEASONAL HIGH'WATER TALE Mlet:ad ii=d: I' i Depth to sail mUlties: la. Depth (1.4erved standing in obs.hole: _id. D i in, Groundwater Adjustment ft.Depth toiweeping from side of obs.hole: 77� Adj.factor,,,... ..- Ad).d�undwater Level— Index Well# Reading Date: Index Well level PERCOLATION TEST Date t TIM"�. Observation I Time at 9" r'� ---- Hole# P 1 Time at 6" -- Depth of Perc r1 i) i Time(9"-6") _._----- --------- Start Pre-soak Time.@ 9 0 - End Pre-soak ' Rate MinJInch Site Suitability Assc$sment: Site Passed_ _ Site Failed; Additional Testing Needed(YIN) Original:.Public Health Division Observation Hole Data To Be Completed on Back ***If pereolafiion test is to be conducted within 100' of wetland,:you must firs wedk prior to beginning. notify the Barnstable C4#servation Division at least one(1) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil ' Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel 35" l3Z' G Meo -GW-4'-�e �•s 71 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consn m- istenc Gravel) b t , ,r -2 76 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi tent %Oravel DEEP OBSERVATION HOLE LOG Hole# N Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. on isten Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary - No L Yes Within 100 year flood boundary No X Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist,in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on �� (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was performed by me consistent with the required t in ,experti Zeand experience described in 3,10 CMR 15.017. Signature Date404" Q:ISEPTICVERCFORM.DOC Simmer.CleaTier.Greenfr_ V June 18, 2008 P Rosenthal 2105 Devonshire Rd Ann Arbor Mi 48104 To whom it may concern, I am writing this letter regarding the above stated property. I recently performed a Title V Inspection at 315 Vineyard Road on 6/13/2008 . The system although currently at a good working level with no evidence of hydraulic failure, The primary cesspool is not structurally sound. The sidewalls are severly corroded with heavy root infiltration. This is the reason for the failure classification. Should you have any questions regarding this Title V Inspection please feel free to contact me @ (508) 775-2800. Sincerely, Brad J. White Bluewater 0.� , r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 315 Vineyard Road Property Address Prudence Rosenthal �)0� Owner Owner's Name information is required for Cotuit MA 02635 06/13/2008 every page. CityTrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:V11hen filling out A. General Information " forms on the computer,use 1. Inspector: only the tab key to move your Brad J. White cursor-do not Name of Inspector use the return key. Bluewater Company Name 350 Main Street Company Address = C West Yarmouth MA A2673 4i CitylTown State ! ip Code ,3 (508)775-2800 . Telephone Number License Number co 6. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system ❑ Passes ❑ Conditionally Passes © Fails ❑ Needs Further Evaluation by the Local Approving Authority 06/13/2008 Inspector's ture Date The syste 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 god 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. t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 315 Vineyard Road Property Address Prudence Rosenthal Owner Owners Name information is COtUIt required for MA. 02635 06/13/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 1.5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved, by the Board of Health,,will pass. Answer yes, no or not determined.(Y, N, ND) in the❑for the following statements. If"not . determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 315 Vineyard Road Property Address Prudence Rosenthal Owner Owner's Name information is COtult required for MA 02635 06/13/2008- every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to.broken q P P 9 y oken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C). Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp.doe•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 315 Vineyard Road Property Address Prudence Rosenthal Owner Owner's Name information is COt{Jlt required for MA 02635 06/13/2008 every page. City/Town State 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: D) System Failure Criteria Applicable to All Systems: i 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 EJ 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 ❑ Nor clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. pp y t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts 6 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 315 Vineyard Road Property Address Prudence Rosenthal Owner Owner's Name information is required for Cotuit MA 02635 every page. City/Town 06/13/2008 State Zip Code Date of Inspection B. Certification (coot.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ M'/ 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. ❑ sell Any portion of a cesspool or privy is less than 100 f eet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes If the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply I ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 5 of 15 Commonwealth of Massachusetts a Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments ssments M 315 Vineyard Road Property Address Prudence Rosenthal Owner Owner's Name information is required for Cotuit every page. City/Town MA 02635 06/13/2008 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: Y�e.,s/ No trJ ❑ Pumping information was provided b p y the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previ ous, ions 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 u LI ❑ 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 inspected for the condition of the baffles or tees, material of consuct otn,e tank 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)] I t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 i Commonwealth of Massachusetts F Title 5 Official Ins _ pection Form Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments ,. 315 Vineyard Road Property Address Prudence Rosenthal Owner information is Owners Name required for Cotuit MA 02635 every page. Citylrown 06/13/2008 State Zip Code Date of inspection D. System Information Residential Flow Conditions: Number of bedrooms n Unknown (design): 5 ( g ) Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms)': Unknown Number of current residents: 0 Does residence have a garbage grinder? ® Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ® Yes-9 No Laundry system inspected? Yes ® No Seasonaluse? ® Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Wellwater Sump pump? ® Yes O ' No Last date of occupancy: Seasonal Use Date . Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ® Yes ® No Industrial waste holding tank present? ® Yes ® No Non-sanitary waste discharged to the Title 5 system? ® Yes ® No Water meter readings, if available: Last date of occupancy/use: i Date. Other(describe): I t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntar y Assessments ,M 315 Vineyard Road Property Address Prudence Rosenthal Owner information is Owner's Name required for' Cotuit MA 02635 every page. Cityrrown 06/13/2008 State Zip Code Date of Inspection De System Information (cont.) General Information Pumping Records: Source of information: Caretaker indicated Never Pumped Was system pumped as part of the inspection? ® Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system l� Single cesspool Ind Overflow cesspool Privy ❑ � � Shared system (yes or no) (if yes, attach previous inspection records, if any) I ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest I 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: I House was built in 1968. No plans on file at town hall. System a i Y appears to be original Were sewage odors detected when arriving at the site? ® Yes No t5insp.doc•030 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 r Commonwealth of Massachusetts Title 5 Official Ins ection F Subsurface Sewage Disposal System Form-Not for VoluntaryForm . Voluntary Assessments °�M ,• 315 Vineyard Road Property Address Owner Prudence Rosenthal information is Owner's Name required for COtuit MA 02635 every page. City/Town 06/13/2008 State Zip Code Date of Inspection D. system Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2111 feet Material of construction: ❑ cast iron ❑40 PVC 0✓ other(expl— a—in)�-- Orangeburg Distance from private water supply well or suction line:—*O' Over 115' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Building sewer is made of Orangeburg and should be replaced due to deteriation of piping. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ® Yes ---------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? t5insp.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for VoluntaryAssessments ments M 315 Vineyard Road Property Address Prudence Rosenthal Owner Owner's Name information is required for COtuit MA 02635 every page. Cityrrown 06/13/2008 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.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass,9 El 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal El fiber lass 9 ❑ polyethylene ❑other(explain): t5insp.doc„03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 315 Vineyard Road Property Address Prudence Rosenthal Owner Owner's Name information is required for Cotuit every page. Citylrown MA 02635 06/13/2008 State Zip Code Date Of Inspection Do 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 [I 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 Distribution Box (if.present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Pump Chamber(locate on site plan): Pumps in working order: ® Yes No Alarms in working order: ® Yes ® No t5insp.doc-03/08 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 VoluntaryAssessments ments ,M 315 Vineyard Road Property Address Prudence Rosenthal Owner Owner's Name information is required for Cotuit MA 02635 every page. Cit Town 06/13/2008 State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition'of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers. number: ❑ leaching.galleries number: i ❑ leaching trenches number, length: ❑ - leaching fields number, dimensions: overflow cesspool _ number: -- 1 @ 6'x 6' ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure level of vegetation, etc.):, po nding, damp soil, condition of Soil is dry. No signs of hydraulic failure. Overflow cesspool is completely Bone dry. Vegetation is normal. Overflow is 30"below grade and bottom of cesspool is 102"below grade. t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 official Inspection F p orm Subsurface Sewage Disposal System:Form-Not for Voluntary Assessments 315 Vineyard Road Property Address Prudence-Rosenthal Owner Owner's Name information is required for Cotuit MA 02635 every page. CRY/I own 06/13/2008 State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2- Overflow Depth—top of liquid to inlet invert 31-9" Depth of solids layer 0" Depth of scum layer 1/2" Dimensions of cesspool 6'x 6' Materials of construction Block Indication of groundwater inflow.. ® Yes No Comments(note.condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Soil is dry. System consists of a primary and an overflow cesspool. Primary cesspool had very heavy root infiltration.Also blocks on sidewalls seemed severly corroded. Not structurally sound. I 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.): I I I t5insp.doc•03/08 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments sments ••'"r 315 Vineyard Road Property Address Prudence Rosenthal Owner Owner's Name information is required for Cotuit every page. City/Town MA 02635 06/13/2008 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. SC)' �%J« ALL 71-E c_ i 0 C4gS. XUA . z t bCcK > Y� T I W L t5insp.doc•03108 `� •? `�Gj Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 ' r Commonwealth of Massachusetts W Title 5 Official Inspection Form s d p Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 315 Vineyard Road Property Address Prudence Rosenthal Owner Owner's Name information is required.for Cotuit MA 02635 every page. City/Town 06/13/2008 State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water 0 Check cellar 0 Shallow wells Estimated depth to high ground water: 11' 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) Lld Accessed USGS database-explain: Well MIW 29/Zone A/Level 7.8/Adjustment 1.4 x 12"= 16.8" You must describe how you established the high ground water elevation: There is a slope off in the rear right of the property. Used lazer level to shoot elevations with no indication of groundwater @ 11'or 132". Bottom of the deepest point on the system is at 102". Add the required adjustment of 16.8" brings the total to 118.8 leaving an additional 13.2". t5insp.doc•03/08 Title 5 Official Inspection Four:Subsurface Sewage Disposal System-.Page 15 of 15 ' 1 - --- - -- I : I , � I 1 ! I ! � - _ 6► I -a � i I ! _-` -� ! - ; I i i _ I l9 _ --1 f -- i ! i I i ! 1 _ j -�— ' - --I - -- -- - I---!---- -�. .-- - - -- -- - - - - �- - --- - --- - --- '- - -! ---- '- -- ---'--- - i ! I I � I I..- i� -NbI. -'-FhYc��t,��' j 7F 41.0 co -- .•..._._s_ -- _.!.— ? — — — —I — ! _ — I —.�_..� — —— i— I— _ _ .� _. ! i�i� �. —iQf f% PQ IpC` V-I.—_.. 1 1 I I i I e. - I— __ 1 ! I ._ _..__ .. -I i I ---+ I,_....{ ) _ ! I . I I -r—__.,__- i f - i _.._!. 9 Thomas&Betts Corporation j0 452 John Dietsch Blvd. (SEP P.O. Box 2510 Attleboro Falls, MA 02763 (508) 699-9800 Facsimile(508) 695-8111 4 1998 to N ` Thomas 06OBeffs s August 10, 1998 Mr. and Mrs. Amnon Rosenthal 2105 Devonshire Road Ann Arbor, Michigan 48104 Dear Mr. and Mrs. Rosenthal: Enclosed please find the laboratory results of the analysis of your well water,which we recently sampled at your property located at 315 Vineyard Road in Cotuit, Massachusetts. The water sample, designated as RW-16, was collected by GZA GeoEnvironmental, Inc. and analyzed by the Mitkem Corporation laboratory. Chloroform was found in your well water at a concentration of 1 part per billion. This contaminant is not related to the 106 Falmouth Road Site. These results were sent to the Massachusetts Department of Environmental Protection (DEP). We understand that the DEP generally advises that"there is currently no drinking water standard for chloroform in non-chlorinated water supplies. The Department's Office of Research and Standards has established a drinking water guideline for chloroform of 5.0 ppb in non-chlorinated water supplies. Chloroform is considered to be naturally occurring and ubiquitous throughout Cape Cod. Chloroform has also been associated with on-site septic systems." If you have any questions regarding chloroform, please call the Barnstable Board of Health or DEP. As you may recall, the contaminants of concern at the 106 Falmouth Road Site were industrial solvents and cleaners potentially related to historic operations at that facility. To test for such materials, the laboratory analyzes for the range of VOCs specified by the EPA's testing method. That is why the Laboratory Analysis Report covers such a long list of organic compounds. Beside the list of compounds are two columns of data. The first column shows the concentration of the compound, in parts per billion(ppb),that was found in your well water. The letters "ND" mean the compound was not detected. The second column shows the lowest level at which the laboratory could accurately quantify the compound. We appreciate your allowing us to come and test your water. If you have any questions, please do not hesitate to call Mike Powers at GZA(401-421-4140, ext. 3404). Sincerely, William O. Frigon Attachment: Laboratory Analysis Report cc: Town of Barnstable Board of Health Mark Wood,DEP MITKENI CORPORATION GZA GeoEnvironmental, Inc. JUL 01 �ggg June 29, 1998 140 Broadway Providence, RI 02903 Attn: Ms. Hilary Fortune RE: Client Project#: 31751.13, Residential Well Sampling Lab Project#: E0963 Dear Ms. Fortune: Enclosed please find the data report of the required analyses for the samples associated with the above referenced project. If you have any questions regarding this report,please call me. We appreciate your business. Sin ely, Edward A. Lawle Laboratory Operations Manager s 175 Metro Center Boulevard • Warwick,-,Rhode Island 02886-1755 • (401) 732-3400 • Fax(401) 732-3499 email: mitkem@worldnet.att.net f CORPORATION Client: GZA GeoEnvironmental, Inc. Client Project: 31751.13, Residential Well Sampling Lab Project: E0963 Date samples received: 6/22/98 Project Narrative This data report includes the analysis results for five (5) aqueous samples that were received from GZA GeoEnvironmental,Inc. on June 22, 1998. Analyses were performed per specification in the Chain of Custody form. For reference, a copy of the Mitkem Sample Log- In form is included for cross-referencing the client sample ID and laboratory sample ID. All of the analyses were performed according to method specifications. No unusual occurrences were noted during sample analysis. This data report has been reviewed and is authorized for release as evidenced by the signature below. Edward A. Lawler Laboratory Operations Manager 0DD CORPORATION Analysis Report: Purgeable Volatile Organics Client: GZA GeoEnviron mental, Inc. Analysis Date: 6/25/98 Client ID: RW-16 Concentration in: ug/L Lab ID: E0963-03 Dilution: 1 Analysis: Method 524.2 Reporting Analyte Results Limit Dichlorodifluoromethane ND 0.5 Chloromethane ND 0.5 Vinyl chloride ND 0.5 Bromomethane ND 0.5 Chloroethane ND 0.5 Trichlorofluoromethane ND 0.5 1,1-Dichloroethene ND 0.5 Methylene chloride ND 0.5 trans-1,2-Dichloroethene ND 0.5 1,1-Dichloroethane ND 0.5 2,2-Dichloropropane ND 0:5 cis-1,2-Dichloroethene ND 0.5 Bromochloromethane ND 0.5 Chloroform 1 0.5 1,1,1-Trichloroethane ND 0.5 Carbon tetrachloride ND 0.5 1,1-Dichloropropene ND 0.5 Benzene ND 0.5 1,2-Dichloroethane ND 0.5 Trichloroethene ND 0.5 1,2-Dichloropropane ND 0.5 Dibromomethane ND 0.5 Bromodichloromethane ND 0.5 cis-1,3-Dichloropropene ND 0.5 Toluene ND 0.5 trans-1,3-Dichloropropene . ND 0.5 1,1,2-Trichloroethane ND 0.5 Tetrachloroethene ND 0.5 1,3-Dichloropropane ND 0.5 Dibromochloromethane ND 0.5 1,2-Dibromoethane ND 0.5 Chlorobenzene. ND 0.5 1,1,1,2-Tetrachloroethane ND 0.5 006 Page 1 of 2 E0963-03 MITKEM CORPORATION Client ID: RW-16 Lab ID: E0963-03 Reporting Analyte Result Luna Ethylbenzene ND 0.5 Xylenes(total) ND 0.5 Styrene ND 0.5 Bromoform ND . 0.5 Isopropylbenzene ND 0.5 Bromobenzene ND 0.5 1,1,2,2-Tetrachloroethane ND 0.5 1,2,3-Trichloropropane ND 0.5 n-Propylbenzene ND 0.5 2-Chlorotoluene ND 0.5 4-Chlorotoluene ND 0.5 1,3,5-Trimethylbenzene ND 0.5 tert-Butylbenzene ND 0.5 1,2,4-Trimethylbenzene ND 0.5 sec-Butylbenzene ND 0.5 1,3-Dichlorobenzene ND 0.5 4-Isopropyltoluene ND 0.5 1,4-Dichlorobenzene ND 0•5 1,2-Dichlorobenzene ND 0.5 n-Butylbenzene ND 0.5 1,2-Dibromo-3-chloropropane ND 0.5 1,2,4-Trichlorobenzene ND 0.5 Hexachlorobutadiene ND 0.5 1,2,3-Trichlorobenzene ND 0.5 Naphthalene ND 0.5 QC Batch: V1 B0625A Surrogate Recovery: Bromofluorobenzene 112% 1,2-Dichlorobenzene-d4 102% ND= Not Detected 00 ( •Page 2 of 2 E0963-03 CORPORATION Analysis Report: Purgeable Volatile Organics Client: GZA GeoEnvironmental, Inc. Analysis Date: 6/25/98 Client ID: Trip Blank Concentration in: ug/L Lab ID: E0963-05 Dilution: 1 Analysis: Method 524.2 Reporting Analyte Results Lunt Dichlorodifluoromethane ND 0.5 Chloromethane ND 0.5 Vinyl chloride ND 0.5 Bromomethane ND 0.5 Chloroethane ND 0.5 Trichlorofluoromethane ND 0.5 1,1-Dichloroethene ND 0.5 Methylene chloride ND 0.5 trans-1,2-Dichloroethene ND 0.5 1,1-Dichloroethane ND 0.5 2,2-Dichloropropane NO 0.5 cis-1,2-Dichloroethene ND 0.5 Bromochloromethane ND 0.5 Chloroform ND 0.15 J 1,1,1-Trichloroethane ND 0.5 Carbon tetrachloride ND 0.5 1,1-Dichloropropene ND 0.5 Benzene ND 0.5 1,2-1-)ichloroethane ND 0.5 Trichloroethene ND 0.5 1,2-Dichloropropane ND 0.5 Dibromomethane ND 0.5 Bromodichloromethane ND 0.5 cis-1,3-Dichloropropene ND 0.5 Toluene ND 0.5 trans-1,3-Dichloropropene ND 0.5 1,1,2-Trichloroethane ND 0.5 v Tetrachloroethene ND 0.5 1,3-Dichloropropane ND 0.5 Dibromochloromethane ND 0.5 1,2-Dibromoethane ND 0.5 Chlorobenzene ND 0.5 1,1,1,2-Tetrachloroethane ND 0.5 U�1 4 O Page 1 of 2 E0963-05 1 f CORPORATION Client ID: Trip Blank Lab ID: E0963-05 Reporting Analyte Result Limit Ethylbenzene ND 0.5 Xylenes (total) ND 0.5 Styrene ND 0.5 Bromoform ND 0.5 Isopropylbenzene ND 0.5 Bromobenzene ND 0.5 1,1,2,2-Tetrachloroethane ND 0.5 1,2,3-Trichloropropane ND 0.5 n-Propylbenzene ND 0.5 2-Chlorotoluene ND 0.5 4-Chlorotoluene ND 0.5 1,3,5-Trimethylbenzene ND 0.5 tert-Butylbenzene ND 0.5 1,2,4-Trimethylbenzene ND 0.5 sec-Butylbenzene ND 0.5 1,3-Dichlorobenzene ND 0.5 4-Isopropyltoluene ND 0.5 1,4-Dichlorobenzene ND 0.5 1,2-Dichlorobenzene ND 0.5 n-Butylbenzene ND 0.5 1,2-Dibromo-3-chloropropane ND 0.5 1,2,4-Trichlorobenzene ND 0.5 Hexachlorobutadiene ND 0.5 1,2,3-Trichlorobenzene ND 0.5 Naphthalene ND 0.5 QC Batch: V1 B0625A Surrogate Recovery: Bromofluorobenzene 114% 1,2-Dichlorobenzene-d4 102% ND= Not Detected Oil Page 2 of 2 E0963-05 MITKEM CORPORATION Analysis Report: Purgeable Volatile Organics Client: GZA Geo Environmental, Inc. Analysis Date: 6/25/98 Client ID: Concentration in: ug/L Lab ID: Method Blank, V1 B0625A Dilution: 1 Analysis: Method 524.2 Reporting Analyte Results Limp Dichlorodifluoromethane ND 0.5 Chloromethane ND 0.5 Vinyl chloride ND 0.5 Bromomethane ND 0.5 Chloroethane ND 0.5 Trichlorofluoromethane ND 0.5 1,1-Dichloroethene ND 0.5 Methylene chloride ND 0.5 trans-1,2-Dichloroethene ND 0.5 1,1-Dichloroethane ND 0.5 2,2-Dichloropropane ND 0.5 cis-1,2-Dichloroethene ND 0.5 Bromochloromethane ND 0.5 Chloroform ND 0.5 1,1,1-Trichloroethane ND 0.5 Carbon tetrachloride ND 0.5 1,1-Dichloropropene ND 0.5 Benzene ND 0.5 1,2-Dichloroethane ND 0.5 Trichloroethene ND, 0.5 1,2-Dichloropropane ND 0.5 Dibromomethane ND 0.5 Bromodichloromethane ND 0.5 cis-1,3-Dichloropropene ND 0.5 Toluene ND 0.5 trans-1,3-Dichloropropene ND 0.5 1,1,2-Trichloroethane ND 0.5 Tetrachloroethene ND 0.5 1,3-Dichloropropane ND 0.5 Dibromochloromethane ND 0.5 1,2-Dibromoethane. ND 0.5 Chlorobenzene ND 0.5 1.1,1,2-Tetrachloroethane ND 0.5 012 4' Page 1 of 2 E0963-MB MITKEM CORPORATION Client ID: Lab ID: Method Blank, VlB0625A Reporting Analyte Result Limit Ethylbenzene ND 0.5 Xylenes(total) ND 0.5 Styrene ND 0.5 Bromoform ND 0.5 Isopropylbenzene ND 0.5 Bromobenzene ND 0.5 1,1,2,2-Tetrachloroethane ND 0.5 1,2,3-Trichloropropane ND 0.5 n-Propylbenzene ND 0.5 2-Chlorotoluene ND 0.5 4-Chlorotoluene ND 0.5 1,3,5-Trimethylbenzene ND 0.5 tert-Butylbenzene ND 0•5 1,2,4-Trimethylbenzene . ND 0.5 sec-Butylbenzene ND 0.5 1,3-Dichlorobenzene ND 0.5 4-Isopropyltoluene ND 0.5 1,4-Dichlorobenzene ND 0.5 1,2-Dichlorobenzene ND 0.5 n-Butylbenzene . ND 0.5 1,2-Dibromo-3-chloropropane ND 0.5 1,2,4-Trichlorobenzene ND 0.5 Hexachlorobutadiene ND 0.5 1,2;3-Trichlorobenzene ND 0.5 ' 1 Naphthalene ND 0.5 QC Batch: V1 B0625A Surrogate Recovery: Bromofluorobenzene 108% 1,2-Dichlorobenzene-d4 102% ND= Not Detected 013 Page 2 of 2 E0963-MB MITKEM CORPORATION Analysis Report: Purgeable Volatile Organics Client: GZA GeoEnvironmental, Inc. Analysis Date: 6/26/98 Client ID: Concentration in: ug/L Lab ID: Method Blank, V1 B0626A Dilution: 1 Analysis: Method 524.2 Reporting Analyte Results L MA Dichlorodifluoromethane ND 0.5 Chloromethane ND 0.5 Vinyl chloride ND 0.5 Bromomethane ND 0.5 Chloroethane ND 0.5 Trichlorofluoromethane ND 0.5 M-Dichloroethene ND 0.5 Methylene chloride ND 0.5 trans-1,2-Dichloroethene ND 0.5 1,17Dichloroethane ND 0.5 2,2-Dichloropropane ND 0.5 cis-1,2-Dichloroethene ND 0.5 Bromochloromethane ND 0.5 Chloroform ND 0.5 1,1,1-Trichloroethane ND 0.5 Carbon tetrachloride ND 0.5 1,1-Dichloropropene ND 0.5 Benzene ND 0.5 1,2-Dichloroethane ND 0.5 Trichloroethene ND 0.5 1,2-Dichloropropane ND 0.5 Dibromomethane ND 0.5 Bromodichloromethane ND 0.5 cis-1,3-Dichloropropene ND 0.5 Toluene ND 0.5 trans-1,3-Dichloropropene ND 0.5 1,1,2-Trichloroethane ND 0.5 Tetrachloroethene ND 0.5 1,3-Dichloropropane ND 0.5 Dibromochloromethane ND 0.5 1,2-Dibromoethane ND 0.5 Chlorobenzene ND 0.5 - 1,1,1,2-Tetrachloroethene ND 0.5 014 Page 1 of 2 E0963-MB MITKEM CORPORATION Lab ID: Method Blank Client ID: ,V1B0626A Reporting Analvte Result Limit Ethylbenzene ND 0.5 Xylenes(total) ND 0.5 Styrene ND 0.5 Bromoform ND 0.5 Isopropylbenzene ND 0.5 Bromobenzene ND 0.5 1,1,2,2-Tetrachloroethane ND 0.5 1,2,3-Trichloropropane ND 0.5 n-Propylbenzene ND 0.5 2-Chlorotoluene ND 0.5 4-Chlorotoluene ND 0.5 1,3,5-Trimethylbenzene ND 0.5 tert-Butylbenzene ND 0.5 1,2,4-Trimethylbenzene ND 0.5 sec-Butylbenzene ND 0.5 1,3-Dichlorobenzene ND 0.5 4-Isopropyltoluene ND 0.5 1,4-Dichlorobenzene ND 0.5 1,2-Dichlorobenzene ND 0.5 n-Butylbenzene ND 0.5 1,2-Dibromo-3-chloropropane ND 0.5 1,2,4-Trichlorobenzene ND 0.5 Hexachlorobutadiene ND 0.5 1,2,3-Trichlorobenzene ND 0.5 Naphthalene ND 0.5 QC Batch: V1 B0626A Surrogate Recovery: Bromofluorobenzene 112% 1,2-Dichlorobenzene-d4 106% ND= Not Detected a1 Page 2 of 2 E0963-MB MITKEM CORPORATION Lab Project#: I E0963 Rl� Client Name: GZA GeoEnvironmental, Inc. Client Proj#: 31751.13 Logged In By: � Client PO#: 3-02043 Project Name: Residential Well Sampling Reviewed By: P�-5 Date Due: 6/26/98 Total Price: $ - Date: 6-2y—`i$ Time: f y0 Project Mgr: PAS Salesman: PAS Del Req'd: Completed?: YES Lab ID Client ID Matrix Analysis Price Sampled Received TPI IR BNA Herb 1L Wet Met V-GC V-MS Su -01 RW-22 AQ 524.2 6/19/98 6/22/98 1 -02 RW-21 AQ 524.2 6/19/98 6/22/98 1 -03 RW-16 AQ 524.2 6/19/98 6/22/98 1 704 RW-2 AQ 524.2 - 6/19/98 6/22/98 1 -05 Trip Blank AQ 524.2 6/19/98 6/22/98 1 TPf IR BNA Her >L Wet Met V-GC V-MS Su NOTESZ 0 0 0 0 0 0 0 0 5 0 ORIGINAL REPORT GOES TO: INVOICE GOES TO: ADDITIONAL REPORT GOES TO: GZA GeoEnvironmental,Inc Attn: Hilary Fortune Same None 140 Broadway Phone: 401 421-4140 Provid ce,RI 02903 Fax: 401 751-8613 6/24/98 1:28 PM Page 1 of 1 Lab Project M E0963 WHITE COPY-,Original YELLOW COPY-Lab Files PINK COPY-Project Manager W.O. # 0 o CHAIN-OF-CUSTODY RECORD (for lab use only) ANALYSES REQUIRED Sample Date/Time Matrix o u z _ Q I.D. o ' X ry s s a $ g m $ m - Total (Very Important) GW-,GIOUnd W. c _ ? ' 1 sw=su lace w. d N #Of Note M.Waeiew. g o N a g Cont. ff DW=Drinking W. 7 ar "� m m — m = — & Omer Iepe<il ] i fUA g 1 a a r 4 I f wo 2 /.3 Va L itW PRESERVATIVE (CI-HCI,N-HNO,,S-H,SO,,Na-NaOH,O-Other)* CONTAINER TYPE (P-Plastic,G-Glass,V-Vial,T-Teflon,O-Other)* I I I I I I I � I I I I I I Ell RELINQUISHED BY: Affiliation) DATE/TIME BY:(Affiliati NOTES:Preservatives,special reporting limits,known contamination,etc.: Unless otherwise noted,all VOA vials have been preserved w/1:1 HCL.) RELINQUISHED BY:(Affiliation) DATE/TIME R&CE11VED ion) l � RELINQUISHED BY:(Affiliation) DATE/TIME RECEIVED BY:(Affiliation) 150L PROJECT MANAGER: TURNAROUND TIME:❑Standard ❑ Rush Days,Approved by: GZA FILE NO. `� /7,1J P.O. N.O. 3 GZA GEOENVIRONMENTAL, INC. ENGINEERS AND SCIENTISTS PROJECT 140 Broadway PROVIDENCE,RI 02903 LOCATION (401)421-41 �� �,� FAX(401)751-868613 COLLECTOR('. �/(,) SHEET / OF� MITKEM CORPORATION Sample Condition Form Page_of FMITKEM Project: Received By: Reviewe Date: 1 Client Project: Client: Sample ID Preservation (pH) Comments/Remarks/ Condition: Lab Client HNO3 H2SO4 HCI NaOH Corrective Action` 1)Custody Seal(s) Present/Absent Coolers/Bottles Intact/Broken 2)Custody Seal Number(s) 3)Chain-of-Custody Present/Absent 4)Cooler Temperature Coolant Condition 5)Airbill(s) Present/Absent Airbill Number(s) , 6)Sample Bottles Intact Broken Leaking 7) Date Received 8)Time Received 9)Project Due Date * See Sample Condition Notification/Corrective Action Form yes/no MEW- No. Fee-----��--- -�—. BOARD OF HEALTH TOWN OF BARNSTABLE Application for Vell Conotruct ion permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel ------------------------ Owner Address / / D- J�ati.� lrwe �o�l a • �D i�� _ ---------------------------------------------- -:= f�" -- - - - ----/'-----------Y------------�---�� Installer — Driller _ Address Type of Building Dwelling ------------------------------------------ Other - Type of Building----------------------------------- No. of Persons------------------------------------- --- Typeof Well - v G Q- ------------------------------------ Capacity----------------------------------------------------------------------- Purpose of Well T'[----------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate Compliance has been issued by the Board of Health. Signed- date Application Approved By- - - -- - ---------------- __ -/date e- -( --_ Application Disapproved for the following reasons:---------------,-------------____________________________—______—____ - ------------------------- - -__------------------------------------------------------------------------------ -- - --- ------ date Permit No.------------------------ -------------- ----------------- Issued----------------------------------- - -— ——__ date BOARD OF HEALTH TOWN OF BARNSTAB LE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired d�c ------------------------------------ Installer r at------------- - --- - - - ----------------------------------------------------------------------------------- has been installed in accordpice 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.V a= -1-----Dated------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------------------------------------------------------- Inspector--------------------------------------------- -_--- - No--------------------- Fee- BOARD OF HEALTH TOWN OF BARNSTABLE 0.ppfitation-*rVell Con5truct ion Permit , N Application is=hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: Rj Cn 7�;7 -r`-=`4 - - -------------------------------------=----------------- `, Location - Address Assessors Map and Parcel _ o - - --- --- - - 3 U/h t G id ------------ f--------------------- L ------ Address -- - __-- --—- - - - - Owner ,// D.A Scati,.r ��w� (� D� ll _ I-' - P6- noy `�- `'��.t.L r-�U '026L7 ----- -- ---- --- -------- ----- - —._ -_ - - -- Installer — Driller Address Type of Building . Dwelling ------------------------------------------- Other- Type of Building ----- No. of Pers'ons-=--------------------------------------------- Type of Well ° ------------ Capacity - -------- Purpose of Well--d`-'-'-e; 7,c__ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed-----------------_-------------- - a (JG�✓,r tee. - - ------------------------ o� date e� Application Approved By---- �^=^ V date Application Disapproved for the following reasons:----------=-----------------------____--__--- --------- —_____--------------- -- �,{,� e� date Permit No. -°- - / �' 5 ---- Issued - - --- -- - ---- ----- - ---------------- ----------------------------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO C[E`RTIFY, That the Individu 1 Well Constructed ( ), Altered ( ), or Repaired ----------- —Installer i at- -.� 1 ` -- -- C =---------------------------------------------------------------------------------------- I has been installed in accordah the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. vlf: -�E-Dated-------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------- ---------------------------- Inspector- - - -- ----- -- ------------------------------ BOARD OF HEALTH TOWN OF BARNSTABLE lVerr Con!5truct ion Permit No. - = --- Fee—"='= --------- Permission is hereby granted ----------------------------------------------------- to - - -�-= at: Construct (��_Alter tern--.' o��ir-(----�n Individual Well---------------------------------------------------------------------------------------- No Street as shown on the application for a Well Construction Permit No--------------,---------------------------------------------------------------- Dated - - — `--'-a- �f- " ------------------- ----------— -- - - = -- — --- - -— Board of Health DATE------------------------------------------------------------------------------------