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0117 BERRY HOLLOW DRIVE - Health
' 117 BERRY HOLLOWS �1�'va.__ Marstons Mills A = 044 = 018 'y I �I i TOWN OF BARNSTABLE LOCATION 7 Ak&g& ) • D,• SEWAGE# IO/7 VILLAGE N. —ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO[ QED%�/�C SEPTIC TANK CAPACITY LEACHING FACILITY:(typ ft-)Ae4c& C.41."begi (size) NO.OF BEDROOMS OWNER PERMIT DATE: h Z17 COMPLIANCE DATE: r Y Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY tI q3' O a6 - No. 9� THE COMMONWEALTH OF MASSACHUSETTS FEE D OARD OF HEALTH ��✓�_� OF � r APPLICATION FOR DISPOS 'SYSTEM CONSTRUCTIO ERMIT Application for a Permit to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) - [-]Complete System ndividual Components x [io �yA�l Map/Par el# - Address L T p on nstalle ' ame � 10 DA. AAA 7 6 AddydSs�g1 Add;;? Telepho�ne# T el phone Type of Building: ��J1 '` Lot Size Nri � Sq.feet Dwelling—No.of Bedrooms Garbager ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(mi i.req ired) gpd Calculated desi n flow gpd Design flow provide gpd Plan: Date 1 Number of sheets _ Revision Date Title Description of Soil(s) Soil Evaluator Form No. 162 Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR A ERATIONS lx0 The undersi ne agrees to i the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and er grees not plat the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ' � Date Fq�/7 ItOpecfo 2 c l FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 b_ --- -- ---- --- - - -- -- - ------- -- --- -- ----- IV L� s N0. TI-t COMMONWEALTH PF MASSACHUSETTSF EE �O 1�30'Aj OE HEALTH v� •F- b APPLICATION FOR DISP(�Sj: SYSTEM CONSTRUCTIO ',,PERMIT o Application for a Permit to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) - ❑Complete System ndividuaI Components 1rl 6 02 11.. //��/do ti � w er- 190 �i Map/Par el# Address L T p on # t-niti 6 Addpn_ �b I'!• Addressr >� 7 'telephone# el phone Type of Building: �J '` v Lot Size J561 Sq.feet Dwelling—No.of Bedrooms Garbage ri der ( ) Other w -Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(mi i.req fired) gpd Calculated desi n flow gpd Design flow providecly gpd_ Plan: Date Number of sheets Revision Date Title ff Description of Soil(s) 60G Soil Evaluator Form No. Name of Soil Evaluator 1 Date of Evaluation DESCRIPTION OF REPAIRS OR A ER4TIONS f t The undersi ne agrees to i the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and er grees not plac the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ' DateIF In4perLtion k.h s' FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 f i q 1 No. °I7'r ! HE COMMONWEALTH OF MASSACHUSETTS FEE 0C BOARD OF HEALTH CF IFICATE OF COMPLIANCE Description of Work: /Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal~System;Cons cted( ),Repaired( ),Upgraded ),Abandoned( ) at has been installed in accdr—dancj with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated � '��j��^�-7 Approved Design Flow ? (gpd) Installer Designei:J✓'t 1 M46VIJ Inspector ��AI Date K r 0`1 The issuance of this certificate shall not be construed as a guarantee It the system willsfunction as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 y No. THE COMMONWEALTH OF MASSACHUSETTS FEE dv BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCT19X PERMIT Permission is hereby ra to Construct Repair Upgrade (Y Abanjon an individual sewage disposal system at as described in the application for Disposal System Constr ction Permit No. o 17—/ dated G Provided: Construction shall be completed within three years of the date of this per, i . local cond'd ns must be met. Date �,�1 /—7 Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON f Town of Barnstable Regulatory Services { Richard V. Scali,Interim Director BARNMBU& MAS& Public Health Division , i6gq �0 p'f1639 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: Zd l Sewage Permit# _Assessor's Map\Parcel'y/ Designer:` y, ?tom gs6,/J Installer: — r f I Address: �4mw, /'�'1� Address: a4a, m+� On � i�� �G T; was issued a permit to install a (date) (mstaller) septic system at 1 Z-7. fl) b!L. based on a design drawn by a7 doss s M ,r dated O 7-(designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. 'greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were-found satisfactory. I ceytify that the system referenced above was constructed in co niiance with the terms of e IAA approval etters.(if applicable) OF ���qs t o DAVID cG r stalle ature) � MASON N \ 1 No. . s a (De ' er's Signature) (Affix Desi ►mv�1, mp Here)' PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVE_ D BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc Town of Barnstable P# Department of Regulatory Services G I Public Health Division Date J - 1 200 Maio Street,Hyannis MA 02601 A C Date Scheduled Time / Fee Pd. �' O Xl UVLL/J KLLKVLLLLy LIJJGJJ//L SILL JVI 1.JG 11$ �G 1/LS�IV�KE P11A YI Performed By: a Jam'\V V y Witnessed By: -LOCATION& ENERAL INFORMATION Location Address '+� ".� D1 Owner's Name 5./1..11�()yl �p�Il�/1 ' F �Idress i r'�V11!/C�TyH110\0Assessor's Map/Parcel: 1q lie, � JIEngineer'sName D, 1 e NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other fl SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) //�� V El <> Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs,hole: in. Groundwater Adjustment ft. PERCOLATION TEST Date Time Observation Hole# Time at 9" Depth of Perc Time at 6" C..ow End Pre-soak Rate Min./Inch Site Suitability Assessment Site Passed Site Failed: -Lw Additional Testing Needed(YRN) Original:Public Health Division Observation Hole Data To Be Completed on Back--------= ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTICIPERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) otding (Structure,Stones,Boulders. - D •1 l Consistency.%Gravel) L— q Cd f -IN DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,BoWders. DEEP OBSERVATION HOLE LOG Hole# Depth from Sod Horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Consistency,%Graven Flood Insurance Rate Mao: / Above 500 year flood boundary No Within 500 year boundary No Within 100 year flood boundary No_V/ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pe io to al exist'mall areas observed throughout the area proposed for the soil absorption system, if nnt,what is the denth of na Irally necurrine n nus material? Certification 1(� �°, I certify that on W �"{ (date)I have passed the soil evaluator examination approved by the Department of Enviro ental Protection and that the above analysis was perfo a by me consistent with the required ' 'ng,exp az per' nce described in 310 CMR 15.017. Signatttre Date L/ Q:\SEPnCIPERCFORM.DOC down cape engineering, inc.SIEVE SOILS ANALYSIS 117 HOLLY BERRY LN MARSTON MILLS, MA DATE OF REPORT: 6/13/17 JOB : GRAIN SIZE ANALYSIS-SIEVE TEST SITE: 117 Holly Berry Lane, Marstons Mills LOCATION: Dave Mason Test Hole I, I6 F SIEVE ANALYSIS Weight Sample(Grams):. 210.3 a SIZE :WEIGHT RETAINED % RETAINED % PASSED { (sum ) 4- ------------ ----------- ----------------0%: - - 3 --------- ------------- 0.. ------------ 0.0% --------- ------- 100.0% 0.0 0.0%: 100.0% -------------r ... - ..............- y- --------r- ---------- #4 ----- ----------------0 0%� _ 100.0% { #16-------------------- ---� a---------------------" -- #20 81.2 38 6%s 61.4% ----- ---r - _.. =- #40 148,9' ------------70 8%: ---r----•--•------- - --- r- #50 ......__ _86 6% 13 4% #80------- - 203.4; ----- -- 96 7%: 3.3% ------- _-- --- •--------- •--- #100 -----------•-- 205..A------------- --9%;------------2.1% #200 - ---------- 208---- --- -----99 3%: -----------0=7% 1 PAN: ------------------209_4:------------166. lo.. ----------0.0% SAMPLE � 210.3; NOTE:TEST ON PASSING#4 ONLY, 6.0% RETAINED ON#4<45%O.K. RESULTS: SOIL CLASSIFIED AS AASHTO A-1-b(GRAVEL AND SAND)(UNCOMPACTED) PERCENTAGE OF MATERIAL PASSING#4 SIEVE : #4 100% (TEST ONLY MATERIAL PASSING#4) OK #5010%-100% OK #100 0%-20% OK #200 0%-5% OK SAMPLE MEETS TITLE 5 FILL SPECIFICATION ' >99%SAND RESULTS: PERMEABLE MATERIAL—CLASS I<2 MIN./IN. MATERIAL(0.74 G SL} NONCOMPACTED SOIL DESCRIPTION: MEDIUM/COARSE SAND Aso`' DAMEL P A. t' OJAI.A ° No.40980� 1 �qo", S S Q�O 1 Ivp& V E� I i �try ram, Town of Barnstable Barnstable` Regulatory Services Department AMmaka0v + L1RNSTABLE, • 1 ' v a ASS.s639. ��+ Public Health Division m FD MAC b 200 Main Street Hyannis MA 02601 2007 Office: 508-8624644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4990 2403 May 15, 2017 WILSON, SANDRA L TR 117 BERRY HOLLOW DRIVE MARSTONS MILLS, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system_ocated at 117 Berry Hollows Road, Marstons Mills, MA was inspected on 04/28/2017 by David B. Mason, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h). Distribution box needs to be replaced. You are ordered to repair or replace the septic system within two (2)years 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 as McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\I 17 Berry Hollows Road Marstons Mills.doc • �T�ram, r�, �, Town of Barnstable RAW MAWX ; � KAM Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA'02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A..McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground . ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. _ ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA. ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO 2 YEAR DEADLINE CRIT RIA e esspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑Leaching pit or cesspool with high liquid level, <12" below inlet(per Town Code §360-9.1) Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER 441—)is Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts 0/9 t! W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�M 117 Berry Hollows Road, Marstons Mills. Property Address K, Sandra Wilson, Trustee and Wilson Realty Trust " Owner Owner's Name information is 0 required for every Marstons Mills MA 02648 April 28, 2017 CW page. City/Town State Zip Code Date of Inspection I;Ji 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. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. ,� Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-833-2177 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority � •�8/ 4/28/17 Inspector's Signature The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pagep1 off117 vJ V/q V Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 April 28, 2017 required for every p page. CityTTown 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: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated.are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*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): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 April 28, 2017 required for every P page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 Aril 28 2017 required for every p page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 cesspool is less than 6" below invert or available volume is less than day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 Aril 28, 2017 required for every p page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet . from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 ❑ ❑ 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M10 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 April 28, 2017 required for every p page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: 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) [31.0 CMR 15.302(5)] D. System Information Residential Flow Conditions: 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 April 28, 2017 required for every p page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No 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 ears usage d No 9 ( Y 9 (gp ))� Detail: Marstons Mills Water District has no water records for this property. Well water. Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate 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: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c°M 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 Aril 28, 2017 required for every p page. Cityfrown 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: BOH Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 April 28, 2017 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance issued November 5, 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 6' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 100 feet Comments(on condition of joints, venting, evidence of leakage, etc.): Unable to observe due to depth of sewer line Septic Tank(locate on site plan): Depth below grade: 5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) A portion of the tank is under 5' of material and a stone block retaining wall. The septic tank is only H10 with additional weight that it is not designed to handle. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Typical 1000 gallon tank Sludge depth: 71, t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 Aril 28 2017 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 2" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank structural integrity is questionable because a portion of the tank is under 5' of cover and a stone block retaining wall is over a portion of the tank adding additional weight. Existing tank is only H10 and in this location should be H2O. Collapse of the tank is possible. 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 l5ins.doc•rev.6/16 Title 5 Ot icial Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 III Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 April 28, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M s 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 Aril 28, 2017 required for every p page. City/Town 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 Over 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.): The dbox is structurally decayed with evidence of collapsing in due to condition. There is evidence of solids 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 Aril 28, 2017 required for every P page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching pit is holding effluent, there is evidence of the use of an acid additive based on condition of concrete. There is evidence of the inlet pipe being backed up with solids staining the pipe. There is evidence of staining above the inlet pipe. Leaching pit is 3 inches below grade. The conditions noted in this report only represent the condition of the system on April 28, 2017 at the time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 Aril 28, 2017 required for every P page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts L: Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 Aril 28, 2017 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts L: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 April 28, 2017 required for every _ P 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: 12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Ground water contour map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Based on groundwater contour map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 117 Berry Hollows Road, Marstons Mills Property Address Sandra Wilson, Trustee and Wilson Realty Trust Owner Owner's Name information is Marstons Mills MA 02648 Aril 28 2017 required for every p page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 LOCATION O SEWAGE PERMIT NO. a AF lid VILLAGE /4f#p Jo�tir /�'��Ifs i►NA INSTALLER'S NAME i ADDRESS was r. AA S D u#n/C /r1A2s ow /�I•l/, M.�s BUILDER OR OWNER k8nnc7��t 1 t,�c' __sZtloReWd rl D,4iur, RtT �,v/,�,,:yl { Ato, DATE PERMIT ISSUED zoot DATE COMPLIANCE ISSUED we Se;t h Syido s a q O J r hq://www.townof bamstable.us/Assessing/HMdisplay.asp?mappar=044018&seq=1 4/27/2017 y ENVIROTECHLABORATORIES,INC. MA CERT.NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name Desmond Well Drilling Location 117 Berry Hollow Rd Address PO Box 2783 Marstons Mills,Ma Orleans MA 02653 Sample Date 09/16/11 Collected By Client Sample Time 13:30 Sample Type Well/Geothermal Date Received 09/16/11 Lab Order Number DW-112724 Well Specs 4"SCH40 PVC/50733' Location Source Date Collected Time Collected Comments - - -- p - -,_ ---09/16/11 - 13:30 - Analysis Requested Units Recommended Limits Analysis Result Method Date Analyzed Analyzed By Total Coliform /100ml 0 0 SM9222B 9/16/2011 RS pH pH units _ _ _ 6.5-8.5 _ 6.59_ SM4500-H-B 9/16/2011 LL — Specific Conductancen umhos/cm 500 118 EPA 120.1 9/16/2011 LL Nitrite-N mg/L 1.00 <0.004 EPA 300.0 9/17/2011 LL Nitrate-N mg/L 10.0 0.60 EPA 300.0_9/17/2011 LL Sodium -- - -- — mg/L 20.0 13.9 EPA 200.7 9/19/2011 --MC-- Total Irons mg/L 0.3 1.07 EPA 200.7 9/19/2011 MC Manganesen mg/L 0.05 0.048 EPA 200.7 9/19/2011 MC ----- ---...___.----- Comments: Iron and manganese are not a health hazard,but can cause taste,staining and odor problems. Water meets EPA standards and is suitable for drinking for parameters tested. d Date.---.—.--- 91,2-2111 Ronald J.Saari Laboratory Director BRL=Below Reportable Limits *See Attached Page 1 of 1 ❑Certication is not available for this analyze for non potable water samples.. Massachusetts Department of Environmental Protection >� Bureau of Resource Protection WELL DRILLER Please specify work performed: Address at well location: New Well Street Number: Street Name: 117 BERRY HOLLOW ROAD Please specify well type: Building Lot#: Assessor's Map#: Geothermal Open Loop Discharge Well Assessor's Lot#: ZIP Code: Number Of Wells: 02648 City/Town: Well Location BARNSTABLE In public right-of-way: GPS • Yes No North: West: 41.66995 70.42845 Subdivision/Property/Description: Mailing Address: • click here if same as well location address. Property Owner: Street Number: Street Name: SHEEHAN _ _! 117 BERRY HOLLOW ROAD City/Town: State: Engineering Firm: IBARNSTABLE MASSACHUSETTS ZIP Code: 02648 Board of health permit obtained: • Yes • Not Required. Permit Number Date Issued: 2011 017 9/6/2011 Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock (Auger ' Choose Bedrock WELL LOG OVERBURDEN LITHOLOGY From To(ft) Code Color Comment Drop in Extra fast or slow Loss or addition of (ft) drill stem drill rate fluid 0 5 Silty Sand Brcwn Yes: Fast Slow: Loss Addition: 5 20 Sand And Gravel Brown Yes'; Fast Slow;: Loss Addition -- --- -_ 20 40 Fine To Coarse Sand Brown Yesi Fast Slow' Loss Addition', 40 50 ; Fine To Coarse Sand Brown Yes. Fast Slow, Loss Addition WELL LOG BEDROCK LITHOLOGY n Visible Extra From Drop in Extra fast or slow Loss or addition of To(ft) Code Comment Rust Large (ft) drill stem drill rate fluid Staining Chips F— � Choose Code • Yes, • Fast Slow Loss Addition. Yes: Yes ADDITIONAL WELL INFORMATION Developed Yes No Disinfected Yes No Total Well Depth 50 — __ Depth to Bedrock Fracture Surface Seal Type None Enhancement Yes No CASING L- is Casing above ground? From: To: tFrom To Type Thickness Diameter- Driveshoe .. 10_ Polyvinyl Chloride ' Schedule 40 Yes: �_— SCREEN No Screen From To Type Slot Size Diameter 10 56 Continuous Wire PVC 0.010 4 WATER-BEARING ZONES DRYWELL From To Yield(gpm) 35 -- 50---._. 15 ----— PERMANENT PUMP(IF AVAILABLE) --� ---Choose Pump ---Choose Horsepower--I Pump Description Horsepower Description--- Massachusetts Department of Environmental Protection Bureau of Resource Protection-Well Driller Program Well Completion Reports(General) _ 4�r Pump Intake Depth(ft) Nominal Pump Capacity(gpm) L ANNULAR SEAL I FILTER PACK ter a From To Material 1 Weight Material 2 Weight(g Wal) Batches Method Of Placement Choose Material Choose Material Choose One- C C L GEOTHERMAL INFORMATION Thermal Conductivity Thermal Dif usivity Formation Water Sample taken (BTU/hr.ft.°F) (ft2/day) Temperature(°F) DEP UIC# from this well? I MAS 1A 41 0-20217 Yes • No WELL TEST DATA Time Pumping Time To Date Method Yield(gpm) Pumped Level (ft Recover Recovery(ft BGS) (HH:MM) BGS) (HH:MM) 9/16/2011 Constant Rate Pump 15 1:00 35 F01 35 � - - -' I — — WATER LEVEL Date Measured Static Depth BGS(ft) Flowing Rate(gpm) 9/16l2011 35 15 COMMENTS WELL DRILLERS STATEMENT.. This well was drilled or altered.-under my direct supervision,,according to the applicable rules and regulations,and this report is complete a knowledge. Driller PATRICKDESMOND Registration# 877 Monitoring[M] Supervising Drill Firm I DESMOND WELL DRILLI', Rig Permit# 024 Date Job Compl NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. f Cam!' Massachusetts Department of Environmental Protection Bureau of Resource Protection WELL DRILLER Please specify work performed: Address at well location: New Well Street Number: Street Name: 117 BERRY HOLLOW ROAD Please specify well type: Building Lot#: Assessor's Map#: GeoThermal Open Loop Assessors Lot#: ZIP Code. Number Of Wells: 02648 City town: Well Location BARNSTABLE In public right-of-way: GPS • Yes No North: West: 41.67006 70.42805 Subdivision/Property/Description: Mailing Address: • click here if same as well location address Property Owner: Street Number: Street Name: SHEEHAN 117 - BERRY HOLLOW ROAD City/Town: State: Engineering Firm: 1BARNSTABLE MASSACHUSETfS ZIP Code: 02648 Board of health permit obtained: • Yes Not Required. Permit Number: Date Issued: W2011017 9/6/2011 Massachusetts Department of Environmental Protection �� Bureau of Resource Protection-Well Driller Program Well Completion Reports(General) r�y P Well Driller - General Well Form DRILLING METHOD Overburden Bedrock (Auger r Choose Bedrock WELL LOG OVERBURDEN LITHOLOGY From To(ft) Code Color Comment Drop in Extra fast or slow Loss or addition of (ft) drill stem drill rate fluid 0 5 Silty Sand Brown Yes Fast Slow Loss Addition --. (5 20 1 Sand And Gravel Brown Yes Fast Slo-.v, Loss Addition; 20 R= Fine To Coarse Sand Brown -----,— Yes;, Fast Slow; Loss Addition; 40 50.5 rFine To Coarse Sand Brown Yes Fast • Slow; I Loss Addition _— WELL LOG BEDROCK LITHOLOGY _From Drop in Extra fast or slow Loss or addition of Visible Extra To(ft) Code Comment Rust Large (ft) drill stem drill rate fluid Staining Chips �hoose Code Yes: Fast Slow Loss Addition Yes Yes ADDITIONAL WELL INFORMATION Developed Yes No Disinfected L-Yes No Total Well Depth 50 5 Depth to Bedrock Fracture Surface Seal Type None Enhancement Yes No: CASING Is Casing above ground?: From: To: �— .:From To -Type -. - - _,Thickness„ Diameter Driveshoe _ 46.5 Polyvinyl Chloride Schedule 40 14 Yes SCREEN No Screen From To Type Slot Size Diameter 46.5 (50.5 Stainless Steel Well Point 0.012 4 WATER-BEARING ZONES -• DRYWELL'; From To Yield(gpm) 33 F67o—51 15 PERMANENT PUMP(IF AVAILABLE) 3 Wire Variable Speed Pump Description Horsepower Submersible 1 1/2 r 'a Massachusetts Department of Environmental Protection .y Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Pump Intake Depth(ft) 145 Nominal Pump Capacity(gpm) L5_ ANNULAR SEAL/FILTER PACK Water From To Material 1 Weight Material 2 Weight(gal) Batches Method Of Placement Choose Material Choose Material Choose One-- GEOTHERMAL INFORMATION Thermal Conductivity Thermal Diffusivity Formation Water Sample taken (BTU/hr.ft.°F) (ft2/day) Temperature(°F) DEP UIC# from this well? MAS 1A 41 0.20217 Yes No WELL TEST DATA Time Pumping Time To Recovery(ft Date Method Yield(gpm) Pumped Level (ft Recover (HH:MM) BGS) (HH:MM) BGS) 9/1 6120 1 1 Constant Rate Pump 15 2:00_ I3" 0:01 33 WATER LEVEL Date Measured Static Depth BGS(ft) Flowing Rate(gpm) 9/16/2011 33 15 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision„according to the applicable rules and regulations,and this report is complete a knowledge. Driller 1PATRICKDESMOND Registration# 1877 Monitoring[M] C Supervising Drill Firm I DESMOND WELL DRILLI'. Rig Permit# 024 Date Job Compl NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. No.------ ---- - -- Fee-----,-------------- BOARD OF HEALTH DESMOND WELL DRILLING, INCT O W N OF B A R N S TA B L E 5 RAYBER ROAD,BOX 2783 OR(508)240-1000 MA 02653 Zipp[ication forlVel1 Congtrutt ion Permit (508)2 Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an in ivi ual Well Location — Address Assessors Map an P cel Owner Address _ /L��11 �o-- -------- ---' -rfZ( --®r L"`4"Ka------ Installer — Driller Address Type of Building Dwelling Other - Type of Building—=-----—________ No. of Persons--- --------•------------• Type of Well (S 9 7-44 a L59- Capacity S4 -- — --- Purpose of Well--- �6 � - 1 =-- _-- —_- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of He th Private Well Protection Regulation — The undersigned further agrees not to place the well in operation unt Certificate.of Co liance has been issued by the Board of Health. Signe -- -- - 9 /— -- a / Application Approved By _ rts a Application Disapproved for the following re ns: -----------------___—_—_— _—__ date Permit No. — -- Issued----— , —_—------------- BOARD OF HEALTH DESMOND WELL DRILLING, INC'O W N OF B A R N S T A B L E 5 RAYBER ROAD,BOX 2783 ORLEANS,MA 02653 (508)240-1000 C ertif itate Of (Compliance THIS A TO CERTIFY, That the Individual Wel onstructed ( ), Altered ( ), or Repaired ( ) Installer at has been installed in accordance with the provisions of the Town of Barnstable B a fMa Well Protection Regulation as described in the application for Well Construction Permit No. d------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE -- --- — - - Inspector---_—_-- ---- ------- . No - ---------- _ r' Fee-----,------------- " BOARD OF HEALTH TOWN OF BARNSTABLE ,DESM®ND WELL DRILLING, INC: 5 RAYBER ROAD,BOX 2783 ORLEAN 2 MA ao-1000 02653 (508) 'application for Yell (Con.5truct ion Permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at. Location — Address Assessors Map and Pafcel — Owner — _ Address lttC)0 3 _W z t,. _D 2 ALL�,c -- - -�J 164- t , -2 tD - Installer — Driller Address Type of Building Dwelling--- -------------___-----____-- Other - Type of Building---_—__--___- No. of Persons------ Type of Well �� ( - /4 t-- Capacity---- YP 44x& m Ca acit Purpose of Well--- --ppLy _ DjSC&4*'LGI 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 unt*,r a Certificate.of Co iance has been issued by the Board of Health. Signe Application Approved By � _--- __ date Application Disapproved for the following re ns: �"' — —----—_—_ -- — --— ——date —— Permit No. Issued----- --�T' �- dat / / ----------------- i BOARD OF HEALTH DESMOND WELL DRILLING, IT-OWN OF B A R N S T A B L E 5 RAYBER ROAD,BOX 2783 ORLEANS,MA 02653 (508)240-1000 (Certificate ®f (Compliance THIS TO CERTIFY, That the Individual Well—Constructed ( ), Altered ( ), or Repaired ( ) LU L_L.r_11 - Installer at—_ 17 has been installed m accordance with the provisions of the Town of Barnstable Board f lth Priv Well Protection Regulation as described in the application for Well Construction Permit No.C� ^� ►Dat�d—_ -- - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. y S - DATE Inspector------;------------- ------------ i BOARD OF HEALTH DESMOND WELL DRILLING, INT O W N OF B A R N S T A B L E 5 RAYBER ROAD,BOX 2783 ORLEANS,MA 02653 ell Conaruct ion Permit (508)240-1000 No. - � J Fee- r- Permission is hereby granted �� �__ @'_C. -hu6�-att -n--------- — to Construct ( ),,Alter ( ), or Repair ( ) an Individual Well at: -_0 L©C't 1 _VS JZ _(J Z---- S Street as shown on the application for a Well Construction Permit _q / No.- ___—____ Dated- - __2h Board of Health DATE— f rom: "Bob Franey" <dfraney@comcast.net> Subject: FW: Marstins Mills 117 Berry Hollow Drive - file copy for UIC Dater September 2, 2011 9:53:33 AM EDT To: "Michelle Desmond \(Desmond Well Drilling, Inc.\)" <michelle@desmondwelldrilling.com> From: Brunelle, Eugene (DEP) [mailto:Eugene.Brunelle@state.ma.us] Sent: Tuesday, April 12, 2011 1:52 PM ` To: lightone@comcast.net; rjfraney@comcast.net Cc: Cerutti, Joseph (DEP); Rao, Purnachander (DEP); health @town.barnstable.ma.us Subject: Marstins Mills 117 Berry Hollow Drive Dear Mr. Sheehan, I'm writing to provide you with MassDEP Underground Injection Control (UIC) registration number. MAS41A020217-5C2 for the installation of one roams: "Bob Franey" <rjfraney@comcast.net> Subject: FW: Marstins Mills 117 Berry Hollow Drive - file copy for UIC Date: September 2, 2011 9:53:33 AM EDT To: "Michelle Desmond \(Desmond Well Drilling, Inc.\)" <michelle@desmondwelldrilling.com> From: Brunelle, Eugene (DEP) [ma iIto:Eugene.Brunel le@state.ma.us] Sent: Tuesday, April 12, 2011 1:52 PM To: lightone@comcast.net; rjfraney@comcast.net Cc: Ceruitti, Joseph (DEP); Rao, Purnachander (DEP); health@town.barnstable.ma.us Subject: Marstins Mills 117 Berry Hollow Drive Dear Mr. Sheehan, I'm writing to Provide you with MassDEP Underground Injection Control (UIC) registration number. MAS41A020217-5C2 for the installation of one Massachusetts Department of Environmental Protection 7 Bureau of Resource Protection - Drinking Water Program IL/ I BRP WS06e Residential Units (four units or fewer) Registration of Underground Discharges to Injection Wells Modification to an Existing UIC Registration (BRP WS-06e) ❑ Questions Any questions may be directed to the UIC Program at(617) 348-4014 or to the UIC'Contact at your Regional MassDEP Office. Find your region: http://mass.gov/dep/about/region/findyour.htm Submit Application to: MassDEP Drinking Water Program 1 Winter Street—5th Floor, Boston, MA 02108 Attn: UIC Program MAILING ADDRESSES UIC Program, MassDEP Northeast Regional Office (NERO), 205b Lowell Street, Wilmington, MA 01887 UIC Program, MassDEP Southeast Regional Office (SERO), 20 Riverside Dr., Lakeville, MA 02347 UIC Program, MassDEP Central Regional Office (CERO), 627 Main Street, Worcester, MA 01608 UIC Program, MassDEP Western Regional Office(WERO), State House West, 4th Floor, 436 Dwight Street, Springfield, MA 01103 UIC Program, MassDEP Boston Office, One Winter Street—5th Floor, Boston, MA 02108 SERVICE CENTER PHONE NUMBERS: Northeast Regional Office 978-694-3200 Southeast Regional Office 508-946-2714 Central Regional Office 508-792-7683 Western Regional Office 413-755-2214 Send duplicate copies of all forms to: (Local Board of Health' `Local Plumbing Inspector wsMe[1]•rev.02/10 BRP WS06e-Residential Units•Page 5 of 5 i Massachusetts Department of Environmental Protection Bureau of Resource Protection - Drinking Water Program BRP WS06e Residential Units (four units or fewer) Registration of Underground Discharges to Injection Wells Modification to an Existing UIC Registration (BRP WS-06e) ❑ See Instructions UIC Registration Fee: check the appropriate category ® WS-06e. Residential Exemption (for four units or fewer) the following well types (typical residential activities) are exempt from a UIC registration fee-. 5A7, 5D2, 5G30 & 5X18 See Instructions Transaction Type Important:When � -.a, filling out forms Registration: ® Initial- new registration ❑ Initial -existing registration ❑ Closure%Registration on the computer, use only the tab . Modification: ❑ Change of owner/operator ❑ Change in or additional well/code(s) key to move your a r� cursor-do not use the return — ❑ Change in location well(s) ❑ Change in#of discharge wells key. For modifications (required) UIC Registration ID#issued by MassDEP in the original UIC Registration A. Residential Unit Information For modifications, enter only new or revised information. Ed Sheehan Property name/Private Residence Company name,(if different) s117'Berry Hol'fow D�.� W Marsto sn Mills L-- Property Street Address City/Town MA 02648 Barnstable Water Sul El Public Supply.State Zip Code County ® Private 508-367-0378 lightonel @comcast.net Telephone Number Email(optional) See Instructions B. Owner/Operator Information For modifications; enter only new or revised information. Name of Owner Street Address City/Town State Zip Code Telephone Number Email(optional) Ownership Type: Private: ❑ Private ❑ Commercial ❑ Nonprofit ❑ Other: specify Public: ❑ Local ❑ Regional ❑ State ❑ Federal ws06e[2]•rev.02/10 BRP WS06e-Residential Units•Page 1 of 5 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Drinking Water Program BRP WS06e Residential Units (four units or fewer) Registration of Underground Discharges to Injection Wells Modification to an Existing UIC Registration (BRP WS-06e) ❑ See Instructions C. Injection Well Information For modifications, enter only new or revised information. Registration: ® Individual or ❑ Area See Instructions- 5A-7 or-*" e'ra9L e r-uct, 5-4 -7 Table at end Well Type Well Code See Instructions Well Construction (check all that apply) Number of wells: 2 ❑ Drywell ® Dug well ❑ Cesspool ❑ Septic Tank ❑ Drainfield/Leachfield ❑ Trench Drain ❑ Other(describe): See Instructions Type of Discharge: ® Geothermal Heat Pump-open (5A7) ❑ Closed Loop Heat Pump (5A7) ❑ Groundwater Infiltration (5G30) ❑ Water Purification Discharge (5X18) ❑ Sump (5G30) ❑ Stormwater- roof drainage (5D2) ❑ Stormwater-other drainage List water purification units discharging to Class V well: See Instructions 1 #of entry points to existing system #of entry points for proposed system Total#of entry,points to system See Instructions 35 28,,0 fine sand Depth to water table(ft) Depth to bedrock(ft) Soil type(s)at site See Instructions Distance to nearest private drinking water well(within 1250 feet) MonthNear of well construction See Instructions Distance to nearest Public Water Supply(within 2500 feet) Name of nearest Public Water Supply See Instructions 497' 85 Distance to nearest wetland or water body Distance to nearest septic system D. Operational Status See Instructions Well Operation Status: ® Designed, not yet constructed ❑ Under Construction ❑Active ❑ Temp. abandoned ❑ Conversion to another well type ❑ Partial Closure[conversion to another well type (well code) ❑ Permanently abandoned/not reported previously ws06e[2]•rev.02110 BRP WS06e-Residential Units•Page 2 of 5 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Drinking Water Program BRP WS06e Residential Units (four units or fewer) Registration of Underground Discharges to Injection Wells Modification to an Existing. UIC Registration (BRP WS-06e) ❑ E. Site Information Additional Information required: Must attached In All additional information that is relevant to the installation or operation of this in ection well and to the -see Instructions p J determination of its potential to endanger underground sources of drinking water(USDWs)— including a site map showing the facility and UIC well(s), on-site drinking water wells, all other on-site discharges and the drains leading to the well and/or drainage area served by the well. MSDS sheets for chemicals likely to be discharged into well must be submitted. Who must register: Any party who discharges to a Class V Well as defined in 310 CMR 27.00 must apply except those listed as exempt from the registration requirement as per 310 CMR 27.07. If you have not previously registered and you are closing the use of the well(s)for one (or more) uses but want to continue using the well(s) for one (or more) uses you must mark the top of this form Change in or Additional Well Code(s) and attach to this submittal a Pre-Closure Form for the well(s)/activities being closed. If you have not previously registered and you are converting the well from a"prohibited" use to a use that is"authorized by rule"you must mark the top of this form Conversion Change in or Additional Well Code(s) and attach to this submittal a Pre-Closure Form for the well(s)/activities being closed. Who must submit a Modification Form: If the Owner or Operator information changes you must notify the UIC program at least 30 days prior to the change(s).. If you are adding wells (Area Registration); relocating the well(s), changing the discharge (Well Code) to the well(s) or adding additional discharges (Well Code) you must notify MassDEP at least 60 days prior to the change. If you are closing the well(s) and relocating the well(s) and are planning to have the same discharge (Well Code), you must mark the top of this form Relocation of Well(s) and attach to this submittal a Pre-Closure Form for the well(s) being closed. Fee Residential units (flour units or fewer) effective 10/08/04 are exempt from the UIC application fee (no Transmittal Form needs to be submitted)for residential activities. There is no application fee associated with submitting a Modification application to an existing registration. BRP WS-06e- Residential Unit(4 units or fewer)/ Residential Activity—Fee Exempt No Transmittal Form (or number) is needed when submitting a Modification to an existing Registration. There is no annual compliance fee associated with this Registration. ws06e[2]•rev.02/10 BRP WS06e-Residential Units•Page 3 of 5 i Massachusetts Department of Environmental Protection Bureau of Resource Protection - Drinking Water Program BRP WS06e Residential Units- (four units or fewer) Registration of Underground Discharges to Injection Wells Modification to an Existing UIC Registration (BRP WS-06e) F. Affidavit The injection well(s) described above is used for placement or injection of fluids into the ground. I/we understand that this well is subject to inventory requirements and compliance with the regulations under the Underground Injection Control Program established pursuant to the Safe Drinking Water Act, P.L. 93-523, and amendments, and I/we hereby serve notice that the well is proposed or in service. I/we agree: 1. That the well(s) described herein will not be used for discharges other than those described above; 2. That I/we will notify the MassDEP Drinking Water Program/UIC Program (on forms provided by the UIC program) if any of the information (including Ownership, Location or Type of discharge) for the above well(s)changes, but before the change (30 days minimum notice on ownership/operator and 60 day notice on all other changes); 3. That I/we will notify the MassDEP Drinking Water Program/UIC Program (on forms provided by the UIC program—Pre-Closure Notification Form)when the above well(s) is no longer in use, but before abandonment and file a Post-Closure Notification Form within seven days of completing the closure with the UIC program. 4. That I/we will maintain financial responsibility for the well described above; and 5. That I/we will provide a sampling tap (approved by MassDEP) and allow sampling at the point of injection. I/We certify under penalty of law that I/we have personally examined and am familiar with the information submitted in this document and all attachments and based on my personal knowledge or inquiry.of those individuals immediately responsible for obtaining the information, I/we believe the information is true, accurate, and complete. I/we am aware that there are significant penalties for submitting false information, including possible fines and imprisonment. 2/28/2011 Signature Date Robert J. Franey, Jr Pres. RJ Franey Mechanical Services, Inc. Printed name of preparer Position/Title ws06e[2]•rev.02/10 BRP WS06e-Residential Units•Page 4 of 5 Town of Barnstable Geographic Information System February 24,2011 045017001 ` #110 045048 #120 046018 #860 045047 #104 061039 044018 #475 #117 044006 044019 #830 #106 044010003 #0 044028 a lk( #714 044010001 s` # 044010002 26 *30 e 044007002 #20 044007003 #27 061058 DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:044 Parcel:018 N boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel 1'=100'may not meet established map accuracy standards. The parcel lines on this map Owner WILSON,SANDRA L 8 EDWARD F Total Assessed Value:$378200 • are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:1.00 acres Abutters VJ E boundaries and do not represent accurate relationships to physical features on the map Location'117 BERRY HOLLOW DRIVE such as building locations. Buffer s Aerial Photos Taken April 19,2008 Tgwn of Barnstable Geographic Information System February 24,2011 045048 045047 #120 #104 045017001"' #110 f Y 04401a #117 f' At; - r;. 044019 - 044028 #105 #714 P:044 Parcel: N DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Ma Selected Parcel boundary determination or regulatory interpretation. Enlargements beyond a scale of Owner:W ILSON,SANDRA L&EDWARD F Total Assessed Value:$378200 1"=100'may not meet established map accuracy standards. The parcel lines on this map w- -E are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:1.00 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:117 BERRY HOLLOW DRIVE such as building locations. Buffer Aerial Photos Taken April 19,2008 Town of Barnstable Geographic Information System February 24,2011, 045048 045047 #120 #104 045017001 #110 w G�� 4` f 4° rove IP 044018 #117 04401,9 . 044028 #105 #714 0 0 18 Feet DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:044 Parcel:01 H boundary determination or regulatory Interpretation. Enlargements beyond a scale of Owner:WILSON,SANDRA L&EDWARD F Total Assessed Value:$378200 Selected Parcel 1"=100'may not meet established map accuracy standards. The parcel lines on this map - are only graphic representations of Assessor's tax parcels.They are not true property Co-Owner: Acreage:1.00 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:117 BERRY HOLLOW DRIVE ' such as building locations. Buffer �� ZD 10, a if kit yr 2 .V LV6, wa flo © �Ke �,,.,,.rw."'.. o��' •.w..�.a.s.:..._,.zr..�.se.+.,... 1 �� :a r.T t I LOCATION , _ SEWAGE PERMIT ' NO. VILLAGE - A ri ,�'1#r �� • I I N S T A LLER'S_ NAME h ADDRESS PA s e UILDER OR OWNER kd DATE PERMIT ISSUED ' • I DATE COMPLIANCE ISSUED U Sid I Ln e i • i r_ LOCATION (/ SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS J,-o5r,p4 - s p u#a/o 8 U I L D E R OR OWNER Al on a Le ee d D it i lye, 10519.r-r fiig1..ydA DATE PERMIT ISSUED DATE COMPLIANCE ISSUED So Idc Nil i c ' , C.s+ 4! No.... O r .67 C"', PJ. Fms..l.................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 'J.'OW%61.............OF.....` �rlU�� .................................... App iratiun for Dispuiial Works Tonstrurtiun raulit Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal System at: AUAAt... .................... ..............................k k i.... .• ` ---------------------•------•---- ocation-ldddrss� or I.otNo: .�..--i -r...: . ....... .. .....�caner Address a . -• ........ --- Installer Address Type of Building Size Lot42,t)_- _,........Sq. fit Dwelling—No. of Bedrooms..__.__________________________________Expansion Attic (� Garbage Grinder / a p, Other—Type of Building<'14''�.�- ...... No. of persons............................ Showers (oj,) — Cafeteria ( ) Other fixtures f-------------------------------------------- •--•--•-----.--••---------- . 3-0-••......-•-•gallons. Design Flow__•____________ _ _ ..._( _�___..gallons per person per day. Totaledaily flow................ p ga� `i WSeptic Tank—Liquid capacity/.OeO..gallons Length .__ _____ Width._._.._,_ .._ Diameter................ Depth, __.... x Disposal Trench— No..._.4............ Width.`.................. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......�_------------- Diameter.....IV.......... Depth below inlet.......k....._... Total leaching area.A�sq. ft. Z Other Distribution box ( ) Dosing nk aPercolation Test Results Performed by....... k?Nk--- '!_FFd - ......................... Date.._A'._L : 8.!z:.......... ,,-a Test Pit No. I----- ....minutes per inch Depth of Test Pit----{._2,._....... Depth to ground water........................ rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-••--------••---------------•-•---- •••-•--•••-••-••••-----------................-••--••-•-•-•-•.....•-•••---••---••-•--•••-•-----•-•._..........----•.•••. O Description of Soil..jta r•�--�-&?-�--7---- = c?l. ..�--.... r 1 "1 L/�4 `� 9 Cxj ---------------------------•---------------- �1.�-11?�h r -f �1 . ......--------•--------------------------------------------------.....-------" W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... •---------------------------•-------------------•---------------------------------...........--•--------••----------"----------------------------------"------......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board of health. Signed•-- ..... . ..................... ......------------......•-- Date Application Approved By__..___.__-.==�`.!d)°___........... - ....._.._ `��.�- - r----- - -•-••--•--------•-------•--•-----•- -Date Application Disapproved for the following reasons---------------------------------------------------------------•----------------••-----------------........_...-- --------•--•-•----•••-------•-••...............••-••---•--•----•--------...-••-•.....-------•------•••-•--••--••••••-•--------•-----•-----••-••-•-•---------------••------------------•-•-••----•----- Date PermitNo......................................................... Issued....................................................... Date e � r Log Number: 18A Date: 7/8/82 Of BA,q BARNSTABLE COUNTY HEALTH DEPARTMENT 5 SUPERIOR COURT HOUSE V BARNSTABLE, MASSACHUSETTS 02630 o • q$� DRINKING WATER LABORATORY ANALYSIS PHONE: 362 EXT.. 3 1 �S1 Client: Kentebo Residence Collector: Frederick Clifford Mailing Address: BOX 5 Affiliation: Clifford Well Drilling Waquoit, MA 02536Time & Date of Collection: 7/7/82, 1:00 p.m. Telephone: Type of Supply: well water Sample Location: Bog Rd-, Lot 9 Date of Analysis: 7 7 2 Marstons Mills Parameter Sample Result Recommended Limits Coliform bacteria (organisms/100 ml) 0 0 pH 5.4 Conductivity 95. 500.0 Iron (ppm) .1 0.3 Nitrate-Nitrogen (ppm) .65 10.0 xx Water sample meets the recommended limits of all above tested parameters. Water sample is drinkable but has higher than average levels of This does not represent a health hazard but future monitoring is recommended (2-3 times per year). We will test for Sodium. Water sample is drinkable but may present aesthetic problems to users (staining, odor or taste). Water sample is of poor quality and is not recommended for human consumption. f Resampling and retesting is suggested. Results only. REMARKS: cc: Barnstable Board of Health cc: Clifford Well Drilling Analyst: c WA, 11/18/81 1 4 J 1 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 methodsr-For this reason,'it.would be advisable to retest any well water that is not approved. ^ � .. ... Y pH is the measure of acidity or alkalinity of the water. On 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.O to 6.5 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 The presence of iron in water in concentration of .3 ppm or greater may: give the water a bittersweet astringent 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 Cape Cod's water is .2 - .6 ppm. Although the presence of iron in water may cause the problems listed above, it is not considered deleterious to health. Iron may be removed by use of an iron 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 infant 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. 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 runoff water:getting into the well:.I,-, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... W. ..............oF...... .:ez.(v.�5,. ..b--Je .................................... , .Applirotion for Biopoii al Works Tomitrurtion ramit Application is hereby made for a Permit to Construct () ) or Repair ( } an Individual Sewage Disposal System at: f . l � .................... ...•-•--- ... �-9 ............................. ...... - ............. - e Location-Addle too l 1 g rV i o f� or Lot No ' ...A.1...... ............. ........... . -•------- ._......---- (� wner Address 4 G/ Installer Address Type of Building Size Lot .......Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic (►!) Garbage Grinder ( ) `4 Other—Type of BuildingG'fIl2 <.r�- No. of persons............................ Showers — Cafeteria Otherfixtures -----•-------------------------------------•-----------•••••............-•-----••------ --------•••••••••-........•••.......--•-•••-•..........••-••- W Design Flow............. ....,11Q.....gallons per person per day. Total daily flow__...............33 ?.__...........gallons. � � _ i a+ i WSeptic Tank—Liquid capacity/6.00..gallons Length .___fin._.. Width__ .i..jo.."_ Diameter________________ DepthJ___.,a.ie_.. x Disposal Trench—No..._.I............ Width.................... Total Length.................... Total leaching area___•-__-------_____sq. ft. Seepage Pit No....._I.............. Diameter.....6........... Depth below inlet........{v_......... Total leaching area.., -_ .. q, ftt. Z Other Distribution box ( ) Dosing 5nk ( ) / aPercolation Test Results Performed by__•.._�4.G_�....�-9 ' ? .fit........._ Date `'- .............. Test Pit No. I.....�_____minutes per inch Depth of Test Pit_____�_�........ Depth to ground water........ ............ f% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.-__-_____-____---____. a •--••••••--••---••--••............••--•-......•-••••. ••..........--••••-••••••-•-----------•-•-•--------------------------•••........--••--........._---••- O Description of Soil..:,_..SGr.l......-- - °4 ,5��6...:5 ,-- 3 /i j' W VNature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------------------•----------------------------------------------------•--•-•--•--.....---•---•----------------------------------•----------------------------------------•-•--•------•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with. the provisions of TITI.- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board of health. ••--•......_...-•--•---• o-8- Date Application Approved BY "... ...' `... iY 7... 'z------ Date Application Disapproved for the following reasons:----•----------•-------•-------•------------------------------------------------------•-••--•••--••••-•__------ f ......................................•..................•-••-•--••---•••...........------••••.............••••••-•--•----•-•--••-•••-----••-•---•--••-••----=.••-------•----..................--------• ` 3. -,Permit No........................................................... Issued_........................................................a Date; .R THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trdif irate of TootpliFanrr THIS TO CERTIFY That the Inddual Sewage Disposal System constructed (V) or Repaired ( ) bY----------•-__•-�� Individual ",r=••---•-- •-----•..................•-••----•--- .. ----------.. ..-------•---•--.....---•--••-•�--.......--•------..........---•---•-•---._._..__.... staller has been installed in accordance with the provisions of TIT r 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----- UL�_____________ �d' ___-._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU S A GUARANTEE THAT THE SYSTEM WIL F NCTION SATISFACTORY. DATE---- �...7..., .......................................... Inspector.... _ ... .....---------•----.................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �........!AJ ....OF.......... f�6 5�6..bl.c...................... FEE.. 3 5............. Disposal rko Tono#ratrttion rrotit Permission s reby granted---- 5r:..----.. _ram ........................................................ to Construct or Repair ( ) an Individual Sewa,g Disp,(js4 System at No...._... � FIrt 4?� 7 .r^ ... -----..... ••• . . -----• Street as shown on the application for Disposal Works Construction Permit No.................. . Dated-------------------------- ----- - ----•-----------•--------------------- oard of Health t' DATE.................�All.,V.X ......... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 1 ASSESSORS MAP : -- -- - - -- - ---- TEST HOLE LOGS � Q -. PARCEL: �� o � __-__ ..___ l) The installation shall cojrlj:)� kvitli 'Title V and "Town o('?�� loatd of SOIL EVALUATOR: 1 �l� �y, I lealth Re�ultAtions. FLOOD ZONE: . �`��I �1P�1G _ ------ '�/► WITNESS : WO(Ii, , i , i , i REFERENCE: G'Q o `2) The tnst«Ilei sh1111 vuil'y lh�, IucuUun ul'titililics, sewer iuvcrty and s�ilic, (� l�O - - - - —� ��Ia DATE Q 44 1 components prior installation p p for to lnstallat o and setting base elevations. ly W�C'�'�q t,� fit, �.1 j PERCOLATION RATE -< M1 1 3) All gravity septic piping to be 4 inch Sell 40 PVC at I/8" per Foot. The first _. _ O V♦' 14V- 67,5 N a VZ two feet out of the d-box to the ieaching shall be level. - -- -- 4 This plan is not to be utilized for property line determination nor an other TH- 1 TH-2Fo*\ ) p p P Y Y � lr purpose other than the proposed system installation. �1 4 4 � tp 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H 10 septic components. 7) The property is bounded by property corners and property lines. �n r�j � l o G/ 8) The property owner shall review design considerations to approve of total LOCATION MAP ` /�' T!- (� _ 1 design flow and number of bedrooms to be considered for design Receipt Ltir of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. "A� C - ' � 1. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per 5 > . Title V specs. �� 'I' 1 �9�,� t ,yam l 10)System components to be l0 feet from water line. Sewer lines crossing the Nt`vfi — 7 - - --- water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if 15 i(O applicable a e e o as a orem �' SEPT I C SYSTEM DES I GN 11) 1f a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. { / FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such exists. BEDROOMS AT GAL/DAY/BEDROOM F;0 GAL/DAY 13)Tile installer shall verify the location, and elevation of the sewer lines exiting the dwelli quantity dwelling"prior to the installation. NJ �,- l SEPTIC, TANK 14)This plan is representative only that a system can fit on a property meeting a --- I Title V requirements. - CAL/DAY x 2 DAYS - GAL USE IC GALLON SEPTIC TANK (4Aq-6t4 �fUWPbL t�OT V� °\ \ L/ 00- i SOIL :',BSORPT N S 10YSTEM � � �j�L.•�� 1�-C�W4� �� �04�� �U`tC.�� /' �t OF�q _ \ 51 DE AREA: Z DA � Z�J t- 12,E x7ix o;1 I (,� d�� AVID v�� p.00 �� 3oTTOM AREA: �.� 231, 1�1Asor� y E v No.loss 1y1 b� SEPTI SYSTEM SECTION - n - --_tt LT) P lox U 0 -fft",� • A �*tc ,/ do tw-�j I d GAL I�. ��` W - b _ I SEPTIC TANK Z� ID —� — , S 1 TE AND SEWAGE PLAN LOCAT ION I I `11 _ `?(b._ �L!�(ti1✓ (?Pi�iFi_ ' �. �'J�- - �Zb�' PREPARED F 0 R : 1}�Q-�?►�►`-I pCl� 1 � g SCALE: ' O DAV I D B . MASON DATE: t� O g DBC ENVIRONMENTAL DESIGNS W EAST SANDWICH . MA z DATE HEALTH AGENT ( 508) 833_ 2 1 77 , n 7-77 , S01L L0 NO. 1 N0. 2 SITE PLAN ;78.0 O 4 • 1f sa f. 3 1711 /4 4 a TOP OF FOUNDATION EL.: 8�.d , 5 b , r1E�/rM 0 •• r9NL� ! a r , ,/ 8 IN E L ZZ ors► • • .77 1N El.. 7�3 . .. 2 COVER 1/8 -3/8 WASHED STONE ,•,. r, -.� ; .;_. ...: •de IN.EI. Z4) 728 0 , oco e. 1N.EL. 0000 . o manic©c/NT"E © 1 ''F= e N o ` o e a .. e !N. El. , a 13 -D/B W/ 6 SUMP o 0 0 3/4 1 1/2 WASHED STONE o _, _ 4 . 60, 4 LIQUID I D LEVEL . . .. Q o.6� ,�.- p -� 14 g v O 0 0 p o O o b r f70OdO . . e 6 EFF. DEPTH; 15 o p om 6,0 e . , o 06 . 6o a PERC ..TEST RESULTS G000Ob . v v PRECAST SEPTIC TANK WITH a o p PERC RA p o PRECAST LEACHING PITS 0 o b C o WHITNESSED BY: o�,. ,�-, -ouzo CAST IN PLACE INLET AND EL. :��.o 0o o b NO.. - SIZE . �- ��,g. x 7,,e „ . OUTLET T S PER TITLE Y - � ,�.tir - .B� BOARD 0F' HEALTH — DIA . Lx SIZE o00 �o DATE. / �. - N 8 DIA. ' /`/G X -q'/ " y✓'/LSE x S e9" .1.7E'Ef o 9 a 8 kku 0( $° PROFILE OF PROPOSED. SEWAGE SYSTEM SYSTEM DESIGNED BY THE TOWN OF REGULATIONS AND STATE TITLE g FOR SUBSURFACE DISPOSAL OF SEWAGE SCALE • 1/4 = 1 0 — I //� a o -' N .B . 1. ALL PIPES SHALL BE SCHEDULE _ 4 P.V.C. SEWER PIPE o S,%, u fill 2. ALL PIPES SHALL BE SLOPED 114' PER FOOT EXCEPT FOR -79 - 4 � � �t THE FIRST 2 FEET OUT OF THE O / B WHICH SHALL BE LEVEL ,, � 52 J /�• t 3- DESIGN FLOW BEDROOMS AT 110 GALDAY PER BR. 33aGAL/DAY �oT k SEA~ / i 11 ��o X Z.s_ 49s" / \ SEPTIC TANK . SIZE . GAL. �zo, ����_► 1 20 o,ST s-EOT, t USE oo� GAL. W/ T GARBAGE DISPOSAL c LEACHING SYSTEM: USE - � -c�s �- ,� ciNG . iT- o .q• x E; -,�- - .� a 7 O. ". T,y 1✓� z' Off` S TO/Y .�z-L �i 7- EFFECTIVE AREA. SIDE , 0. TOTAL FLOW �cos' ��- ! ✓.,- �' - : ''' .;t TOTAL. REQ D FLOW��d X xe W/a__.__�GARBAGE .DISPOSAL r .. RESERVE FLOW GAL/DAY 7111-72 ' REFERENCE PLANS r _ P ED BY AP ROV t - T� 0 A R D� 0 F. HEALTH �— . DATE N PROPERTY E RT Y OWNER :E R �r�-�,, -- - v SITE D SEWAGE PL ►N RO 0 - , . CDR. . .�`..�. r . BE R SI LE F "E• 0 E ,r,r, -•_:� .- . ,r DOOM NG AI���, W L�. �G _ . . • - . � BATE �, _ .,r t ASSDCtATES fA DOYLE Ma_ l ` SASS.,