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HomeMy WebLinkAbout0266 LONG POND ROAD - Health 266 Fong Pond Road (Marstons Mills) �4.'IIN OF BARNSTABLE LOCATION 0�0q- atis 9611 1Kc�� SEWAGE #�' VILLAGE aLS&O IS ��/s ASSESSOR'S MAP Si LOT INSTALLER'S NAME & PHONE NO. UA►' c 0 SEPTIC TANK CAPACITY / �o© r-� 4 � LEACHING FACILITY:(type n,S± (size) D oNO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER)2 i BUILDER OR OWNERS r Ave.S DATE PERMIT ISSUED: DATE .COUPLIANCE ISSUED: VARIANCE GRANTED: Yes " No �/ � •L�y I.iq j � f t1 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 266 Long Pond Rd Property Address O'Fria Owner's Name C'f Marstons Mills MA 02648 2/1/16 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 Telephone Number. B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2/1/16 Ins or's Sig u Date ; I s' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board' of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or y 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. 266 Long Pond Rd•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 15 Ao - Vs Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 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 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Pumping suggested every 3 yrs to prolong the life of the system 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: n/a ❑ 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 266 Long Pond Rd•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 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) 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. 266 Long Pond Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 Cityrrown 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: n/a D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 266 Long Pond Rd-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. 266 Long Pond Rd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 Cityrrown 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)[310 CMR 15.302(5)] I . 266 Long Pond Rd•03/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 Cityrrown State Zip Code Date of Inspection 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 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a 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: Date Other(describe): n/a 266 Long Pond Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No recent pumping 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): Approximate age of all components, date installed if known and source of information: Pp 9 P ( ) 1987 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 266 Long Pond Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts UTitle 5 Official Inspection Form I IF Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 266 Long Pond Rd Property Address O'Fria Owners Name Marstons Mills MA 02648 2/1/16 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 6116"feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments on condition of joints venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 61 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Inlet cover raised If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000g Sludge depth: trace Distance from top of sludge to bottom of outlet tee or baffle >12 11 Scum thickness trace Distance from top of scum to top of outlet tee or baffle >21. Distance from bottom of scum to bottom of outlet tee or baffle >2" i How were dimensions determined? Measured 266 Long Pond Rd•0301 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 Cityrrown 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.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a 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.): n/a 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): I n/a 266 Long Pond Rd-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): n/a *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.): Probing gives no indication that the d-box has a raised cover. It was not excavated due to its excessive depth Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No. 266 Long Pond Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 CityrTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 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.): 600g Leach Pit is 9' below grade, cover raised to 6"of grade, dry at the time of inspection, clean sidewalls, no indication of past backup 266 Long Pond Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 Citylrown 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 Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): n/a 266 Long Pond Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 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: >20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Per elevation of the home 266 Long Pond Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 266 Long Pond Rd Property Address O'Fria Owner's Name Marstons Mills MA 02648 2/1/16 City/Town 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. c, C X �- � �° 0 266 Long Pond Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 L • , COMMONWEALTH OF MASSACHUSETTS fu EXECUTIVE OFFICE OF ENVIRQNMENTAL.AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �'q9 /fib a O Oe1 ti�A�Tg9C F TITLE 5 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ' 6pca Owner's Name: Owner's Address: .0 Date of Inspection 3 Name of Inspector: (please Dri t) Cr1 Ji L&r k-k 0`/ Company Nam. Mailing Address: 0 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to ection 15.340 of Title 5(310 CMR 15.000). The system:. . Passes Conditionally Passes eds urt er Evaluation by the Local Approving.Authority ails � .- Date: � !. Inspector s:Signatur . The. system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DE ),within 30 days of completing this inspection.If.the.system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP..The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments.: • ****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. f Title 5 Inspection Form 6/1-5/20.00 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS 6J " 4 SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) \°� 1 Property Address: cgzo/o ` Owner: Date of Inspection: Q / Inspection Summary: Check A,B;C,D or E%ALWAYS comp lete.All of Section D A. ystem Passes: I have not found any information which indicates that any ofthe.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;vyill 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 i e p p (s)are replaced obstruction is removed distribution box is:leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 ; . Page 3 of 11. OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART`A CERTIFICATION.(continued) Property Address: � I kyvj Owner: P �•oSh��_ 1 )Date of Inspection: /0/ 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 systerti 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(i)(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: y g p _ 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 coliform bacteria and volatile organic.compounds indicates that the well.is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are.triggered.A copy of the analysis must be attached to this.form. 3. Other.: 3 Page 4'of 11 OFFICIAL INSPECTION FORM-NOT FOR..VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART A CERTIFICATION(continued) Property Address zae : r��1tXX�ii�— /irk Owner:AUa_ziA,D 6-eS_J711407k_ _ Date of Inspection: ®/ D. System Failure Criteria applicable to all systems: g You must indicate es or no to each of the following for.all inspections; Y � P Yes Ng( n/ Backu of sewage into facility or.s stem component due to overloaded or clogged SAS or'cess,ool P b Y. Y:. . P �� p ischam r effluent r D _e o ondm of fluen to ttie surface of the ground or surface waters dine to an overloaded or P g g 7 clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or-clogged SAS or j cesspool Liquid depth in cesspool is'less than b"below invert or available volume is less than%Z 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. 1� . Any portion of a cesspool.or privy`is within a Zone 1 ofa.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 duality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence'of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered:A copy of the'ahalysis must be attached to this form.] (YeYNo)The system fails:I have determined that one or more of the above failure criteria exist as described in 310 CMR 15:301 therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correctthe 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 drinkingwater supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 1I 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. 4. .j Page 5 of 1 l OFFICIAL INSPECTION FORM,—.,N.OT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1?& Atd kooa ►' 0aCa Owner: Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the followip : , Yes No Pumping.information-was provided by.the owner,occupant,or Board of Health —e/Were.any of the system components pumped out in the previous two weeks? i__ 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 backup _ Was the site inspected for signs of breakout? V'_ 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.acid depth of scum? V_ Was.the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface-sewage disposal systems? ba The size and location of the Soil Absorption System:(SAS)on the site has been determined, ,sed on: Yes no l/ Existing information. For example,a plan.at the Board of Health. t/_ _ 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(3)(b)] f 5 r - - Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR"VOLUNTARY.ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL SYSTENI�INSPECTION FORM -PART C SYSTEM INFORMATION Property Address:�6?6�0 Owner: a 0- Date of Inspection: p / �^ FLOW CONDITIONS RESIDENTIAL Number of bedrooms:(design): 3 Number of bedrooms(actual):. DESIGN flow based on 310 GIvIR 15:203 (for"example: 11.0 gpd x#of bedrooms):'20 Number of current residents: s Does residence have a garbage grinder(yes or no):Y49 Is laundry'on a separate sewage system (yes or no).// [if yes separate inspection required] Laundry system inspected(yes or no)���- �� ���� Seasonal use: (yes or no)./ . Water meter readings, if available(last 2 years usage(gpd)): Sump.pump(yes or no):a_ Last date of occupancy:�. �h���t,✓- ���/L1L(/I �/� 2� � COMMERCIAL/INDUST'RIAL./?U- Type of establishment:. Design flow(based on 310 CMR 1.5.203): gpd " Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank resent es or no): b P (Y _ Non-sanitary waste discharged to'the Title 5 system(yes or no):_ Water meter readings, if available:" Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records P11 �C,�OSource of information: Was system pumped as.part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity'pumped determined? Reasori Tfor pumping: TYPE OF SYSTEM c/Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _:Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system"owner) Tight tank — gAttach a co of the DEP approval — PY PP _Other(describe): Approximate age of all components,date installed (if known)and source of information: Were<sewage odors-detected when arriving at the site(yes or no),/. ,?O' 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION.(continued) Property Address: Owner: Date of nspection: O/ BUILDING SEWER(locate on site plan) /X1 Depth below grade: Materials of construction:_cast.iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:Zlocate.on site plan) . gDepth below grade: S Material of construction:_zccncrete_metal_fiberglass_polyethylene _other(explain). If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) , Dimensions: Jo, �k (o k '5 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:_J9 How were dimensions determined:. t./ ,Q9®h/✓ � Comments(on pumping recommend6flons, fniet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc 0i(a/1to� u GREASE TRAPcate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 r Page 8 of 11 OFFICIAL:INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM'INFORMATION(continued) Property Address: O& . Owner: C1 P/A A fi 2Ca. Date of Inspection: 34 /n/ TIGHT or HOLDING TANK:/(tank must'bepumped at time of inspection)(locate on site plan) Depth below grade: l- Material of construction: concrete "' metal `fiberglass .polyethylene' other(explain): .Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:Zof present must be o ened)(locate on site IanP 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 CHAMBE ;�locate on site plan) Pumps in working order(yes or no): Alai*ms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances,•etc;): 8 f .r Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATI.ON(continued) Property Address:,Xxee mil) "V)t Aa sLl� Owner: Date of Inspection: /0 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type V leaching pits,number:j 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, e c.): 10A CESSPOOL060-(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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIV%locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level-o,f ponding,condition of vegetation,etc.). 9 j Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR-VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:c 1 Y/,G✓ MA Owner: ptJlP �.Si� � Date of Inspection:, . SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch ofthe.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. ✓(��/ '" �a ,a 10 Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4jx4 p� /J � Owner:�Q' 'e r2\_m16 Date of Inspection: 2 /p SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check).-all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: �hecked with.local excavators, installers-(attach documentation) _i/Accessed USGS database-explain: You must describe how you established the high ground water elevation:11 C No.. ............_....... Fss........._.._.... ......_ THE COMMONWEALTH OF MASSACHUSE77S BOARD OF E TH 07 ...................OF. ........ .......... .-..---_--_-_.-__------.-------.............•.•. Appliration for Disposal urko onsuUan ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: P_ ..... . . .. .. .._...... ... .-•..... . ....... . j..1.s _--• Location-A es -•••••-.-•_••-.-•--.-••-.--or•Lot No. ------------------- *----- ------ ner Address W Instal er Address UType of B 'ding Size Lot..����_/ .--...Sq. feet Dwelling—No. of Bedrooms.... ... ..............................Expansion Attic (� Garbage Grinder Other—T e of Building .._..... No. of persons............................ Showers ( )—Type g ..... p ( ) — Cafeteria P4 Other fixtures . ..... W Design Flow....................��...._......gallons per person per day. Total daily flow....•...•..-. _ .--........•.........gallons. W Septic Tank—Li uid ca acit /M-. allons Len -. .... Width. _%..1®..... Diameter................ Depth..`�........ P q P Y-••---•-- g �--- �- x Disposal Trench—No. ............... Width.................... Total Length................ Total leaching area...................sq. ft. Seepage Pit No...®!_1/C"_..... Diameter..l ..... Depth below inlet...s .:..s------- Total leaching area.;��y__:...sq. ft. Z Other Distribution box ( Dosing-tank ( ) `-' Percolation Test Results Performed by.......l.E'.� i........ ............... Dated �..... ........_. "� ,4 Test Pit No. l..:!�.....:._..minutes per inch Depth of Test Pit.... Depth to ground water...e a..•...._.__. rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ...•••...••--••-•••••••••••--••-•.................••-•-•-••..........••••---•-••••-•..........•-••...•---••••---•.._.........--••••-••••••._...----••......•. 0 Description of Soil........................................................................................................................................................................ x U -•-•-•••............•--•••-••••....._...•••••...••••--•••••••---••••-••••••-••.......•••-••-••---•••-•-••-••-••••-•-•-.....-•-••-•.........-••••-••....-•-••...........•••--•.........................•- w --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•...._......••- V 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 TITU 5 of the State anitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by th oard of health. Signed....-, . V ......... ... '..1 . . Application Approved By.........-•••-•..............•-•--...... ----•-------------Dav •. Date li Application Disapproved for the f ollowi reasons--------------------------------•-------.................---------•-•----...-----.......................•-••---- ......................••--••••••••-••- •--•� •-�•-•-•..........•-•...........•••--•------•-----------••••---•••-•••-•••-•-•-•••••-••...•--•-•--_... Date ...--••-•--- PermitNo.... .� ®.... -.__.._ Issued•....................................................... Date A No.- Fim ......... ........ .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF E TH '4 ... ............OF. ........ ............. ................................................ Appliration for Disposal Works Toustrurtion ramit Application is hereby made for a Permit to Construct ( -��®r Repair an Individual Sewage Disposal System at: .............. ------------ ... .. .. . .............. ................ . ......................... - Location ,A e'sor Lot No. ........................ .......................................... ------------------- ....................... nerAddress............................. .................................................................................................. ...................... --------------�_.. al Address Type of B ing Size ........Sq. feet QTA Dwelling—No. of Bedrooms if..............................Expansion Attic ( Garbage Grinder V� Other—Type of A Building ... 4�- --------- No. of persons......_..._..........__.____ Showers — Cafeteria QI Other fixtures . .................................................................0................................................................................ Design Flow....................&�...........gallons per person per day. Totalcjaily flow._...........3.3-D.....................gallons. 1:4 Septic Tank—Liquid-capacityArM..gallons Length.fe.�..... Width.%�.l.... Diameter..._............. Depth.ok........ Disposal Trench—No ........ Width...........---.... Total Length............_—Total leaching area'...................sq. ft. Seepage Pit No....&/ Diameter..Zl��...... Depth below inlet...3-z..A....... Total leaching area.._ ......sq. ft. Z Other Distribution box Dosin6tank A .......................... ................... Percolation Test Results ,Performed by.. Date -�X/...../i............... Test Pit No. .... -::---minutes per inch Depth 'of. Test Pit... ..... Depth to ground water...4/19 .................. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.._.........__..._...... P4 ----------**-----------------------------------*---------------------".....0........*"**"*---*----------------*----------------------------------*......... 0 Description of Soil......................................................................................................0.................................................................. x U ....................................0..............................0....................0.............................................................................................0................. W .....................................................................................................................................0.................................................................. 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 T I T LF, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed....... .......................... ................0.......... ------------------------------------ Dat All........................................ '�!I 6 Application Approved By.......... .... ................... ...... Date Application Disapproved for the foliowi ea sons:...............................................................0........................................... ...............................0...................................................................................................0......................0.............................................. I Date PermitNo......................................................... IssuedL..................0.................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA)_TH . ...........................OF... ..................... Tatifiratr of Tuampliatta THIS IS TO CERTIFY, That the Individual Sewage D'sposaj�.em�const..ucted (_,j'-or Repaired P .1 j . .............. .. ..... ................6, . . . ............................................ ler ....Ao . ....... ...... by.... ------- TO—----*; I Instal at..�f ....... ;K'e/ ......................................................................................................... co'7 ............. dated_....._....has been installed in a or nce with the provisions of T.� _F 5 of Tlii� State Sanitary Cod described in the orrIks Construction Permit No �F e0s e application for Disposa ........ ..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. I DATE.............................................................................. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT. ...........................................OF............... . . . .... ....... .................................. N I............ FEE......................... iii Disposal orkin 11111rMt Itt prrmft Permission is hereby granted....................6A----------TT" . ..................................................................... to Construct or Repair an In i idual Sewagp Disposal System at No_'I'zy__...... ........ ..................................... .................. Street D ted------as shown on the application for, isposal Works Construction mit No. ..... .... ... ...... ....................... ... ................................. Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON EL. s3 Xo. . . TOP OF FOUNDATION •-• CONCRETE COVERS CONCRETE COVET 4"CAST IRON I •r{�7rr ' 'mnr,•m, OR SCFIEDULE 402 MAX. P.V.C. PIPE 4"SCHEDULE 40 PV.C.(ONLY) i2"MAX, �• PITCH I/4"PER.FT PIPE - MIN. e.o PITCH 1/4"PER.FT LEACH • �--INVERT io ' PIT /y. PRECA. o , ° \ LEACHI. SEPTIC TAriI( INVEgT INVERT "e . a.; PIT OF INV RT EL.S1Y.x.Zf 60 ELy3�`� EQUI 1ST. X ;�. I > EL f� S!S .. .. .. GAL: JNV�RT �' �� �• • EL. i.578 /INVERT p a b: "TO I .'. w w 3 4 EL'S!?.SO ;• U_n SU WA SHE HE �`' STONE ' PROFILE OF �- - SEWAGE DISPOSAL SYSTEM 1 . /VOGROUNO WATER TABLE 3S"U i NO SCALE SCSI L LOG WITNESSED BY DATE /.4.�//�f3... TIME. . . .. . . :. �- to iFFO'e� BOARD OF HEALTH TEST HOLE I TEST HOLE 2 ELE V. . . . . . �e TR.�ND,.• cflP� .c ✓O ELEV. .. .. . . . . . . �• � � . ENGINEER mn m'n DESIGN DATA : . 3 SJeSo/< NUM©ER OF 13EDROOMS .3 TOTAL ESTIMATED FLOW 3.3,CD GALLONS/DAY 130'rTOM LEACHING AREA �/3 , , SQ.FT• /PIT SIDE LEACHING -AREA . . . . / , , . SO.FT./ PIT GARBAGE DISPOSAL . .AI9 (50 % AREA INCREASE) 3-iZ er;o TOTAL LEACHING AREA SQ.FT r<-3s KO _ _ r _ PERCOLATION RATE . .�; ?-, .. A1.IN/INCH: .O .WATER ENCOUNTERED _ LEACHING AREA PER PERCOLATION RATE .. . . . .. SQ.FT. NLJM0ER OF LEACHING PITS O /✓ APPROVED . .. . . . . . BOARD OF HEALTIi � 2- . s3. �`/. �(�� = •//,3.SF. • > / 6 DATE./O���. . �/� , �. R.H. : .�1 .�.�..�(.�•.S.J. ./3� .�.�"� =3 Z 7. Gel? s 2A- AGl NT OR INSPECTOR \ L q JOHN P.O. BONGINEERING JACOBI X616 �.: �o . . P . . . . . : . . . E• SANDWICH � PETITIOUER ' ' A 02537 �. Department of Environmental Management/Division of Water Resources i WATER WELL COMPLETION REPORT WELL LOCATION Address L07- 41, 40"",.A-4 114 w C City/Town ,t,M f 1& /'N1 R G.S.Quadrangle Map S // Grid Location Mp//7'e(z\ Owner/")/' 0m—e5 c�V� -/ 1Gt�NP �OsTr 6etm Address/0JS AT 6A- 'cam: I ble Mct 0.) 6(0g' WELL USE CONSOLIDATED WELL Domestic®P Public ❑ Industrial Type of Water-bearing Rock Other Water-bearing Zones Method Drilled Q er 1) From To �c! 21 From � To Date Drilled /�g/O 3) From To - 4) From To CASING � �� Depth to Bedrock Length 64 Diameter Type Puc UNCONSOLIDATED WELL STATIC WATER LEVE r Water-bearing Materials Feet below land surface • .I(' � Sand: fire❑ medium Er coarse®' Date measured / / F Gravel: fine medium❑ coarse[] GRAVEL PACK WELL Screen: e- Slot# /J length y from L I to 6 a, Yes ".;N'o 'Q . Split Screen (or 2nd screen) , WATER QUALITY TESTS MADE Slog length from to -Chemical Q Biological:®� Depth To Bedrock PUMP TEST Drawdown r> feet after pumping 11 days hours at 6 GPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS:.(On well or water) Materials From To DRILLER Firm ,QA , S co ",vr 1/ ✓P� 6) ys // . A4 eA Address /•Jo• +?Uft 9l'o cocis.� City mATAIe if e 44,R (9a65/q R/d 6e Registration No. ea,—) jv Operator's ignature Please Print irm y BOARD OF HEALTH COPY 25M•10.85-807101 ��tf111il1fllfttlitf1111f1tififltiit(1t1ti1!ffiftiif�Tlif►"tfffi?"ft'";.ir�+t+fffilttff tfttbttf(ttitit(ttf(tjliififti►iHlfiitititilitlfi i(t"�fiiiff`ttlli►flffl If`t(ff?Iftttii(1liiPi'flit(tflliif'ftfittttiitftltitn't�► if�llr ENVIROTECH, LABORATOR1; ES 449 Ate. 730•.Sa'p¢6h; MA 02563• (617) 888-6460 Mr.. Ames c/o' ' CLIENT: Maine Post & Beam LOCATION' Lot 4 Long.,Pond. Rd: ADDRESS: 1095,Rte 6A Marstons Mill's,MA 02648: ' _- z= W.Rarnstabl'e,MA.0�668. 4• COLLECTED BY: S.Solb''o i:" SAMPLE DATE:. '7/28/87 •TjME; 4:00 PM _ DATE RECEIVED': .7 29 87.. SAMPLE )D: E 577 JOB #:;. New Well �_ WELL DEPTH: RESULTS OF ANALYSIS: 1 Parameter Units'. I; Recommended limit, Result •' =x Coliform bacteria/100 ml (MF;Meth'od)! 0 0'. c pH iP Wunits � 6.0-8.5 _ 5.64 Conductance timhos'/gym 500 101 _ Sodium nrgf,L•... 20.0 10,5 - Nitrate-N mg�L' . ;. ji 10.0 3-.00 Irongy,L 0.3 Manga6ese mg/.L. 0.05 ---- c. Hardness•. mg/,L as,1COCO`3 Sulfate mg/L'; 250 Potassium mg'/L+ 20.0 '3 _ x Alkalinity mg/L'; . 200 . . _ Chloride mg/L. 250 'Iron level is not' a aiealt Hazard. COMMENT z : is . I•, A .' YES NO =» }L[ }L ❑ WATER IS SUITABLE FOR DRINKING;P�RPOSES FOR PARAMETERS TEST D od _ + PATE -_ ��EaltilltlliiliitlUi!!i!(l111a1lltill,littllill!!Uilltiltilltltll�l,illlUill!lll,a�llltilititititdita,l,alilllllklti,ltllUl�ilt:tttll:UUfdll!l1111!!t!!!li!!!!lliii!lllUili!llll1111!!!!lltit!litiilltlil!!1lliitllli11,U111i;;1i11ttli�� 4 rPr APPROVE D Earnstab a Conservati n Commission Il WI lot- '�1".6 0111` Signed Data s. �p 10 gi , r • x s i 1 , 4 k' t v 4 �4 w; qqq Y , A • x n• ' r , ct x w ate l S • r �Y�',," /V6 Gl4tl»,f r" AP#' M 16Y DRAM XY W, R