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1643 OST.-W.BARN. RD - Health
1643 Ost Marstons Mills rA-127033 f Page 10 of 1.1 OFFICIAL.INSPECTION'FORM=k,NOT FORNOWNTAIt3':A SSE SSMENTS SU89URFA:CB SEWAGEMISPOSAL SYSTEMINSPECTIOMFORM PART:C` SYSTEM M—ORMATION(4©ntir►ued)" Property-Address: 1643 d�se2v c2 2e .lJ. Ba2n�t a�2e 2d.- IV.-Ba29.staUP-, Ma.- Owner: Aan LaCon.te . Date of Inspection: 9/2 n 0,4 " x EWAG .DISPO AT.,SYSTRM SKETCH i7�1P Provide a sketch of the sewage dis osal system including ties to at least o permanent referenc:Ian• arks or benchmarks.Locate all wells 100 feet.Locatewherepublic•water applyentgrs.thebuild =. 10 y -- -- ,�• � �, mow.,�a a �, r t Page 10 of 11 OFFICIAL INSPFJ��?TON F'(�RM�NOT T�?�QI�IiJNTAg3�:ASSES:4MENTS SU-89UI PACT,SEWAGEDISP.OSAL SYSTMINSPECTION ORM PART;C: SYSTEM P F'ORMATI.ON(continued)` x . Property-Address: 16 4 3 O.st e2v i.Ue ./V,,Ba znz.t agie 2d. U. Ba2gzi-aUe, Ma. Owner:Ann LaCon;te Date of Inspection: 9/20 04 SKETCH EWAGIEMSPO Provide a sketch of the sewage dis osal system including ties to�ateast o perinairertt reference lan arks or benchmarks.Locate all wells 100 feet.Locate where pubwater pply enters.the building. 10 ` C •ex YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: Fill in please: Lh � . APPLICANTS YOUR NAME/S: aJ�_5 BUSINESS = YOUR HOME ADDRESS:rt L 2 bs r-iryf He TELEPHONE;# Home Telephone Number SOR 3�0-�49 NAME OF CORPORATION: NAME OF NEW:BUSINESS RC S riA[ Iia� TYPE OF BUSINESS ►5 Co, u /Dn 5c�'ViaS CC& sc�cfx3 ett�cs IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS io,4 s 0 ' L - MAP/PARCEL NUMBER 1a'I �; (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual has ten �l�V MU en�pg•M the permit requirements that pertain to this type of business. '' ST">OMPLY WITH ALL 6 I HAZARDOUS MATERIALS REGULATVI.q Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has 1'�Ien i o d f the.licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: `V I TOWN OF BARNSTABLE Dated Z.l 01 I -Zb TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: Y-.4 C, n5�rc c_�C)1? BUSINESS LOCATION: It q 3 65,kryMe- 12r� r A��� d /'� 1U.2 INVENTORY ,MAILING ADDRESS: 3&cm,p TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: c, EMERGENCY CONTACT TELEPHON NUMBER: 5-69-360-g313 MSDS ON SITE? TYPE OF BUSINESS: Cc,nA-_/.,-,,,r kn„sA-uGfi'a✓f INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammabies Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes �h tt 1�In►�P o� e AboVz. Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash /Lw, Ajkg�CA WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applic is Signature Staff's Initials r — y J pF NflR�I+ 11� 'rin. �O M Barnstable County Health Laboratory ANALYTICAL REPORT FOR Barnstable Health Department Report Prepared for: Barnstable Health Department Thomas McKean P O Box 534 Hyannis, MA 02601 Order#: G0007189 No.of Samples: 1 Date Received: 08/09/2000 Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 08/18/2000 I OF"HA Page: CERTIFICATE OF ANALYSIS 1 Barnstable County Health Laboratory Report Dated: 08/18/2000 Report Prepared For: Barnstable Health Department Order Number: G0007189 Thomas McKean P O Box 534 Hyannis, MA 02601 Laboratory ID#: 0007189-01 Description: Soil Sample#: 718901 Sampling Location: 1643 Osterville-W.Barnstable Road West Barnstable Collected: 08/09/2000 Collected by: Harrington Received: 08/09/2000 Test Parameters ITEM RESULT UNITS MDL MCL Method# Tested LAB: Organics TPH by GC\FH) 3000 mg/L 5.0 D3328-78 08/15/2000 Approved By: e_, .�, (Lab Director) Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 TT T � � � f �� � � , q � ,� � � � . � � _� �� i . � � GROUNDWATER ANALYTICAL ASTM Method D3328-90 (Modified) Hydrocarbon Fingerprinting by GC/FID Field ID: 718901 Laboratory ID: 35196-01 Project: BCU7189 QC Batch ID: HF-1376-M Client: Barnstable Cty. Health and Env. Dept. Sampled: 08-09-00 Container: 120mL Glass Received: 08-09-00 Preservation: Cool Extracted: 08-10-00 Matrix: Soil Analyzed: 08-15-00 %Moisture: 10 Dilution Factor: 5 Qualitative_Identification This sample has GC/FID characteristics that are similar to: 1. Fuel Oil No. 2/Diesel Fuel. 2. Based on the distribution of the isoprenoid hydrocarbons to the n-C alkanes,the Fuel Oil appears to be heavily weathered. Analyte Concentration Units Reporting Limit Total Petroleum Hydrocarbons 3,000 mg/Kg 260 QC Surrogate Compound �— Recovery QC Limits ortho-Terphenyl d 60- 140 % Method Reference: Comparison of Waterborne Petroleum Oils by Gas Chromatography,Volume 11.02,Water,American Society for Testing and Materials(1990). Analytical protocol modified by use of an internal standard. Results are quantified on the basis of 5a—androstane. Sample preparation protocol modified by use of microwave accelerated solvent extraction. Results are reported on a dry weight basis. Report Notations: BRL Indicates concentration, if any, is below reporting limit for analyte. Reporting limit is the lowest concentration that can be reliably quantified under routine laboratory operating conditions. Reporting limits are adjusted for sample dilution and sample size. d Indicates surrogate recovery outside recommended limits due to required sample dilution. Groundwater Analytical, Inc., P.O. Box 1200, 228 Main Street, Buzzards Bay, MA 02532 GROUNDWATER ANALYTICAL ASTM METHOD D3328-90 (Modified) Hydrocarbon Fingerprinting by GC/FID Lab ID: 35196-01 Hy drocarbons Laboratory 0.7 0.6 0.5 0.4 03 0.2 0.1 O.C. 0 5 10 15 20 25 30 35 40 Retention Time (Minutes) I Barnstable County Department of Superior Court House Health and the Environment P. O. Box 427 Barnstable, MA 02630 (508) 375-6605;6612 CHAIN OF CUSTODY CLIENT NAME: erl/'Ta- P-Pife- 4e ! ADDRESS: PROJECT NAME: Att.Q PROJECT NUMBER: PROJECT SITE: Adam 16117 057e,-.-d1# —6/60rh .SAMPLER: DATE/ SAMPLE SAMPLE NO. OF ANALYSES COMMENTS TIME: NUMBER LOCATION SAMPLES REQUIRED 41 RELINGUISHED BY:/ DATE/TIME: RECEIVED BY: DATE/TIME: RELINGUISHED BY: DATE/TIME: RECEIVED BY: DATE/TIME: f ok N CUSTOMERINVOICE Invoice Date: 08/18/2000 Barnstable County Health Laboratory Barnstable Health Department Invoice#: G0007189 Thomas McKean PO #: P O Boy:534 Hyannis,MA 02601 Total Paid: $0.00 Amount Due: $98.45 Payment Terms: Date Invoice Service Procedure Description Completed QTY $Price Amount Laboratory TPH by GC\FH) 08/18/2000 1 $98.45 $98.45 Grand Total: $98.45 Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Barnstable County Department of Superior Court House Health and the Environment P. O. Box 427 Barnstable, MA 02630 (508) 375-6605; 6612 CHAIN OF CUSTODY CLIENT NAME: l-fa, 44e � ADDRESS: 7 A6(aA;,,,R PROJECT NAME: A44R,4A.,- (vet' o-F f/r, s PROJECT NUMBER: PROJECT SITE: Q e.-;fg`o - 6, 1�+m SAMPLER: 10i I,,r)-r d.J 1 A, DATE/ SAMPLE SAMPLE NO. OF ANALYSES COMMENTS TIME: NUMBER LOCATION SAMPLES REQUIRED a � RELINGUISHED BY: DATE/TIME: RECgEIVED BY: DATE/TIME: � RELINGUISHED BY: DATE/TIME: RECEIVED BY: DATE/TIME: SEWAGE INSPECTIONS t 44 ii DATE ��Z LOCl:TION � 3Jt��� W bl1_ VILLAGE ASSESSOR'S MAP & LOT la-- IN�PECTOB � �C©��o�' (end �� T'oc SEPTIC TANK CAPACITY 100 O LEACHING FACILITY: (type) L 1" (size) J©� NO. OF BEDROOMS BUILDER OR OWNER A60 C Cnn OWNER MAILING ADDRESS �.il � 7 j i 1 \� ►�- %�' � � � i � ate_ �d �\ /� � i i (Ts u� O ��ci �. OCT 0 6 2004 TOWN OF BARNSTABLE HEALTH DEPT. DATE.1La2/pq-- 1643 O,3teav� ��e Gle�t Ba2ns.taf .i2 PROPERTY ADDRESS:------ ,AAP L3a znh.taP__ee Na.' PARCE&+• ®3 20668--------- On the above date, tw septic System at the above address was Inspected. This system consists of the following: 1.-�000 gaiiora 6ePt-ic .tank. 2.,diztaigutton &ox. it. 3. 1-1000 gaiion .�each.ing /� Based on inspection, I certify the following conditions- eased i.s a title dive .se/2t'c hy�tem. 5:. the .3e/2tiC- ,6ydtem "3 in /2/Lo/2ea wOakiag o2de2 at the /22ebent time; i SIGNATURE: - ---- -- ;., Name.Ro.&eat P aoiih i _------ --- r j Company:_L.1i_fu�oe2 Address:jj..a.'Box 6 6 ------------- LX try Centeav� ��e (�a. 02632 — M ( 508)775-3338 Phone.------------------------- THI S CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPW P. MACOMBER & SON, INC. Tanks.,Cesspools-Leachfields Pumped & Installed. Town Sewer Connections p.0. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIR NMMAL AFFAIRS DEPARTMENT'OF ENVIRQNII ENTAL"PROTICTION TITLE 5 OFFICIAL INSPECTION FORM--NOT.-YOR VOL'FNTA RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA CERTIFICATION PropertyAddress: 1643 gaanzs agee ad. lJ Ba2n�ta��e. Na.• Owner's Name: 4nn LaCoate Owner's Address: 21 7o))o n A f- F))oavff , l)]n_.02149 Date of Inspection: ,Q/2 n n 4 Name of Inspector: (please print) 1?.o 0 0 f .?��g-�Ua. Company Name: ,.- -P MacomAz t ..S.on Lric. Mailing Address: .6.6 •026 3,2 2n e2U C e, d . ---� Telephone Number: 5 0 8—7 7 :3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal systet 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 bite sewage disposal systems.I am a DEP approved system inspector pursuant to�Section.15:340.6f•'Title 5(310 CMR,•15:000). The system: XX Passes -Conditionally Passes Needs Further Evaluation.by the Local Approving Authority ail Y/ Inspector's Signg tore: Dater 0�ot The system inspector shall submit a copy of this inspection reogal'o the-Approving Authority-(Board of Health or , DEP)within 30 days of completing this inspection.If the system:is.a shared systetn 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 inspectiotrand 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. t Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAtGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 16 4 3 n.s f n.2 v ' L L3a2n-5 t a&.ee zd.- Owner: An» / rnnf o Date of Inspection: 9120104 Inspection Summary: Check A JB C;D or.E/ALWAYBLcamplete>all of Section,D A. System Passes: _no I have not found any information which indieates'thatany-of the failure criteria described in 310 CMR 15.303.or in 310 CMR 15.304 e3ist,,Any failure criteria not evaluated are indicated below. Comments: The .ih '.in paope¢ woak"in.G oaaza at the i2,e,ent lt.ime,- B. System Conditionally Passes: no One or more system components.as described in the"Conditional.Pass"°section.need to be replaced.o.r. 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. n o. The septic tank is metal and.over 20 years old*or the septic-tank(w:hether metal or not)is,structurally unsound,exhibits substantialtinfiltration or exfiltration.or tank failure:is.4mrninent: System.will pass inspection if the existing tank is replaced with'a complying septictank.as approved by.the:Board.ef 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.o 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 distriBiition box is leveled or replaced ND explain: n o 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 pipes)are replaced obstruction is removed ND explain: .2 Page 3 of 11 Opp. ICIAL U.4SPECTION FORM-NOT IFOR VOLUNTARY ASSESSMENTS SUBStff ACE SEWAGE DISPOSAL SYSTEM INSPECTION,1F`ORM PART:A CERTMCATION(6ontinued) : Property.Address:1 6 4 3 0,3;teavj e ee. GJ.-Baanzt a ie ad. Gl , aanz d Ie a_ Owner:. Ann Laconty Date of Inspection: 9/7 n/R 4s C. Further Evaluation-is Required by the Board of Health: 20 Conditions.exist whichrequire further..evaluation•by.theBoard: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 det&mines4fi accordance with 310.CMR 15:303.1 b that the System is-not furretioning in.a.mantier whichavill-protect public health,safety and the%environment: n o Cesspool or privy is within;50 feet of a.surface water 2 o Cesspool or privy is within 50.feet of a bordering vegetated wetland or a salt marsh. 2. System will fail unless the Board 4 Health{and Public Water Suppliers-if any),determines:that the system is functioning in a mariner that protects thepublic health,safety and environment: no The system has a septic tank and soil absorption system.(SAS).:and the SAS is within 100 fe.et-of a surface water supply or.-tributary to a.surface water supply. no The system has-a.septic tank and SAS and tIhe!SAS iswithin a Zone 1 of a-public water-supply, n o The system has a septic tank and.SAS!and-the-SAS is within-50 feet of a private water supply well. n o The system has a septic tank and SAS and the-SAS is less than 100 feet..but 50 feet ox;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-tis form. 3. Other: Page 4 of I 1 OFFICIAL,INSPECTIOOrN FORM NOT.TOR;VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION-FORM PART A . CERTIFICATION(continued) Property Address:16 4 3 Uzt e zv itee 0.•Ba29-6.t aP,.ee 2d. 0. /3aaa.6.ta..Re, N Owner: Ann /_aLnnf �o Date of Inspection: 9 J n J(T4 D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to.each.of the:following:for all inspections: Yes No _ x Backup-of sevrage:into i Aity.:or system component due to overloaded-or.clogged SAS.or cesspool x Discharge:or ponding of effluent to the surface;of the..ground or..surface:waters due to'.an overloaded or clogged SAS or cesspool x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool x hiquid depth in-cesspool is less than.6"below invert or available volume is less than 1A.day flow x Required pumping more-than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped x Any portion of.the SAS,cesspool or privy is below high ground water elevation. _ x Ariy,portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. x Any portion:ofa cesspool-or privy is within a-Zone-1.of a.public.well.. x Any portion of a cesspool or privy is within.50 feet of a private water supply well. x Any portion of a-cesspool or:privy is less than 100 feet but greater.than 50.feet from a.private water supply well with no acceptable water quality analysis..[This:system.passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates:that the well is.free from pollution;fr..om:that:facflity 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 attaehed.to this€orb.] n° (Yes/No)The system fails.I have determined that:one or:.more of:the:4bove 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 1:01000 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 _ x the system is within 400 feet of a surface drinking water supply x the system is within 200 feet of a tributary.to a surface drinking water,supply x the:system is located in a nitrogen sensitive area Qnterim 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 to accordanc e with 310 CMR 15.304.The system owner should contact the appropriate regional.office of the Department. . 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS $i1SURFACE SEWAGE DISPOSAL`SYSTEI�I INSPECTION FORM PART B CHECKLIST Property Address: 1643 0.6.t e2vi i. z Gl.'.13u2n,3t a9.ee •itd., / n2 Owner: Ann LaConte Date of Inspection: Check if the following have been dpne You must indicate"yeg"'or"no"as to each of the following: Yes No x — Pumping information was provided by the owner,occupant,or Hoard of Health x Were any of the system components pumped out in the previous two weeks? _ x Has the system received normal flows in the previous two week period? _ x Have large volumes of water been introduced to the system recently or as part of th�inspection? x Were as built plans of-he system'obtained and examined?(If they were not available tote is N/A) x Was the facility.or-dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site.? x Were the septic tank manholes uncovered,open ofed,and the interior.of the tank inspected for the condition the_baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and.depth of scum? x _ Was.the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'? The size and location of the Soil Absorption System(SAS)on the site.has been detetgnirted based on: Yes x Existing information:For example,.a plan at the Board of.Health. _ x Determined in the field(if any of the failure criteria related to Part C is at issue approxim6tion of distance is unacceptable) [310 CMR 15.302(3)(b)) . 5 Page 6 of 11 OFFI< IAL WSPF1 IO !1:FORM'-NOT FOR VOLUNTARY ASSE$SN NT;S SUBSUIUACE SIEWAGE OISPOSAUSYSTMINSPEETION]FORM PART-.0 SYSTEM:INFO TIOA1 Property Address; 1643 CJ,ste2v.ii-,ee Gl. Baanstagie, 2d.- IV.,/3ajz&.6t aI-ee. Ma. Owner: Ann f n r n n f o Date of Inspection:„ .Q 111,2 0 AQ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): ,,3 Number of.bedrooms.(actual): 3 `�-- 3z170-330gld DESIGN'flow-based on'3lO C1G1 15.203':(for exai*e:'110'gpd z#-ofbedrooms): Number of current residents: .: 1 Does.tesidence have a garbage"der(yes br no):'°is laundry on a separate sewage.system.(yes or-no):.no [if yes separate lnspeetion required) Laundry system inspected(yes or no)- Seasonal use:(yes or no): •n o 'Water meter readings,if available(last 2 years usage(gpd)):we-e i wa.t e 2 we 2.g h a. not 1~e e n Sump pump(yes orno): no tented within 12a6t yeaa it hhouid Last date of occupancy: unknown &e done at thin time 'see /2ages .6a and 69 COMMERCWV*XJSTRIAL Type of estate at: na. ,. Design flow.( on S 10 CN M 15.203): na gpd' Basis.of 4�sig� ow(seats/persons/sgft,etc.):, na Grease trap present(yes or no):4na Industrial waste holding tank present.(yes or no): na Non-sanitary waste discharged to the Title 5 system-(yes o n r no)h Water..meter readings, if available: na Last date of occupancy/use: , na OTHER(describe):. a. 'GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for.pumping: ,,• TYPE OF SYSTEM xx Septic tank,distribution box,soil absorption.system _Single.cesspool —Overflow cesspool Privy _Shared system.(yes or no)(if yes,attach previous inspection recbrds, if any) _Innovative/Alternative-technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) - -Tkghttank. —Attach a.copy•of the DEP.approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: unknown Were sewage odors detected when arriving at the site(yes or no):i 6 - BARNSTABLE COUNTY DEPARTMENT OF HEALTH & THE ENVIRONMENT P.O. BOX 427 Of '"4v SUPERIOR COURT HOUSE 0 BARNSTABLE, MASSACHUSETTS 02630 J Ar�gs ' PHONE: 362-251 EXT. 337 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sarrrplhe wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bottles sterilized at home are not acceptable. 2. It is recommended to use a si4ight faucet, preferably NOT svvingtype. 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving one inch air space. Do not rill bottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or anything else. 5. Fill out the reverse side of this form. The laboratory requires accurate and complete information. The person filling the bottle must sign the form 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, nitrate, sodium and copper)is 525,00. Checks should be made payable to Barnstable Counry. Exact change is required if paying in cash. Additional tests require additional fees. Consult Lab or a price list for exact information. 7. Samples are accepted Monday - Thursday from 8,00 AM to 4:00 PM and Friday 8:00 AM to 1:00 PM. They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated. 8. Completion of tests and results takes 7.10 business days. Results will be sent in the mail. 9. Special requests such as results in 2 -3 days and sample acceptance on Friday from 1:00 PM to 4:00 PM are available for an additional charge. Contact the laboratory for availability. NOTICE: WATER FROM THE SAME SOURCE CAN PRODUCE CONTRARY RESULTS T TESTED AT DTFFERENT TTMESIND/OR D=.R.ENT LOCATION$. THE COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR DAMAGES RESULTING FRQM THE &EUANQE ON RESULTS OF WATER TESTS ACCUR6TE.LY PERFORMED. PLEASE COMPLETE: REVERSE` UDE OF FORM VRIVATE WELL HATER SAMPLE DATA COLLECTION SHEET VIAL tlb+t$ERS FIELD BLA14K E I'D 'I>F,U=f:I B E R DATE R E C ' D 1 COLLECTION DATE ?.AfET11NG ADDRESS COLLECTION TIME WELL DEPTH 5rR44T ADDRESS " " YEAR WELL INSTALLED MAP/PARCEL T'LC'PH0NE COLLECTED BY : E APPOINTMENT tl-eL'DED' ? F N FOR TESTING : ( ) SUSPECT A PROBLEM (EXPLAIN) ( ) REQUIRED ( ) FOR INFORMATION ONLY ( ) NEW WELL ( ) REAL ESTATE TRANSACTION ( ) OTHER ( EXPLAIN) Cl-67RNCE OF WELL FROM POSSIBLE CONTAMINATION SOURCES ( IN FEET) SEPTIC TANK\CESSPOOL FARM SALTED ROAD UST LANDFILL INDUSTRY -JAS STATION OTHER TjZF_WTlENT USED: ( ) NONE ( ) WATER SOFTENER ( ) FILTER; SAMPLE TAKEN BEFORE/AFTER TREATMENT (CIRCLE) RESULTS VOC ROUTINE C1FLOROFORM TOTAL COLIFORM\100 ML 1 . TRICHLOROETHANE ( PPB) pli _ CONDUCTIVITY IRON (PPM) _ 11ITRIITE-11ITROGEN ( PPM) SODIUM (PPM) COPPER (PP14) At TS DATE : ANALYSIS DATE: f Page 7 of 11 e OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 4 Owner: 4 n n /,(,n n 210 Date of Inspection:�Z 2 b �G BUILDING SEWER(locate on site plan) Depth below grade: " Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply e,I or suction line: 10 f Comments(on condition of joints,venting,evidence of leakage,etc.): t tear vented h2ortgh the house vent. SEPTIC TANK:_(locate on site plan) Depth below grade: 1 Z" Material of construction: x concrete metal_fiberglass_polyethylene _other(explain) If tank is-metal list age:_ Is age confirmed by a Certificate o certificate) f Compliance(yes or no):_(attach a copy of Dimensions: 4' 10"wide/5 '*$"h ighf8' 6".long Sludge depth: }n n-,, Distance from top of sludge to bottom of outlet tee or baffle: 24,7 Scum thickness: }&ri r v Distance from top of scum to top of outlet tee or baffle:x_ Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined; Comments(on pumping recommendations,inlet and outlet tee or baffle conditi structural as related to outlet invert,evidence of leakage on, irate ;etc.): ' grih',liquid levels aka e.. GREASE TRAP: n o(locate on site plan) Depth below grades Material of construction: concrete_metal fiberglass(explain): n _ _other other Dimensions: n a Scum thickness: n a Distance from top of scum to top of outlet tee or baffle: ri a Distance from bottom of scum to bottom of outlet tee or-baffle: n a 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.): Title S TnenAr�inn Fnrm �ii sionnn 7 Page 8 of I I OFFICIAL jN-S•PECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS &V—RF;A►,CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 4 3 O,s.t e2v.i.e ee Id.-Ba2nz.t ag�a ,zd.. Gl. Brinn Ain fay Na. Owner,-dn'n /r,/'.,rafa Date of I•bspection: 9120104 w TIGHT or PIO'LDING TANK: n° (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: na Material of construction: concrete metal fiberglass___polyethylene other(explain): Dimensions: na Capacity: na gallons Design Flow: na gallons/day Alarm present(yes or no): na. Alarm level: na Ala:rtn"im working order(yes or no):na Date of last pumping: na Comments(condition of atarm and float.switches,etc,): .t.igh.t o2 ho ed.ina tank not 1Z,�,3en4.- DISTRIBUTION BOX:ye (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: no 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.) &ox hays one iatelta.P.-noev.idence ole Asoeids caa2y oye2.- no ev.c ence p4 .leakage ..into Oa 'out 01 9ox.• PUMP CHAMBER: no (locate on sife.plan) Pumps in working order(yes or-no):na Alarms in working order(yes or no):na Comments(note condition of pump.chamber,condition of pumps and appurtenances, etc.): Rump cham9e2 not sae.6ent., 8 . Page 9 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS --, SUBSURFACE SEWAGE IIISPOSAL.SYS'ITEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address:/h 4 3 Q A i a s zz a U.,Bagna-ta9.ee 2d.- Owner:. 44Ae--f a a f a Date of Inspection: 9/2 0/0 4 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) oca.ted ape /?aae 10 If SAS not located explain why: - Type -9- aleaching pits,number: 1 �leaching chambers,number:. n a leaching galleries,number: no leaching trenches,number,length: no leaching fields,number,dimensions: /20 overflow cesspool,number: no 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.): Lomay to medium aaad.• No a.ignaa o� hyd/zaue-ic �ai�uge. So-i.ea age d2u Veggtd;t.ion .ia noamai.- CESSPOOLS:n o (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: NA Depth—top of liquid to inlet invert: Depth of solids layer: N,4 Depth of scum layer: NA Dimensions of cesspool: NA Materials of construction: indication of groundwater.inflow(yes or no):N Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ceaapooia age not p/leaent— PRWY:no (locate on site plan) Materials of construction: NA Dimensions: NA Depth of solids:. NA Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc): /?g.ivy .ia not Ngeaent. 9 Page 10 of 11 OI`k'ICL&L INSPECTION•FORM- NOT FO•,VOLUNTARY,ASSESSMENTS SUSgURFACESEWAGEMISPOSAL SYSTEM.INSPECTION:FORM PARS'C' SYSTEM INF-ORMATI.ON(continved)" Property.-Address: 1643 Uhteav��Pe lJ. L3a2n��a��e 2c1. Owner: Ann LaConte_— Date of Inspection: 9 i 2 D'4 " SKETCAt 1PEWAG�DISPO t Ieast o permanent reference lan arks or Provide a sketch of the sewage is osal system including ries to a p benchmarks.Locate all wells }00 feet.Locate where public water apply enters the building. • �� (ems l /� ' lop i 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION(continued) Property Address 643 0h1 e2v.c�.'l3a sn,3.t aP,.2e 2d. l�l_ /�nnnn}nD.pv-, On. Owner: d n n /a C an fo Date of Inspection: o g 4 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water I 10: 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 r@viewed: 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:h t f'D_.f n,nn 0.n n n Al n e.te.-ma.,ups You must describe how you established the high ground water elevation: uhed:anhva.tu and (7iiiA2 modei 12116194 aaound cva.tea agove sea 92 000 01 ,pate#2 annuae 2anyez of Leaching Pit ' Beet Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per FRimpte4Wthod 3 �' Therefore,the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. cpa t1 f 1''"'"T' ,rr�,.•..,...,e-...=.,,rrr... •I UP" WARD OF HEALTH n IUNN Btble E DdSIOSAL RYSTFh( INSPECTION FORM PART D CERTIFICATION Sl)IISUItFACE 9ENAG � 1 , r...s•,-T..,.;.,_r.,,:-�,.�.:..�,.•�„�.,.rnr�+r..,-m.,• ..T`fPL OR PAINT GI.EANLI— P/ICPERTY INSPECTED STREET ADDRCS S �6�3 U���2U�-��� �.• BaR2�'tagie ad. ASSESSORS MAP , DIDOCK AND PARCEL # 127-033 OWNER•' s NAME {lane -nronte PARZ' U - CCRTIFICATION NAME OF INSPECTOR /2o�e2 Paoiin.i COMPANY NAME Joseph P. Macomber - &- -Son Inc COt1PANY ADDRESS Box^_ � Centerville Mass 02b32 yt,�� LIP Stcvvt Tovn VC G tY COMPANY TELEPHONE ( 508 ) 775-33.38 FAX ( 508 ) 790-1578 C F RT I F I CAT'I 0 N.. STATEMENT I certify that I .. hsve Person aloY inspected ortedishtr.ueWaaccuratege gaandystem this address and that the it�formati n reported complete as of the time of �inspectior}� `Phe inspection was performed and any ' ndations regarding upgrade-, maintenanc recolnlne e , and repair are consistent ning and experience in the proper function and maintenance of o with my' trai site sewage disposal, systems Check one : . XXX System .PASSED The inspection which I have conducted tos not foun any adequatela protect public which indicates that th.e system fails healCll or the env ironmenta�9dst�ted in the FAILURE303 ,CRITERIAfailtire section o criteria not evaluated are � this form , System FAILED* The inspection which I have. eonaticted, has found that the system fails protect the public health and the environmentoinpaRT ccordan e wit E Titlt 5 , ;I.10 co15 , 30 , and as specifically nte CRITERIA of this i pectin form.% q go ate. [nsp ector Signature . of this crct-fication must be provided to the OWNEl3, the BUYER in6 copy )t AI, '( where apPllcablej and the 130nRD OF ,,, ,o If the inspection FAILED , xh,e owner or operator. ahal.l upgrade ' the eyetem F within one year or the date of the inspection, unless. allowed or required otherwise as provided in 3.10 CMR 15 , 3.05 , partd , TOWN OF BARNSTAIILE LOCATION LfL , d ICrJI& b.dq&j WAGE # - 4 t{ VILc.AGE A ✓J � ASSESSOR'S MAP LOT I INSTAII LFR'SNAM12 & PIIONENO.U. 4peNz,agx SEPTIC TANK CAPACITY D LEACHING FACILITY:(type) (size) )10V NO. OF BEDROOMS PRIVATE WELL OR- BUILDER OR OWNER L DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes NO. ° r � � ti� �L � 1 9 tiff �� I r i � 1 i � ` ' � �1� � ��;� , 'gyp: `�� � �� i ,�i ,0 No...a.Y Fmc..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------------T-own------------------OFI............Barnatab.l.a............................................ Appliratiou for Disoviial Vorkg Towitrurtion "amit V Application is hereby made for a.Permit to Construct or Repair (XX) an Individual Sewage Disposal System at: ........ kz.QLS.t....RaX.11A....aQAJ(j................... .................................................................................................. Location-Address or Lot No. Ann-..LaC_0.ntp............................................................ ........................................................ Owner 7 Address ZZ................................................ .................................................................................................. Installer Address U Type of Building Size Lot.............................Sq. feet Dwelling-y-No. of Bedrooms................3..........................Expansion Attic Garbage Grinder P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow.....................--.....................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width......:......... Diameter..........-----. Depth.............--. Disposal Trench—No. .................... Width.....--............. Total Length............-....... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.........---.--..... Depth below inlet............_....... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0.4 0-4 Percolation Test Results Performed by.—...................................................................... Date------------------ --------------------- Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ Test Pit No. 2................minutes per inch Depth of Test Pit.--....._....---.--. Depth to ground water.-----.............----- ................................................................................................................................... -----------------",-- 0 0 Description of Soil....................................................................................................................................................................... x U .......................................................................................................................................................................................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable...........1=10-0-0....gall-Q.n...tan.k.................................. .................................................................................................................... ...g.allm...Pit..................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in I - operation until a Certificate of Compliance has be n issued by Do4rd of heal ............... Signed ...... ........ .... .. t . Date Application Approved By................. ........ 4-_n.�L 7--s-- -_ Date Application Disapproved for the following reasons:............................................................................................................... ........................................................................................................................................................................................................ Permit No........!jqr.nag�.�-/................... Issued.............................. Date -AA&. Date MEW. THE COMMONWEALTH OF MASSACHUSETTS Fes$.. BOARD OF HEALTH -:.:�..................OF............. _._.......................... Appliration for Uhipvii al Workii Tonitxnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (.-) an Individual Sewage Disposal System at: • :.X.-: .... .........7...... .:.-- ;-'---=--- ------•---------- ------------•----------...------------...... ---- ----...------------...------------------------ Location-�Address or Lot No. .........................,..,_..__._.................... - ``' ' Owner Address W ' 2sta'ller Address Type of Building Size Lot............................Sq. feet U Dwelling-No. of Bedrooms.................3-------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -------------------------------• - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. t� Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—NTo..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank (----)--------------------------------------------------- Date........................................ aPercolation Test Results Performed b ................. Test Pit No. 1________________minutes per inch Depth of Test Pit..................... Depth to ground water_-_--__---_--_-----_,--- fi Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ a -------------------•---•-------------••-•---•-•--------•-•-•............•••............-•-•........................................................ 0 Description of Soil........................................................................................................................................................................ x V W •--•------------------------•---------•-----------•••------•------------------------------------- --------------•---------------•••••••--•-••-------•-------•-----••----•......-•••--•-------•-----••-- UNature of Repairs or Alterations—Answer when applicable____________ I?u"t.. n? ................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T' p S 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----I.::,_'' '!f f.X W/1.E/',«0, fr . ------------ ......................... -----------------••-............ Date Application Approved BY "-' ...-•-•-----••• �y ZY �- �Dat� Application Disapproved for the f ollo g reas s:__..._ .................................................................................._ .........................••-----------------------------------....--•------•------------------------...---••--------••--•---•••-••-•••-•••••---•••-•-•••-••••••--••-•••---•••--•••---••---•--•-•-------- Date PermitNo. t ----------------- Issued....................................................... �'S`~ -v r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF................'` l , ,t �, Trtif iratr of TontVIiFanre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by--------- t :. =?=4C-•----------------------------------------------------------------------------------------------------------------------------------------••- Installer -- -_i i has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No---------- v�. . dated_.............................................'a' C" THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION QSATISFACTORY. DATE....................... o 'D .................................. Inspector---------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............P;Zrt.............OF.....................I z< ::5.t No......_.. pble................................. FEE......�...:� �� .. Tontrndion amit Permission is hereby granted...•---•-J. i a-wi;aza?nl:ie-r....J.t----...................................................................................... to Construct ( ) or Repair ( )OXan Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit No.......(/,,�-,�Pated.......................................... ....................................... ---- _ ba ealth DATE..................... S..0............................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS