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Home My WebLink About0072 ALDER BROOK LANE - Health 1 72 Alder Brook Lane i West Barnstable A= 132-044 I i 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 72 Alderbrook Lane Property Address ; Stephen & Mary Rose ; Owner Owner's Name _0 information is . required for every West barnstable Ma 02668 8-11-17 , page. City/Town State Zip Code Date of Inspection J:t: 11.1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation � Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-11-17 Inspector's Signature Date 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. CitylTown 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: System was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Alderbrook Lane Property Address Stephen & Mar Rose �� Y Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is West barnstable Ma 02668 8-11-17 required for every page. Citylrown 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)] 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): 300gpd (1974) t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage See below 9 ( Y 9 (gPd))� Detail: "WELL WATER" Sump pump? ® Yes ❑ No Last date of occupancy: 1 month Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is West barnstable Ma 02668 8-11-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pumped 3 years ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1974 plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 11101, Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: Well located >100' from SAS feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 101, feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gallons Sludge depth: 7 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 5 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA p g feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is West barnstable Ma 02668 8-11-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level) above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was in working order at time of inspection with no sign of past backup or carry over. D-box was replaced in 2008. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (2)6'x6' pits ❑ 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.): Leaching was in working order at time of inspection. System has 2 leach pits and both pits had approximately 8" of standing water. One pit appeared to be stained to the top and one pit had a stain line >2' below the inlet invert. Cesspools (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 Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for VoluntaryAssessm As sessments 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately REAR. B DECK Al-29' A2-31'6" A3-357' A4-51' A5-54' B1-19' (D B3-26' 134-44' 135-27' T II t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7M 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >1'6" below bottom of SASfeet 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: A hand hole was augured to 11'8"where ground water was encountered. The bottom of the leach pit was 9' below grade. Well SDW-252 Zone :A Reading: July 2017 Depth: 46.9'Adjustment 1' showing high groundwater 1'8" below SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 72 Alderbrook Lane Property Address Stephen & Mary Rose Owner Owner's Name information is required for every West barnstable Ma 02668 8-11-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1B:0,�4 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments _ 72 Alderbrook Lane )09 Property Address Robert Nanof Owner Owner's Name information is West Barnstable required for MA 02668 08/13/2008 every page. 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. Important: A. General Information When filling out ( ru forms on the ({ computer,use 1. Inspector: only the tab key to move your Brad J. White cursor-do not , use the return Name of Inspector key. Bluewater C7 ^� Company Name 350 Main Street Company Address - West Yarmouth MAC 2673 ' CitylTown a State Zip Code (508)775-2800 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposals stem at this address Y 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 JO Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 08/13/2008 Inspector's Signatu a Date The system insp ctor shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 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. t5insp.doc•03/08 �� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name information is West Barnstable required for MA 02668 08/13/2008 every page. Ci frown 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: 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: II 1 I Observation of sewage backup or break out or high static water level in the distribution box due I to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 /d' 1 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name information is g West Barnstable required for MA 02668 08/13/2008 every page. Cityf own State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): LJ distribution box is leveled or replaced ND Explain: Distribution box is corroded and needs to be replaced. ❑ 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: 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, j safety and the environment: i ❑ Cesspool or privy is within 50 feet of a surface water 1 ❑ 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) i determines that the system is functioning in a manner that protects the public health, safety and environment: I ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp.doc•03/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M 72 Alderbrook Lane - - - Property Address Robert Nanof Owner Owners Name information is West Barnstable required for MA 02668 08/13/2008 every page. Clty/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform' bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: 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 '/2 day flow ❑ Required pumping more than 4 times in the last year NOTdue to clogged or i obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ E9010, Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name information is West Barnstable required for MA 02668 08/13/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ [2/"" Any portion of a cesspool or privyis within a Zone 1 of a public well. ❑ 19 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ I� 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. I 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 l ❑ ❑ the system is within 400 feet of a surface drinking water supply I❑ ❑ 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 I Area—IWPA)or a mapped Zone II of a public water supply well If you have answered es to any y 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 I regional office of the Department. I I t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 r Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° M 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name information is required for West Barnstable MA 02668 08/13/2008 every page. Citylrown 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: Ye s No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ff Were any of the system components pumped out in the previous two weeks? R ❑ ..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? Q/ ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) L7 ❑ Was the facility or dwelling inspected for signs of sewage back up? L�J ❑ 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: LJ ❑ Existing information. For example, a plan at the Board of Health. L� ❑ 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 i t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name information is West Barnstable required for MA 02668 08/13/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms Unknown 3 (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203,(for example: 110 gpd x#of bedrooms): Unknown Number of current residents: 1 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 N No Water meter readings, if available(last 2 years usage (gpd)): Wellwater Sump pump? ® Yes No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) i 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: I i Last date of occupancy/use: Date Other(describe): i t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 i Commonwealth of Massachusetts Title 5 Official .Inspection Form Subs _urtace Sewage Disposal System Form .Not for Voluntary Assessments ,M 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name informationis West Barnstable required wir for for MA 02668 08/13/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Bluewater May 14, 2008 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: V Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ l NO) 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: IM System was installed in 1974 per as built plan of septic system i .Were sewage odors detected when arriving at the site? ® Yes ® No t5insp.doc•03/08 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts qz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name information is West Barnstable required for MA 02668 08/13/2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 26 11 feet Material of construction: ❑cast iron ❑40 PVC Orangeburg � other(explain): Distance from private water.supply well or suction line: Over 115'+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Building sewer is in good condition. No evidence of leakage. Used camera to check piping. Septic Tank(locate on site plan): Depth below grade: N, 1711 feet Material of construction: 0 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ® Yes ® No ------------------------------------------------ _ Dimensions: 1,000 gallon tank Sludge depth: 211 Distance from top of sludge to bottom of outlet tee or baffle 28" 0" Scum thickness j I I Distance from top of scum to top of outlet tee or baffle 9" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured t5insp.doc•03/08 1 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM , 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name information is West Barnstable required for MA 02668 08/13/2008 every page. Cltyrrown 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.): Inlet and outlet baffles are in good condition. No evidence of leakage in or out of tank. Liquid level is normal. Recommend risors on inlet and outlet covers Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i I I f 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): j t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name information is required for West Barnstable MA 02668 08/13/2008 every page. 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.): 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 �ow 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box is severly corroded and needs to be replaced. No evidence of solids carryover. Box only has two outlets leaving it and is 20" below grade. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ® No Alarms in working order: ® Yes ® No t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name information ati is West Barnstable required for MA 02668 08/13/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits number: —So 2 @ 6'x 6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: i I I Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): i W Soil is dry. No signs of hydraulic failure. Vegetation is normal. Pit A had 3'from pipe to water, and i Pit B was bone dry at time of inspection. Pit A is 18"bg and Pit B is 24" bg. j i t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 I I, i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,••�''� 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name information is West Barnstable required for MA 02668 08/13/2008 every page. City/Town 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.): J t5insp.doc•03/08 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 ,M 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name information is required for Nest Barnstable MA 02668 08/13/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) e.•e-w tabu nas 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. 77Z I 116EG% I 32 2- 3�I - 4y 2-7 a ?;'rA - 4 t5insp.doc-03/08 NOT OTi TO COS li.E Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Alderbrook Lane Property Address Robert Nanof Owner Owner's Name information is required for West Barnstable MA 02668 08/13/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water Check cellar Shallow wells Estimated depth to high ground water: 10'-6"or 126"+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) &0' Accessed USGS database-explain: Well SC-W 252/Zone A/Level 47.3'/Adjustment 1.4 x 12"= 16.8" You must describe how you established the high ground water elevation: Augeered through the bottom of leaching Pit B to a total depth of 126"with no indication of the groundwater. Bottom of the deepest pit is @ 96". If you add the required adjustment of 16.8 this brings the total to 112.8".This leaves and additional 23.2"of additional seperation. t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 90' ITT Pj t�.Fa do CS BAN S rAZ;,C AAA 8/o/d8 Aa�� 1-0 it Imp-i i (2(a � W ilr%4 E 0 (CA-In6t4 CIF \`elµ No r T r r Commonwealth of Massachusetts �3a — 0;Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name - information is required for every West Barnstable ✓ Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Chad hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. Company Address Forestdale Ma 02644 City/Town State Zip Code «� 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my iinspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes � A CT r (/•rG7. 3. ® Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/4/2020 Inspector's Si re Date The system inspector shall mit opy of this inspection report to the Approving Authority(Board of Health or DEP)within 3 of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is 'West Barnstable Ma 02631 5/4/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summa-y: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tan<will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 l I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: bottom of leach pits are less then 4 feet above ground water. Per Barnstable regulations reports shall be summited as needs further evaluation by local authority 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 r Commonwealth of Massachusetts 1 ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no" for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts fwF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1 72 Alderbrook Ln Property Address Rose Owner Owners Name information is required for every West Barnstable Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): unknown Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 2)6'x6' precast pits with 2'stone Number of current:residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this-eport.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readir:gs, if available(last 2 years usage (gpd)): Detail: private well. Homeowner to conduct well sample and submit results to health dept Sump pump? ❑ Yes ® No Last date of occupancy: unknownDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 r Commonwealth of Massachusetts �= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste hclding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: unknkown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: tank and 1st pit 1974 Dbox-2008 2"d pit unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.25 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 25+feet Comments (on condition of joints, venting, evidence of leakage, etc.): no signs of leaks or poor venting l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �r 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5'feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal h10 tank with concrete baffles If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'6"x5' Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): concrete baffles in place. no signs of leaks tank is at working level tank should be pumped in 1 year. then every 2 years under normal usage t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 r Commonwealth of Massachusetts jn Title 5 Official Inspection Form p� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locale on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top cf scum to top of outlet tee or baffle Distance from bottcm of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D63 h10 with 2 outlet pipes Dbox is solid with no major decay or leaks t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2)6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form �r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2 pits-6'x6' precast with 2' stone. 1 pit stained to top 2nd pit staining 2' below invert 2nd pit was dry with stain level 2' below invert. clean concrete over high stain level 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 15 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately o w -() /p O, ibec i 4 zo 3 DO Ll � 0 132 _ 19 gI 03 3� ra / 63 - --), 6 Ay s/ 6y- qq , Jq5 sy 6�_ ,?a► t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: hand augered hole on lower side of property. encountered ground water. set up lazer level bottom of leach pit was 12.9' below transit head .. encountered ground water was 13.7' below transit head. leaving bottom of leaching pit .8'above encountered ground water. Town GIS mapping have area of pits at el. 18' bottom of leach pit el. 9 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Alderbrook Ln Property Address Rose Owner Owner's Name information is required for every West Barnstable Ma 02631 5/4/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6(Checklist) completed ® D. System Information: For 8:.Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 6s L TOWN OF BARNSTABLE LOCATION 72 QLt,KGgzoy- a SEWAGE# VILLAGELJ. aZ/4SMR A ASSESSOR'S MAP&PARCEL 1-0 INSTALLER'S NAME&PHONE NO. DAVt()2 &9No�F (500-P5 1bGO SEPTIC TANK CAPACITY A QW �f�L�oNS LEACHING FACILITY:(type) 2_ LzAcwg& P1r5 (size) NO.OF BEDROOMS 3 0 OWNER. 2 NL1d� PERMIT DATE:&P16;PCOMPLIANCE DATE: Separation Distance Between the: ��SP Maximum Adjusted Groundwater Table to the'Bottom of Leaching Facility Vo feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facili feet FURNISHED BY A3 -2 2 , 4 - ' 5 ,, y ,45�- s� as - �{ - qq� TOWN OF BARNSTABLE L:X°ATION '/ Z ACZ1---L 11AAM L (4 3A LN• SEWAGE # Z/�92[[!147 a/t-5 tiILLAGE I,.� 6AV-nfS"t A 11 IS ASSESSOR'S MAP & LOT T INSTALLER'S NAME&PHONE NO. r&ot,i 3:2 - 6 y 4 SEPTIC TANK CAPACITY �.uw Csu-�wS LEACHING FACILITY: (type) 7- 3' ► S (size) N0.OF BEDROOMS BUILDER OR OWNER rJ PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 4 3± Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 72 0-0 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fe t of leaching facility) 7 Feet Furnished by T'S 1 h1S�tr s J O _ S� P 1 J e 1 i s� No. 2-oD Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for �Bigonl i§potem con5tructton 'Perrmit Application for a Permit to Construct( ) Repair(/ Upgrade( ) Abandon( ) ❑ Complete System [?'Individual Components Location Address or Lot No.72 IQu-14gg :(6t- L&< Owner's Name,Address,and T I N . WjCS,, 1B&Q ►srca3ce,,�, oZotie�� ®� csm) 2-®l13l Assessor's Map/Parcel -2 Qt..Drcl %toot n� Installer's Name,Address,and Tel.No. Ooa)7' 6-23CO Desi ner's Name,Address and Tel.No. DAW,O � 'avQNtE Nj0 95p aM+J Sen.�T !I W-`1�44� M 0V,N n O'Z .73 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) god Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank poo &.6%.LomS Type of S.A.S. 2- Description of Soil Nature of Repairs or Alterations(Answer when applicable) 9,FP(ACE 12KISTINh 1)cS pidr —co Seye"A-E c_,aax? stem . P-ep LAC 6- 0011,'PT L►XJE ro 1'3 5r0_W7lUr-1 Byx Date last inspected:gj a)o"u Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by thA Board of Health. p. Signe V ' '� " Date S 19 O Application Approved by Date Q06 Application Disapproved by: Date for the following reasons Permit No. Z�0 0 6_ Date Issued 9 " /.7— O6 No. .200,5'"3U Fee THE COMMONWEALTH OF MASSACHUSETTS Entered incomputer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplicotion for Mi.5po al *p,5tem Cori!6truction Permit t. Application for a Permit to Construct( ) Repair Upgrade$( ) Abandon(°) ❑ Complete System U Individual Components Location Address or Lot No.72 Owner's Name,Address,and T I.N��gg. WE5 l'8ax_w5rwg(c..no, ._ Q0BeLT 4"a 111Q CSe )3(a2-ol�jl Assessor'sMap/Parcel �- �2 4i-DtW400C N l��t T3e►nry sraa�F a hna Installer's Name,Address,and Tel.No. (50g)7-75 ZSGO Desi ner's Name,Address and Tel.No. ; DIWi'o :r, '$uQN(E Nj� 3 sty MA a St n.�'r` W•y/14enovTzi wva o't(o7'3 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) t> I Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd E Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 000 6,6L .omS Type of S.A.S.7- (o,X CL' LFAC u.,Nr.- P rr% Description of Soil Natu►e of Repairs or Alterations(Answer when applicable) 4YtGCF EX t5l'1N(r 1a,4a;p_igUritaN Rr)g pJr' T6 5tyerLC OrPLACr C)J-n?r LiPQE -ro T)tsr0t8yrAyQ BUx IA Se NY- Date last inspected:31 IZ 0`3 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health ��pp 'S igne 7 7 Date 61 19 C Application Approved by '�I� Date I G k G o :._Application Disapproved,hy: __` _ Date LY for the following reasons Permit No. �O 0 U Date Issued ---------- ----- -------------------------------- THE COMMONWEALTH OF MASSACHUSETTS N� , - ARNSTABLE,MASSACHUSETTS L ;- j� / �N (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (114 Upgraded ( ) Abandoned( )by DA V I O _1�v2N,e A/A N/0 F at �7Z AtpF 60_004 SANK %A,134'45r'AEX4_,T'4 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Noz 6 " 3416 dated 6 5 d Installer ' /4� /L A-T f-�- Designer A #bedrooms A �I � Approved design flow gpd The issuance�off'thiis permit�shalI not be construed as a guarantee that the system ill ncti/on/as',designe�/ Date /) b` `� /� Inspector /�/;'/�A- N W //,f ----�� ——— No. Fee -7 V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 'i.5pooX i§p!6tem Con$tructton Permit Permission is hereby granted to Construct ( :) Repair ( U grade ( ) Abandon ( ) System located at "I 2 A L C�€ Q- P0U and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this P fmit. / Date �j ( — Approved by G ✓/. Page: 1 of 2 CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory (M-MA009) Report Prepared For: Report Dated: 7/18/2013 Sally Desmond Desmond Well Drilling Order No.: G1375128 P 0 Box 2783 Orleans, MA 02653 Laboratory ID#: 1375128-01 Description: Water-Drinking Water Sample#: Sample Location: 72 Alderbrook Lane,West Barnstable Collected: 07/10/2013 Collected by: Map&Parcel 1321044 Received: 07/10/2013 Routine M ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Nitrate as Nitrogen 0.07 mg/L .0.01 10 EPA 300.0 LAP 7/12/2013 Iron IND mg/L 0.10 0.3 SM 311113 LAP 7/11/2013 Manganese NID mg/L 0.10 SM 3111B LAP 7/18/2013 pH 5.0 PH AT 25C NA 6.5-8.5 SM 4500-1-1-13 DCB 7/11/2013 Sodium 40 mg/L 2.5 20 SM 3111 B LAP 7/11/2013 Total Coliform Absent P/A 0 0 SM 9223 RG 7/10/2013 Conductance 290 umohs/cm 2.0 EPA 120.1 DCB 7/11/2013 Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician..Note: The Nitate-N analysis was subcontracted to Envirolech Lab. Attached please find the laboratory certified parameter list. Approved By: (Lab Manager) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS lu M Barnstable County Health Laboratory (M-MA009) Recipient: Sally Desmond Matrix: Water-Drinking Water Desmond Well Drilling Sampled: 07/10/2013 1:00 P 0 Box 2783 Received: 07/10/2013 Orleans, MA 02653 Collection Address: 72 Alderbrook Lane,West Barnstable Order#: G1375128 Sample Location: Map&Parcel 132/044 Description: RKT-72 Alderbrook Ln Lab ID: 1375128-01 Date Analyzed: 7/10/2013 @ 14:15 1 Sample#: Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Sodium level is-above the maxium contaminant level. Those on a low sodium diet may wish to consult a physidan.Note:The Nitate-N analysis was subcontracted to Envirotech Lab. EPA 524.2- Volatile Organics by GC/MS Result MCL MDL Result MCL MlDL Parameter li ug/L ug/L ug/L Parameter ug/L ug/L Dichlorodifluoromethane ND 0.50 Chloroform 8.6 80 0.50 lChloromethane ND 0.50 cis-1,2-Dichloroethene ND 70 0.50 2.0 cis-1,3-Dichloropropene ND y Mn I chloride ND 0.50 0.50 Bromomethane ND 0.50"-- Dibrornochloromethane ND 0.50 1,1,1,2-Tetrachloroethane ND 0.50 Dibromomethane ND 0.50 1,1,1-Trichloro*ethane ND 200 0.50 Ethylbenzene ND 700 0.50 1,1,2,2-Tetrachloroethane ND 0.50 j Hexachlorobutacliene ND 0.50 1,1,2-Trlchloroethane I ND 5.0 0.50 IIsopropylbenzene ND 0.50 1,1-Dichloroethane ND 1 0.50 Methylene chloride ND 5.0 0.50 1,1-Dichloroethene v ND 7.0 0.50 Methyl-tert-butyl ether ND 0.50 1,1-Dichloropropene ND Naphthalene jY ND 0.50 0.50 n-Butylbenzene ND 0.50 i1,2,3-Tdchloropropane _ND 0.50 n Propylbenzene ND 0.50 ..1,2,4-Tdchlorobenzene ND 70 0.50 p-Isopropyltoluene ND i1,2,4-Tdmethylbenzene ND 0.5o sec-Butylbenzene ND 0.50 1,2-Dibromo-3-chloropropane I ND 0.50 1 Styrene ND 100 0.50 1,2-Dibromoethane(EDB) i ND 0.50 1 tert-Butylbenzene ND 0.50 1,2-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 510 1,2-Dichloroethane ND 5.0 0.50 Toluene ND 1000 0.50 11,2-Dichloropropane ND 0.50 Total xylenes ND 10000 0.50 1,3,5-Thmethylbenzene ND I 0.50 trans-1,2-Dichloroethene ND 100 0.50 1,3-Dichlorobenzene ND 0.50 'Itrans-1,3-Dichloropropene ND 0.50 1,3-Dichloropropane ND 0.50 Trichloroethene ND 5.0 0.50 1,4-Dichlorobenzene ND 5.0 0.5o Trichlorofluoromethane ND o.50 12,2-Dichloropropane ND 0.50 Surrogates %Recovered QC Limits j2-Chlorotoluene ND 0.50 1 p-Bromofluorobenzene 114% 70-11-30- 14-Chlorotoluene ND i 0.50 i I 1,2-Dichlorobenzene-d4 94% 70 1 130 Benzene ND 5.0 0.50 Bromobenzene ND 0.50 Bromochloromethane ND 0.50 iBromodichloromethane 1 0.64 0.50 !Bromoform ND 0.50 ICarbon tetrachloride ND 5.0 0.50 Chlorobenzene ND 100 0.50 p lor 50 ethe ND oan _-0. Attached please find the laboratory certified parameter list. Approved By: .......... (Lab Director) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page 1 of 1 Massachusetts Department of Environmental Protection Bureau of Resource Protection WELL DRILLER Please specify work performed: Address at well location: New Well Street Number: Street Name: 72 JALDERBROOK LANE Please specify well type: Building Lot#: Assessor's Map#: Domestic I 132 Assessor's Lot#: ZIP Code: Number Of Wells: 1044 102668 City/rown: t^ Well Location BARNSTABLE Y" In public right-of-way: GPS North: West: 41.71371 170.38675 1 Subdivision/Property/Description: Mailing Address: b click here if same as well location addres Property Owner: Street Number: Street Name: ROSE 172 JALDERBROOKLANE City/Town: State: Engineering Firm: IBARNSTABLE MASSACHUSETTS ZIP Code: 02668 Board of health permit obtained: iji Yes rJ i Not Required Permit Number: Date Issued: W2013 012 1 17/9/2013 0 ry r .<f'a " ; .• Cw1 "� a 9'f Massachusetts Department of Environmental Protection L7��j Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) P Well Driller - General Well Form DRILLING METHOD Overburden Bedrock Auger --Choose Bedrock WELL LOG OVERBURDEN LITHOLOGY From To(ft) Code Color Comment Drop in Extra fast orslow Loss or addition of . (ft), drill stem drill sate fluid F2_07 Fine To Coarse Sand jBrown Ye rjn Fast rjo Slo Loss rjoi Addition F2_0_7F3_57 Fine To Coarse Sand I Brown ] Ye rjn Fast Tjj Slow ije}.Loss rya Addition WELL LOG BEDROCK LITHOLOGY :From Drop in Extra fast or slow toss or addition of Visible Extra. To(ft) Code ,Comment Rust Large (ft) drill stem drill rate fluid Staining Chips. Choose Code �y. Ye rjii Fast Tjo Slow ij�Loss Addition Le Le ADDITIONAL WELL INFORMATION Developed iji Yes Tjr No Disinfected ajr Yes J)r No Total Well Depth 135 1 Depth to Bedrock Fracture Surface Seal Type INone Enhancement �jT Yes Tl No CASING I IS Is Casing above ground? From: 1 To: (O From To Type Thickness Diameter Drlveshoe 0 32 Polyvinyl Chloride Schedule 40 0 Ye SCREEN No Scree From To Type Slot Size Diameter 32 35 Stainless Steel Well Point 0.012 WATER-BEARING ZONES DRY WEL From T.o Yield(gpm) 18 35 10 PERMANENT PUMP(IF AVAILABLE) 2 Wire Constant Speed Pump Description Horsepower Submersible 1/2 Pump Intake Depth(ft) 131 Nominal Pump Capacity(gpm) 110 ANNULAR SEAL/FILTER PACK r Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) From To Material 1 Weight Materlal2 Weight WaterBatches Method Of Placement (gal) Choose Material lChoose Material � 1= Choose One WELL TEST DATA Time Pumping Time To Recovery (ft Date Method Yield (gpm) Pumped Level (ft Recover (HH:MM) BGS) (HH:MM) BGS) 7/9/2013 Constant Rate Pump 10 1:30 18 001 20 WATER LEVEL Date Measured Static Depth BGS (ft) Flowing Rate (gpm) 7/9/2013 1 10 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete a knowledge. Driller WILLIAM URQHART Registration# 1299 Monitoring[M] Supervising Drill Firm IDESMONDWELL Rig Permit# 1024 Date Job Compl NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. No. 1") Fee r- BOARD OF HEALTH TOWN OF BARNSTABLE Z(pplicatiou _for Yell Con5tructiou Permit Application is hereby made for a permit to Construct(✓�, Alter( ), or Repair( ) an individual well at: 1'Zv NARr "�fbck Ln-,�Nl 427 k gAlj. 132I ()`I Location-Address Assessors Map and Parcel Sk& -� Owner Address �2S�o U�6% \x c • Installer-Driller T Address Type of Building / Dwelling Other-Type of Building No. of Persons Type of Well LI„ S C,kAHb f VC_ Capacity 10 q ern Purpose of Well Abw,.— ^— p6 Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certifwate of Compliance has been issued by the Board of Health. Signed 1191)1 -�7�ate A )lication Approved B ! � PP PP Y Date Application Disapproved for the following reasons: c� J Date Permit No. w 3 _ G ) a Issued 7 )9 11 3 Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed(�, Altered( ), or Repaired( ) bytYY1es WQ 11 l"l')4 /� 1 t1�� in Installer at 12 A\ciL-! 1 I,,v1. 1!v •%oxyCY stn�tq- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Pro ction Regulation as described in the application for Well Construction Permit No.L.� 17—61 a Dated 1 1 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector IC No. 1^��C) — AA Fee 1 BOARp OF HEALTH TOWN O__F:. BARNSTABLE . 01ppricatiou jFor Yell Cou6tructiou Permit Application is hereby made for a permit to Construct Alter( ), or Repair( ) an individual well at: �L L-\, W 2I nyu Location-Address Assessors Map and Parcel J Owner Address a �QSr�ax� NORA L%,% \, ( 1�• b f ox Z'la3 0,A Q o"S t\ A 02C,53 Installer-Driller Address Type of Building - Dwelling J Other-Type of Building No. of Persons Type of Well H �QAyn CyL Capacity 14 ± qnm Purpose of Well Hod _ (�G�o•�l`Q Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certi Cate of Compliance has been issued by the Board of Health. Signed \ \) <. - Dale e v ) Application Approved Bye h / Date Application Disapproved for the following reasons: ` Date � Permit No. Issued 7 19 /l ) 3 Date BOARD OF HEALTH TOWN OIF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed()), Altered( ), or Repaired'( ) by N C)Yl Mn,,\ \N 0 ^� J Installer ttaller 1 at Z A , A1r •�.. ? Ca lk Ala has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection . Regulation as described in the application for Well Construction Permit No.1,J —G Dated a I THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE ° ell Cortgtruction Permit No. �} r�-.� ► 3'.-'d Fee J Permission is hereby granted to �Q c�mCD W 9 a. N��i" , Ili Installer J to Construct Alter( ), or Repair( an individual well at: No. 7 l�, r-�r��l on��b� u111C>,(r�s�rt 6c Street as shown on the application for a Well Construction Permit No.W -&-c 13 —G) a. Dated 7/ Date r] 3 Approved I THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA i JUL-09-2013 09:36 From:BRRNST HEALTH 15087906304 To:5082401003 P.2J2 Y. Nil vi. Yr •'tp •flu {fl..` •'it�J ter' l 51 � \ /� �- S/G'. aL E.✓,, ._ _ F'E45-7 .4434O✓4 -400D - -� PL 0 7"" PL A nI r• r O C.a r/o/v• 1,C ;. ,: �^� '.dam-: ' S CA G 6 Z;)A T& ;.j — ='s.• •�., r. a,.••1• %'.; ^ifs: ARLAAI A2,6,9 - tea• v .& ,q rQi: 47 CEriFY•.T/•/A T 7AIE EXi,57= � /IVG FOUNDA riO V LC O4 Tip v IS AAv17_i_w _CdJ�lFD,�iyW/rq .F Y', ,3!I "rW4 8U/GI3/NG SETd:4C'4''L'E.q&i.2E c y �:va Vs -r3u�vyoae w� w sr. yo�r.�•io un�.��,a. IIV ?6/2006 WED 10: 34 FAX 5083627103 Barnstable CTY HealthLab Barnstable Health JZ012/_'02 CERTIFIC.A`�E OF ANALYSIS Page: ., 111 ((jin Barnstable County Health Laboratory i �' `+S3:fCF7J Report Prepared For: Report Dated. 11/26/2008 Brian Spano 1 1 Today Real Estate Order No.: G0850130 16 Spruce Street t,. Hyannis, MA 02601 dl? at,Qira ID#: 0850130-01 Description: Water-Drinking Water Sample 9: Sampling Location: 72 Alder Brook Rd.W.Barnstable,MA Collected: 11/251DA' Collected by: B.Spano Received: 11/25/200 3 i ATwaine RESULT UNITS RL MCL Method# Tested q: `citrate as Nitrogen ND mg/L 0,10 10 EPA 300.0 11/25/2008 I Copier 0.14 mg/L 0.10 L3 SM3111B 11/25/2008 ;iron ND mg/L 0.10 0.3 SM 3111 B 11/25/2008 Sodium 55 mg/L 1.0 20 SM3111B 11/25/2008 r. `TotalColiform Absent P/A 0 0 SM9223 1I/25/2008 f 1 r Conductance 260 umohs/cm 2.0 EPA 120.1 11/25/2008 I (" di 1 H 7 3 pH-units 0 SM 4500 H-B 11/25/2008 a::� Sodium level is above the maxium contaminant level Those on a low sodium diet may wish to consult a physicians x r _. .'-- .._ � a Approved By: y, (La irector) f 1 I � ......... .. ......__.._ ................. ............. .. .....__.... _.._..._.... ............. ...__..... .........._...._.... ........ .... .................... 1, ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, P®.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 • l Y ij CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report Prepared For: Report Dated: 11/26/2008 Brian Spano Today Real Estate Order No.: G0850130 16 Spruce Street Hyannis, MA 02601 Laboratory ID#: 0850130-01 Description: Water-Drinking Water Sample#: Sampling Location: V2 AI'der Brook Rd W Barnsta6le'1VrA� Collected: 11/25/2008 I Collected by: B.Spano Received: 11/25/2008 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 11/25/2008 Copper 0.14 mg/L 0.10 1.3 SM3111B 11/25/2008 Iron. ND mg/1: 0.10 0.3 SM311iB 1i/25/2008 Sodium 55 mg/L 1.0 20 SM 311113 11/25/2008 Total Coliforrn Absent P/A 0 0 SM9223 11/25/2008 Conductance 260 umohs/cm 2.0 EPA 120.1 11/25/2008 i pH 7.3 pH-units 0 SM 4500 H-B 11/25/2008 I Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician Approved By.:-,._- -- Z.�� (La erector) f C5 r rn ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Im All Town of Barnstable Barnstable Regulatory Services Department 'Ce j _ BAMSCABLE, p MAC Public Health Division i639, �m m Alf°" A 200 Main Street, Hyannis MA 02601 2007 Office: 508-8624644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO August 20, 2008 Robert Nanof 72 Alderbrook Lane West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 72 Alderbrook Lane,West Barnstable, MA was last inspected on August 13, 2008,by Brad J. White, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Distribution box is severely corroded and needs to be replaced. . You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF E BOARD OF HEALTH G Thomas McKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 7736 Q:\SEPTIC\Letters Septic:Inspection Failures\72 Alderbrook Lane.doc j f _ SENDER: • • COMPLETETHiS SECTIONON ! a tHn5n mplete Items 1,2,and 3.Also complete A. Signature rn 4 ff Restricted: Ilvery Is desired: X ❑Agent I ❑Addressee I at your name an address on the reverse try that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ ' tach this card to the back of the mailp!ece, ® ! ;or,on the front if space permits. fit' I D. Is delivery addressdifferentfrom.iteml? ❑Yes 1. cle Addressed ^to: m,,� M If YES,enter delivery address below: El No 7 �ti I I / 3. Service Type Q, r- ❑Certified Mail ❑Express Mail 1 I , �l ❑Registered ❑Return Receipt for Merchandise ! ❑insured Mail ❑C.O.D. I I i 4. Restricted Delivery?(Extra Fee) ❑Yes I 2. Article Number ) I (1'ransferfrom.servlce label) : I 7 0 0 6 2150 0002 10-4 y i Ps Form.3811,February 2664, ' Domestic Return Receipt 102595-02-M-1540; Town of Barnstable � kPIR", Public Health Division :' 7-00 Main Street Hyannis,MA 02601 s ' . 02 0004606238 7006 2150 0002 1041 7736 ! MAILED FROIA ZIP CODE 02601 Albert Colton 94 Holly Point Road Centerville, MA 02632 NIXIE 029 RETURN 0 SEN�IR UNCLAIMED n/ UNADLE TO FORWARD 7 11111 ) 1 )) 1)11)D 1 )) B)D 111I) ) Town of Barnstable Barnstable edcaft Regulatory Services Department I .ARAtSCABLE. p MASA �b;¢ Public Health Division db ♦� m A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO August 20, 2008 Robert Nanof 72 Alderbrook Lane West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 72 Alderbrook Lane,West Barnstable, MA was last inspected on August 13, 2008,by Brad J. White, a certified septic inspector for the State of Massachusetts. The inspection of.the septic system;showed that the system "Conditionally Passed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Distribution box is severely corroded and needs to be replaced. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF E BOARD OF HEALTH Thomas McKean,.R.S., CHO- - Agent of the Board of Health CERTIFIERMAIL#71D06 215f0-,0002 1041 77f36 Q:\SEPTIC\Letters Septic Inspection Failures\72 Alderbrook Lane.doc Of THE T°lY Town of Barnstable � IIA.RNSTABLE, � A b 9 1. � Inspectional Services Department lE0 µAY Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. o Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTAER e J 0 f—t-- f- cre C', Repair deadline: D V1 e-. Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc 1 f7 q � Commonwealth of Massachusetts Executive Office of Environmental Affairs m Department of APR a Environmental Protecti '° °fS 199, William F.Weld y xe . Governor rotary Argeo Paul Cellucci Q .Struhs Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INFORMATION FO Commissioner PART A CERTIFICATION _ Property Address: 72 ALDERJROOK LANE.W.BARNSTABLE Address of Owner: Date of Inspection: MARCH 28, 1997 (if different) Name of Inspector: TAMES A.ORPHANOS Company Name,Address and Telephone number: CERTIFIED INSPECTION ASSOCIATES 47 CAMERON ROAD.N.FALMOUTH.MA. 02556 (508) 564-5653 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. The system: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's SignatGthport ��/�,ti Date: APRIL 4. 1997 The system Inspecsubmit a copy of this inspection report to the Approving.Authority within(30) days of completing this inspection. Ifm is a shared system or has a design flow of.10,000 gpd or greater,the inspector and the system owner shall submi to the appropriate regional office of the Department of Environmental Protection. The original should be sent.to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A] SYSTEM PASSES: X I have not found any information which.indicates that the system violates any of the failure criteria as defined in S10 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need.to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection.. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration.or exfiltration,or tank failure is imminent. The system will'pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95)- 1 One Winter Street • Boston, Massachusetts 02108 • FAX(617)556-1049. • Telephone(617)292-5500 i� Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 ALDER BROQ�Kl Owner: WILLIAM R.&ALICE C "*AN Date of Inspection: MARCHJ28. A}7 B] SYSTEMCONDITIONALLY P T ontinued) Sews r breakout or high.static water level observed in the distribution box is due to broken or ob pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with the:approval of the.Board of Health): _ broken pipe(s)are replaced, obstruction is removed distribution box is leveled or replaced The system required pumping more.than four times a year due to broken or obstructed pipe(s). The system will pass inspection.(with.the approval of the Board of Health): broken pipe(s)are replaced obstruction is removed N 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 the.public health,safety and the.environment.. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN'A MANNER WHICH WILL PROTECT THE PUBLIC,HEALTH AND 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 FAQ.UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE DETERMINES THAT THE SYSTEM IS FUNCTIONING K A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has aseptic tank and.soil absorption system and.is within 100 feet to a surface water supply or tributary to a surface wafer supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50'of a private water supply well.. The system has a septic tank and soil absorption system and is:less than 100 feet but 50 feet or more from a private water supply well,.unless a well water analysis 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. 3.) OTHER (revised 11/03/95 2 r SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM l.'r PAS,(.A CERTIFICATION (continued) Property Address: 72 ALDER BROOK LANE Owner: WILLIAM R.&ALICE E.DOWMAN Date of Inspection: MARCH 28, 1997 D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined.in 310 CMR 15.303. The basis for this determination is outlined below. The Board of Health should be contacted to determine what will be necessary to correct the failure.. Backup of sewage into the facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or the 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 1/2 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public.well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FANS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist:: ___ 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 ll of a public water supply well. The owner or operator of any such system shall bring the system.and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for :further information. (revised 11/0.3/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B. CHECKLIST Property Address: 72 ALDER BROOK LANE Owner: WILLIAM R. &ALICE E. DOWMAN i Date of Inspection MARCH 28, 1997 Check if the following have been done: X Pumping information was requested of the owner,occupant,and Board.of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system- recently or as part of this inspection.. X As built plans have been obtained and examined.. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout.. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of- scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. b. (revised 11/03/95) 4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 72 ALDER BROOK LANE Owner: WILLIAM R.&ALICE E. DOWMAN Date of Inspection: MARCH 28, 1997 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 2. Garbage grinder(yes or no): NO Laundry connected to system (yes or no): YES. Seasonal use (yes or no): NO Water meter readings,if available: HOME IS SERVED BY A PRIVATE WELL Last date of occupancy: HOME IS CURRENTLY OCCUPIED COMMERCIAL/INDUSTRIAL: N/A Type of establishment: Design flow:--gallons/day Grease trap present: (yes or no) Industrial Waste Holding Tank present:(yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings,if available: Last date of occupancy OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ACCORDING TO THE OWNER,THE SEPTIC TANK WAS PUMPED IN TUNE OF 1996. System pumped as part of inspection: (yes or no) If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy --_ Shared system(yes or no) (if yes,attach previous.inspection records,if any) --- Other(explain) --- -------------------------=----------------------------------------------- APPROXIMATE AGE of all components,date installed(if known)and source of information: 8/19/74,ACCORDING TO CERTIFICATE OF COMPLIANCE#114,ON FILE AT THE BOARD OF HEALTH.. Sewage odors detected when arriving at the site: (yes or no) NO revised.11/03/95 5 4 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 ALDER BROOK LANE Owner: WILLIAM R.&ALICE E.DOWMAN Date of Inspection:. MARCH 28, 1997 SEPTIC TANK: X (locate on site plan) Depth below grade: 14" Material of construction: X concrete metal FRP other(explain) Dimensions: 4'WIDE X 8' LONG X 4' DEEP Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 34" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 11" Distance from bottom of scum to bottom of outlet tee or baffle: 14" Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) INLETAND OUTLET TEES ARE PRESENT AND IN GOOD CONDITION. LIQUID LEVEL WAS 48" AT THE TIME OF THE INSPECTION AND THERE ARE NO ADVERSE INDICATORS. GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction: concrete metal FRO 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: r Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 ALDER BROOK LANE Owner: WILLIAM R.& ALICE E.DOWMAN Date of Inspection: MARCH 28, 1997 TIGHT OR HOLDING TANK: N/A (locate on site plan) Depth below grade: ------- Material of construction: concrete metal FRP other(explain) Dimensions: —---_-------------------------------- Capacity:-------- gallons Design flow:--------- gallons/day Alarm level: ----------- Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: X_ (locate on site plan) Depth of liquid level above outlet invert: 0" (STATIC) Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE D-BOX IS LEVEL AND THERE ARE NO ADVERSE INDICATORS PUMP CHAMBER: N/A (locate on site plan) Pumps in working order: (yes or no) _-___- Comments: (note condition of pump chamber,condition of pumps and.appurtenances,etc.) ---------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------- (revised 11/03/95 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 ALDER BROOK LANE Owner: WILLIAM R.&ALICE E.DOWMAN Date of Inspection: MARCH 28, 1997 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,but may be approximated by non--intrusive methods) If not determined to be present,explain: ---- --- --- ---------------- --------------------------------------- Type: X leaching pits,number: TWO leaching chambers, number: ------------------- leaching galleries,number: ----________________________ leaching trenches,number,length: ______________________ leaching fields,number,dimensions: _ _______________ overflow cesspool, number: ________________ ------------- Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) THERE ARE NO ADVERSE SURFIC AL INDICATORS. CESSPOOLS: N/A (locate on site plan) Number an d 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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) ---------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------- PRIVY: N/A (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.) --------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------- (revised 11/03/95 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 ALDER BROOK LANE Owner: WILLIAM R. &ALICE E.DOWMAN Date of Inspection: MARCH 28. 1.997 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 72 Ai nERBROOK I ANF N 19.8' 27.0' 31.6' 26.0' 35.2' 51.0' / 44.4' 54.0' NOT TO SCALE DEPTH TO GROUNDWATER Depth to groundwater: 10.0' feet method of determination or approximation: EXISTING DATA FROM SOIL LOG OF DESIGN PLAN ATTACHED TO PERMIT#114 ON FILE AT THE BOARD OF HEALTH (revised 11/03/95 9 - /< <7 z ' -2, - - / - - -- 5EW Q 64E_P_ER-MIT M O - - - - -�--- - -50RS 1v�AP N0, l 3 3 V ILL.AGE- - -G✓� ---rARC M - - 1 N �'- L E. -5-U -E-et -D R- - .-5 U-1 L D E R S.-Q & - - A-D D R- 55 ---Do►�TE=PE=Rt�/l1T ISSUED b - --D h.TE-G0.KAI LI A6ACE-ISSUED ; �� - oC> Ilk � ��T No... d /------- Fas.... .. .............._ t THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH is _ ..........OF.......... . ... . . \ Applirtation -fear I-4pnii al Marks Cnowitraartioaa Prrutit 133 Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ,' l , . ........At.. c ton-Add ss or Lot No. Owner r p Address W lsLr Ct aller Address Q Type of Buildipp Size Lot____________________________Sq. feet v Dwelling l—� No. of Bedrooms----------- _____________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ________________ - W Design Flow_. .................��-- ---- __ allons per person per day. Total daily flow------------- -------gallons. WSeptic Tank J Liquid capacity/-' i_gallons Length---------------- Width-............... Diameter------:--______ Depth---_-_-__---- x Disposal Trench—No_____________________ Width____.__------ ___ otal gth_____ Total leaching area--------------------sq. ft. Seepage Pit No......... �__.. Diameter_ .�Y'�...._ t e .... To 1 leaching area-__ 6_,,p�scL. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by---- ------------- Date_----------:----d-_--------------.--. Test Pit No. I-_______________minutes per inch Depth of Test Pit.................... Depth to ground water---_____-___-__----__--. �14 Test Pit No. 2................minutes per inch Depth of T st Pit.................... Depth to ground water__-__-__-:_-________---. 9 -------------------- ---- -- -- - •---••. / O Description of Soil_--------- _- ��` �G�s-r�!.-� -=---------------- ---- --- -- -- --------------- x f�1 ---------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------...._.... --•----------- 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been •ssued 11 by the boa d oft alth. Signe ------ - - - -- ----- Date Application Approved BY /�. ._.. `� ' e l ate ' Application Disapproved for the following reasons:---=-'--------------------------------------------------------------------------------------•'-"--...•---------- --------------'•--'-•------------------------------------------'•------------------------•------------•------•---------"--•'-----••-----•----------------------------------------------------------- '' Date Permit No. Issued ��----- ............... te No. ! ....... ,. FEs.... ............... THE COMMONWEALTH OF MASSACHUSETTS �OARD O . HEALTH /S 3 XpV ra inn -fur` _gVvoa1 Works Tomitrurltnn Vrrmft Application is hereby made for a Permit to Constr ct ( or Repair ( } an Individual Sewage Disposal System at: ------------- Location.Addr,a<ss or Lot No. , ._ ------- ------ - - ----- ................................................. r Address W tiI ]ler . Address r.• y,: ',. U Type of Building/ 4. Size Lot............................Sq. feet », Dwelling t—No. of Bedrooms------------ -------------------xExpansion;Attic ( ) Garbage Grinder ( ) a Other—Type of Building _ __________________________ No of persons-- �t.._..... It- ._ Showers ( ) — Cafeteria ( ) Other fixtures ------------------- ----------------------------------- ----- '• � ; = d = - W Design Flow _________________ ...._..._.. __gallons per person per day. Total daily flow .____....- __.__ ... .._.__gallons. WSeptic Tank Liquid capacity/ allons Length................ Width................ Diameter-:._. Depth.__.---__.----- • Disposal Trench—N Diameter.. rT..__°�De-th-b gth_____,j _. Total leaching area....................sq. ft. x ram/ 1 Seepage Pit No...... .. ..-•--m Width__-_.�...._.�^ P otae w• ..._1tj -----------. To .1 leaching area.--70C_4�,(L. ft. Z Other Distribution box ( ) Dosing tank ( ) ` ' ~' Percolation Test Results Performed by_- --- -----------------Depth to ground water...--._------.--.-.__.. G14 Test Pit No. 2----------------minutes per inch Depth of Test Pit--_--_-__.__.______- Depth to ground water..........._---__--.__. .......... 1 ------------------------------------•--------- r� Description of Soil---------„`--------------'' 'd` -----'--•---'%=....--�'•---�'�---- �"`" -=---------------------------------------••-------••----- -------------------------------------------------------------------------------------------------------------------------x W UNature 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued y the board of health. Signe __ �!. _.�z_ -r V+(�G(: .t�l � -•-----•-------------- ----•--1 ��•� /' "r "^'"............• �}? f� ate---�F Application Approved BY-------- -----•- -- - --•---r------•-- -- ----- ----g•'---•- ----- - •-•• >/- � ) ate Application Disapproved for the following reasons:---•--.._-•------...--••-•---�-•-----------•-----------•-•-•-- •-----......-•-----• •-•------- ---------••--•---•---•-••-------•••--------••----•-------•-----•---.......••----•-••--------•--•••-----•---•-•••••••---•-----------•...................................................... --------- .. -------------- _ Date Permit No. Issued. --...-- fi Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 14 ............OF........ y'j •9,fG .. Trrtifirntr of Tomphatta T S PS TO CERTIFY, TI t the i Q1V-;ual Sewa e I posal System constructed (�') or Repaired ( ) by-•-._r� ... CSC. ,1` ---•--•--------------•------••-•------------• ' taller at--"..... -•" ...... ...��'-t�'-'------ --- ► r-- � �' 0�'"�Z ...................................... has been installed in accordance with the provisions of Article XI of j The State Sanitary Code as described in the application for Disposal Works Construction Permit No............I.L..!.............•._.__ dated...:I_._ _= .--?-.4 ------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO ED AS 44UARANTEE THAT THE SYSTEM WILL N ION SAT FACTORY. DATE............. •1 ... ........................ Inspector.................................................................................... ---- • T E COMMONWEALTH OF MASSACHUSETTS BOARD•• F HEA TH... .................. 4�4.............................. 4 No- - .4 ------------------ FEE..(, ............... • DiVi:Vu al urk,i �u�nf �trt' a rrmif ' Permission is hereby granted--= ..... �,A, ---. ... r •----- , ! -----_--------------- to Construe ) or Re it ( an Individual eage posal System » at No.-;a r -----� � _--- .. L-l�---- rtia:,L-r x .,.( ......-•-••------- ..... . . V Street N as shown on the application for Disposal Works Construction Pe&mit o . ...... Dated--_-f__..__rt__��.�. Board of Healt .0— (/ DATE----- • --- --- --------- - ............................................. - FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS • t- x ' r a. 1 't4 , , � \` f ell" � � �� Zl) - 1 C - A� o PLAIV Y -+ • w APO .:CAC *' x�! �y ' i_ r t -' .-=crvv �; � .S/LL F1.E✓______Fir ABo✓E PoAaD U CAT/GIN= � 5 "_��2 i "�� ".`* fi- SCALD �J:%2 —DA47L I - /C'�_j •�':- _�rlr,�!: T4 Nt'C PLAN /2�F�Q�NCE : f3�.�`/,vf7 :'� P• .4'//-rRk41 4- /lf4-sy S -,4 X4 J q, Y �-= /r T.4 'h!.'.":�7.1 53,.k' --^ -•. - CRQi.�',E.[.!. h ;--tr�O.�t cc��F, f.'.�'t t'�tt C � �?.s•,`4 —l3AtfiN ST�L t n`'�G✓S7.E} rF f,'L'f,.r_,.r. r A16,e6eYEx�sr- 04 if n /NG F`OUMDA7"/ON 1-bC,17-/0N ISCOZ0E .AN LOfi AS'SWOWA/AND_y .� .a___CONFOZV Wl,-,q �.,.+�7£,0 THE SU/LD//vG SETl3Ac-,e UieEMf�t/7 '`.,1t OF T//,/E TOWN 0F �Lr?!VT1 H!4----- �a,Ld v17 5t-TZ Yoe 7 ._-.•y�q R�.ES L7(,!�-f7'`L/1/s�v �"r`��t� }C,7Z0 Lt/ELL 3 TLC YGo2 CO.�''�? 8 W/GLOW s7 >02M0 U77/710 fir,A-44. 1 t t t I CENTER Jd pSTNGSLIDERSAND&AYWINDoW.t 1 �•1 REMOVE EXISTING DECK,INST 1 NEW DECK W/AZEK FLOORING AND ' 1 PAINTED WOOD RAILING SYSTEM. LIMIT OF NEW WORK ---------------------------------- t 1 1 ; b 1 t FUACEOF EX�ISTNDEBUr-FROM -,1t c �( , ' ----------- '{ ' 1 EW 3'-0'XI'-0' t .1 L 1 ANDERSON 400 SERIES j ' WINDOW W/6 OVER 6 GRILLES 1 ALK 6V CLOSET I ` .MATCH ESOSRNO 1 1HARDWOODE3as1 , LOCATION W O FRAMELESS® ; MIRRORB TM (J^C� LOGT70N IDES STING WINDOW 1 1 sp CL 1 MA FAMILY ROOM , f BEDROOM - t ® , NEW TILED SHOWER WITH r - 1 BATHROOM 1 FRAMELESS GLASS.PROVIDE LIVING ROOM 1 t ING FOR A BENCH 1 � t E105TNG W 1 1 LOCATION , i j 2 , 1 t 1 A32 -- 1 b O GLASSAT _ \ � a FJCIOsnNSTING WINDOW ( ON ON BATHROOM / I ON E)OSTING STAIRS r KffC71p, LJ I 1 I i I FRONT HALL I I I ; DINING ROOM I ❑ OFFICE I BEDROOM I CL I o I I o I I I I 9 1 m I r 1 I I I i UP O UP I I � 1 LAUNDRY ROOM W W D D i f 1 17ARAGE I v - � I 1 A3.1