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0090 ALDER BROOK LANE - Health
1 � 004 4a-jie-- ... .t e F r I a a a _.. TOWN OF BARNSDTABLE L� I,CCATION � ! � L4e,Q !J�`9 SEWAGE # qla VILLAGE We 5E -�� ;rC Imo' ASSESSOR'S MAP & LOT_( - 6 4115� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY D '� LEACHING FACILITY: (type) Oo 6 ' e{ (size) NO.OF BEDROOMS 3 r B BUILDER OR OWNER Gttl o u !- 1 �1 S I o PERMITDATE: - &---COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ,�- 3.� � � �" �1 ,�� s�-��" No. Z� -/"go THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migpool *pgtem Congtruction 30ermit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. is0"�- 2? c Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. (Ef7'C K e-4-1 C+C j PrN Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil 36 �t Sum — 3a Ta /321% C1Lr----J S4-P Nature of Repairs or Alterations(Answer when applicable) 1"_�) 0.4 L -- j.tip G, t4 t S(ia N L Date last inspected: 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 Certifi- cate of Compliance has been issued by this Board of Health. Signed �l� �� Date ► g 3 l Application Approved by .r' Application Disapproved for th follo tng reasons Permit No. Date Date Issued 13 No. �i Fee t� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Mi5ponl *p!5tem Con5truction J)ermit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. E-O,T- R Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. f h1C f�� �0..� Sr • $ RO S N-tlL, L-A Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil n- �� �r SUZ g.0 SAD"-P Nature of Repairs or Alterations(Answer when applicable) lk .t OA L /.Uoa �.`�a EAge N 2 ` S ;a N a. CPp t=l-r t i7^ S�s 'ram► Date last inspected: 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 Certifi- cate of Compliance has been issued by this Board of Health. Signed _ '51— Date 1 L g Application Approved by SkZn4, Application Disapproved for the folio mg reasons 4 Permit No. en � �� Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of (Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installg ( )or repaired/replaced( ✓�on by ('hCk4�t CO�SC' °, for � `� �tJLL.t� a*- 9b J`R 0 L Q � 6 \C_ L*,N L_ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.A- 600 dated Use of this system is conditioned on compliance with the provisions set forth below: No. l r !lJ d Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1Bi5poe ar *pftem Construction Permit Permission is hereby granted to t-�-tc 1i�4 tc 40, , to construct( )repair( % an On-site Sewage System located at `70 S> t-A W and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/heriduty to comply with Title 5 and the following local provisions or special conditions. All construction must be compll�etteed within two years of the date below. Date: 1 - /f� Approved by LOCATION 5EW6,C4E PERMIT UO. INSTQLLER5 U&ME ADDRESS _ DUI DER 5 1.1 &AAE QDDRE SS DQTE PERNAIT ISSUED '- - 7— — — — D.&TE COMPLI b6MCE ISSUED ; 7 2-17 G I Y :y e.,r[:,•,h VA t✓R{t b(►•'y 71 71j. e , c j lc:�.�\�•P-3- ��- •RAJ'' �f ., .'i I ' � i,� !. ' , 4.1' !� 'f_± jgti, .e'N�lt�i'�Y.-'Ijt ijjj, . .,.... 1 fl T.� '� / 1 j {+• `�c :H 1: ,l J t (' NE- r1t t±� FS3. �.1 �.. � ♦ •1 W t" nJv ' ` � ' \ �✓ , r � e _A - Ai!<'°.f. , r.-L q, V 1 >f' iZ `4 n +f 'f'. �. i, r4 N apt= a�� 'L Maim �, ,. 5 r r F,,rat �'�f ttr•. ., •. r t� t r�' A .},� a aIr 7`c /, � �; 1 !r � T V� Ii,Y��t`ct}�yetl,4�aS';.• ri�,.�yl. ly co � •:, 1 r t., D, tip t nl r y u R • I , ; ri o-t � ��+I/�1 s{t trJc'Y I'�i}�.p� '�7"',`l a , .t � 1 n j�•, a ',a.AS:;rr�l:S�'1:� .:r;s! r tl CC• 1 t o� •h4 SCg La.�.� 1 , U All �. IODD 41 AAA-[ rot*Vr iC- ' oft wAK tA ;am.�4../ta►..�•!��M� G� �'� eBC.1. f at�r1. 1 15loti't t J iovNDA>/ON coC4 /01V ni .: ;3. c.; .• NOI'VN. A A14P.;XQQt -G�QNFO�'�I ITfr n C 4s s f r g' wILFkEo T/-/EF. F�IJ/�D✓N6 3ETf�4��Q //�f�,M U TAYI.OR OF TN4E TVWAI OR r:kA-C24."5X-44.5VSL.�.[ . h1\Ffli rt`:``yg � B �vicco sr: )1A LOCUTION ' 5EWLIC,E PERMIT UO. � c" PA/4 Lie 9—e ��c 1 �. IWSTQLLER S ►&ME ADDRESS BUDDER 5 Q &"F- �- UDDRE SS DI►Z'E PERNAiT ISSUED DATE COMPLI W-4CE ISSUED : '7 6 I� �� i Y i THE COMMONWEALTH OF MASSACHUSETTS BOARD PF HEALTH ' Z --------OF....... _. ...,-t,4, ............... Appliration -for Ui-qpuiia1 parks Cnowitrurtion Prrmit -Po Applicationis hereby made for a Permit to Construct (I.-I'or Repair (T an Individual Sewage Disposal System at: Location-Address or Lot No. 1�1,_�. � r► .:..� �1. .LL.� - -�1 .......... Owner Address W Installer Address d Type of Building Size Lot.. . Sq. feet U Dwelling—No. of Bedrooms------—3.............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ----------------------- No. of persons..----T................... Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------•----•--------•---- a ----------------- W Design Flow______" ___ ,1______.____gallons per person per day. Total daily flow--_-_ _.___.__ __.___._.'_.._.gallons. WSeptic Tank—Liquid capacitv_1.611 P_gallons Length________________ Width................ Diameter...........----- Depth.___-_-------. x Disposal Trench—No_____________________ Width_______-_-__. ---__- Total Length-------------------- Total leaching area--------------------Sq. ft. Seepage Pit No.3- (a_Y'D . Diameter____________________ Depth below inlet..... Total leacliina ar a._ -------------sc. f z Other Distribution box ( ) Dosing tan �'� � �kl� � a � ��° l Percolation Test Results Performed by._ , ,�` a,�_ c. . a �4!' �-.... / �. Date .-.. Test Pit No. 1_.__..�—___-minutes per inch Depth of lest Pit____________________ Depth to ground water..--------_--._.--.----. (� Test Pit No. 2......_.........minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.--.-----.---.--_--. - Description of Soil B-�...�---- ------------------- � ' u�ue�►.. , - ` x V --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 'ssued by the b. ar..d-o health. �J� Sig. d...- - -•-----....................... -- • -•------------- -------------------------------- Date Application Approved By..--- -_ __ { b �--- ---- <� ----- ��/ // /- Date Application Disapproved for the following reasons________________________ __________________________ __-•_--••-•--•-------•---•--------•----------•---•------------•-•-------•-----------------•------------- Date PermitNo........................................................ Issued........................................................ Date t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T_ Appliratiun -fur Di-quott1 Workii Ton,strurtiun 13rrmit Application is hereby made for a Permit to Construct (1 ) or Repair ( an Individual Sewage Disposal System at: 4 _ //' Gam" • ..'S/1 .!i t. Location-Address 7 or Lot No.�, lJl1 , f f._i.W r►m ° ,-i\ ta_(. `^ ........... I u E�► 1 .......... 1 err =�= =""`= ----.....•-•-•-----..... Owner Address W Installer Address Q Type of Building Size Lot.�_'a;,_7.�.....Sq. feet Dwelling—No. of Bedrooms-----= ---------------------------------Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ____________________________ No. of persons-__-- -__._.-_---___--__ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------------------------- W Design Flow----- �.......572)------------gallons per person per day. Total daily flow...- _-__.---._--gallons. USeptic Tank—Liquid capacity i_Z0_P__gallons Length---------------- Width..___...._.._.. Diameter---------------- Depth---------------- xDisposal Trench—No.................... Width-------------------- Total Length-------------------- Total leaching area.._..-.._-._---_----sq. ft. Seepage Pit No.a__:`_.'_xu __. Diameter____________________ Depth below inlet_:__.,_............ Total leaching area..,--------------sq. ft. z Other Distribution box ( ) Dosing tank . ) �� '-' 1. Percolation Test Results Performed by...__.V__ . _I // / _ W -vr.1 r ' Date__....... " .. Test Pit No. 1_____ ________minutes per Inch Depth of Pest Pit.................... Depth to ground water...___._..-_....____.... �14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ a+ ........ 41 - Y! '-'-� _.- /' � - / �e :� `2,�"."...--41'� '-( f. x V ........-•-----------------•--------------------------•-----------•••--••---•-•-•-•-••-•--•••--•---••••-•••••-•....-•------------•••-.....--••--•---------------•-••.._....---------•---••------------- W -------------------------------------I------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 issued,by the board of health. i ./J V' '��/ Date Application Approved BY .. -'-��---L '` .................. Date Application Disapproved for the following reasons:......................�...____..__.__.____.._.._......_...._........_....__.._..............._....__......... ...•-•••'•-••••--•---••••-••-••••••••----••-••-••..... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS 1 _ BOARD OFHEALTH l c�Uti...........O F.................. -)r .».. e, ..... ... . ........................................ (9rrtif irate of Toutphaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) b ••••- Installer %r at----•----v`-- C -- r t ........-�` .. µ ---- ----•.................-..... s. has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF) HEALTH �.,..• ............. .......✓.........OF....................`.............t........ . / No..� .................. FEES-•f2'-•----........ Dinpotial lVarkii Clunitrnrtiun Prrmit Permissionis hereby granted.............................................................................................................................................. to Construct ( or Repair ( ) an Individual Sewage,Disposal System F atNo_.�* ............................. -----------------------------------•-----------.......•. ---.......---------------......----------------......---------...---------.......... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... '--------•-•-•--•••-• -••---•..........................•---------•--•--••---••••..................---•-- Board of Health DATE. FORM 1255 HOBBS & WARREN. INC.. 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OF rwa.T3� /Ns �F 'S A►ireW'" ..bs .• r lift p r3t f ; 't : R'rw5w =,,:p "�:... ,•, t - C,QO -ELF {-.7,o4)0'4d) QO .3•�`'�k' _ . yA zAAC U7?/� ' jj I 3?fG �" wa a '-4 AM.�u No.—I.� (D- C) Fee----_�/ ----- BOARD OF HEALTH TOWN OF BARNSTABLE 2pplicat ion fforVei[ Con5truct ion Permit Application is he by made for ape it to Construct ( , Alter ( ), or Repair (/ )an individual Well at: Location — Address Assessors Map and Parcel Owner Address Installer — Driller Address Type of Building n- Dwelling ___---- Other - Type of Building—=------- -- No. of Persons---------------_____ Type of Well /!6t --- Capacity--- — —------- —--— Purpose of Well---- ��------ --_ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ��f��C — _ — __--- -e1 ( Application Approved By -_-_---- --- date Application Disapproved for the following reasons: -------- - --_ —_— ___ - _C—�--- I ---- date — agoPermit No. "" �p ® -_ Issued --1--�-� /___ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individua Well Co structed ( ), Altered ( ), or Repaired bye- 1 �� / � -- --— —---— —_— ---- aller at C� �Zdb,-ro , 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 d�---lbated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. "i DATE-- Inspector----- — --- — —____ No.----__---------- Fee---- ---------- BOARD OF HEALTH TOWN OF BARNSTABLE 0(pplitat ion-for Vell Cootruttioni3ermit r Application is he eby made for a perm.it to Construct (A) Alter ( ), or Repair (r)an individual Well at: Location - Address - Assessors Map and Parcel Owner Address — Installer - Driller Address Type of Building Dwelling Other - Type of Building No. of Persons---------- Type of Well� Capacity------------ Purpose of Well_-- l b Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. { Signed date1Application Approved By date Application Disapproved for the following reasons: 1 �� - -{— -------`---�-------- date Permit No. © Issued date BOARD OF HEALTH TOWN OF BARNSTABLE �. Certificate ®f Compliante THIS IS TO CERTIFY, That the Individual Well Co structed ( ), Altered ( ), or-Repaired (P -- - —- iiislaller has been installed in accordance with the provisions of the Town of Barnstable Board of Health PrivateWell Protection Regulation as described,in the application for Well Construction Permit No�- --�� (Dated q-- -- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE—_- - Inspector—__-__ _---_-__-- --------____-- BOARD OF HEALTH r TOWN OF BARNSTABLE; Ivell Cootruttion jermit No. v� �=G 3 Fee- 7` Permission is hereby granted to Construct ( ), Alter ( ), or Repair eratn Individual Well at: -- 7 No. C� Street as shown on the application for a Well Construction Permit No.- W �� -� ��t- —_ Dated---- l �i Board of Health DATE _� to r 0319o�� (COMMONWEALTH OF MASSACHUSETTS4t9 1 = EXF,CUTIVE OFFICE OF EMrIRONMENTAL AFFAIRS b DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE OFFICIAL INSPECTION PORN[-r NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A I41- ems' C RTIFICATION 0 't= Property Address: Owner's Name: �oq, 0-M Owner's Address: Date of Inspection: Name of Inspector, (please print) Company Name: Mailing Address: Telephone Number: CERTIFICATION STATEMENT IN, I certify that I have personally inspected the sewage disposal system at this address and that the infonnation reported Below is true,accurate and complete as of the time of the inspection.The insp�;ction 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 CIVIR 15.000). The system: t4' ses Conditionally Passes Needs Finflier Fvaluation by the Local Approving Authority Fails 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 spd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of Inspection and under the conditions of use at that time.This inspection does not address how the system will perform to the future tender the same or different conditionof use. Title 5 Inspection Form 6115i2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: , Date of Inspection: Inspection Summary: Check A,B,C,D or R/A�L��, complete all of Section D i Syste Passes: zI have riot 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,N, D)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 llie Board of Health. A metals, tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high Static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settle:l or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pip-(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a v(.ar 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, a t III A Page 3 of I I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: '�4> J4,'J ,ag L Owner: Date of Inspection: 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 fa-iling 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 prhy is within 50 feet of a bordering vegetated wetland or'a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,If any)determines that the system is functioning in a manner that protects the public health.safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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 welly*.Method used to determine distance *'"This system passes if the well water aralysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of am!nonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: _ ,,. 3 .. Page 4 of 1 I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR Vj PART A CEWrIFICATION{contimiedl Property Address: -� �ei, L �..._ Owner: Date of Inspection: 6 D. System Failure Criteria applicable to all systems: Ycu rr ugl indicate"yes"or"no"to each of the following for ls,�l inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than►/day flow — Required pumping more than 4 times in the last year Nudue to clogged or obstructed pipe(s).Number of times pumped_,. _r 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 I 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 aupply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for callform bacteria and volatile organic compounds Indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form,] (Yes/No)The system.fps.I have determined that one or more of the above faiueue 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 t3 gpd. ow of 10,000 gpd to I5,000 You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes 110 the system is within 400 feet of a s►.u-`ace 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 IZ 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. ,riora C Dnanartinn rl%""All;/')AA 1 `, 4 Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_ �!Oat, _ Owner: r3 . C,,o5 S Date of Inspection: _ Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Ye No P mping information was provided by the owner,occupant,or Board of Health ere an of the system/ y ys components pumped out in the previous two weeks? ! — Has the system received normal flows in the previous two week per ? /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? J Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the battles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum 7 — azwas the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems 7 The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For exarrtple,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(3)(b)] Ti►ia S T"rt% e44^m Finr-m 4/1 S/)AAA 5 Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SLTESItRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM T4 INF'OR1vIA7CION Property Address: 40 Owner: Date of inspection:! -- t. RESIDENTIAL FLOW CONDITIONS Number of bedroomm(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR. 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: I_ Does residence have a garbage grinder(yes or no): t� Is laundry on a separate sewage system(yes or no):-A (if yes separate inspection required) Laundry system inspected(Xes or no)-O Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage Sump pump(yes or no): — Last date of occupancy: COMMERCIAVINDUSTRIAL Type of establishment: Design flowZ 310 CUR 15 3):—`irgpd Basis of desseat$/perso .sgR,etc.): Grease trap es or no .Industrial wng t present(yes or no): Nor,-sanitaryis arged to the Title 5 system(yes or no):Water meter ,if available:Last date ofy/use: �— OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: ,� Was system pumped as part f the inspection(yes or no): ��ll ' If yes,volume pumped:, gallons--How was quantity ptu-ffped deterowred?�a�" Reason for pumping: Ce TYP OF SYSTEM 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) --Fight tank _Attach a copy of the D P approval Other(describe): -�. Approximate a of all ompo`ents,date installed(if own)and source of information: 71196 Were sewage odors detected when arrivingat the site ea r (Y ono). T41A ril141Mf1f n 6 . Wage 7 of I I OFFWTAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS S1`3SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Adaress: 'e AIL Owner: J , SS Ll- Date of Inspection: BUILDING SEWER(locate on site plan) Depth below gra-ie: 1_ Materials of con::truction: cast iro Distance from riv — — _—other(explain):_-----�_ p ate y well or suction line: ------- Comments(on on of joints,venting,evidence of leakage,etc.): SEPTIC TANK:__._(locate on site plan) Depth below grade:_ Material of coal o�action: concrete metal fiberglass____polyethylene If tank is metal 1 i.yt age: �..—I - g _� s age confirmed b a Certificate certificate) y ftcate of Complianre(yes or no}: (attach a copy of "1'k Dimensions: Sludge depths �� Distance fcotn top of sludge to bottom of outlet tee or baffle: Scum thickness: - Distance from tnp Of scum to top of outlet tee or baft7e; _ Distance f}on)bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: ___ as Comments t(on pumping recommendations, e, t and outlet tee or baffle conditfo structural inte as related to outlet invert,evidence of leakage,etc.): n' 8nry, liquid levels ------------- --- ASE TRAP:,(locate on site plan) Depth below de:_ Material of cons . n: concrete metal (explain): — - —fiberglass ,polyethylene____other Dimensions: Scum thickness: Distance from top of scum to top of ou filet tee ffle:_ Distance from bottom of scum to bottom' of outlet tee . affle:� Date of last pumping: _ - Comments(on pumping recommendations,inlet and outlet tee or a condition st-actursl inte as related to outlet invert,evidence 4leakage,etc.): sty,liquid levels ------------- —�. Thlo i r»o»erfin» Tnrm R/1CMlltlt 7 Page 8 of 11 01710AL INSPECTION T VOLUNTARY "t. S iRFAc_E SEy�A E D SPOSAL YSTEllI I ASSESSMENTS INSPECTION FORM PA RT C SYSTEM INFORMATION(continued) Property Address: Owner: Date of In �c sl ectlon: TIC;HT or HOLDING TANK: (tank must be pumped at time of inspection)(loc site plan) Depth below grade: Material of construction: concrete_-__metal_ ass----Polyethylene other(explain):, Dimensions. Capacit.,: ons Design Flow: gallons/day Alarm present no): Alarm le Alarm in working order(yes or no). D O last pumping:_ Comments(condition of al— arm and float switches, etc.): i DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distrib on to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): -----__ ------------- - PUMP CHAMBER: (locate on site plan) Pumps in working order. no): Alarms in work' er(yes or no): C.omme note condition of pui ap chamber,condition of pumps and appurtenances,etc.): ------- _ Tiria t TnonorFinn i:nrm All; ,Ann 8 Page 9 of I OF>FICIAL INSPECTION FO14VI_NOT FOR VO T'b SUBSURFACE SENVAGE DISPOSAL SYSTEM E TON F RM TS Tip p PART C SYSTEM INFORMATION(con, nlled) Property Address: �p � L Owner: -- Date of fnspectt� o'nt SS SOIL ABSORPTION SYSTEM(SAS) (locate on site plan excavation not rqnired) If SAS not located explain why: ,aching pits,number:_ leaching chambers,number: leaching galleries, number:leaching trenches,number,l— ength;�_— _ leaching fields,number,dimensions: w�_ — overflow cesspool, numbers -------- innovative/alternative system TYIT/na ne of technology: Comments(note condition of soil, signs of hydraulic failure, Level of pondinf,damp soil,condihOn vegetation, of et8h etc.): - ~`t g on, CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site nj Number and configuration: Depth—top of liquid to inlet invert: — —`--_— Depth of solids layer:_ --- Depth of scum layer: — Dimensions of cesspo Materials of co ction — Indic groundwater inflow(yes or no)::__ `-- - Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition:;f ve e g tahon,etc): PRIVY. (locate on site plan) Materials of construction: Dimensions: _ Depth of solids; Comments condition of soil,signs of hydraulic I a,ita;Q, Ievel of pondin;,condition _ n of t getation, etc.): TWA 9 '. Page 1 o of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM WFORMA'TION(continued) Property Address:_ QO Owner: Date of Inspection: 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 ehters the building. P 46 � 10 S- Page 11 of I 1 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ASSESSMENTS PART C SYSTEM INFORMATION(continued) Property Address: ` a LO G Owner: Date of Inspectlon: 15 10-b SITE EXAM Slope I—;+--- s ld rc Surface water Check cellar o iL Shallow wells Estimated depth to ground water7j!Lrfeet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: bserved 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: '\ Titla C Tnv»earfinn Rnrm l,il�17f1(Nl 11 CERTIFICATE OF ANALYSIS r, Page: 1 I Barnstable County Health Laboratory Report Dated: 3/23/2006 Report Prepared For: I Lynn Marie Ford Order No.: G0634847 Cape Cod Cooperative Bank P0 Box 310 ' Yarmouthport, MA 02675-9986 _Laboratory ID#• 0634847-01 Description: Water-Drinking Water Sample#: Sampling Location 90 Ald_erbroo_k_-Ln.W.Barnstable,MA Collected by: I Mullin `- -- --- _� Collected: 3/22/2006 Received: 3/22/2006 Routine ITEM RESULT UNITS RL MCL Method# LAB: Inorganics Tested Nitrate as Nitrogen BRL mg/L 0.10 ]0 EPA 300.0 3/22/2006 LAB: Metals Copper BRL m /L 0.10 g 1•3 SM3111B 3/23/2006 Iron BRI, mg/L 0.10 0.3 SM 3111B 3/23/2006 Sodium LAB: Microbiology 61 mg/L 1.0 20 SM 311113 3/23/2006 Total Coliform Absent P/A 0 0 309 3/22/2006 LAB: physical Chemistry Conductance 320 umohs/cm 2.0 EPA 120.1 3/22/2006 pH 5.3 pH-units 0 EPA 150.] t� 3/22/2006 Sodium level`is akio've the maximwm contaminant level_T1 ose on a low.sodium diet may..-:wish t o It a physic a�n Approved By: (Lab Di "tor) d --es ati U .+-F c-n RL = Reporting Limit MCL=Maximum Contaminant Level 3 Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 1 Vj000--� No. Fee----- ---- ----- BOARD OF HEALTH TOWN OF BARNSTABLE Zpplitat ion for IVell Con0ruction3permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (:--,,Ian individual Well at: Location — Address !1 Assessors Map and Parcels ��Owner Address leac(_C t. _— /�o. )�o}c_�llno AA-4 ------------- ------------- -------- Installer — Driller Address Type of Building Dwelling— _ct 4 --- ___ — ---------- Other - Type of Building—= ------------ No. of Persons-------------------------- Type of Well �/ --- - -- Capacity ---------- ----- Purpose of Well--'D^",•S h L----- -- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certific to of Compliance has been issued by the Board of Health. Signed — — lJeo ------ date V—) 9 Application Approved ByT / - -- date Application Disapproved for the following reasons: --------------------------- -- - — —_------------------------- date Permit No. — Issued---- -- -- ---- -- ------------ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY That the ndividual Well Constructed ( ), Altered ( ), or Repaired ( 44 �--- �RL&tip by--- — _— —_-------------------------------___------- 1 / / Installer at Q© a`d cl�J/o�`� K- —--- — —_ ---- ------- 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. -------Dated---- --- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. ` DATE-- Inspector---- ---- - -- 1 — — No. - :•Fee,--6-1 ------------� BOARD OF HEALTH TOWN OF BARNSTABLE- ,(pprication,forlftl Con!6truct ion Permit Applic�}tion is hereby made for a permit to Construct ( ), Alter ( ), or Repair (-)an individual Well ao 904 ��!�'•nv�� �� w /��� .., /3>AqS /V/ ?'. 1 —_ Location - Address Assessors Map and Parcels - __�r>L�� 1 /o�S ___ — L- 4 G��/ �i ov`1 �ti t,.]• �/,;�.�,.� �—_ /� / /+Owner Address U 1_ SCG�.� �i L.�c (C IO/��• � — ✓�`� �o� Ma o�G /f- — Q Installer - Driller Address Y Type of Building Dwelling e - Other - Type of Building--=-- ------- No. of Persons------------------ r Type of Well 2 ---- Capacity-----------— -— -------- Purpose of Well--OR Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Ce tificate of Compliance has been issued by the Board of Health. Signed U�✓'t% — — 1 J�G ao date Application Approved By _ ----- date Application Disapproved for the following reasons: ------------ -------------- -- - ------ ------ —_-- date --- Permit No. — Issued-- ----- -- ----- _date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THIS IS TO CERTIFY That the,Individual Well Constructed ( ), Altered ( ), or Repaired (4 LuN� / by-- - // ----- ___-Installer ------ ----------- ------ --- ' qO � l�r, / at /o `` Zk. —— ------- 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. ---------Dated----THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-- - Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Yell Con5tructionPermit No iO4. --- Fee------ Permission is hereby granted 6A Scju_�` 11 — — --------- to Construct ( ), Alter ),//or Repair ( t'f an Individual WeAr" t: No. c/o 4(�c i p Sao/� ry . ) �.� �D Street-'� ------- --- ----------------------------- Streit- as shown on the application for a Well Construction Permit No.- _ Dated— -��' DATE oard of Health c alraizr aacar_�mq-es v H I' :W .. SUl"--LzS._.._........__.. _-' ._ 1 .._L.. i p I I .: ... .. IZ f � OS r a u ' 4 -�P_6�/CtiC'4QLti[RECTt72ZkG�'SEStciJ �l I t - • 10 m 1 to v riO s I _ �v.lRfi m I m ' 1 V I I 1 I 1.1 : ! 2� V I �:I Z ..2:.l 'N:L....FIC..R�'Z.3'fa•Q I CD Lw LL 1 I ' i d ' — a _...-- ¢cc,• J : A I I ----- _�f�i_:ROo�