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HomeMy WebLinkAbout0057 ANGELA WAY - Health 57 Angela Way ; West Barnstable A= 133 - 072 TOWN OF BARNSTABLE LOCATION 5'7 anqcicx (am( SEWAGE# OO)y-38S `TILLAGE W. ASSESSOR'S MAP&PARCEL ��33- 7�. INSTALLER'S NAME&PHONE NO. �r'v Q EXc mvo.4►on 411`) - 06 S 3 SEPTIC TANK CAPACITY �SOO 4v� LEACHING FACILITY: (type)TPcnc),c S (x.) (size) '2 x 3 x 43 NO. OF BEDROOMS y OWNER 1VN E cP PERMIT DATE: 10-1 G-J q COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Al- /1 L AZ' l ' C3-sl' .D3-yS' Cy- 732•, .D4 - ,751'y D c B �I TOWN OF BARNSTABLE `LOCATION SLIAIAQ�;# Z.�lJs Li VILLAGE . ASS OR'S MAP&PARCEL INS+A T T ER-z& TAME&PHONE NO. SEPTIC TANK CAPACITY /15 0 61- /_ „I-S LEACHING FACILITY:(type) �i TS (size) NO.OF BEDROO MS � OWNER PERMIT DATE: GQMPLJbt11TCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY f / 5171", f / rFront / fi♦f♦I♦ • f,J f.f i f f f f f f / ! f 8 2 19 12 50 �y 52 TOWN OF$ARNSTABLE L fCATION_�A^� I W SEWAGE # VILLAGE W. RAC6 Q ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l SCfU : ty � 9x ' SLEACHING FACILT TD NO. OF BEDROOMS_ BUILDER OR OWNER �� Oro Sr- PERMITDA T E: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet ,Private Water Supply Well and Leaching Facility (If any wells exist on site or.within 200 feet of leaching facility) r Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ' g facility) I- r Feet Furnished by 5'C TIC- T S eCCtdn hUr Pool . C 5 O O IBI - ICI Aa- I-) - 13 bS- 33. (0 �3- a9.� y b3- a&� cam,. Commonwealth of Massachusetts 133 d�� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Angela Way Property Address Catherine&Bryan Eger Owner Owner's Name l information is West Barnstable ✓ Ma 02668 9-8-2020 required for 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. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information S( #' on the computer, Daniel Hawkins use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 �y Company Address Sandwich Ma 02563 City/Town State Zip Code enro (508)477-0653 S114324 Telephone Number License Number Be 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 inspection; 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 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Dan Hawkins Digitally signed by Dan Hawkins Date:2020.09.08 13:44:39-04'00' 9-8-2020 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 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 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Angela Way �V Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary A Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The system was in working order at the time of inspection. 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 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Angela Way L Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Angela Wa �:�� 9 Y Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town 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: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f Commonwealth of Massachusetts �y Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Angela Way L� Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ El Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E] Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 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. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ D 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.] ❑ Q The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 II of a public water supply well t5insp.doc-rev.7/26/2018 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 U 57 Angela Way Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town 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 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? 11 ❑ Has the system received normal flows in the previous two week period? ❑ 0 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) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? E ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? El ❑ 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: El ❑ Existing information. For example,a plan at the Board of Health. ❑ Q 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 Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Angela Way Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 4 Number of bedrooms (design): Number of bedrooms(actual): 440/GPD DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes ❑i. No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes Ej No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑g No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: "WELL WATER" Sump pump? ❑ Yes ❑■ No current Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts . p Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F' f u 57 Angela Way Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No r Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 2019 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 57 Angela Way Property Address Catherine 8r Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 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: New d-box and SAS added to existing Tank in 2014 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 31 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.dcc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t.. 57 Angela Way Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 ' 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' Depth below grade: 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 1 Dimensions: 500gallons 3" Sludge depth: 3311 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1491 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f c Commonwealth of Massachusetts Title 5 Official Inspection Form f. b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 57 Angela Way Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 15msp.dcc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 - c Commonwealth of Massachusetts �n Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Angela Way u Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town 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): 0" Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Angela Way Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town 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.): NA * 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: ❑ leaching chambers number: ❑ leaching galleries number: (2) 3'x43' 0 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 Farm:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments sy 57 Angela Way V Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every ' page. City/Town 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.): The SAS was in working order at the time of inspection. Leaching trenches were dry when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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.): r t5insp.doc•rev.7/26/2018 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 cam, Commonwealth of Massachusetts k Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e 57 Angela Way Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids 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 15 of 18 Commonwealth of Massachusetts - �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Angela Way —u% Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage dis osall system, including ties to at least two permanent reference 9 P Y 9 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 ^aeaeaing As-Built Cards TO IX OF BARNS"TABLE LOCATION_ 7•-Z A�t_s_t� SEWAGE# drq:3S.S' VII LAG+E:La.L_ �ce� y c ASSESSOR'S M"Sc PARCEL 1 g'4-77 INS:TA.LL S NAME&PHONE NO. sac$ Exoa.altiot� V"1�7t - Our S SEP'nC TANK CAPACITY :roo �a LEACHING FACII_TV-(`type} (size) 2.x:8 x 43 NQ.OF BEDROOMS, OWNER PER MIT DATE: J[?-741--!y cc>mPL1ANCE DATE: Separation Distance Between the: -Maximum Adjusted,OvoundwacerTable to the Bottom of Leaching Facility Private Water Supply'Wall:and Leaching Facility(1f any wells exist on. site or within 200 feet of tcaciaing facltiiy) Feet Edga of Wetland and Leaching Facility(_if any wetlands,exist within 300 Peet of leaching.facility) Feet FUPLNISJWDABY Al- A-Z -7 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Angela Way Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town Satet 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: No GW @ 132"feet Please indicate all methods used to determine the high ground water elevation: FX1 Obtained from system design plans on record 10-16-2014 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 plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.do�-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts �a Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Angela Way u Property Address Catherine&Bryan Eger Owner Owner's Name information is West Barnstable Ma 02668 9-8-2020 required for every page. City/Town 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 II No. R y (��I /I> Feel A91 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:—y_ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21pplitation for Bisp08af ,pBtem Cunstruttiun permit Application for a Permit to Construct( ) Repair(VI/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components ' Location Address or Lot No. 5 r7 ovq-elQ (�k wg Ow er's Name,Address,and Tel.No. Assessor's Map/Parcel 7 Ua�_hy ,EJM (774) 62) _3 q 7Y_/ Ins 8 ller's N e,Address,and Tel.No. Designer's Nam Address, d Tel.No. � CIO VCt iUlq_,6L0�'- 177- 0&63 J�WV4n Vf Type of Building: Dwelling No.of Bedrooms 14 Lot Size 2, sq.ft. Garbage Grinder( ) Other Type of Building' j No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date 1011,0 I i q Number of sheets Revision Date Title Size of Septic Tank `C.X 15 7L j n ci l,6 DD Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued by this Boa of H alth. I l Signed Date D l Application Approved by,_? A, A �5 Date Application Disapproved by Date for the following reasons Permit No. Q (��?j Date Issued /D 't ✓I �r } is d 4 ' t � 3 No. y (C 31 'ii Fee 10,2 !- THE COMMONWEALTH,OF MAJ SSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN q"pARNSTABLE, MASSACHUSETTS Yes 2pplicatlott for Misposal 6pstettt ConstrUctiott Vermit Application for a Permit to Construct( ) Repair(v)/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 5'7 Qnq-ela WAY Vll U Owner's Name,Address,and Tel.No. C'ad-h � �G t7 7 4 l 521 -3 4 7� Assessor's Map/Parcel 7 y 1 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 64-0 �XW VOf'W(L5ok-q 7 7 o 6563 -Down 36)_-q5 V( Type of Building: Dwelling No.of Bedrooms Lot Size T=Lj sq.ft. Garbage Grinder( ) Other Type of Building���a 4 n 0 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 4440 gpd Design flow provided gpd Plan Date loll, l j q Number of sheets_ Revision Date Title Size of Septic Tank �e X�4 ►n i^�u Type of S.A.S. }� Description of Soil Nature of Repairs or Alteratiois(Answer when applicable) t 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 Certificate of Compliance has been issued by this Boar f H alth. Signed ( Date Application Approved by t k,r-,&t /—j �—S Date Application Disapproved by a Date for the following reasons Permit No. /Lf R 6 Date Issued j f7 ' ✓ --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance 2 THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) ?ALndoned( )by fat as been constructe ' acc cc with the` visions of Title 5 and the for Disposal System Construction Permit N A. ted�` Installer h ��J ` ��� u Designer n #bedrooms Approved d s' flow o gp o The issuance of this pe it all not Ve co trued as a guarantee that the system ction de/s/igned. Date Inspector / ( S i ;� No. Fee j0f THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-213ARNSTABLE,MASSACHUSETTS Misposal 6pStent Construction Jermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at 5-7 \&10 k \A 1 ci r a s`f c'i b i e and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date /0 - uo CV Approved by TOWN OF BARNSTABLE LOCATION S�7 nocici Wg4 SEWAGE# ao)y - 38S VILLAGE (J. ,Go, o 5-joS<_ ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. EX0;aVo.4 r or\ 4-In 0653 SEPTIC TANK CAPACITY ) O 0. / L a �/ / LEACHING FACILITY: (type)Tronc),c (size) Z x 3 x 43 NO. OF BEDROOMS 14 OWNER PERMIT DATE: Jo-1G-J q COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Al- l/ L AZ. 1? ' C3-Sl j3 yS' ON- ?3'2" - ,Dq - "7y-y'' .D r 3 � 0 Town of Barnsi.ble Departing ut of Regulatory.Services ���, Public Health Division Date � MAM 200 Main Street,Hya nis NSA 02601 - Date Scheduled e �+ee l.J°d l00 - Time . SoilI Suitability .Assessment for Se 0 � Performed-By:!�`n,,'-e GanS`G1veS Witnessed By: LOCATION& GENERAL INFORMATION Location Address f7 rt NQed< w Owner's Name f� Map/Parcel: /� � 48 7 ���at Address f Assessor's Map/Parcel ! Engineer's Name Qk_/e NEW CONSTRUCTION REPAIR Tcle hone# tej (3 6a- Land Use:La�� Slopes(%) 0— 5� Surface Stoues Distances from: Open Water Body�JV,-./ {1 possible Wet•Area L—L '`� ft Drinking Water Well - (�ft � Drainage Way [O`' ft Property Une ft Other ft SIMCTC.U.'(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands-In proximity to holes) r / i i 51 Parent material(geologic)q6(C,61 � 01 Depth tp)3adrgcl£ Depth to Groundwater. Standing Water in Hole:N/A Weeping from Pit Rage �f l Estimated Seasonal High Groundwater / DE ERIVNATION FOR SEASONAL HIGH WATER TABLE Method Used: V" f,- _ Depth Observed standing in obs.hole: la. Depth to SQ11 mQulgc Depth to weeping from side of obs.hole: In, Groundwater Ad,Justtnent . Index Well#1 Reading Date: Index Well Iavol :__ ___- Adj,fetdr ,_Ar .Cltwuildwaterl,evxl „ PERCOLATION TEST Date- Thna, Observation I Hole#k _ Tlmv at 9" Depth of Perc SL•�VL CZ Time at 6" Start Pre-soak Time @ 'limo(9"-G") End Pre-soak Rate M1n.fluch Site Suitability Assessment. Site Passed Sitg Failed: Additional Testing Needed(.YIN) Original: Public Health Dlvlsio❑ Observation Hole Data To Be Completed on Back----- ***If percolation test is to be conducted within 100' of wetland,you]trust first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\S EPTIC\PERCFORM.D O C • . : � ,. � ` - .tea.,. ., . DEEP-OBSERVATION HOLE LOG Hole#�� Depth from Soil Horizon Soil Texture .Shcl Color Soil• Other ; Surface(in.) (USDA) (Munsell) Mottling (Structure, Stones;Boulders, o i ten:y,96'Cravell - A S tayjP, 3/z to YP CDo Z DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Sail Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsis en `Ya Grave y C �0-132_ C DEEP OBSERVATION HOLE LOG Kole 9. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Co t to c Q e (DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color 9,311 Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stories;Boulders, • Cositn , +4 ]flood Insurance hate Map: Above 500 year flood boundary No Yes Within 500 year boundary No 11 Yes Within 100 year flood boundary No. Yes Depth of 1 atutrally Occurring Pervious Material Daes at least four feet of naturally occurring pervious aterial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious matariall Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in�10 CMR 15.017. Signature Datb QASEPT1aP.E1ZCF0RM.D0C down cage engineering, inc. SIEVE SOILS ANALYSIS 57 ANGELA WAY W. BARNSTABLE, MA DATE OF REPORT: 10/15/14 .JOB : GRAIN SIZE ANALYSIS-SIEVE TEST SITE: 57 ANGELA WAY WEST BARNSTABLE, MA LOCATION: DCE TEST HOLE SIEVE ANALYSIS Weight Sample(Grams): 230.0 SIZE :WEIGHT RETAINED I % RETAINED % PASSED (sum ) --------------:......................................................:---------------------;..................................... 1" 0.0I 0.0%I 100.0% --------------......................................................>-------------------- 0 -0------------------ 3/4" .0€ 0.0% 100.0% --------------i.......:..............................................:---------------------=------------------ 1/2" O.OI 0.0%I 100.0% --------------i......................................................►---------------------„-------------- 0 ---- .. 3/8" .0i 0.0%:: 100.0% --------------i..............................................6.....:---------------------=------------------ #4 O.OI 0.0%I 100.0% '-------------i......................................................r---------------------q..................................... #10 12.8:: 5.6%€ 94.4% --------------......................................................:---------------------:..................................... #20 69.8I 30.3%I 69.7% -------------i......................................................>--------------------4..................................... #40 1575: 68.5%i 31.5% --------------i......................................................:---------------------:..................................... #50 186.5I 81.1%I 18.9% --------------i......................................................>-------------------- ..................................... #80 213.7 92.9%i 7.1% --------------:......................................................:---------------------;..................................... #100 218.61 95.0%i 5.0% -------------„.....................................................t--------------------- ------------------ #200 226.5i 98.5%E 1.5% ....................................................... PAN: I 228.5I 100.0%;------------0.0% SAMPLE: 230.0€ NOTE:TEST ON PASSING#4 ONLY, 4% RETAINED ON#4 <45% O.K. RESULTS: SOIL CLASSIFIED AS AASHTO A-1-b (GRAVEL AND SAND) (UNCOMPACTED) PERCENTAGE OF MATERIAL PASSING#4 SIEVE : #4 100% (TEST ONLY MATERIAL PASSING#4) OK #5010%-100% OK #100 0%-20% OK #200 0%-5% OK SAMPLE MEETS TITLE 5 FILL SPECIFICATION >98%SAND RESULTS: PERMEABLE MATERIAL-CLASS 1 <2 MINJIN. MATERIAL NONCOMPACTED SOIL DESCRIPTION: MEDIUM/COARSE SAND Department of Environmental Management/Division of Water Resources i WATER, WELL COMPLETION REPORT 1 n WELL LOCATION Addfess4-r d'5 t311 _7 ;fx1� City/Town �,4.r 1 Ar+�C� MA C 5 G.S.Quadrangle Map / N! Grid Lo��-j�ion Owner zy, C1" U l S1 y Address "c4e)l.t WELL USE CONSOLIDATED WELL Domestic[�/ Public ❑ Industrial ❑ y/AGGI',r'Type of Water-bearing Rock Other .Water-bearing Zones Method Drilled _-0 7A,-y 1) From To 2) From To Date Drilled 3) From To 4) From To CASING �' /� / Depth to Bedrock Length-A I J / Diameter 11' (4 Type I/C, /` UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing Materials Feet below land surface,3 f/ /y Sand: fire❑ medium❑ coarse❑ Date measured a Y Gravel: fine❑ medium❑ coarse❑, GRAVEL PACK WELL Screen:/ 1 ey Slot t length from 't C? to C/ Yes ❑ No ❑ I.Split Screen (or 2nd screen) WATER QUALITY TESTS MADE Slot# lenqth ffrrjjjom to i Chemical LJf Biological Depth To Bedrock PUMP TEST Drawdown feet after pumping days T_hours at NO, GPM. How measured_ R ecoveryZ1#1 Lt after _,t 6 Mlhturs. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To Cb Q {D�IRILLR Cb Firm), h/.dlUl L 'S 'I"! Add�s4AeV ,A l''i RI�I P !) '� �^ City �/ GLd` rt�/ f�Sf Registration I�lo. JC �/14 Operator s Signature Please pant fir y BOARD F HEALTH COPY 2SM-10.85.807101 'OFFICE r LABORATORY '%1498 HIGH STREET 176 PLYMOUTH STREET BRIDGEWATER, MA 02324 BRIDGEWATER, MA 02324 OLIVEIRA ENVIRONMENTAL LABORATORIES, INC. FOOD- DAIRY PRODUCTS-WATER -WASTEWATER CHEMICAL Er BACTERIOLOGICAL ANALYSES 697-2650 October 24, 1987 L. Wile & Son Drilling Co. 11 Annasnappitt Drive Plympton, Mass. 02367 Source: Well Water - Drilled Well - 6-inch PVC Well ) - 80 feet deep - producing 25 gals/min. (static water level 31 feet) . Located on the property of Mr. Jay Cruise - Lot 23 - Bodfish Estates - West Barnstable, Mass. Coliform Count /100 ml @ 35 C 0 Membrane Filter S.P.C./ml @ 35 C 260 Color (APC units) 0.00 Sediment slight Turbidity (NTU) 1.50 Odor none Taste satisfactory pH 6.40 Specific Conductance 120. micromhos/cm mg /liter Total Alkalinity (CaCO,) 31.0 Free CO, 23.9 Total Hardness (CACO,) 42.0 Calcium (Ca) 9.60 Magnesium (Mg) 4.40 Sodium (Na) 8.70 Potassium (K) 1.03 Total Iron (Fe) 0.17 Manganese (Mn) L 0.01 Silica (SiO,) 13.0 Sulfate (SO,) 9.00 Chloride (CI) 8.50 Nitrogen - Ammonia 0.05 Nitrogen - Nitrite 0.005 Nitrogen - Nitrate 0.20 Copper (Cu) L = less than 1 On site collection made by L. Wile & Son Drilling Co. - 10/20/87 at 10:00 A.M. Sample delivered .to laboratory by Mr. L. Wile - 10/20/87 at 2:15 P.M. Bacteriologically, this well water is of a satisfactory sanitary standard and is suitable for drinking and domestic purposes. Chemically, this well water meets the standards for all of the chemicals tested. Director ' Ii ` 4 The Standard-Plate Count indicated the general bacterial population of the well at the time of collection. Coliform Group Bacteria: Significance The coliform group bacteria includes organisms found in the intestinal tracts of warm blooded animals, birds,decaying organic matter(hay, leaves, wood, etc.), the top 2 to 3 feet of the soil, lakes, ponds, brooks, rivers, drainage and types of vegetation. Because the organisms can cause some illness; because the presence of coliform organisms in the water suggests that other more harmful organisms may be present, water containing one or more coliform group bacteria per 100 ml of sample should not be used for drinking or cooking purposes unless boiled 5 minutes or disinfected by other means. This bacteria is of animal origin(intestinal tract)and may be considered as closely associated with disease causing organisms.On this factor, none should be present. Color — APC Units- Ground water ought to be practically free from color. For attractive water - color should not exceed 15 units. Turbidity — NT Units- Recommended limit not to exceed 5 units. Odor£t Taste — For water to be of high quality, the water should be odor free and taste good. pH — The pH value defines the concentration of free hydrogen ions in solution. Expressed on a scale extending from 0 or very acid to 14 or very alkaline with 7.0 being neutral. Specific Conductance — Conductivity is a good criterion for measuring the degree of mineralization and assessing the affect of diverse ions on chemical equilibria. Total Alkalinity — The alkalinity of this water represents its content of carbonates and bicarbonates. Free Carbon Dioxide — Well water having a low pH and a Free CO, level in excess of 50. mg/I will be corrosive to iron, bronze, brass and copper tubing and fittings. Total Hardness — Standard not to exceed 50. mg/l. Waters having a hardness level of 50 to 100 are in the medium hardness range, over 100 very hard. Calcium -- Calcium contributes to the total hardness of water.Appreciable amounts of calcium salts break down on heating and form scale in boilers, pipes and cooking utensils. Magnesium — Magnesium is a common constituent of natural water. Magnesium and calcium ions are principal contributors to water hard- ness. Concentrations in excess of 125 mg/I can exert a cathartic and diuretic action. Sodium — Recommended limit not to exceed 20 mg/l. Potassium — Potassium concentrations in drinking water seldom exceed 20. mg/I. Total Iron — Standard not to exceed 0.3 mg/I. Manganese — Standard not to exceed 0.05 mg/I.The principal reason for limiting the concentration of manganese is to reduce esthetic and economic problems. Silica — Silica content of natural water is most commonly in the 1 to 30 mg/l. Silica in water is undesirable because it forms difficult to remove silica scales. Sulfates — Standard not to exceed 250 mg/l. Chloride — Standard not to exceed 250 mg/l. Nitrogen — Ammonia is present in variable concentrations in many surface and ground waters. Its occurrence in ground water is generally a result of natural reduction processes. Nitrogen - Nitrite — Nitrite in water poses a health hazard, but fortunately seldom occurs in high concentrations. Waters with a nitrogen - nitrite concentration over 1 mg/I should not be used for infant feeding. Nitrogen - Nitrate — Standard not to exceed 10. mg/l. Nitrate, in high concentrations can and do cause methemoglobinemia or so-called nitrate poisoning in infants. Water with 10 or more mg/I of nitrate is unsatisfactory and is not considered safe for drinking or cook- ing. It is especially dangerous to children and should never be used in infant formulas. Copper — Standard not to exceed 1.0 mg/l. L , OFFICE LABORATORY 1498 HIGH STREET 176 PLYMOUTH STREET BRIDGEWATER, MA 02324 BRIDGEWATER, MA 02324 l - OLIVEIRA ENVIRONMENTAL LABORATORIES, INC. FOOD- DAIRY PRODUCTS-WATER-WASTEWATER CHEMICAL£t BACTERIOLOGICAL ANALYSES 697-2650 October 24, 1987 L. Wile & Son Drilling Co. 11 Annasnappitt Drive Plympton, Mass. 02367 Source: Well Water - Drilled Well - 6-inch PVC Well - 80 feet deep - producing 25 gals/min. (static water level 31 feet). Located on the property of Mr. Jay Cruise - Lot 23 - Bodfish Estates - West Barnstable, Mass. Coliform Count /100 ml @ 35 C 0 Membrane Filter S.P.C./ml @ 35 C 260 Color (APC units) 0.00 Sediment slight Turbidity (NTU) 1.50 Odor none Taste - satisfactory pH 6.40 Specific Conductance 120. micromhos/cm mg /liter Total Alkalinity (CaCO,) 31.0 Free CO, 23.9 Total Hardness (CACO,) 42.0 Calcium (Ca) 9.60 Magnesium (Mg) 4.40 Sodium (Na) 8.70 Potassium (K) 1.03 Total Iron (Fe) 0.17 Manganese (Mn) L 0.01 Silica (S!i%) 13.0 Sulfate (SOO 9.00 Chloride (CI) 8.50 Nitrogen - Ammonia 0.05 Nitrogen - Nitrite 0.005 Nitrogen - Nitrate 0.20 Copper (Cu) _ L = less than On site collection made by L. Wile & Son Drilling Co. - 10/20/87 at 10:00 A.M. Sample delivered;to laboratory by Mr. L. Wile - 10/20/87 at 2:15 P.M. Bacteriologically, this well water is of a satisfactory sanitary standard and is suitable for drinking and domestic purposes. Chemically, this well water meets the standards for all of the chemicals tested. Director The S4andard-Plate Count indicated the general bacterial population of the well at the time of collection. Coliform Group Bacteria: Significance The coliform group bacteria includes organisms found in the intestinal tracts of warm blooded animals, birds,decaying organic matter(hay, leaves, wood, etc.), the top 2 to 3 feet of the soil, lakes, ponds, brooks, rivers, drainage and types of vegetation. Because the organisms can cause some illness; because the presence of coliform organisms in the water suggests that other more harmful organisms may be present, water containing one or more coliform group bacteria per 100 ml of sample should not be used for drinking or cooking purposes unless boiled 5 minutes or disinfected by other means. This bacteria is of animal origin(intestinal tract)and may be considered as closely associated with disease causing organisms.On this factor, none should be present. Color — APC Units- Ground water ought to be practically free from color. For attractive water- color should not exceed 15 units. Turbidity — NT Units- Recommended limit not to exceed 5 units. Odor Et Taste — For water to be of high quality, the water should be odor free and taste good. pH — The pH value defines the concentration of free hydrogen ions in solution. Expressed on a scale extending from 0 or very acid to 14 or very alkaline with 7.0 being neutral. Specific Conductance — Conductivity is a good criterion for measuring the degree of mineralization and assessing the affect of diverse ions on chemical equilibria. Total Alkalinity — The alkalinity of this water represents its content of carbonates and bicarbonates. Free Carbon Dioxide — Well water having a low pH and a Free CO, level in excess of 50. mg/I will be corrosive to iron, bronze, brass and copper tubing and fittings. Total Hardness — Standard not to exceed 50. mg/I. Waters having a hardness level of 50 to 100 are in the medium hardness range, over 100 very hard. Calcium -- Calcium contributes to the total hardness of water.Appreciable amounts of calcium salts break down on heating and form scale in boilers, pipes and cooking utensils. Magnesium — Magnesium is a common constituent of natural water. Magnesium and calcium ions are principal contributors to water hard- ness. Concentrations in excess of 125 mg/I can exert a cathartic and diuretic action. Sodium — Recommended limit not to exceed 20 mg/I. Potassium — Potassium concentrations in drinking water seldom exceed 20. mg/I. Total Iron — Standard not to exceed 0.3 mg/I. Manganese — Standard not to exceed 0.05 mg/I.The principal reason for limiting the concentration of manganese is to reduce esthetic and economic problems. Silica — Silica content of natural water is most commonly in the 1 to 30 mg/I. Silica in water is undesirable because it forms difficult to remove silica scales. Sulfates — Standard not to exceed 250 mg/I. Chloride — Standard not to exceed 250 mg/I. Nitrogen — Ammonia is present in variable concentrations in many surface and ground waters. Its occurrence in ground water is generally a result of natural reduction processes. Nitrogen - Nitrite — Nitrite in water poses a health hazard, but fortunately seldom occurs in high concentrations. Waters with a nitrogen - nitrite concentration over 1 mg/I should not be used for infant feeding. Nitrogen - Nitrate — Standard not to exceed 10. mg/I. Nitrate, in high concentrations can and do cause methemoglobinemia or so-called nitrate poisoning in infants. Water with 10 or more mg/I of nitrate is unsatisfactory and is not considered safe for drinking or cook- ing. It is especially dangerous to children and should never be used in infant formulas. Copper — Standard not to exceed 1.0 mg/I. nj ru ru .. o ,o I OFFICIAL USE Ln rn Postage $ C3 Certified Fee J� P_o_stmark C3ReturnReceipt Fee S Here O (Endorsement Required) Restricted Delivery Fee Fib y O (Endorsement Required) i p NJ MTotal Postage&Fees $ 2�f� ?Off o Steven L Charlip.Tr { 57 Angela Way i West Barnstable, MA 0268 Certified Mail Provides: i ■ A mailing receipt ■ A unique identifier for your mailpiece m A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Maile or Priority Mail& o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt maybe requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. a For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and,present it when.making an inquiry. "I a PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 ;I - i Town of Barnstable Barn Regulatory Services Department ;ifta j anuvsr"M MAn 9� 0 a1� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director. FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1230 0001 0358 0222 October 4, 2014 Steven L Charlip Tr 57 Angela Way West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic stem located at 57 Angela Way, West Barnstable, MA was last inspected p Y g Yi on 7/25/2014, by Reid C. Ellis, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool in the past. • Outlet tee needs to be replaced, also needs a 12" riser in the rear to meet Code. • Distribution bog leaking: side walls are falling apart, it has 2 outlet pipes; no flow dials, 38" deep with no riser. You are ordered to repair/replace the e septic system components within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. 0ORD R OF HE BOARD OF HEALTH r McKean, R.S., CHO Agent of the Board of Health ) ls ► � QASEPTIC\Letters Septic Inspection Failures or Future Evl\57 Anaela Way W.Bam Sept 2014.doc —N—. i o`O'E'Owti Town of Barnstable U.S.POSTAGE>>PITNEY BOWES Public Health Division SANNSfABLE. • 200 Main Street _MASS. Hyannis,MA 02601 ''` = ZIP 02601 $ 006.480 02 1 VV 0001383424 SEP. 30. 2014 7014 1200 000.1 0358 0222 Steven L Charlip Tr v � Oti 57 Angela Way �e CLQ West Barnstable, MA 02668_ R ATTEMPTED — 'PJ'OT KNOWN UNABLE TO FORWARD BC: 026014002OO 27':22—.03+� 0 � � 'Ill1 #II�I11, 19l I�s�l l '1111i��1 �`1�„IIIII Jill 11111I1eI1III! -� ... _ , •• , • •• ',sec d' ._ —. .�._ _ G s ENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1;2,and 3.Also complete A. signature item 4 if Restricted.Delivery is desired. ❑Agent j IY Print your name and address on the reverse X ❑Addressee I so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery E Attach this card to the back of the mailpiece, I or on the front if space permits. P' D. Is delivery address differentfrom item 1? ❑Yes I 11. Article Addressed to: If YES,enter delivery address below: ❑No TV,A I Steven L Charlip Tr 5TAnAgela Way Afflest,Barnstable, MA 0268 3. Service Type ❑Certified Mails ❑Priority Mail Express' ❑Registered ❑Return Receipt for Merchandise - - I ❑ Insured Mail ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes i 1 2 Article Number I YTransfertrorrrserdoe►adeQ 7014 1200 0001 0358 0222 0 f . PS Form 3811-July 2013 Domestic Return Receipt t { :s z�.. t •. t• z tt ._. s z l s t t; .�_z 1.1 z t z. }i-_�.s�i t i. Town of Barnstable Barnstable .�. Regulatory Services Department A P �STA8� 0 D 9q, MASS 0,39. Public Health Division • 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 0222 October 4, 2014 Steven L Charlip Tr 57 Angela Way West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 57 Angela Way,West Barnstable, MA was last inspected on 7/25/2014, by Reid C. Ellis, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool in the past. • Outlet tee needs to be replaced, also needs a 12" riser in the rear to meet Code. • Distribution box leaking: side walls are falling apart, it has 2 outlet pipes; no flow dials,38" deep with no riser. You are ordered to repair/replace the e septic system components within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. OPORDkR OF HE BOARD OF HEALTH McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\57 Angela Way W.Barn Sept 2014.doc v http;Jjissgl2JinkranetjpropdatajParcelDetail.aspx?ID=8458 (; j} X 11,11 live Search p, I Application Center(2) g http--www,town,barnstable,,, N Application Center ®Suggested Sites• web Slice Gallery �k� Favorites r Parcel Detail av BARNITABLE law&�11 s Logged In As: September Parcel Detail i s 2014 P � I T Parcel Info Parcel Developer '' ID 133-012 Lot LOT 23 I ' r: Pri ! Location 157 ANGELA WAY I �----- Frontage � Sec�— I Dec Road Frontage Village WEST BARNSTABLE ( Disbict W BARNSTABLE Town sewer exists at this { address No Road Index 1933 Asbuilt Septic Scan: P I nteractive 133072_1 I ; Ma I l 133072-2 i Owner Info Owner ICHARLIP,STEVEN L TR I Co-Owner %EGER,BRYAN D&CATHERINE Streets 157 ANGELA WAY Street2 i I' City JVVEST BARNSTABLE I State DMA Zip 026fi8 Country l Land Into Acres 1.4fi Use Single Fam WAD Zoning RF Nghbd D108 Done 1�1�hJLJ'I� Local Intranet 00% -- ---- --— —— ---- — — _ _...-------- — -------- ----- - 5ParceI Detail-windows l,,, 1p Adverusement-window.,. 10,09 AM �D D��y" THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) m A 7 . DATA ti ru ru �IMT Town of Barnsi� l ti M Regulatory Services DE CertifiedtFee • BARNSr"LE, m► s 0 Return Receipt Fee Postmark Public Health Divis P Here 9� ibjq. 1 O (Endorsement Required) A 200 Main Street,Hyannis MA c3 Restricted (End rseme°eRe" e Required) ` Gc1(U Total Postage&Fees $ ! ' ra Office: 508-862-4644 FAX: 508-790-6304 �! M1 Steven L Charlip Tr CERTIFIED MAIL# 7014 1200 0001 0358 0222 57 Angela Way West Barnstable, MA 0268 October 4, 2014 Steven L Charlip Tr 57 Angela Way West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 57 Angela Way,West Barnstable, MA was last inspected on 7/25/2014, by Reid C. Ellis, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool in the past. • Outlet tee needs to be replaced, also needs a 12" riser in the rear to meet Code. • Distribution box leaking: side walls are falling apart, it has 2 outlet pipes; no flow dials, 38" deep with no riser. You are ordered to repair/replace the e septic system components within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. OORPDkR OF HE BOARD OF HEALTH McKean, R.S., CHO \ Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\57 Anaela Way W.Bam Sept 2014.doc f Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 57 Angela Way, West Barnstable,MA Property Address Steven L Charlip,Steven L Charlip LLC, 83 Ridgeway Road,Weston, MA 02497 Owner Owner's Name information is required for every West Barnstable MA 07/25/2014 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. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not REID C. ELLIS use the return Name of Inspector key. ELLIS BROTHERS CONSTRUCTION ffi Company Name 23 ENTERPRISE ROAD ! a —i Company Address :' YARMOUTH PORT MA f FQ 02675 >, City/Town State t_> Zip Code 37 508-362-6237 S121891 " Telephone Number License Number zz 47i 51 B. Certification Z ri 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 Inspe or's Si nature d 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. ��► 1 t5ins-3/13 Title 5 Official Inspection VF : bsurface Sewage Disposal System•Page 1 of 17 m I r Coinmonwealth of Massachusetts Title 5 official Inspection i=orm Subsurface Sewage Disposal System Form-Not for Voluntary'Assessments M >•�''� 57 Angela Way, West Barnstable MA Property Address Steven L Charlip,Steven L Charlip LLC 83 Ridgeway Road, Weston MA 02497 Owner owner's Name information is required for every West Barnstable MA ; 07/25/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always completeall of Section D A) System Passes: zo t� 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: i B) System Conditionally Passes: ❑ One or more � f system components as desc bed in the"Conditional Pass"section need to be replaced or repaired. The system, upon coil npletion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determine "(Y, N, ND)forthe following statements. If"not determined,"please explain. } i 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 exfil ration 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 thar 20 years old is available. ❑ Y ❑ N ❑ ND(Explain b low): i i • i t5ins•3113 t Title 5 official inspectlori 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 ••'� 57 Angela Way, West Barnstable, MA Property Address Owner Steven L Charlip,Steven L Charlip LLC, 83 Ridgeway Road, Weston, MA 02497 information is Owner's Name I required for every West Barnstable MA 07/25/2014 page. CitylTown 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 of high static water level in the distribution box due to broken or obstructed pipe(s)or due to a bro en, settled for uneven distribution box. System will pass inspection if(with approval of Board of H alth): ❑ 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 i ❑ ND(Explain below): i j ❑ The system required pumping more than 4 tim'h.s 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 [I N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): i C) Further Evaluation is Required by the a d of Health: f ❑ Conditions exist which require further evaluati n by the Board of Health in order to determine if the system is failing to protect public health, s fety or the environment. 1. System will pass unless Board of Healtl i determines in accordance with 310 CMR 15.303(1)(b)that the system is not functior ing in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of surface water ❑ Cesspool or privy is within 50 feet of bordering vegetated wetland or a salt marsh t5ins-3113 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Angela Way, West Barnstable, MA Property Address Owner Steven L Charlip,Steven L Charlip LLC, 83 Ridgeway Road, Weston MA 02497 Owners Name information is — required for every West Barnstable MA 07/25/2014 page. CitylTown 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 functionii ig in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil bsorption system (SAS)and the SAS is within 100 feet of a surface water supply or tribut iry to a surface;water supply. ❑ The system has a septic tank and SA and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAE and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS an 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 analysi , performed at a DEP certified laboratory, for fecal . coliform bacteria indicates absent and the pre nce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other f ilure criteria areitriggered.A copy of the analysis must be attached to this form. 3. Other: j i i i D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following fo'r all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ; �„b,` 'l,A T- Discharge or ponding of effluent to the surface of the ground due to an overloaded or clogged SAS or cesspool g d or surface waters ❑ 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 than %day flow Is less t5ins.3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary!Assessments M 57 Angela Way, West Barnstable, MA Property Address Owner Steven L Charlip,Steven L Charlip LLC, 83 Ridgeway Road, Weston MA 02497 Owners Name information is required for every West Barnstable MA page. 64-y own 07/25/2014 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: ❑ L,Id/ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 1100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a or cesspool privy p p vy is within a Zone 1 of a public well. i ❑ 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 thatlone or more of the above failure criteria exist as described in 310 CM 15.1303, therefore the system fails. The system owner should contact the Boar of Health to determine what will be necessary to correct the failure_/� E) Large Systems: To be considered a large system t e 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"n "to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a urface drinking water supply ❑ ❑ the system is within 200 feet of a nbutary to a surface drinking water supply the system is located in a nitroger i sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone I of a public water supply well I 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 br failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The systen ownerrshould contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,•�''! 57 Angela Way, West Barnstable, MA Property Address Steven L Charlip,Steven L Charlip LLC, 83 Ridgeway Road,Weston, MA 02497 Owner Owner's Name information is West Barnstable MA required for every i 07/25/2014 page. Cityfrown 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? LJV/ ❑ 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 sig El Was the site inspected of sewage back up? signs of break out? pected for ❑ Were all system components,4iluding 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 sludgeland 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: ldJ'/ ❑ Existing information. For example, a plan atithe 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)j D. System Information Residential Flow Conditions: e� Number of bedrooms(design): Number of;bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd z#of bedrooms): t5ins•3113 Title 5 Official Ins pectiori Form:Subsurface Sewage Disposal System•Page 6 of 17 eX Commonwealth of Massachusetts i Title 5 official inspection Fd'r n Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Angela Way, West Barnstable, MA I Property Address Owner Steven L Chadip,Steven L Charlip LLC 83 Ridgeway Road, Weston, MA 02497 information is Owner's Name required for every West Barnstable MA 07/25/2014 page. CitylTown State Zip Code Date of Inspection D. System Information Description: i i i f Number of current residents: s Does residence have a garbage grinder? Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes �/Nj;/No Laundry system inspected? ❑ Yes Seasonal use? �/' ❑ Yes LT No Water meter readings, if available(last 2 years usage(gpd)): Detail: - / d�/���/ �'°-� (J�✓�?fit_.. R Sump pump? i ❑ Yes No Last date of occupancy: i Date Commercial/Industrial Flow Conditions: ,/} �J I Type of Establishment: i i Design flow(based on 310 CMR 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 i Water meter readings, if available: t5ins•3/13 Title 5 official inspection Form.Subsurface Sewage Disposal system•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary;Assessments 57 Angela Way, West Barnstable, MA .Property Address Steven L Charlip Steven L Charlip LLC, 83 Ridgeway Road Weston MA 02497 Owner Uwner's Name information is required for every West Barnstable MA i 07/25/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Pt Date Other(describe below): i General Information ! i Pumping Records: Source of information: Was system pumped as part of the inspection? U Yes ❑ No If yes, volume pumped: I � gallons How was quantity pumped determined? �' �/ ✓���� Reason for pumping: Type of yytem: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool i ❑ Privy f ❑ 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 operatoriunder contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3H 3 Tile 5 Official Inspecliori Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts 4 Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Angela Way West Barnstable, MA i Property Address i Steven L Charlip,Steven L Charlip LLC, 83 Ridgeway Road, Weston MA 02497 Owner Owner's Name information is required for every West Barnstable MA 07/25/2014 page. 667r-town State Zip Code Date of Inspection D. System Information (cont.) 11 Approximate ague of all components, date installed (if known)and source of information: i Were sewage odors detected when arriving at the site? I ElYes IJ/No Building Sewer(locate on site plan): °? i Depth below grade: feet Material of construction: I ❑ cast iron V40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage)etc.): 6 �� s Septic Tank(locate on site plan): i Depth below grade: ` ii Teet � ;t,e"8' of construction: I concrete ❑ metal ❑fiberglass g El!polyethylene El other(explain) i If tank is m I, st age: /Iars Is age nfi ed by a Certificate of Compliance?(attach a coertificate) ❑ Ye ' o Dimensions: Sludge depth: t5ins•3113 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary;Assessments 57 Angela Way, West Barnstable, MA Property Address 1 Steven L Charlip,Steven L Charlip LLC, 83 Ridgeway Road, Weston, MA 02497 Owner Owner's Name information is ` required for every West Barnstable MA i page. City/Town 07/25/2014 State Zip Code Date of Inspection D. System Information (cono Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness f Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle c7 How were dimensions determined.? Comments(on pumping recommendations, inlet and outlet teeior baffle conditio tru liquid devel as relate. outlet invert, idence le ka {) , cltural integrity, All Grease Trap(locate on site plan): i Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ lass er 9 ❑ polyethylene El other(explain): Dimensions: i Scum thickness 1 i Distance from top of scum to top of outlet tee c r baffle ! Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: I Date t5ins-3113 Me 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts Title 5 official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary';Assessments 57 Angela Way, West Barnstable, MA Property Address Owner Steven L Charlip,Steven L Charlip LLC, 83 Ridgeway Road, Weston MA 02497 Owner's Name information is required for every West Barnstable MA i 07/25/2014 page. CiR own State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendati ns " le"t and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evi rice of leakage, etc.): g ty, i t 1 i f i i Tight or Holding Tank(tank must be purr ed at time of inspection) (locate on site plan): i Depth below grade: Material of construction: i ❑concrete ❑ metal fiberglass ❑ polyethylene El other(explain): I Dimensions: Capacity: gallons i Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No f t Date of last pumping: Date ': Comments(condition of alarm and float sV fitches, etc.): 1 "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 Commonwealth of Massachusetts I lug Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary;Assessments 57 Angela Way, West Barnstable, MA Property Address Steven L Charlip,Steven L Charlip LLC, 83 Ridgeway Road,Weston, MA 02497 Owner uwner's Name information is required for every 'West Barnstable MA 07/25/2014 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 - Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, an evidence of leakage into or out of box, etc.): 4; /41 e i e t4Z 1a4Zj a ' Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* i Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, ondition of pumps and appurtenances, etc.): i f i *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation Inot required): If SAS not looted, explain why: i 3 t t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts i Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary;Assessments .y 57 Angela Way, West Barnstable, MA Property Address Owner Steven L Charlip,Steven L Charlip LLC 83 Ridgeway Road, Weston MA 02497 information is Owner's Name required for every West Barnstable MA } 07/25/2014 page. CitylTown State Zip Code Date of inspection D. System Information (cont.) Type: leaching pits number: ❑ 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) YZ h16� 4�� + . �. j�1 Cesspo is (cesspool must be pumped rinspection)(locate on site plan): Number and configuration i Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer i Dimensions of cesspool Materials of construction Indication of groundwater inflow ! El Yes ❑ No t5ins-3f13 Titre 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i J Commonwealth of Massachusetts t Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments 57 Angela Way, West Barnstable, MA Property Address Owner Steven L Charlip,Steven L Charlip LLC 83 Ridgeway Road, Weston, MA 02497 Owners Name information is i required for every West Barnstable MA i page. 07/25/2014 CityI1 own 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.): i Privy(locate on site plan): i Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs f hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 or 17 Commonwealth of Massachusetts Title 5 Official inspection F6rm Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments M , 'y 57 Angela Way, West Barnstable, MA t Property Address Owner Steven L Charli ,Steven L Charlip LLC, 83 Ridgeway Road, Weston, MA 02497 Owner's Name information is O required for every West Bamstable MA 07/25/2014 page. City/Town State Zi Cod p e Date of Inspection D. System Information (cunt.) 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 1 i l i Lk 3 r i M . 3. ' C.3 28�?- Di , moo, C 5 1 t5ins-3/13 a Titte 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts t lug Title 5 Official Inspection Forte Subsurface Sewage Disposal System Form-Not for Voiuntary)Assessments I 57 Angela Way, West Barnstable, MA Property Address Steven L Charlip,Steven L Charlip LLC 83 Ridgeway Road, Weston MA 02497 Owner Owner's Name information is required for every West Barnstable MA 07/25/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Site Exam: i i ❑ Check Slope ❑ Surface water �� ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: j feet Please indicate all methods used to determine the high groundwater elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: t Date' ❑ Observed site(abutting property/observation hole within 150 feet of SAS) i ❑ Checked with local Board of Health-explain: ❑l Checked with local excavators, installers-(attach documentation) L�1 Accessed USGS database-explain: i You must describe how you esMblished he h' h ground water elevation: a4z Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 i Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts i • Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Angela Way, West Barnstable, MA Property Address Steven L Charlip,Steven L Charlip LLC, 83 Ridgeway Road Weston, MA 02497 Owner Owner's Name information is required for every West Barnstable MA page. Ci crown 07/25/2014 State Zip Code Date of Inspection E. Report Completeness Checklist [(Inspection Sumrr.ary:A, B, C, D, or E checked LvJ Inspection Summary D(System Failure Criteria Applicable;to All Systems)completed ,,_/ y ) V tern Information—Estimated depth to high groundwater tch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Eorm:Subsurface Sewage Disposal System•Page 17 of 17 OF HA CERTIFICATE OF ANALYSIS Page-. 1 of 1 Barnstable County Health Laboratory (M-MA009) �9cHu Report Prepared For: Report Dated: 08/1112014 Eleanor G.Claus, Realtor Kinlin Grover,Yarmouthport Order No:: G1481991 927 Rt 6A Yarmouth Port, MA 026.75 Laboratory ID#: 1481991-01 Description: Water-Drinking Water Sample#: Sample Location: 57,Angela.Way,West Barnstable Collected: 07/28/2014 Collected by: Received: 07/28/2014 Routine ITEM RESULT UNITS RL MCL METHOD# ANALYSTTESTE NOTE Nitrate as Nitrogen 2.6 mglL 0.16 10 EPA 300.0 LAP 07/28/2014 Copper 0.33 mglL 0.10 1.3 EPA 200.8 LAP 08/11/2014 Iron ND mg/L 0.10 0.3 EPA 200.8` LAP 08/11/2014 pH 5.7 PH AT 25C NA 6.5-8.5 SM 4500-H-B' DCB' 07/28/2014 Sodium 22 mglL 2.5 20 EPA 200.8 LAP 08111`/2014 Total Coliform Absent P/A 0 0 SM 9223 RG 07/28/2014 Conductance 230 umohs/cm 2.0 EPA 120.1 DCB 07/29/2014 Sodium is above their maxium contaminant level. Those on alow sodium diet may wish to consult a physician. Attached please find the laboratory certifed parameter list,. :Approved By (Lab Manager) a� ND=:None Detected R.I. Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph 508-376-6605 • .ar��FK �91 CERTIFICATE OF ANALYSIS ` Barnstable County Health Laboratory(M-MA009) �iCH13Sb f Recipient: Eleanor G.Claus,Realtor Matrix: Water-Drinking Water Kinlin Grover,Yarmouthport Sampled: 67/28/2014 11:06 9271Rt6A Received:: 07/28/2014 1123 Yarmouth Port, MA 02675 Collection Address: 57 Angela Way,West Barnstable Order#: G1481991 Sample Location: Lab ID: 1481991-01 Description: Routine Voc Sample#• Date Analyzed 07/28/2014 @` 9:21 Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Sodium is above their maxium contaminant level.Those on a low sodium diet may wish to consult:a physician. EPA 524.2- Volatile Org►ankS by GC/MS R-6sult MCL MDL Res"I MCL. ML Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L Dichlorodifluoromethane ND •.0 50 Chloroform 0.53 80 0.50 Chloromethane ND 0.50 cis-1,2=Dichloroethene ND 70 0.50 Vinyl chloride ND 20 0.50 cis-1.,3-Dichloropropene ND 0.50 Bromomethane ND 0.50 Dibromochloromethane ND 0.50 1,1,1,2-Tetrachloroethane ND 0.50 Dibromomethane ND 0.50 1,111-Trichloroethane ND zoo 0.50 Ethylberizene ND 760 0.50. 1,1,2,2-Tetrachtoroethane ND 0.50 Hexachlorobutadiene ND 0.50` 1,1,2-Trichloroethane ND 5.0 0.50 Isopropytbenzene ND 0.50 1,1-Dichloroethane _ ND 0.50 Methylene chloride ND 5.0: 0.50' 1,17Dlchloroethene ND 7.0 0.5o Methyl=tert-butyl ether ND 0.50 1,1-Dichloropropene ND 0.50 Naphthalene ND 0:50 1,2 3-Trichlorobenzene ND 0.0 n-Butylbenzene; ND 0.50 1,2,3-Trichloropropane ND 030 n-Propylbenzene ND; 0.50 1,2,4-Trichlorobenzene ND 70 0.50 p-Isopropyttoluene NU 0.50 1,2,4-Trimethylbenzene ND 0.50 sec-Butylbenzene ND` 0.50 1,2-Dibromo-3-chloropropane _ ND 0.50 Styrene ND 100 0.50 1,2-Dibromoethane(EDB) ' ND 0.50 tert-Butylbenzene ND 0.50` 1,2-Dlchlorobenzene ND 600 0:50 Tetrachloroethene ND 5 0` 0.50 1,2-Dichloroethane ND 5.0 0.50 Toluene ND 1000' 0.50 1,2-Dichloropropane ND 0.50 Totalxytenes ND 10000 0.50 1,3,5-Trimethytbenzene ND om trans4,2-Dichloroethene ND: 100 0.50 1,3-Dichlorobenzene ND 0.50' trans-1,3-Dichl6ropropene ND 0.50 1,3-Dichloropropane ND 0.50 Trichloroethene ND 5.0' 0.50 1,4-Dichlorobenzene ND 5.0 0.50 Trichlorofluoromethane ND 0.50 2,2-Dichloropropane ND 0.50 0 0 Surrogates /o Recovered' QC Limits(/o) 2-Chlorotoluene ND 0.50 4 Chlorotoluene ND oso p-Bromofluorobenzene 97% 70 130 - 1,2-Dichlorobenzene-d4 94% 70 1 130 Benzene' NO 50 0.50` Bromobenzene ! ND_ 0.50 Bromochioromethane ND 0.50 Bromodichloromethane ND 0.50' Bromoform ND 0.50. Carbon tetrachloride ND 5.0 0.5.6 Chlorobenzene ND 100 0.50 _ND Chtoroethane ND Attached please find the laboratory certified parameter list. Approved' By: (Lab Director) JMCLMamu Io�ntain an(L elND:=NonelDetected 2L = Reporting Limit 2C) Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph:508-376-6605 Page 1 of 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Angela Way Property Address Rodliff Owner Owner's Name information is West Barnstable required for MA 02668 October 18, 2011 every page. Cltyrrown 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: ti A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name rQ 189 Cammett Road Company Address Marstons Mills MA 02648 Citylrown State Zip Code 508-428-1779 S1 12855 Telephone Number License Number B. Certification LU ca I certifythat I have personally inspected the sewage disposal system at this address and that the 3 information reported below is true, accurate and complete as of the time of the inspection. The inspection L: was performed based on my training and experience in the proper function and maintenance of on site ez sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of -- Title 5;01.0 CMR 15.000). The system: ¢ ` U.- ® !0.asses ❑ Conditionally Passes ❑ Fails CJ f; ~ `''j O'Weeds Further aluation by the Local Approving Authority V October 18, 2011 Job# 11-185 114pector's Sigi 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-1 MO Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 V f Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Angela Way Property Address Rodliff Owner Owner's Name information is required for West Barnstable MA 02668 October 18, 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Tank was not in need of pumping at time of inspection. Leaching system was functioning properly. 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•11/10 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 57 Angela Way Property Address Rodliff Owner Owner's Name information is required for West Barnstable MA 02668 October 18, 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Angela Way Property Address Rodliff Owner Owner's Name information is required for West Barnstable MA 02668 October 18, 2011 every 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—.day flow t5ins•11110 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 57 Angela Way Property Address Rodliff Owner Owner's Name information is. required for West Barnstable MA 02668 October 18, 2011 every 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 57 Angela Way Property Address Rodliff Owner Owner's Name information is required for West Barnstable MA 02668 October 18, 2011 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 15ins-11/10 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 57 Angela Way Property Address Rodliff Owner Owner's Name information is required for West Barnstable MA 02668 October 18, 2011 every page. Cltyrrown 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?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d N/A Well Water 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 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 ' 57 Angela Way Property Address Rodliff Owner Owner's Name information is West Barnstable required for MA 02668 October 18, 2011 every page. CitylTown 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: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons IHow 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 ❑ Ti ht tank. Attach a co of the DEP approval. I g PY PP ❑ Other(describe): t5ins•11/10 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 57 Angela Way Property Address Rodliff Owner Owner's Name information is West Barnstable required for MA 02668 October 18, 2011 every page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1990+/- Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1' Depth below grade: 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: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 2" l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 57 Angela Way Property Address Rodliff Owner Owner's Name information is required for West Barnstable MA 02668 October 18, 2011 every 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 30" Scum thickness 2 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 12" 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.): Liquid level was found at outlet invert and tees were intact. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Angela Way Property Address Rodliff Owner Owner's Name information is required for West Barnstable MA 02668 October 18, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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.): i Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 57 Angela Way Property Address Rodliff Owner Owner's Name information is West Barnstable required for MA 02668 October 18, 2011 every page. Cltyfrown 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.): No solids or high stains. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Angela Way Pn�perty Address Rodliff Owner Owner's Name information is required for West Barnstable MA 02668 October 18, 2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two 6x6 pits. ❑ leaching chambers number: ❑ leaching galleries number.- El 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 pit#2 had one foot of standing water and a high stain line at 50% capacity. Pit#1 was not excavated. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Angela Way Property Address Rodliff Owner Owner's Name information is required for West Barnstable MA 02668 October 18, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments fi.. 57 Angela Way - ---------------- - - Property Address Rodliff Owner Owner's Name information is required for West Barnstable MA 02668 October 18, 2011 every 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 Front \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ 8 2 19 12 50 52 Commonwealth of Massachusetts • _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Angela Way Property Address Rodliff Owner Owner's Name information is required for West Barnstable MA 02668 October 18, 2011 every 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: 12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Low area at rear of property with no surface water is lower in elevation than SAS. (Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Angela Way Property Address Rodliff Owner Owner's Name required for is West Barnstable required for MA 02668 October 18, 2011 every page. CitylTown 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 l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION,,�.Jrr— 23 1Ay6-1ELA i vi4 y SEWAGE # 7�71? VILLAGE L ,, RAO-k ) ASSESSOR'S MAP & LOT/3,3 INSTALLER'S NAME & PHONE SEPTIC TANK CAPACITY /--Zc0 Cam-I LEACHING FACILITY:(type) QI 1 (size)/(SVOO✓4 NO. OF BEDROOMS-PRIVATE WELL OR PUBLIC WATERS BUILDER OR OWNER C'Pc f S L. r DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: ^1 _ VARIANCE GRANTED: Yes No ' 1 y. 3� �n� r p 7- Fps... -.��....:.�.... THE COMMONWEALTH OF MASSACHUSETTS BOA R® Off` HEALTH - .... J ...............OF_........ , pphrFatiou for M-4pog al Works Totti3trur#inn rautit Application is hereby made for a Permit to Construct (\,\Q or Repair ( ) an Individual Sewage Disposal System at: # tt�� ,, n T n 1�lecQe,?4 -� 7Z34 V4.. t�JA.4--------- - .... �_ Location-Address or ` o. ......-- IN1...... ...�L�r.. .U ........ wsa i#l.Slv.............. � ._.�.i3 J�� i -`�`11C�c?�� r.M ......... Owner Address a ...................... a. � — Installer Address PQ Type of Building ( ) Size Lot....__6 gr9OO.Sq. f� U Dwellin No. of Bedrooms...........................................Expansion Attic Garbage Grinder ( Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures __________________________________ W Design Flow...............11D-.....................gallons per person per day. Total daily flow............. `EQ...................__gallons. 1:4 Septic Tank—Liquid capacit .Vs O..gallons Length..._lD�.4. Width__s`S'�.._ Diameter---N/i-r---- Depth_.' '.6!__- Disposal Trench—No. __-_`t A..... Width.................... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No-------�Z)------ Diameter-------- Depth below inlet......(._......... Total leaching area_ZU'1_,k:..sq. ft. Z Other Distribution box ( vl� Dosing tank ( ) '-' Percolation Test Results Performed by.... ........... Test Pit No. 1....E_7._minutes per inch Depth of Test Pit..... ........ Depth to ground waterL\49G...E.ucnu*ri, Test Pit No. 2.L."Z-_..minutes per inch Depth of Test Pit......t..-V........ Depth to ground water.�Iam..EmwutLl O Description of SoilC_I�. L © --� . dQ l.�..r a,�`•1 �� 1~lL�h f ............................ Mom!?..S U ' - N< ........................... -- w `�' r--3 ............................ - Z?9M�_�.,"(a--�t49-- U Jaure of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------------------------------------------•--------.....-------•---------.._...•---•-•------•-•---•-----•--••••----•-•---•-----••••---•••-•---•--•-•••-•-•---•------•-••-----------••-- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of L_11 = 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued issued by the board of health. g dam- ... { 11).. c Date Application Approved By......... ---.1.). --- ..................................... ....... Date Application Disapproved for the following reasons-----------------------••-------------------------------•------------------------------------------.........----- ......................................................--•--•----------------------•-------•----..._......-•----------•-•--•-•--•••---------•-----•---•••--•--•-•-••-••-••-•-••------•-----••----.------ Date PermitNo.......0_2=-----7-i-v-------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS • —+� BOARD OF HEALTH Appliratiun for Disposal Works Tunstrartiun rumit Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal System at ------- Location-Addressoi.Lot .No...--•-•- !_,.--••._•- .......... �--� t��:l=............... Owner Address a .....................i..-.�'•LatlS L4.act..---' .,p.,_t ti- --------•------•--------- -•----------------------------•-•-------------------•--------------------•-----•--------••---••--- Installer Address Type of Building Size Lot------ --_3-/.AEE-.Sq. feet ., Dwelling—No. of Bedrooms_--..._.....4.............................Expansion Attic ( ) Garbage Grinder (✓r Other—Type of Building ............................ No. of persons..........--.........------. Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------- -•--•-----•••-• . W Design Flow..............LLD......................gallons per person per day. Total daily flow...........ff�`�:u_ ....gallons. WSeptic Tank—Liquid capacityls�L...gallons Length..-1+ __ Width......`_.. Diameter...:!z":?..... Depth__5._'.f_`.'.. Disposal sposal Trench—No. _-A/A..._.. Width.................... Total Length_-_.........._._.... Total leaching area--------------------sq. ft. Seepage Pit No......�Z)------- Diameter...... .--.---. Depth below inlet..... Total leaching area-3 9__A._..sq. ft. Z Other Distribution box (t/S Dosing tank ( ) 1 ....Percolation Test Results Performed by.... '--G4 u:.....�-�r.<<�-,��,ti: �,�,__•t:.____-__-•.- a Test Pit No. 1...._._-.�___minutes per inch Depth of Test Pit.....a........... Depth to ground watek\�l_�--=_---j=7%"L sue;,,, (T, Test Pit No. 2. :--._minutes per inch Depth of Test Pit.... 2.......... Depth to ground O Description of So• _/q.... •--• --�'�--3 = `'`'`= y' c�" —fr q G!a—. _1--- ---•------ G ! IH �. f a t -y.-( . Z T `—I ^L `icy`-Gz i -S t% t ��X-r`�1._-_l_l9..t`�ta-- 4). -. It=-V _r 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 iT"1•_.i: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. /2 l ' = •-----. 1 ��.... Date Application Approved By.:-..---:`' ..�.�. . �.-t::: -----r� R J Date Application Disapproved for the following reasons:......................................-......................................................................... ...................................................... ----------•---•-•--•••-•--------..............•••---------------•----•-------•-•------•-•--------------------------•------------...........------ Date PermitNo.-----�.......:.....7-f e--------•-------..... Issued..........................-............................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......�?( sa:I................OF........ `.................................... �rrtif irate of ( omplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( } .�r�9 ..'t1. ....... _..Z_eYYticr::v by (:�1...........ti q f / 'Installer �1/e ,2 g at............ �` '� L 1.1�11.:E,�_ >;a._.lt1l-t 4!? '- ---------•-�`/.�,�. ! ?��:.y_r_ �_9,Y_ro== ----------------- has been installed in accordance with the provisions of I1 t� 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------. _~'_-_7z..ip'...... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................I-..-...1.-.=.tr...-----••-----....... Inspector...................... .. .......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' fr h fl. :x<.:Z..............,OF......-.""--.'�`"_r .. ! _.� NO.. ,� F .. FEE(3,7 .......... Disposal Works &-instrnrtiun Vprrmit Permission is hereby granted---------1' ' n '.c;�....._..�i'1. ..__y.4-0::: ,. to Construct (,V) or Repair ( ) an Individual Sewage Disposal System at No------------------•.L....7..... �-r� r�...', �------Z_`== --- shown qy as shown on the application for Disposal Works Construction Per No. �`___ ated__..f .. .l.,._ � ............. !, - ` - �y C. r - / }(" .......... Board of Health DATE 1- Q.I/i.UU FORM 1255 HOBBS & WARREN, INC., PUBLISHERS FROM :down cape engineering inc FAX NO. :15083629880 Oct. 22 2014 11:37AM P1 E Thomas F. +re'ilex,Director M nARNSTAIPEs, n Nmm. Public Health Division Eb aha��' Thomas 1V1 cKean,I(Diirertua tom Msiu Street,Hymids,MA.07.60:9. Office: S09-362-4644 1'Rx: 503-740-6304 Inutallerc IDesiper(>r iSt>hem6yn,Farm Date: / Sew2gc PeE it# A APX stake:: 3�E Cagy✓u was ill":•�aed a perraU -to 7.TIYWL a uLlLV1 (ZLtJt�. er� ,�tir,system at C, / w _ . --.___hued ou a desip n.drawn by (address) Pd>Lted es�. er above wf�g instilled ,,tihtiialiL�i�ll-y acorn thug to - I Cf;rflfy tut dio, septic sysie.-in iefurf;ur.cd. the des�ieA wbich Wy include minuz approved. rha:uges such us, lateral reloo,9ti.on of'tlLc &.1atnb'utif,rst box aadlor sc'Pfir,Milk.. I erLtify that the septic systcuL rc&je>lced Shove wars iusta.11ed vviili mi& r*bauges geatcr than 1.0' latf181,relocation.a'the 511E ox gay vertical.rk-docati-on,of tiny companeut of.the sopt.ir, syste—m)but m accordance with State 4. Local Regolatio:ns. Man ro.visim or certi c.i.-,m 4juilt by f.os'ipper to fnllow. DANIELA OJALA - ( nstall.er':i Sign-'I.tIlre CNIL C" x No.46502 S T E� sS�oroAL / St (��1tix Dnsi Pt•,r'' Stamp aerP. -- (z?e�g1�nC1'';;�Lgi1L1.t1}rE� fi ;ti'TJTbl�31�,•, fitJFtP1 TO BA�G'i'1C� IDIVISI6^DPl. i ERTJ�!�CAfF OF !L'l�NK1r"I,i:APTC' WtI�L.,f�(Cb 1' `CIS, FORM AND A -AU f`.I'. P4" tLIiIF: i yEP 1�if'1' AMPd5�.AGE i&91&;9d:T]CE!AL:t'>Fi Y9iT�N., 'Il'S [d �;1l., f n-Va n7A IOn. ;.Rla ri r 1P.�rnTl'lfi(rff hA N flrT 1-26-114.dw; 3 COMMONWEALTH OF MASSACHUSETTS / EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ✓✓✓ DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVED CERTIFICATION Property Address: 57Anzela Way JUN 14 2001 West Barnstable, MA 02668 Owner's Name: Jay Cruise TOWN OF BARNSTABLE Owner's.Address: Same HEALTH DEPT. Date of Inspection: June 7, 2001 Map: 133 Parcel. 72 Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Boz 49 Osterville,MA 02655-0049 Telephone Number: (S08) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Nwds,Further Evaluation by the Local Approving Authority F its g Inspector's Signature: Date: June 8, 2001 The system inspector shall sub it 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. Notes and Comments ****This report only describes conditions.at.the_time.of inspection and under the conditions of use at that time. This inspection does not address.how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of i l i OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 Angela Way West Barnstable. MAJ . Owner: Jay Cruise - Date of Inspection: June 7, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: � r► _ - -- -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: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will ass inspection if_with a royal of the Board of Health p P ( . - .PP_ broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 AnQela Way - - -'- West Barnstable, MA Owner: Jay Cruise , Date of Inspection: June 7, 2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board ofHealth(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 *.*-,his system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 Angela Way West Barnstable, AM Owner: Jay Cruise Date of Inspection: June 7, 2001 D. System Failure Criteria applicable to all systems: You must indicate either`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 'h 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 l of a'public well: v _ ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B -CHECKLIST Property Address: 57 Angela Way ' West Barnstable. MA '! Owner: Jay Cruise Date of Inspection: June 7, 2001 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 foraigns,of sewage backup. . ✓' 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: Yes No ✓ 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(3)(b)]. 4 5 4 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION Property Address: 57 Anvela Way West Barnstable, MA Owner: Jay Cruise Date of Inspection: June 7, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 3 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes cr no):_Nn [if yes separate..inspection requiredl Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Private well Sump Pump(yes or no): No Last date of occupancy: Currently occupied COIVEUERCIALANDUSTRIAL Type of establishment: Design flow(based on 310-CMR 15.203): . gpd_. .. ...- Basis of design flow(sears/persons/sgft,etc.). 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Never pumped-per owner Was system pumped as part of the inspection(yes or no): 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) ,Tight Tank Attach a copy,of the DEP approval Other'(describe): r: , 'Approximate age of all components,date installed(if known)and source of information: March 2 1988-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 r Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C S-STEM INFORMATION (continued) Property Address: 57 Angela Way <: a West Barnstable, MA Owner: Jay Cruise Date of Inspection: June 7, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): ✓ locate on site plan) SEPTIC TANK: ( p ) Depth below grade: 24" Material of construction: ✓ concrete metal _fiberglass _polyethylene _other(explain) g g ._.. .YCertificated_ .... _ . .- p . . (y � ._ .. �, p If tank is metal list age:—Is-age confirmed b a Com liance es or-no): ... attach a co y of certificate) _ Dimensions: 1500 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 12"+ Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 5" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tees were present The lictuid level was even with the outlet invert There were no signs ofleakage. Recommend pumping and installing risers to bring covers with 6"ofgrade GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of Comments pumping: pumpingrecommendations,inlet and outlet tee or baffle condition, uid structural integrity,liq ;l as related to outlet invert,evidence'of leakage,etc.): " w '' 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �F SYSTEM INFORMATION (continued) Property Address: 57 Angela Way West Barnstable, MA Owner: Jay Cruise Date of Inspection: June 7, 2001 TIGHT or HOLDING TANK: None (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: izallons Design Flow: allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION+BOX:. �(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level and there were no signs of leakage or solids The D-box was approximately 3'6"below grade. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 I Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'SYSTEM_-INFORMATION (continued) Property Address: 57 Angela Way West Barnstable. MA Owner: Jay Cruise Date of Inspection: June 7, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'with]'stone(per design plans) 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.): One pit(44)had 3'6"ofwater on fhe botiom The scum line was'4=up from the"bottom. There werenosigns of failure. The cover was 2'below grade The bottom to grade was approximately 8'6" The other pit(#5)was located but not dug up. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: ' Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Angela Way ; •. West Barnstable, MA Owner: Jay Cruise Date of Inspection: June 7, 2001 Map: 133 Parcel: 72 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchma rks. Locate all wells within 100 feet. Locate where public water supply enters the building. E Poo Al— Ia,lo 19 i3a - 13 . 3 c3- a°►.� a 1 c noA< + bS- 33. V — _ - �s— y� y 10 Page l l of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - `-SYSTEM INFORMATION (continued) Property Address: 57 Angela Way r. West Barnstable, MA._ Owner: Jay Cruise Date of Inspection: June 7, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: information on file Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: . • S You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 8'6" Using information on file at the Board of Health, the water elevation in the well was at 32'. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 � � e n� C- --=P, pZ r�i CERTIFICATE OF ANALYSIS Page: 1 of 1 J �M;1 Barnstable .County Health Laboratory (M-MA009) rar1-7�st Report Prepared For: Report Dated: 6/14/2012 Jason Adams Order No.: G1268028 P O Box 1203 Barnstable, MA 02630 Laboratory ID#: 1268028-01 Description: Water-Drinking Water , Sample#: Sample Location: 57 Angela Way West Barnstable, MA Collected: 06/06/2012 Collected by: J.Adams Received: 06/06/2012 Test Parameters I ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Total Coliform Present /100mL 0 0 SM9223 RG 6/6/2012 Recommended maximum contamination level exceeded due to Coliform Bacteria. Tested negative for E.coli. Approved Attached please find the laboratory certified parameter list.- A PP By: ------- -- --- -..-.----.-------------------�- (Lab Director) r Q f / ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 i Health Master Detail Page 1 of-1 = Ee�xJf�!� - �- Logged In As: TOWN\miorandd Health Master Detail Wednesday,June 20 2012 Application Center Parcel Lookup Selection Items Parcel Septic Perc Well Fuel Tank Parcel: 133-072 Location: 57 ANGELA WAY, WEST BARNSTABLE Owner: ADAMS,JASON M &JENNIFER R Business name: Business phone: I Rental property: rj Deed restricted: r Number of bedrooms T-0 Contaminant released: r Fuel storage tank permit: r Save Parcel Changes ! Return to Lookup Parcel Info Parcel ID: 133-072 _ Developer lot:LOT 23 Location:57 ANGELA WAY Primary frontage: Secondary road: Secondary frontage: Village:WEST BARNSTABLE Fire district:W BARNSTABLE Town sewer exists at this address: No Road index: 1933 133072_1 Asbullt Septic Scan: Interactive map 133072_2 Town zone of contribution:AP (Aquifer Protection Overlay District) State zone of contribution:OUT Owner Info Owner: ADAMS, JASON M &JENNIFER R Co-Owner:%CHARLIP, STEVEN L TR Streets:C/O STEVEN L CHARLIP LLC Street2:83 RIDGEWAY ROAD City:WESTON State:MA zip: 02493 Country: Deed date: 12/13/2011 Deed reference:25915/278 Land Info Acres: 1.46 Use: Single Fam MDL-01 Zoning:RF Neighborhood: 0108 Topography:Above Street Road:Paved Utilities:Septic,Well,Gas Location: Construction Info Building No ear Buil Gross Area Living Area Bedrooms Bathrooms 1 1988 8890 441 Bedroom 2 Full + 1H Buildings value:tt445,000.00 Extra features: o77,100.00 Land value: A246,700.00 --http:/%issgl2/intranet/healthMaster/-HealthMasterDetaii.aspx?iD=13s072 6/20/2012 - 06/07/2012 THU 13: 59 FAX 5083627103 Barnstable CTY HealthLab --- Barnstable Health 2001/001 I cyoF.a,�s CERTIFICATE Page: 1 of 1 a g� OF ANALYSIS g Barnstable County Health Laboratory (M-MA009) �> c' C b Z- Report Prepared For: Report Dated: 6/712012 L' e Jason Adams Order No.: G1267946 .�� P O Box 1203 Barnstable, MA 02630 I Laboratory lD#: 1267946-01 Description: Water-Drinking Water Sample#: Sample Location: 57 Angela Way West Barnslable,MA Collected: 06/04/2012 Collected by: J.Adams Received: 06/04/2012 Routine ITEM RESULT UNITS RL MCL METHOD# TESTED Nitrate as Nitrogen 1.9 mg/L 0.10 10 EPA300.0 6/5/2012 Copper ND mg/L 0.10 1.3 SM 3111E 6/6/2012 Iron ND mg/L 0.10 0.3 SM3111B 6/60112 pH 7.4 PH AT 25C NA 6.5-6.5 SM 4500-H-13 6/5/2012 Sodium 14 mg/L 1.0 20 SM3111B 6/6/2012 Total Coliform Present PIA 0 0 SM9223 6.!4/2012 Conductance 240 umohs/cm 2.0 EPA 120.1 6/5/2012 I Recommendedamaximum cocomination level exceeded due to Coliform 8_ ac: t steel negative for E.coli.Retesting is . reeomme den d. i Attached please find the laboratory certified parameter Hsi. 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I I I . � I . .� I I - I I , I I I I . 11 - I I I I i � � � I I I - I I I , � I I � I I __ - I � �I�- I I I . ­1 � � _ � _11;_ . ­ � � I � LEGEND SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES MARKED WITH MAGNETIC TAPE OR COMPARABLE MEANS FOR FUTURE EXISTING CONTOUR LOCATION. ASSUMED ore 99 -- (NOT TO SCALE) 1. DATUM IS ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2. MUNICIPAL WATER IS NOT AVAILABLE 69 oao� X 99.1 EXIST. SPOT ELEV. \ PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL (3RADE e 99 PROPOSED CONTOUR SYSTEM DESIGN. MINIMUM .75' OF COVER t, 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. qn e7p !y S ER OVER PRECAST 2% SLOPE REQUIRE OVER SYSTEM 49.0 -50.0 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS [98.41 PROPOSED SPOT EL. PRECAST H-10 TO BE AASHO H-ZQ GARBAGE DISPOSER IS NOT ALLOWED RISERS (TYP.) NOTE: MIN, WALL THICKNESS 2" cows TH 1 2'0 1.6' 4"�SCH40 PVC � o PIPES LEVEL 1ST 2' /- 2" PEASTONE OR GEOTEXTILE 5. PIPE JOINTS TO BE MADE WATERTIGHT. TEST HOLE DESIGN FLOW: 4 BEDROOMS © 110 GPD = 440 GPD �l FILTER FABRIC EVER STONE EXISTING 47.0' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH eeQ 2 SLOPE OF GROUND USE A 440 GPD DESIGN FLOW 10" 1500 GAL H-10 14" EXIST* TEE SEPTIC TANK** TEE 310 CMR 15.000 (TITLE 5.) 50.2f' Oo0o0o000606060006060000000600 0 o0o0000000000000 6000600000000 ill (� ° o 0 6" MIN. SUMP 0000000000000000000000000°0000 0 00°000°000000000 00000000000000 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO �° Ond UTILITY POLE SEPTIC TANK: 440 GPD (2) = 880 ADD GAS BAFFLE ::. ° O''° ° 00 ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° 00 °,o°o'o°0°000 12" MIN. INT. DIM. 46.5 °o°o°o°o°o°o°o°o°o°o°o°o°o°o°o 0 0°0°0°0°0°0°0°0° °o°o°o°o°o°o°o r W o�r,�o 0 0_ 00000o000o0o0o0o0o0o0000000000 0 000000000000000 00°0°0°0°0°0°0° 44..29 BE USED FOR LOT LINE STAKING OR ANY OTHER Wi I I FIRE HYDRANT RE-USE EXISTING 1500 GAL. SEPTIC TANK ** 46.71' 46.54' 4" PVC SET AT .005'/' SLOPE ,/ PURPOSE. le Stfeet Sttee NOTE: NOT ALL sYMeoLs MAY APPEAR IN DRAwINc ::.,_, "' •' ON 2' DOUBLE WASHED 3/4" - 1 1/2" STONE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. M°P LEACHING: _ SIDES: 2[2 (43 + 3) 2 (.74)] = 272 GPD i6'79� 9.WITHOUT COMPONENTS B� BOARD BE OFHEALLLED TH AND CONCEALED 6" CRUSHED STONE OR ME('iHANICAL PERMISSION OBTAINED FROM BOARD OF HEALTH. *THE INSTALLER SHALL VERIFY THE BOTTOM 2[43 x 3 (.74)] = 191 GPD COMPACTION. (15.221 [2]) LOCATIONS OF ALL UTILITIES AND ALL TOTAL: 626 S.F. 463 GPD 2 % SLOPE 1 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING ( ) ( % SLOPE) DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCUS MAP BUILDING SEWER OUTLETS AND MIN. BOTTOM TH 1 ELEV. 37.5' LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES ELEVATIONS PRIOR TO INSTALLING ANY USE (2) 43' LONG x 3' WIDE x 2' DEEP EXIST. D° BOX 6' LEACHING PRIOR TO COMMENCEMENT OF WORK. NOT TO SCALE FOUNDATION- SEPTIC TANK 85 PORTION OF SEPTIC SYSTEM LEACH TRENCHES OF PERF. SCH. 40 PVC PIPE AND STONE FACILITY 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED ASSESSORS MAP 133 PARCEL 72 **INSTALLER SHALL CONFIRM MINIMUM SEPTIC LEACHING FACILITY AND REPLACED WITH CLEAN MED. TANK SIZE AT 1500 GALLONS AND ITS SAND, TO MEET SPECIFICATIONS OF 310 CMR 15.255(3). SUITABILITY FOR RE-USE. REPLACE WITH 1500 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND GALLON SEPTIC TANK APPROPRIATE TO SITE REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. CONDITIONS IF NOT SUITABLE �O 13. INSPECTIONS REQUIRED BY OWNERS ENGINEER, 24 q HOUR NOTICE REQUIRED FOR ALL INSPECTIONS. MAP 133 PARCEL 72 7.42 AC.+ MAP 733 PARCEL 70 TEST HOLE LOGS 0 ENGINEER: DANIEL E. GONSALVES, SE #13587 MAP 133 DONNA MIORANDI PARCEL 73 5:3.89 WITNESS. RS w r" . 10/6/14 DATE. Qp s PERC. RATE _ < 2 MIN/INCH ua-I � I 1\ 0 4509 CLASS SOILS P# ELEV. ELEV. 53.58 54.57 / 53.63 I i % p" 49.0' p" 48.5' o / ' / ' A ' LS �. /�LS BENCHMARK: ,� / A5 / / UNSUITABLE / /� UNSUITABLE /1OYR 3/2 / /10YR 3/2 i PATIO - 49.6 CORNER CONCt,ETE / v - WELL /j X TING r p' OFF E IS 57 - \ � I i • � - 'B / / B 5 I_�I NG � / /12 I X AWE FN�' X 51.7� o TQP X X BLS UNSUITABLE /10YR jLs�; UNSUITABLE %5�. 6 I 10YR 4/6� 4/6/ s3.79 X 53.58 / X 48.05 �� ��� 28" �/ 46.7' 30" / 46.0' / 2.7 / MAP 133 � C% OFF WELL / �' / PARCEL 39 1 �- 1 5 / / UNSUITABLE / LS LS � / UNSUITABLE -- 51.1-1- i - �. / 4�.� / rr /10YR 5/6/ 44.0' /10YR 5/6 j / 43.5 49 5� /r -9 60 / 60 / / ;' / / / 9.68 s / SIEVE 50i 49.8:2 e% j i x Nc• �/ � � � / � / � � 44.1� 4_ -� M CS M CS CO 49.87 49.56 \ // I' / NOTE: SIEVE / / 2r X n �� / j 42._0 ANALYSIS 35 % 2.5Y 7 4 2.5Y 7 4 9.52 / COMPLETED ON / / 9.76 49.87 i OL 10/15/14 gg PO q9,2! i 9.t 0.79 49.83 X 46.98 49\62 � X 48.56 % � � / / 42.00 132" 38.0' 132" 37.5' / 41.94 NO GROUNDWATER ENCOUNTERED 83 ON / ( X 41.30 C. E�. APR /� ",��. X 4d.0.-5 � % � 41.73 N CE /�� i / � x 4 .42 9.81 E / W% BOULDER 41.41 49�/ / 8.� 41.0�- PLAN ka X / x,4�06 % 40.81 40 TITLE 5 SITE X 7.76 :i. �� % 0.88 / 40 70 �� x 39.64 OF X _i i 40,45� X 3 / x40�' 57 NGELA WAY A6/ 40/9 R 45.29I I I 40,33/3 ti WEST S T A V L 5 REMOVAL OF UNSUITABLE SOIL REQUIRED 40.74 EXIWELL �T. PREPARED FOR AROUND PERIMETER OF LEACHING FACILITY, ,' 44 98I G 4 19 DOWN TO SUITABLE SOIL LAYER. REPLACE ��f�� �� 4/ WITH CLEAN MED. SAND, TO MEET �� 43.95 MAP 732 �33.�� SPECIFICATIONS OF 310 CMR 15.255(3) % o J� XQ14a tj B E"'N" 'C A VAT 10 N E GEE R PARCEL 41 DATE: OCTOBER 6, 2014 REV: OCTOBER 16, 2014 (NOTES) X 41.56 Scale: 1"= 20' Cj. 0 10 20 30 40 50 FEET off 508-362-4541 = H OF hfq ssgc AI fax 508-362-9880 SRN OF yG c C:..'3 DANIEL N I downcape.com O 1 ©ANIELA. A. down Cope en. neerbi //1C. � '�' OJALA a OJALA CIVIL o No,40980„ / No.46502 °Pess\o�'� civil eng%neerS land surveyors �Oc, 'tot E¢�o� qNO s URN Ey0 sr �Ncn, 939 Main Street ( Rte 6A) DATE DAB A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 DICE ## >4-255 - _ i I I