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Home My WebLink About0023 APOLLO DRIVE - Health =23 .Apolloive i a �� TOWN OF BARNSTABLE LOCATION Z:F4941ZZO %94ef SEWAGE # VILLAGE kilefJ � fs � 'ESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. I SEPTIC TANK CAPACITY LEACHING FACILITY:(type) /'0 le-l�l (size) T�iy NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BAR OR OWNER 1-10/1 !.S" 6-' 6-row svla��c/'li DATE RE - RD: DATE COMPLIANCE ISSUED: . VARIANCE GRANTED: Yes No Telephone(508)432-0530 INVOICE ROBERT B. OUR CO., INC. INVOICE NO. 27385 CESSPOOL BUILDING a CLEANING ALL TYPES OF MACHINE DIGGING INVOICE DATE FILL O HARDENING O LOAM 12-21-93 GREAT WESTERN ROAD•P.O.BOX-982•NO.HARWICH,MASS.02645 JOB LOCATION: #26451 23 Appollo Road F West Barnstable, MA Lewis Gordon SOLD 1100 Route 134 TO South Dennis, MA 02660 Y? R ORDER NO. SALESMAN TERMS SHIPPED VIA NET/1 OTH PROXr r DESCRIPTION* PRICE AMOUNT - Septic Inspection on 12-18-93: $100.00 Septic system consists of: C - One 1000 gallon septic tank, pipe down 3' , found empty on 12-18-93• D - One 61x6I precast pit with stone, found dry on 12-18-93, has been full at one time, pipe down 3' Septic system appears to be in working order on 12-18-93• This septic inspection reflects the present condition of the septic system and is not a guarantee as to the life or future condition of said system. rr 1 A � o O CAPE BUSINESS FORMS-SO.YARMOUTH.MA.-TEL I-SOG892-0872 189817-BH ORIGINAL INVOICE No. �\b--- -�1-� Fee---`-1 ------ BOARD OF HEALTH TOWN OF BARNSTABLE Zippiication forlVell Con0ruction jermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )a individual Well at: Zd Af Location — Address Assessors Maf and Parcel ZI -------__..------------- Owner Address Installer.— Driller Address Type of Building Dwelling Other - ,Type of B __Building-=--__—__—__--- No. of Persons--- __ Bu Type of Well-- - Capacity--------------—---- ---- Purpose of Well-��-- --- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate.of Compliance has been issued by the Board of Health. Signe date Application Approved By -- date Application Disapproved for the following reasons: date Permit No. I.L_� — Issued— -� .�od-. —_____—__ te BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed Altered ( ), or Repaired ( ) by __-- � Installer at-_ � / has been installe in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ----------------Dated-------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. A DATE _ _ Inspector No. -------------- Fee-------------------- BOARD OF HEALTH .� . TOWN OF BARNSTABLE 2pplication,jorVell Con9truction3permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repai3`�'j )a individual Well at: -,--Address — ---- ysess `VMa' nd/9Parcel� _ Owner Address �— Installer.— Driller Address Type of Building Dwelling-- ,—_ _— --------- Other - Type of Building- -_—__--__-_ No. of Persons--- Type of Well ___.___ Capacity--____—_____—_.—___--__—__—_ Purpose of Well- _-__— --__ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate.of Compliance has been issued by the Board of Health. Signed-- ---------- _—�1�date —__— �Yn� 2� - Application Approved By date Application Disapproved for the following reasons: date 61 Permit No. Issued---— 1y --------------------------------- ---------- -- ----- --_ ----- te--- ----------- — BOARD OF HEALTH TOWN OF BARNSTABLE C ertif hate (Of-Compliance THIS IS TO CERTIFY, That a Individual Well Constructed (� ), Altered ( ); or Repaired ( ) by�� _------=- .� Installer --- -------�--- , athas been installe in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. --_—___________Dated------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE —_ - -_ Inspector-- -----`- ------ ---- --------------------------------------------------------------------------------------------------- - BOARD OF HEALTH TOWN OF BARNSTABLE Well cootructionpermit No. V y----19_�' Fee-� Permission is hereby granted ! __?/ � ✓"� - -—______-- -- — — to Construct ((,)!Alter ( ), or Repair ( ) an Individual Well at: No. Street ---------- --------- - - as shown on the application for a Well Construction Permit ll No.- _- Dated- ._------------------- -------------- ----- Board of Health DATE l Page: 1 M: CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory Report Dated: 12/3/2004 Report Prepared For: Order No.: G0428730 Tara Marini 154 Clearwater Drive East Harwich, MA 02645 Laboratory ID#: 0428730-01 Description: Water-Drinking Water Sample#: 28730 Sampling Location 23 Apollo Drive West Barnstable MA) Collected: 11/29/2004 Collected by: T-Marini Plan Book 233 Pg 19 Lot 14 Received: 11/30/2004 Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen 0.39 mg/L 0.1 10 EPA 300.0 11/30/2004 LAB: Metals Copper BRL mg/L 0.1 1.3 SM 3111B 12/2/2004 Iron BRL mg/L 0.1 0.3 SM 3111B 12/2/2004 Sodium 20 mg/L 1.0 20 SM 311IB 12/2/2004 LAB: Microbiology Total Coliform Absent P/A 0 Absent 307 11/30/2004 LAB: Physical Chemistry Conductance 220 umohs/cm 1 EPA 120.1 11/30/2004 pH C.9 pH-units 0 EPA 150.1 11/30/2004 Sample has higher than average levels of Sodium.Those on a low Sodium diet may want to consult a physician. Approved By: ` (LaV Director) Q)DUPUCATE RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED . 00T 0 12003 TOWN OF BARNSTABLE TITLE C HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: MAP a---�- PARM Owner's Name: LOTOwner's Address• Date of Inspection: F,.nl- ZS 2a73 Name of Inspector: ( lease print) ra- Company Name: � :� ��a, A Mailing Address: o c � Telephone Number: CERTIFICATION STATEMENT 1 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: C ` �' P g Date: t � � �C 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. Notes and Comments ' ""Tt ;'report only describes conditions at the time of inspection and under the conditions of use at that time.T 'i inspection does not address how the system will perform in the future under the same or different conditi i of use. Title 5; )ection'Form 6/15/2000 page 1 I r Page 2•of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) , Property Address: r Owner: IV, IV, Y Date of Inspection: , Inspection Summary: Check A,B,C,D or E/ LWAYS complete all of Section D A. Sys Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more s tem components as described in the"Conditional s"section need to be replaced or repaired.The p system,u c ys p completion of the replacement or repair,as roved b the Boar PP Y d of Health,will pass. Answer yes,no or not determine (Y,N,ND)in the for the ollowing statements.If"not determined"please explain. The septic tank is metal and over 0 years old*o e septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or xfiltratio or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying - as approved by the Board of Health. •A metal septic tank will pass inspection if it is cturally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years is a ilable. ND explain: Observation of sewage bac p or break out or high s is water level in the distribution box due to broken or obstructed pipe(s)or due to a br en,settled or uneven distribu 'on 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 pass inspection If(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed . ND .Main: . 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSME :CS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART A CERTIFICATION(continued) Property Address: /' Owner: U j Date of Inspection: S .x �' Sl 7_- rz C. Further Evalu n is Required by the Board of Health: T_ Conditions exist which ire further evaluation b e Board of Health in order to determine if the system is failing to protect public health,sa or the enviro nt. 1. System will pass unless Board of determines In accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a nner w.hi will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface r Cesspool or privy is within 50 feet of a bordering ve ted wetland or a salt marsh 2. Syst will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is fu ioning in a manner that protects the public health,safety and environment: _ The syste as a septic tank and soil absorption system(SAS)and th AS is within 100 feet of a surface water sup p or tributary to a surface water supply. — The system has a sep ' tank and SAS and the SAS is within one 1 of a public water supply. The system has a septic d SAS and the SAS is in 50 feet of a private water supply well. _ The system has a septic tank and S and the S is less than 100 feet but 50 feet or more from a private water supply well".Method use dete me distance "This system passes if the well water analy ' ,p formed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds ' icates th the well is free from pollution from that facility and the presence of ammonia nitrogen and ate nitrogen is ual to or less than 5 ppm,provided that no other failure criteria are triggered.A copy the analysis must be ched to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) nn �` Property Address: r . Owner. 0$-„ r� • Datiof Inspection: - D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool -r Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year 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 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.] —&DYes/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 Systems\� To be considered alar' a system the system must serve a facility with a ign flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes'or"no"to each of the followin (The following criteria apply to ' e systems in addition a criteria above) yes no _ the system is within 400 feet of face drinking water supply the system is within 20 eet of a tribu .to a surface drinking water supply the system is 1 ted in a nitrogen sensitive a(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of public water supply well If you have- swered"yes"to any question in Section E the syst 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 I 1 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSM. TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR) PART B CHECKLIST Property Address: 1)- AziA-)AIV �. Owner: Date of Inspecti n: 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 — X 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: 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)] 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: n- , Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 C 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): t�b Is laundry on a separate sewage system(yes or no):1�b[if yes separate inspection required] Laundry system inspected( es or no): WA Seasonal use:(yes or no): 1 4 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): ,{Q Last date of occupancy: .t COMMZCIAL/INDUSTRIAL Type of es lishment: Design flow ed on 310 CMR 15.20 t;pd Basis of design fl (seats/persons ,etc.): Grease trap present or no _ Industrial waste holding present(yes or no):_ Non-sanitary waste di arg to the Title 5 system(yes or no):— Water meter read' s,if avails Last date of o pancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):�.� If yes,volume pumped:_gallons--Now 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): Approximate age o all components,date installed(if known)and source of information: � ✓�k�.ln;r.0 Were sewage odors detected when arriving at the site(yes or no): b 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: F 161 . Owner: Date of Inspectiod : ,_ OOL BUILDING SEWER(locate on site plan) Depth below grade:—12 0 1/ Materials of construction:_cast iron _40 PVC_other a lain): 5t. �1�0 .T Vc Distance from private water supply well or suction line: _ Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: >C (locate on site plan) Depth below grade: 0 Material of construction:&concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: Sludge depth: S" Distance from top of slyd4e to bottom of outlet tee or baffle: Cko) 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: _ How were dimensions determined: ;} Comments(on pumping recommendations,inlet anb outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): [ YW1 e "" ;Y GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction: concrete_meta _fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top outle a or baffle: Distance from bottom of scu o bottom of o et tee or baffle: Date of last pumping: Comments(on pumpin ecommendations,inlet an utlet tee or baffle condition,structural integrity,liquid levels as related to outlet in rt,evidence of leakage,etc.): 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSA'fENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -1 !'I � Owner: j KIN Date of Inspection:. r , TIGHT or HOLDI TANK: (tank must be pumped at time-of inspection)(locate on site plan) Depth below grade: Material of construction: co rete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gall s/day Alarm present(yes or no): Alarm level: Alarm in orking order(yes or Date of last pumping: Comments(condition of rm and float switches,etc.): DISTRIBUTION BOX: !�t (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: / Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage ' to or ut of b x,etc.): J -• PUMP CHA BER: (locate on si tan) Pumps in working or a no): Alarms in working or r no): Comments(note dition of p chamber,condition of pumps and appurtenances,etc.): g I Page 9 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 , -4-- 4, Owner: 1) Date of Inspection. .. SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:� �j;�•�(�,;�(�, leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: sspool must be pumped art of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet inv Depth of solids layer: Depth of scum layer: Dimensions of cesspoo Materials of constru on: Indication of gro dwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (loca on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note Condit' of soil,st s of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ -�.1 I Owner: Date of Irspecti n: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. C B .G IZ C, 65i)1: �1 a +OE5 'fay je�PvrJ ,�y�s 3-0, 13aw I0 Wage 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a �- Owner: Date of Inspection. L SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet JNlo 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 ISO 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: - fY 11 . Aa ll1 j 4ddI ( 70fo JAN 13 AN 8:� 53 DIVISION i r, I � O - iron JfJ .s a C.�J-fC L. 3.3-D -3 i • k a � Ito . I0