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Home My WebLink About0501 CEDAR STREET - Health s; 00 5®1 Cedar Street tl� West Barnstable A = 109 - 061 a pF F q r I�nky� CERTIFICATE OF 'ANALYSIS �. x 0 E� Barnstable County Health Laboratory (KMA009) Recipient: Shaun F.Harrington Order No:• G18105088.. All Cape Well Drilling Report Dated: 03/16/2018 P 0 Box 126 Submitter: Well Driller Brewster, MA 02631 Description: Lab Analysis Laboratory ID# 18105088-01 Matrix: Water-Drinking Water Sample#: Sampled: 03/15/2018 8:00 By: MH Collection Address: 501 Cedar St.W:Barnstable;MA Received: 03/15/2018 10:20, By: Ellie Sample Location: Turn Around. Standard Routine M ITEM RESULT UNITS RL MCL METHOD# NA ALYST TESTED. TIME Nitrate as Nitrogen 0.29 mg/L 0.10 10 EPA 300.0 LAP 03/15/2018 15:20 Iron 0.15 mg/L 0:10 0.3 SM M 11 B LAP 03/16/2018 15:20 Manganese 0.080 mg/L 0.025 0.050 SM 3111B LAP 03/16/2018 15:20 pH 6.8 PH AT 25C NA 6.5-8.5 SM 4500-H-B : DCB 03/15/2018 15:07 Sodium 31 mg/L 2.5 20 SM 3111B LAP 03/16/2018 15:20 , Total Colifofm Absent P/A 0 0 SM 9223. RG 03/15/2018 . 16:13 Conductance 140 umohs/cm 2.0 SM 2510E DCB 03/15/2018 15:06 Sodium/eve/is above the maxium contaminant level. Those.on a low sodium diet may wish to'consult a physician. Attached please.find the laboratory certified parameter list.- Approved By: —' (Lab Manager) C4 n ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, Po. Box 427, Barnstable, MA 02630 Ph: 608-376-6605 Page: 1 of 1 i CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory (M-MA009) Recipient: Shaun F.Harrington. Order No.: G18105088 All Cape Well Drilling Report bated: 03/19/2018 P 0 Box 126 Submitter: Well Driller Brewster,. MA 02631.. Description: Lab.Analysis Laboratory ID#: 18105088-01 Matrix: Water-Drinking Water, Sample.#: Sampled: -03/15/2018 8:00:. By: MH Collection Addr: 501 Cedar St.W.Barnstable;MA Received: 63/15/2018 10:20 By:. Ellie Sample Location: Turn Around: Standard Analyst: yn Method: EPA 524.2 Dilution 1 Date Analyzed: 03/15/2018 @ 1001 EPA 524.2- Volatile Organics by 6C/M5 Result MCL Q L. Result MCL MDL. Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L. Dichlorodifluoromethane ND 0.50- . Chloroethane ND o.5o Chloromethane ND 0:50 Chloroform ND 80 0.50 Vinyl chloride ND 2 0 0.50 cis-1,2-Dichloroethene ND 70 0.50 Bromomethane ND 0.50 cis-1;3=Dichloropropene ND 0.50 1,1,1,2-Tetrachioroethane ND 0.50 Dibromochloromethane ND 0.50 1,1,1-Trichloroethane ND 200 0.50 Dibromomethane ND 0.50 1,1,2,2-Tetrachioroethane ND 0.50 Ethylbenzene ND 700 0.50 1,1,2-Trichloroethane ND 5.0 0.50, Hexachlorobutadiene ND 0.50 1,1-Dichloroethane ND 0.50 Isopropylbenzene ND 0.50 1,1-Dichlor6ethene ND 7.0. 0.50 Methylene chloride ND 5.0 0.50 1,1-Dichloropropene ND .0.50 Methyl-tent-butyl ether ND. 0.50 1,2,3-Trichlorobenzene ND 0.50 Naphthalene ND 0.50 1,2,3-Trichloropropane ND' 0.50 n-Butylbenzene ND 0.50 1,2,4-Trichlorobenzene ND 70 0.50- n-Propylbenzene NU 0.50 . 1,2,4-Trimethylbenzene ND 0.50 p-Isopropyitoluene ND 0.50 1,27Dibromo-3-chloropropane ND 0.50 sec-Butylbenzene ND 0150 1,2-Dibromoethane(EDB) ND 0.50 Styrene ND 100 0..50 1,2-Dichlorobenzene ND 600 0.50 tert-Butyl benzene ND 0.50 ` 1,2-Dichloroethane ND 5.0 0.50 Tetrachloroethene ND 5•0 0.50 1,2-Dichloropropane ND 0.50 Toluene ND .1000 0.50 1;3,5-Trimethylbenzene ND 0.50 Total xylenes ND; 10000 0.50 1,3-Dichlorobenzene ND 0.50 trans-1,2-Dichloroethene ND 160 0.59,, 1,3-Dichloropropane ND 0.50 trans 1,3-01chloropropene ND 0.50 1,4-Dichlorobenzene ND 5.0 0150, Trichloroethene ND 5.0- 0.50 2,2-Dichloropropane ND 0150 Trichlorofluoromethane ND 0.50 2-Chiorotoluene ND 0.50 Compound I %Recovered QC Limits(%) 4 Chlorotoluene ND 0.50 1,2-Dichlorobenzene-d4 100% 70 1 130 Benzene ND 5.0 0.50 p-Bromofluorobenzene 81% 70 130 Bromobenzene ND 0.50 Bromochloromethane ND 0.50 Bromodichloromethane ND 0.50 Bromoform ND• 0.50 Carbon tetrachloride ND, 5;0 0:50 Chlorobenzene ND 1 50. 0.50 Attached please find the laboratory certified parameter list. Approved By: ,, - _ .. -. (Lab Director) 3 / 7/2-�/�' ND=None Detected' RL = Reporting Limit. MCL.=Maximum Contaminant Level 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508=375-6605 Page:1`of 1 f Ma r, 20. 2018 2; 35PM No. 0209 P. 1 CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory (M-MA009) Recipient: Shaun F.Harrington Order No.: G18105088 All Cape Well Drilling Report Dated: 03M6/2016 P O Box 126 Submitter: Well Driller Brewster, MA 02631 Description: Lab Analysis Laboratory IN: 181'05088-01 Matrix: Water-Drinking Water Sample#: Sampled: 03/15/2013 8.00 By: MH Collection Address: 501 Cedar St.W.Barnstable,MA Received: 03115/2018 10:20 By; Ellie Sample Location: Turn Around: Standard Roudne_M ITEM RESULT UNITS RL MCL METHOD# ANALYS2'TESTED TIME Nitrate as Nitrogen 0.29 mg/L 0.10 10 EPA 300.0 LAP 03A612018 15:20 Iron 0.15 mg/L 0.10 0.3 SM 311.18 LAP 03116/2018 15:20 Manganese 0.080 mg/L 0.026 0.050 SM 3111E LAP 03/16/2018 16:20 pH 6.8 PH AT 25C NA 6.5-8.5 SM 4500-H-13 . DCB 03/16/2018 15:07 Sodium 31 MA 2.6 20 SM 31118 LAP 03/16/2018 15:20 Total Coliform Absent PIA 0 0 SM 9223 RG 03/15/2018 , 16:13 Conductance 140 umohsJcm 2.0 SM 2510B DCB 03/16/2018 16:06 Sodlum level is above the maxium contaminant lave/. Those on a low sodium diet may wish to consult a phyalc/an. Attached please find the laboratory certified parameter list Approved .By: (Lab Manager) o/ ND=None Detected RL - Reporting Llmlt MCL^Maximum Contaminant Level 3195 Main Street, PO.Box 427, Bamstable, MA 02630 Ph: 50.8-375-6605 Page:. 1 of 1 Mar. 20. 2018 2: 35PM No, 0209 P. 2 CERTIFICATE OF ANALYSIS r ` Barnstable County Health Laboratory (M-MA009) err Recipient- Shaun r.Harrington Order No.: G18105088 All Cape Well Drilling Report Dated: 03/19/2018 P 0 Box 126 Submllter: Well Driller Brewster, MA 02631 Description: Lab Analysis. habaratnry IDftz 18105088-01 Matrix: Water-Drinlang Water Sample#!: Sampled: 03/15/2018 8:00 By: MH Collection Addr: 501 Cedar St.W.Bamstable,MA Received: 03/15/2018 10.20 By: Ellie Sample Location: Turn Around: •Standard Analyst: yn Method: EPA 524.2 Dilution: i Date Analyzed: 03/15/2016 @ 10:01 EPA 524.2- Vo/affle Organics by GC/MS Result MCL MOL •Result MCL W1 Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L Didilorodifluoromethane ND 0.50 . Chloroethane ND ISO Chlommethane ND 0.50 Chloroform ND 80 0.50 Vinyl chloride ND 2.0 0.50 c18-1,2-DIchioroethene ND 70 0.50 Bromomethane ND 0.50 ds-1,3-Dlchloropropene. ND 0.50 1,1,1,2-Tetrachloroethane ND 0.50 DlbromacNoromethane ND 0.50 1,1,1 Tdchlomethane ND 200 0.50 Dlbromomethane ND 0.50 1,1,2,2-Tetmchloroethane ND. 0.50• Ethylbenzene ND 700 0.50 1,1,2-Tridhloroethane ND 5.0 •0.50 Hexachlorobutadlene ND 0.50 1,I-Dlchloroethave ND 0.50 Isopropylbenzene ND 0.50 1,1-Dlc hloroethene ND 7.0 0.50 Methylene chloride ND 5.0 0.50 1,1-Dlchloropropene ND 0.50 Methyl-tent-butyl ether ND 0.50 1,2J.Trichlorobenzene ND 0.50 Naphthalene ND 0.50 1,2,3-Michloropropane ND 0.50 n-Butylbenzene ND 0.50 1,2,4-Tdchlorobenzene ND 20 a.50 n-Propylbenzene ND 0.50 . 1,2,4Trimethylbenzene ND 0.50 p-Isopropylboluene ND 0.so 1,2-Dlbromo-3-chloropropane ND 0.50 seCButylbenzene ND 0•So 1,2-01bromoethane(EDB) ND 0.50 Styrene ND 100 0.50 1,2-Dlchlorobenzene ND 600 0.50 tert-BuMbenzene ND 0.50 1,2-Dldhloroethane ND 5.0 0.50 Tetrachloroethene ND 5.0 0.50 1,2-Dichloropropane ND 0.50 Toluene ND 1000 0.50 1,3,5-Trimethylbenzene ND 0.50 Total xylenes ND 10000 0.50 1,3-Dichlorobenzene ND 0.50 trans-1,2-DIcNoroethene ND 100 0.50 1,3-Dichloropropane ND 0.50 trans-1,3-Dichloropropene ND 030 1,4-Dlchlorobenzene ND 5.0 0.50 Tdchloroethene ND 5.0 0.50 2,2-Dichloroprbpane ND 0.50 Trlchlorolluoromethane ND 0.50 2-Chlorotoluene ND 0.50 Compound 9!°Recovered n70 ts(%) 4-C?�IOroLoluene ND 0.50 1,2 DlthlOrObenzene-d4 100% 130 Benzene ND 5.0 0.50p-Bromofluorobenzene 81% 130 Bromobenzene ND 0.50 Bromochloromethane ND 0.50 Bromodlchlommethane ND. 0.50 Bromofbrm ND 0.50 Carbon tetrachlorlde ND 5.0 0.50 Chlorobenzene ND 100 0.50 Attached please find the laboratory certified parameter list. Approved By: (Lab Director) ND-None Detected RL = Reporting Limit MCL=Maximum Contaminant Level v 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page I-of 1 d . " CERTIFICATE OF ANALYSIS h, Barnstable County Health Laboratory. (M-MA009) 4syf�:E�t`,ahC' Recipient: Shaun F. Harrington Order No.: G18105088 AII;Cape Well.Drilling Report Dated: 03/.1.612018 P 0 Box 126 Submitter Well Driller Brewster, MA 02631 Description: Lab Analysis LaboratorV•111D71' 1111031z: Matrix: Water-Qrinking>WaterSample#: \ Sampled: 03/15/2018 8.00 By: MH Collection Addr Barnstable;MA 1 Received.: 03/15/2018 10:20 By: Effie ' Sample Locati n: Turn Around: Standard Routine M ITEM RESULT UNITS RL MCL. METH D# ANALYST TESTED TIME Nitrate as Nitrogen p,2g mg/L 0.10 16 EPA 30U LAP 03/15/2018 1.5:20 Iron 0.15 mg/L 0,101 U. SM 31118 LAP 03i16/2018 15:20 Manganese 0.080 mg/L 0.025 0.050 SM 3111 B LAP 03/16/2018 15.20" pH 6;$ PH AT 25C NA &545 SM 4500-H-B DCB 03/15/2018 15:07 Sodium 31 mg/L 2.5 20 SM 311.1B LAP 03/1612018 15:20 TotaPColitorm Absent P/A. 0: 0 SM 9223 RG; 03/15/201.8 16:13 Conductance 140 umohs/cm 2.0 SM 2510E DCB 03/15/2618 15:06 Sodium level is above the maxrum contaminant teveL Those on a low sodium diet may wish to consult a physician Attached please find-the laboratory certified parameter list Approved BY: .......... (Lab Manager) �� I ' t _ a f _ F ND=None Detected RL Reporting Limit MCL=Maximum Contaminant,Level. 3195 MaImStreet, P.O..Box:427, Barnstable, MA 02630 Ph:508-375-6605 Page; 1 of 1 r ��pF HAND\ E CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory(M-MA009) .Recipient: Shaun F.Harrington Order No.: G18105088; All Gape Weil Drilling Report Dated 03/1912018 P 0"Box 126 Submitter Well Driller Brewster, MA.02631 Description Lab Analysis .....__ Laboratory 30#: 1810SO88-01 Matrix: `Water-Drinking Water i Sample#: Lib) Sampled:- . 03/15/2018 8:00 By MN Collection Addr: -,Tit Cedar St.W.Bamstable,MA Received: 03/15/2018 10:20 By:: Ellie Sample Location: Turn Around: Standard. j Analyst: yn Method: EPA 524.2 Dluhont a Date Analyzed: 03/15/2018 @ 10:01 .EPA 524.2 Volatile Organics bby GC/MS Result MCC ` L 5u !_ MQL Parameter us/L ug/L ug/L Parameter ug/L ug/L ug/L Dichlorodi8uoromethane ND AM Chloroethane: ND :0.50 Chlororrethane ND 0.50 Chloroform ND 80: 0:50 Vinyl chloride ND 2,0 0.50 cis 1;2=Dichioroethene ND 70 0450 Womorrethane ND 0.50 cis-1,3-Dichloropropene ND 0.50 1,1,1,2-Tetrachloroethane ND 0.50 Dibromochloromethane ND 0.50 1,1;1-Thchloroethane ND 200 0.50 Dibromomethane ND 0.50 1,1,2,24etrachloroethane ND 0.50 Ethylberizene ND 700 0.50 1 1,2-Tr chloroethane ND• -5.0 0.50 Hexachlorobutadiene ND 0.50 1,1-Dichloroethane: ND, 0.50 Isooropylbenzene ND 0.50 41-Dichloroethene ND 7.0 0.50 Methylene chloride- ND U 0.50 ' 1,1-01chloropropene ND 0.50 Methyl=tent-butyl ether ND 0.50 1,2,3:Tnchlorobenzene ND 0.50 Naphthalene ND 0.50 1,2,3-Trichlorapropane ND aso n eutylberizene ND osa 1,2,4 Trichlorobenzene ND 70 0.50 n-Propylbenzene ND 0.50 1,2,4-Trimethylbenzene ND 0:50 p-Isopropyltoluene ND o.so 1,2-Dibromo-3-chloro0ropam ND a 5o sec-Butyibenzene ND 0.50 1,2-Dibromoethane(EDS) ND 0.50 Styrene ND 100 0.50 12-DicNombenzene ND 600 0.50 tert-Butyibenzene ND 0.50 1 1,2-Dichloroethane ND` 5.0 0:50 Tetrachloroetheh6 ND 5;0 0.50 1,2-Dichloropropene ND 6.50 Toluene ND . 1000: 0.50 1,3,5-Trimethylbenzene ND 0:50 Total xylenes ND 10000 1 0.50 1,3-Dichiorobenzene NO. 0.50 trans-1,2-Dichloroethene ND 100 0.50 1,30chlbropropane ND a.50 trans-1,1Dichloropropene Nil. 0.50 1;4-Dlchlorobenzene ND 5.0 0.50 Trlchloroethene ND 5.0 0.50 2,2-Dichlor6propane ND' 0.50 Tnchlorofiuoraniethane ND 0.50. 2-Chlorotoluene ND 0.50 l Compound %Recovered QG Limits("/o) a 4 Chlorotoluene: ND 0'50 1,2-Dfchlorobenzene-d4, 100°/. .70 1 130 Benzene ND' 5.0 ozo p=Bromofluorobenzene 81;0/6 70 1 130 Bromobezene ND o.50 - Bromochlaromethane ND. 0.50 Bromodic iloromethane ND. 0.50 Bromoform ND Mo I Carbon tetrachloride ND' 5.0 0.50 Chtorobenzene ND< 100 0.50 Approved By: Attached please find the laboratory certified parameter list. (Lab;Director) ND-None Detected RL = Reporting Omit MCL=:Maximum Contaminant Level E 3195.Main Street, P0.Box 427, Barnstable, MA 02630 Ph:508-375-6605 Page 1 of 1 E Fee ! V BOARD OF HEALTH TOWN OF BARNSTABLE 01pp icattou _for 3Ve1Y �6ugtructiou der it Application is hereby made for a permit to Construct Alter( ), or Repair(/ an individual well at: &Q'A N (!sf- 1(0 7 1 C L X Z, Location-Address_ Assessors Map and Parcel L�i IV V B^ {'�' , iE � �O t L,V Owner I� Address Installer-Driller Address Type of Building / Dwelling Other-Type of Building No. of Persons Type of Well {�-G $- �c't r Capacity /C) 6-a Purpose of Well 1-4 '1 RVC�— Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private We 1 Prote/f 6 Regulation-The undersigned further agrees not to place the I,,- well in operation until a Certificate of ColnI31' n•e hasbeen issued by Board of Health. Signed Application Approved B Date Application Disapproved for the following reasons: Date Permit No. gcjl� Issued Date ------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed •(,Altered( ), or Repaired by A 11 (C?- ')R IA-1,-, I I r Installer at �� U N��.y �� has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well rotection Regulation as described in the application for Well Construction Permit No.Qs901t=-GOO Dated 3&//8� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector i No.��^'i Fee 6— BOARD OF HEALTH '! TOWN OF BARNSTABLE Yicatiou jf or Vell,$Dow5truction Verrn'it Application is hereby made for a permit to Construct Alter( ), or Repair( ) an individual well at: Location-Address Assessors Map and Parcel Lj ( Owner Address All /1 Installer-Drille'r r Address Type of Building F Dwelling Other-Type of Building No. of Persons Type of Well {�- c, }-��j`A" Y Capacity /C-) Purpose of Well 1--{4 Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private W�Protection bon Regulation-The undersigned further agrees not to place the well in operation until a Certificate�Compllance h Abe the-Board of Health. Signed Da e Application Approved By \\// ko h g Date Application Disapproved for the following reasons: i Date Permit No. Qd Issued [9 )/ Date ------------------------------------------------------------------------------------------------- -- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed(,,)! Altered( ), or Repaired(�)� ` by r� 1A 1 p I 1 Installer at ! has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private�W/ell Protection Regulation as described in the application for Well Construction Permit No.��/�=007 Dated �/% THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector .__-__- ,..�..,.-.-r_ ------------,a----------- - -------•- �-----�-_-----------------------.._ ....�. -.. BOARD OF HEALTH TOWN OF BARNSTABLE Velt Congtructton permit No.dal r 1`�1� "`�'"Yj Fee Permission is hereby granted o ` C',z20 Installer to ConstructV, Alter( ), or Repair( an individual well at: No. Street / as shown on the application for a Well Construction Permit No. !. ,--Dated Date By,,, (9 RECEIVE® ECOJECH SEP 2 9 2003 Environmental TOWN OF BARNSTASLE wweco-tech.us HEALTH w. DEPT. THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 501 Cedar Street MAP 1 tMMtaW Wq �21VS��S1 PARCEL. Owner's Name: Manuel&Olivia DaCosta p Owner's Address: 501 Cedar Street LC- \p2. West Barnstable,MA 02668 _- Date of Inspection: September 25,2003 Name of Inspector: (Please Print) David D. Coughanowr,R.S. Company Name: Eco-Tech Environmental Mailing Address: 43 Triangle Circle Sandwich,MA 02563 Telephone Number: (508)364-0894 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: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature Date: Se-0- 26, W03 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 Inspector's Note—> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ****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 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 501 Cedar Street Barnstable Owner: Manuel&Olivia DaCosta Date of Inspection: September 25,2003 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 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,or 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 breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The 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 four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain 2 Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 501 Cedar Street Barnstable Owner: Manuel&Olivia DaCosta Date of Inspection: September 25,2003 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 and 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 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 by 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 1 3 Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 501 Cedar Street Barnstable Owner: Manuel&Olivia DaCosta Date of Inspection: September 25,2003 D)System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed by 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 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 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 CUR 11,104.The system owner should contact the appropriate regional office of the Department. i 4 Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 501 Cedar Street Barnstable Owner: Manuel&Olivia DaCosta Date of Inspection: September 25,2003 Check if the following have been done:You must indicate either"Yes" or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks? Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? Y _ Were all system components,excluding the SAS located on site? Y _ Were the septic tank manholes uncovered, opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y _ Existing information.For example,Plan at the Board of Health. _ N 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)] I 5 Page 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 501 Cedar Street Barnstable Owner: Manuel&Olivia DaCosta Date of Inspection: September 25,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents 2 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required) Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings,if available(last two year's usage(gpd): n/a—well in use Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/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: System not pumped in recent past(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: X Septic tank,Viex, soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternate 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 of all components,date installed(if known)and source of information: Age: 23+years Disposal Works Permit issued 10/17/79(BOH permit#79-478) Were sewage odors detected when arriving at the site: (yes or no) no 6 Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 501 Cedar Street Barnstable Owner: Manuel&Olivia DaCosta Date of Inspection: September 25,2003 BUILDING SEWER_(Locate on site plan) Depth below grade: 2 ft Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints,venting, evidence of leakage,etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling SEPTIC TANK:Yes (locate on site plan) Depth below grade: 4 inches Material of construction: X concrete_metal_fiberglass_polyethylene other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle: 28 in Scum thickness: 2 in Distance from top of scum to top of outlet tee or baffle: 9 in Distance from bottom of scum to bottom of outlet tee or baffle: 13 in How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Pumping recommended within 1 year and maintenance pumping is recommended eve!y 2 years. Liquid level at outlet invert.Tank and tees appear structurally sound and functioning as intended.No evidence of leakage in or out 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 last pumping: Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 501 Cedar Street Barnstable Owner: Manuel&Olivia DaCosta Date of Inspection: September 25,2003 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: gallons Design flow:_gallonstday Alarm present(yes or no):_ Alarm level:_ Alarm in working order(yes or no):_ pumping:Date of last Comments:(condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: None (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 is equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.) None indicated on as built card. 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.): I 8 r Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION(continued) Property Address: 501 Cedar Street Barnstable Owner: Manuel&Olivia DaCosta Date of Inspection: September 25,2003 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located,explain why: Type: X leaching pits,number 1 _leaching chambers,number _leaching galleries,number _leaching trenches,number,length _leaching fields,number,dimensions _overflow cesspool,number —innovative/alternate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) Soils above leaching pit appeared unsaturated.No evidence of surface ponding breakout,lush vegetation or other evidence of hydraulic failure was observed.. CESSPOOLS: none (cesspool must be pumped at time 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: 501 Cedar Street Barnstable Owner: Manuel&Olivia DaCosta Date of Inspection: September 25,2003 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'(Locate where public water supply enters the building) LEPAICH LOCATIONS O A B 1 6.5 f t 21.5 f t 2 10.5 ft 20.5 ft 2 3 47 f t ± 36 f t ± SETAVC TANK o B A EXISTING DWELLING # 50 A WELL - 155 f t FROM SAS PER DESIGN PLAN CEDAR STREET NOT TO SCALE 10 . Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 501 Cedar Street Barnstable Owner: Manuel&Olivia DaCosta Date of Inspection: September 25,2003 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 50+ feet Please indicate(check)all methods used to determine high ground water elevation: X Obtained from system design plans on record-If checked. date of design plan reviewed 10/17/79 Observed Site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of health-explain: Checked local excavators,installers-attach documentation) X Accessed USGS database You must describe how you established the high ground water elevation. Approved design plan on file with Board of Health shows bottom of leach nit to be 4 feet above the bottom of a witnessed test pit in which no water was encountered USGS topography maps show lot is situated over 50 feet above nearest surface water. 11 LOCATION SEW E PERMIT NO. VILLAGE 110AL /e INSTA LLER'S NAME i ADDRESS BUILDER OR f/ OWNER �6 AszO/7 �cJP �J�� d� f�i •ems/Y /1 r //!/GC'O DATE PERMIT ISSUED _ / � � -7 -7 DATE COMPLIANCE ISSUED 1 � ��7 `72 S i ,. i No..... � � YmB.............................. • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (I OF......... ... .. . -.- Appliration for Uiipooal Works Tonotrnrtion 1hrmit Application is hereby made for a Permit to Construct �(>6 or Repair ( ) an Individual Sewage Disposal System at -- ......!WCLE•-•-•------ ----- ---- -------••-••---••................ Locatio Address or Lot No. // --- Qo .1.4.!�_ ............. // �Q / B. ( r... a �l C-//I/�-2 !S.'.../�l!'Ie STL .. .. 'd ••.._ Installer Address !/ d Type of Building �/ Size Lot.... Z7-- ....Sq. f t aDwelling—No. of Bedrooms___-1!_..0 l.ec.�....•...............Expansion Attic ( ) Garbage Grinder (No) p, Other—Type of Building _ln!_pod....__..... No. of persons......... Showers (� ) — Cafeteria ( ) PL4 Other fixtures ---- ...1 W- ---------------------------------------•---------------- W Design Flow..............Y ......................gallons per person per day. Total daily flow-------2 3D_......................gallons. WSeptic Tank—Liquid capacity- Mallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No. ......../.......... Width..........4_...... Total Length......... Z. Total leaching area....................sq. ft. Seepage Pit No.........I.......... Diameter........ Depth below inlet...... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing t ( ) ~' Percolation Test Results Performed b . _ .._._./42.. :................ Date.. ._._... ___. 1_4 Test Pit No. 1......�.�.._..minutes per inch Depth Test Pit................... Depth to ground w ter............_.._...____. 44 Test Pit No. 2------I........minutes per inch Depth of Test Pit.................... Depth to ground water........................ W ....._ . .. ................................ ..__.. _ .._.......... ODescription of Soil------•••--- ........C.C?r9-;''��s. ... .---_.............2`......�-- - ------------------------------------- x ��} -------- W ......i E'-- '—VVI r u- P''f -' �. U Nature of Repairs or Alterations—Answer when applicable________ .A, Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ed y th ;oaoof al _.S' ed. ... • ............ . ........................ D e Application Approved BY / L I�I_7............. ------------- Dac Application Disapproved for the following reasons:-----••---------------•-------------------------------------------------------------------------••••....---•--•- ...........-•--•....................••-••••--•-•......---•-.....----•----•----------------------•--------------•----•-••.....--••---•-•••••-•---•--•••-•-•••----•-•-••••••-•••-••---••••-•••-•-•-•-..._. Date / h Permit NO.... Issued._.I�. .._..!-7 7 r••••••••.......•••- Date No.._.......'y.. Fims.... Q............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......- oF...... ...,...... `4............................................... Applirtt#iou for Disposal Works Cnnaa�#rur#inn�Cermi# Application is hereby made for a Permit to Construct .06 or Repair ( ) an Individual Sewage Disposal System at: lar..... -'....... . .... ...- _ ~ Locatio Address f J� /, i Owner jy /� -(/ M Installer Address Type of Building / Size Lot....^_�____L- 3----Sq. f t U Dwelling No. of Bedrooms____! -liter�. Expansion Attic.•+ g— - ---- --------- p ( ) Garbage.Grinder ,� a Other—Type of Building W�_od__.. .... No of persons......... _____________ Showers (�') — Cafeteria ( ) Other fixtures ------...IfN!N-' -----•-•-•---- ----- W Design Flow..............RP..._........D�_..gallons per person per day. Total daily flow.......�,3.�_......................gallons. W Septic Tank—Liquid*capacity..:__;_.%allons Length................ Width---- ------ Diameter................ Depth................. x Disposal Trench—No. ........1_..........tWidth........._,,// Total Length..____.__}'�yZ Total leaching area....................sq. ft. Seepage Pit No........1.......... Diame'ter-------- ---------•Depth below inlet......!.± ________ Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing t ( ) Percolation Test Results l`t Performed by..__... .f................ Date_- _--- •:-l2`l_ 7 Test Pit No. I......1. -----minutes per inch Depth Test Pi -- Depth to roun � p P g d w er----------------------- Gt, Test Pit No. 2......I.........minutes per inch . Depth of Test Pit.................... Depth to groundwater........................ D ----- ----------- ----•---------•---. ............................ D1_es on of x ....... --- ------------------ .� U Nature of Repairs or Alterations—Answer when applicable.......__.._----- P -•------------------•-------.....--••-----------------------------••-----------------•--•--•-•-----•--.........---------------------•--•-----------.................................................... Agreement:, The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions_of TITIS 5 of the State Sanitary Code—. .The undersigned further agrees not to place the sys em in operation until a Certificate of Compliance has been ed y th oa 4olWS -ned .- •. •--- �9 D e Application Approved By....... r.. •--• .... -' ............•--.......... 7.....�'. . r .._.. Dat Application Disapproved for the following reasons--------------------------------•----•---------------•---------•------------------•---••••-•--•-•--........._.._ ........--•---•-----•-•-•-•--••-------------•--------••--•••••-•-•--••--•--f--•--•-••-........•-•---.._...•-••-•-•-•••-•-•------••-•----••----•••----•--•-------•----•---••----------•------•-......•--- 3. Date PermitNo......................................................... Issued_..................`....•-•--•......--...-------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF E'ALTH ............ �rr#ifirtt#r of f�u�t�li�a�arr TH< 1�J TO CFRTIFY That tie It}divic�u 1 Sewage Disposal System constructed ( 1 Repaired ( ) by.....:-... tL-k he.. F t. .i -C .. -••----- 1 ........ -- has been installed in accordance with the provisions of T 5 of The State Sanitary Code as described in the .. .........!application for Disposal Works Construction Permit No 17-f-............. dated-------�':�1��--`-.-�-�------------•. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............................................•--•-......_----•-......-•••-••---- Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH ..... .........OF......... . .... ! ........... D No....... Y...... FEE • ............... Disposa IV 4 Permission is hereby granted--._._ _.�_ j� ._ ..._.._ .i. _ � ...... ........................ to Construct ( ) Re air ( ) an In ividual ...,age' ,isposal S t" l at No..A.V 0)..44 ..'-. .a l 1 >Q � e -l�! �1_/ j � � ... Street as shown on the application for Disposal Works Construction Perpok No.._ :... ....jf Dated..... 1� l'1'�!!1_ .../t�/� , � Board or Health DATE --._--••--•--•--...-- ?.. '< FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS" y - f OJ Sp SAk- Y K r- 0 2 . Ra S �w1 �i}l M A. 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