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HomeMy WebLinkAbout0765 CEDAR STREET - Health 765 Cedar Street Barnstable P ' �= A . 109 095 0 o v o COMMONWEALTH OF MASSACHUSETTS z ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION f i a e TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ( Property Address: 7&< toe N Owner's Name I-' Owner's Address: C-e t IAJ�t At�& 39G .� f . Date of Inspection: �►f tS�06 Name of Inspector:1please print) ` k&,e ,& i Company Name: rd r(,. Mailing Address: at Qt tvev i; Telephone Number: 176 06 1 f CERTIFICATION STATEMENT ti I certify that I have personally inspected the sewage disposal system at this address and that the information reported c below is true,accurate and complete as of the time of the inspection. The inspection was performed bas�ld on myz= rt training and experience in the proper function and maintenance of on site sewage disposal s)stems. I atti 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 e Inspector's Signature: Date: 8 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 ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address tow the system will perform in the future under the same or different conditions of use. i Title 5 Inspection Form 6/15/2000 page I i Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IMSPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: -79� C Owner: Ckoo Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have-not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" ection need to be replaced or repaired. The system,upon completion of the replacement or repair,as ap ved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the llowing statements.If"not determined"please explain. The septic tank is metal and over 20 years old* the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltrati' or tank failure is imminent.System will pass'inspection if the existing tank is replaced with a complying septic 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 o is available. ND explain: Observation of sewage bac or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a bro ,settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)am replaced obstruction is.removed. distribution box is leveled or replaced ND explain: The system equired 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 f obstruction is removed I ND explain: F 1 2 Page 3`of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION(continued) Property Address: 76 Cer S� Owner: �lC�p r Date of Inspection: 2_+t5' 06 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 wetl or a salt marsh 2. Svstem will fail unless the Board of Health(and P lie Violater Supplier,if any determines that the system is functioning in a manner that protects the blic health,safety and environment: _ The system has a septic tank and soil abs tion system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surfac ater supply. _ The system has aseptic tank and S and the SAS is within a Zone I of a public water supply. The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply''well. _ The system has a septic t and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*" ethod used to determine distance *"This system passes i e well water analysis;performed at a DEP certified laboratory, for coliform bacter a and volatile panic compounds indicates that the well is free from pollution from that facility and the presence of am onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria ar triggered. A copy of the analysis must be attached to this form. 3. Other: 3 t Page 4 of 11 OFFICIAL INSPECTION FORM—NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DjSPOSAL-SYSTEM INSPECTION FORM PART.A, N continued CERTIEICATIO (continued) Property Address: $� C t� _ — Owner: S 6 o 't` Date of Inspection: t D 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'/z 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. q' 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. _ a( 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 colifr+rm bacteria and volatile organic,compow ds 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.) Xd—(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 facili a design now of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the f g: (The following criteria apply to large systems in.a9m tion to the criteria above) yes no _ the system is within 400 fe f a surface drinking water supply the system is within 0 feet.of a tributary to a surface drinking water supply the system is 1 ate in a nitrogen sensitive area(Interim Wellhead Protection Area -IWPA)or a mapped Zone II of ublic water supply well If you have answ ed"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Secti D above the large system has failed.The owner or operator of any large system considered a, significant eat under Section E or failed under Section D shall upgrade the system in accordancewith 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 ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 6S,Ce f '� ✓w Owner: :!5,�t cwd' Date of Inspection: 0r(0 6 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 p� 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 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) 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? I _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition 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 m mte_nance 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)] I 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 76 5 CeAt f Owner: S C'"o r Date of Inspection:—�+ti FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4rel" Number of bedrooms(actual): DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x# of bedrooms): Number of current residents. b Does residence have a garbage grinder(yes or no): Kle, Is laundry on a separate sewage system(yes or no):po [if yes separate inspection required] Laundry system inspected(yes or no): Alb Seasonal use: (yes or no): AJO Water meter readings, if available(Iast 2 years usage(gpd)): Sump pump(yes or no):,W Last date of occupancy: t_"A . COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203 gpd Basis of design flow(seats/persons/s ,etc.): Grease trap present(yes or no): Industrial waste holding tank esent(yes or no):— Non-sanitary waste disch Od to the Title 5 system(yes or no):— Water mete/ribe): ' available: Last date ose: OTHER(d GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): kjo 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): Approximate age of all componen s date installed(if own)and source of information: //o R AL/k Were sewage odors detected when arriving at the site(yes or no): 6 IPage7 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner:' �- Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: dye Materials of construction: cast iron e 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: 0 (locate on site plan) Depth below grade: Material of construction:geonerete metal fiberglass_polyethylene _other(explain) _ — If tank is metal list age:— Is age confirmed by a Certificate of Compliance certificate) / P (yes or no):—(attach a copy of Dimensions: �Upac Sludge depth._ 9r, Distance from top 1. sludge to Scum thickness: � bottom of outlet tee-or baffle: a 8 U Distance from top of scum to top of outlet tee or baffle: s� Distance from bottom of scum to bottom of outlet tee or aflle: 16 How were dimensions determined: lRew c/1'� Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related t outlet invert, evidence of leakage tom) `) C W ..&Z A (4 GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction: concrete m fiberglass_polyethylene other (explain): — — — _ Dimensions: Scum thickness: Distance frorn top of scum to to of outlet tee or baffle: Distance from bottom of scu to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumpin ecommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet in rt, 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: - e Owner:—5 6'v r" Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at . e of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: 7no): Design Flow: Alarm-present(yes oAlarm level: er(yes or no): Date of last pumpingComments(conditioches,etc.): DISTRIBUTION BOX: PC (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ,e , Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakagem o or out of box,etc.): A � �, ,` r GDz tgL.S tea m �t u,(�( 'ft�' . au 6` 14 /rti tLGP2. PUMP CHAMBER: (locate on site pl Pumps in working order(yes or no - Alarms in working order(yes o): Comments(note conditio pump chamber,condition of pumps and appurtenances,etc.): 8 i Pace 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS :SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 J- oc&r Owner: J (tip6`f Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): A' (locate on site plan,excavation not required) If SAS not located explain why: Type _jc leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number,dimensions: overflew cesspool,number: innova=ive/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): 7 .fs .S a lAvo re � '�' s�rroJJ a % / n e 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 groundw r inflow(yes or no): Comments(Mote con tion 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 con lion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page l0 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S 'f Owner:�� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply ehters the building. �b �b ?o q3 Pwge i I of 11. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 765 6&& Owner: Date of Inspection: R L tt oo SITE EXAM Slope e e.5 Surface water PO Check cellar ✓Pis Shallow wells IIJd Estimated depth to ground water c70 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 ISO feet of SAS) Checker with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) VG Accessed USGS database-explain: You must describe how you established the high ground water elevation: vs Qrs is 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE l 'IVE OFFICE OF ENVIRONMENTAL AFrA].IIS DEPARTMENT OF ENVIRONMENTAL PROTEC'I-1ON Z F ^ REf d ti W MARTOWN TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSI:>SMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A v CERTIFICATION Propel ty Address: 765 CEDAR ST W. BARNSTABLE 02668 M109 P095 L59 Owner's Name: LOIS ANN DEMKO Owner's Address: 765 CEDAR ST W. BARNSTABLE 02668 Date of Inspection: 2/25/03 Name of Inspector: (please print) JOHN GRACI, INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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 >ny training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEI' �pproved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditional Passes _ Needs Fu er Evaluation by the Local Approving Authority Fails Inspector's Signature: t Date: 2/25/03 The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe ion. 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. 'File original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. SYSTEM SHOWS NO SIGNS OF FAILURE. ****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 differclit conditions of use. _ - �000 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 765 CEDAR ST W.BARNSTABLE 02668 M109 P095 L59 Owner: LOIS ANN DEMKO Date of Inspection: 2/25/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. SYSTEM SHOWS NO SIGNS OF FAILURE. 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. n/a 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: n/a n/a 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: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 765 CEDAR ST W.BARNSTABLE 02668 M109 P095 L59 Owner: LOIS ANN DEMKO Date of Inspection: 2/25/03 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 of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "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. 3. Other: n/a I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 765 CEDAR ST W.BARNSTABLE 02668 M109 P095 L59 Owner: LOIS ANN DEMKO Date of Inspection: 2/25/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: 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 'h 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 2 YRS AGO INFO BY OWNER. _ X Any portion of the SAS,cesspool or privy is below high ground water 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 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.] _ �(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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well 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. d r -Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 765 CEDAR ST W.BARNSTABLE 02668 M109 P095 L59 Owner: LOIS ANN DEMKO Date of Inspection: 2/25/03 Check if he following have been done. You must indicate"yes"or"no" as to each of the following: Yes No X _ 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 X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up X _ Was the site inspected for signs of break out? X _ Were all system components, excluding the SAS, located on site? X _ 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? X _ 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 X _ Existing information.For example,a plan at the Board of Health. X _ 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)] S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 765 CEDAR ST W. BARNSTABLE 02668 M109 P095 L59 Owner: LOIS ANN DEMKO Date of Inspection: 2/25/03 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 Number of current residents: 3 Does 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): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: 2 YRS AGO INFO BY OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _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): n/a Approximate age of all components,date installed(if known)and source of information: 1995 FROM ASBUILT 95-1018 Were sewage odors detected when arriving at the site(yes or no): NO F -Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 765 CEDAR ST W.BARNSTABLE 02668 M109 P095 L59 Owner: LOIS ANN DEMKO Date of Inspection: 2/25/03 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): 160 FEET TO WELL SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" 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 bafflA Z.� 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.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 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: 765 CEDAR ST W.BARNSTABLE 02668 M109 P095 L59 Owner: LOIS ANN DEMKO Date of Inspection: 2/25/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND AND SYSTEM SHOWS NO SIGNS OF FAILURE. PUMP CHAMBER: -(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): n/a R f Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 765 CEDAR ST W.BARNSTABLE 02668 M109 P095 L59 Owner: LOIS ANN DEMKO Date of Inspection: 2/25/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): THE LEACH PIT PIT WAS NOT EXPOSED DUE TO FROZEN GROUND. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—:top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a I e i f • Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 765 CEDAR ST W. BARNSTABLE.02668 M 109 P095 L59 Owner: LOIS ANN DEMKO Date of Inspection: 2/25/03 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. ® weli 1&ry 11 D 4013 —7° w I in Page 1 I of OFFICIAL INSPECTION FORM -NOT.F.OR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addressc'765 CEDAR ST W. BARNSTABLE 02668 M109 P095 L59 Owner: LOIS ANN-DEMKO Date of Inspection: 2/25/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED BY VISUAL AND USGS MAPS AND CHARTS- 12+ FT AND KNOWLEDGE.-OF-AREA FROM PREVIOUS INSPECTIONS. e � � (°SWN OF BARNSTABLE LOCATION LvT- Cl� SEWAGE VILLAGEA��� s�,r/4 G`{� ASSESSOR'S MAP & LOT g 2 INSTALLER'S NAME & PHONE NO. 6 c,U` ��:;t, SEPTIC TANK CAPACITY t LEACHING FACILITY:(type) /" Z,6 (size) NO. OF BEDROOMS �� PRIVAT W OR PUBLIC WATER BUILDER OR OWNER ,Le 64 DATE PERMIT ISSUED: / DATE COMPLIANCE ISSUED: !7' VARIANCE GRANTED: Yes No ��'� r �� ���� � � �� ��` � � � �� �--- � o �3�, � � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH RECE��EO TOWN OF BARNSTABLE sft oul MAR 2 3 1995 Appliration for Diti-Vw3al Works Towitrn t=ion *AMOK co Application is here��de for a Permit to Construct ( or Repair dividual Sewage is •sal System at: 74� AW �o l --"------ ---- .............--------- .................... Locatim• \d ,ss or Lot No. y�. " ............1.!-FI Address....................... . .r�q�n .........._......_...__--.........._._.._ ......................._._............._ .._................................_...._.. r Address Type of Building Size Lot.' ..r ,z�Sq. feet Dwelling—No. of Bedrooms....... .... -__•-___--.....Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------ Design Flow................. ..r......_._...._..--gallons per person per day. Total dail flow-------------- WSeptic Tank—Liquid capacity__A?gallons Length-- - �..��".. Width_V 9.`.._ Diameter---------------- Depth... !A6... x Disposal Trench—No. .................... Width... _.-_ Total Length.....__......•.... Total leaching area.................---sq. ft. Seepage Pit No------- ------------- Diameter. .. -Depth below inlet........ Total leaching area._'++.;.*1.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) k '~ Percolation Test Results Performed by.... wawa..-.�'o(' ....0`1-��._.._....._. Date..............���........... Test Pit No. L..�-�'__-minutes per inch Depth of Test Pit-------... .... Depth to ground water...... _1 ._... fz, Test Pit No. 2..../—f....minutes per inch Depth of Test Pit---------1!___.... Depth to ground water........ '------------------------------------------•--••••-----•---•---------••-•"'----•---------------••--.....................:..------.............••........... kzz- 0 Description of Soil-�-----P `�-.-•--�'-t-S--• � _ . _.. ,. ----- ............... `�. !l' c.� 44C ' � ---------------L01 - -c..--•-c�,o,�Ls£,.....`�. •!V� "'' ST -�.�w.................................................. 0 Nature of Repairs or Alterations—Answer when applicable............................._...........__..__._.__._..._...__....____.__...................__. ..•-----------••...........................•--------•-•-._...--•-•-•--------------------------__.....-------'-----•-.................................................... .............................. Agreement: VEMMNQ The undersigned agrees to install the aforedescribed Individual the provisions of TITLE 5 of the State Environmental Code—The TNEef t n t� h system in operation until a Cer ' ' ate of Co nce has been ' sued l� r ne e Application Approved By ------ ------- - �--- o ------ -----...-- —— - — ---— - -- �... .. ... ......----'— -------.....- — .....- '------.. Dace Application Disapproved for the following reason - --- ---------------------`................................................... ....... .... ......1..... ......... .. ............................................ .. .....-------------------------------- - ..- ........................... -- ------- Permit No. ---------.. Issued --------------- --- - --- ---Da-------- ace No.- -•---•----_..�[/ � � Fps.... ��?.ff.�..�F r' r:THE COMMONWEALTH OF MASSACHUSETTS F � 3� ' BOARD OF HEALTH \ TOWN OF BARNSTABLE Appliration for Biopoottl Wortai Tonotrnrtion rrmitr Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: Igo i SG C'el ��`' IN c r c � - -•--------------------- ,..__..._.. ....... .. Location- Address or Lot No. -----••--t� l i ,- W a 2e .- ------------------ --� •..a% ��!�.!.u_- .�..........---.......-•------- nO vn�r Address I I -Instller Addressy Q Type of Building Size Lot_:!tZ2 ..�3 Sq. feet aDwelling—No. of Bedrooms---...__ t ..............---------------Expansion Attic ( ) Garbage Grinder ( ) p, - Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) LL' Other fixtures ------------------------------------------------------------------ W Design Flow................42._ram_______-____..__--__--gallons per person per day. Total daily flow........... ..................gallons. WSeptic Tank—Liquid capa6ty-_.I0Ugallons Length__-�_.. ..__ Width__ -.--�._____ Diameter________________ Depth___r� '. x Disposal Trench—No. .................... W'dth_0_. .:_. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------- ---------- Diameter.....��_'._P!-�-Depth below inlet........ ......... Total leaching area..-` °.?I-..!..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by �W+ t....C......&-..................x ............ Date------I."_ ....�` ........... Test Pit No. 1___ .__ __minutes per inch" Depth of Test Pit-------k�....... Depth to ground water......',/ ...... fZ4 - Test Pit No. 2.... 4__._minutes per inch Depth of Test Pit...........1....... Depth to ground water........ _. r O Description of Soil._-.....S' =4 - - S .....`.._`'._....boA_M ..C:a ✓J._w/. V ......(�2 ate........ _:..�_�... =- 5 f.Gs! !"1EL.._...1.�-•�- 9-4.._...T?.'_1._. .. ........4. ....... .. W ''�`T <c� ? - `J �.J%�....`. I--.--------- ---� --5- ._'1_..... ' .................................... VNature 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 TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Corfro- ance has been issued by-the board of health. Si ned ..... re Application Approved By .......... .Arl `-A '1. f / . � ....... - ... ..�.................... --v-L. i` .i - > _ ..Date Application Disapproved for the following reason .- .. ............ .. . ......................1........ ._.. ----------------- ....................................... - -1.... -- .......... J/..�------ -�-y--------_--------------------- ------------- C. �'.'"."" �.1 - ......'--- /-, .. -/,---Date-.. Permit No. C .*. ..........._ ...p�... Issued - l Date r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (fPrtifi ate of Complianve THIS IS T-0 CE-XTIFY, hat the 1ndiv4dual­Se age Dis sal System constructed (' or .-paired ( ) {) -��j fop-y/� � �`�p )-A ,� by I !.. .... ..._y�� "l�flns?filler .JX 4 l� �................................ i at ........_-----------------------------------------------------------------------------------------------------------..---------------.-------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Env�ro nmental Code as described in the application for Disposal Works Construction Permit No. ...>/����..-- '�. �.. dated -------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUM AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. '' DATE------'.h e'...... �; 'r' ------------------------ Inspector.:.....,....... C t �...'.....,. .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l TOWN OF BARNSTABLE No../..).....- /... FEE r Diopoottl orki Tonotru#ion Plantit Permissionis hereby granted-------0. C ..-.. ----------------------------------------------------------------------•----•--•-..-----------_.----- to Construct ( ) or-Repair,..( )—am-Individual Sewage-Disposal System at No....--•--• � ��! -a I i �7A1 1 AC / „ / . "Ik ..................................... ( • .................., , v;...... -,•.... ; Street / f :� as shown on the application for Disposal Works Construction! Permit No - - -_,rDated.?.... ,... ------------------------•-•--•••-••---••••...-•-•••... Board of Health DATE.............. --------.,�T�....).�.................. FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS PA44A sec- A w44 pla, Au 16--, rto it— Wit. w i4 Sde4vze are ct.,d, y to f S '- .pit-ccuP �4� - ,�� .ze lue- Q� � 5 '✓ yC--� Fee-�-�-257 BOARD OF HEALTH TOWN OF BARNSTABLE Applitat ion for Melt Con5trutt ion Permit Application is hereby made for a permit to onstruct (V(), Alter ( ), or Repair ( )an individual Well at: for .�7_ s7 —-K —`—�/N�1Y11 ------------------- -----—--—---f©j----------- --C - Location — Address Assessors Map nd Parcel aaa � -�------------------------------------------- -----1_ �- ------_-_-_---_ Ow er ——— — —-- = — — — Address—— —--C Installer — Driller Address Type of Building �. Dwelling—_____ ---------------------____-- I Other - Type of Building--------------------------- No. of Persons------------------------------__ Type of Well- j�.3�i_ c�_!JU _,( �6 'S 'i Capacity - -- "7_/S �fJt'Si7� fuze ./ 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 Certificate of Compliance has been issued-by,the Board of Health. Signed-- - ---- � date ---- Application Approved By - ✓ � — ---— —------ date Application Disapproved for,the following reasons:--------------------------_______________—___________ • ate ' ✓ ---- - Issued-------�-.---- ----- ----- — --- - Permit No.-a��-- -- -- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO ERTIFY, That the Individual Well Constructed ), All re ( ), or Repaired ( ) -------- ----- -------- ------------------ ----- Insta er at --------------- -------- ------ -� - -- has been installed in accordance with the provisions of the Town of Barnstable �Board of Health(Private Well tectiioosn Regulation as described in the application for Well Construction Permit Nlf.''- � `Dated _� `�� �5 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE___--__-_-_-__---------------------------------------____-- Inspector------------------------__ _-- IVo.-r`------=J----- Fee--------------------- BOARD OF HEALTH TOWN[ OF BARNISTABLE • ` Applicat ion-for Vell Con5tructlonpermlt �. Application is hereby made for a permit to onstruct (�C), Alter ( ), or Repair ( )an individual Well at: for e�.� �/_�- - `°�'�—�+'p- /01 -rp t-`-e__(eu- a r 3 •/� �Location — Address Assessors Map and Parcel 1 Own}r n Address ------------------------ - ------------ -------------------------------- -- ------------ --- ---------------------------- Installer— Driller Address Type of Building Dwelling---------------------------------------------=-------- - ' ---------- No. of Persons---------------------------------------------------------- Type' Other -'Type of Building--------------__________ -� � i �l> - 6 ,��6 S ST /a-/� of Well- - '� - Ca acit Z� -------------------------------------------------- �3crrt�. P Y ---- -- Purpose of Well-- , //Sr�G----------------------------------------- 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 Certificate of Compliance has been issued by the Board of Health. Signed --� ---- date L�� Application Approved B —— --------------------------------- date it Application Disapproved for the following reasons:-----------------------________---------—__—-----___--------------------------_---------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------- date Permit No. -�sv--- G%_ -—v— -------------- - Issued -- -- — - - -- --- a date }f BOARD OF HEALTH ` TOWN OF BARNISTABLE rtrtif irate ®f Compliance THIS IS TO,CERTIFY, That the Individual Well Constructed_( ), Alt red ( ), or Repaired ( ) b It ---�'� -�� �"1 '- .-� `<` Z�n= i- Installer _ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit N�____'� -�/Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FGNCTION-SATISFACTORY. " f DATE----------------------------------------------------------------- -------- Inspector- - - ------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Very con5tructionvermit No.- -------------------- Fee-------------------- Permission is hereby granted------T--------------_- '`'1"" �' --L =' �- '"� ------- ----- ------ ------------------------- / to Constry,ct (� )Alter.(No. , �, or Repai�( ) an Individual ell..at:- `l / r>_ _ � r Street v as shown on the ap,Iication.for�a Well Construction Permit _ No.-- //! /ice -- _- --------- --------- Dated---r- - ---------- ------------ -------------------- �� Board of Health + DATE------- - - -- ---- ---------------------- I APPLICATIuN LUR PERCOLATION `ZEST AND OBSERVATION PITS LOCATION_ �OSSUYvI (._taut� � .-.r�, A— APPLICANTVILLAGE 2QSC�r�j ��C� — NO.I DATE ADDRESS �/`c l% !/cam cc cU # CG� ' tip l4� FEE '0/0 c RI TELEPH�NE NO. ?�0-� ENGINEE -y�-7 (Non-refundable TELEPHO �j DATE SCHEDULED 1`Z ' ASSB3SOi '3�b�A�6� pyNO: • • • ` ^ • • • • • . . . . . , . . . . . .Applicant.S.signature �� SOIL LOG . . . . . . . . SUB-DIVISION NAME 7 • �y r�Jv DATE ��� �5; EXPANSION AREA: YES NO ENGINEER ?? TOWN WATER PRIVATE WELL BOARD OF HEALTH EXCAVATOR SKETCH: (Street name etc. ,dimensions of lot, exact locat n of test holes and percolation tests, locate wetlands in proximity to test holes ) NOTES: ,. m. A0 RA 110 �0.r ' v t� S. P(Y c�of PERCOLATION RATE: 4mf rv/IN G C+ ravANI TEST HOLE NO: I ELEVATION: 1 TEST HOLE NO: �- ELEVATION: 2 '"v A 2 3 v 3 4 C' �✓T►°��/ 5 4 � � - d '' 5 6 5 cifOil 8 8 S�� • 9 9 S 10 10 11 ZA c 12 13 12 n 14 13 }}Cj 14 LA 16 T 15 civil •�-Ka u)47-eLk Cos. 16 30792 l SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS LEACHING TRENCHE }� /�4Z E UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: �978Ced"v ��� Q'✓��' ------------- NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED IGNED ON rERC TEST APPLICATION COMPLETED P COPY: RETAINED BY APPLICANT D 0 BOARD OF IiEALTIi 1 =; '- - F�FF. kir J HLJ * 1 S 53 Ehak, I PROP F 6TE�H {R`. S%i y t FT° rt"� C"AH. . . �.��BOXRA 1 O.RJE,� ANC, NIA Cc N;�a;: k�?=i�4A 063 4A0 Rm. 130 Sudwlch, MA a2563 �. (508)888-f-1bp 1-800-339-6460 r� FAX(508)888.6,146 Y jy. EarnstabJ:a, tUk SAMPLE DATE: 4-4--95 COL-LEC,TED 13Y: T,, 14i22 S >qtZ IJal.a.s GATE .F'ECFIVED: ji TIME. 4,!00r-hi LAB T,.I74 ��J. s E4-27 n; JOB TYPE: New ;call SA14PLE :i.D.N0. E4 -37 ?ELL SPEC;;. . 13V/ .01 ' s"atic level 4" PVC well . Flow. 10 G.:P-M, ,. RFSI�LTS OF AN,,.kLYSTS: a , Ln tFf s t► _t8 Rwcomnended'Limit kestilC Coli:form bacteria/100;ni (MY Method), Q 0 'kY Cald pEl units 6. .5 6,64 Y s ; Condi� ctAnce u{t:j(]iti5%Cal 500 �'. Sod;ium mg/L �o.Q 7..7 Manganese mg/t. 1� 05 � 0 o25 Volatile Organics See enclosed report. E �1 601/602 ug/L ]`tone detected. Hk: C:UMMENTS: Iron 'level. is 'trot a health 1i;,�za'rd �' but may cause. taste. and staining problems. x :- S1 h��;�. � v u �tes I�c� WATER IS SUITABLE FOR i)R'1i.,9 PURPOSES FO PARAMETERS TES EU q XX Da to oo:al_d J. sari Lahc tatox 11x:rector ;- LT Tress Than 7 m 9 --------------- ----------I---------------- F 'r_?6=_95._TH1,J 15 :�54 E NV I ROTECH LADS 5 0 8 ,8 88, E.4 4 6 P. 03 GROUNDWATER ANAI YTICAL METWOVS 60, and 602 I "/P 4-.Ifl CD) cs 11W Ift Vol& 4 Lab 10 Fielc fat l n/59 cod ar S&MV I od: 04-04-96 1pmk c! i e n t. Env r OTL a":0 R e 1 v 04-0445 C0rt/P 4ML VOA via! "'C! C001 Analyzed: 04-06-96 matrix: Aqueous REPG_ lNG C,xi c c s,,,T P�PJI f PARAMETER N4 L) BiR L E, ,)jcjj' or-odi fl ucrofnetheil�, Cill ornnallhane ro'R BRL. RA r ry vie t yiene i_nlioriL BN D i c ri I o r o.M,t 1-i ar i e ci BR r h E 'i tog-of or-; -Tri chl o roatka,'E 391, L.drDon Tetrhchloride BRI. F"9 L D"i L b I Y'O�-i" 5RL B R,L 1 2,0 ch"I-ropro p lve I B R IL k j C-Chkruethyl Viny! cis-1,3-Di chi oropropene 8 R L hluene -Dich'!oroprfopelrll� R.R A R L 2-Tri 0 orul thane Dibromochloromethane rhlorcben7 e r,e BRL Ethylbqnzene BPI meta-and pars-Xylent-1 SRL ortho-xylem BRL Bromform BRL BRL BRL 1,3-0ichlorobenzene, BRL 1 ,4-Dichlorobennna f BRL 1,2-Dichlorobenzene QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS 97 - 113 % a.,.3,1 a,-'fri f.'1 uorotol Uene - 1117 % 1 3' 83 1 ,2-Dichloroethane-d4 30 1 BFL = 321ow Reporting LIMIt, * Non-targat 00=60d Method pur;6abla HaloQarbanE and Method 6Aromatics,Purgeable Aromatics, 40 LF,R. 136, ApperAix A (1 --------------- -- ----- ---------- CERTIFIED PLOT".PLAN TOW! _-.i Aea R sa ., 7013 0 m CEDAR STREET N3730'53"E S7`41" 50.00' 8.31' 59.61, E !+/IDE N37* 21 21.72'E -- S85'g"E R=30.00 150.79 L=22.72'EXIS ` SEPTIC SYSTEM ` ` _ —\ \\ � M NT / (COMPILED LOC4T10N) N -- ASSESSOR'S 1 MAP 109 PARCEL 95 43,585f S.F. 765 `w ASPHALT .op0 Sg OWELUNG DRIVEWAY ' �� \ 'ham � �'�• -�w _ SHED %o EXISTING Op eph WELL �1 G�'��•PG�' QQ��O1Q 0 � WELL NG I ,y �PRoPaO " _ C�4c� 01, 181.9� CHAINLINK FENCE . � �88,�6'2 Nor 24.E a�ryh OO�;-ZyF p'9RC �\8� 9 /�A¢M/TRy OOS 4C,, ,O9 PREPARED FOR: FLOOD NOTE: SHANNON LIST SUBJECT PROPERTY FALLS WITHIN ZONE C 'OF THE FLOOD INSURANCE RATE. 765 CEDAR STREET MAP No. 2500010015C, WITH AN EFFECTIVE DATE OF AUGUST 19, 1985, AND W. BARNSTABLE, MA., 02668 IS NOT WITHIN A SPECIAL FLOOD HAZARD AREA (BY GRAPHIC PLOTTING ONLY) 765 CEDAR STREET W.. BARNSTABLE, 1 7 A ASSESSOR'S MAP 109 PARCEL . 95 HEREBY CERTIFY THAT THE INFORMATION SHOWN HEREON IS THE RESULT OF AN ���P`vA of Msq� ON THE GROUND THE INSTRUMENT SURVEY. 4 $F�ANE M. , o BRENNER CA No.45917 9 4 -GIM, NAC. L Z�24�j 3 PREPARED BY.• BAXTER NYE ENGINEERING & SURVEYING DATE: FEBRUARY 26, 2013 . Registered Professional Engineers and Land Surveyors 78 North Street - 3rd Floor, Hyannis, Massachusetts 02601 SCALE: 1"= 40' Phone - (508) 771-7502 Fax - (508) 771-7622 JOB No. 2011—.051 iIt'S X6' LEACH itIIT, WITH 1 'OF.S7�j 23 rONt i­SR- 22.5 EAKOUT:'1,122 6" '�5TREET, 1 27, 24 0 2'GAS i23 4 1 : ,IK 11' FROM'EL'�,127.2'BENQHMAR. GA I6',FROM EL 1 27 2 IJOP:'OF CATCH BASIN GRATE AT:ELEV 1 24.90 %O tWIRE INAGE MENT' ......t77' LOCUS itI�H iEMST. 1 50 00 8 GALLON H10 4j SEPTIC to A�q t04 tKE I 3.1 3 EXIST.'PROP CONIUUH 40 LOCATION MAP -�JNO C EXIS I 32.5 ELEV. W_WEU-M -WA -W PROP. TER LINE ASSES MAP 109 b9 SORS, PARCEL r-vSSIBLE ELECL'-LINE E -,DISTRICT- RF ZONING,PROP.CATCH BA§ MIN. 'LOT SIZE ­'­43560 'S.F.IIMIN4: FRONTAGE- '11 0'O SETBACKS,PROP., I �oi 2 �IFRONT*3 6 32 SIDE 11 5`REAR FLOOD ZONE C AGE 5 61ST. : SE REFERENCE. PLAN BOOK 489, P 34 TTIC PROFILE.WELL 0 SCALE)0 (NOT'T 4 AT 2 I-AS 'T yKING COVEr. , 0 WITHIN T.O.F. EL tj 32.4 (fy� 11 OF F1NISH GRADE COVER TO WITHIN 47 BRING GRADE-PROPOSED OF FINISH"M NIMUM 1 OF'COVER OVER EL 1 '�(D(IST. �EL. 1 PRECAST INVERT AT 29.42 (EXIST. EL 130.0)-9 L 4.v 0.26 t1 .4 f PEASTONE , Pvc)63) FOR FIRST 2'OPE VENT SL (H 1 0 I�1 .4� ; , I% LAY PIPE 0 EL. 1 27.22 140 _0E 07- , .3.3,. ZLO TANK, (H 1 0) 00 GALLON SEPTIC 9 1 29.1 81' 00 OOC 127.81 00 6'x 0------------- tLEACH H10.27. LADPE -DE TH`110F�, Ith6 W 4 126.22 PIT PROPOSED'LEACH PIT AREA AS PROPOSED BY MASTER WELL 'AND TEE o C 0 00 SEPTIC PLANABASED DATED 000 EPTH SET WBOX�-ON c IN't 0 MAY _,�ET D LET DEPT 13j.1994itBY DOWN CAPE :I :�0 ;0, 1 20.22 OUT *411S;*114 ENGINEERING, H CLEAN COMPACTED'GRANULAR MATERIALi TO�3 4 6,TONE 1 C3 CLEAN WASH t4 v 0 --SUITABLE SOIL' TO ELEV. 1 tGROUNDWATER &ISEPTIC DES IGN: (NO��GARBAGE':DISPOSER AUOWE D) EACHING 2 4 FOUNDATION"-- SEPTIC TANK D' BOX, FAci LrT.y DESI N ;FLO&`,3 ­BEDROOMS� (1,1,0 GPD) 330 GPD t:�G 0 b TE H OLE LOGS SEPT] ,51 4�5 C TANK. GOD�* ST 1 500, GALL T! tUSE A ON SEP t TANK'.-LEACHING; VITNESS*_ JERRY DUNNING (s.o.H.)ENGINEER:�:ARNE H. OJALA tI'.6;,G D DATE: JANUARY '5 1995 1''7 GPD , _NC-SIDES:,� (2.' P, 7RATE -4 T ES-:BOTTOM: :4 1 6 MIN/i H N 0 PERC -rr s:-P ECA T EAC G tCONCRETE L HiM .-,,DATUM ASSUMED :,FROM QUAD.,�;,MAP., 'A-343 3,, GPD;' SITE ' L W TOTAL :' 201.1 S.F. SANDVP S 2. murncipAL. WATER:�]S AVAILABI U E 6 �op EL 1,40.0 0 EL '1 39.6 M 'PIP& P PI -70 E T WITH'A �OF STONE::ALL. AROUND.- 3. MINVU PITCH" 0 EDAR: STREET, N ERt'F OT POR-PROPOSED DYIELUNd':014,t6T �'69"C TOP TOP AND ADI 01'4 D 'T U T.,DESIGN LO ING' �ALL, PRECAS FOR BIE�T'H!0.-CONSTRUCTIORbETAILSJO iSE INACCOR DAN C E, WITH, RNSTA SUBSOIL SUBSOIL -T A E JOINTS 5. 'PIPE 13E (WE 8 11 B L MA 0 -'MADE WATERTIGHT. 6 ENVIRONMENTAL' ACODE ,LOMY 3IT-P ROPO �,PVEPARED YOR-t� 136.0 4t, El- 135.6 COARSE PLAN FOR SED',­WORk bNLY,:AN `::NOT._M::BE�. USED -'-THIC; b-7,"WITH COARSE FO R LOT'1INE,,'_'tTAKING SAND'AND,RAVEL it '60-0 EL 30 STONES 9., DB PIPC FOR' S STED�,,FOR HERI TS'GEt RESE ' 'RC STONES A NITH H EPTIC��!SYSTEMI "'TO SAND ' 8CH 4 Pvc,OX-T6 8 WATER�-,,TE tEVELNESS. G tGRAVEL 90 Feet fai 508 .362-9880 0 1 32. =�3_0' ­,�DATE*. MARCH MED. 995'COARSE'wn,, ,,ca pe, �,enom inc. SAND W 1 28.6 'AtINF-NO VIL-`:-EN C71NE �SAND ,E R A!�A�:'BOA" IOAV FOUND LAN V E'Y-,0-R S WATER AND GRAVEL oj D SUR 16 124 a, dJ-J 1.A P� DATE BRNSTABLE - AIA A m 9 9 . 6- th�-'ain -ya rm 'e�'WATER ItVED ','DA7'E FOUN D APPO 8 I