HomeMy WebLinkAbout0040 CHURCH STREET - Health 40 Church streetmt
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CERTIFICATE OF ANALYSIS Page: 1
� i Barnstable County Health Laboratory (M-MA009)
tom'
ystcaiu5t^' Report Prepared For: Report Dated:2/10/2011
David Sullivan Order No.: G1160981
40 Church Street
West Barnstable, MA
Laboratory ID#: 1160981-01 Description: Water- Drinking Water
Sample#: Sample Location: 40 Church St. West Barnstable, MA Collected 2/3/2011
Collected by: Customer Received 2/3/2011
Routine
ITEM RESULT UNITS RL MCL METHOD# TESTED
Nitrate as Nitrogen 0.15 mg/L 0.10 10 EPA 300.0 2/3/2011
Copper 0.20 mg/L 0.10 1.3 SM 3111 B 2/10/2011
Iron 0.18 mg/L 0.10 0.3 SM 3111B 2/10/2011
pH 6.5 PH AT 25C NA 6.5-8.5 SM 4500-H-13 2/3/2011
Sodium 18 mg/L 1.0 20 SM 3111 B 2/10/2011
Total Coliform Absent P/A 0 0 SM9223 2/3/2011
Conductance 160 umohs/cm 2.0 EPA 120.1 2/3/2011
Water sample meets the recommended limits for drinking water of all the above tested parameters.
...._.-_----------... ... --- -- -- ---
Attached please find the laboratory certified parameter list. Approved B
( b irector)
'I
_;may
r 3
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
Y; CERTIFICATE OF ANALYSIS
M
Barnstable County Health Laboratory (M-MA009)
Recipient: Matrix: Water-Drinking Water
David Sullivan Sampled: 02/03/2011 9:45
40 Church Street Received: 02/03/2011 10:32
West Barnstable, MA Collection Address: 40 Church St.West Barnstable,MA
Order#: G1160981 Sample Location:
Description: R E Kit
Lab I 1160981 Ol Date Started: 02/03/2011
Sample#: Date Completed: 02/03/2011
Project#: PS Code:
Comment: Water sample meets the recommended limits for drinking water of all the above tested parameters..
Analyzed: 2/3/2011 @ 13:52 Method: EPA 524.2
Analyst: yn Dilution Factor: 1
EPA 524,2 - Volatile Organics.by GCIMS
Result MCL MDL Result MCL MDL
Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L
Dichlorodifluoromethane ND 0.50 Chlorobenzene ND 100 0.50
Chloromethane ND 0.50 Chloroethane ND 0.50
Vinyl chloride ND 2.0 0.50 Chloroform 2.5 80 0.50
Bromomethane ND 0.50 cis-1,2-Dichloroethene ND 70 0.50
1,1,1,2-Tetrachloroethane ND 0.50 cis-1,3-Dichloropropene ND 0.50
1,1,1-Trichloroethane ND 200 0.50 Dibromochloromethane ND 0.50
1,1,2,2-Tetrachloroethane ND 0.50 Dibromomethane ND 0.50
1,1,2-Trichloroethane ND 5.0 0.50 Ethylbenzene ND 700 0.50
1,1-Dichloroethane ND 0.50 Hexachlorobutadiene ND 0.50
1,1-Dichloroethene ND 7.0 0.50 Isopropyl benzene ND 0.50
1,1-Dichloropropene ND 0.50 Methylene chloride ND 5.0 0.50
1,2,3-Trichlorobenzene ND 0.50 Methyl-tert-butyl ether ND 0.50
1,2,3-Tricfiloropropane ND 0.50 Naphthalene ND 0.50
1,2,4-Trichlorobenzene ND 70 0.50 n-Butylbenzene ND 0.50
1,2,4-Trimethyl benzene ND 0.50 n-Propylbenzene ND 0.50
1,2-Dibromo-3-chloropropane ND 0.50 p-Isopropyltoluene ND 0.50
1,2-Dibromoethane(EDB) ND 0.50 sec-Butyl benzene ND 0.50
1,2-Dichlorobenzene ND 600 0.50 Styrene ND 100 0.50
1,2-Dichloroethane ND 5.0 0.50 tert-Butylbenzene ND 0.50
1,2-Dichloropropane ND 0.50 Tetrachloroethene ND 5.0 0.50
1,3,5-Tdmethylbenzene ND 0.50 Toluene ND 100o 0.50
1,3-Dichlorobenzene ND 0.50 Total xylenes ND 10000 0:50
1,3-Dichloropropane ND 0.50 trans-1,2-Dichloroethene ND 100 0.50
1,4-Dichlorobenzene ND 5.0 0.50 trans-1,3-Dichloropropene ND 0.50
2,2-Dichloropropane ND 0.50 Trichloroethene ND 5.0 0.50
2-Chlorotoluene ND 0.50 Trichlorofluoromethane ND 0.50
4-Chlorotoluene ND 0.50
Benzene ND 5.0 0.50
Bromoben2ene ND 0.50
Bromochloromethane ND 0.50
Bromodichloromethane ND 0.50
Bromoform ND 0.50
Carbon tetrachloride ND 5.0 0.50
Attached please find the laboratory certified parameter list. Approved By-.
(L irector))
ND;None Detected RL = Reporting Limit MC`L'-Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 5.08-375-6605 Page 1 of 1
SECTIONDELIVERY
i ■ Complete items 1,2,and 3.Also complete A. Signa
Rem 4 If Restricted Delivery Is desired. G( � " ��;
■ Print your name and address on the reverse X " "'"y""
so that we can return the card to you. "� ❑Addressee
■ Attach this card to the back of the mailpiece, B. Received (Printed Name) C. to of D livery
or on the front If space permits.
I.Article Addressed to: D. Is delivery address different from item 1? ❑Yes
If YES,enter delivery address below: ❑No
David Sullivan
40 Church Street
VP`est Barnstable,MA«02668 3. Service Type
- 16 Certified Mail ❑Express Mail
❑Registered PLRetum Receipt for Merchandise
17 Insured Mail 13 C.O.D. '
i
4. Restricted Delivery?(Extra Fee) ❑Yes i
2. Article Number
(Transfer from serv/ce label) 7008 1830 0002 0500 7782
- '
PS Form 3 811 Februa
O i
t.v, , , , ry 2004 Domestic Return Receipt •
102595-02-M-1540
r
f
;ter Health Master Detail Page 1 of 1
`3 tCf'.t'i "� fi.S:. i' 'ev`i3I�G` £3C1ilt?iHealth Master Detail t'k
d ppa l :3 cn C„etiter Parcel i-ook-up selection. Items
Parcel SepticWellT ` Fuel Tank I
Parcel: 154-005 Location: 40 CHURCH STREET, WEST BARNSTABLE Owner: SULLIVAN, DAVID S &VIRGIN
Business name:, Business phone
Rental property: Deed restricted: Number of bedrooms ..3£
Contaminant released: Fuel storage tank permit: i
WSaVe Parcel Changes Ret
urn Yto Lookup
Parcel Info Parcel ID: 154-005 Developer lot:
Location:40 CHURCH S'T REET- Primary frontage:241
Secondary road: Secondary frontage:
Village:WEST BARNS-tABLE Fire district:W BARNSTABLE
Sewer acct: Road index:0.308
Asbuilt Septic Scan: 154005_1 Interactive map �S"
Town zone of contribution:Wp (Wellhead protection Overlay District) State zone of contribution.OUT
Owner Info Owner: SULLIVAN, DAVID S &VIRGINIA R Co-Owner:
Street1:40 CHURCH ST Street2:
City:W BARNS-TABLE State: MA Zip: 02668 C
Deed date:8/16/2005 Deed reference: 20161/202
Land Info Acres: 2.60 Use: Single Fam DL-01. Zoning:RF Neighborhood: C
Topography:Level Road: Paved
Utilities:Gas,Well,Septic Location:
Construction Info :..iirin; ` ojyea a t et Ji= Ar:al ': ---oms (� thre ;3
1 1963 3026 3 Bedroom 2 Full + 1H
Buildings value:$255,100.00 Extra features: $4,900.00 Land value: $191,700.00
http://issql/Intranet/healthMaster/HealthMasterDetail.aspx?ID=154005 1/28/2009
Town of Barnstable
tab�e
Regulatory Services Barns
of�"E roil, •
yvP` ti� Thomas F. Geiler, Director (,zC
Public Health Division
* snxtvsrnai.e,
9 . MASS. Thomas McKean, Director
Q� 1639n. 200 Main Street y2007
ArFD MA'S A ►
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
i
January,27, 20b9
David Sullivan
40 Church Street s
West Barnstable, MA 02668
As of October 1, 2006 a new rental registration ordinance was put into affect requiring
all property owners of rental units to register their rental units with the Town of Barnstable
Health Division. According to our records, you own the rental property at 40 Church Street,
West Barnstable.
Enclosed is an application. Please use a separate application for each rental unit you
own. Should you . need more applications, they are available online at
www.tow-n.barnstable.ma.us. Go to the Health Division page by looking in the Department
Menu. There is a link to the Rental Registration information on the Health Division page. You
may print out as many as you need, and return them to the Health Division with the appropriate
p
2009 fees included. This must;be completed within (14) fourteen days of your receipt of
this letter.
Failure to-comply with this ordinance will result in the issuance of a non-criminal ticket
citation:in the amount of$100. Each day of non-compliance is considered a separate offense.
Should you have any questions, please feel free to call 508-862-4644. Thank you in
advance for your cooperation.
w
Tiinothy B, O'Connell, R.S.
Health`Inspector
Health Division
Direct.#508-862-4646
HA
CERTIFICATE OF ANALYSIS Page: 1
M
Barnstable County Health Laboratory
Report Prepared For:
Report Dated: 4/22/2004
'
Order Number: G0424818
Oden F. Pyle /AP � 5
40 Church St. P'.O. Box'457 ,
West Barnstable, MA 02668 ORCEL LOT
OT
Laboratory ID#: 0424818-01 Description: Water-Drinking Water
Sample#: 24818 Sampline Location: 40 Church St.W Barnstable MA Collected 4/15/2004
Collected by: O F Pyle Received 4/15/2004
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates <0,1 mg/L 0.1 10 EPA 300.0 4/15/2004
LAB: Metals
Copper 0.2 mg/L 0.1 1.3 SM 3111E 4/21/2004
Iron <0.1 mg/L 0.1 0.3 SM 3111E 4/21/2004
Sodium 13 mg/L 1.0 20 SM 3111B 4/21/2004
LAB: Microbiology
Total Coliform Absent P/A 0 Absent 309 4/15/2004
LAB: Physical Chemistry
Conductance 110 umohs/cm I EPA 120.1 4/15/2004
pH 6.6 pH-units 0 EPA 150.1 4/15/2004
Note: Water sample meets the recommended limits for drinking water of all the above tested parameters.
Approved By:
Director)
A: .
RECEIVED
APR 2 8 2004
TOWN OF,BARNSTABLE-
HEALTH DEPT.
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
COMMONWEALTH OF MAS.SAVCHUEZ`TS
s EXECUTIVE OFFICE OF tNVIRONM,�FNTA%l,5kFF.4IRS
DEPARTMENT OF ENV,,fV6NM NTAL PROTECTION
R
P
F
iJl� �� lJ
PARCH
• � a� AUG 1 9 2004
LOT
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE S
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: Yo - Alat.,GL�/V02L
)EA
Owner's Name:
Owner's Address:
Date of Inspection: //
Name of Inspector• please print) Ni-
Company Name. t _
Mailin-.Address:
�f
Telephone Number:
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 DE.P
approved system inspector pursuant to Section 1.5.340 of Title 5(310 CMR 15.000). The system:
VPasses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP).within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DER The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time:This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Tit]e 5 Inspection Form 6/15/20.00 page 1
Page 2 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICAThON'(continued)
d ' -
Property Address: (�����L-�.�(�,Q,p
Owner:
Date-of Inspection:
Inspection.Summary:. Check A,B,C,D or E./ALWAYS complete all of Section D
A. System Passes:
V I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B... System Conditionally Passes:
One or more system components as described in the "Conditional Pass"section need to be replaced or.
repaired. The system, upon completion of the replacement or repair;as approved by the Board of Health,will.pass..
Answer yes,no or not determined(Y,N,ND)in the for the following statements..If"not determined"please
explain.
The septic tank is metal.and,over 20 years old* or the septic tank(whether metal or not):is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent:System will pass inspection if the
existing.tank is replaced with a complying septic tank as approved by the Board of Health..
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a.Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND.explain:
Observation of sewage backup or break out.or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than*4 times a year due to broken or'obstructed pipe(s).The system will
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: eal� GC/u
Owner: -
Date of Inspection:
C. Further Evaluation is Required by the Board.of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is 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(i)(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
surface water supply or tributary to a surface water-supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well_
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4.of 11
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION.(continued)
Property Address �t �` i '00�C'
Owner
Date of Inspection: /4 00o
D: System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N9
Backup.of sewage into facility or system component due to overloaded.or clogged.SAS.or cesspool
i . V 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 overload.ed;or clogged SAS or
cesspool,
Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times.pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
/ water.supply. „
_ V Any portion of a cesspool or privy is within a Zone 1 of a-public well.
_ Any portion of a cesspool or privy is within 50 feet of a.private water supply well.
Any portion of a.cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This systerrt,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.]
JV� (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 ofa0;000 gpd to 15,000
gpd.
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems.in addition to the criteria above)
yes . no
the system is within 400 feet of a surface drinking water supply
the_system is within 200 feet-of a tributary to a surface.drinking water supply
— the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area,—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section.D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
;4
Page 5 of l I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: v
a&Ze-A �&W—A
Owner:
Date of Inspection: 1
Check if the following have been done. You must indicate "yes"or"no"as to each of the following:
Yes o
Pumping.information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
V _ Has the system received normal flows in the previous two week period ?
_LZHave 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?
bZ _ Were all system components, excluding the SAS, located on site
_ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition
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
' mtenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes o
Existine 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 15302(3)(b)]
5 I
Page 6.of 11
OFFICIAL INSPECTION.FORM=NOT FOR VOLUNTARYASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTEM;INF,Op ,RMATIO
Ala,
Property'Address. -�
lea
Owner: 0,M "9V
Date of Inspection:
/ FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):' Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (fof example: 11.0 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yet mjo
Is laundry on a separate sewage system (y s or no) if yes separate inspection required)
Laundry system inspected(yes., no),:/LT.
Seasonal use: (yes or no): /J
Water meter readings, if av i able last 2 ears usage g d' : ikal
Sump Pump(yes or no)-
Last date of occupancy:
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:I _
Was system pumped as part of the ins, ection(yes o o •
If yes, volume pumped: gallons 7-How was q tity'pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank, distribution box,soili 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 C� {
_jG )
0tther describe `
( Ci) J/l
roximate Me of all co . gnents, date installed(if known) d source f inform ion`.
Were sewage odors:detected when arriving at the site(yes or no):
6
r
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(c/ontinued)
Property Address:
AC` ,
Owner:
Date of/ns�pectio`n'. /
000
BUILDING SEWER(locate on site plan)✓///
Depth below.grade:
Materials of construction: cast iron 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage, etc.):
SEPTIC TAN%;J&Iocate on site plan) .
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes`or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum'to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet.tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet.invert, evidence'of leakage, etc.):
GREASE TRA . ocate on site plan)
✓� P )
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 S of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(conti ued)
Property Address:4,00 'V C -
Owner:
Date of Inspection: ,�;00
e of ins ection locate on.siteplan):
TIGHT or HOLDING TANK: '�D�,tank.must be pumped at time )( . .
/�( P P P
J
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene. other(explain);
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX/ if present must be opened)(locate on site plan)
J 2&
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of
leakage into or out of box, etc.):
PUMP CHAMBE44( (locate on site plan).
Pumps in working
order(yes or no):
Alarms in.working.order(yes or no):
Comments(note condition,of pump chamber, condition of pumps and appurtenances, etc.):
8 .
I
Page 9 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: /*wl
Date of Ins ection: f .
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches, number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
.innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
Wetc.. /V
i�
CESSPOOLSJ,, '(cesspool must be pumped as part offiinspection)(locate on sit p]an)
Number and configuration: 000 . C
Depth'—top of liquid to i f t invert: �r
i
Depth of solids layer: pw #r ", p � - Ile
Depth of scum layer: #-.x I /11 )00_CLt° P-� , .3//Dimensions of cesspool: l(o ')��
Materials of construction:
Indication of.groundwater inflow(yes or no):
omments(note condition of soil,signs of hydraulic failure, ley 1 of ponding, condition of vegetation,etc.):
1
♦ 1
ii fr
PRIVY:/}lir(locate on site plan)
Materiallss of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): .
V , &met., �-�" 1 P�d� a 2;:�
911
n
Page 10 of 11
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
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 enters the building.
6q a
DC)
r/ S
10
Page II of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART C
SYSTEM INFORMATION(continued.)
Property Address:
,�1d4
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 1 feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of.design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Ahecked with local excavators, installers-(attach documentation)
ccessed USGS database-explain:
You must describe how you established the high ground water elevation:
n
Pj r i
i
11
:tie.- -'F - i'Sfr:'^�;,�•^ - ,:.f l:.i
^%rYt4_'.�'•y �....•E.h.;.Y`: . Permit IUn a` -
-
ON
r /�!�//J ;ES 1•o- -
v�tli r�leteC Ji
'ems,
,IlGl 1 r•Y 1 TER LEVEL
/- _ _ - - -• _ __.
S/ � ���� Lot No-
?" s`- ite Location: G
n
/vner: Address.
''•Contractor. /? v ^—,ddress �r5�✓✓�
t r:
qu
_I:fix',.'':r;3r`,r�`•`
STEP 1 Measure depth to viate-table
=1' mon-h/day/gear
'z S i P 2 Using Water—Level fiance Zone
_- and index P
cJl Map 1GCa`?
site and determine:
- _ O Appropriate index v,/ci(..........................:...-.. �'� I
IIVater !eve' ranee zwe .........
r�
, : _
STEP-P S using mcnthly IeNr✓rt "Currant
galMer ReOurms > ondihnns"
determine current depth ,
ego 10V
��
awaterlevel for inCe: lJell -.......................... .�
water
tonth/Dear
I
STEP EP 4 Using Tahk of Wav -ieve! Adjustments
for Index:well (STEP EP 2A), cu.n-ent depth f
to Water level for index Well (STEP EP 3),
and vvater-level zone.(S I tP 22) �
determine adjuAment .......:...................................................................................
1.
STEP 5 Estimate depth to high water
by subtracting the water
level adjus:L-rnent (STEP 4)
from Imeasumf depth to water
level at si tee (STEP 1) ..................
• � �I`��;. ��,--�B�C��uL111�?v,1�ITi,�t.(jcff�ll?dill. �
6�
N
_ �
.% .... ...
7.31 .E ...
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L0 CATJON ��,
SEY� AGE PERMIT N0.
.- '�/'p
VILLAGE _
we's+
INSTALLER'S NAME i ADDRESS
I
BUILDER OR INNER
r,
DATE - PERMIT ISSUED
DATE COMPLIANCE ISSUED 1_17
t
M 41
' T
5
ID
NI
r
No.. .��?.
� �
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® QF HEALTH
r
.--------.oF........ - .........................
ApplirFation for Bilipos al Works Tonstrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at
.....ap.._-C.. ccl................ . ••...... . .•--- ••••.. ...... ..........:--............
Locate - dress
----- ---------- ------------ ----
........ A - r t .............••------
O dress
at .10( .. ......F-..m
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms.............................. .....Ex Expansion Attic a g— --------. p (_ ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons..........--................ Showers ( ) — Cafeteria ( )
Otherfixtures ......................................................-----...--------------------•-----..............------------------.....----•-•--...........•---
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter------.......... Depth................
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) .
Percolation Test Results Performed by........................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.--.................---.
(T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.---................----
0 Description of Soil.............. �,f ..... ..... _ . ..._.__..
---------------------•-------------•-------------•---------•----------•-•....•--.------
x
U --..........•--••••-•-•....-•--•-----•----•••-•-.....---••••................•••---....--------•----•----•-•--•--•----•-•-•••-•-•.....---•--••----•--...................................................
W ---•---------------------•-•----------•-•--•-------------•----------•------------•---•-•-----•-•---•----•----------y-----�-j----------------------------- ..............................................
U Nature of Repairs or Alterations—Answer when applicable.......-d -_--/-DIO --f��. ....................................•----••-••---
---------------------------------•--.....--•----------------------------•---....------..........--•--------....------------------------......------------------------•---......•-•---..._.---•-•=
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ee issued by the board of health.
k...walollie.k...... .V . .....
Application Approved By............. ✓,� -.. ...... mod-a
J� Date
Application Disapproved for the following reasons-----------------------••----•--------------------------•---•--------------•------------------•-••-•--••••-_•-•--
..-•.....................................................•--•----•-----•-....----.....-----•--•----------•-•--•----•-••--•.... .---...--------•-••-^-----•-.....------ .........................
Date
PermitNo.......................................................- Issued.----- ..................
Date /
No...: Fza... 1'.'.f. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ G"Lon 0F........�...>.....t'}? �.T )2.k....
Appliration for Disposal Morks Tonstrur#inn Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
....... :.....�..................�'... ...........M1............................................ ........................... -...J.......................... .. .............................
Location..-Address or Lot,No.- . J ./
...... i ��...i_� ?l-.... ...... ...I i ) �l C.._:.. .... .�.!.a ��11 /`= l(JJ1.`—.::.....----•------------
..
l Owner i Address
a J 1 1 ) )/,( r . 11 - ... .*------l-- ---------`• )`----....... -------------------------
.••---•...............• ......-- ........ -= =
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
ply Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
f-tl Other fixtures -------------------------------- - - ------------------• --------------------
W Design Flow............................................gallons per person per day. Total daily flow.__..__............_....._..............._..gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No-----------_-------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by............................................................0............. Date......-......•..............-............
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..................
--------------------------------------------•-•-------------------------...........------------.........----------•----........._..•---•-............_..-•---
D Description of Soil................. - .:.fr_..r 1{Fl` I
...............•-------------------------------------...-----.........--•----•-------------------------•-•-•--•--•-._...
x
W ::...............................................
UNature of Repairs or Alterations—Answer when applicable........ ..... ......... ._.f...............__...................,............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beenn issued by the board of health. /
d••• I-r=�=xt= iJ.'h 1N 1;� 1!tG%l ti= -'-` �r'/a�:."rr.....
1 - -
I . �,a�
Application Approved By............. -�'-'•�.. .1 -1•. ''! '......------
Date
Application Disapproved for the following reasons:.............................................................................................................._
..................................-......................................................................................................................................................................
Date
PermitNo..........................-.......-...................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH 1
................rl.r..:..............OF.... .................................. �..................................
Terfifirate of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage—Disposal System constructed ( ) or Repaired (k,)
by----•------------........................................` ................................ifi :.:...._.1 -----------------------------------•--•------------------------......--...-----------
' ( i I 1 t 4! II siallI l/d E Li i I --
at.... ...................... ......... ...................•0.......................•.. • . •--.---.-.------------------ ----•---------------
has been installed in accordance with the provisions of TITLE ` of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.le -�._.�� ................ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................./� � N..-•-•----•---.... Inspector........ --•------•- ....................................
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
fro '/ .............� :... ...............OF...... a' '...............................................................
No.... .. FEE.........................
Disposal Oaks Tono#r iA� �
rmit
Permission is hereby granted.....�.:..f_...._.._)).�t-_.__ ::� �� -
to Construct ( ) or Repair ( X) an-Indivi,ual Sewage Disposal S stm ~
Street
as shown on the application for Disposal Works Construction It No..................... Dated..........................................
h'= �-ram' -'�f--;; ............................
Board of Health
DATE........... � ...................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
cv
to C AT ION S,E W A G E PERMIT NO.
VILLAGE
�s r9 rat S-f- b.1C
INSTALLER'S NAME i ADDRESS
_ p " 19CyMb-Pr-A-
. e U1LDE R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED 1�-�
cesos Poo
U -- --------
�"-
cess pov ,9
P J-1)
/c 06 Gp�t L. P. �
' A .
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............. W/....1.......0F...... .......................
Appliratwi n for Uiipuaal Works Tonstrnrtinn Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair UC) an Individual Sewage Disposal
System at: }},,
...... ®__�.bu .. r. �................... ................. ....................... --....... ...........-----------
on-Add
s or Lot No.
� ............................ .... - -�a _. ...................
Owne; ............•...................Address
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
W Other fixtures ---------_-----_-------- ----- ------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length.:.............. Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................•------•--•----•------------------- Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water____--__-_--_-__--_____.
Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................
a
O Description of Soil................62 ...t.. k-, e ..•. - - '.................................................
---------------------------------------------------------•----------------------------------........--------------- ---------------.-----
U Nature of Repairs or Alterations—Answer when applicable._......_ )z9VLQ .: ......................................................
----------------------------------•----------------------•---•--------•-------•----••-•---....... ----.......--------------------------------....--------------------------...................-•------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Tl'I'M 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has Aeen issued by the board of health.
�QY ll
Signed...... ....... � 1Y1. -------------- -®-)&...-•----
Date
Application Approved By--------------------------------------
Date
Application Disapproved for the following reasons:----•---------••----------------------------------------------------------------•------•---------......-•--•----
--------------•--•--......-------------•----------•-----------------------..,.............------------------•-•--•-----......_._.....---------------------'--------------...---------------•--.......--
P1 ,
ate
L
PermitNo......................................................... Issued . ....................................
Date
NoV....�.7.Z.... Fizz..........l. ......... .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
p OF _.l Jt�a' j � �`Jr•` ...li�
Appltration for Dispu l park C� a� r r iun rrnti
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
�1C Ct;���«�
--....... __....__................ ... .......................................... ..•-••-•-•-------•--•---••...........--•-••-•-...-•--••-------•••-.........._........------....._.
- r _ —"Location-Address f/ __-Y or Lot,No.
:-•'-•-----•-- _ -------- -----*---r---------------------•-•---•- r -------------—�-........................
Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other7-Type of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures -------------------------------- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit............_....... Depth to ground water........................
.. ............. -----
ODescription of Soil = = :.. ' ------- -------- ------------•--•...--------------------------•--•----.-----
x t.
w --- -------------------------------•--•------1 -------------------------------------------------------------------------------......----------------------------------------------
.J�w Nature-of Repairs or Alterations-.Ahswer when applicable._..___..:'.. ---_'--------.................................................................
Agreement:
The undersigned agrees to install the �foredescribed Individual Sewage Disposal System in accordance with
Nill the provisions of TITI.% 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health. /� I
Signed
+� Cr
Date
APplicatiori'Approved By-`....................•----.._. `...--•--•--------------------•---•-----........---------•----•- ........................................
4
Application Disapproved f or the following reasons----------------------------------------------•..-------•----....------•-----•--------...._.D;,ate.._......--•-
/ Date
' ;
Permit No.....�' '"
-----...-•-- ---------- Issued. ............................
>" Date,,
THE COMMONWEALTH OF MASSACHUSETTS f
_ BOARD OF HEALTH
.........................:/.J..........OF...........-....`....'...............................................................
Tatiflratr of wIloutphatta
THIS IS TO CERTIFY, That the Indiwidual_.Sewage Disposal System constructed ( ) or Repaired
by........ ........... .!_`....�::!J:..`: -= - =r==•--
- :r Wit' Installer
{ .
has been installed in accordance with the provisions. of 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No . .7 `.- ~- ......................
dated.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
d t'
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.... --------------------------------------- Inspector...................................... --------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
�a 'BOARD
r®F HEALTH
.... .......................................
=l7�' ..............�f... '... °. ...OF....... jf %af� '/
No........ .......... FEE.............--•---
Dispos-al Wore T nstr iou rruti�_
Permission is hereby granted......_._:..I......_! �./(1 �� � J" s , 1 t..
. ----
to Construct ( ) or Repair ( ,,.).an Individual. Sewage Disposal System
atNo.....................------`.._'.......-.....•.......-•---/..................................................----------•-------•----•-------•--••------.......----•-----='...........
' Street. pp
as shown on the application for Disposal Works Construction Pv4a No________ _________ Rated.....7._"._�l�". .�...........
� /
DATE.......... .. ...........•--.._..} Board of Health.-•-------••-•------._._......-------......... !
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ,F""