Loading...
HomeMy WebLinkAbout0181 CHURCH STREET - Health i Barnstable a Commonwealth of Massachusetts I= Title 5 Official Inspectiori Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 kR- Owner Owner's Name f.�a information is required for every X Soutk, `y remont MA 01258 8/31/2015-!� page. CitIfTown State Zip Code Date of Inspection w1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 Telephone Number License Number B. Certification I certify that:] have personally inspected the sewage disposal system at this address and that the information•reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based;on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMI215.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/1/2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healtti'or DEP).within 30 days of completing this inspection. If the system is a shared system or has a design flowof 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ��/// US t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal S em•Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South Eg remont MA 01258 8/31/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: System in working condition. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Church St.West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South Egremont MA 01258 8/31/2015 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due . to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is South E remont MA 01258 8/31/2015 required for every 9 � page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in-cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M s 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South Egremont MA 01258 8/31/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 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. t5ins•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South E9 remont MA 01258 8/31/2015 page. City[Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined? If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out. ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x3= 330gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is South E remont MA 01258 8/31/2015 .required for every 9 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage N/A Well 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: UnknownDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South E9 remont MA 01258 8/31/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes Z No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M SV.,y 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South E9 remont MA 01258 8/31/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1983 Per BOH records. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): i Depth below grade: 61811feet ' Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 6'feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list.age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes. ❑ No Dimensions: 1000Gal H-10 Sludge depth: 6-8" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is South Egremont MA 01258 8/31/2015 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2-3 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? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 Gal H-10 tank in good structural condition. Concrete baffles in place are solid. Tank at normal operating level. Inlet cover 1'8" below grade with outlet cover 66" below grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 10 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South E9 remont MA 01258 8/31/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South Egremont MA 01258 8/31/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont_) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Oil 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.): H-10 DB-3 with 1 line in and 1 line out in fair condition. Walls show wear but are intact and not causing any restrictions. Some solids carryover. No sign of overloading or hydraulic failure. Cover 3' below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No`` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. +. Soil Absorption System (SAS) (locate on site plan, excavation not required): If,SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South Eg remont MA 01258 8/31/2015 a e. Cit /Town State p Zi g Y p Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6x6 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-6x6 Leach pit with stone. Pit found dry at time of inspection with staining about 30". No sign of overloading or hydraulic failure. Cover 3'6" below grade. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South Eg remont MA 01258 8/31/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy (locate on site plan): Materials of construction`. Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South Egremont MA 01258 8/31/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South Eg remont MA 01258 8/31/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +14'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand auger 5'through bottom of dry pit with no water encountered. Bottom of pit at 9'. Before filing this Inspection Report, please see Report Completeness Che cklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 1 Commonwealth of Massachusetts _ . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Church St. West Barnstable, MA 02668 Property Address Edward Cobden PO Box 295 Owner Owner's Name information is required for every South Egremont MA 01258 8/31/2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 LOC&T1 N ' SEW&(GE PERMIT UO. rr F} 3 ^�az 1 VILLAGE IWST&LLER 5 kI&ME e, &DDRESS — -- BUILDERS 1.3&"F- P, [.DORESS DATE PERt.AIT ISSUED D&TE COMPLM 4CE is—SUED: _3-1-s—Y — .— 15 Page: 1 of 1 CERTIFICATE OF ANALYSIS � M Barnstable Count Health Laboratory M-MA009 Y rY � ) Report Prepared For: Report Dated: 9/18/2015 Order No.: G1590380 Linda Davis Hiller 18 Thyme Ln. Osterville, MA 02655 � . Laboratory ID#: 1590380-01 Description: Water-Drinking Water Sample#: Sample Location:' 181 Church St.,W.Barnstable Collected: 09/17/2015 Collected by: Customer Received: 09/17/2015 Routine ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Nitrate as Nitrogen 0.17 mg/L 0.10 10 EPA 300.0 LAP 9/17/2015 Copper 0.14 mg/L 0.10 1.3 SM 3111 B LAP 9/18/2015 Iron ND mg/L 0.10 0.3 SM 3111B LAP 9/18/2015 pH 7.6 PH AT 25C NA 6.5-8.5 SM 4500-H-B DCB 9/17/2015 Sodium 96 mg/L 2.5 20 SM 3111B LAP 9/18/2015 Total Coliform Absent P/A 0 0 SM 9223 RG 9/17/2015 Conductance 710 umohs/cm 2.0 EPA 120.1 DCB 9/17/2015 Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician. Attached please find the laboratory certified parameter list. Approved By: (Lab Director7/'o s ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 i �a b�ha r� a 3. CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory (M-MA009) �Y �7 ;�ss�1IVS`ry� Recipient: Matrix: Water-Drinking Water Linda Davis Hiller Sampled: 09/17/2015 9:45 18 Thyme Ln. Received: 09/17/2015 11:35 Csterville, MA 02655 . Collection Address: 181 Church St.,W.Barnstable Order#: G1590380 Sample Location: Lab ID: 1590380-01 Description: RE Kit Date Analyzed: 9/17/2015 @ 14:20 Sample#: Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Sodium level is above the maxium contaminant level.Those on a low sodium diet may wish to consult a physician. EPA 524.2 - Volatile Organics by GC/MS Result MCL MDL Result MCL MDL Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L Dichlorodifluoromethane ND 0.50 Chloroform 0.72 80 0.50 Chloromethane ND 0.50 cis-1,2-Dichloroethene ND 70 0.50 Vinyl chloride ND 2.0 0.50 cis-1,3-Dichloropropene ND 0.50 Bromomethane ND 0.50 Dibromochloromethane ND 0.50 1,1,1,2-Tetrachloroethane ND. 0.50 Dibromomethane ND 0.50 1,1,1-Tdchloroethane ND 200 0.50 Ethylbenzene ND 700 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Hexachlorobutadiene ND 0.50 1,1,2-Tdchloroethane ND 5.0 0.50 Isopropylbenzene ND 0.50 1,1-Dichloroethane ND 0.50 Methylene chloride ND 5.0 0.50• 1,1-Dichloroethene ND 7.0 0.50 Methyl-tert-butyl ether ND 0.50 1,1-Dichloropropene ND 0.50 Naphthalene ND 0.50 1,2,3-Trichlorobenzene ND 0.50 n-Butylbenzene ND 0.50 1,2,3-Tdchloropropane ND 0.50 n-Propylbenzene ND . 0.50 1,2,4-Trichlorobenzene ND 70 0.50 p-Isopropyltoluene ND 0.50 1,2,4-Trimethylbenzene ND 0.50 sec-Butylbenzene ND 0.50 1,2-Dibromo-3-chloropropane ND 0.50 Styrene ND 100 0.50 1,2-Dibromoethane(EDB) ND 0.50 tert-Butyl benzene ND 0.50 1,2-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 5.0 0.50 1,2-Dichloroethane ND 5.0 0.50 Toluene ND 1000 0.50 1,2-Dichloropropane ND 0.50 Total xylene5 ND 10000 0.50 1,3,5-Tri methyl benzene ND 0.50 trans-1,2-Dichloroethene ND 100 0.50 1,3-Dichlorobenzene ND 0.50 trans-1,3-Dichloropropene ND 0.50 1,3-Dichloropropane ND 0.50 Trichloroethene ND 5.0 0.50 1,4-Dichlorobenzene ND 5.0 0.50 Trichlorofluoromethane ND o.50 2,2-Dichloropropane ND, 1 0.50 Surrogates %Recovered QC Limits(%) 2-Chlorotoluene ND 0.50 p-Bromofluorobenzene 810/0 70 130 4-Chlorotoluene ND 0.50 1,2-Dichlorobenzene-d4 97%, 70 130 Benzene ND 5.0 0.50 Bromobenzene ND 0.50 Bromochloromethane ND 0.50 Bromodichloromethane ND 0.50 Bromoform ND 0.50 Carbon tetrachloride ND 5.0 0.50 Chlorobenzene ND 100 0.50 Chloroethane ND o.50 Approved By: Attached please find the laboratory certified parameter list. (Lab Director) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, P0. Box 427, Barnstable, MA 02630 Ph: 508475-6605 Page 1 of 1 4=L- LOC&MoKi : SEWO C-IE PERMIT UO. — — -�Lpl ff, ei 7— �7, 3 VILLAGE L/ III It�ISTL�,I.LERS 1J�tJlE" � ADDRESS i-q7 asl�d -2;� ®_ BUILDER 'S Q &VAF- �. ADDRESS D4.TE PERMIT ISSUED DATE COMPLI &&ICE ISSUED : I r• 4. r� 's .4 . y r v • fa JAl L <r � N Fin THE COMMONWEALTH OF MASSACHUSETTS \ �2°y BOAR® OF HEALTH ��� R AULR �M o MICHNIEiMICZ - ®J Town Barnstable No.3042 0 - - -------------------------------------------------------- ca rs CIVIL Apli irFa#ion fnr DispatiFal Works C�nni#rnr#inn ami# �s�, Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage isposa io /-8 ` System at: Centerville-W. Barnstable Road- Lots 16 & 17 ................_................................................................................ ................------.....---........-•----•---------•--•--------.........--••---•-•••---•------- Location-Addr s or Lot No. ..Church Street �' ......................•-----..................----•--••------....--•......--...... church . . Address a - Installer Address Type of Buildi Size Lot_.46 156 + Sq. feet Dwelli — o. of Bedrooms.................3........................Expansion Attic ( ) Garbage Grinder (jo) Other ype of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ---------------------------------- W Design Flow............ .............................gallons per person per day. Total daily flow............_.330__....__.-.._.____._..gallons. WSeptic Tank—Liquid capacity_.1 00.gallons Length.... Width_41-10"_. Diameter----1Q'__-__ Depth5'4"_...-_ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..._-_1---------... Diameter.__1Q.-......... Depth below inlet...5 67_'.... Total leaching area.....257......sq. ft. Z Other Distribution box (x) Dosing tank ( ) - '-' Percolation Test Results Performed by....__..Baxter &_ Nye Date.......8�27�81................ aTest Pit No. 1___--.2...-_..minutes per inch Depth of Test Pit......12__...--... Depth to ground water........................ Test Pit No. 2.......2.------minutes per inch Depth of Test Pit------ 2--------- Depth to ground water........................ a ----------------------------------------------•----------------------.............•-----.........---......................................................... 0 Descri tion of Soil....`I'-P#1_0"-24" fill-- 24"--48" loam and subsoil; - -----------------------------------------------•------------- x 48"- 44" med. sand w/ stones; TP#2 o"-12" fill; 12"-48" loam --------------------------------------------------•-•----•------••-----------------.....---------------------------------------•--•----•----------------....--•--...-------•-••-------. W and subsoil; 48"-140" Med. to find sand with stones. x ------------------ ----- ------------------------------------------------------------------------•----------------------------------------------------=---•----------------------------•------------• U Nature of Repairs or Alterations—Answer when applicable----%-------------------------------------------------------------------------------•-.--.--__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance.with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Complianc has been is ed by th board o lth. .. -------------- v -ZS- 3 - -- ----- Application Approved By-----•----- -- -- --- --------- --••---- ---------- -----�e... � 1....... ---------------------------•-------•- Date Application Disapproved foill e Mowing reasons------------- --------------------------------------------------------------•--------------------------•---- ..................••--•-.....-----------------------------------•------.......--•---------•------------------------•-----------------------------------------------------------------•---••------------ Date PermitNo......................................................... Issued....................................................... Date - f l� -7 No.r.... '.......... Fxs. THE COMMONWEALTH OF MASSACHUSETTS 'A OF L BOAR® OF HEALTH �0�� ROGER^�C`y� Town ................OF.Barraly�1�71e PAUL . _ ......------..........................._................. 0 MICHN EWICZ No.30420 ApplirFation for Uhipoii al 19orkii Towitrnrtinn Permit CIVIL o o� a Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage 0�I System at: " Centerville-W. Barnstable Road- Lots 19 & 17 l02� 83 ................-................................................................................ .......-------•----------...--•---•---•-----------•--•-•-•-•--•--•-•-------------......---------•- Church Street Location-Address or Lot No. ......................-.......................JA4.-j-�` .-.�:_.._�-ter-.��:1'� --------------------------------------•-----........---•----................------.....-----•-•--- Owner Address Installer Address �6 ..56 + Type of Building Size Lot....__t _.._..............Sq. feet U Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder 00 ) a g— p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other xtures ------•----•......-----•----•--• • Design Flow-•---•••.-_....................................gallons per person per day. Total dail flow_..._....._.._...............................�, W e n Q e " e ';Iohs. 9 Se tic Tank—Li uid ca aclt _�:d�d_ b �� 10 5 � P q P Y gallons Length................ Width.::_._........_. Diameter._._ .___.._ Depth_....__._.._.... Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..........._........sq. ft. Seepage Pit No.____1............. Diameter... ... ---_-__-__ Depth below inlet._.5.67 Total leaching area____257......sq. ft. Z Other Distribution box (X Dosing nk %a 4er)& 1`nre 8/27/81 Percolation Test Result Performed by..........................---..-_._-------- ._ ............ Date........................................ Test Pit No. 1------ _-------minutes per inch Depth of Test Pit.....�2•••--•••-- Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p TP#x � N " i�Z� 2 "�_8ir,..arid subria; - -----------------------------------------------•-- . �., x IC,EX . ilC �n?/ 9tdi�S i r'm�: ©''-1 ° .__.•_ __..._..._ tA.. _ ._rr.._..:,r Y'. T�� .._ .._.._�_•.......... . ............................................................. W a SL71�GCra-�t O , 1 I�A Q to f im if1t Vith :5'�"All+�.5. --------------------------- ----------•-----------•------------------..........................................................................=..........:-----•................................... UNature 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 T'TT IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Complian has been is ed by the boardeath t = ....................... �5• -Z -. �/ Dat Application Approved B l 1 ''-------- ----------•------•-------•---•...........•----- -••-= �-= y� -•--_•-- PP PP Y--••----- Date Application Disapproved f o -he oRowing reasons-------------------------------------------------------•---------•----------------------------••-------•-•-•--- --....---•--•--••-•....-------••------------•---•---•••--•-----•-•--•--.....-•---•---••--••• ...................--•--------•-•-•-•------...-••-•--------••••---•-••------••---•-•---•-••--•-•----------. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` ..........................................OF..................................................................................... Trrtifiratr of Tnmplianr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed Repaired ( ) i r i� stiller at--=..........................----------•-------------------------------•==------------------------_.._..------------------------------------------------------------------- ...................... has been installed in accordance with the provisions of TITizr5 of fThe State Sanitary Cqk6 as escribed in the application � _.._7.2....................... datedh::- '._ __�.,i--_---__--------•------- PP for Disposal Works Construction Permit '� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTEM WI CTION SATISFACTORY. DATE.... .. .... .......................................................... Inspector.-•-- --• ----•--•-----••••-•••----•--•-••••---•---------------•---.....----•----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.... ---------- Nt c r� �..-/............ FEE.---•-•--•-•--.......... Disposal Workg Tnnitraartilaaa rrmit Permission is by granted............... ....._.... ....... to Cons %( or Rep ..(/ ) an , al Sewage Disposal System f . C fl . Street as shown on/theapcatio or Disposal Works Construction Permi �d'o.................... Dated.___..._._..___..__............_._........ ....................................... Board of HealthDATE-------- ------ -------•- , FORM 1255 HQBBS & WARREN, INC., PUBLISHERS _..�-.-.