HomeMy WebLinkAbout0215 CHURCH STREET - Health 215 Church Street
W. Barnstable
A = 153 026
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`� CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory (M-MA009)
Report Prepared For: Report Dated: 10/7/2016
Sally Desmond
Desmond Well Drilling Order No.: G1697002
P O Box 2783
Orleans, MA 02553
---.-.. ---,..... _—_.. . ....—. -- ... ...--._... - ...... .. ....---- .._..
i
Laboratory ID#: 1697002-01 Description: Water-Drinking Water
Sample#: Sample Location: 215 Church St W. Barnstable Collected: 10/05/2016
Collected by: DWD Received: 10/05/2016
Roufine_M
ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE
Nitrate as Nitrogen 0.35 mg/L 0.10 10 EPA 300.0 LAP 10/6/2016
lron ND mg/L 0.10 0.3 SM 3111B LAP 10/7/2016
mg/L 0.025 0.050 SM 3111B LAP 10/7/2016
Manganese ND
pH 6.5 PH AT 25C NA 6.5-8.5 SM 4500-H-B DCB 10/5/2016
Sodium 120 mg/L 2.5 20 SM 3111B LAP 10/7/2016
Total Coliform Absent P/A 0 0 SM 9223 RG 10/5/2016
umohs/cm 2.0 SM 2510B DCB 10/5/20
Conductance 730 i
Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician.
Vt
Attached please find the laboratory certified parameter list. Approved B `G'�
(Lab Directoyl
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory (M-MA009)
- ............ _...._.....
Recipient: Sally Desmond Matrix: Water-Drinking Water
Desmond Well Drilling . Sampled: 10/OS/2016 13:30
P 0 Box 2783 Received: 10/05/2016 14:00
Orleans, .MA 02553 Collection Address: 215 Church St W. Barnstable
Order#• G1697002 Sample Location:
Description: rtn-M 215 Church St W.Barnstable
Lab ID: 1697002-01 Date Analyzed: 10/5/2016 @ 9:35
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
ResultrMCL MDL Result MCL MDL
Parameter ug/L I!, ug/L ug/L Parameter ug/L ug/L ug/L
Dichlorodifluoromethane ND 0.50 'Chl�rm 1.1 80 0.50
_.. _
Chloromethane ND i 0.50 cis-1,2-Dichloroethene ND 70 0.50
.Vinyl chloride ; ND 2.0 0.50 cis-=,3_Dichloropropene ND 0.50
Bromomethane ND 0.50 Dibromochloromethane ND 0150
1,1,1,2-Tetrachloroethane ND 0.50 Dibromomethane ND 0.50
1,1,1-TrichIoroethane ND 200 0.50 Ethy'Ibenzene ND 700 0.50
- - _...._ ...
1,1,2,2-Tetrachloroethane ND 0.50 Hex3chlorobutadiene. ND 0.50
1,1,2-Tri chi o roetha n e ND 5.0 0.50 Isc-propyl benzene ND 0.50
. --.... -
1,1-Dichloroethane ND 0.50 Me t-iylene chloride ND 5.0
1,1-Dichloroethene ND 7.0 0.50 Met.iyl-tert-butyl ether 0.78 0.50
1,1-Dichloropropene ND 0.50 Naphthalene ND 11.1................................... 0,50
_
-- -
�1,2,3-Trichlorobenzene ND 0.50 n_Butylbenzene ND o,sa
1,2,3-Trichloropropane ND 0.50 - n-Propylbenzene ND
0.50
1,2,4-Trichlorobenzene ND 70 0.50 p-Isopropyltoluene ND o.50
1,2,4-Trimethylbenzene ND 0.50 sec-Butylbenzene ND 0.50
_
1,'2 Dibromo 3-chloropropane ND o.5o Styrene ND 100 0.50
1,2 Dibromoethane(EDB) ND 0.50 tent-Butyl benzene ND
0.50
1,2-Dichlorobenzene - ND 600 0.50 Tetrachloroethene ND 5.0 0.50
l0005.0 0.50 ND 0.50
�1,2QiChloroethane N
�1,2-Dichloropropane ND 0.50 Total xylenes ND 10000 0.50
1,3,5-Tri methyl benzene ND 0.50 trar:s-1,2-Dichloroethene ND 100 0.50
1,3-Dichlorobenzene ND 1 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 0.50
2,2 Dichloropropane ND o.so Surrogates %Recovered
QC Limits(%)
_..._. . ....-.......
2-Chlorotoluene ND o.5o p_gromofiuorobenzene 100% 70 130
- - 0.50 _ -.....,.....
4 Chlorotoluene ND 1,2-Dichlorobenzene-d4 102% 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) `
tam
/ V-r-
ND=None Detected RL = Reporting Limit MCL=Maximum Con
inant Level
3195 Main.Street, P0. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page 1 of 1
Massachusetts Department of Environmental Protection
Bureau of Resource Protection
Well Completion Reports
Lin"
.......... .......... ............................. .......... ................. ...........
Well Driller
m
c�
Please specify work performed: Address at well location:
New Well Street Number: Street Name:
r+
215 CHURCH ST Cn
Please specify wsll type: Building Lot#: Assessor's Map#:
Domestic
Assessor's Lot#: ZIP Code:
Cy
Number Of Wells; 02668
City frown:
Well Location BARNSTABLE
In public right-of-way: GPS
f"Yes (—No North: West:
41.69541 70.37675
Subdivision/Property/Description:
Mailing Address:
click here if same as well location address
Property Owner: Street Number: Street Name:
WOOD 215 CHURCH ST
City/Town: State:
Engineering Firm: BARNSTABLE MASSACHUSETTS
ZIP Code:
02668
Board of health permit obtained:
f:Yes f Not Required
Permit Number: Date Issued:
W2016 022 09/22/2016 }
.......................................................................................i
i
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Well Driller Program
Well Completion Reports(General)
-----------
Well Driller - General Well Form
4 DRILLING METHOD
Overburden Bedrock
Auger -Choose Bedrock--
tt_,.._-
WELL LOG OVERBURDEN LITHOLOGY
__ .... . �......-..........
._._
From(ft) To(ft) Code Color Comment Drop in drill Extra fast or slow Loss or addition
stem drill rate of fluid
20 Silty Clay Brown YES NO �'Fast Slow Loss Addition
f ("Fast Slow Silty Clay Brown ( S _........� LLoss Addition
YENO
40 50 Sil Cla rown f`Fast f Slow
— y _................. B YES NO Loss Addition
50 55 Silty Sand Brown r Fast(-Slow YES NO .. -__._ _ ._ ! Loss7�d..................
......................... ................... ..........
..................................................
....
..................
r.
.........
---------------1: r (11
55 ... ._. Medium Sand Reddish Brown ± i Yf Fast t Slow Loss Addition
YES NO tt
.W.W....-W.-..�... _-
75 80 (('Mediu m San �. Reddish Brown
...__.� l d � Fast("Slow Addition
YES NO ............................... Loss A
_. —
_....._ _ ( C, [Loss
r
80 (85 (Fine To Coarse S • Brown YES Np 'Fast Slow
.._... L ...... .... �........ _ Addition
WELL LOG BEDROCK LITHOLOGY
Loss or j Extra
Drop in Extra fast or i Visible Rust
From(ft) To(ft) Code Comment addition of Large
drill stem slow drill rate fluid Staining Chips
p
( f: 111
r
Choose Code Yes iYes
--� - ............................................................... YES NO Fast Slow Loss Addition --�_-. ���-----�
__.............................................-.:..........:................:::._........_..........�.._..: c:::.:..............................:....::::::.........................::::r_.........._........................................................................._................
�
ADDITIONAL WELL INFORMATION
...................................
Developed t ;Yes t No Disinfected Yes `No
Total Well Depth 85 Depth to Bedrock
Surface Seal Type (None racture Enhancement Yes (:No
CASING 'Is Casing above ground? From: 1 To: 0
From To Type Thickness Diameter Driveshoe
Polyvinyl Chloride ! Schedule 40 4 I�Yes
SCREEN r No Screen
From i
I To Type Slot Size Diameter
......................................................................................__..............................................................................................................................................._...__._........................................................_...._.................................................................................................._..._....._........._.........................._..........
(81 85 Stainless Steel Well Point r
WATER43EARING ZONES r!DRY WELLS _ .,
Massachusetts Department of Environmental Protection
L7,1
Bureau of Resource Protection—Well Driller Program
Well Completion Reports(General)
From To _ Yield(gpm)
17 85 15
PERMANENT PUMP(IF AVAILABLE) Y
........................................................................
:
2 Wire Constant Speed
Pump Description Horsepower I {
Submersible...........................................--.... 3/4
:................................. 1.......3
Pump Intake Depth(ft) 81 Nominal Pump Capacity(gpm) 15
ANNULAR SEAL/FILTER PACK
Water Batches Method Of
From To Material 1 j Weight Material 2 !Weight
(gal) (count) Placement
(Choose Matenal !I Choose Material ( Choose One--
WELL TEST DATA
!Time Pumped Pumping Level(ft Time To Recover Recovery(ft
Date Method Yield(gpm)
(HH:MM) BGS) (HH:MM) BGS)
--
00,
[10/OSI2016 Constant Rate Pump
WATER LEVEL
Date
Static Depth BGS(ft) Flowing Rate(gpm)
Measured
(10/OS/2016 17 15
L.__.-_ .._._ ... -,.,.
COMMENTS
• i
WELL DRILLERS STATEMENT
This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete
and accurate to the best of my knowledge.
DESMOND
Supervising Driller
THOMAS E Monitoring[M] III,
Signature
DrillerDESMOND III Registration# 764 THOMAS,E
DESMOND WELL
Firm DRILLING INC. Rig Permit# 023 Date Job Complete 1^0/27/2016
NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
No.w26(6 'c—N Z7,7 . Fee 1
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tipprication jFor Yell Construction Permit
Application is hereby made for a permit to Construct(J), Alter( ), or Repair( ) an individual well at:
Location-Address Assessors Map and Parcel
�n Sv�u 6 da 215 Cyr S , V�( ,`13uc�Nl4_ , 02�6
Owner Address
Installer-Driller Address
Type of Building
Dwelling y
Other-Type of Building No. of Persons
Type of Well SOM O e�(— LtI' Capacity i of y--
Purpose of Well a, PA
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Za 6
Date
Application Approved By
Date
Application Disapproved for the following reasons:
—7 ,' Date
Permit No. 1,0 CSC/ Issued VZ72—Az I
Date
--------------------------------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate of (tomphance
THIS IS TO CERTIFY,that the individual well Constructed(�), Altered( ), or Repaired( )
by 1y�(—
Installer
at 215 C, ,.�c�.. �'; •�4� h.S �.-
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 No.k)Z(x(V —cZ-Z. Dated f(&o zG�L
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
----
1
No.W Z'0(G zz Fee '(
BOARD OF HEALTH
TOWN OF BARNSTABLE
01pprication _for lVell Cou6tructiou Permit
Application is hereby made for a permit to Construct(,J), Alter( ), or Repair( ) an individual well at:
Location-Address' Assessors Map and Parcel
14 � (1t)c� 2!5 C by rtw. S� ctc �cl �� C)7G�
Owner Address
Installer-Driller Address
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well SL\-V p QV - y' Capacity 101 �
Purpose of Well;6a\1'
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 912011 t
Date
Application Approved By
Date
Application Disapproved for the following reasons:
Date
Permit No. t") Issued 7 l�
Date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate of Compliance
THIS IS TO CERTIFY,that the individual well Constructed(/), Altered( ), or Repaired(
by
J Installer
at Z 1s
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 Nozu?or6 -QZZ Dated ? 4„
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date, Inspector
BOARD OF HEALTH
TOWN OF BARNSTABLE
( Verr Con5tructiou Permit L� W
No. b ' O Z� Fee �J .
Permission is hereby granted to CY,—.% n�
Installer
to Construct(v6, Alter( ), or Repair( an individual well at:
No. .7i& riSA-.Ao(&—
Street
as shown on the application for a Well Construction Permit No
Date ( Lzz/zo Approved By
Town of Barnstable Barnstable
of tr+E to
AN-AmMcaUY
Regulatory Services Department
BARNSTABLE.
�.9'0. 539.. �� Public Health DivisionAll
.y�639 �0
o MA� 200 Main Street, Hyannis MA 02601 2007
ti
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
March 21, 2008
Abraham Dietz
215 Church Street
West Barnstable, MA 02668
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 215 Church Street, West Barnstable was last inspected on
March 2, 2008, by Michael Kellett,.a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Sanitary tee at the outlet end of the tank is crumbling and in need of replacement.
You are ordered to repair or replace the septic system within Two (2) years from the date
of this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BO RD OF HEALTH
u
Tho McKean, R.S., CHO
Agent of the Board of Health
CERTIFIED MAIL# 7006 2150 0002 1038 7046
Q:\SEPTIC\Letters Septic Inspection Failures\215 Church Street.doc
I`
r Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System F g p y Form Not for Voluntary Assessments � s
215Ch r M u ch Street !1�5
Property Address
Abraham Dietz
Owner Owner's Name
information is 'West Barnstable
required for MA 02668 03/02/08
every page. CitylTown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out :., ..
forms on the
C:LD
computer, use 1. Inspector: `
only the tab key "
to move your cursor-do not Michael Kellett
use the return Name of Inspector z _
key- Aardvark Environmental Inspections
F
Company Name
t± P.O. Box 896 µ
Company Address
East Dennis MA 02641
City/Town State yip Code
508-385-7608 S13742
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
03/03/08
Inspect is 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 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.
fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°7M 215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is West Barnstable MA 02668 03/02/08
required for
every page. Citylrown 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:
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:
IThe sanitary tee afthe outlet-en-d-of-the-tank-was-crumblingand-in need of replacement.
---�.4
❑ 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
fail•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is required for West Barnstable MA 02668 03/02/08
every page. Cityl own State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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:
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 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.
fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is required for West Barnstable MA 02668 03/02/08
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
moretfrom 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 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 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.
fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is required for West Barnstable MA 02668 03/02/08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cost:)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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 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.
fail•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is required for West Barnstable MA 02668 03/02/08
every 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)]
fail-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Y: W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
215 Church Street
"M
Property Address
.Abraham Dietz
Owner Owner's Name
information is required for West Barnstable MA 02668 03/02/08
every page. CitylTown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 10/07
Date
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:
Last date of occupancy/use: Date
Other(describe):
fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is required for West Barnstable MA 02668 03/02/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® 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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
04/27/81 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
fail-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is
required for West Barnstable MA 02668 03/02/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 1.3
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: .5
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: 1000 gal
Sludge depth: 9
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle even
Distance from bottom of scum to bottom of outlet tee or baffle 11
How were dimensions determined? measured
fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is required for West Barnstable MA 02668 03/02/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was sound and tight with atee that had dissolved to the liquid line liquid was at the outlet
invert.
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
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):
fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a �M 215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is
required for West Barnstable MA 02668 03/02/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
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
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert even
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.):
The box was level and tight with some carryover present
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
fail•08/05 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
f
Commonwealth of Massachusetts
4 r Title 5 Official Inspection For
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is required for West Barnstable MA 02668 03/02/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2@2'x25'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovativelalternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
This system has two stone lined trenches which were two feet wide by twenty-five feet long and a
6'x4' pit surrounded bytwo feet of stone. There was no sign of ponding or failure.
fail-o8m Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is
required for West Barnstable MA 02668 03/02/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
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
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.):
fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
loom= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is required for West Barnstable MA 02668 03/02/08
every page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
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.
a
S
fail•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
. Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
215 Church Street
Property Address
Abraham Dietz
Owner Owner's Name
information is West Barnstable required for MA 0266$ 03/02/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to ground water: 25
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:
USGS maps show an elevatoin of over 25'.
fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Town of Barnstable
y�F THE Tp�
Regulatory Services
snxrsrAI M ; Thomas F. Geiler,Director
MASS. . g
9�A 1639. Public Health .Division
TEp Mp`l A
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862 4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although.the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observations and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
i
COMPLETE •N COMPLETE THIS SECTIONON DELIVERY
0 Complete items 1,2,and 3.Also complete A Sign u
item 4 if Restricted Delivery is desired. Agent
0 Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. ived by,(P" d Name) C. Da of?elivery
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
D. Is delivery add different from item 17 Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
I I
jPOO c-a rc, ` -"CA 1—
a ks-
0TL66 3. Service Type
e Certified Mail ❑Express Mail
❑Registered ®Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number _ 7006 2150 0002 1038 7046
(Transfer from service labe l)
PS Form 3811,February 2004 Domestic Return Receipt 102595-0240-1540
II
UNITED STATES POSTAL SERVICE First-Class Mall
Postage&Fees Paid
LISPS
Permit No.G-10
I
• Sender. Please print your name, address, and ZIP+4 in this box • j
A
I
I I
i 0 W.
ot
Town of Barnstablehealth Division _ ,:;200 Main Street �i'1 -n
Hyannis,MA 02601
J
rase, Sveke,t3' c{01 �1fiiEfl
(JI M I
i
COMPLETE THIS SECTION,ON DELIVERY
SENDER: COMPLETE,THIS SECTION .
■ Complete items 1,2,and 3.Also complete A. Signa 1, r
Item 4 if Restricted Delivery is desired. ,-'0 Agent
I N Print your name and address on the reverse ❑Addressee
SO that we can return the card to you. B. ived by(Prl d Name) C. Da of slivery
® Attach this card to the back of the mailpiece, nVl%"/ 3
or on the front if space permits. Ad
D. Is delivery add different from Item 11 50yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
awes 0h r-C� 5
A,"N t � Cit L 3. Service Type
1 ■Certified Main ❑Express Mail
0 Registered ®Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(aft Fee) [3 YM
z Article Number 7006 2150 0002 1038 7046
(rmnler from servloe
'PS Form"3811 February 2004: Domestic Return Receipt 102595-024e-1540
'is!i ! rt faa'
I .
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rpplicatton for Oig aal *pttem Cow6truttion VCrmtt
Application for a Permit to Construct( ) Repair(grade( ) Abandon( ) ❑Complete System ❑Individual Components
�L\' e�Vrc
Location Address or Lot No. L_ S I�` r�� �... Owner's Name,Address,and Tel No.
i�la w.
Assessor's Map/Parcel wl 15-3 @ O
Installer's Name,Address,and
Tel.No. �. Designer's Name,Address and Tel.No.
Type of Building: /
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
ll C.►
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed .,,, �. Date -3 2 Odd
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. , Date Issued
....,10,v'�-�.;
No. Fee
THE COMMONWEALTH OF MASSAC,HUSETTS
Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for &gpogal *pgtem Conotructiou permit
Application for a Permit to Construct O Repair(/) Upgrade O Abandon( ) ❑ Complete System ❑Individual Components
Z�� C`lhv�.� S�
Location Address or Lot No. � � Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel ) Q 0,00
Installer's Name,Address,and Tel.No. --- Designer's Name,Address and Tel.No.
k-�t.a\e-cry eO41 /
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other .Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 4
V,4—�e r
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
/Compliance has been issued by this Board of Health.
a
Signed _ �,. 0. n. Date 3
AApplication Approved b Dat
PP PP Y � /l l!!/l .•, ..J e
- \- im^ /
v y. ..
Application Disapproved by: Date !
for the following reasons
.4
Permit No. U Date Issued-
THE COMMONWEALTH OF MASSACHUSETTS -
�C,� �" BARNSTABLE, MASSACHUSETTS
004 Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( )
Abandoned( )by � ` Q" dH,i
at Clad rel„ ['Q'~ \/-� � has een constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �/c� dated
Installer Designer
#bedrooms Approved design flow / „( gpd
The issuance of this pe)indshall{not be construed as a guarantee that the system Zuf furiction as designed.✓' p
Date t, Gam'}/ /�� Inspectorf
-------/—�--------------------
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
Digpool *pgtem Cougtruction J)ermit
Permission is hereby granted to Construct ( l) Repair ( Upgrade ( ) Abandon
� ( )
System located at -/ S' C' v r"
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be�c'o�m feted within three years of the date of this permit.
Date /U� Approved by
%OF H4
CERTIFICATE OF ANALYSIS Page. 1
Barnstable County Health Laboratory
Report Dated: I1/12/2004
Report Prepared For:
Order No.: G0428520
Abraham Dietz MAP �._..�_ 5
215 Church Street PARCEL " ®Z
West Barnstable, MA 02668 LOT
Laboratory ID#: 0428520-01 Description: Water-Drinking Water
Sample#: 28520 Sampling Location 215 Church Street West Barnstable MA
Collected: 11/3/2004
Collected by: NM Map 153 Parcel 026 Received: 11/3/2004
Routine
ITEM RESULT UNITS RL MCL Method# Tested
LAB: Inorganics
Nitrate as Nitrogen 0.25 mg/L 0.1 10 EPA 300.0 11/3/2004
LAB: Metals
Copper 0.24 mg/L 0.1 1.3 SM 311113 11/5/2004
Iron 0.52 mg/L 0.1 0.3 SM 311IB 11/5/2004
Sodium 56 mg/L 1.0 20 SM 311113 11/5/2004
LAB: Microbiology
Total Coliform Absent P/A 0 Absent 307 11/3/2004
LAB: Physical Chemistry
Conductance 390 umohs/cm 1 EPA 120.1 I1/3/2004
pH 5.7 pH-units 0 EPA 150.1 11/3/2004
Sample has higher than average levels of Sodium.Those on a low Sodium diet may want to consult a physician.Based on the
results,the water is suitable for drinking,but may present aesthetic problems(taste,odor,staining)due to I n.
Approved By. e
Director)
• >
C)
Cfl
RL = Reporting Limit --1 M
MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
ION S`EIN ACE PERMIT NO.
LW ;
VILLAGE
INSTALLER'S N E i ADDRESS
OR OWNER
DATE PERMIT ISSUED 4 N
DAT E COMPLIANCE ISSUED . � .•:-
t��/ �_ �
D
•,.r
�--
� _ _._ �-
� .
No.._.P..�.. Fx$... ..................
THE COMMONWEALTH-OF MASSACHUSETTS
a(p BOAR® F� H EALTt-�
r
� o ...---•. .�,A..�....OF............
�s
�3 Applirathiaa rear 'Dispos al Works Ta nstrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal
System t
....-. . -....: ter... - . •....................................
atio Add s or Lot
- .. � -...._... .�:. . ................... ... .... �_.......
........
Installer a
� Address
U Type of Building Size Lot....'Se(.1'0.0_..Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g ---------------------------- P ( ) — 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.........................
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Q+' ------------------------------------------------------------
--•
------......................................................................................
0 Description of Soil........................................................................................................................................................................
x
V ......--•-•--•----•.................••----•-----------
UW •-•----•......................•-••---------•-----•----•-------•------------•----••------......-----•...--•-----••- _
Nat re of Repairs or Alteration —Answer when applicable._..__ l__�_.____.__
----� � .....
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITA IE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by the board f health.
gned.. ........ • ... ••--•..... .... ... ............V.. . ......
Date
Application Approved By.... C9 � l�-... .... .-- . .................... ..................
Date
Application Disapproved for the following reasons:-------••-----••-•------------------------------------------•-••------------•--------------•---•-•----•---------
..-•------------------------------.....-----.-•--...----------•-•---•-----•..-----------•----•---•--------..- ..........._..--
. 7ti.�
Da
Permit No. _.._ Issued.... ............ .............
Date
V
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H EA1
.:: ....OF........:.:. .............. ........................
Appliration for Disposal Works Tonstrurtion, Prrutit
Application is hereby made for a Permit to Construct or Repair O<Oan Individual Sewage Disposal
Syst t
........ . .......
.... ... . .... . ................... ................................ . ...................................
alio Ad 9s or I'D
. ........
.... .. ... ........ A..... 0
0w er s
...................... .......4�ed ...6........................
Installer Address
Type of Building Size Lot..__' 1.120.0...Sq. feet
....... .........
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width.____........... Diameter-_-_--_---__-__- Depth................
Disposal Trench—No..................... Width.._......._..__._... Total Length_..__............... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter.............__..... Depth below inlet.........._........ Total leaching area..................sq. f t.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
Wiest Pit No.`
1................minutesperinch Depth of Test Pit._____.....__....... Depth to ground water..._................._.-
GX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................:_. Depth to ground water..._._._............_...
P4 *...*........................................................................................................................................................
0 Description of Soil........................................................................................................................................................................
W
---------------------------*---------*-------------------------------*-------------------------------------------------------------------------------------------------*----------------
. .6,-po V /4...1....� ...I-...
4
U Na i; f Repairs or Alteration when app1icable-----
j---- . ............
mAgreeent
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 b issued by the 2ard f health.
gned .. . .... ...I......... .......................... .. . ...... 7
D..........
Application Approved By ... . ...... ..... . ........... .... .......... . .. ....................
Date
Application Disapproved for the following reasons:..............................................................................................................
........................a..................................................................................................................................I.............................................
Date
PermitNo......................................................... Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... . .. ............................. OF............. A.kiN..TZA114.16.... .......... .....
THIS IS TO CERTIFY, That the Wividual Sewage Disposal System constructed ( ).,or Repaired o
by..............Z�&Ie>e.............
qp/
........................................................................................................
Installer
at &;i4etZ.A-A Z"L:...............................................
.............4A27......3............ ...... .................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.-6.10......16.5.. ..................................
S........ dated---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIOtj SATISFACTORY.
DATE................. 7— fY
......................................................... Inspector__Z,_Q�?;�O/-----------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........OF........L;.&..T1..A151 .........................................
au
No.... Disposal 10�rks Tonstrudion frrmit FEE.-.5................
Permission is hereby granted................ ----------------------------------------------------------------
----------------------------------
to Construct ( or Repair an ndividual Sewage Disposal System
a
atNo........o ..;..........3........!....... ... .........Ze..,..............L' ..... -a.4... ...............................................................
Street
as shown on the application for Disposal Works Construction P_Panut't No..................... Dated.._....___........................._......
........................................
ByA of Health
DATE------` 72...14fP..................4,
...............
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS