Loading...
HomeMy WebLinkAbout0230 CHURCH STREET - Health 230 Church Street W. Barnstable P. A - 153 021 •.. Rn,..r... ..,—x.F�, g-.r •' .. _ T. vcc tea. .-,� ... _. .per-. ,- :.° n ,. - ,,.,1 `t. P r' v �S �-\ COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF.ENVIRONMENTALAFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r ' 1: TITLE 5 OFFICIAL INSPECTION:FORM..-NOT FOR VOLUNTARY ASSESSMENTS. .. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVED CERTIFICATION Property Address:. )��,� en MAY .2 8 2002. �Ly.N ���`� TOWN OF BARNSTABLE Owner's Name:�;1 h—PP a-1 n. ,6,1/. HEALTH DEPT. Owner's Address: .®. Date of Inspection:, Name of Inspector: lease print). A�T / W Company Name: Vic: �'hn�7S/a�/sots 3 Mailing Address: ea `/oy MAP , 4 v� PARCEL • 0;Z Telephone Nmemo umber 1- � - LOT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a.DEP approved system inspector pursuant.to Section 15.340 of Title 5(310 CMR 15.000). The system: /Passes Conditionally Passes Ne s.Further Evaluation by the.Local Approving Authority. f' Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to.the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the. DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority., Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will.perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Q Property Address: ,� &.mi �Sb v,pl - Owner:. ' Date o nspection: ©�a Inspection Sumi mart': 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: R. System Conditionally Passes: QA6 —O,ne:or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The systern,�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 aspapproved by the Board of.H.ealth. *A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicatinj that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or highJstatic water level in the distribution box due to broken or ob'strueted pipes)or due io' 'a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is,removed distribution box is leveled or-replaced ND explain: The system.required pumping more thanA times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction.is removed 'ND explain:.- 2 f Page 3 of 1'1 OFFICIAL INSPECTION FORM. NOT FOR.V.OLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION(continued) Property Address: CD ��p�(�fj ,Qp,/ Owner: Date of nspection: G 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. 11. System will pass unless-Board of Health determines in accordance with 310 CMR 15.3030)(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 aseptic 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 aseptic tank and SAS and the SAS is less.than 1-00.feet but 50 feet or more from.a private water supply well**,.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other - failure criteria are triggered.A,copy of the analysis must be attached to this form.. . 3. Other: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: P ep� Owner' Date of I spection: giG ()(�a D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the-following for all inspections: Yes N 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 around or surface waters due to an overloaded or Jclogged SAS or cesspool 1/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or lcesspool - Y/ 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 _ Anyportion 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. J Any portion of a cesspool or privy is within a Zone l of a public well. _ Any portion of a cesspool or privy is within 50.feet of a private water supply well. Anyportion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in310 CMR 1.5.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correctthe failure. E. Large Systems: To be considered a large'system the system must serve a facility with a-design flow of 10,000 gpd to:15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The'following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered ."yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 f Page 5 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONF.ORM- PART B CHECKLIST Property Address: �d "2A Owner: Date o �nspect�ion ; 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 systerr. components pumped out in the previous two weeks Has the system received normal flows in the previous two week period? r/ Have large.volumes of water been.introduced to the system recently or as part of this inspection? V" _ Were as built plans of tae system obtained and examined?(If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break ou.t? Were all system components, excluding the SAS, located on site Were the septic tank mEnholes 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: Yes no _ Existing information. For example,a plan.at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C.is at issue.approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of I 1 OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY°ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION Property Address: 0 1,14 Owner: � Date of inspection: eyw /lQ, 00 FLOW CONDITIONS RESIDENTIAL 1,� Number of bedrooms(:design): .: Number of bedrooms(actual): DESIGN flow based on 310 C.MR 13.203(for example: 11:0- d x#of bedrooms): Number of current residents: _ t Does residence.*have.a garbage grinder(yes or no):�� Is laundry on a separate sewage°system (yes or tro): [if yes separate inspection required) Laundry system inspected.(yes or no Seasonal use:(yes or no& .. J Water meter readings, i available(last 2 years usage(gpd)): (.1e � "?V Sump pump(yes or-no);/ v Last date of occupancy:" • a eat COM MER CIAL/IND USTRIA Lc.-� Type of establishment:.. Design flow.(based on 3l0 CMR.15:203): : . gpd' Basis of design flow('seats/persons/sgft,etc.): : .. Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title"5 system'(yes or no):' Water meter readings, if available: Last date of occupancy/use: . OTHER.(describe): GENERAL INFORMATION Pumping Records Source of irif8imafion:wj�l)-"iopd Was system.purnped as part of th" inspection(yes or nojj- If yes,volume pumped: gallons--How was quantity pumped determined?.., Reason'for pumping: . - TYPE OF SYSTEM tz Jeptic 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 ob_tained from system owner) _Tight tank _Attach a copy:of the DEP.approval Other`(describe): proximate a e of all components, date installed(if known)and source of information. Were:sewage odors-detected when arriving.at the site(yes-or no)L,4&-� 6 f - Page 7 of I 1 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a-z 1 i lc,�,A Owner: Date o Inspection: O BUILDING SEWER(locate on site plan), — Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain):- Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC.TANK:_/locate on site plan) Depth below g t.�2d' rade: '° OL2 Material of construction: concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a.copy of certificate) Dimensions: Res k Co Sludge depth: Distance from top of sludge.to bottom of outlet tee or baffle: Scum thickness:, Distance from top of scum to top of outlet tee or baffle: >✓ Distance from bottom of scum to bottom of outlet tee or.baffle: How were dimensions determined. %gQhy" 10A 4 c A Comments (on pumping recommen ations,inlet and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert evidence of leakage,etc . _ o ea Z / n` ;ai � GREASE TR��Iocate.on.site plan).' `+ Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:- Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet.tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART C SYSTEM INFORMATION(continued) Property Address:02 6, I Owner> Date of nspectian:. O� 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and-float switches, etc.): DISTRIBUTION BOX: if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leaka-e into or out of box( etc,._): PUMP CHAMBER locate on site plan) Pumps in working order(yes or no): Alarms in working order(.yes or-no); $ Comments(note condition of pump chamber, condition of pumps.and appurtenances,etc.): 8 r Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner: Y"J Date of Idpection: Md4z /(may,,2000 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not,located explain why: Type leaching.pits,number:_ leaching" e ching chambers,number: ching 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. 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 or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of_vege.tation;etc.):. PRIVYi 3--(locate on site plan) Materials of construction: Dimensions: Depth of solids: . Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM"NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: 000 A Owner• �. Date o nspection: 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. 10 Page 11 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a��� ® "jp4 Owner Date ot`nspection: SITE EXAM. Slope Surface water Check cellar. Shallow.wells Estimated depth to ground wate- feet Please indicate(check).all methods used to determine the high ground water elevation: Obtained from.system design plans on record-If checked,date of design.plan reviewed:. Observed site(abutting property/observation hole within 150 feet of SAS) Checked-with local Board of Health-explain: Checked with,local excava_ors, installers-(attach documentation) Accessed USGS database=explain: You must describe how you established the high ground water elevation: A^ M 4zillya 11 � f Permit Number: Date: Completed by:. yfGH GROUND-WAT'E•R LEVEL COMPUTATION Site Location: 2ic3i� G / ^ l Lot N`o.. Owner: /+h Address Contractor: L-� ; c Address: Notes:. STEP'' 1 , Measure depth to water table to nearest.1/10`it...:............. — :............ .Date J month/day%year STEEP 2 Using.Water-Level.Range Zone and Index WeII.M:a.plocate site.an.ddetermihe: " OAppro.priate.index well.........................................370 /- 3J Water-level range zone_ .......... ........................ .... I aT .P•: 3_: Using monthly.repo.rt,:"'Current Water Resources Conditions" determine currentde,pth-to , /gyp I = water.level for index well ............. JL=-G month year STEP. 4. Using,Tabie.o.;-a/Vater-Leval Adjustments for index well (STEP•2A:)_current depth* I. to water level fora index wel.l (STEP 3}, and water-level zone (STEP 2B) determine-water-level adjustment .................. 7 I STEP: o =stimate depth to:high water by subtracting th.e water level adjustment-(STEP 4) from measu.red:.depth to water level-at site.(STEP 1) ............................................. ..................................... t gu,,v' Iq 7 I^' a�aona.� .J:'-z. ,1 `i2piodi<t,IblGLO1T1'�Dilt,tJi�l, I�:��.T1. _ j 5. 0 �� ,__ �1 L --�- TOWN OF BARNSTABLE LOCATION 6ZI SEWAGE # J5�-2-K3.4' VILLAGE �'/'®d5����i� ASSESSOR'S MAP& LOT � ,Cz INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 4A0 44 LEACHING FACILITY: (type) xi (size) 1ox�fd NO.OF BEDROOMS BUILDER 0 OWNE PERMUDATE: COMPLIANCE DATE: IS Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility St Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished by ��230 IZr�r sy� a� 7/ ' f � � I I « °f CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory I h �qss� Report Prepared For: Report Dated: 9/9/2009 Andrew Clark Order No.: G0954504 P O Box 943 Rest Barnstable, MA 02668 Laboratory ID#: 0954504-01 Description: Water-Drinking Water Sample#: Sampling Location 230 Church St.West Barnstable,MA Collected: 9/2/2009 Collected by: Andrew Clark Received: 9/2/2009:' - Routine _ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 9/2/2009 - - •-- Copper 0.15 mg/L 0.10 1.3 SM 3111B 9/9/2009 ; Iron ND mg/L U 0 0.3 SM 311113 9i9/2009 Sodium 8,8 mg/L 1.0 20 SM 311113 9/9/2009 Total Coliform Present P/A 0 0 SM9223 9/2/2009 Conductance 130 umohs/cm 2.0 EPA 120.1 9/2/2009 pH 7.0 pH-units 0 SM 4500 H-B 9/2/2009 The recommended maximum contamination level for drinking water exceeded due to Coliform Bacteria Retesting is recommended d Attached please find the laboratory certified parameter list. Approved By: v 'a\ (La irector) 4 5-1 V ]Y R1,IY - ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory vY a Report Prepared For: Report Dated: 9/16/2009 Andrew Clark Order No.: G0954564 P 0 Box 943 West Barnstable, MA 02668 Laboratory ID#: 0954564-01 Description: Water-Drinking Water Sample#: Sampling Location: 230 Church St.West Barnstable,MA Collected: 9/4/2009 Collected by: Andrew Clark Received: 9/4/2009 j I Test Parameters ITEM RESULT UNITS RL MCL Method# Tested Total Coliform 11 CFU/l00mL 0 0 MF-SM9222B 9/4/2009 I I Attached please find the laboratory certified parameter list. Approved By: (Lab ector) ai�8 0 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION Certified Parameter List as of: 12 July 2009 M-MA009 BARNSTABLE COUNTY HEALTH&ENV DEPT, BARNSTABLE, MA Analytes Methods for NON-Potable Water Methods for Potable Water ALUMINUM EPA 200.8 ANTIMONY EPA 200.8 EPA 200.8 ARSENIC EPA 200.8 EPA 200.8 BARIUM EPA 200.8 BERYLLIUM EPA 200.8 EPA 200.8 CADMIUM EPA 200.8 EPA 200.8 CHROMIUM EPA 200.8 EPA 200.8. COBALT EPA 200.8 COPPER EPA 200.8, SM 3111 B EPA 200.8;SM 3111 B IRON SM 3111 B LEAD EPA 200.8;SM 3111 B EPA 200.8;SM 3111 B MANGANESE EPA 200.8;SM 3111B MERCURY EPA 200.8 NiCKEL EPA 200:8;SM-3 i11B - EPk200.8;SM 311113 SELENIUM EPA 200.8 EPA 200.8 SILVER EPA 200.8 EPA 200.8 THALLIUM EPA 200.8 EPA 200.8 VANADIUM EPA 200.8 ZINC EPA 200.8; SM 3111B PH SM 4500-H-B SM 4500-H-B SPECIFIC CONDUCTIVITY EPA 120.1; SM 25106 HARDNESS(CAC03),TOTAL SM 23406 CALCIUM SM 3111B MAGNESIUM SM 3111B SODIUM SM 3111B SM 3111E POTASSIUM SM 3111 B ALKANILITY,TOAL SM 2320B SM 2320E CHLORIDE EPA 300.0 FLUORIDE EPA 306.0 SULFATE EPA 300.0 EPA 300.0 / NITRATE-N EPA 300.0 EPA 300.0 NITRITE-N EPA 300.0 TURBIDITY EPA 180.1 TOTAL DISSOLVED SOLIDS SM 2540C CHEMICAL OXYGEN DEMAND HACH METHOD 8000 BIOCHEMICAL OXYGEN DEMAND SM 521013 - TRIHALOMETHANES EPA 524.2 VOLATILE HALOCARBONS EPA 624 VOLATILE AROMATICS EPA 624 VOLATILE ORGANIC COMPOUNDS EPA 524.2 1,2-DIBROMOETHANE EPA 504.1 1,2-DIBROMO-3-CHLOROPROPANE EPA 504.1 PERCHLORATE EPA 314.0 HETEROTROPHIC PLATE COUNT SM 9215B TOTAL COLIFORM MF-SM 9222B TOTAL COLIFORM ENZ.SUB.SM 9223 FECAL COLIFORM EC-SM 9221 E FECAL COLIFORM MF-SM 9222D MF-SM 9222D E.COLI EPA 1103.1 EC-MUG-SM 9221F E. COLI MF-SM 9213D ENZ.SUB.SM 9223 ENTEROCOCCI EPA 1600 Effective Date: 12 Jul 2009_Expiration Date:30 Jun 2010 I f - LEIMassachusetts Department of Environmental Protection - Drinking Water Program N , Nitrate Report _ I: PWS INFORMATION.-. Please refer to your::DEP Water Qualify Sampling Schedule(WQSS)to Help complete,.this f 't ... .,� PWS ID#: 0020022 j City 1 Town: West Barnstable PWS Name: Great Marsh Health Services PWS Class: COM ❑ NTNC ❑� TNC ❑ DEP LOCATION sr= Y '3 Sample r Date '� f^ DEP Location Name* h, Sample{Informatiori' ' � y, �� � {Collected By (L`oC)ID# a s� h e r4 Acltlrfietl? Collected A 10000 Sink in Basement '(M)ultiple d (R)aw Yes ❑ 9/4/2009 Derek Ritchie (S)ingle ❑ (F)inished B ❑ multiple ❑ (R)aw Yes ❑ ❑ (S)ingle ❑ (F)inished C ❑ (M)ultiple ❑ (R)aw Yes ❑ ❑ Sin le ❑ Finished D ❑ (M)ultiple ❑ (R)aw Yes ❑ ❑ (S)ingle ❑ (F)inished Routrrie or =Ongmal;Resubmitted or*=`#t' x �,�a��" If ResulimittedtRe ort�list below ' ` ,."' t:` iy'q�-x,'-,r'- r J, +S s*k s+' •ftv U=f' ';y'-1 `- '�. ' ''f 5 ,.�s .i �:. ,+ Special'Sample;; Confi'rmatron,Report ; � (1)Reason for Resubmtssionr� OriginaArO l Sample CollectedssDate A W IRS ❑ SS d❑ Original ❑ Resubmitted ❑ Confirmation Resample❑ Reanalysis ❑ Report Correction B ❑ IRS ❑ SS ❑ Original ❑ Resubmitted ❑ Confirmation Resample❑ Reanalysis ❑ Report Correction C ❑ IRS ❑ SS ❑ Original ❑ Resubmitted ❑ Confirmation Resample❑ Reanalysis ❑ Report Correction D ❑ IRS ❑ SS IEJ Original ❑ Resubmitted ❑ Confirmation Resample❑ Reanalysis ❑ Report Correction SAMPLE NOTES ,';(S,uch as If a Manifold/M,ultiple sample;°Ust=thesources�that were on llne,dunngdsample collecttontAN_ A g _. C D j t ++rF §1 '.•�� d} +w:5.•.w.??',X 4.+-,..i'°':4^ a. rrr^�"..wnrx,�"W ^n yam.` 3 a 'yyu" :<t'..s„ Y.: .P �i; s- I , .,.., ., n. ., �; •� � ;��# tea, Primary Lab MA Cert#: M-MA009 Primary Lab Name: lBarnstable County Health Lab I Subcontracted?(Y/N) Analysis Lab MA Cert#: Analysis Lab Name: h - KATE »�MC:Ld a x s r ,.* ,� m 'rya � -..� k a �' � � ', :: � `�; ., � i' aA- ethod � _ ,E sa fl •Date�anaglyzed ti ;a �l3esult(mg/L)� lmg/L) (mg/L) �� ;a .A G.. �:7r.1;a.x�..:- �s.�;•n:�,�,Y:F_ �,.:>:+.,a..t�� � s....,��.�`ct_c:s�,�.:,'�:..�,�:y-�.r.,a..,.. ..��.c.--c.�.-`.� '- -� ^.� fi: r_'". �' r a a ti; A 0.91 10 0.10 EPA 300.0 9/4/2009 954W-01 B 10M q s Finished water results equal to or exceeding 1/2 of the MCL(5 mg/L)triggers quarterly monitoring. Finished water results exceeding the MCL of 10 mg/L requires confirmation sampling within 24 hours. Notify MassDEP of any MCL exceedances. AB SAMPLE A B C• p _ l certify underpenalt�es:o[IawthatI amtheperson -Primary Lab Director Signature: authorized,to fill out this form and+the inforrriahon contained herein is Date: i true.;accurate:,and complete to the-'best extent my,kho of wledge If not submitting these results electronically,mail TWO copies of this report to your DEP Regional Office no later than 10 days after the end of the month in w ich you received this report or no later than 10 days after the end of the reporting period,whichever is sooner. DEP REVIEW STATUS(Initial and Date) Review WQTS 0 Accepted 0 Disapproved Comments Data Entered I LA) %)aA NP Cg-3 /® i iol /& 15 `pF BqR� CERTIFICATE OF ANALYSIS Page. ,J 7. Barnstable County Health Laboratory ;sss,�c►tus�', Report Dated: 1/18/2005 Report Prepared For: Order No.: G0529054 Andrew Clark P O Box 943 W Barnstable, MA 02668 _ _ _ Laboratory ID#: 0529054-01 Description: Water-Drinking Water Sample#: 29054 Sampling Locationr 230 Church St West Barnstable MA J Collected: 1/12/2005 Collected by: A.Clark Received: 1/12/2005 Test Parameters ITEM RESULT UNITS RL MCL, Method# Tested S LAB: Metals Manganese 0.01 mg/L - 0.01 SM 3111B 1/13/2005 Routine +Ammonia ITEM RESULT UNITS RL MCL Method# Tested LAB: IC Lab Ammonia: BRL mg/L 0.1 EPA 350.3 1/12/2005 LAB: Inorganics j Nitrate as Nitrogen 71 BRL mg/L o.l 10 EPA 300.0 1/1,2/2005 LAB: Metals. Copper : BRL mg/L' 0.1 1.3 SM 3111B 1/13/2005 Iron BRL mg/L 0.1 0.3 SM 311113 1/13/2005 Sodium 44 mg/L 1.0 20 SM 3111B 1/13/2005 LAB: Microbiology Total Coliform Absent P/A 0 Absent 307 1/12/2005 LAB: Physical Chemistry Conductance 190 umohs/cm 1 EPA 120.1 1/12/2005 pH 8.0 pH-units 0 EPA 150.1 1/12/2005 I EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Tested LAB: GUMS 1,1,1,2-Tetrachloroethane BRL ug/L. 0,5 EPA•524.2- 1/12/2005 1,1,1-Trichloroethane BRL ug/L 0.5 200 EPA 524.2 1/12/2005 RL = Reporting.Limit - MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page. 2 CERTIFICATE OF ANALYSIS 9s �' Barnstable County Health Laboratory .,S,�CHVSt%1 Report Dated: 1/18/2005 Report Prepared For: Order No.: G0529054 Andrew Clark P O Box 943 W Barnstable, MA 02668 1,1,2,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 1/12/2005 1,1,2-Trichloroethane BRL ug/L 0.5 5.0 EPA 524.2 1/12/2005 1,1-Dichloroethane BRL ug/L 0.5 EPA 524.2 1/12/2005 1,1-Dichloroethene BRL ug/L 0.5 7.0 EPA 524.2 1/12/2005 1,1-Dichloropropene BRL ug/L 0.5 EPA 524.2 1/12/2005 1,2,3-Trichiorobenzene BRL ug/L 0.5 EPA 524.2 1/12/2005 1,2,3-Trichloropropane BRL ug/L 0.5 EPA 524.2 1/12/2005 1,2,4-Trichlorobenzene BRL ug/L 0.5 70 EPA 524.2 1i12/2005 1,2,4-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 1/12/2005 1,2-Dibromo-3-chloropropa BRL ug/L 0.5 EPA 524.2 1/12/2005 1,2-Dibromoethane(EDB) BRL ug/L 0.5 EPA 524.2 1/12/2005 1,2-Dichlorobenzene BRL ug/L 0.5 600 EPA 524.2 1/12/2005 1,2-Dichloroethane BRL ug/L 0.5 5.0 EPA 524.2 1/12/2005 1,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 1/12/2005 1,3,5-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 1/12/2005 1,3-Dichlorobenzene BRL ug/L 0.5 EPA 524.2 1/12/2005 1,3-Dichloropropane BRL ug/L 0.5 EPA 524.2 1/12/2005 1,4-Dichlorobenzene BRL ug/L 0.5 5.0 EPA 524.2 1/12/2005 2,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 1/12/2005 2-Chlorotoluene BRL ug/L 0.5 EPA 524.2 1/12/2005 4-Chlorotoluene BRL ug/L 0.5 EPA 524.2 1/12/2005 Benzene BRL ug/L 0.5 5.0 EPA 524.2 1/12/2005 Bromobenzene BRL ug/L 0.5 EPA 524.2 1/12/2005 Bromochloromethane BRL ug/L 0.5 EPA 524.2 1/12/2005 Bromodichloromethane BRL ug/L 0.5 EPA 524.2 1/12/2005 Bromoform BRL ug/L 0.5 EPA 524.2 1/12/2005 Bromomethane BRL ug/L 0.5 EPA 524.2 1/12/2005 Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 1/12/2005 Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 1/12/2005 RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 r Page: 3 CERTIFICATE OF ANALYSIS J 9� in Barnstable County Health Laboratory Report Dated: 1/18/2005 Report Prepared For: Order No.: G0529054 Andrew Clark P O Box 943 W Barnstab='.e, MA 02668 Chloroethane BRL ug/L 0.5 EPA 524.2 1/12/2005 Chloroform 1.5 ug/L 0.5 EPA 524.2 1/12/2005 Chloromethane BRL ug/L 0.5 EPA 524.2 1/12/2005 cis-1,2-Dichloroethene BRL ug/L 0.5 70 EPA 524.2 1/12/2005 cis-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 1/12/2005 Dibromochloromethane BRL ug/L 0.5 EPA 524.2 1/12/2005 Dibromomethane BRL ug/L 0.5 EPA 524.2 1/12/2005 Dichlorod ifl no rom ethane BRL ug/L 0.5 EPA 524.2 1/12/2005 Ethylbenzene BRL ug/L 0.5 700 EPA 524.2 1/12/2005 Hexachlorobutadiene BRL ug/L o.5 EPA 524.2 1/12/2005 Isopropylbenzene BRL ug/L 0.5 EPA 524.2 1/12/2005 Methyl-tert-butyl ether BRL ug%L 0.5 EPA 524.2 1/12/2005 Methylene chloride BRL ug/L 0.5 5.0 EPA 524.2 1/12/2005 n-Butylbenzene BRL ug/L 0.5 EPA 524.2 1/12/2005 n-Propylbenzene. BRL ug/L 0.5 EPA 524.2 1/12/2005 Naphthalene BRL ug/L 0.5 EPA 524.2 1/12/2005 p-Isopropyltoluene BRL ug/L 0.5 EPA 524.2 1/12/2005 sec-Butylbenzene BRL ug/L 0.5 EPA 524.2 1/12/2005 Styrene BRL ug/L 0.5 100 EPA 524.2 1/12/2005 tert-Butyl benzene BRL ug/L 0.5 EPA 524.2 1/12/2005 Tetrachloroethene BRL ug/L 0.5 5.0 EPA 524.2 1/12/2005 Toluene BRL ug/L 0.5 1000 EPA 524.2 1/12/2005 Total xylenes BRL ug/L 0.5 10000 EPA 524.2 1/12/2005 trans-1,2-Dichloroethene BRL ug/L 0.5 100 EPA 524.2 1/12/2005 trans-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 1/12/2005 Trichloroethene BRL ug/L 0.5 5.0 EPA 524.2 1/12/2005 T rich lorofluoromethane BRL ug/L 0.5 EPA 524.2 1/12/2005 Vinyl chloride BRL ug/L 0.5 2.0 EPA 524.2 1/12/2005 (Sa ple has higher than average levels of Sodium.Those on'a low Sodium diet may want to consult a physician: I RL = ReportingLimit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 92630 Ph: 5087375-6605 f F NA V Page. 4 CERTIFICATE OF ANALYSIS i Barnstable County Health Laboratory Report Dated: 1/18/2005 Report Prepared For: Order No.: G0529054 Andrew Clark P O Box 943 W Barnstable, MA 02668 Approved By. (La irector) RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 TOWN OF BARNSTABLE /� SEWAGE # 9 17'34 VILLAGE 0,1l 95 t04 1tf-' ASSESSOR'S MAP & LOT /53—eZ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY A"Pd e;ft- LEACHING FACILITY: (type) � .L�. +.s � (size) /oxYd�,C3 NO.OF BEDROOMS BUILDER OHO WNE Uzdrn PERMTTDATE: COMPLIANCE. DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility St Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) IS-6 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by f �a N 1' I 7! i VT 1 , i i No. Fee k THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for �Digpogar *pgtem Cougtruction Permit Application for a Permit to Construct( )Repair(P/)Upgrade( )Abandon( ) ❑Complete System eindividual Components Location Address or Lot No. ' Z® � 1 u �— Owner's Name,Address and Tel.No. !.� �T Caro` G!'�r ��On ultl� Assessor's Map/Parel LIP"1arIf61��/e Installer's Nam ,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7/Y.,F9l Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder e-eo Other Type of Building. No. of Persons Showers( ) Cafeteria( ) Other Fixtures f Design Flow 114() gallons per day. Calculated daily flow `� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank r5�� X16�-/rr9 Type of S.A.S. 57 Description of Soil Nature of Repairs or Alterations(Answer when applicable)j-2-le- 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 Certifi- cate of Compliance has been issued this and f Health. 17 Signed _ Date Z �Z�6 Application Approved by Date A—I - g Application Disapproved for a fo owing reasons Permit No. Date Issued -� N .. _�4-;. ���-� � t , t; :rt. .' �yew. ���. ..• ._Z � .'[• 'v' *�\,y-�.... G tl�J O Fee No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Application for 30igpogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(1/)Upgrade( )Abandon( ) El Complete System Individual Components Location Address or Lot No. 7,JT® Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Nam ,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7/-93yy Type of Building: Dwelling No.of Bedrooms �Jewe_e Lot Size sq.ft. Garbage Grinder(�� Other Type of Building /re No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ��� gallons per day. Calculated daily flow 21 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank X�Sy%�4 Type of S.A.S. 47%L Description of Soil /el X yQX Z Nature of Repairs or Alterations(Answer when applicable) T/f�L� ✓G".d0%�l" 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 Certifi- cate of Compliance has been issued b this - and f Health. / Signed Date Application Approved by Date - 1 Application Disapproved for t e fo owing reasons r Permit No. / 3 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (tompriance THIS IS TO CE TIFY,th t the On-site Sewage Disposal System Constructed( )Repaired (k-)Upgraded( ) Abandoned( )by at Z c30 G /'G 7= �' /ems �' E has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 71?-43 b dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date D �. ' Inspector Y"`7 No. ��- -------------------- ((��� f✓ .3 D Z� Fee %,5�7(n — THE COMMONWEALTH OF MASSACHUSETTS ," PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 3igogal *pgtem Construction Permit Permission is hereby granted to Consp uct( Repair(✓)Upgrade( )Abandon( ) System located at Z, t2 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 completed within three years of the date of this permit. Date: 0 ^ �V Approved by . i LAG JS' sol d � i I I � Id v.}3T/4 L W W 10/9197 NOTICE:CE: This Form Is To Be Used For the Repair Of]Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CON]STRUCTION1 PERMIT (WITHOUT ENGINEERED PLAINS) hereby certify that the application for disposal works construction permit signed by me dated 157//Z"4"; , concerning the property located at Z �O G���'�t b �` �"� meets all of the following criteria: V/There are no wetlands located within 100 feet of the proposed leaching facility here are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed 6/There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will=be located less than fourteen (14) feet above the maximum adiusted groundwater table elevation. Please complete the following: l A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) ��'/ B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder.cent a/ TOWN OF BARNSTABLE LOCAT10N 22W.OvLi.L m SEWAGE # J= VILLAGE WE" � ASSESSOR'S MAP &/L/OT .Z711SP�C,i�yQ;S NAME&PHONE NO. SEPTIC TANK CAPACITY /DOS LEACHING FACILITY: (type) L �/� (size) /DOd • NO.OF BEDROOMS BUILDER OR WNE PERMITDATE: CO LIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ti: _' t �� ��/��� n _ 3`g �g • i TF ; OF BARNSTA TOWN _2 .jo J4,wor@ 12 Fo.c; 71. L ' k-z- , � �srnxcnM 771 ,gyp Jff44 —-� L '3n�.tDv'.J+lzt".d. • xc. , k � .I. .. - - � -L ' — — i f� O ; . L� . .... . .. t r., - . f <.. .r. ,,. .. .. _. w_.-_ �. .. r ... .. ..... .., .F-_.... :, _ - ;m��i tom. / I. . - - .. . %1. . . . C, - . . I. . . • ,. I. • . . . . . . .. - . . . .. ..- . . . . .. . . . _ . : ., . ". . .- _ .. . . . . • _ . , .. . % ... . .. . . :.. .. ' . .. . .. . . .. . - . i . --- . . , . _ —_ . . . -.. . . . .. . . . . . . . f, . . . i <.�: .. . . .. . -. I r . . . . . . . . . . i . . . . . i 1. _. . . .. ' . t -. . 1. . . . . . . j I I . . . ,i .. . . . . - _ . . . _ ..• I. ' . i�tcrJoisT�. J2�o . i ' :. • I' . .. . .. . . . .� .L �!{ I ; ' . C �' .. , - - .. i .. _ .. - .:. _ . I . .� 1 . i 14 z� - . y I . .. _ - ,�� � i~ . - , . . - . . _ ' . . . . . : . . _ _._ _ T . -%:. I . . . ` .: motor.-/-- .. .. - , . - .. — - - - - .. .. - -rTCr _ .. - .. . .. ., .. .. . .-�. - . . . _ _ . . . ... .. . .. - - . , .. - - _ - S . .. .. -- .. . . : - .. ... . , .. -. ' " - - V _ / - .. _ .. .. - .. % :. .. . .. fi - - - � . . -1 - . . . • � . . . . - . . . _ _ �'. . . . .. ' . .. . _ .. . . , . a. ; - ---- . I. .. -- _ . ... ---- . ... _ . -- - . . - . . _ :. .:. , . . . . .. - .... — - t' ; r -_... . ... . .. z .- F->.... _ ,. _ ,.._. . . x _ , _ 5 � w .. _ a. � .. _ w _ k .5 _ ... r .. .. ... u -aL• ... _. _ ._ .. .. - ... r .. a a_y. "i -..a _ -. ... ..... .,o- ._ •� r. „f ^%.,_...,. ir. .fir :"'_, .fi:.4 .. _ ... :- -. .Y �... A, .,.. r I lam. r+.v .. r _. G ... +. ,c ..I�i. .. .. ._`a,1. �,":...'•. v. .. ... ... — , ..'?e {y _. -Y:,:e..--.....::ire ,.,erq_•... ..y .: :..