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HomeMy WebLinkAbout0052 COVENTRY LANE - Health L Coventry Lane A= 110—004-006 W.Barnstable � 0 . S� 4115 ri4 4,J //6 -ooy-6a� Commonwealth of Massachusetts = Title 5 Official Inspection Form XJ ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " PQ Property Address e 4J I{ 7-0 c.e— Owner Owner's Name �G ✓� "Q� '•ss information is CPA— required for every le.—s ILgosjs 6/ �/f ®—��•6�� o�' page. City/Town State Zip Code :Da of spec on Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, ,a o�� �• use only the tab key to move your Inspector: cursor-do not use the return it O key. Name of Inspector "— Company Name Company Address o_�6410L atylTow Q Sea �V o ���® State Zip Code -- Telepho `7 mbe �� License Number Bo 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 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspecto 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 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal. System Form _ Not for Voluntary Assess ments 4 Property Address so Owner Owner's Name information is required for every �s ®a page. City/Town �/ rw �� State Zip Code Date of Insp ction B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) ;z:t ses: fo und 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ns.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address a Owner Owner's Name �- information is �S 1� required for every � O�_ page. CltylTcwn 5• Certification (cont.) State ZipCode Date of nspec on ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑i Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Fora' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M Property Address Owner Owner s Name information is required for every QS� page. q�/t Oa r 6$ X Clty/Town State Zip Code Date of In ectio 13o Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ �/Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ �� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . W Title 5 Official Inspection Form Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. Clty/Town State Zip Code Date of In ectio Bo Certification (Cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or /obstructed pipe(s). Number of times pumped: ❑ L�h/ 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. ❑ 1(d' 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.] ❑ he 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. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Co _1 Owner Owners Name -Z- Q 64 information is required for every &w4 page. City/Town C. Checklist State Zip Code Date of I pecti Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes o ❑ mping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ he system received normal flows in the previous two week period? ElHave 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: eExisting information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms n desi : — ( 9 ) Number of bedrooms (actual): — DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): SJO t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner L information is Owner's Name required for every ��Iej w�� �; ® q, page. City/Town D. System Information State ZipCode Date e of Ins ection Description: o Number of current residents: O Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes [4� K;a Seasonal use? ❑ Yes o Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑/'Yes 9-90- Last date of occupancy: 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: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Nam '" information is required for every _ Q sy in 4 64 A4 ®�6 6 page. City/Town State Zip Code a Date of I pecti n Do System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes [�i�o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S em: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts r Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M over Property Address Owner Owner's Name/ i information is (/'t// �j/� required for every qiy� r�%-T 01)(.6 -L page. CltylTown State Zip Code Date of 1 spect' n D. System Information (cont.) Approximate a e of all components, date installed (if known)and source of information: _ YO Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): s/ Depth below grade: feet Material of constructi;4'0 El cast iron 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): 2 �/ Depth below grade: v feet Materia 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: Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r �^I�p / W �hIl Property Address Owner Owner's Name information is required for every page. Gty/Town (OV p�L State Zip Code Date of In pection D. System Information (cont.) Septic Tank(cont.) 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 57 Al vi Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? _/e Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): --j97(A 600'07 4 (4�0 cjw C X L7 �/L Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass 9 ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6f16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts N - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 0 Ile" Owner Owner's Names e n information is required for every page. City/Town JI' State ZipCode Date of I pection Do System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass g ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner information is Owner's Namel �requT/: ired for everypage. Clty/TownState Zip Code Date ::�:: D. SystemInformation (cont.) 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 leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Cove-!94 Owner Owners Name LL information is required for every �� ��s �� �,4 ®�6 6� llspVecti �:� page. Clty/Town State Zip Code Date of Do System Information (cont.) Type W 7(a3',�� �/� ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): �e— GN c S01 C. 0&7 Gva C/ Cl/' 04 Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address vevi Owner Owner's Name information is required for every �eS Q�/�s {, AX �6 61 � �� 6 page. City/Town State Zip Code Date of nspe ion De System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: - - ------ — Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name v` information is /� �� required for every (/l/� /) page. City/Town State Zip Code Date of spe Ion Cl ®. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where is water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately Se g L? Flo l,� Ls 4-417-le-- 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s o evi4n Property Address Owner Owner's Name information is 4 required for every �/1 page. City/Town State ��!! ZipCode ate of I pectin D D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: oL 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) Ind'-�Checked with loc oard of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must d cribe how y u established the high ground water elevatio : � �Cr1 o W V4 C;,/&W A G"C/ Slow SA o N✓,c% Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r ' r commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M C04 Property Address Owner -� information is Owners Name required for every page. City/Town State ZipCode Date Inspection E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked Imo'inspection Summary D(System Failure Criteria Applicable to All Systems)completed S em Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 52 Coventry Lane Property Address Martha Lumino D- np o 0(,p Owner Owner's Name information is required for W Barnstable Ma. 02668 8/21/2007 every page. City/Town 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 computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return <ey. Capewide Enterprises,LLC Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City9Town State Zip Code (508)428-4028" S14454 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 cr 8/21/2007 Inspector's Sign Date — r Cr*1 M 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. r ' ****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. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 l f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 52 Coventry Lane Property Address Martha Lumino Owner Owner's Name information is required for W.Barnstable Ma. 02668 8/21/2007 every page. City/Town 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: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial 'infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 f Commonwealth of Massachusetts = W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Coventry Lane Property Address Martha Lumino Owner Owner's Name information is required for W Barnstable Ma. 02668 8/21/2007 every page. City/Town 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: r ❑ 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. I❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. €5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �1M ,•'°V 52 Coventry Lane ' Property Address Martha Lumino Owner Owner's Name information is required for W Barnstable Ma. 02668. 8/21/2007 every page. City/Town 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 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 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 El ® 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. t5insp•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 w 52 Coventry Lane Property Address Martha Lumino Owner Owner's Name information is required for W Barnstable Ma. 02668 8/21/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 chairi of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® 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 El ❑ 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. :5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ,.•''v 52 Coventry Lane Property Address Martha Lumino Owner Owner's Name information is required for W Barnstable Ma. 02668 8/21/2007 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? ® El information 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)] t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Coventry Lane Property Address Martha Lumino Owner Owner's Name information is required for W Barnstable Ma. 02668 8/21/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: unknown 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 ears usage Well Water 9 ( Y 9 (gpd))� Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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): .5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 f Commonwealth of Massachusetts . W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Coventry Lane Property Address Martha Lumino -Owner Owner's Name information is required for W Barnstable Ma. 02668 8/21/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information - a Pumping Records: Source of information: Capewide Enterprises,LLC Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 1000 gallons How was quantity pumped determined? Measured Reason for pumping:. Maintenance 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) El maintenance 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: 1993 Were sewage odors detected when arriving at the site? - ❑ Yes ® No t5insp-08/06 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 M 52 Coventry Lane Property Address Martha Lumino Owner Owner's Name Information is required for W.Barnstable Ma. 02668 8/21/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence"of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 2' � Depth below grade: 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: 8'6"x4'1 0"x57' Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle na Scum thickness 0 Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? Tank pumped during inspection. i ,t5insp•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 52 Coventry Lane Property Address Martha Lumino Owner Owner's Name hformarequired for is W Barnstable Ma. 02668 8/21/2007 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) J Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every 2-3 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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 I 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): ,t5insp•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 wM 52 Coventry Lane Property Address Martha Lumino Owner Owner's Name information is required for W Barnstable Ma. 02668 8/21/2007 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 No 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.): Box is level and has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 52 Coventry Lane Property Address Martha Lumino Owner Owner's Name information is required for W Barnstable Ma. 02668 8/21/2007 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: ® leaching chambers number: 3-Flowdiffusors ❑ leaching galleries number: leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil.Leaching was dry at time of inspection.Stain line was 6" below pipe in flowdiffusors. t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 52 Coventry Lane Property Address Martha Lumino Owner Owner's Name information is required for W Barnstable Ma. 02668 8/21/2007 every page. City/Town State Zip Code Date of Inspection D. System Information(cont.) 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.): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary-Assessments c 52 Coventry Lane Property Address Martha Lumino Owner Owner's Name information is .required for W Barnstable Ma. 02668 8/21/2007 , 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. i /If i ? A' 5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 52 Coventry Lane . Property Address Martha Lumino Owner Owner's Name information is required for W Barnstable Ma. 02668 8/21/2007 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: Bottom of leaching 65' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record Y 9 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: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used:Gaherty.& Miller model 12/16/94 Ground water elevations. Used:USGS Observation well data June 1992. Used:Technical Bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 1 t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable �pF 1HE 1p� yPti� Regulatory Services sARrsrnsLE ; Thomas F. Geiler,Director NUM 9�ATF1639. GMA A`�� Public Health Division 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 observation s 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. TO OF BARNSTABLE LOCATION SEWAGE # VILLAGE Y � ` ASSESSOR'S MAP & LOT /l6.6e!j,aiG INSTALLER'S NAME & PHONE NO. �� ✓��e �� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO. OF BEDROOMS RIVATE W L OR PUBLIC WATER BUILDER OR OWNER ZG/ DATE PERMIT ISSUED: .7 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No L/ a 4 lz 1/ C 3 it C i ASSESSORS MAP NO: PARCEL N0: f�f3 , 0�,Q ,5- — /Fizz THE COMMONWEALTH OF MASSACHUSETTS F BOARD OF HEALTH OWN OF BARNSTABLE ,�li ltr fur li��pl�t u! 3 urli C�l�gt�tr rtinn ermi Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal System at: ........L.o7 5 CoV +•l'P2`r..� ------�'=-�T..nJ AS 2S 2o�: ....O 10....110-----p!�2c 44b � � ` Location-Address orEQt No. --�: �--�-•- � 1---W-. .. �T'6V E C. sue. s.a.S.--.......--- .......... -�4� ��1�...I_ ?�...1�1�.1`sh1lU,.S Installer Address d Type of Building Size Lot-._3o}4nd.......Sq. feet Dwelling—No. of Bedrooms..........�..............__-_-.-.--.--Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ............................ Design Flow.............55-____---_--._-._..____---gallons per person per day. Total daily flow..-_-_-_-_-53P.......................gallons. W 9 Septic Tank—Liquid capacity_144i0k.galIons Length.--8 Y::? Width___+Y'�_... Diameter_.............. Depth_._.' Disposal Trench--No. __.DNE........ Width.....)_2......... .Total Length.....3Z........ Total leaching area_.--'5.(.5 .....sg/t.U/� Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---TH.O.M. .45...../Y)!�.LL-A ...p ........ Date...3111--9 3.................... ,tea Test Pit No. I......-.....minutes per inch Depth of Test Pit.J.4.4......... Depth to ground water..Mm( ........ Gi, Test Pit No. 2....`Z-.....minutes per inch Depth of Test Pit__ P____.... Depth to ground waterloz............. a c C^II 0 Description of Soil.--•! �" �, 7a� ...._5U821.4....... z'..1. --.-5►_crl..FIN "/ J.-SA!t'b..�'''M4 ka5 .--------- --t...-- ......36.-.`r..51 .......................................► ........... UNature of Repairs or Alterations—Answer when applicable._.............................................................................................. ----•-•--•-•--••••-•-••-•--••--••-•-••••••--•••---•••---••-•-•-•-••-•--••------•-------•-••----•••-••••---•-•-------------------•._........•-••-•••-•••---•.....-•--•-•-•••----•-•---•-..........------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environm 1 Code—Th ersigned further agrees not to place the system in operation until a Certificate of Complianc s been is d by t e b r of health. Signed ........ . ... .. . - ------ ........ . .. ................................. ....... .E.`i. r-� ....... _ oa Application Approved BY ----- .... ........... .. .........'......... .... .`-.jam Dire Application Disapproved for the following reasons: ...... ............................... ..... .. . ............... ........ ......................------------------- ........................................... ................. . . ..................................................................... . .......................................... ........................................ PermitNo. ............................................... - Issued ..............�... ...... :...� Dace �.-...-.y._� ^('+.t:-_ � •�.+^....- .-._r.+.-'�-.� J..�"--^••�----�....,..1_....w.;,r,,;,,sr-w,.,.�.✓4��•.✓'lr.r.•.-�^-^'W�,�w.«-..r. .+�.:_+...+.-+�-..ti.,.r'..r•.i��r..cf:.r^�:�-,+iL"ta..+•+i tit�.FJ-4 ; OF i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH \ 7 -/,2 TOWN OF BARNSTABLE r- Appliration for Di►i,poittl Works Tonitrurtion ramit Application is hereby made for a Permit to Construct, V) or Repair ( ) an ,Individual Sewage Disposal System at: ; ,s ......1�0 �� COVetgj f....LANt.._... BAN �1 .5 Sso s__.._m !°--..l.+n ;�&2c F ..4.b -•--• ------ ----- _' r_ Location d9ress Cr \� \o _Lk-2� _c f,4Z.. l 7►': , I ,f.t. r_ ....... J ��+ncr t AddPc`ss ` r ' n W �l F\) �.• CC •----•--_---_-I "_� __ Installer Address UType of Building Size Lot.--�D_�t__d.......Sq. feet ..� Dwelling— No. of Bedrooms....-.-___3........................._..Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.-.-----------.------------- Showers ( ) — Cafeteria ( ) 04 Other fixtures ------------------------------- - - W Design Flow..............55........................gallons per person per day. Total daily flow.....---...33.0.......................gallons. R: Septic Tank—Liquid capaeity.je.04-gallons Length___ y3--.- Width.-_�Yz-.... Diameter................ Depth....I.'.C- Disposal Trench--No. ..-O-Of........ Width.....J-Z......... .Total Length-----.7........ Total leaching area_.S�1_5 sq/it.&/j) 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.... f.� ,�.�-._./>1 G L .� L!!N--•_p •....__. Date...3'I I-- 3-_•..•••-..•-.•-__.. ,.a Test Pit No. 1----�_Z.....minutes per inch Depth of Test Pit.-I.4..4-.'_---.--- Depth to ground water..AaAlf........ ri. Test Pit No. 2.....` -.----minutes per inch Depth of Test Pit.-]U.......... Depth to ground water.10-2.'."........... ----- .............................••---•--•-•-•-••--=-•--••------•----------------. O Description of Soil.#-1..... =4t z1 1d>''._. ..SU.I -_S'A--_-!�!!(TH RxktCS U .......... _ ..... !f-Sui l. �-"-�f �-- l.S �I �1_NE Si4N1 I�n ........ W :mil YJ--. 1.ry SA. + ..................... ........................................... •-------- --••---.....-------•--•--...----...•.--.....-•-•-----------.-.------•---------. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The further agrees not to place the system in operation until a Certificate of Compliance has been issu d by the board of health. Signed ... ................................. ....... .ii.�i.. . .......... Application Approved B .�«.. . ------------------ ri--- .�.�.. •...-i.. ... ................... ... -.....'�.............?�.._ Application Disapproved for the following reasons: . ........................................................... .................... ................ ...................................... . . ...................... . ....................--- . ................................ ----------- ----------------------.... e''r Dace Permit No. l' ...~"+J .. ....... Issued ...... . - .�"'....�.�-....-- e Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�er#ifirate of Gmyliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed j or Repaired ( ) by ........ ._...-.., .l. _ _----------------------- ___......... . .................... . ............................... at ...4../......... .. ........�t .. .�' :..,C� .1G! ..._........ ................................................ has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ... � .....',,� .1�/.. dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. — ...._................_-------------- Inspector T�......;1. .,_ ..........:---....................... _...... DATE..._......._ %/...._................Y..:.. . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j� TOWN OF BARNSTABLE FEE._ , Disposal Workii Towitrurtion rrrmit Permission is hereby granted_.. �a -f/3e? NT_�,:D�.. ......•----------------------------•----•-----•----.........--- to Construct (�')i or;tfRepair ( ) an Individual Sewage Disposal System at No.. �.. � .0 IJ..lrsp _ --�C �4�> '------....A--- /7�' -�f` .�..�........ , ' _... r n Street as shown on the application for Disposal Works Construction ermit�N.o--------9- ,f Dated..... .....:��_..... . { D ................. Board of Health DATE..--- /ll � _ 1 � ; FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION al NO. © C) VILLAGE U,j 0 _ DATE_'? APPLICANTf FEE____j o 0 ADDRESS 7-4 5cNoaL S'f WGSt Ve,NN1S MA TELEPHONE NO.3�'�-3ogp (Non-refundable ENGINEER Piti,���., �� M,T ( _TELEPHONE NO. 037 8 -7-11D DATE SCHEDULED A21M .7F�c T- (A icant s signature . . . . . . .SORoo'OS obiAP 0AP04O . 000 . . 00 . . . 000 . aoo . . . . . . o . . . a . . . . . . . . o „ o . . . . . . . a . o . . . . . . . . . . . . . • ASSES LOT '-SO IL LOG SUB-DIVISION NAME BOM ISH FAal15 11 DATE 3-11-q3 TIME AM EXPANSION AREA: YESZ_NO -THOCnA$ ()1GL0_LhK) PC ENGINEER .�.; TOWN WATER PRIVATE WELL DUNK//VC-i- BOARD OF HEALTH lZ Ear jZ.EA L-N EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: ca A� O +Ttt-1 F) T}J-Z b PERCOLATION RATE: Z M h/ CME0-F1P-S -5.4rv0) TEST HOLE NO: i- A ELEVATION: TEST HOL N0: Z' ELEVATION: 1 7o 1 TaP 2 2 5u13so�L 42" 3 3 98» 4 5 SIL 5 61 - 6 7 :Mev 7 5fbNv 8 5A►vn 8 9 cN�TH lo2N 10 8oc► e,., 1�„ 10 11 OF 11 144° 12 Lf 12 13 13 14 14 15 15 16 16 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD?< LEACHING PITS LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEEIRING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P E AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT ' e ENVIROTECH LABORATORIES. Mass. Cert. #:MA063 -449 Route 130 Sandwich, MA 02563 • (508) 888-6460- CLIENT: Reef Realty LOCATION: Lot 5 Coventry Lane ADDRESS: P.O. Box 186 W. Barnstable, MA W. Dennis, MA COLLECTED BY: Fred Clifford SAMPLE DATE: 6-4-93 TIME: 8:OOAM DATE RECEIVED: 6-4-93 SAMPLE ID: 5CL JOB #: New well WELL DEPTH: 64' RESULTS OF ANALYSIS: Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 0 pH pH units 6.0-8.5 6.41 Conductance umhos/cm 500 102 Sodium m /L 20.0 g 10.5 Nitrate-N mg/L 10.0 0.08 Iron mg/L 0.3 0.11 Manganese mg/L 0.05 Hardness mg/L as CaCO3 500 Sulfate mg/L 250 Potassium mg/L 20.0 Alkalinity mg/L 200 Chloride mg/L 250 Turbidity NTU 5.0 Color APC units 15.0 Background bacteria COMMENT: yu NO WATER IS SUITABLE FOR DRINKING PURPOSE OR PARAM RS TESTED. DATE I �.r GROUNDWATER =_ ANALYTICAL - EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Field ID: 5 CL Lab ID: 5310-01 Project: Reef Lot 5 Batch ID: VHA-0159-A Client: Envirotech Sampled: 06-04-93 Cont/Prsv: 40ml VOA Vial/NaHSO4 Cool Received: 06-07-93 Matrix: ; Aqueous Analyzed: 06-09-93 PARAMETER CONCENTRATION REPORTING LIMIT (ug/L) (ug/L) Dichlorodifluoromethane BRL 5 Chloromethane BRL 1 Vinyl Chloride BRL 1 Bromomethane BRL 5 Chloroethane BRL 1 Trichlorofluoromethane BRL 1 1,1-Dichloroethene BRL 1 Methylene Chloride BRL 1 trans-1,2-Dichloroethene BRL 1 1,1-Dichloroethane BRL 1 cis-1,2-Dichloroethene * BRL 1 Chloroform BRL 1 1,1,1-Trichloroethane BRL 1 Carbon Tetrachloride BRL 1 Benzene BRL 1 1,2-Dichloroethane BRL 1 Trichloroethene BRL 1 1,2-Dichloropropane BRL 1 Bromodichloromethane BRL 1 2-Chloroethylvinyl Ether BRL 1 trans-1,3-Dichloropropene BRL 1 Toluene BRL 1 cis-1,3-Dichloropropene BRL 1 1,1,2-Trichloroethane BRL 1 Tetrachloroethene BRL 1 Dibromochloromethane BRL 1 Chlorobenzene BRL 1 Ethylbenzene BRL 1 m+p-Xylene * BRL 1 o-Xylene * BRL 1 Bromoform BRL 1 1,1,2,2-Tetrachloroethane BRL 1 1,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL 1 1,2-Dichlorobenzene BRL 1 QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS a,a,a-Trifluorotoluene 30 31 103 % 87 - 113 1,2-Dichloroethane-d4 30 26 88 % 83 - 117 BRL = Below Reporting Limit. * Non-target compound. Method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986). No. I Fee--_ _ _ BOARD OF HEALTH TOWN OF BARNSTABLE Appricat ion i orVerr Cootruct ion Permit Ap 11-c t s hereby m e for a permit to Construct (A), Alter ( ), or Repair ( )an individual Well at: -- =— — -- — — — -- -- ---— —— —_ P Location — Address Assessors Ma d Parcel Owner Address ___---- ------ i7v _4� Installer — Driller dress Type of Building `� g Dwellin --1- - ---�-`- -___-------------- Other - Type of Buildin ------- No. of Persons---- .A ---- --- YP g-------=---- T e of Well YP �---- -- Capacity-------------______-----_---___.___._..�__ Purpose of Well _ ��_^ —__�_ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation ujia�,,,Cgtili ce has been issued by the Board of Health. Si nedApplication Approved By---- - ddaattee date Application Disapproved for the following reasons:-- ----- ---- ____-------------------__________-------------------------------------__ ___----------_—_�— __ _ date -- Permit No.----------- ----- --------------------- Issued------- ------ - date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS T EE TIFY, T t/the jn 'vi al Constructed ( ), Altered ( ), or Repaired ( ) by -- — � 1—P`�— - ----- — -- --- -- - -- Installer at—�— ------ ------ --- --— --- ---- _has been installed in accordance with the provisions of the Town of Barnstable By of Health Private Well Protection Regulation as described in the application for Well Construction Permit No :3/Dated -------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------ - —-— --- - - — ----- Inspector---- --=-- -———_ 4 w ' No.--------- -----t. d Fee------- ----------- BOARD OF HEALTH TOWN OF BARNSTABLE A.pprication-*rVell Con5tructionpermit A Pp plic tion s hereby made for a permit to Construct (A), Alter ( ), or Repair ( )an individual Well at: Location/ Address Assessors Map and Parcel � e �eP� ----------------------------------------- QksG- -- f Owner Address •�- Installer — Driller dress Type of Building Dwelling3 --- ------------------- Other - Type of Building ---- No. of Persons--------------- Type of Well _�/1/�SG�it�G't�_ --------- Capacity---------- ------------Purpose of Well - Agreement: . The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until)til a Certificate of Co li :ce has been issued by the Board of Health. Signed----- -- '----�-------------------- ® / date — Application Approved By Y� ,,, ��" ✓ ` — —_—_ date Application Disapproved for the following'reasons:------------------------------------------------------------------------__ Permit No. — date / Issued ---—-- - -- -------� —_—� e — - r!--`�_------------------------ date -B.OARD .OF-:HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS ,TKO--�CE�RTIFY, That tthe )ndividual Well Constructed ( ), Altered ( ), or Repaired ( ) by- -V_c 1�,/_ i' - ----------------------------------------------------------------------------------- Installer at-— ? ---------------------------------------------------------------------------------------------------------------------------------------- - --has been installed in accordance with the provisions of the Town of Barnstable Board of Health Aated Private Well Protection Regulation as described in the application for Well Construction Permit No ftiq-q-7! -------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------- ------------------------------- Inspector—------------------------------------------------------------- —-- -- BOARD OF HEALTH TOWN OF BARNSTABLE Veri Con5truct ion Permit V- ------ `�-� `� ----- -----------No. v� G ,/� Fee K Al Permission is,hereby granted - _I____ ------r,t-IrrO On-------------------------------------------------------------------- to Construct ( Alter ( ), or Repair`(\ ) an Individual Well at- �- �i : z ' ?fix- -Wo_�_��_A_Pnf�A`8 No'• -- a- �— -� ---1- --y - — Street as shown on the application for a Well Construction Permit No.- -----------------------—---------- Dated---- --- Board of Health � DATE----------- 12)-------------- l 3 '��M ` ,e, f/ S> S9 \ o. <o a l N \�Ap to r eop, V N ti '` rb x s f R 1hrf ;-.ak' :,3. 1 ...�, e .>� LI,{ h t�, tl J!'1' k[Siaw Y•�r 1Y "' ' s'��'a9m�7 �s } `d4`"y,• },rr ! #. f r /,..rv^ t Y ( 4 .,'" IAa 7�S 4 '''$ Y ��• d Y w .M b � '{ J ;} , y•a,.rg� .e^e,,{� .rt ,�tL? s/il' .,y :s',Y � ^tiy�a'fi t in `,y �...f!H ti".r4� tr �'� `r7,y��`�"�'� I`yo� gk�ti�a.• i�� � .r� s'' T f # ;x r d ;ik- 51- i } �+"£siSRa 3 M. v Ys. ,y,'•}'1 ,t,4,�' t �t xl�w � { �,x�"'I�.L �� ���,� aG��+^;P.�,•.� y'�'',.� _ h- L, t< y 4;a, yir•. .w t'"'yo.t 1'7 awa�`t'�tiR,. 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'� 3. a$'"" 4. .i R, "�'; ` '•1,-..G mot.c.;' °'� ,^.0 yr +�.rf!;,.,;k«��"K`F ...'r.>.~' x.: °' ^.. �l f. r+C +'�',rvrf '�f b � 1 ��. •r «.�-+ .1� �, �!la���� � yy � ;-" u ref. . 's`{ � � ��r� �� „ &j 13 ) ENVIROTECH LABORATORIES Mass. Cert. #:MA063 449 Route 130 Sandwich, MA 02563 • (508) 888-6460 CLIENT: Reef Realty LOCATION: Lot 5 Coventry Lane ADDRESS: P.O. Box 186 W. Barnstable, MA W. Dennis, MA COLLECTED BY: Fred Clifford SAMPLE DATE: 6-4-93 TIME: 8:OOAM DATE RECEIVED: 6-4-93 SAMPLE ID: 5CL JOB #: New well WELL DEPTH: 64' RESULTS OF ANALYSIS: Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 0 pH pH units 6.0-8.5 6.41 Conductance umhos/cm 500 102 Sodium mg/L 20.0 10.5 Nitrate-N mg/L 10.0 0.08 Iron mg/L 0.3 0.11 Manganese i -. mg/L 0.05 Hardness mg/L as CaCO3 500 Sulfate mg/L 250 Potassium mg/L 20.0 Alkalinity mg/.L 200 Chloride mg/L 250 Turbidity NTU 5.0 Color APC units 15.0 Background bacteria COMMENT: M NO WATER IS SUITABLE FOR DRINKING PURPOSE OR PARAM RS TESTED. 'v DATE ^� GROUNDWATER ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCO) Field ID: 5 CL Lab ID: 5310-01 Project: Reef Lot 5 Batch ID: VHA-0159-A Client: Envirotech Sampled: 06-04-93 Cont/Prsv: 40ml VOA Vial/NaHSO4 Cool Received: 06-07-93 Matrix: Aqueous Analyzed: 06-09-93 PARAMETER CONCENTRATION REPORTING LIMIT (ug/L) (ug/L) Dichlorodifluoromethane BRL 5 Chloromethane BRL 1 Vinyl Chloride BRL 1 Bromomethane BRL 5 Chloroethane BRL 1 Trichlorofluoromethane BRL 1 1,1-Dichloroethene BRL 1 Methylene Chloride BRL 1 trans-1,2-Dichloroethene BRL 1 1,1-Dichloroethane BRL 1 cis-1,2-Dichloroethene * BRL 1 Chloroform BRL 1 1,1,1-Trichloroethane BRL 1 Carbon Tetrachloride BRL 1 Benzene BRL 1 1,2-Dichloroethane BRL 1 Trichloroethene BRL 1 1,2-Dichloropropane BRL 1 Br.omodichloromethane BRL 1 2-Chloroethylvinyl_ Ether BRL 1 trans-1,3-Dichloropropene BRL 1 Toluene BRL 1 cis-1,3-Dichloropropene BRL 1 1,1,2-Trichloroethane BRL 1 Tetrachloroethene BRL 1 Dibromochloromethane BRL 1 Chlorobenzene BRL 1 Ethylbenzene BRL 1 m+p-Xylene * BRL 1 o-Xylene * BRL 1 Bromoform BRL 1 1,1,2,2-Tetrachloroethane BRL 1 1,3-Dichlorobenzene _ BRL 1 1,4-Dichlorobenzene BRL I 1,2-Dichlorobenzene BRL 1 QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS a,a,a-Trifluorotoluene 30 31 103 % 87 - 113 % 1,2-Dichloroethane-d4 30 26 88 % 83 - 117 % BRL = Below Reporting Limit. * Non-target compound. 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