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0011 DESIRE'S LANE - Health
11 Desires Lane, W. Barnstable A= 088-007-006 Lot 7 r 1i C i No. 4210 1/3 BLU ESSELTE 10% (0 0 0 0 0 TOWN OF BARNSTABLE LOCATION // 4wesx- Ii 4,-' SEWAGE# s900 106 VILLAGE 44,15YW 1.0_::_ ASSESSOR'S MAP&PARCELS 7—(® INSTALLER'S NAME&PHONE NO. $C's SEPTIC TANK CAPACITY /S-270 LEACHING FACILITY:(type) (size) 41' t9 Y/O NO.OF BEDROOMS 1 OWNER PERMIT DATE: COMPLIANCE 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 a� �-C-?9- tF s s. r ®40 Commonwealth of Massachusetts b g8 -60(o r Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �w M 11 Desires Ln. Property Address Devin Donaldson h+: Owner Owner's Name information is 4 every West Barnstable ✓ required for eve MA 02668 5/7/2018 page. City/Town State Zip Code Date of Inspection , Inspection results must be submitted on this form. Inspection forms may not be altered inlany way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services reb Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 Telephone Number License Number B. Certification I certify that 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 5/15/2018 inspector's Signature "`y- Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name information equir for is every West Barnstable required for eve MA 02668 5/7/2018 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: System in working condition. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name information is every West Barnstable required for eve MA 02668 5/7/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name information is required for every West Barnstable MA 02668 5/7/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprn, 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 '/z day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts u . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name required fn is every West Barnstable required for eve MA 02668 5/7/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet.of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 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. l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Desires Ln. ^M Svey`eW Property Address Devin Donaldson Owner Owner's Name information is West Barnstable required for every MA 02668 5/7/2018 page. 'Cltyrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 110x4= 440gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 . Commonwealth of Massachusetts u v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name information is every West Barnstable required for eve MA 02668 5/7/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage N/A Well 9 ( y g (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts U u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name information is required for every West Barnstable MA 02668 5/7/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes,attach previous inspection records, if any) El 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name information is required for every West Barnstable MA 02668 5/7/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2009 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36"feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: +10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank (locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete El 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: 1500Gal Sludge depth: 8-101, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of'Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name information is required for every West Barnstable MA 02668 5/7/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 3-5" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal tank in good structural condition. PVC tees in place. Tank at normal operating level. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name information is every West Barnstable required for eve MA 02668 5/7/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: . gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection ec m p ton Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name information equir for is every West Barnstable required for eve MA 02668 5/7/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 DB-3 with 1 line in and 3 lines out in good condition. Box is clean and level with minimal solids carryover:No sign of overloading or hydraulic failure. Cover 14" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-31113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name required fn is every West Barnstable required for eve MA 02668 5/7/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-500Gal ❑ 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.): 3-500Gal Leach chambers with stone in a 10'x40'x2' trench. No standing effluent in chambers during inspection. No sign of overloading or hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name information is required for every West Barnstable MA 02668 5/7/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessm Y ry ents 11 Desires Ln. (Property Address !Devin Donaldson Owner Owner's Name information is required for every West Barnstable MA 02668 5/7/2018. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3H 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name information isequired or every West Barnstable MA 02668 5/7/2018 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 high ground water: +10' 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: 2009 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data per plan on file at BOH. No water at 10'. Max bottom of leaching is 61 . Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Desires Ln. Property Address Devin Donaldson Owner Owner's Name information isequired or every very west Barnstable MA 02668 5/7/2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 or 17 „its „-„ullt arus Page 1 of 2 TOWN OF BARNSTABY,F�';•: LOCATION 1/ D�Sr�'�rs A.- SEWAGE# �00 /04 VILLAGE L!/, dAO�t�q�� ASSESSOR'SMAP&PARCEL S(F:'- INSTALLER'S NAME&PHONE NO. _ 8 C r- cif/'—J;517 SEPTIC TANK CAPACITY LEACHING FACILITY:(type)_,j'—LC, NO.OF BEDROOMS OWNER P 1/1 E, PERMIT DATE: S / _COMPLIANCE DATE: �L(to ri Separation Distance Between the: a ^' 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). r feet FURNISHED BY •`' t II r , o http://www.townof barnstable.us/Assessing/HMdisplay.asp?mappar=088007006&seq=1 5/2/2018 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 9/25/2013 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. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your y� cursor-do not Sean M. Jones U use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification ZEF• I certify that I have personally inspected the sewage disposal system at this address,and thattt e 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 maintenance7'df on sits sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1kiQ pa Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fair e13 CQ ❑ Needs Further Evaluation by the Local Approving Authority 9/25/2013 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. ****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•3113 Title 5 Official Inspecti&FS.bsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 9/25/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 11 desires Lane West Barnstable is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 3x 500 gallon precast leach chambers. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts w r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is West Barnstable Ma 02668 9/25/2013 required for every i page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: El Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is West Barnstable Ma 02668 9/25/2013 required for every i page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 9/25/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 11 Desires Lane M Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 9/25/2013 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 9/25/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d well 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 9/25/2013 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information If Pumping Records: t Source of information: Was system pumped as part of the inspection?, ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 9/25/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system installed 5/21/2009 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 2 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: 1500 gallons Sludge depth: 6" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 9/25/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Inlet cover is on a riser Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 9/25/2013 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M s 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 9/25/2013 Cit /Town State Zip Code Date of Inspection page. Y p D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): Distribution box was in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Nci* 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every west Barnstable Ma 02668 9/25/2013 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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.): s.a.s was inspected by running a camera through the vent. The system was found to be in good condition with no sigh of past or present hydraulic overloading. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 11 Desires Lane Property Address Paul Foley Owner Owners Name information is required for every West Barnstable Ma 02668 9/25/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) m A 7L DATA Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 /25/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached,separately ra tj 1 0 .n s- a � o 3 c A- 7 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 9/25/2013 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 high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Desires Lane Property Address Paul Foley Owner Owner's Name information is required for every West Barnstable Ma 02668 9/25/2013 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I - Page: 1 of , CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory (M-MA009) Report Prepared For: Report Dated: 09/302013 Paul Foley Order No.: G1377258 11 Desires Lane West Barnstable, MA 02668 Laboratory ID#: 1377258-01 Description: Water-Drinking Water Sample#: Sample Location: 11 Desires Lane,W Barnstable,MA Collected: 09/25/2013 Collected by: Customer Received: 09/25/2013 Routine ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Nitrate as Nitrogen 2.2 mg/L 0.10 10 EPA 300.0 LAP 09/25/2013 Copper ND mg/L 0.10 1.3 SM 3111E LAP 09/27/2013 Iron ND mg/L 0.10 0.3 SM 3111B LAP 09272013 pH 6.8 PH AT 25C NA 6.5-6.5 SM 4500-H-13 DCB 09/2512013 Sodium 11 mg/L 2.5 20 SM 3111B LAP 09/272013 Total Coliform Absent PIA 0 0 SM9223 RG 09252013 Conductance 250 umohs/cm 2.0 EPA 120.1 DCB 0925/2013 Water sample meets the recommended limits for drinking water of all the above tested parameters. Attached please find the laboratory certified parameter list. Approved By: 4-0-1 (Lab Manager) ND=None Detected RL = Reporting Limit MCL=Mabmum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION Certified Parameter List as of 01 Jul 2013 M-MA009 BARNSTABLE COUNTY HEALTH 8 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 3111B EPA 200.8;SM 3111B IRON SM 3111 B LEAD EPA 200.8 EPA 200.8 MANGANESE EPA 200.8;SM 3111E MERCURY EPA 200.8 NICKEL EPA 200.8;SM 3111E EPA 200.8;SM 3111B 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-8 SM 4500-H-B SPECIFIC CONDUCTIVITY EPA 120.1;SM 2510B HARDNESS(CAC03).TOTAL SM 2340B CALCIUM SM 3111 B SM 3111 B MAGNESIUM SM 3111E SODIUM SM 31116 SM 31118 POTASSIUM SM 3111B ALKANILITY.TOAL SM 2320B SM 23208 CHLORIDE EPA 300.0 FLUORIDE EPA 300.0 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 SM 2540C NON-FILTERABLE RESIDUE(TSS) SM 2540D TOTAL ORGANIC CARBON SM 5310B CHEMICAL OXYGEN DEMAND HACH METHOD 8000 BIOCHEMICAL OXYGEN DEMAND SM 5210B TRIHALOMETHANES EPA 524.2 VOLATILE HALOCARBONS EPA 624 VOLATILE AROMATICS EPA 624 VOLATILE ORGANIC COMPOUNDS EPA 524.2 1,2-0IBRO.MOETHANE EPA 504.1 1.2-DIBROMO-3-CHLOROPROPANE EPA 504.1 PERCHLORATE EPA 314.0 HETEROTROPHIC PLATE.000NT SM 9215B TOTAL COLIFORM MF-SM 9222E TOTAL COLIFORM EPA 1604 TOTAL COLIFORM ENZ.SUB.SM 9223 FECAL COLIFORM MF-SM 9222D MF-SM 9222D E.COLI EPA 1603 EPA 1604 E.COLI EPA 1103.1 NA-MUG-SM9222G E.COLT MF-SM 9213D ENZ.SUB.SM 9223 ENTEROCOCCI EPA 1600 EPA 1600 Effective Date:01 July 2013_Expirstion Date:30 Jun 2014 j00No. / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y application for TMPonl 6pgtem Coltgtruction permit Application for a Permit to Construct( ) Repair(a/) Upgrade( ) Abandon( ) ❑.Complete System Zndividual Components Location Address or,Lot No. / / 165 Ile.5 - Owner's Name,Address,and Tel.No. 6109-too 7.0ex //� ,q , �a�`�s��r��� a�v/ ley Assessor's Map/Parcel w Q Installer's Nam ,Address,and Tel.No. _7 7,)-7/��`Q/ Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size 6�(� sq. ft. Garbage Grinder ( � Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.re uired) gpd Design flow provided y gpd Plan Date 7i� Number of sheets Revision Date Title l Size of.Septic Tank _/ r5�6 A45,X, Bz5t_ Type of S.A.S. — P Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in LApplication ordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of mpliance has bz-en issued by this Boa of Healt Signe 8 Date plication Approved by Date Disapproved by: Date the following reasons Permit No. --plWo Date Issued No. .�/ / � J /� -, "�-,..- �...-.,t.•' ��Fee L� (/i�✓ V . f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -:TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for Mi5po5al *p5tem Construction Permit y 4 Application for a Permit to Construct,( ) Repair Upgrade( ) Abandon(• ) ❑ Complete System Individual Components r Location Address or Lot No. / �5� } by Owner's Name,Address,and Tel.No. Assessor's Map/Parcel y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: r Dwelling No.of Bedrooms Lot Size 4/3,f�&PVI sq. ft. Garbage Grinder (11 0 `1, Other Type of Building ReI;Weeee No.of Persons' Showers( ) Cafeteria( ) Other Fixtures Design Flow(min. required), � gpd Design flow provided rl '7 gpd Plan Date 7/7 5 /,!Q Number of sheets Revision Date Title r.f / 7�1°'p��/ylf // r P S// �' A, Size of.Septic Tank / n6 �'1' j . Type of S.A.S. Description of Soil /";p Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the.system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed T'• v /70 ,#a� Date —,7 7 Application Approved by / /I V�'111J�il fa1h Vj W Date 10S IN Application Disapproved by: y Date for the following reasons Permit No. �I - ( �/ �� Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT�IIF(Y,that the On-site Sewage Disposal System Constructed ( ) Repaired ( �� Upgraded ( ) Abandoned( )by at / r��/17° iS �.� ✓ �' � p/n✓. r?' '4as been con tructed/i accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. I!/( "�// /!/� dated Installer `` (( Designer #bedrooms Approved design flowN L gpd The issuance of this permit shall not be construed as a guarantee that the system will function j- /as designed. Date �� Inspector i ,/ t1 ,A -,a1 No. ( /!� "r Fee r� THE COMMONWEALTH OF MASSACHUSETTS Y PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS -Mig;po5at *pgtem Con5truction Permit Permission is hereby granted to Construct ( ) /Repair ( rli ) Upgrade ( ) Abandon ( ) System located at // l9 p-92/ 7� S A4 . 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: ConsJ�ttuct' t be completed within three years of the date of this on mus permit. Date / r y roved b A Ap I FROM :down cape engineering inc FAX NO. :15083629880 May. 29 2009 11:03AM P3 Town of Barnstabie Regulatory Services Thomas F. Geiler,Direeteor " �ArtNttlAasY.�, + MAR Public Hsalth .®ivisio n �r�b ruN A. �— Thomas McKean,Director 204) Main Strece$:,Hysanis,AIIA 02601 Officer: 508-962-4644 Fax: 508-790.6304 Installer Form Dante: � ! Seawa$gePeraaaiit# OZ..,,7=jaJ Assessor's MatplPIRI-Vel Designer: p 0e, 0 e 1 rWi l I ns;Rtler: � � /7J �i►o �(�o,� Q,►r1'�UtA� Wes- l� / (�'J'I uf�.�J (,//J' �f/�T- I� On Q���� a'. was i5tiued Et permit to in�,ibil) a. 9-.- (date) (.installer) swi.c systean at /..� I f f/rPj - based on a design drawn by � (address) 'I n i el dated (de ner) l certify that the septic system referenced above was installed substantially according to the design, which may include minor, aq proved changes such as lateral. relooatiori of the distribution.box and/or septic tFa3k, _ T uertify thaL the septic system referenced above was installed with major changes (i.e. lneanter than. 10' iateral relocation of the SAS or any vertical relocation of any compuneni of the septic system) but in a.ccordancc with State & Loca.l R.egul.ati.ons. Plan revision or certified as-built by designer to follow_ —__..... � UANIELA, (lnsta.lJ. Signature) OJALA 'nl e� civil. y --� Nc.46502 (T)esigneT's Signature) l (Affix Desngncr s Siarnp Here) PLEASE RETURN TO BAIINSTABLE PUBLIC. 1097.At..aI_i. DIVISION. C:7F_RTMC.ATIE OF Cr`ll@B LIANCL WILL N0'1' III!', ISSUED UNTIL BOTU TITdS FORM AND AIS-13U11LT CARD ARE, RECEIVED D'Y''FIIE BARNSTABLE PUBLIC HEALTH T.WL910N. TEUNIK.YOU., Q:11caftlt/ScpticlDesigncr Cu fication Form 3-26-04.doe. TOWN OF iBARNSTABLE LOCATION INI-7 ��51� /�• SEWAGE # 'X � VII..I.AGE �' ,��rf�� e ASSESSOR'S MAP & LO-L aa7kgjg; INSTALLER'S NAME&PHONE NO. 4PI i 6044:5�, 7T'l`,83AO SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 6 �'>!�/lf'"4'y/.S (size) NO.OF BEDROOMS BUILDER OR OWNER ✓����� PERMTTDATE: !02g-" COMPLIANCE DATE:1dO Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 leachintv Feet Furnished by �> 36 t, ZUSETTS No. b �.�. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASS Application for Mizpaal *p!5tem Cutt9tructiun Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner' Name,Address and T No. 14 7 �� /I ��1��- .�� ������ �/'��/���%� /tee Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: p QW.1 ing No.of Bedrooms Garbage Grinder�) Other Type of Building No. of Persons Showers(Z) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow N 44 J gallons. Plan Date 7 Z T Number of sheets Revision Date Title Description of Soil 0 d _7A If 4V_Q Nature of Repairs or Alterations(Answer when applicable) 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 t ' ealth. _ / Signed Date diA Application Approved by 2 -- Application Disapproved for the ollowing reasons Permit No. /o� _��� Date Issued A No. Fee [ 7 7_5✓� THE COMMONWEALTH OF MASSACHUSETTS , fit!C16_, �� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSA USETTS 2ppiication for Migpool *pgtem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner' Name,Address and Tel.No. 07 7 �s E /I V6-s�26 .CA P a144 4) 441V&_V14,I//0/&;0,,4 /Ae Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: p DWxdling No.of Bedrooms T Garbage Grinder�) Other Type of Building No. of Persons Showers(1.) Cafeteria( ) Other Fixtures Design Flow + gallons per day. Calculated daily flow gallons. Plan Date '7 Z 9L Number of-sheets Revision Date Title / / Description of Soil �' L � f}Al 6. Al Alte D Nature of Repairs or Alterations(Answer when applicable) Date last inspected: ! l 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 th' n° J Signed Date 1.19 � Application Approved by Application Disapproved for the ollowmg reasons Permit No. �l� -� 7 �..'Z. Date Issued -----_____—__ _____—— _____ _-- ------ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compitance _ THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed or repaired/replaced( )on by for as has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated i�, :V fR-f-_ Use of this system is conditioned on compliance with the provisions set forth below: No. ( l" Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi!5poai *pgtem Construction Permit Permission is hereby granted to t' rC to construct( repair( )an On-site Sewage System located at Qg S 1 IZCs S LA-N G'"' 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. All construction must be completed within two years of the date below. Date: Approved _y- %"�� : ENVIROTECH LABORATORIES,INC. MA Cert. No.: M-MA 063 449 Rte. 130 • Sandwich, MA 02563 (508) 888-6460 • 1-800-339-6460 FAX(508)888-6446 CLIENT: Aqua Jet LOCATION: 7 Desires Lane ADDRESS: W. Barnstable MA SAMPLE DATE: 8-20-96 COLLECTED BY: Client DATE RECEIVED: 8-20-96 TIME: N/A LAB I.D. #: E8356/E8269 JOB TYPE: New Well SAMPLE I.D. #: E8356/E8269 WELL SPECS. : 120' Deep RESULTS OF ANALYSIS: Parameters Units Recommended Limit Result Coliform bacteria/100m1 (MF Method) 0 0 pH pH units 6.0-8.5 6.93 Conductance umhos/cm 500 102 Sodium mg/L 28.0 12.7 Nitrate-N/Nitrite-N mg/L 10.0 0.05 Iron mg/L 0.3 0.08 Manganese mg/L 0.05 0.005 Volatile Organics See Attached Report EPA # 601/602 ND COLT-IRT1 S: YES WATER IS SUITABLE FOR DRINKING PURPOS FOR PARAMETERS TESTED. g}O{ _ / Date b Ronald Saari Laborato'ey Director IT = Less Than ND = None Detected ' 8-23-96 13:26 ;GROUNDWATER-ANALYTICAL ENVIROTECH - ----------------- _- - _ 5-08 759 4475;4 2/ 4 v GROUNDWATER ANALYTICAL EPA METHODS 601__and 602 Volatile Organics (GC/PID/ELCD) Field ID: E8269 Lab ID: 14120-01 Project: Aqua Jet/7 Desires Batch ID: VG2-0899-W Client: Envirotech Sampled: 08-15-96 Cont/Prsv: 40mL VOA Vial/HC1 Cool Received: 08-16-96 Matrix: Aqueous Analyzed: 08-20-96 PARAMETER CONCENTRATION REPORTING LIMIT (ug/L) (ug/L) Dichlorodifluoromethane BRL 5 Ch-loromethane BRL 5 Vinyl Chloride BRL 5 'Bromomethane BRL 5 Chloroethane BRL 5 Trichlorofluoromethane BRL 1 1,1-Dichloroethene BRL I Methylene Chloride BRL I trans-1,2-Dichloroethene BRL 1 1,1-Dichloroethane BRL I cis-1,2-Dichloroethene * BRL 1 Chloroform BRL 1 1,1,1-Trichloroethane BRL I Carbon Tetrachloride BRL I Benzene BRL I 1,2-Dichloroethane BRL 1 Trichloroethene BRL I 1,2-Dichloroproppene BRL I Bromodichloromethane BRL 1 2-Chloroethyyl Vinyl Ether BRL 5 cis-1,3-Dichloropropene BRL 1 Toluene BRL 1 trans-1,3-Dichloropropene BRL 1 1,1,2-Trichloroethane BRL 1 Tetrachloroethene BRL 1 Dibeomochlcromzth'ane BRL I Chlorobenzene BRL 1 Ethylbenzene BRL 1 meta-and Para-Xylene * BRL 1 ortho-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 30 101 % 87 - 113 % 1,2-Dichloroethane-d4 30 27 89 % 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). ENVIROTECH LABORATORIES, INC. MA Cert. No.: M-MA 063 449 Rte. 130 . Sandwich, MA 02563 (508)888-6460 • 1-800-339-6460 FAX(508)888-6446 CLIENT: Aqua Jet LOCATION: 7 Desires Lane ADDRESS: W. Barnstable MA SAMPLE DATE: 8-20-96 COLLECTED BY: Client DATE RECEIVED: 8-20-96 TIME: N/A LAB I.D. #: E8356/E8269 JOB TYPE: New Well SAMPLE I.D. #: E8356/E8269 WELL SPECS.: 120, Deep RESULTS OF ANALYSIS: Parameters Units Recommended Limit Result Coliform bacteria/100ml (MF Method) 0 0 pH pH units 6.0-8.5 6.93 Conductance umhos/cm 500 102 Sodium mg/L 28.0 12.7 Nitrate-N/Nitrite-N mg/L 10.0 0.05 Iron mg/L 0.3 0.08 Manganese mg/L 0.05 0.005 Volatile Organics See Attached Report EPA # 601/602 ND COMMENTS: YES NATER IS SUITABLE FOR DRINKING PURPOS FOR PARAMETERS TESTED. XXX _ Date Ronald Saari Laborato Director LT = Less Than ND = None Detected 8-23-96 13:26 :GROUNDWATER ANALYTICAL -- ENVIROTECH _ - -- --- 4----- - 4 GROUNDWATER ANALYTICAL EPA METHODS 601_and 602 Volatile Organics (GC/PID/ELCD) Field ID: E8269 Lab ID: 14120-01 Project: Aqua Jet/7 Desires Batch ID: VG2-0899-W Client: Envirotech Sampled: 08-15-96 Cant/Prsv: 40mL VOA Vial/HC1 Cool Received: 08-16-96 Matrix: Aqueous Analyzed: 08-20-96 PARAMETER CONCENTRATION REPORTING LIMIT (ug/L) (ug/L) Dichlorodifluoromethane BRL 5 Chloromethane BRL 5 Vinyl Chloride BRL 5 Bromomethane BRL 5 Chloroethane BRL 5 Trichlorofluoromethane BRL 1 1,1-Dichloroethene BRL I 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 I Benzene BRL I 1,2-Dichloroethane BRL 1 Trichloroethene BRL 1 1,2'-Dichloropropane BRL 1 Bromodichloromethane BRL I 2-Chloroethyyl Vinyl Ether BRL 5 cis-1,3-Dichloropropene BRL 1 Toluene BRL 1 trans-1,3-Dichloropropene BRL 1 1,1,2-Trichloroethane BRL 1 Tetrachloroethene BRL 1 Dibromochlo.romethane BRL I Chlorobenzene BRL 1 Ethylbenzene BRL 1 meta-and para-Xylene * BRL 1 ortho-Xylene * BRL 1 Bro.moform 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 30 101 % 87 - 113 % 1,2-Dichloroethane-d4 30 27 89 % 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.-6� -`..- ®�- Fee---= -�. :. BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rVell Congtruct ion Permit Application is hereby made for a permit to Congruct ( ), Alter ( ), or Repair ( )an individual Well at: -_------------Ue r-R � �a� - -Low - }w(�. -- $_-_C � '� ®© - - --- Location — Address Assessors Map and Parcel ------------------------------ ---------------i--------------------------------------------------------------------------- w Addre s filLo-;��--oOT—Tody- ----------- tt--------- -�' ---------------_ - /�- ------------------ Installer Driller — Address Type of Building - Dwelling1� Other - Type of Building --- —------------------- No. of Persons---------------------------------------------------- Typeof Well--' --- -- ------------ r,, - Capacity-------------------------------------------------------------- Purpose of Well---- L�`k - 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 unt' ertifi Ate .of C p ' as been issued by the Board of Health. Signed ------- --------- ------------------- --------------------------------- date Application Approved ---- ----- ----------------------- -- -- date Application Disapproved for the following reasons:------------------------------------------------------------------------------------------------------ ------------------------------- —---------- -- ---------------------------------------------------------------------------------- date Permit No. - - - — `-—--------------- Issued ---- = _ --- --------------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS S TO CE TIFY, That t Indivi`du�I Well Constructed ( ), Altered ( ), or Repaired ( ) at]1 -- r,-' `�F—�"S l��__ 40717Installer—W` �--------- - - � q Y/�e----------------------—-------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No�°�-oa-`-=' / ---� ted--- z-�-`- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- ---- ---—-- - - --- - - Inspector-------------------------------------------------------------------------- No.-t'1' ------ ---------�� � Fee � BOARD OF HEALTH ' TOWN OF BARNSTABLE Zipp[ication-ftlDrC[ Contructionpermit Application is hereby made for a permit to Construct ( ), Alter ( ),QorgRepair ( )an individual Well at: -� —tJe ► ��'s---La11- - Lo -7� 6. ------------0-9Q_ -iQ ` z__Oo ------------------------------ Location — Address Assessors Map and Parcel Lau�t.t_e__------�-S__ � �h- --- ---- -------------------------------------------- -------------------------------------------------------- .- Owne Ad d s _9(Q — -— ------- -7 d ---------------- f t------- 0 'a �Insta ller riller r Aress Type of Building__ A Dwelling Other - Type of Building-------------------------------- No. of Persons------------------------------------------------ Type of f Well of Well -- Capacity----------------------------------------------------- .Purpose — ------ ----�----- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Bar`nstable Board of Health Private Well Protection Regulation The undersigned further agrees not to place the w 91 in operation unt' ertifi to .of C p ' as been issued by the Board of Health. Signed -- - - --- ------------ ------------------------------ date Application Approved -- - r-`""---a — — — '..-f �• G� date Application DiLppro.ved for the-following reasons:---------------- ""-----------------------------------—--------------------------------- ----------—-- --«----— --- ------------------------------------------------------------------------------------------------------------- date Permit No. �-------- -------—-------- Issued ---I' `'+�- ,rC' --------------------- i date +t• / a� ... .,_•.. ._..-_...�... � --•-�1��+9.r:nw.+�r,rwcc:wr'r.�.aa.a�e�e�+.e.+:...r.n.+�.+'I�ainaw,.A!�!aw•.M�Rr!1�+� �. � ._:......�.,. BOARD OF HEALTH At, OF BARNSTABLE , Certificate Of Compliance THIS S TO CEFTIFY, That toe Individu 1 Well Constructed ( ), Altered ( ), or Repaired - f- J ----------------------------------------------------------------------— ----- —-- 1 Installer at - j Q� --1��_— ----We ,- s �t �P---------------------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No#- f—OK'-'toted--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- --- -------- - --- -- Inspector--------------------------------------------— - ------------ .ispb,+raiir.:�'nd:.o.�ak,ww�wWs mc.,..,.rlr�....'M.�..�ew.i.afb.�.�.. _ •: `79Rk - .� _ �'—'� BOARD OF HEALTH TOWN OF BARNSTABLE Yell Contructionpermit No. r---ILZ Fee `--� Permission is hereby granted- __ 4 _ to Construct ( ), Alter ( ), or Repair ( ) an Individual Well at: ` ` / N o. r(l ,�_F-�� -� �- LET - -- L' fh_jr -L_P 1� - Street II as shown n t e;r�a;tp for a Well Construction Permit01 -�!�' r � �------------------------------- Dated-----------1r-r-------------------- ---------��---------- ----- — --------- Board of Health DATE------ -- — -- --- --- - f 0 . FOUNDATION--- 0 SEPTIC TANK D' BOX ---- -- �} 10' *A Z t t14 �1�1� 4. Aloo N �� ti: PLAN REFERENCE: o F 1. DATUM IS w1✓� (GARWE DISPOSER IS •. BEDROOMS (l? GPD) MINIMUM PIPE PITCH TO bE 1/8" PER FOOT. D DESIGN FLOW 3. FOR ALL PRECAST UNITS TO BE Gpp (_ � _ GALLONS 4. DESIGN LOADING. _ 5. PIPE JOINTS TO 8E .MADE- WATERTIGHT. QALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE. IN ACCORDANCE ENVIRONMENTAL CODE TITLE V. LLB GPD 7. THIS PLAN IS FOR PROPOSED WORK. ONLY AND NO-�—= USED FOR .LOT LINE STAKING. GPD g PIpE FOR SI~PT1C SYSTEM TO SCH. 40--4" .PVC. S.F. �,5 . C GPD �PTti _rAl;.►k- ? I�' (zvotAf�'. 141Q LA_ I t t sz� i"c�2�� ►'Zt�'r' . 10. COMPONENTS NOT TO BE BACKFILLEO OR CONCE� INSPECTION BY BOARD OF HEALTH AND PERMISSIO FROM BOARD OF HEALTH. SITE AND .SEWAGE PLAN IN THE TOWN OF: BOARD OF HEALTH ��.�,� �•��,�'G.�' 7 j L. — •'/h PREPARED FOR: L 16 ti r-4 MA DATE 0 SCAM: _ DATE: 4 1 -I- z� - b ' � I)I cape engineering, inc. �`P``� "',° `"AME O: ARpE CIVIL ENGINEERS a ALA B�ACA LAND SURVEYORS s Grill 4Io. 307fIY 1°.% I mpkin qt.- ouch ma 0"" . .S. DA9 SYSTEM DESIGN: SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE GIV LEGEND MARKED WITH MAGNETIC TAPE OR NOTES GARBAGE DISPOSER IS NOT ALLOWED PROVIDE IF NEC., WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. PROP. VENT 1. DATUM IS ASSUMED 6, 99 - EXISTING CONTOUR ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2" PEASTONE OR GEOTEXTILE CONCRETE COVERS TO WITHIN 3" GRADE ti-14 2. MUNICIPAL WATER IS NOT AVAILABLE 99.1 EXIST. SPOT ELEV. DESIGN FLOW: 4 BEDROOMS ® 110 GPI = 440 GPD \ TOP FOUND. L. 11 11, FILTER FABRIC OVER STONE gP 99 PROPOSED CONTOUR USE A 440 GPD DESIGN FLOW MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 114 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. o o 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS P`��o o BLOCKS OR 3' MAX. COVER TO BE AASHO H-29 r �a 198.4] PROPOSED SPOT EL. SEPTIC TANK: 440 GPD (2) = 880 MIN. a' COVE " PRECAST RISERS Q�e ��\ M 4"SCH40 PVC 4 0SCH40 PVC MORTAR ALL TH1 ** EL. 112.7f PIPES LEVEL 1ST 2' COMPONENTS H-%0 5. PIPE JOINTS TO BE MADE WATERTIGHT. Locus�e TEST HOLE RE-USE EXIST. 1500 GAL. SEPTIC TANK (TYP.) INV'S EL. 110.0 0 °° o o 0 11 . ACHING: 4, '�" 50o NGAL H-10 14" , y o 0 0 0 ° V o 0 0 0 0 EL. 111.0 6. CONSTRUCTION DETAILS _TO BE IN ACCORDANCE WITH t °°°°°°°° °A°° °°� °A ° °°°°°° 310 CMR 15.000 (TITLE V.) le Willo" 2% SLOPE OF GROUND LE TEE TEE 111 .3 $* ° ° ° ° �0�0 o DODO °o °o°°°° �(]00 --DOOM MOP t 5tree SEPTIC TANK o 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 jo-,, '' MIN. SUMP o°°°o°o° aa00a���00� ° ° ° o ���a00a�0�� ° ° ° ° treSIDES: 2 (40 + 10) 2 (.74) = 148 GPD o 0 0 0 0e o > ° ° ° ° ono°o°oo°o °°°°°° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO5 e(RE-USE)•• cAs BAFFLE : ° °°o°o°O°o° °12" MIN. INT. DIAM. c�i '°°°°°°°° �aaoaoa000a °°°°°°°°°° 000000a000a •°°°°°°°° UTILITY POLE ° ° °' BE USED FOR LOT LINE STAKING OR ANY OTHER 00,0* 0 ; °o°o°o 000aaonE1mm o°o °oo°o aaaaoM00000 :°o °o BOTTOM 40 x 10 (.74) = 296 GPD FIRE HYDRANT 110.31' 110.14' °°°°°°°° °°°°°°°°°° ° ° ° ° PURPOSE. ° ° ° ° ° °o°o°o EL. 108' TOTAL: 600 S.F. 444 GPD 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING 4' 3/4"-1-1/2" DOUBLE WASHED STONE H-20 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. DEPTH OF FLOW = (3) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED USE (3) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) " ALL AROUND PRECAST STRUCTURES WITHOUT INSPECTION BY BOARD F HEALTH AND WITH 2.25' STONE AT ENDS 5' BETWEEN UNITS AND 2.6' TEE SIZES: 6 CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 40' X 10 PERMISSION OBTAINED FROM BOARD OF HEALTH. AT SIDES INLET DEPTH = � 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING _ COMPACTION. (15.221 [2]) -0*THE INSTALLER SHALL VERIFY THE OUTLET DEPTH = 14" LOCATIONS OF ALL UTILITIES AND ALL LOCUS MAP BUILDING SEWER OUTLETS AND DIGSAFE (1-888-344-7233) AND VERIFYING THE ELEVATIONS PRIOR TO INSTALLING ANYLOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF WORK. NOT TO SCALE PORTION OF SEPTIC SYSTEM (_1.6 7. SLOPE) ( 1 % SLOPE) NO GROUNDWATER FOUND 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE MA REMOVED 5' BENEATH AND AROUND THE PROPOSED ASSESSORS MAP 88 PARCEL 7-6 APPROVED DATE BOARD OF' HEALTH FOUNDATION EXIST. SEPTIC TANK 68 D' BOX 16' LEACHING LEACHING FACILITY. . FACILITY NO"NEW CONSTRUCTION"PROPOSED 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. "INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE WITH 1500 GALLON H-10 SEPTIC TANK IF NOT SUITABLE. I I EXIST. WELL TEST HOLE LOGS Q . . ENGINEER: ARNE H. OJALA, PE, SE WITNESS: DAVID STANTON, RS DATE: 4 27 09 � PERC. RATE _ < 3 MIN/INCH LOT 7 12540 43,686 SF CLASS I SOILS P# ELEV. z ELEV. AFLc� oil Oltp" 114' ' O/A O/A SL SL tiQ) so, \ 10YR 4/3 1'OYR 4/3 EXIST. , O 6� B B DWELL. tii SL SL 83 TOP FNDN.115. _ / / 60 / 109 60 / 109 110.26 116.11' 114.93114.62 " 10YR 6 4 „ 10YR 6 4 , / \��� 5.54 \� 8.66 11 .79 / 114.99 �j PATIO C C 112.2 11.93 13.7 113.96 / / PERC ,J u\ 1 1 5.06 PAVED DRIVE. 114.07 S 3.94 11 /1 13.9 O O 1 1 5.1 2 114.98 , LS LS �j6 11 O E ST. 1500 114.78 \ DRAINAGE O L. ST 114.72 / EASEMENT 2.5Y 6/4 2.5Y 6/4 x115.21 \ 1-1 1195 11 9 1 4.66 \ 114.72 / O X / + l 14.60 126.5 ' 5 F LPWN A05 132" 103' 132" 103' I 1 15?011 4� v EpGE 0 1 13 4� N } 4 � \ 15.491 1�6 NO GROUNDWATER ENCOUNTERED P BENCHMARK: USE CORNER r' X 120. 0 �� , �� X 1 16 64 CONC. PAD AT GARAGE 1 15.39 1 1 1 4. AT ELEVATION 115.7' \ �J�I o�� o 126.0 SHED � O EXIST. WELL 11 Lt:: SITLE PLAN 5' REMOVAL OF UNSUITABLE SOIL REQUIRED AROUND PERIMETER OF LEACHING FACILITY, 11 .$ DOWN TO SUITABLE SOIL LAYER. REPLACE OF X 1 5 WITH CLEAN MED. SAND, TO MEET SPECIFICATIONS OF 310 CMR 15.255(3 ►50' 11 DESIRE'S LANE \ TH1 x 1 13.44 WEST BARNSTABLE 120.3 1 x 113.45 PREPARED FOR P OP. NT WITH CHARCOAL FILTER A BU SCR EN (FINAL PLACEMENT BY CO TRAC OR ITH HOMEOWNER BORTOLOTTI CONSTRUCTION/FOLEY �° APPROX. LOC. ON ULTA ON EXISTING SAS APRIL 28, 2009 WELLS THIS DIRECTION > THAN 150' TO Scale: 1"= 20' PROPOSED SAS 0 10 20 30 40 50 FEET LINCFMA ��NOFs off 508-362-4541 ssgc Sq�, I fax 508-362-9880 DANIEL ��� �. �o DANIEL) . �Gs downcape.com A. �� o OJALA J '< OJALA CIVIL OOWO cope engineering, � /nC" o.40980 No.46502 F civil engineers ��s `° �F`t0 S ST �� land surveyors �NIJ L E '-i / 939 Main Street ( Rte 6A) DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 09-077 09-077.DWG(SBO) MMM EL „ . r , SEPTIC PROFILE "PEST HOLE LOGS T.O.F. AT EL � —----� — —^._ —--- (NOT TO SCALE) ' — ACCESS COVER TO WITHIN 6" OF FIN. GRADE ✓ _ ACCESS COVER (WAIERTIGFIT) TO ENGINEER:__►-4I77- I f WITHIN 6' OF FIN. GRADE - - j (,,� MINIMUM .75' OF COVER OVER PRECAST r 2X SLOPE REQUIRED OVER SYSTEM I (� WITH ` --- `` --- ESS -���'- ` f v — -- --- I I RUN �'PE LEVEL -- - - --_ — --(,` -- ` _ --- _-- t2 \\\� a II7 z ,4 �J 17 (DELL) FOR FIRST 2' DATE: �___—_�.— _._ ✓ �- N• "_ r _ T ' ✓ 11iss5 PROPOSED �� L / ;rl' GALL �� ON SEPnC 1 I i R 3 --- r: _= PERC. RATE TANK (H _ . -- ---- -- - - -- - I_! - - - - „� CLASS SOILS P# t { (,x SLOPE) _6' CRUSHED STONE OR MECHANICAL '.._._-_.._._.___._���_- -•- -- --.._._.__-_ \� I '� `� DEPTH OF FLOW d COMPACTION. (15.221 (2]) Q TEE SIZES: i % SLOPE (,-_ SLOPE) \` 0° O -0 -------_----- INLET DEPTH OUTLET DEPTH = L LOCATION MAP i ASSESSORS MAP _ r PARCEL :_.__ LEACHING FOUNDATION— - -- SEPTIC TANK - - - D' BOX - -- - FACILITY 1 c, � I 1 FLOOD ZONE �J BUILDING ZONE: SETBACKS: FRONT - - SIDE - -- - M�r. 1 REAR - - - ---- �f A. �� I PLAN REFERENCE: Cie c �I r'i I Z 1 ;�� I ,..+r t , ' ,� l��'Er� -NOTES:- SF.PTIC DESIGN: (GARBAGE DISPOSER Is n rt d.r1rJ�. •Lr, ___) 1 DATUM ISJ0 _ +-Ir�.i✓_, --- --- - -- -- - - -- - L0ti: BtCRCOMSDE_SIGv 2. , ��� USE A G P D DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1 i 8" PER FOOT. 0,441 �I ( SEPTIC TANK: .! <4 GP^ 1 - may'' GALLONS T _, 4. DESIGN LOADING FOP. ALL PRECAST UNITS U 8E AASHO--H__._.__. _ L S. PIPE JOINTS TO BE MADE WATERTIGHT. '{ �_ ---� r USE A :� GALLON SEPTIC TANK � ._ /� `� IO I 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. > _- r- LEACH G:_ ENVIRONMENTAL CODE TITLE V. IN ``�- .. /r' r � 11� SIDES: a:3_'�i = •s- Z�9 P I F GPD THIS LAN S FOR PROPOSED WORK ONLY AND NOT TO B_ t i�_ - -" •-� GPD USED FOR LOT LINE STAKING. g PIPE FOR SEPTIC SYSTEM TO SCH. 40-4' PVC. •-- i !0. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WI I HO' J' �` ,- � � _T �y � l � r INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED �� 7 FROM BOARD OF HEALTH. c,. n h I t r� Nz \\ ` M SITE AND SEWAGE PIAN_ 0I{_ IN THE TORN OF: BOARD OF HEALTH • ---...._J / MA PREPARED FOR: •' L�, ►--r� ' ^ _.. ,._.;�„ .;; 1 - _ APPROVED DATE - 0 � feet -- * SCALE: '% DATE: ' r.r` ;� 7-1 I CA �t I I' ? . r.1fi(1✓mil`.-!4,%,�''M`' i '� �O.-�s{':.1 A. J\ — '�. �'"" �L' �4 �'Q•-~ down cape engineering, inc. /�v.�`" °' \ .ZK Of 01�,; CIVIL ENGINEERS % ARNE tiG� � Aa. F a� 0 LA - LAND SURVEYORS '' 'L PHONE SO6-362-4.541 FAX 508-362-96SO 7jZ 1 'F' / �'S•`�•d£n Q`v 4ty � te'y , :x �jy�P 939 main st. yarmouth, ma OJALA, .S. DATE