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HomeMy WebLinkAbout0039 DESIRE'S LANE - Health 39 DESIRES LANE --- WEST BARNSTABLE A = 088 008 002 0 I� i' Town of Barnstable P# �,� Department of Health,Safety,and Environmental Services oyVia Public Health Division Date )6zz vZ Q, 367 Main Street,Hyannis MA 02601 BARNSTABLE. MAM �0r 19. Date Scheduled b Time Fee Pd. Soil Suitability Assessment for Sew Disposal Performed By: :10 V MA /A6Lf_ L&J. PG Witnessed By: LOCATION & GENERAL`INFORMATION Location Address Owner's Name 301 DEsWO,- Address 6Air/) Assessor's 6Att.�5`�gt3 arcel: ✓ Engineer's Name PAO" X MC LEL 1W-,) NEW CONSTRUCTION REPAIR Telephone# 5-08- 95` 3 qz"' Land Use 0�1 Slopes(°/.) Surface Stones qlr-< Distances from: Open Water Body IVA _ft Possible Wet Area ..NA—ft Drinking Water Well ft Drainage Way_" ft Property Line 24 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 141 7— nn••/V1 Parent material(geologic) Q JfL✓.J Dr Depth to Bedrock IVN Depth to Groundwater: Standing Water in Hole: /VAZ Weeping from Pit Face Estimated Seasonal High Groundwater . _. .. - . DETERMINATION FOR SEASONAL HIGH WATER'TABLE Method Used. MA Depth Observed standing in obs.hole- - in. Depth to soil iilotilcs: Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION;TEST Date141tit-Time a Observation Hole# � Time at 9" 0^^) yO 5 �7 4, Depth of Perc `2t� Time at 6" 12M IN S-E Start Pre-soak Time @ 0 Time(9"-6") 171 m1N 5-3 56 C. End Pre-soak G 5 M N/)N GS Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back—� Copy: Applicant t►- , . e DEEP:OBSERVATION HOLE.LOG Hole# i Depth from Soil Horizon Soil Texture Soil Color - Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % 2-4 Il � s �. IDYti S/ 1321,1 LS 2.51 ? DEEY.OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. _ istencv.%Graven O/ A s�, iD yti 2 i32N � S 2-5 2 DEEP:OBSERVATION HOLE.LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % .DEEP..OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No— Yes Within 100 year flood boundary No— Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? _ If not,what is the depth of naturally occurring pervious material? 4 Certification' I certify that on 1— (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise d experience described in 310 CMR 15.017. Signature_ Date r�r September 20, 2012 Donald Desmarais, R.S. Barnstable Health Department 200 Main Street Hyannis, MA 02601 RE: Sean& Kathy Leaver 39 Desires Lane (assessors map 88,parcel 008/004) West Barnstable,MA Dear Don: On September 17, 2012, we conducted a perc test at the above referenced property to determine the perc rate of the soil in the C horizon in the area of the existing septic system. The perc rate we obtained at 72"deep was less than 5 min/in. When this perc rate is applied to the previous design,the existing 40' x 10' leach area has a calculated capacity of 444 gallons/day, enough for a 4 bedroom dwelling. This lot has a private well and has an area of 46,148 sf. This lot area meets the title five requirement of at least 40,000 sf fora 4 bedroom dwelling. As we discussed,by meeting these two requirements we have determined that the,existing septic system and the lot are both large enough to support a 4 bedroom dwelling.: If you have any questions or require additional information,please call me at 508-385-3426. Sincerely, Thomas McLekaA, P.E. Cc: Sean&Kathy Leaver P.O.Box 1163,East Dennis,MA 02641 "� (508)385-3426 bassriverengineering@comcast.net Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address { THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE a= Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 page. Citylrown State Zip Code Date of Inspection Un CA 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 C on the computer, use only the tab 1. Inspector: key to move your cursor-do not Joseph M Martins use the return Name of Inspector key. Sepcheck Comp Company Name 17 Northside Dr Company Address South Dennis MA 02660 City/Town State Zip Code 508-385-5891 SI 147 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 1/12/2017 Insp ctor'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•113 Title 5 Official Inspection Forth:Subsurface 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 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repai as approved by the Board of Health, will pass. Check the box for"yes","no"or"not determined"(Y, N, ND)for the foil o i g statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic k(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or t failure is imminent. System will pass inspection if the existing tank is replaced with a compl i g septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it' structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is les an 20 years old is available. ❑ Y ❑ N ❑ N xplain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 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 xplain below): ❑ obstruction is removed ❑ Y ❑ N ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ ND (Explain below): QVz ❑ The system requZnth than 4 times a year due to broken or obstructed pipe(s). The system will pass approval of the Board of Health): ❑ broken p ❑ Y ❑ N ❑ ND(Explain below): obstructi ❑ Y ❑ N ❑ ND (Explain below): /In Evaluation is Required by the Board of Health: ns exist which require further evaluation by the Board of Health in order to determine if em is failing to protect public health, safety or the environment. em 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 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool' ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 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. t5ins•3/13 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 ,M 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE IMA 02668 1/12/2017 page. Cityfrown 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): Engeetter Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3,113 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 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1500 GALLON SEPTIC TANK, DISTRIBUTION BOX, AND 4 500 GALLON LEACH CHAMBERS IN A 10'X40'X2' DEEP STONE VOLUME. 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 HAS WELL g ( y g (gp )) WATER Detail: NOT METERED Sump pump? ❑ Yes ® No Last date of occupancy: 1/12/2017 Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 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: PER BARNSTABLE PLANT PUMPED IN 2006. PER LAST INSP REPORT PUMPED IN 2010. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 18 YEARS, INSTALLED 1999. PER BARNSTABLE HEALTH DEPT. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: —2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10feet Comments (on condition of joints, venting, evidence of leakage, etc.): NO EVIDENCE OF LEAKAGE Septic Tank (locate on site plan): Depth below grade: 1 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: APP 10X6X5 1500 G Sludge depth: 6" t5ins•3/13 Tide 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 wM s. 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 page. CitylTown 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 23" Scum thickness 1" 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 18" How were dimensions determined? CORETAKER Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): HAS PVC INLET TEE. HAS PVC OUTLET TEE. LIQUID LEVEL OF 48"AT OUTLET INVERT. NO EVIDENCE OF LEAKAGE. Grease Trap (locate on site plan): Depth below grade: N/A 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 page. Citylrown 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: N/A 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 Tide 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 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 page. Citylrown 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 AT INVERTS 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.): EXAMINED DBOX W CAMERA. SIDES ARE CLEAN. NO EVIDENCE OF SOLIDS CARRYOVER OR HIGH LEVEL. 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.): N/A *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 500 GALLON CHAMBERS ❑ 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.): OPENED ONE COVER OF LEACH CHAMBER. SAS IS DRY. MODERATE STAIN LINE AT 6" ABOVE LEACH BOTTOM. ALL STONE IS CLEAN. SIDES ARE CLEAN. GRADE TO SAS BOTTOM IS 5.5'. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM ,e 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information i; required for„very WEST BARNSTABLE MA 02668 1/12/2017 page. City/Town 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: N/A 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments ,. 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 page. City(rown State Zip Code Date of Inspection D. System Information (cost.) 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 0 Lo-eq I FROM T DISTALICES A 33.5 : 13IzJy, o A 2-= 3 7 ' Qa = 3/' o z A ­- D iaof "L C3 = V ' ; b3 = yI� CH = S-4' ; b y _ Sa' Gve Lc. `a190� b Ilk C, 3 A t f. D �o� . 4 t5ins•3/13 Title 5 Official Inspecffon Forth: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 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 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: >=82 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: USGS MAP, GOOGLE MAPS, CCC GROUNDWATER CONTOUR MAP. You must describe how you established the high ground water elevation: SITE IS 120'ASL. TESTHOLE RECORDED NO GROUNDWATER AT 13.0' GRADE TO SAS BOTTOM IS 5.5'. MAX GROUNDWATER RISE IS 8'. CCC GROUNDWATER CONTOUR IS APP 30'ASL. SEPARATION MATH: 120-( 5.5+ 8 +30)= 76.5'. 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 '0 39 DESIRE'S LANE WEST BARNSTABLE MA Property Address THOMAS J MCLELLAN AND HELEN M MCLELLAN 39 DESIRE'S LANE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 1/12/2017 page. Cityfrown 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 'nformation—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i R ENGINEERING Septic • design s McLellan, P.E. kineer September 20, 2012 Donald Desmarais, R.S. Barnstable Health Department 200 Main Street Hyannis,MA 02601 RE: Sean&Kathy Leaver 39 Desires Lane (assessors map 88,parcel 008/004) West Barnstable, MA Dear Don: On September 17, 2012,we conducted a perc test at the above referenced property to determine the perc rate of the soil in the C horizon in the area of the existing septic system. The perc rate we obtained at 72" deep was less than 5 min/in. When this perc rate is applied to the previous design,the existing 40' x 10' leach area has a calculated capacity of 444 gallons/day, enough for a 4 bedroom dwelling. This lot has a private well and has an area of 46,148 sf. This lot area meets the title five requirement of at least 40,000 sf for a 4 bedroom dwelling. As we discussed, by meeting these two requirements we have determined that the existing septic system and the lot are both large enough to support a 4 bedroom dwelling. If you have any questions or require additional information,please call me at 508-385-3426: Sincerely, Thomas McLe , P.E. Cc: Sean&Kathy Leaver P.O.Box 1163,East Dennis,MA 02641 / (508)385-3426 bassriverengineering@comcast.net �r Public Health Division Date fp / 367 Main Street,Hyannis MA 02601 �fixersELM t KAM ��rEotlru�i+"�� Date Scheduled / � Time �� Fee Pd. 91--) Soil Suitability-Assessment for Sew Disposal Performed By: H U(��� !'I(il.G�,1�Q/y PF Witnessed By: LOCATION& GENERAL INFORMATION Location Addresst 'Owners Name 3q DC-SIRE5, k. Al EAti f vt Address 6Ar Assessor's Map/Parcel: Engineer's Name THomX W 1.ELLaN NEW CONSTRUCTION REPAIR Telephone# ��p" E5- 3�[ Land Use Slopes(N t% Surface Stones Distances from: Open Water Body NApossible Wet Area Drinking Water Well f� Drainage Way Y �a R Property Line !(l R Other R 1 ISKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in"proximity to holes) N 6 141.7- 1; 6� T+I 7�. �� P Parent material(geologic) aJ—1.11A Depth to Bedrock IjQ Depth to Groundwater: Standing Water in Hole:�� Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL IIIGGII WATER'TABLE _ Method Used: iV Depth Observed standing in obs.hoie: in. Depth to soil utotites: Depth to weeping,from side of obs.hole: 'n• Index Well# in. Groundwater Adjustment _ R, Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION<TEST: Date ..•I ►ZTtmc .;6'a [Hole servation # Time at 9" Q m of yQ Sec— Depth of Perc 72t' Time at 6" -2- Start Pre-soak Time© 0 Time(9"-611) 2 m l,v �� L End Pre-soak L 5M;A) Rate Min./Inch GS 5 NIN/IIJ Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) g original: Public Health Division Observation Hole Data To Be Completed on Back-�Copy: Applicant t. r; .DEEP OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture Soil Color - Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % y " 5 10q Q_ q/Z :'1.:;.­:::.:::.:�: DEEP OBSERVATION'HOLKLOG ;Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.%Graven 132N C (' S 2.5 DEEP OBSERVATION.HOLE LOG Hole# Depth from Soil Horizon . Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. oGravel) DEEP OBSERVATION HOLE LOG Hole.#. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % Flood Insurance Rate Map, Above 500 year flood boundary No_ Yes f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °s 39 Desire's Lane, West Barnstable M-88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information is required for every 39 Desires Lane West Barnstable MA 02668 August 30, 2012 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:Whenfilling out forms A. General Information on the computer, PY use only the tab 1. Inspector: (0 key to move your cursor-do not Troy Williams use the return key. Name of Inspector ; Troy Williams Septic Inspections �y Company Name 19 Hummel Drive Company Address South Dennis MA 02660 City/Town State Zip Code (508)385- 1300 S1682 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority August 30, 2012 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-11/10 a Title 5 Official s ion Form:Subsurface Sewage Disposal System-Page 1 of 17 I Commonwealth of Massachusetts a Title 5 Official Inspection Form . r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Desire's Lane,West Barnstable M -88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information equ ire forlevery 39 Desire's Lane,West Barnstable MA 026W August 30, 2012 ' 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: ® 1 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 meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: b ❑ 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)fog the following statements. If"not r 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): .a N/A a, E t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Desire's Lane, West Barnstable M-88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information is required for every 39 Desires Lane, West Barnstable MA 026 August 30, 2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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): N/A ❑ 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): N/A 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 316 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 L . 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Desire's Lane, West Barnstable M-88 P-008-004 Property Address Kathy Leaver Owner Owner's Name irmat yu edlon forlevery 39 Desire's Lane, West Barnstable MA 026 August 30, 2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A D) System Failure Criteria Applicable to All Systems: stems: 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/:day flow t5ins•11/10 i Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "t 39 Desire's Lane, West Barnstable M-88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information is required for every 39 Desires Lane West Barnstable MA 026 August 30, 2012 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 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 39 Desire's Lane, West Barnstable M-88 P-008-004 Property Address Kathy Leaver Owner Owners Name information is required for every 39 Desires Lane, West Barnstable MA 026 August 30, 2012 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): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Desire's Lane, West Barnstable M-88 P-008-004 Property Address Kathy Leaver Owner owner's Name information is required for every 39 Desire's Lane,West Barnstable MA 026 August 30, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 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 Private well 9 ( y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A t5ins•11/10 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Desire's Lane, West Barnstable M-88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information is required for every 39 Desire's Lane,West Barnstable MA 026 August 30, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): General Information Pumping Records: Source of information: Last pumped in 2010 per info from owner. 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-11110 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 39 Desire's Lane, West Barnstable M-88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information is required for every 39 Desire's Lane, West Barnstable MA 026 August 30, 2012 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: Tank, d-box and leaching were installed on 8/6/99 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1811+ feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): Depth below grade: 10"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: 6'X10.5'X6' 1500 gallon Sludge depth: 4" t5ins•11/10 Title 5 Official Insp ection 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 39 Desire's Lane, West Barnstable M-88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information required forfevery 39 Desire's Lane, West Barnstable MA 026 August 30, 2012 page. City/Town 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 2'8" Scum thickness .. thin layer 611 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? probe/measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet and outlet tees were found present.and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): N/A Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle NIA Date of last pumping: N/ADate t5ins.11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Desire's Lane, West Barnstable M-88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information is required for every 39 Desires Lane,West Barnstable MA 026 August 30, 2012 page. Citylrown 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.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): N/A Dimensions: N/A Capacity: N/A gallons Design Flow: N/A ' 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.): N/A "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form v Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Desire's Lane, West Barnstable M-88 P-008-004 Property Address Kathy Leaver owner Owner's Name information is required for every 39 Desire's Lane, West Barnstable MA 026 August 30, 2012 page. Citylrown 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 level 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.): D-box was found level and in working order. 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.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Desire's Lane, West Barnstable M -88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information is 39 Desire's Lane, West Barnstable MA 026 August 30, 2012 required for every g page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-500 gallonwith 27"of stone ❑ 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.): Chambers were found with 13"of water present with walls found clean above water level. Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 I, Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °r 39 Desire's Lane, West Barnstable M-88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information is required for every 39 Desire's Lane,West Barnstable MA 026 August 30, 2012 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.): N/A Privy(locate on site plan): Materials of construction: N/A . Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins-11110 Title 5 Official Inspection Forth: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 39 Desire's Lane,West Barnstable M -88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information is required for eery 39 Desire's Lane,West Barnstable MA 026 August 30, 2012 page. Cityfrown 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 ©;N a� (� l�'N� 1.�.•r1�5.• I i tp G �/q F►-owl- . � I ; 3yv, - 2? 1311 ?_ 3 3 - 13o ' L 3 t /y3 ` ISo 3 0 t5ins•11/10 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 39 Desire's Lane,West Barnstable M -88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information is required for every 39 Desire's Lane, West Barnstable MA 026 August 30, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25'0'+ 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. 10/28/98 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: AIW 253 Zone B 49.0' 3.2'adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 13.0'. Groundwater adjustment at the time of inspection was 3.2'. Bottom of leaching at 5.0'was found not to be located in the high groundwater elevation at the time of inspection. Groundwater map for Barnstable estimates groundwater at approx. 30.0'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Forth: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 39 Desire's Lane, West Barnstable M -88 P-008-004 Property Address Kathy Leaver Owner Owner's Name information is 39 Desire's Lane, West Barnstable MA 026 August 30, 2012 required for every g page. Citylrown 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form` Not for Voluntary Assessments � /` Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information M-88 P-8.2 Important:When filling out forms 1. Property Information: on the computer, d�� use onlylythethe tab 39 DESIRES LN W. BARNSTABLE D key to move your Property Address cursor-do not KATHY LEAVER use the return key. Owner's Name 39 DESIRES LN I re5 Owner's Address W. BARNSTABLE MA 02668 City/Town State Zip Code . Date of Inspection: 2-8-08 Date 2. Inspector: JAMES D SEARS #S-1623 Name of Inspector BLUEWATER Company Name 350 MAIN STREET Company Address r`,r WEST YARMOUTH MA {02673 -� Cityfrown State ' slip Codes IS, 508-775-2800 - c, > Telephone NumberCD1is B. Certification ' .I certify that I have personally inspected the sewage disposal system at this addres 3 and tQ?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: N Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Eval ation by the Local Approving Authority 2-11-08. pector'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. 39 Desires Ln t5.doc.doc-03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts --- Title 5 Official Inspection Form ..._.._ c Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 39 DESIRES LN Property Address W. BARNSTABLE MA 02668 Cityrrown State Zip Code KATHY LEAVER 2-8-08 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all.of Section D A) System Passes: X x❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: N/A ❑ 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: B. Certification (cont.) 39 Desires Ln t5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System. Page 2 of 16 Commonwealth of Massachusetts - Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System.Form 39 DESIRES LN Property Address W. BARNSTABLE MA 02668 City/Town State Zip Code KATHY LEAVER 2-8-08 Owners Name Date of Inspection B) System Conditionally Passes (cont.): N/A ❑ 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 ❑ 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: N/A ❑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 CUR 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 39 Desires Ln t5.doc.doc o 03/2006 Title 5 Official-Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 _.................. Commonwealth of Massachusetts Title 5 Official Inspection Form I Not for Voluntary Assessments r =' Subsurface Sewage Disposal System Form B. Certification (cont.) 39 DESIRES LN Property Address W. BARNSTABLE ' . MA 02668 Cityrrown State Zip Code KATHY LEAVER 2-8-08 Owners Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): N/A 2. System will fall 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 absorptionsystem (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 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. B. Certification (cont.) 39 Desires to t5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System. Page 4 of 16 l .. ........... Commonwealth of Massachusetts Title 5 Official Inspection . Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 39 DESIRES LN Property Address W. BARNSTABLE MA 02668 Cityrrown State Zip Code KATHY LEAVER 2-8-08 Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: N/A You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Z Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Elx❑ Static,liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in h leaching is less than 6" below invert or available volume is less d g ❑ than.'/z day_flow ❑ x❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ x❑ 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. ❑ x❑ Any portion-of a cesspool or privy is within a Zone 1 of a public well. ❑ x❑ Any portion,.of a cesspool or privy is within 50 feet of a private water supply well. ❑ x❑ 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.] ❑ x❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10 9P 000 d. Yes No ❑ 0 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. B. Certification (cont.) 39 Desires Ln t5.doc.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts �+ fJJ Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 39 DESIRES LN Property Address W. BARNS TABLE MA 02668 Cityrrown State Zip Code KATHY LEAVER 2-8-08 Owner's Name Date of Inspection 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. N/A 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., C. Checklist 39 Desires Ln t5.doc.doc•03/2006 Title 5 Offici Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 ..... .... Commonwealth of Massachusetts __ _ _ p Title 5 Official Inspection Form Not for Voluntary Assessments . f Subsurface Sewage Disposal System Form 39 DESIRES LN Property Address W. BARNSTABLE MA 02668 Cityrrown State Zip Code KATHY LEAVER 2-8-08 Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes" or"no" as to each of the following: YES NO x❑ ❑ Pumping information was provided by the owner, occupant,or Board of Health ❑ x❑ Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? j ❑ Z 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) x❑ ❑ Was the facility or dwelling inspected for signs of sewage back up? x❑ ❑ Was the site inspected for signs of break out? ❑ Were all system components, including 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? 0 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: p . ❑ Existing information. For example, a plan at the Board of Health. ❑ Z 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)] I Do System Information 39 Desires Ln t5.doc.doc a 03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.• Page 7 of 16 Commonwealth of Massachusetts s Title 5 Official Inspection Form __ . . Not for Voluntary Assessments Subsurface Sewage Disposal System Form y 39 DESIRES LN Property Address W. BARNSTABLE . MA 02668 City/Town State Zip Code KATHY LEAVER 2-8-08 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 5 Does residence have a garbage grinder?• ❑Yes O No Is-laundry on a separate sewage system? [if yes separate inspection required] ❑Yes N No Laundry system inspected? ❑Yes N No Seasonal use? ❑Yes N No Water meter readings, if available last 2 ears usage(gpd)): WELL 9 ( Y 9 Sump pump? ❑Yes 0 No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: N/A Type of Establishment: Design flow(based on 310 CM 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): D. System. Information (cont.) 39 Desires Ln t5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System �-- Page 8 of 16 ........... .......... . Commonwealth of Massachusetts Title 5 Official Inspection Form ti Not for Voluntary Assessments ,. Subsurface Sewage Disposal System Form 39 DESIRES LN Property Address W BARNSTABLE MA 02668 City/Town State Zip Code KATHY LEAVER 2-8-08 Owner's Name Date of Inspection General Information Pumping Records: Source of information: BLUEWATER Was system pumped as part of the inspection? X❑Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Reason for pumping: Type of-System: x❑ 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) ElInnovative/Alternative technology. Attach a copy of the current operation and. maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed if known and source of information: 1999 PERMIT#99-231 Were sewage odors detected when arriving at.the site? ❑Yes Z No - D. System Information (cont.) 39 Desires Ln t5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 " Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments =' Subsurface Sewage Disposal System Form 39 DESIRES LN Property Address W. BARNSTABLE MA 02668 City/Town State Zip Code KATHY LEAVER 2-8-08 Owner's Name Date of Inspection Building Sewer(locate on site plan): X Depth below grade: 22"feet Material of construction: ❑ cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 90 + feet Comments(on condition of joints, venting, evidence of leakage, etc.): SCH 40 PVC CLEAN NOTE: LINE FROM TANK TO D-BOX WATER BLASTED & NOW CLEAN Septic Tank-(locate on site plan): X Depth below grade: 16" INLET SIDE 7" OUTLET SIDE 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 Dyes ❑ No certificate) Dimensions: 1500 GAL PRECAST - Sludge depth: 411 Distance from top of sludge to bottom of outlet tee or baffle 26" 311 Scum thickness A 8" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? SLUDGE JUDGE 39 Desires Ln t5.doc.doc•03/2006 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System Page 10 of 16 ��v I Commonwealth of Massachusetts - � Title 5 Official Inspection Form ...... . _i° Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) W. BARNSTABLE MA 02668 Cityrrown State Zip Code KATHY LEAVER 2-8-08 Owner's Name Date of Inspection 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 AT WORKING LEVEL, INLET TEE, OUTLET TEE, INLET AT 16", OUTLET AT 7", NO SIGN OF LEAKAGE OR OVER LOADING. NOTE: MAINT PUMP AFTER INSPECTION. Grease Trap (locate on site plan): N/A- Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): . Dimensions: Scum thickness Distance from top of scum.to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/A Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 39 Desires Ln t5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System. �� Page 11 of 16 Commonwealth of Massachusetts - � Title 5 Official Inspection Form Not for Voluntary Assessments Ma Subsurface Sewage Disposal System Form D. System Information (cont.) 39 DESIRES LN Property Address W. BARNSTABLE MA 02668 Cityfrown State Zip Code KATHY LEAVER 2-8-08 Owner's Name Date of Inspection Tight or Holding Tank(cont.) N/A Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No ❑ ❑ Alarm level: Alarm in Working order: Yes No � e 9 i 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): X 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.): D-BOX IS 2'X2'-3' BELOW GRADE, FOUR LINES OUT BOX IS CLEAN AND SOLID, NO SIGN OF OVER LOADING Pump Chamber(locate on site plan): N/A Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 39 Desires Ln t5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form .. Not for Voluntary Assessments Subsurface Sewage Disposal System Form. D. System Information (cont.) 39 DESIRES LN Property Address W BARNSTABLE MA 02668 Cityrrown State Zip Code KATHY LEAVER 2-8-08 Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): V I Soil Absorption System (SAS) (locate on site plan, excavation not required): N/A If SAS not located, explain why: Type: ❑ leaching pits number: x❑ leaching.chambers. number: 4 ❑ 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.): LEACHING IS FOUR 500 GAL DRY WELLS WITH & STONE ON ENDS. 27" OF STONE ON SIDES, TOP OF LEACHING AT 40"W/COVER AT 10". 18"WATER IN LEACHING, NO HIGH STAIN LINE. NO SIGN OF OVERFLOWING OR SOLID CARRY OVER. 39 DesiresLn t5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System - Page 13 of 16, J Commonwealth of Massachusetts 2.1 Title 5 Official Inspection Form ' Not for Voluntary Assessments Subsurface Sewage Disposal System Form Da System Information (cont.) 39 DESIRES LN Property Address W. BARNSTABLE MA 02668 Cityrrown State Zip Code KATHY LEAVER 2-8-08 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A 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): N/A Materials of construction: Dimensions Depth of solids Comments(rote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 39 Desires i-n t5.doc.doc 03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System e Page 14 of 16 -- 1 f Commonwealth of Massachusetts ................. Title 5 Official Inspection Form - .. Not for Voluntary Assessments Subsurface Sewage Disposal System Form v D. System Information (cont.) 39 DESIRES LN Property Address . W. BARNSTABLE MA 02668 Cityrrown State Zip Code- KATHY LEAVER 2-8-08 Owner's Name Date of Inspection 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. Cry.R B o � � i 33 - = ' A 3 C3 - l �3 t5insp.doc.doc-03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11 Page 15 of 16 JS , Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ........ Subsurface Sewage Disposal System Form D. Systemi Information (cont.) 39 DESIRES LN Property Address W. BARNSTABLE MA 02668 Cityrrown State _Zip Code KATHY LEAVER 2-8-08 Owner's Name Date of Inspection Site Exam: Slope YES Surface water NONE Check cellar YES DRY Shallow wells NONE Estimated depth to no groundwater: 1 V Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 10-28-98 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) ❑x Accessed USGS database-explain: USGS WELL SDW 253 49"5"ZONE B ADJ 3-7 You must describe how you established the high ground water elevation: SEE ATTACHED 39 Desires Ln t5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1.6 of 16 } G�i /IN ff z17 3 l -) rS 13 j�,G• to 4� y. 3-/ �I Ala . t Y TOWN OF BARNST LE F LOCATIONS'"` SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY j LEACHING FACILITY: (type) �O :Y (size) _ NO. OF BEDROOMS BUULDER OR OWNER 7 f h IPERMITDATE: 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 Furriished 6y K h ` F \ r ? TOWN OF BAR4ASSE b LOCATION 3 �'"`" SEWAGE # L/a_ — VILLAGEW i3 s R S MAycr & LOTQ!J —� INSTALLER'S NAME&PHONE NO. -` al-" r e y'/ � �' 3&y- t' SEPTIC TANK CAPACITY i LEACHING FACIIITY: (ty ) D X 9 t� (size) y Ste° NO.OF BEDROOMS ; BUILDER OR OWNER I 1 ,1 4e PERMITDATE: COMPLIANCE DATE: I 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) I Feet Furnished by r_. _ •fir �. 2 9 No. / a r � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYicatiou for Migogar *p,5tem Cougtruction Vermit Application for a Permit to Consttuc (✓ R air( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components cS� Location Address or Lot No./,1� b"n e,S�y C Owner's Name,Address/and Tel.No. J L.��S't' ISC�nS'�'Gb� ��� �♦ �i-���{-ric.�< !1C/kf /��� � Cc � sso�Map/Parcel " �crce " pZ O. `lam°'f jSt/ RCSEd��C AJA O hAp �(��y Installer's Name,Address,and Tel.No. Designer's Nafne,Address and Tel.No. C 5,44 of,..1 G l ^.A �p Qo� $'SS W• A. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //D gallons per day. Calculated daily flow gallons. Plan Date �' "`� Nu ber of sheets Revision Date Title St +e Secaer� G, 1 4-,44r+cL Size of Septic Tank /Siv Type of S.A.S. Description of Soil b e ea6E.3p ,71 CIS ..��. 11.0 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 is Bold of Health. Signed ,.✓lam Date y Application Approved by6 — Date T-- Application Disapproved for the following reasons Permit No. Date Issued No: Y Y % ".<� Fee l/ THE COMMONWEALTH OF MASSACHUSETTS �"Entered in computer: Vill Yes PUBLIC HEALTH DIVISION -TOWN OF�BARNSTABLE., MASSACHUSETTS - goph ation for Migonl *p5tefu Con5tructton Per' it4 'OCr6'00 Application for a Permit to Constru air Upgrade( )Abandon ❑Complete System ❑Individual Components PP (w�Pg / ( ) P Y Po Location Address or Lot No.,/.. � �; Den 2 e S C A c . Ow er's Name,Address and Tel.No. CCj-j ICT42 .�ridc /7cMt PKirSO�MagZel 0�' 'Installer' Name,Address,and Tel.No. 1 Desi ner's Nazne,Address and Tel.No. c" s-a�,mow, �� �� �� po ate S �✓, r �._M,4 1 �s 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 a it t Design Flow //b gallons per day. Calculated-daily flow 11.3-3a gallons. Plan Date 3' 4 9 p Nu ber of sheets Revision Date 1 _ Title Sl to d+ YeLjci�c foe" 'j N`ype+r�c� 1 on o &I � Gr' �'/7-C. Size of Septic Tank Typpe of S A.S. Description of Soil 6 y De co� G r �-c% — `1 P..t''^, 7A 4,9 3�:?' -- SS Lour- ss'=� /S'6^ _5:4H0y &C,, ,,Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees-toensure the construe>ion and maintenance of the afore described on-site sewage disposal'system in accordance with the provisions of T• le 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued,! is Bo of.Health.. Signed' af' Date "f f a' i� % Application Approved,b�"y' 01 Date .► iik •- Application Disapproved for the.following reasons ' 4 Permit No. F'' j Date Issued w i ----- -- -1-- _ -- ' THE COMMONWEALTH OF MASSACHUSETTS ` BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(!-�')-kepaired( )Upgraded( ) at :7y e `l has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9— 7 3 r dated Installer 0',-_ " Designer A/ The issuance of this P �l e. `t sh n�ott g be construed as a u e s arantee that thtem ill function as des�i ned� y 10 Date ; Inspector �� - g v� '- / i No. `'?' /" �'l- n/ -------------------- ,-----Fee s' �'/� THE COMMONWEALTH OF MASSACHUSETTS -�� PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi5po0ar *potem Con.5truction Permit Permission is hereby granted Cons ct O Repair( Upgrade( )Abandon , a-- System located at � ���J�© � � , � 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. '1 Provided: Construction must be(completed, ithin three years of the date of thi&p m,t! 9 Date: �5 �/1 Approved b �-i" �� �/l �"% '��� / j ENVIROTECHLABORATORIES,INC. MA CERT.NO.:M-MA 063 449 Rte.130 Sandwich, MA 02963 908(888-6460) 1-800-339-6460 FAX(908)888-6446 CLIENT: Fitzpatrick Home Building LOCATION: Lot 3 ADDRESS: PO Box 154 Desire Ln, Forestdale MA 02644-0154 W Barnstable MA. COLLECTED BY. Gl'i:ent. SAMPLE DATE: 3-26-99, SAMPLE TIME: NIA. WATER SAMPLE TYPE: New Well DATE RECEIVED:3-26-99 LAB LD. #: 993478A. WELL SPECS.: N/A. RESULTS OF ANALYSIS: Parameters Units Recommended Results Method Date AnaWed Limits Coliform bacteria f100m1 01 01 9222 R 3/26/99 pH pH'units 6.5-8.5 6.111 4500 H+ 3/26/99 Conductance umhos/cm: 500 387 120.1 3126/99, Nitrate-N/Nitrite-N mg/L 10.0 0.42' 4500-NO3 E. 3126/99 Sodium mg/L. 2&0, 47.8 200.7 3/29/99 Iron mglL. 0.3 < 0.02 2003 3/29/99 Manganese mg/L 0.05 <0.002. 200.7 3/29/991 Volatile Organics Chloroform ug/L. 100, 2.0 EPA. 524.2, 412/99 COMMENTS: pH':is below recommended limit and may have corrosive characteristics. Sodium,level is not a health hazard., WATER'MEETS EPA STANDARDS AND IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. Date on d J. Sa i Laboratory fl ctor <=less,than >=greater than TNTC=tao numerous to count yl t R.I. Analytical Specialists in Environmental Services CERTIFICATE OF ANALYSIS Envirotech Laboratories, Inc. Date Received: 3/29/99 Attn: Mr. Ron Saari Date Reported: 4/05/99 449 Rte. 130 P.O. #: Sandwich, MA 02563 Work Order #: 9903-02575 DESCRIPTION: FITZPATRICK BLDG. (TWO WATER SAMPLES). Subject sample(s) has/have been analyzed by our laboratory with the attached results. Reference: All parameters were analyzed by U.S. EPA approved methodologies. The specific methodologies are listed in the methods column of the Certificate Of Analysis. If you have e ions regarding this work, or if we may be of further assistance, please contact us. Appro c James Michael J. n Vice P es t Quality Co trol Coordinator enc: C a il o stody 41 Illinois Avenue, Warwick, R'I 02888 950 Boylston Street, Unit 102, Newton Highlands, MA 02461 Tel: (401) 737-8500 Fax: (401) 738-1970 Tel: (617) 965-5133 Fax: (617) 965-5624 y�. Page 2 of 5 R.I. Analytical Laboratories, Inc. CERTIFICATE OF ANALYSIS Envirotech Laboratories, Inc. Date Received: 3/29/99 Approved by: Work Order# 9903-02575 R.I. t Sample#: 001 SAMPLE DESCRIPTION: 993478A LOT 3 DESIRES LANE 3/26/99 SAMPLE DET. ANALYZED PARAMETER RESULTS LIMIT UNITS METHOD DATE/TIME ANALYST Volatile Organic Compounds Bromodichloromethane <0.5 0.5 ug/l EPA 524.2 4/02/99 20:50 RAM Bromoform <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Dibromochloromethane <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Chloroform 2.0 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1,2-Dibromoethane(EDB) <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Benzene <0.5 0.5 ugh EPA 524.2 4/02/99 20:50 RAM Carbon Tetrachloride <0.5 0.5 ug/l EPA 524.2 4/02/99 20:50 RAM 1,2-Dichlorcethane <0.5 0.5 ug/l EPA 524.2 4/02/99 20:50 RAM Trichloroethane <0.5 0.5 ug/l EPA 524.2 4/02/99 20:50 RAM 1,4-Dichlorcbenzene <0.5 0.5 ug/l EPA 524.2 4/02/99 20:50 RAM 1,1-D ichlorc ethane <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1,1,1-Trichloroethane <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Vinyl Chloride <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Bromobenzene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Bromomethane <10 10 ug/1 EPA 524.2 4/02/99 20:50 RAM Chlorobenzene <0.5 0.5 ugh EPA 524.2 4/02/99 20:50 RAM Chloroethane <5 5 ug/l EPA 524.2 4/02/99 20:50 RAM Chloromethane <5 5 ug/1 EPA 524.2 4/02/99 20:50 RAM 2-Chlorotoluene <0.5 0.5 ue/1 EPA 524.2 4/02/99 20:50 RAM 4-Chlorotoluene <0.5 0.5 u h EPA 524.2 4/02/99 20:50 RAM Dibromomethane <2 2 ug/1 EPA 524.2 4/02/99 20:50 RAM I 1,3-Dichlorobenzene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1,2-Dichlorobenzene <0.5 0.5 ug/I EPA 524.2 4/02/99 20:50 RAM trans-1,2-Dichloroethene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM cis-1,2-Dichloroethene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Methylene Chloride <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1,1-Dichloroathene <0.5 0.5 ug/l EPA 524.2 4/02/99 20:50 RAM 1,1-Dichloropropene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1,2-Dichloropropane <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1,3-Dichloropropane <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1.3-Dichloropropene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 2,2-Dichloropropane <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Ethylbenzene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Styrene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1,1,2-Trichloroethane <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1,1,1,2-Tetrachloroethane <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1,1,2,2-Tetrachloroethane <0.5 0.5 ug/l EPA 524.2 4/02/99 20:50 RAM Tetrachloroethene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1 . • I r I y Page 3 of R.I. Analytical Laboratories, Inc. CERTIFICATE OF ANALYSIS Envirotech Laboratories, Inc. Date Received: 3/29/99 Approved by: Work Order# 9903-02575 R. ytical Sample#: 001 993478A LOT 3 DESIRES LANE 3/26/99 SAMPLE DET. ANALYZED PARAMETER RESULTS LIMIT UNITS METHOD DATE/TIME ANALYST 1,2,3-Trichloropropane <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Toluene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Xylenes <0.5 0.5 ug/l EPA 524.2 4/02/99 20:50 RAM 1,2-Dibromo-3-Chloropropane <10 10 ug/1 EPA 524.2 4/02/99 20:50 RAM Bromochloromethane <1 1 ug/1 EPA 524.2 4/02/99 20:50 RAM n-Butylbenzene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Dichlorodifluoromethane <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Trichlorofluonomethane <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Hexachlorobutadiene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Isopropylbenz2ne <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM p-I sop ropyltoluene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Naphthalene <0.5 0.5 ug/l EPA 524.2 4/02/99 20:50 RAM n-Propylbenzene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM sec-Butyl benzene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM tert-Butylbenzene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1,2,3-Trichlorobenzene <0.5 0.5 ug/l EPA 524.2 4/02/99 20:50 RAM 1,2,4-Trichlorobenzene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1,2,4-Trimethylbenzene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM 1,3,5-Trimethylbenzene <0.5 0.5 ug/1 EPA 524.2 4/02/99 20:50 RAM Methyl Tertiary Buthyl Ether <I 1 ug/1 EPA 524.2 4/62/99 20:50 RAM n-Hexane <10 10 'ugll EPA 5214.2 4/02/99 20:50 RAM SURROGATES RANGE EPA 524.2 4/02/99 20:50 RAN! 4-Bromofluorobenzene I11 80-120% EPA 524.2 4/02/99 20:50 RAM 1,2-Dichlorobenzene-d4 110 80-120% EPA 524.2 4/02/99 20:50 RAM I I Z6vvvujt,( 0 VU 4 �,�eo%d XT � * Fee--- -- I BOARD OF HEALTH a. TOWN OF BARNSTABLE 0(pp[ication-*rVe[C Cootructionpermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel _ ----------------- Owner 1 Address Installer — Driller I Type of Building Address Dwelling--- !4-`��1MIJE-------------- ------ Other- Type of Building------------------------------ No. of Persons-----------------------------___—_____ Type of Well— —-- ----- - -— -— - Capacity- _10---- d -- — - --— Purpose of Well---- -�� ----� -- - Agreement: The undersigned agrees to install the fo 'de ' ed individual well in accordance with the provisions of The Town of Barnstable Board of Hea h P 'va a ell r tection gulation — The undersigned further agrees not to place the well in operation until er if e Co liance h been issued by the Board of Health. Signed �-- - ------- ----- date Application Approved By ---- -= -- date Application Disapproved for the following reasons:-----_-__---------- ----------------------------------------- date Permit No. (A/1 L Z — Issued ------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by--- A-1 __Cg'af _z4/zt'/ ------------------- Installer — — at— --L'o 1- 3 > Dz3 treJ L i I/V. *3aer � a6 has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Pr tection Regulation as described in the application for Well Construction Permit No. Dated—THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------- —_-- — Inspector----------------_-___- -- —_-_ 1 ✓ � � 1 No.1-- � � r "� r , ;`,> ,Fee---"I`--- > =- BOARD OF iHEALTH r TOWN OF OF BARNSTABLE Application-forlVell Con.5truct ion Permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: '1 Location Address "r Assessors Map and Parcel - .J,_ -r Owner � Address Installer — Driller Address Type of Building 'N Dwelling----T{iAIM�------------------------------------- t Other- Type of Building-=-------------------------- No. of Persons--=-- ---------- Type of Well Capacity — Purpose of Well---- `�--- - =----- Agreement: The undersigned agrees to install thejeell ' ed individual well in accordance with the provisions of The Town of Barnstable Board of Hea h P 'vr tection gulation - The undersigned further agrees not to place the well in operation until ih liance h been issued by the Board of Health. t Sig..A01 - 11 date A lication Approved B PP — - - - . PP Y -- - date y Application Disapproved for the,following reasons: k date Permit No. 73 ----- Issued---f-v�- L---- - --- date — _ua-an4a�9n1i.'�i`3M4ifL�i4i�w'�e.iobai4i4i4iTi?i!®4fitd4.Y!ifSSia4i9ifi4i4alifili?04ifti4i4i Dili4ifilitb!.i9i4i.pS{84i!TYQ3!iM4i!►?G8..!iRb464lTiTi'11f469itieaPQ4P4j;b K46 BOARD OF HEALTH TOWN OF BARNSTABLE y Certificate Of Compliance- THIS IS TO CERTIFY, That the Individual_Well Constructed ( ), Altered O;or Repaired ( ; ------------------------------------- Installer _ at- -- LO7� 3 j, be_j //`CJ Gv . /1a,-,7s-I 6cle has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Pr tection Regulation as described in the application for Well Construction Permit No. Dated- - -- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY: DATE-------- --- Inspector------—- - -- '�'`' ,Z'.cy:-.rt-3tiRG`1Eb4i43ofIVi.T.iti?i!vi+\L4iNi4i4.`.4bewTGTL4XYNiii'lia7ilSPY4RiaZtasi@'i6iFi8iilli4iCali47liti4if5TiTil9`a?i4s+liayTif�gia};�;ysyPiFq�aTc � �,,.� -t BOARD OF HEALTH TOWN OF BARNSTABLE Veil CongtructionPermit 3 6-0No. ------ -- R Fee--- -- Permission is h reby granted V Aj/ 6 66 L l -__—_- -- to Construct ( Alter ( ), or Repair ( ) an Individual Well at: Street as shown on the application for a Well Construction Permit No.- 9 q - 2 ,----- Dated- 1� • � � Board of H Hiealth DATE t Town of Barnstable P# ?a73 Department of Health,Safety,and Environmental Services Public Health Division Date // .- 367 Main Street,Hyannis MA 02601 s BABNBTABM MA89. Date Scheduled �1/&/�Ir3� 3 /�p8 Time A✓q /� . OD rfp'MA't� � l� Fee Pd. �Ut� Soil Suitability Assessment for Sewage Disposal Performed By: 0 VGA Witnessed By:G67 y �UN�/�✓G LgCATIQN&GTERAL INFORIVIATIgI Location Address Owner's Name La T ¢ .DEs/�Es LA�rt` FITZPA7 �M��w�Dj�r Address Assessor's Map/Parcel: Engineer's-Name - �/. boy4z- ASSo�igZ�S NEW CONSTRUCTION REPAIR Telephone# 56 3-1 q9/� Land Use 1114eV/V7_- Slopes(%) Surface Stones VE2y lj!W 496Y6E_9/5:,p Distances from: Open Water Body > 300 ft Possible Wet Area 2(O ft Drinking Water Well ,j Q ft ' Drainage Way 70 ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) n� 262,/5 L a. L off" N 6Z,¢I Zoq•Go Parent material(geologic)J/��7 �[��� g���/ Depth to Bedrock N l--' Depth to Groundwater: Standing Water in Hole: /V S !� �r Weeping from Pit Face /C Estimated Seasonal High Groundwater G_60 3 26M /y elo TErAT�oN sEAc�rrAl, tVVAT 7CAT�E Method Used: ..................:.:....:. Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. .-Index Well# 'Reading Date: Index Well level...--- Arli.factor Adj.Groundwater Level_ PERCCLATION TEST pate l�' :.T►r1 . ......... ... ... .. ........:..............::::.:::::: Observation Hole# Time at 9" u i Depth of Perc 6o t�_75 1 _ 7s 9� 3 / Time at 6"Z ��"20 Start Pre-soak Time @ /13 ' i6 Time(9"-6")0 '19:14l 49.'0V 30 End Pre-soak 1'52:04 113i2,� Z ����f = QD!03.'ZS'PE2 Rate Min./inch �� �Af Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) e4, -SS 7_91e Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant .. DEEP OHSEI ATIdN I OL BOO I olry Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) I i Consistency.%G**ravcl*l (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. a26,4-/V i c_s YS/ !J�Y �0�2 G G 24.` 97" C s4='11y leY/z 7 3 ..: DEEP OBSERYATIQN HALE LOB Hole# Depth from Soil Horizon Soil Texture Soil Color- r .Soill . :r Other Surface(in.) (USDA) (Iviunsell) Mottling (Structure,Stones,Boulderes. Gravel) $ LaA-ryJ i �o.�rn /oY2 7 3 . DEEP OBSERVATI0X HbLE HOC Hole-; ..... Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistencv.° Gravel) DEEP OBSERVATION HiOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° Gravel) _Flood Insurance Rate Masr: Above 500 year flood boundary No Yes V Within 500 year boundary No Yes Within 100 year flood boundary No V Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? —&� If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with * the required training,expertise and experience described in 310 CMR 15.017. Si g nature `` Date , i j �'L�iH11JGa - - i I I - - -- - . ---------------- - : _ — _ -- 1 I _.. j 1A L - ., .. 'SCALE. B 1 p APPROV _ DRAWN By REVISED LiTDRAW ING NUMBER -------------- L r r i ` r fin' t 22 o w c� Ell 0 a — --� C] I-- 1 114 2 — �G9O S, ��-•I �, dQ L - - -- , i , 4 i ,a - � I 1 t - - -- - - -oN -- --- - o" -►�' I 4 ' SCALE: 3 1 q APPROVED BY.:. DRAWN BY DATE k ._ .. REV ISEO l�l y��. _.-y r-� _ �I DRAWII G .EIER �I J. ,i 1 .. { .( i I ti� 0 I CL 61 Lj ILJO 'I SCALE:V u/� I Q„ APPROVED BT: - DRAWN BY DATE: y�z-��0 REVISED---, ... _ . - _ RAW BER ( _ o �oei� i V fr z-/�-vr- - - - - _ --- z - ---- - - - -- -- - - -- -- 3 I I uuW> 6-71xp ( I ---------- --------- f cw to SCALE: APPROVED BY: DRAWN BY i REVISED DATE i r x � yI I i 10 IG IVI : ---- — J •. :. � � � ���/ DvSyGP>� /,1, f -�� rA!'-:)� 7irc 1 If ,r. j�UO�' GRyp:.i � � - ---�-- ¢ -- �Y,� ,�ru � .t,F{--� C�i/�J-�v�5%S2�X/J_��p_=r�ti7-fin �ov(EJ f� ,L i a I ` L lJ i , I v y2 wj 5 � / / .. " SCALE:j If= I_On APPROVED BY: DRAWN BY DATE ':(3' - '�' REVISED CJJ� DRAWING NUMBEII a soiGs 7�sr R�urrs ?bP fAt.WDAT/GY✓ Ems• /.O 54V46E �Y=72W F/N• t�RADE /y/A✓• St oPE OF Z7 Alt �Eco.•�_ �EcoyP. a 4- o�.4.vi�s 6"N�lX Cov�R 9"iyiN• C MWX. " ¢~ Fib 5YI7// 3G l"!AX• "5r. 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