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HomeMy WebLinkAbout0028 ELMERS WAY - Health E mers Way nstable 95 028042 e TOWN OF BARNSTABLE �63 LOCATION OT <2\ 5 SEWAGE #�1J� f/ VL LAGE ASSESSOR'S MAP & LOT G ,-..1 �_ V�l�G.�I��T�,S�� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY fti- , LEACHING FACILITY: (ty ) /4, (size) NO.OF BEDROOMS BUILDER OR OWNER ` PERMITDATE: 'e-1 COMPLIANCE DATE: �5Z;7 1 US 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 Fumished by ' f y. e L r&4 - n31 TOWN OF BARNSTABLE LOCATION 2Y 44 Afe�'S �a� SEWAGE # ,VILLAGE W' � �—,I_ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 4�4441 ,« SEPTIC TANK CAPACITY /OiC)U act-1,4011 LEACHING FACII.ITY: (type) NO.OF BEDROOMS ® 0 WA6P&; -Qt OWNER e C C v PERMITDATE: .A;PLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwatee-Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by . s Page t0 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(coaauued) Properly Address: Owner.�V'SF.sw C 'w Date of Impution: 6 taaos- SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch oftbe sewage imposai system including ties to at least two pmmaneut mfermce landmarks or benchmarks.l.ocme all wells within 100 feet lore where public ware supply ebt=the building. s 3a R� al i Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °< 28 Elmers Way Property Address Kathleen Connor Owner Owner's Name information is required for every West Barnstable Ma 02668 6/30/2011 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, GI , i use only the tab 1. Inspector: ,14 61 key to move your V cursor-do not Sean M Jones use the return Name of Inspector key. S M Jones Title V Septic Inspection ffi Company Name 74 Beldan Ln. Company Address Centerville Ma 02632 Citylrown State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 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 16.340 of Title 5(310 CMR 15.000).The system: ' 0 Passes ❑ Conditionally Passes ❑ Fails ❑i Needs Further Evaluation by the Local Approving Authority -ter ``-CD � 6/30/2011 i Inspector's Signature Date a Es Tlae-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. 6 t5ins•09108 Tine 5 Official Inspection Form:sutwface Sawa Disposal system•P ge I of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 Elmers Way Property Address Kathleen Connor Owner Owners Name information is required for every West Barnstable Ma 02668 6/30/2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/00 Me 5 Official Inspection forth: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 28 Elmers Way Property Address Kathleen Connor Owner Owner's Name information is required for every West Barnstable Ma 02668 6/30/2011 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): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning In a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09108 Title 5 Official inspection Fam:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments "t 28 Elmers Way Property Address Kathleen Connor Owner owner's Name information is required for every West Barnstable Ma 02668 6/30/2011 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's*. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•0=8 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 Elmers Way Property Address Kathleen Connor Owner Owner's Name information is required for every West Barnstable Ma 02668 6/30/2011 page. Cityrrown State Zip Code Date of inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 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"yee 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•09= 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 \Vj 28 Elmers Way Property Address Kathleen Connor Owner owner's Name information is required for every West Barnstable Ma 02668 6/30/2011 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 443.70 gpd provided t5ins-09MB: Title 5 Official Inspection Forth: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 y 28 Elmers Way Property Address Kathleen Connor Owner Owners Name information is required for every West Barnstable Ma 02668 6/30/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 II Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 Elmers Way Property Address Kathleen Connor Owner Owner's Name information is required for every West Barnstable Ma 02668 6/30/2011 page. Cityrrown State Zip Code Date of Inspe&jon D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® 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/Altemative 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•09/01, Title 5 Official Inspection Forth: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 28 Elmers Way Property Address Kathleen Connor Owner Owner's Name information is required for every West Barnstable Ma 02668 6/30/2011 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System repaired 9/22/2005 per town records 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: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, vented through roof Septic Tank(locate on site plan): Depth below grade: .5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallons Sludge depth: 3" t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 Elmers Way Property Address Kathleen Connor Owner Owners Name information is required for every West Barnstable Ma 02668 6/30/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank needs to be cleaned now and again every 2 years as maintenance. Water level was at bottom of outlet invert, tank not leaking and was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 TAIe 5 Official Inspection Forth: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 28 Elmers Way Property Address Kathleen Connor Owner Owner's Name information is required for every West Barnstable Ma 02668 6/30/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal I System Form-Not for Voluntary Assessments y 28 Elmers Way Property Address Kathleen Connor Owner Owner's Name information is required for every West Barnstable Ma 02668 6/30/2011 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was functioning as intended, no signs of past hydraulic overloading. Pump Chamber(locate on site plan): s Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 6 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 �< 28 Elmers Way Property Address Kathleen Connor Owner Owner's Name information is required for every West Barnstable Ma 02668 6/30/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 7 hi cap infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection the s.a.s. was dry with no signs of past saturation. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09100 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 28 Elmers Way Property Address Kathleen Connor Owner Owners Name requinform r on is West Barnstable Ma 02668 6/30/2011 requiredd for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 Elmers Way Property Address Kathleen Connor owner Owner's Name information is required for every West Barnstable Ma 02668 6/30/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately QE P'A 3 oEGtc ON 4a'(�I 7 r 7f A-Z A-3 '72'(0 t5ins•09/08 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 Foam-Not for Voluntary Assessments °< 28 Elmers Way Property Address Kathleen Connor Owner Owners Name information is required for every West Barnstable Ma 02668 6/30/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow we`Is Estimated depth to high ground water: 12+feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 9/16/2005 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Design plan dated 9/16/2005 indicates that no groundwater was encountered @144"and system was designed with a seperation of 5+feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I f Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 Elmers Way Property Address Kathleen Connor Owner Owner's Name information is required for every West Barnstable Ma 02668 6/30/2011 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 Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i y Massachusetts Department of Environmental Protection IL Bureau of Resource Protection Well Completion Reports Well Driller Please specify work performed: Address at well location: New Well Street Number: Street Name: 28 ELMERS WAY Please specify well type: Building Lot#: Assessor's Map#: Domestic Assessor's Lot#: ZIP Code: Number Of Wells: 02668 a City/Town: Well Location BARNSTABLE In public right-of-way: GPS r Yes No North: West: 41.68906 70.35069 Subdivision/Property/Description: Mailing Address: r click here if same as well location addres Property Owner: Street Number: Street Name: PROTHERO 28 ELMERS WAY ` r City/Town: State: Engineering Firm: Ul�t}—�^ BARNSTABLE MASSACHUSETTS ZIP Code: 02668 Board of health permit obtained: Yes C) Not Required Permit Number: Date Issued: W2014 028 9/15/2014 II I Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock Auger I --Choose Bedrock WELL LOG OVERBURDEN LITHOLOGY From To(ft) Code Color Comment Drop in drill Extra fast or slow Loss or addition of (ft) stem drill rate fluid 0 20 IFine To Coarse Sand Brown GJ YES 0 NO G Fast ro Slow r Loss 0 Addition 20 40 Fine To Coarse Sand Brown 0 YES GO NO r Fast r Slow r Loss GJ Addition 40 60 Fine To Coarse Sand I lBrown G YES 0 NO 0 Fast r Slow 0 Loss r Addition 60 70 Fine To Coarse Sand Brown r YES r r Fast rs Slow Loss 0 Addition NO 70 90 Silty Sand jBrown 0 YES 0 Fast r Slow 0 Loss 0 Addition 90 100 Silty Sand jBrown 0 YES G}NO G Fast G Slow GJ Loss r Addition 100 107 Silty Clay Light Gray -� G YES NO GJ Fast 0 Slow G Loss Go Addition 107 115 IFine To Coarse 113rown 0 YES G NO 0 Fast GJ Slo] r Loss 0 Addition WELL LOG BEDROCK LITHOLOGY From Drop in drill Extra fast or slow Loss or addition of Visible Extra To(ft) Code Comment Rust Large (ft) stem drill rate fluid Staining Chips Choose Code Ga YES r NO r Fast G Slow 0 Loss GJ Addition rJ Ye Ye ADDITIONAL WELL INFORMATION Developed Yes No Disinfected G:;Yes G No Total Well Depth 115 Depth to Bedrock Fracture Surface Seal Type INone Enhancement Yes r No CASING I 5—J1 Is Casing above ground. From: 1 To: 0 From To Type Thickness Diameter Driveshoe 0 ill Polyvinyl Chloride Schedule 40 4 r Ye SCREEN ❑No Scree From To Type Slot Size Diameter ill 115 Stainless Steel Well Point 0.012 4 WATER-BEARING ZONES ❑DRY WEL From To Yield(gpm) r� Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program i Well Completion Reports(General) 72 115 10 PERMANENT PUMP(IF AVAILABLE) ---Pump Description Choose Pump Horsepower �Horsepower--- -Choose Description--- Pump Intake Depth(ft) Nominal Pump Capacity(gpm) ANNULAR SEAL/FILTER PACK From To Material 1 Weight Material 2 Weight Water(gal) Batches Method Of Placement Choose Material Choose Material --Choose One WELL TEST DATA Time Pumping Time To Date Method Yield(gpm) Pumped Level (ft Recover Recovery (ft BGS) __ (HH:MM) BGS) (HH:MM) 9/26/2014 Constant Rate Pump � 10 1:30 74 0:01 72 WATER LEVEL Date leashed Static Depth BGS (ft) Flowing Rate(gpm) 9/26/2614 72 10 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. Supervising Driller DESMON THOMAS E Monitoring[M] Sit III, Driller DESMOND III Registration# 764 gnaure THOMAS, DESMOND WELL Date Job Complete Firm DRILLING INC. Rig Permit# 023 10/3/2014 I 'Qr-ifA' � CERTIFICATE OF ANALYSIS Page: 1 of 1 Barnstable County Health Laboratory (M-MA009) 1� h� HlSs�fi Report Prepared For: Report Dated: 9/30/2014 Sally Desmond Desmond Well Drilling Order No.: G1483628 P O Box 2783 Orleans, MA 02653 Laboratory ID#: 1483628-01 Description: Water-Drinking Water Sample#: Sample Location: 28 Elmer's Way W. Barnstable, MA Collected: 09/26/2014 Collected by: Customer Received: 09/26/2014 Routine_M . ITEM RESULT UNITS RL MCL METHOD# TESTED Nitrate as Nitrogen 1.3 mg/L 0.10 10 EPA 300.0 9/26/2014 Iron ND mg/L 0.10 0.3 EPA 200.8 9/29/2014 Manganese ND mg/L 0.0030 EPA 200.8 9/29/2014 pH 5.7 PH AT 25C NA 6.5-8.5 SM 4500-1-1-13 9/26/2014 Sodium 29 mg/L 0.10 20 EPA 200.8 9/29/2014 Total Coliform 0 /100ML 0 0 SM 9222B 9/26/2014 Conductance 270 umohs/cm 2.0 SM 2510E 9/2612014 Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician. Attached please find the laboratory certified parameter list. Approved B (Lab Director) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 7M CERTIFICATE OF. ANALYSIS ' 9 Barnstable County Health Laboratory (M-MA009) Recipient:_ Sally Desmond Matrix: Water-Drinidng Water Desmond Well Drilling Sampled: 09/26/2014 11:15 P 0 Box 2783 Received: 09/26/2014 11:25 Orleans, MA 02653 Collection Address: 28 Elmer's Way W.Barnstable,MA Sample Location: Order : 148G14 6288 Description: 2day-28 Elmer's Way Lab I le 1483628-0i Date Analyzed: 9/26/2014 @ 13:33 Sample#: Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Sodium level Is above the maxium contaminant level.Those on a low sodium diet may wish to consult a physician. EPA 524.2- Volatile Organics by GC/MS Result -M9k M Result JJQ. KU Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L Dichlorodlfluorometthane ND 0.50 Chloroform 3.3 80 0.50 Chloromethane NO 0.50 cis-1,2-DMoroethene ND 70 0.50 Vinyl chloride ND 2.0 0.50 ds-1,3-DicNompropene ND 0.50 Bromomethane _ ND 0.50 Dibromochloromethane ND 0.50 1,1,1,2-Tetrachloroethane� ND 0.50 Dibromomethane ND 0.50 1,1,1-Trichloroethane ND 200 0.50 Ethylbenzene ND 700 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Hexachlorobutadiene ND 0.50 1,1,2-Trichloroethane ND 5.0 0.50 Isopropylbenzene ND� 0.50 1,1-Dichloroethane ND 0.50 Methylene chloride ND 5.0 0.50 1,1-Dichlaroethene ND 7.0 0.50 Mettryi-tertdwtyl ether ND 0.50 1,1-Dichloropropene �+ ND 0.50 Naphthalene NO 0.50 1,2,3-Tdchlorobenzene ND 0.50 n-Butyibenzene ND 0.50 1,2,3-Trlchloropropane ND 0.50 n-Propylbenzene ND 0.50 1,2,4-Trichiorobenzene ND 70 0.50 p-Isopropyltoluene ND 0.50 1,2,4-Trimethylbenzene ND 0.50 c-Butylbenzene ND 0.50 1,2-Dlbmmo-3-c hloropropane ND 0.50 Styrene ND 100 0.50 1,2-Dibromoethane(tDB) ND 0.50 tert-Butylbenzene ND 0.50 1,2-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 5.0 0.50 1,2-Dichloroethane ND 5.0 0.50 Toluene ND 1000 0.50 1,2-Dichlompropane ND 0.50 Total xylenes ND 10000 0.50 1,3,5-Trlmed ylbenzene ND 0.50 trans-1,2-Dichloroethene ND 100 0.50 1,3-Dichlorobenzene ND o.5o trans-1,3-Dichloropropene ND 0.50 1,3-Dichloropropane ND 0.50 Trichioroethene ND 5.0 0.50 1,4-Dichlorobenzene ND 5.0 0.50 Tdchlorofluommethane Nb o.50 2,2-Dlchloropropane ND _ N 0.50 Surrogates - %Recovered QC limits(%) 2-Chiorotoluene ND 0.50 0 � p-Bromofluorobenzene 88/0 70 130 4-Chlorotoluene ND 0.50 1,2-Dichlorobenzene-d4 94"/o M 70 130 Benzene ND 5.0 0.50 Bromobenzene ND 0.50 Bromochloromethane ND o.5o Bromodlc hloromethane ND 0.50 Bromoform ND 0.50 Carbon tetrachloride ND 5.0 0.5o Chiorobenzene ND 100 0.50 Chloroethane ND 0.50 Attached please find the laboratory certified parameter list. Approved B (Lab Director) 9 � � ND=None Detected RL = Reporting Limit MCL=Ma:amum Contamina t Level Superior Court House, PO.Box 427, Bamstable,- MA 02630 Ph: 508-375-6605 Page 1 of 1 No. W d-v l"1 — OK Fee BOARD OF HEALTH TOWN OF BARNSTABLE 01ppYication jfor Yell Con6truction Permit Application is hereby made for a permit to Construct( Alter( ), or Repair( ) an individual well at: a8 /mac GJ A,/ f g 0a A y z Location-Address Assessors Map and Parcel O er - Address 1 s 12 I1 ?oJ 3 aec XM J 1ZAv6r TZ� Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well Capacity/0-/S,�P»'! Purpose of Well Repm-ir 2>el-4t-C - Con-',ym�Ac�1 '-a- LLB Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificat f Compl' a ha�been issued by the Board of Health. Signed �-/S'/ Date Application Approved By Date Application Disapproved for the following reasons: 1,J f� �j y Date Permit No" 9 6 I �I 6�" Issued Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well onstructed( ), Altered( ), or Repaired by Installer at o� W r has been installed in accordance with the provisions Of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector -_-__ f ' nd- t f (f �No. W 0 "[ , 0 Fee f BOARD OF HEALTH TOWN OF BARNSTABLE 2ppltcatton ff or Yell Con!5tructton Perron Application is hereby made for a permit to Construct( Alter( ), or Repair( ) . an individual well at: o�Q C�nzirc /—)AI/ 02* /in t/Z Location-Address Assessors Map and Parcel Owner Address 1 cmo..rl e 1 I 7- Installer-Driller Address Type of Building Dwelling r Other-Type of Building No. of Persons Type of Well !�z Capacity/0- Purpose of Well r�-ep,.,,r� JZ=1,4c-< — /'nh4wmi>�o.q -pa4ALCi Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certifica/ f Compli�mce ha been issued by the Board of Health. Signed / nn Date Application Approved By Date Application Disapproved for the following reasons: Date ( Q� Permit N 61 L1 6�y Issued Date M BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate of Compliance THIS IS TO CERTIFY,that the individual well onstructed( ), Altered( ), or Repaired by Installer at W( has been installed in accordance with the provisions 6f the Town of Barnstable Board of Health Private Well Protection 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 SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE q J� NMI Construction Permit No. W � �� b�V Fee `7 Permission is hereby granted to )" ",d 4,.-.-1/l nstaller to Construct( ),,Alter ), or Repair(t an9individuaalll well at: No. °�/ J w - I:rl.1,..-- Street ff � �( o� as shown on the application for a Well Construction Permit No. W a d ` — a d ( ` r nn � Date `I' — I Approved By No. 2;5bJ'sfp3 " Fee I Jd �= THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Ziooar *potent Con!aruction Permit Application for a Permit to Construct( . )Repair( )Upgrade l)Abandon( ) El Complete System AIndividual Components Location Address or Lot No. ag S Owner's Name,Address and Tel.No. Assessor's Map/Parcel ka Pk_(_ la%all<s Name,Address,and Tel.No. O Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size- Js rsq.ft. Garbage Grinder N� Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures �/ — 7 Design Flow T V gallons per day. Calculated daily flow RV3F �c�� gall9j. Plan Date Number of sheets Revision Date ���/�! Title I .� Size of Septic Tanks�KI S� 1000 Type of S.A.S. I •C�Td + ��r�1d� Description of Soil! Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in 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 thts oard o Signed Date 9`p os Application Approved by Date Application Disapproved for the following reasons Permit No. as �:j 3 Date Issued 5 U� No. 1200s— Fee f vo'x THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migpaaf bpgtem Cone;trurtion Permit Application for a Permit to Construct( )Repair( )UpgradeC<)Abandon( ) El Complete System A Individual Components 1+. Location Address or Lot No.5 S 1A Owner's Name,Address and Tel.No. Assessor's Map/Parcel y 9v_- s Name,Address,and Tel.No. Designer's Name,Address and Tel.No. sad- stl� . s, �t/�"� a Type of Building: t 414-Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No. of Persons ^-� Showers( ) Cafeteria( ) Other Fixtures Design Flow �7 gallons per day. Calculated daily flow --3�0_ga11o0 Plan Date;: G'i—/ n-�� Number of sheets Revision Date Title Size of Septic Ta k V--,c t S-%/✓��- =0 Type of S.A.S. L Description of Soil; --A r) �� �A Nature of Repairs or Alterations(Answer when applicable) i 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<�eerrime tht oazd o al h ' Signed Date Application Approved by Date 2 U vS Application Disapproved for the following reasons w Permit No. OS �43 Date Issued 20�US' ------------------------ ------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ` Certif irate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned( )by h er "5 Se r-)+i at 2 6 :E 1 w:U'S W�7 \i �h has been constructed in arc rdance with the provisions of Title 5 and the for Disposal System Construction Permit No. � l0 3 dated Installer ` Designer The issuance of this permA shall n t be construed as a guarantee that e syste 1 rt tion as dejoed. Date Inspecta -- "`-- / =--- -- --------------= ------ .._ No. ��S y(o3 Fee pan THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi$ o$at $tem Construction Permit � p Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at .-V S and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date:_. 12 0 vs Approved by �//��_-__ °r a Page: 1 CERTIFICATE OF ANALYSIS Q M' Barnstable County Health Laboratory y Report Dated: 9/30/2005 Report Prepared For: Order No.: G0533283 Rebecca C. Buffum 28 Diner's Way W Barnstable, MA 02668 Laboratory ID#: 0533283-01 Description: Water-Drinking Water Sample#: 33283 Sampling Location 28 Clmer's Way,West Barnstable;MAC Collected: 9/29/2005 Collected by: R.B. Received: 9/29/2005 Test Parameters ITEM RESULT UNITS RL MCL Method# Tested LAB: Microbiology Total Coliform Absent CFU/IOOmL 0 0 309 9/29/2005 Water sampleFETthe recommended limits for drinking water of all the above tested parameters. Approved By:__ (La irector) RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 i6/ 7 ; :` �' " CERTIFICATE OF ANALYSIS Page:e: 1 Barnstable County Health Laboratory Report Dated: 9/27/2005 Report Prepared For: Order No.: G0533205 Rebecca C. Buffum V4 28 Elmer's Way W Barnstable, MA 02668 Laboratory II)#: 0533205-01 Description: Water-Druilring Water Sample 4: 33205 Sampling Location: 28 Ebner's Way West Barnstable,MAa Collected: 9/22/2005 Collected by: R.B. Received: 9/22/2005 Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen 1.0 mg/L 0.10 10 EPA300.0 9/22/2005 LAB: Metals Copper 0.11 mg/L 0.10 1.3 SM 3111B 9/27/2005 Iron 0.17 mg/L 0.10 0.3 SM 3111B 9/27/2005 Sodium 16 mg/L 1.0 20 sM 3111B 9/27/2005 LAB: Microbiology Total Coliform Present P/A 0 0 309 9/22/2005 LAB: Physical Chemistry Conductance ( 150 umohs/cm 1.0 EPA 120.1 9/22/2005 pH 6.5 pH-units 0 EPA 150.1 9/22/2005 Recommended-maximum contamination 16ve1 exceeded due to Coliform Bad-na.�Retesting is recommended. ------------------------ Approved By: ( b hector) RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 , 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM E , S,,2 ,hereby certify that the engineered plan signed by me dated concerning the property located at Vr-?Z c�.c'S b meets all of the following criteria: • This failed system is connected to'a residential dwelling only. There are.no.commercial or business.uses.associated with the.dwelling. • The soil is.classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or.may conduct deep test holes and percolation tests.at the site without a health agent present. • There is no.increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) /0 8-,Qp B) G.W.Elevation +adjustment for high G.W. DIFFERENCE BETWEEN A and B 8 C7 SIGNF,D : DATE: NOTICE Based upon the above information-, a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. aSD - = yta ,� elos" gASepti6pereexemp.doa 1 1 - 1 3L, Town of Barnstable °p1HErp Regulatory Services Thomas F. Geiler,Director BAMSTABLE, t � Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: ShM Environmental Services Inc. Installer: r Address: P.O. Box 627 Address: East Falmouth, MA 02536 �A R-N oo-,ram On ID 5 btK SQ„2:kC_ was issued a permit to install a date) (installer) septic system at (48 212D:(9f>�q . ���based on a design drawn by (address) Shay Environmental Services, Inc. dated a Q� (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. ss CARMEN �N nstaller's Signature) E. SHAY No. '1181 C'ISTEa�O SgNI TAR\Pa ( esigner's Signature) (Af ix De i Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form r CO_ MONWEALTH OF MASSACHUSETTS _EXECUTIVE OFFICE OF ENVIRONME TTA-'. AA F.A"RS T SIABLE ' DEPARTMENT OF ENVIRONMENTAL-,,Ap �, ,CTION , . 3 �71ti cagy_----- __—__. TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 5�2 o _ Owner's Name: �p� rnA Owner's Address- tom"'`tob J Date of Inspection: �� oa cw Name of Inspector.(pleRse print) i LPL Company Name: �� Mailing Address- I wdpt'�'Ft o^S Telephone Number, n"`s Oa 6c(( CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the inform on reported training and experience in the proper function below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my ati 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 Needs Further Evaluation by the Local Approving Authority Fails 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 I0,00o gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/1512000 page i Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IXSPOSAL�SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 8 ay Owner. Date of inspection:_ — — Inspection Summary: Check A,B,CM or E/ALWAYS co all of Section D A. System Passes: I have hot found any information whic dicates that any of the failure criteria described in 310 CMR 15303 or in 310 CNiR 15.304 exist.Any "ure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section jieed to be replaced or repaired.The system,upon completion of the replacement or repair,as approved b e Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the folio ' g statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the ptic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or failure is imminent.System will pass inspection if the existmg tank is replaced with a complying septic tank ved by the Board of Health. "A metal septic tank will pass inspection if it is siru y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is ailable. ND explain: Observation of sewage backup or Teak out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, ed or uneven distribution box.System will pass inspection if(with approval of Board of Health): token pipes)=zeplaced obstrxtim i Temoved distribution box is leveled or replaced ND explain: The system r ed pumping more than 4 times a year due to broken or obstructed pil*s).The system will pass inspection if( approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I R Page 3ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address- Owner: 0 Wte of Inspection: p 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 s em is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 03(l)(b)that the system is not functioning in a manner which will protect public health,safety a 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 a salt marsh 2. System will fail unless the Board of Health(and Pab c Water Supplier,if any)determines that the system is functioning in a manner that protects the pu is health,safety and environment: _ The system has a septic tank and soil absorp on system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface w supply. — The system has a septic tank and SA d the SAS is within a Zone I of a public water supply. — The system has a septic tank an- AS and the SAS is within 50 feet of a private water supply well. The system has a septic d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well .M od used to determine distance "This system passes if the ell water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile org c compounds indicates that the well is free from pollution from that facility and the presence of ammoni nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are tri red.A copy of the analysis must be attached to this form. 3. Other: 3 f 'tom Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DOSAL SYSTEM INSPECTION FORM PART.A- CERTIFICATION(continued) Property Address: Owner: Date of Inspection•D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for aIl 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 K Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than%Z day flow A 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 I of a public well- Any portion of a cesspool or privy is within 50 feet of a private water supply well. -tom 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 cotifnrm bacteria and volatile organic-compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equat to or less than 5.ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described 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 serves facilitj, a design flow of 10,000 gpd to 15,000 gpd. - You must indicate either"yes"or 1516"to each of the folio (The following criteria apply to large systems in addi ' to the criteria above) yes no _ — the system is within 400 feet of a ce drinking water supply — — the system is within 200 f of a tributary to a surface drinking water supply — — the system is Iota a nitrogen sensitive area(Interim'Wellhead Protection Area—IWPA)or a mapped Zone H of a publi water supply well If you have answered es"to any question in Section E the system is considered a significant or answered "yes"in Section D ve the large system has failed.The owner or operator of any Iarge system considered a. sig a ficant threat der Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The sy in owner should contact the appropriate regional office of the Department. 4 i Page 5 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART R CRECKLJST Property Address: Owner: WA Date of Inspection: 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? 0� 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? A _ Was the facility owner(and occupants if different from owner)provided with information on the proper mtenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Ygs no (� _ Existing information.For example,a plan at the Board of Health. 01 _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)j310 CMR 15.302(3)(b)] 5 i Page 6 of 11 OFFICIAL.INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �p E 6(/� Owner- yy�, Date of Inspection:RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 31 Q CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents:__2__ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):AP[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):AV Water meter readings,if available(last 2 years usage(gpd)): Sump PAP(yes or no):Aig Last date of occupancy. C.v COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seatslpersons/s c.): Grease trap present(yes or no): Industrial w/holdingwent(yes or no):Non-sanitaed to the Title 5 system(yes or no): Water metelable:Last date oOTHER(d Pumping Records GENERAL INFORMATION Source of information: Was system pumped as part of the inspection(yes or no): AP R yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank —Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 61 6 i Page 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURfFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a Owner:-s 'K �f'S Date of Inspection- BUILDING SEWER(locate on site plan) . Depth below �p grade: l6 . Materials of construction:_cast iron �40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joins,venting,evidence of leakage,etc.): SEPTIC TANK: Of (locate on site plan) Depth Below Grade: Material of construction:�C concrete metal fiberglass___polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no}: certificate) —(attach a copy of /Dimensions: fiber Sludge depth: V0 Distance from top of sludge to bottom of outlet tee or baffler. Scum thickness: at of Distance from top of scum to top of outlet tee or baffle: 49 or Distance from bottom of scum to bottom Of outlet tee r baffle: /d •� How were dimensions determined: �/L s Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): _4 GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete metal fiberb _polyethylene_other (explain): — Dimensions: Scum thickness:_ Distance from top of scum to top of out, tee or baffle: Distance from bottom of scum to bo In of outlet tee or baffle: Date of last pumping: Comments(on pumping reco endations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,ev' ence of leakage,etc.): 7 i Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: GV� t� Owner: Date of Inspection• $ TIGHT or HOLDING TANK: (tank must be pumped at time of mspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: /�i Design plow: day Alarm present(yeAlarm level: rder(yes or no): Date of last pumpComments(condiitches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ,0.,11411 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage' t or out of box,etc.): SE q k oCM PUMP CHAMBER: (locate on site plan) Pumps in working order(yes o o):. Alarms in working order or no): Comments(note con n of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9ofII OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSUPISACI SE*AGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: $ ir[w. ig W Owner: _ Date of Inspection:_ Los SOIL ABSORPTION SYSTEM(SAS): /( (locate on site plan,excavation not required) If SAS not located explain why: Ty E i.eaching pits,number.I leaching chambers,number- leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etcV C 6>W CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of constructio Indication of gmundw er inflow(yes or no): Comments(note c dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comme-nts(note con tion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: -P #ff a�rte tG Owner:--,6y j 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. S� an Page I I of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q�% Owner: Date of Inspection:spection: SITE EXAM Slope V615 Surface water U-10 Check cellar Q Shallow wells Estimated depth to ground water :L feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Of Accessed USGS database-explain: You must describe ho/w�you established the high grow d water elevation: t�.SC' 3 Ylldi S �j �A��GLK e /2 Ii i CERTIFICATE OF ANALYSIS Page. 1 Barnstable County Health Laboratory REC Ir✓�® Report Prepared For: Report Dated: 4/15/2003 Order Number: G�U93�1-35� 2003 Rebecca Buffum (d�APp TOWN OF BA 28 Ehners Way PARCEL d 2 q O HEALTH DE PTABLE West Bamstable, MA 02668 LOT Laboratory ID#: 0319335-01 Description: Water-Drinking Water Sample#: 19335 Sampling Location: 28 Elmers Way, West Barnstable Collected 4/8/2003 collected by: Rebecca Buff Received 4/8/2003 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates 0.5 mg/L 10 EPA 300.0 4/11/2003 LAB: Metals Copper 0.5 mg/L 1.3 SM 3111E 4/15/2003 Iron 1.5 mg/L 0.3 SM 3111B 4/15/2003 Sodium 20 mg/L 20 SM 3111B 4/15/2003 LAB: Microbiology Total Coliform Absent P/A Absent 307 4/8/2003 LAB: Physical Chemistry Conductance 190 umohs/cm EPA 120.1 4/8/2003 pH 6.5 pH-units EPA 150.1 4/8/2003 Note: Based on the results of the parameters tested,the water is suitable for drinking,but may present aesthetic problems(taste, odor,staining)due to Iron. Approved By: k/6 T 0 Z IS" o (Lab Director) r ,:(i :,�Gj: . . _;,; :.t,, nor'...• �' - Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 `LOCATION SEWAGE PERMIT NO. .vILLAGE �°I � - D2.� -T343 INSTA LLER'S NAME i AD0R'ESS I/ ry IfIAo 4f" i U I L.0 E R 0 OWN ER DATE PERMIT ISS-UEO �j�� DATE COMPLIANCE ISSU-ED /Z�� ` 1 s I . � .a ccn 9 Fas... ...............M ;THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .............. .................. ......OF.......................................................................................... Allp iratiun for Diipuutal Works Tuntrurtiun Fermi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �2S U1 � �� anon-Address Lot No. Owner Address Installer Address dType of Building Size Lot_�- o.I._<......Sq. feet U Dwelling—No. of Bedrooms................ ........_ .Expansion Attic ( ) Garbage Grinder ( ) Other—,Type of Building No. of persons............ ........... Showers — Cafeteria Q' Other fixtures .........•••... ------••------• . gallons per person per day. Total daily flow......__®_.......... W Design Flow------...--�^•�r--........................g P P P Y Y dons. WSeptic Tank—Liquid capacity.(®®O..gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter......i.®.e...... Depth below inlet...... ....... Total leaching area... ��_...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•-------------------•-----•-------------------------••--•----....-----------•......-•--------•-••........................................................ O. Description of Soil ---.. -- •--------------••-•-•-••-•-•-•-•-- x U �A� � ......,,t.r -•:-- CIf�._..----cr,1.. W ••••-•-•-----------------------------------------------•-•-•--------•-------••----•-•--•-•--------••----••-•--•----------------••--••---••-••--•--••--•-•--••-----------•-•-------------............... UNature of Repairs or Alterations—Answer when applicable._.............................................................................................. •-------•--•--•-•-----------••-••---........•-•••••-•--•----------•---•-•........................••---••......-------•-----------••••-•---•-----•••---................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be ed h_e bboaard1 of health. Signed................ "' —.................................... -------•••-•--••-----•-•--•----• Date Application Approved �'/X. Date Application Disapproved for the following reasons---------------••----•---------------------------....---------------------------•--------._...-•----............. ....................•--•-•--•----------------•--•--•--------•---•--------------•---------......--•--•-----•---•----•-----•----------------•---•-•-•------------•--•-•----------•----------•---------•--- Date Permit No...........................••• Issued....................................................... -•--------••-•------------ Date I No,............- '.'Sd F�$...'I ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .............. ...............OF.......................................................................................... ApplirFa#ilau for Disposal Works Tonstrurtiuu rrutit .Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: N ---- .------•--• ......-•-••- '- uo -Address Lot No tollttivx �t: t�t1 1 OS 'AY L.V . �' �t' E'r"�'1 , 41 A .......................... ............................................. ................ . -•-•--... ......•. . -•--•-..`............. i Owner ddress Installer Address dType of Building Size Lot...'UA.—e.._..Sq. feet Dwelling—No. of Bedrooms________________.._......._..._..__..Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building � _ No. of persons G4 YP g P Showers ( �) — Cafeteria ( ) a' Other fixtures ____________________________ W Design Flow............etc-. ....•...............•__gallons ber person per day. Total daily flow-------- *."'� .._______._........_..gallons. WSeptic Tank.—Liquid capacity-#� _gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.....if............. Total Length.............r...... Total leaching area....................sq. ft. Seepage Pit No----_-------------- Diameter......«........ Depth below inlet...... Total leaching area......_'.��___sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----------------------------------------•--•------••-----...........--•-•-..................................................------•............................................................. 0 Description of Soil......................................................................................................................................................................... x �., W ................ ----------------•-••---------••---•----------------•-•---••--•-•••------•--•-•-•-•-...--•-•••----------•--•--•----•-•-----............-•-•----•--••--................................ U Nature of Repairs or Alterations—Answer when applicable.______________________________________________________________................................. ...•--•••-••••----------•-••--•------•--•---••-•-•••---•-----••--•----••----•----•--------------•---------•-------------------------------............................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1Z- 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be d �ar.d ealth. Signed-----------------•-•--..._.... ------•----....._................ •---••......••-••.......--- e ---- -•--------•.................. --•--� ��....................APPlication Approved r Date Application Disapproved for the following reasons--------------------------------------------------------------------------------------------------------------- ----•-••--•••...•---•••--------•-----••-......-----••-•--•••..................•--••-•---------------•............-••---.........•.....•....•............---•-•.....•-----......--...- ......--_._...-- Date Permit No............. Issued....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH FE .....................................I....OF..................................................................................... Trrtifiratr of ToutpliFatta TILLS IS T ERXIFY, t the Individual Sewage Disposal System constructed ( ) or Repaired ( ) t9v�,. � ,e.2'1av �` .-•------•--•-••------•-••-•---. ------- ------- ----•--------•---...._.............._..._._........... © tr+Mi i4/ I�'�'�` � l� - Installer. n. 11�i•e1 ' � \ at. .................................................. ••--•--- ---•---- ----------•••••••-•-... .--_----- - fJr""/ e�qq has been installed in accordance with the provisions of TITLE ThI to Sanitary Code as described in the application for Disposal Works Construction Permit No-----�Z__'__..._.....d............. dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUcN•CC ON SATISFACTORY. DATE................• / ..... -........ Inspector......_.....��- ' THE COMMONWEALTH OF MASSACHUSETTS yyy BOARD OF HEALTH ......--•••••........ No._ ........ s.4.- FEE.........J............ Dispoo q urk Zonstra irru rrutit Permissionis hereby granted---- -----------------••••._........... ... •------•--•-----•-----•-•••---....-•--------...------•••••-•-------..................•••... to Construct ( -or a air ( an Individual Sew ge Disposal Syst atNo.............. t1 L1j ---•---- ............... �Q . �! .---------•-••-•.................. Street as shown on the application for Disposal Works Construction Permit No......................vDated............................._............ •----••-------.----•--•---------------- oard of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ';.4 :L OF r I P�f: jl}j2� SH�j(,e :(�/�g� Mail to: '14I LING ADDRESS: 0(mere, WAY' L 7L)t v%STA- Board of Health Town of Barnstable TELEPHONE NiJ.N BER: ���' � P.O.Box 534 CONTACT PERSON: nA A (R"e beCC Pr �`� � Hyannis, MA. 02601 Does your firm store any of the toxic or hazardous materials listed below., either for sale or for your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO This form must be returned to the Board of Health regardless of a YES or NO answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing a dress : I-� .{ ADDRESS: 0�I E' ��.�'�' �`�ld ICJ • G4. iZIACIt 91 TELEPHONE: l? A} . +L\"-, dpte 3*g1 LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous characteristics and must be registered when stored in quantities totalling more than 50 gallons liquid volume or 25 pounds dry weight. Please put a check beside each product that you store: Antifreeze (for gasline or coolant systems)- Refrigerants Automatic transmission fluid Pesticides (insecticides , Engine and Radiator flushes herbicides,rodenticides) Hydraulic fluid (including brake fluid) Photochemicals Motor oils/waste oils Printing Ink 150—G�00 Gasoline, Jet fuel Wood preservatives Diesel fuel, Kerosene, #2 heating oil (creosote) Other petroleum products: grease, Swimming Pool chlorine lubricants Lye or caustic soda Degreasers for engines and metal Jewelry cleaners Degreasers for driveways & garages Leather dyes Battery acid (electrolyte) Fertilizers (if stored Rustproof ers outdoors) Car wash detergents PCB' s Car waxes and polishes Other chlorinated -hydro- Asphalt & roofing tar carbons, (inc.carbon Paints, varnishes , stains, dyes tetrachloride) Paint and lacquer thinners Any other products with Paint & Varnish removers, deglossers "Poison" labels (including Paint brush cl'c6 aners chloroform, formaldehyde, Floor & Furniture strippers hydrochloric acid, other Metal polishes - acids) -- Laundry soil & stain removers Other products not listed (including bleach) . which you --feel may be Spot removers & .cleaning fluids toxic or hazardous (please (dry cleaners ) list) : Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners Drain cleaners Toilet cleaners ' Cesspool cleaners Disinfectants ' Road Salt (Halite) 1 BRIAN T. FERRARI !' DRAFTING' & DESIGN 9 8 TOWN NECK ROAD SANDWICH MA. 02563 508=888-0003 00 2'-/O//2" 2'-6//2" Z'-3 3/4" 6" NOTE: I � All federal, sae an local codes will be O O O O I considered as part E I of the specifications o o: L-IW 70 cIEIL�VG of this building, and exisr�N� a re to be adhered to even if Y vary the from 7-0ffl-IAIN ;® 2G/G6 B this plans specifications. A licensed contractor and/or the home owner will assume all responsibility ner/ovewwDow for compliance with ADD 26/66DI: O 780 CMR: The Mo. State s ---- Building Code. Neither Brian T. Ferrari olffopoori I nor any other participating ro OfcoMf ��Nreol SJ�wre designers assumes 1 A7 I-1POOv1 OPTION d iuN6 A responsibility over any a (WINDOW I-IUST Of MOVfO) phase of construction i or the completed ( building. The purchaser of this plan will assume full responsibility to verify all elements of this plan for design and j accuracy prior to OOP �t�N o ct u a L-c.o-n.st.r_u cti-o n ---�._ KATHY C 0 N N 0 R G1��fiN� S ✓"u�"S. 28 E LM E R S WAY a��s_ 63 W. BARNSTABLE, MA. D2668 311�/off _---------- ___.. JOB NO.: 001 t W�y� HK� io�. SCALE: 1 /4"= 1 '0" DATE. JANUARY 1 1 , 2006 r' PAGE 4 of 5 i s�a� so:� If ty Ss ,n !Jo ASV x4-mar' %S/s t g7EtYS ZO 7- A. .41 1 Hof Alrr .. .101 Adr- ool SGA 1, — _.. .Y 4 F WVA^ t N 0 L To FRTUR P • To f1N�s�Czt2o►v�.� � 2% v -n4W ONS Fool aF F Nt6N 4RJDE oYEFZ '0E*44 AREA �o ' �,,( �•- /o�--o� 2't OF ' .l�A 'S�To►JE F'l�R. " -(yo''nnWY I - A.24"f7 ZOV99 i OPX 1 F it�lF�l,'f�RATI.k.* td CNk'f 1ROf.t 2 IN. P Get V44,40r o -V WOW -pWF -F " / r ci+ Qu ClTP l eAc-k i yfOWA9NF-o tR'f' GALLON ._ r ►NVERT 84.E ? Pt'�► 5?oNE cqp. GIT. 4mi �►�A. '4 � ;' ,. 74ROtiSrID i S Ai'��T�t G fil�i IrC lMvsR? PIPS 11C' / i �►' `t�j �$$ boa. Q c�b7; Q �( - 2O"MIM, Selo G 'l 5EP'1'rG SYSTEM CONsYRuc-noN � <���� - 2 V-lvllzQNmjF,N-rAL AL.L C-0t4 0FZA4 MQ -'HEMash. � � � i � � Num � omC>OF sQ ao ; CODS TITLE ,; -..—. _ R" i Se V 7-t-17 � �S T&*Vr1 *w r l-_ � a - E,� D E-51 CA t-i FLo vA/ : G.P 7- hr ,ar SEPTi G'f�tNK, �!5TR I �?iON 00�( ��`•, '`��A � . AN O 1.-V,^c o-G P4 T To BE Or r `b xr`".-' R EQ O: i-6AC � CA PA 1'�'d� o G'.f'L?; RE0titFroRCrl-t? CONCRSTa 2-5" G'.P. D. H 10 1.. OA p I 14Ca Ila� • :1 V R14E*I� Nor Td OF, LOCA 1 GV CRAIG yG SHCJR, 27d83 c Cl LOCA'f t W . 5 � + 8�0►5 ' P�AI t . Rya.� of 00 ENGINEERING, CER. DESIGNING BUILDING INC. ALTk A(aePJ7r AFMOVAt, DENNIS,'MASS. .: SHORT40 0 I►pLMLir 1 2-16" DIAM. ACCESS MANHOLESVENT 1 � SECTION A -A 6' �_ �� -� -�-gpt�-' o•�'�. Schedule 40 PVC w/Charcoal Odor east 24 inches �Filter-� �� :':' -•"•'urn:-`�`': : _ �•, 1` PROFILE VIEW OF ADDITION TO LEACHING SYSTEM ; f b Mo<e PIN 10' min. from 'NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. 3' of 1/8" - 1/2" Washed Peaston Existing Foundation house to septic tank 3/4" to 1 1/2 " Washed Crushed Stone INLET / + / Septic tank coven must be D-BOX cover must be TOP,OF FOUNDATION = ELEV. 100.00 (Assumed) Within 6 Inches of Finish Grade w/in 6 inches 4' PVC (CAPPED) INSPECTION PORT TO BE \ 06 T Vfty of Finish Grads - Grade over Septic Tank - 92.00 ,-Grade over D-Box - 6e.00 ode ow SAS - ELEv. 67.30 / INSTALLED AND TO BE WITHIN 6. OF GRADE •'J r, •t''J A\ THE ACCESS COVERS FOR THE SEPTIC TANK.T DISTRIBUTION BOX AND LEACHING COMPONENT no ' :r s -+v •^.r r rrs T+�-.�• SET DEEPER THAN 6 INCHES BELOW FINISHED ' . ••h'.'� •. .''. •'' .~ GRADE SHALL BE RAISED TO WITHIN 6' OF S - 0.02 3 HOLE H-10 STEEL REINFORCED PRECAST CONCRETE J DHO BOX 3' Maximum Cover FINISHED GRADE. t6' EXIST. S.0.01 or is Greater S• 0.0/0' Der foot Top (X System-EIw. .64.25 n s _ EXIST. PIPE N o 1,000 GAL w p SEPTIC TANK a ..:�= an^��`' -. j x N to 45' t0" Effectivs DeJth ,yam' FROM EXIST. FOUNDATION I' I' PLAN VIEW INSTALL Tui-nTE GAS BAFFLES OR EQUALS teo� � !/ �,,._ �,,_r--'=es on s00 _' L II °i or sae. a, ^ n 3.75' 3-24' REMOVABLE COVERS 612aos RSN eeeee�y a 2Ms NAvrea - CONCRETE RILL FOUNDATON� H-10 •n 5.75" r N y II I`) e0 0.83' (10 inches) \ ° _° v I�i a on n Effective Length i . ..;.,., 4• y..; ° 6 h.ot 3/a•-1 1/2' ai ' > M 'O SOIL ABSORPTION SYSTEM (SAS) 3 mk,'N.erw+ce ` : } GENERAL NOTES SYSTEM PROFILE v 0 �i _ ,r INLET c canpocted stone ; W aD INLET 6 mh. f 2:min. Wet to outlet e•mM. i Not to Scale - -S II ' INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN - ou7tET 1. Contractor is responsible for Di safe notification „ U :� and protection of all underground utilities and pipes. c ` 3 ; Not to Scale s• _7- ' 1__ 5 _7. e, _ _ --1 2. The septic tank on distrl ution box shall be set 6 in.of 3/4'-T 1/2' 0 11 u NOTE; OVERALL HEIGHT OF INFILTRATOR IS 18 /EFFEC'IVE HEIC►•' IS 'C '� g I ~• 4'-0" mM. level on 6" of 3/4 -1 1/2" stone. " compocted stone a EFEective Width s.sae. Llquid depth o b 3. Bockfill should be clean sond or gravel with no NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE -� ° ' 8 m stones over 3" in size. z ''" ` 4. This system is subject to inspection during installation ``r -�--------'--'---- -------- --- �.; 'r" ' by Carmen E. Shay - Environmental Services, Inc. yl 3 Bottom of Test Hole 1 Elev.= 75.50 ` ' ` `' •Obs. G•ou^dwC!e- - Test 'agile 1&"2 Eft►u�►None Observed ,>_ 6'-0' �; •' �10" 5. The contractor shall install this system in accordance x M=• -8..r ' .. ", „ _; TI with Title V of the Massachusetts state code, the approved Ian ,.: ,,• r - ..n-.. .. . CROSS SECfi�ON' - ;. END S�C � :Oh P "•'r' and Local Regulations. TYPICAL 1000 GALLON -SEPTIC TANK 6. If, during installation the contractor encounters any ( soil conditions or site conditions that are different 1 ? NOT TO SCALE from those shown on the soil log or in our design I installation must halt & immediate notification be UNDEVELOPED LOT mode to Carmen E. Shay - Environmental Services, Inc. 7. No vehicle or heavy machinery shall drive over the T-t o r PERCOLATION TEST septic system unless noted as H-20 septic components. `V\ UNDEVELOPED LOT 8. Install Tuf-Tito gas baffles or equals on all outlet tee ends. cb `� \ ) \ \ 9. All Distribution Lines shall be 4" diameter Sch. 40 NSF PVC pipes. Co , \ \ \ � Date of Percolation Test: SEPTEMBER 06, 2005 Test Performed By. CARMEN E. SHAY, R.S., C.S.E. 10. All solid piping, tees & fittings shall be 4" diameter Results Witnessed 8 WAIVER (per BARNSTABLE BOH y (P ) Schedule 40 NSF PVC pipes with water tight joints. O Excavator: ROBERTS SEP71C SERVICE 11. SITE and Surrounding Properties are NOT Connected r" Percolation Rate: 4 min./inch 0 50 BELOW GRADE. to Municipal Water. . PRIVATE WELLS LOCATED AS SHOWN. o o I Test Hole Test Hole 1 \ \• `, ; \ 'O rn ! No. 1 No. 2 D PTH SOILS ELEV. DEPTH SOILS ELEV. . I I \ 1 \ b.t ` 1 + �c,t. .. ,. ______ \. ;.r iri5 ., '•t , d :' tiCP.'t / p o, ., t THE PROPERTY LINES ARE APPROXIMATE AND 0 88.0p0A 87.50 i\ t LOT 6 o t COMPILED FROM THE SURVEY PLAN GENERATED BY # N I Loamy Sand Loamy Sand EDWARF KELLEY OF HYANNIS,---MA-ENTILTED - - -- -- - - - \ \ `\ u1 10 YR 3/2 10 YR 3/2 "CERIFIED PLOT PLAN OF LOT #6 ELMER'S WAY, W. BARNSTABLE, M 1 .66 ACRES187.501DATED 08/23/1982 I 0"-6" A 0'-6• A 87.00 Sandy Loom Sandy Loom IT SHOULD BE USED FOR NO PURPOSE OTHER THAN \`'----�'�/ \ \\ \ \ \ // ,' \\\ I 6 30. 10 9 5/6 6s.5o1 6 10 YR s/6 THE SEPTIC SYSTEM INSTALLATION. \ \ \\ ---- I l ` -24' B. 85.50: \ Sil t Slit Loom i foam EXISTING LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE \ \\ \ 2.5Y8/6 2.5Y8/6 \\ \\ \\ \\ \\ \\ 30•-48" C+ 84.00 24'-48" C, 83.50 Fine Sand Fine Sand I NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE w/ obbies/Boul ors w/ obbies/Boul rs - FROM THE EXISTING LEACH PIT TO BE DISPOSED __ ? 2.S Y 7/4 i 2.5 Y 7/4 I OF AS PER BOARD OF HEALTH SPECIFICATIONS. 144" C: 6.00 i 4 C 4D"- 8"-144" 2 5.50 ;0 ASSESSORS O I ASSESSORS MAP 195 PARCEL 028/042 . _ t _ O ,-- ZONING - RESIDENT AL ' - _-�., ter,_ _ . . < • .. �. „ .. ,. _ / \ ..._ y \ \ `� \ \ r l \ ....: t..,�- \ ... .,.r4• . . \ 1 C v � Perc ill _ r, Depth to Perc: 50" to 68" Perc Rate- 4 min, inch Groundwater Not Observed; ^„.,; THERE ARE NO,WETLANDS LOCATED WITHIN A 200' RADIUS �w __ ---4 I ____,._.....�_..�.__..__- ___--. _ _ _ _- _-._.. .�._ _ ._... - CF„ �C�E F!ev -„--<..-,r,.-'.�,�-... ,..-->.�-- . - ---.E._PRO FR'v. ! - `\ \ t \\ ( ADJUSTED 6120SEev. _ No Adjustmen R quire t .. - ___ _._. n� TN o ALL OUTLET PIPES FROM THE I a � \ • 1\1 " •�',\` // \` \\ \\\\\ \\\ \\\ ,1, , � - - ''' `` �\. \\ \\`\ ,i ..Z - DISTRIBUTION BOX SHALL BE i \\ i SET LEVEL M0 AT LEAST 2 FT. 2• aGX+CRETE COVER LEGEND ST HOLE #\1 ` \ ` EL = 88.00 ` 3- 5, a,nET � DENOTES PROPOSED f \ \ \ \ \ \ 1V �`. KNad(aVTS p p \_------\ ` 15.5' ouTtET -� 1 1r INLET \ i • ,, SPOT GRADE --------------- _ �6, X 104.46 DENOTES EXISTING I PROJECT BENCH MARK ___,, 4• _ scH. 40 ToiI ;:,,• SPOT GRADE \ \ \� \ \\ PLAN SECTION CROSS-SECTION TOP OF FOUNDATION \ , �ti �\ ` �,* \\ \ PL PROPERTY LINE �Assu ed r � � Sun `\\ D-Box ";i� , •"'�',ir. \\ `\\ \ \ Room :;;i,,. •�S"�• , 50' w�ST HOLE #2 \` 3 HOLE DISTRIBUTION BOX - H-10 LOADING PROPOSED CONTOUR i' i� ,------ \ \ ` �',•t L, LEA 87.50 ' --- / O NOT TO SCALE ' ��`�' `--- - Pp`J� - ----- ~.V•+ ` __--'� 97- - - - -97 EXISTING CONTOUR j ' \ ` 's • Failed , I �• \ 'x 'I:scch Pit EXISTING DECK LO - I 3 BEDROOA! C �� •':• n. `i8.5' - 15' Breakout Met �'r DEEP TEST HOLE & �Pp • _ _ Design Calculations PERCOLATION TEST LOCATION HOUSE EXIST. r,t ��: 0 Elev. 84.00 1000 GALLON `\ ' 1 ` Nlumber of Bedrooms: 3 Equivalent to 330 Gal./Day (440 Ga+./Day PROPOSED A' CUENT'S REQUEST) i' #28 \ H-10 SEPTIC TANK �,� 6t GprbOge Grinder: NO _ - L �- '7 FENCE 3 `\ \\ - .__ - Leaching Capacity Proposed: 440 Gal./Day Minimum (AT CLIENT'S REQUEST) Septic Tank - 2 x 440 Gal./Day = 880 USE EXIST..1,000 GAL, Septic Tank. 5 .5' �� \ SOIL ABSORPTION AREA: Using percolation rote of < rnin./imch I pRIVA'E DRINKING WATER WELL Bottom Area: 0.74 gal/sq. ft. x 500 sq. eft. 370 gal!ofts Sldewoll Area: 0.74 gal./sq. ft. x 99.6 sq. ft. 73.7 gallons \ \ \\ Providing: = 40.70 gallons VI IONS Usfe: (7) INFILTRATOR HIGH, CAPACITY H-20'' UNITS AVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, N0. DATE: DEFINITION -C) SE L;SED IMTH 4.0' OF WASHED STONE ON taE STtS; AND OF WASHED STONE ' \ \ \ \ IN-GROUND \ `\ \ xe '' Qtw THE ENDS. NO STONE UNDER. I ,,; :. a n ' \ \ \ SWIMMING POOL •\\ \\ fy0 L07. 7 ,. .., .,,. , .: , I '. ! . ,n;! .♦. , :\ , I . � _ ii �'R1:,r..r. , , , ,. .: 1. , .i , ...tit � E: :, •1 1; i :,' n. 1 r ,.\ �,i.. t; t , t i . i•� 'i ''i , ( :. NiS ''f : : d ' 1 fs •, .. 1 ' \ I EXISTING DRIVEWAY P D \ \ P RO I OS DFO R i s SUBSURFACE SEWAGE DISPOSAL SYSTEM \ tI I I '96, OF S R E i , 1 I i ,�& M . FUM #28 ELMER'S WAY ; I � II j i ,, �o �,, W. BARNSTABLE MA ., I , 0 28 ELMER 'S WAY �„ PREPARED BY: t I - W. BARNSTABLE, MA 02E) CARJIEiV E. ,S'HA Y R N � ENVIRONMENTAL SERVICES, INC. to ' G3j0 0 ``� 0 20 a 50 0: P.O. BOX 627 O EAST FA M T � ,STEML OU H, MA 02536 L'L 1�IE1� S W� Y sANITAR1Pa • I TEL/FAX : 508-539-7966 i (40 FOOT RIGHT OF WAY) I SCALE: 1 "=20' DRAWN • BY: CES DATE. SEPT. 16, 2005 PROJECT#SD-802 FILENAME: SD802PP.DWG SHEET 1 OF 1 i